Keeping Intelligence in the Clinical Encounter

You may wonder why it has taken me this long to get around to reading Gödel, Escher, Bach by Douglas R. Hofstadter. I blame the conditions at the coal-face. It is brilliant stuff. On page 26 of the 20^th Anniversary edition by Penguin (2000), after an introduction to strange loops in music, art, and mathematics, the author turns to intelligence and the abilities that are essential for it to pertain. I précis the section slightly:

Essential for intelligence are the ability to:

respond to situations very flexibly
take advantage of fortuitous circumstances
make sense of ambiguous or contradictory messages
recognize the relative importance of different elements of a situation
find similarities between situations despite differences which may separate them
draw distinctions between situations despite similarities which may link them
synthesize new concepts by taking old ones and putting them together in new ways
come up with ideas which are novel

Of interest to me here are not the limits of artificial intelligence, but how much these abilities are utterly intrinsic to the job of a therapist. Hardly surprising, one might say, since therapists are human.

But let’s look again, and reflect on the extent to which mental health work is being encouraged to follow practices that blunt or neglect these abilities.

Above is a list of things that questionnaires, categories, proformas, and protocols are bad at.

Therapeutic Attitude, therefore, is the attitude that insists on retaining intelligence in the clinical encounter.

Home page: https://afwest.com/

Two Stories About Jade

I was told these stories as a child. Looking back now I think they nearly summarise my approach to teaching.

The first tale was given to a group of us at junior school by the Bishop of Hereford.
A man wanted to become a connoisseur and collector of jade. One particular teacher came very highly recommended by his friend, so the man went to see him. He was welcomed, shown to a room and sat in front of a small piece of jade. The teacher left him there, returning an hour later to collect the piece of jade and his fee, and to bid our protagonist goodbye. This happened the next day and the next. Several weeks later the man bumped into his friend who asked how the lessons were going. “Appalling!” he replied, “He just leaves me alone in the room in front of a piece of jade for an hour. Doesn’t even say a word. And to add insult to injury, this morning it wasn’t even good quality jade!”

The other story my father liked to re-tell from the diaries of the diplomat Harold Nicholson. Nicholson was sat next to a Chinese official at a meal and was told, “In my country we have a proverb – Better a tile, intact, than a broken piece of jade.” “That is an excellent proverb” said Nicholson, writing it in his notebook. When he had done so he found his interlocutor frowning, “Or, maybe I have the proverb wrong. I think perhaps it is – Better a broken piece of jade than a tile intact.” “That, too, is an excellent proverb.” said the diplomat, “I shall write that down as well”.

I thought I should follow the example of the Bishop who, I can see now, was practising and preaching the same thing – at least on that occasion, but ending the blog at that point would no doubt results in a bemused reader, so here is my translation:

The Bishop’s point is that teaching is more effective if it is implicit. The man became an expert – he became something he had not been before. Had he been instructed by an explicit, content-based approach, he would have remained the same as before, just with some extra information. I did think I might do the same, and leave these stories suspended, but the required repetition and exposure (and in psychoanalytic terms the frustration tension) would have been missing; You would have had to sit with my blog for a few weeks.

The second story is, for me, about the nature of knowledge. Certainty is attractive but illusory, but the fact that the certainty is illusory does not make the information any less useful. In fact it makes it more useful by virtue of being more flexible. Secondly, apparently mutually exclusive opposites, far from being a problem, are what makes the world go around. The story is explicitly about whether it is substance or form that determines quality. That would be the explicit, content-based message – the substance, but it is the process, or form, that interests me more. Either that, or the flickering ambiguity that oscillates my attention between the two and leaves me suspended in a sort of pleasurable trance of unknowing.

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Self-care and remote-working

Remote-working is here to stay. This post on behalf of Developmental Conversations offers tips for maintaining self-care drawn from experience, conversation, and published sources. Key sources are listed below.

Most will apply generally to working from home. Some refer particularly to video-conferencing. Not all suggestions will apply or be useful to everyone. Have a look and see what you think.

Curating the context:

General wellbeing:

Eat, Exercise, Sleep
Protect boundaries (see below)
Practice self-compassion
Build morale (see below)

Transition

Pay attention to the transition from normal into remote working. A major problem with the Coronavirus pandemic has been that it bumped huge numbers into remote working without any preparation or training, and without much in the way of choice. It is not too late to remedy that:

Acknowledge it as a major transition. Go easy on yourself. Don’t give yourself a hard time if you get some things wrong or are slow to pick up speed.
Don’t assume that you can work at the same pace as you did before. Communication by video link requires more effort. We have become communication novices overnight and there are lots of techniques still to learn.
Schedule a lighter diary to start with – that is, one that looks lighter. You may well find that you are more tired after it than you expect.
Learn and plan more explicitly than you normally do. So much of face-to-face communication and time management we learned by implicit means and over years, so now we need to read up and network to gather tips and strategies. Write them down. Adapt them to suit your work and temperament and build them into your practice.

Space

Dedicated space

If possible establish a space devoted entirely to work, remote linking or otherwise. If you do not have the luxury of space that can be devoted only to this, then have a place that you can reliably use – and you do use – for the remote linking, so that camera angles, background etc are already settled. Some people walk.

Good lighting

This is important for your comfort (eye strain), productivity (energy and focus) and, when it comes to video calling it is important that your face is clearly, but not harshly, illuminated for the person you are meeting.

Noise control
- ambient noise needs to be minimised for you to be clearly audible, and for you and others to be undistracted.
- volume control covered also below. This will be affected by equipment, distance from the microphone etc.
- com suggest a white noise machine to shut out distracting sounds. I have no idea if this works and I am not going to try it, but it is a thought. I doubt if this is for the video call, though.
Comfortable seating
Plenty of surface area. You need to be able to take notes without rustling, reach for references without leaving the frame etc.
Personal joyful stuff. Traject recommend this, and I am not sure. The comfort and uplift that this provides needs to be weighed against distraction and boundary diffusion.

Time

Protect your time.
Set a daily schedule:
- Make sure you know what is work time and when you are off work.
- Make sure you know what project you are engaged in at any one time.
Include casual connections with colleagues (as you would do in the workplace), not just formal meetings.
Schedule fresh air and exercise.

Communication

Broadly speaking, channels of communication and communication skill have both been reduced drastically, all round, so more effort will be needed:

Be positive and supportive.
Overcommunicate rather than undercommunicate.
Clarify:
- how others can reach you
- when others can catch you
- expectations
- and clear up issues quickly with a phone call.
Interpret problems as miscommunication rather than malice.
Ask for feedback
Reply promptly
Establish how to share documents

The Work

Your working style

Identify your “productivity weaknesses” and address them:
- Procrastination
- Distraction
- Fatigue
- Boredom
Maintain your brand or culture and, if in a team, the team culture.
Maintain morale:
- Dress and groom
- Chart project progress

The meeting

Not everything requires a meeting.
On the other hand, the human face humanises.
Ground yourself before you start.
Volume
- Can you be heard?
- Can you hear without strain?
- Consider confidentiality – being overheard
- Earphones?
Decide on Chair, facilitator, use of mute, hand signals, and chat.
Decide on speaker view or (eg for chair) gallery view.
Decide on chat before, after, or not at all.
Establish alternative routes of communication
- For documents
- In event of interruption
- Chat function
Ask for feedback
- Can you be heard?
- Were you understood?
- Did you understand?
Avoid multitasking
Avoid rudeness in the room (like looking at your phone)

Here are some sites to which I am indebted for ideas:

A good description of the need: https://twitter.com/LeapersCo/status/1257941168182243328?s=20

Traject: Trajet home page

https://twitter.com/ByTraject/status/1244814375485083648?s=20

Inc.com https://www.inc.com/lindsey-pollak-eileen-coombes/remote-work-home-productivity-communication-self-care-morale-team.html?utm_content=122166550&utm_medium=social&utm_source=twitter&hss_channel=tw-893547756282822656

MyCareAcademy https://twitter.com/MyCareAcademy/status/1242015839433474048/photo/2

Realbusiness.co.uk https://realbusiness.co.uk/mental-health-covid-19/

@Leapers https://www.leapers.co/

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Narrative Matters

We have kept a lot of our children’s books. They represent such good value in terms of revisit rate, and they remind us of happy times.

I just had another look at Creation Stories retold by Ann Pilling and illustrated by Michael foreman (Walker, 1997). The first story tells how, before there was anything else, there was an egg. A giant popped out and grew (over the next eighteen thousand years) pushing the land and sky apart until he could rely on them to stay in their place, at which point he went on to other tasks like carving valleys and mountains. When he died, all of his body parts were used in some way; his hair for forests, bones for rocks, and his tears formed the rivers.

I am impressed by the multiple layers of wisdom in this tale. At the level of content (and with a nod to the likely purchaser) it acknowledges the tiring job of the parent in creating and maintaining the space in which offspring can grow. It also introduces us to the importance of sustainability.

But at the level of process we realise that those who developed and treasured this story chose, for their progenitor, not an immortal but a flesh-and-blood being very much like us. Someone who can get tired and weep; Someone who dies and decays, and for whom it is possible to grieve.

Also, we are not invited to believe this story as a literal representation of fact, or required to believe the improbable; Dogma, immortality, and unreachable qualities, are not held up as objects of devotion or aspiration.

In this way generations are taught the importance of symbolic truth and the ordinariness of cosmic events, as well as the crucial role that narrative has in making sense of our existence and contextualising our experience.

We can take reassurance from the fact that stories will do this important job for us, particularly if they are obviously located in the symbolic realm, rather than the concrete. It is better if these stories don’t take themselves too seriously. Stories that are too eager to convince us of their truth and too bullying in their insistence upon compliance are harder to make friends with; are less adaptable; are more likely to drive us from our neighbour over issues of difference.

A parent reading this story to their child might stand to learn at least as much as the child, if not more. And I generally think that that is the mark of a proper children’s story.

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Music Again

This post is a sort of dialogue with a podcast interview about music therapy. I provide the link here and encourage anyone who reads this blog with any interest, to listen to the podcast. The interview is really more about the creation of therapeutic space, but it also economically exemplifies what I have called “Therapeutic Attitude” and has added to my own conception of it.

Philippa Derrington is a Senior Lecturer within the Division of Occupational Therapy and Arts Therapies at Queen Margaret University in Edinburgh and leads the MSc Music Therapy course there. Here she is interviewed by Luke Annesley, a jazz musician and music therapist who produces the British Association for Music Therapy podcast series Music Therapy Conversations.

Music Therapy Conversations. Episode 25. Philippa Derrington

In this interview, Philippa describes setting up a music therapy space in a school, in the corner of a garage, and using large instruments (to occupy and therefore command space) and anything she could salvage from the school skip. In doing this she demonstrates beautifully one aspect of therapeutic attitude, which is taking responsibility for the space.

Therapy is exploration and, as such, requires a secure base (1,2). The therapist is as responsible for this aspect of therapy as any other. If a therapist is lucky enough to be able to totally control the physical environment, then they can (and should) do so creatively. But it may be that significant aspects of the environment are fixed and out of the physical control of the therapist. When this is the case the therapist can make sure that, when in the room, they “extend themselves to its boundaries” (3).

When I have managed to put an idea into words and another practitioner from a different discipline expresses something similar, I find it hugely affirming. As I listened to this podcast I found myself thinking over and over again, “this is Therapeutic Attitude!”

Take, for example:

PD: “Respect takes first place for me in work with any adolescent” (16m00s)

– and compare with –

AW “A crucial aspect of therapeutic work with children is the forming of a respectful relationship with them: discussing, offering genuine choices, and relating to them as valid, motivated humans with a right to, and the potential for, a life of their own, rather than simply existing as a product and part of the lives of others.” (BWSG p 151)

Or:

PD “A most important element is being able to get alongside the young person” (18m40s)

compare…

AW “…my position is alongside the child, looking at the conundrum, as though to say, “Is this what you would like us to think about?” (p12)

And:

PD “…the importance of not-knowing, and staying with that.” (20m09s)

compare…

AW Chapter Four on Uncertainty which leans heavily on D. W. Winnicott’s “..contain conflicts…. instead of anxiously looking around for a cure” (4) and John Keats’ concept of Negative Capability (5).

I am excited enough by the similarities, but here is a point of divergence or extension which gives me pause for thought. Luke and Philippa have a conversation (14m08s) about how in the school she is “always a music therapist, but not always doing music therapy”. This is really interesting. I wrote a section (p11) “Being a Psychiatrist” in which I contrasted being a psychiatrist with doing psychiatry, but I wanted to make a different point and distinguish between (in the frame of virtue ethics) being a psychiatrist as opposed to performing a set of tasks which constituted psychiatry but which might as well be alien (being versus doing). I still think that my point is an important one, but Phillipa and Luke’s point is also, and they complement one another . A therapist must have therapeutic attitude when “doing therapy” but the attitude is also important when in one’s professional role – being a therapist – but not actually in session. Philippa clearly protects the sessions in betweenwhiles, but only to the extent that each client requires. This is a form of “holding in mind”. The attitude extends beyond the session and becomes part of the professional person; Perhaps even the person.

Have a listen!

refs:

Bowlby, J. (1988). A Secure Base: Clinical Applications of Attachment Theory.
London: Routledge.
Byng-Hall, J. (1995). Creating a secure family base: Some implications of
attachment theory for family therapy. Family Process, 34: 45–58.
Being With and Saying Goodbye. Cultivating Therapeutic Attitude in Professional Practice p89.
Winnicott, D. W. (1971b). Therapeutic Consultations in Child Psychiatry. London: Hogarth & The Institute of Psycho-Analysis. p2.
Gittings, R. (1966). Selected Poems and Letters of John Keats. Oxford:
Heinemann Educational. p40-41.

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A new home in free musical improvisation

I do have concerns, though, about those children who have been taught to play a sport, a musical instrument, or a complex board game, to the exclusion of playing which is the freer, more creative, and developmental activity. = Being With and Saying Goodbye, Ch 5 Thinking

I joined Oxford Improvisers in 2018 because I am a musician as well as a clinician and was in need of stimulation and a new direction. This turned out to be a brilliant move, and further explanation is perfectly relevant to Therapeutic Attitude.

In Oxford Improvisers I found myself immediately welcomed, and at home. Home, of course, is a secure place from which one can venture.

“Exploration requires a secure base, as attachment theory has taught us, but there is no certainty* in terms of the anticipated outcome. The confidence shown by the clinician, then, must be a confidence in process coupled with an optimistic acknowledgement of the uncertain future” (BWSG Ch 4).

In that chapter, which is on Uncertainty, I consider “an appropriate analogy [for the practising clinician] to be that of the improvising musician who uses landmarks and artistry, and is confident that the result will be music whilst not being at all sure what will actually come next”. I was already describing clinical work in child and adolescent mental health as improvisation, though I had little experience of musical improvisation at the time.

The picture above, taken by Gabriele Pani and tweeted for @OX_Improvisers , shows overlaid objects; a piano (barely visible in this version), toy piano, guitar, watch, plastic spoon, drum sticks and mallets. What moves me about this picture is that each of these objects is taken seriously and lightly at the same time. The same is true of participation.

The difference between participants is respected; indeed this difference is essential to the activity. At the same time participants are valued equally; valued to the same extent, but for different reasons or qualities.

Uncertainty is not only accepted; nor even simply embraced; it is encouraged and nurtured. Any “rules” introduced are not to constrain movement, but to provide something to bounce off.

From the conclusion of Chapter 3, The Nature of evidence, I have selected the following points:

For the development of an individual existence there must be freedom of movement.
If statistics and “facts” are to be used in relation to human growth, they must be understood such that the individual’s room for manoeuvre can be demonstrated.
This amounts to an attitude of irreverence towards the apparently immovable.
Humour in the clinical setting reveals the creative space between how things are and how they might be.
Despite humanity’s constant search for certainty, possibility and hope can only exist where there is uncertainty.

This all contributes to the attitude of clinical practice that evolved through my own working mid-life and that I have come to call Therapeutic Attitude. Small wonder that I found myself a new home with a group of free musical improvisers on retirement from my NHS job. Therapy has to be creative and for therapeutic creativity one requires freedom of movement within a safe space.

♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪

*PS in the lines quoted above I actually wrote “security” but “certainty” gets us closer to what I was thinking.

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Everything worth waiting for is worth the wait

Jan Fortune has just blogged on Why writers need to wait – indeed, not just writers but all artists. The virtue of waiting is not generally appreciated in our everyday worlds where anything that doesn’t arrive instantly runs the risk of being walked away from – or, more accurately, we run the risk of walking away from – and therefore losing – everything that does not come to us at the snap of the fingers.

This chimes so well with what I have said about therapeutic attitude that it might be considered an argument defining therapy as art but for the false dualism. Art and science are not a mutually exclusive dyad any more than body and mind. Each involves the other; And good scientific research also requires the capacity to wait.

I shall briefly recap on waiting in therapy as this is a blog on Therapeutic Attitude.

D. W. Winnicott, the ground-breaking paediatrician-turned-child-therapist probably best-known for the idea of the “good-enough mother” wrote of the “capacity in the therapist to contain the conflicts … and to wait for their resolution in the patient instead of anxiously looking around for a cure”. In doing so he was, whether he knew it or not, echoing the poet John Keats who wrote to his brother of his admiration for people who were “capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason”. (I suspect that Winnicott was perfectly aware of the connection because he also wrote elsewhere that, “if what I say has truth in it, this will already have been dealt with by the world’s poets”.)

This irritable reaching after cures and facts is something we see a great deal of at the moment. Perhaps it can come as some relief to know that it was also prevalent in Keats’ time.

Everything worth waiting for is worth the wait. Therapy and healing are creative processes, the instant therapy is a con and an addiction, your doctor is an artist as well as a scientist, and emergence is the key. We are living things, and development (of which healing is an example) is a living thing. We need to create the right conditions, be patient, and allow it to emerge.

Refs.

Winnicott, D. W. (1971). Therapeutic Consultations in Child Psychiatry (p2). London:
Hogarth & The Institute of Psycho-Analysis.
Gittings, R. (1966). Selected Poems and Letters of John Keats (p40-41). Oxford: Heinemann Educational.
Winnicott, D. W. (1986). Fear of breakdown. In: G. Kohon (Ed.). The British School of Psychoanalysis: The Independent Tradition (pp. 173–182). London: Free Association Books.

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Therapeutic Attitude

This site explores "being with and saying goodbye", the attitude that sustains professional practice, and that itself now needs sustenance

Tag: Creativity