In Being With and Saying Goodbye I have concentrated mainly on the work that can be conducted through conversation of a fairly decorous and measured variety, even if not always using verbal language. There is a species of Being With that I neglected to mention. Thinking about it now, it is easy to imagine why. If you read on there is a possibility that you will be offended by the analogy that I draw, but I hope you can bear with that and get to the point I am trying to make.

The mental health problem that people fear most, I suspect, is that of totally losing control; of ceasing to be human. My hunch is that this is where a lot of the stigma against mental ill-health comes from. Instead of addressing that fear and stigma, society busies itself with surface psychology. Money and rhetoric are poured into this to reassure us that plenty is being done. Meanwhile, those with fear of fragmentation go round the mill of medications, revolving doors, and pejorative labelling. I think that they often feel profoundly alone and abused. This is the opposite of Being With.

I suspect that in BWSG I neglected this aspect through shame at how much fear I can feel myself and how much I can shrink from accompanying those gripped by that lonely fear. I am less afraid when wearing my work clothes. Power has its advantages.

This omission from BWSG occurred to me recently when I was talking to someone who re-trains ex-race-horses so that they can be ridden and loved in a second career. It recalled a conversation I had had shortly before with the extremely anxious parents of an incredibly anxious child. He had probably always been fairly anxious, but had managed it through his prodigious talents and sheer effort of will. Something had caused this approach to fail, and he had been sent plummeting into a vortex of sheer terror, when there is no floor and where successful omnipotence, potent parents, and the phantasised all-powerful benign oversight, are exposed as mere clay and collapse crashing all around. He was terrified.

In discussing this with the parents, drawing on past experience to try to advise them, I found myself explaining that for the time being at least they had to acknowledge that they could not hope to interact with their son in any way that was familiar to them. The analogy that seemed to help them was that of being in the presence of a very frightened animal: A spooked horse, perhaps.

I have been in the presence of terrified people. It is something that my formal training did not address very well, so I fall back on my native character, inherent and shaped over the years. The closest to explicit training that approaches this would probably be that hopelessly clunky bit where they tell you where to sit in relation to the door: I and the “other” are expected to be reassured by the fact that each of us can run out of the room if we have to. The image that this always evokes in me is of us colliding, jammed, in the doorway in a mutual rush to escape. To be fair there is some merit it getting us to think about our positions in the room. Position is power and power corrupts. We need to be big enough but not too big; friendly enough but not too friendly. But it doesn’t allow for the encounter on the stairs, for example. We are also taught about breathing rate, pacing, and such-like. Sure enough, it is useful to be aware of these things as well (there is so much to be aware of), but at the start of the meeting, as the whole family come in, I don’t want to look as though I was trained by the SAS.

And so, occasionally, there comes a point where I realise that there is a terrified animal in the room with me. Why does this apparently demeaning analogy help? What is the approach that it evokes?

In the presence of this terrified being, with whom there can no longer be any normal social interaction, we resort to sounds and behaviours. There are three tasks. One is to reduce the threat. We (I say “we” advisedly because there is pacing and matching going on – that is part of the point) – we manage eye contact differently, soften the voice to soothing sounds, and position ourselves in the space so that the other feels neither abandoned, nor encroached upon or trapped. The second task is for me to manage myself. There is no merit in being unthreatening if I, the parent or professional, am obviously terrified. I must at least appear as though I am intact and unthreatened; undaunted by the vortex. This is easier to project if it is the truth. The third task is to re-establish some semblance of conversation with the other person. No use, though, expecting my words to be grasped and responded to in kind. It is more likely that, whatever words I choose, the meaning conveyed will be “I am OK, we are OK, the world is OK, it’s OK, you can be OK…”. It is more like a dance, or a musical improvisation. I am situated and relaxed in the world and I am inviting you to mirror me because if you do, then I think you will feel more in the world as well.

Now here is a problem. If I managed this moment successfully, and the parents were with me, then I have modelled what may be a new behaviour for them. But they are unlikely to be able to replicate it straight away. When this situation is behind us, the parents usually have to return home with their child. They will ask me what they should do in a recurrence. I will make some suggestions, but instruction under these circumstances inevitably become clunky, like the training we receive. How many times have parents been told to “make sure all knives and sharp implements are out of the way”? This is like “sit equidistant from the door”. It is all well and good, but it is impossible. We cannot make the environment safe – only safer.

It is the attempt to make situations totally safe that result in abuse – what is sometimes called iatrogenic abuse, though this hurts me – it is not only doctors who are guilty, and most of us do the best we can. Going back to the first and second tasks, above (reduce the threat, and manage my own fear) there will come a time when this cannot be done. What do we do then? Well, here are two examples from early in my training, before I started specialising in Child and Adolescent work. Go easy on me. I was a kid myself:

1. An adult male ran – barefoot, as it happened – first at the wall and then at me, in a corridor. I stepped to one side and let him pass. I followed him some way out into the street, gave up the chase, and called the police.
2. An adult female, at a similar stage in my training, slapped me in the face. I shouted at her, “Don’t ever do that again!” and continued the assessment.

The genders in these vignettes are telling. This is about power. In the first instance I knew I was outgunned and I called on a service that I knew would not be. What they did, was out of my hands. In the second I believed myself to be the more powerful, in a crude, physical sense. When the chips are down, the world we live in is physical. I exploited, perhaps, her past experience of abuse and her fear. I did so entirely on reflex and out of instinct. The fact that we were able to sit again, and to return to talking, reassures me to some extent that she felt safe enough. I knew I had made a mistake – it would be years before I knew enough about myself to guess that the mistake was likely to be that I had shown too much of my smart-Alec. But the point is that the container has to be capable, physically, of containing. And it has to imply that capacity without resorting to it. It is another impossible paradox that we manage as best we can.

I want to return to the animal kingdom. It is a useful analogy because it makes explicit the fact that we have regressed, in this situation, to a pre-verbal level of existence. At these times we call on our animal avatars. What would I like my avatar to be at these times? I would like to be an elephant, caring, wise, and benevolently invulnerable. But I have to be nimble enough to step to one side without trampling. I know, also, that I can show my cornered tiger. I hope that I have learned its power, so that all that is needed is the bearing of teeth in a smile, or the raising of a bushy eyebrow. It is a tough (beautiful) brutal world. I may be able to help you if I survive.

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