Music Again

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:

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

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Everything worth waiting for is worth the wait

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.

  1. Winnicott, D. W. (1971). Therapeutic Consultations in Child Psychiatry (p2). London:
    Hogarth & The Institute of Psycho-Analysis.
  2. Gittings, R. (1966). Selected Poems and Letters of John Keats (p40-41). Oxford: Heinemann Educational.
  3. 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 Alliteration

Therapeutic Alliteration

Every argument worth making, it seems, can be summarised in a limited number of words all beginning with the same letter. So here are the Four Ps of Therapeutic Attitude. The last one is A, so I made the middle two either P/A to balance it out.

By the way, the “you” addressed here may be a therapist, but not necessarily. Everyone can bring some therapeutic attitude to the table in whatever relationship they are in. If you are in a position of professional responsibility, then I believe you have a duty to do so. Oh, and first check out Attitude

So here are the four Ps: Position, Posture, Purpose, and Appreciation. That’s P for ‘preciation.

Position

Are you visible? Accessible? Are you in a place in your own life that enables you to park your issues and engage fully in the therapeutic relationship for the allotted time? There is little point in having all the other attributes of a therapist if you are hidden away or beset constantly by other demands. Position can also refer to your “position on issues”. Where are your red lines? I suggest, very simply, “Support the other if you can do so without harming anyone”. If you have read much else of what I have written you will know that I have other red lines; I will not serve the machine, for example. Red lines are relatively static and provide the channels through which Purpose (see below) is directed.

Posture/Appearance

Body posture is both a useful metaphor, and a way to evidence and influence a more internal posture. You need to be upright without being rigid; relaxed without being slumped; alert without being rapacious; responsive without jumping to conclusions or into action. Some aspects of your posture will become evident from your responses. To maintain therapeutic attitude, you need to be located in the real world, but not too subservient to it. Stable, yet poised for movement. How you appear will hopefully inform others as to your position and likely style.

Purpose/ Approach

The purpose of therapy is to enable positive developmental change; enable and encourage, but never force or demand. The agenda arises in – is set and owned by – the other person. Any other would-be influences can be considered part of the environment. If the client has been sent or brought by a third party – then the agenda of that third party is something that you and your patient or client can look at with interest. Someone may come to you with an agenda and that is fine, but you will be curious towards it, and ready for it to change.

Appreciation

Appreciation of the other includes warmth, greeting, acknowledgement (that they are real and valid), acclaim, and humour. There are two keys to appreciation. One is Sensitivity. There is no merit to acclaim, for example, if it is insensitive. Some people are not rewarded by a fanfare, but rather a shy nod. Others will only notice a fanfare and will experience a shy nod as a brush-off or will not notice it at all. The other key to appreciation is genuineness, and it is at the point of appreciation that genuineness is most crucial. It is possible to manufacture Position, Posture, and Purpose and act them out – possibly against the grain, though this will require a good deal of effort – but genuineness must be genuine. Fake genuineness, when detected, simply results in disengagement; if undetected, fake genuineness can be toxic. Therapeutic work, therefore, is a vocation. You do it because you really want to, and because it really matters to you.

TA = P + P(A) + P(A) + A(P)SG . What could be simpler?

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Horse-Whispering

Horse-Whispering

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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Transference: A reflection on not being the Other

Transference happens. We could argue about how much, exactly how, and whether the name is right, but that would be pointless. The point is that we can, at times, react towards another person as though they were not who they actually are (friend, boss, shop assistant etc), but an important other from our own past or distant lives.

Some of us do it more than others. Some people seem almost to do nothing else. It can be trivial, but it can also seriously hamper relationships and personal development. People who enter therapy and are likely to be doing so exactly because they do have problems with their relationships and their personal development. They may be expected to be particularly prone to this type of relating. For this reason, therapists need to be adept at managing the situation.
                                                                                                                                                          Therapy encourages transference by 1) establishing a particular kind of relationship which has inherent in it a degree of asymmetry, and then 2) having as its remit the exploration of areas in which the patient or client is unconfident or unskilled and which evoke earlier relationships. Some styles of therapy may further encourage this by their use of silence and by developing what has been called the “frustration tension”.
                                                                                                                                                                  The therapist cannot simply dismiss the confusion by saying, for example, “Stop it. Don’t be ridiculous! I’m not you mother!” They have to keep it going enough for it to be seen, understood, and worked with. It would be unforgivable, though, if the therapist were to encourage or consolidate the confusion, by continuing to play the part and recapitulate the original trauma.
                                                                                                                                                                      In other words – and here I am getting to the crux of it – the therapist has to be able to be enough of all these others (these fathers, mothers, lovers, siblings etc) to be plausible to the client’s unconscious whilst manifestly NOT being these people. In a sense, they need to be able to be any number of people whilst emphatically not being them.
                                                                                                                                                                           Not being should perhaps have a hyphen, because this activity of not-being is different to a simple absence. As in the mind-experiment of trying to not think of a pink giraffe, not-being to a large extent draws attention towards being. Not-being subsumes a degree of being. In a sense, it flirts with being. Think, for example, of the counsellor whose skill set should include knowing how one might take the session deeper, in order to not-do so. Or the doctor who is required to be able to prescribe a medication before their decision to not-do so can take on significance. The mountain guide must know what would be a reckless action in order to be saved from carrying it out.
                                                                                                                                                            Adding to this, the therapist must also be genuinely themselves and 100% present whilst in a way leaving much of themselves outside the room: bringing their skills, attention, and beneficial intent into the room – giving them a voice – yet leaving their own factual lives outside. They have to remember the right things. They have to remember who they are without the constant rehearsal of self-revelation and, whilst stripped in this way, they have to not-accept the roles and characteristics transferred within the therapeutic relationship.
                                                                                                                                                            Therapists, then, if they are to be therapists rather than functionaries, have to be sufficiently capable and supported to perform this balancing act; a balancing that includes things repeatedly touched upon in Being With and Saying Goodbye such as equipoise, believing whilst suspending belief, uncertainty, and paradox. The space between being and not being (which I have here called not-being) is what Winnicott might have termed a “potential space”. It is there yet not-there; the essential ambiguity needed for the play that is therapy.
                                                                                                                                                                    Do think, reply, discuss. Here, or @afwesty via Twitter