Counselling, Mindfullness, Psychoanalysis, Psychotherapy, Reflective Practice, The Inner World, The unconscious, Ways of Being

The Expert 2

The expert

I finished yesterday’s blog with a quote from Bion to the effect that the therapist should enter their session with their patient with neither memory or desire or expectation of outcome. That takes some doing! I have lost track of the number of times my patients have confounded my expectations- both positively and negatively. Patients whom I thought would stay for at least a year leave unexpectedly after a month. Patients whom I knew would gain nothing from seeing me stay for a year or more and take a huge amount from the work. Sessions where I have been in fear and trembling of the attack I knew would come prove me wrong. And vice versa. In a week I move from being invaluable, generous and understanding to being greedy, rapacious and useless. Which proves the value of Bion’s maxim.

It is a rule that I’m learning to practice. To “trust the process”. To believe that between us, me and my patient can come to a shared understanding in the session of what it is that I am required to know. (As usual it’s this point at which I mildly envy my CBT colleagues who have a fixed programme which they can follow.) Working my way has advantages and disadvantages. As a nurse it meant that I never could write a “proper” Care Plan because I always worked with the transference-  which was unpredictable. It also made my teaching slightly difficult for similar reasons. I still can’t write a lesson plan with learning outcomes etc. I taught in the transference. (A way of working that took some of my students a long time to get to grips with. Some never did.)

How does this relate to Consultants, Experts etc? For me the Expert is the one who is comfortable with not-knowing. The one who can respond to a question with an honest answer and not bludgeon me with their knowledge. (My G.Ps are brilliant examples of how to listen to their patient.) Why does it matter if I’m heard or not? Because not being heard invalidates me. It wipes me out and reduces me to a set of symptoms that only they can fix.(As you might imagine, I am not necessarily a “good” patient.I expect from others what I try to practice myself. Certainly in the clinical realm.)

The picture above picks up the idea of an expert.The climber has reached a peak with hard work, skill and endurance. And has earned the right to enjoy the view. But the number of unclimbed peaks still outnumbers the one on which he stands. That knowledge should keep all of us humble-no matter how expert we consider ourselves.

Psychoanalysis, Psychotherapy, Reflective Practice, The Inner World, The unconscious, Ways of Being

The Expert

In the space of a week I have had the dubious pleasure of seeing two consultant cardiologists in two different hospitals. In one case I wished that I had had some kind of lethal weapon with me. Or had been taught to kill just using a biro and some lip salve. Bond et al would have known how to do it quickly and efficiently. (His companion would have offered no resistance after his mentor had been so dispatched.) Sadly I was unable to act out my fantasy-which may have been a good thing. I’m still ambivalent on this point. What made me so angry was his attitude. I offered some opinions about my health and suggested that some of my symptoms were probably side effects of some of my medication. “How do you know that?” “Well, I researched the drugs on the web. And read the information sheet that comes with them. These suggest that what I have are side effects.”

“Everything can be found on the Internet these days.” was the response.

I felt like a five-year old who has said something clever in class but who has been firmly put in his place by the teacher and told not to be clever again. The Consultant then proceeded to outline the treatment programme he planned for my heart, which would happen next week. that said the “conversation” was finished and I was dismissed. (Sadly this only repeated my previous experience as an in-patient at Papworth. It felt that everyone looking after me would have been happier if my heart could be nursed apart from the rest of me. Then the surgeons could do their clever technical stuff without me getting in the way.)

My next encounter was in a local cardiac unit. Full marks to the team for being fun, human and interested in me as a whole person and not just a cardiac case. Even the Consultant was reasonably human-to a point. He had his regime in mind and was not going to be deflected from it. When I refused to take a drug he wanted me to have, he was not happy. But conceded that I could make this choice. Again I felt reduced to the level of a five-year old being told “Don’t argue. Daddy knows best.” (He might. I acknowledge his skill. But it is still my body. I have to suffer the side effects, not him. And I will not be railroaded into a course of action that feels damaging.)

The psychoanalyst Wilfred Bion said  of Desires: The psychoanalyst can start by avoiding… Desires for results, `cure’ or even understanding must not be allowed to proliferate.” I will take this idea further in the next blog.


The expert

Counselling, Psychotherapy, Reflective Practice, Religion, Spirituality, The Inner World, The unconscious, Ways of Being

History or His Story? 2

historyThis piece will take the History / His Story split into the clinical world and look at the nature of stories. Churchill observed that “History is always written by the winners.” This holds good in the personal realm as well as the public one. I see many patients who come with a version of  their history written by the “winning” part of their psyche .This is often a highly edited version of their history written by a depressed part of them. Or by a part desperate to continue a story about their idyllic childhood. People do have lovely, happy, good enough childhoods. These people, however, do not usually end up in a succession of damaging relationships with partners who seem set on destroying them. Nor do they try to commit suicide, get involved in abusing drugs and alcohol or have multiple sexual partners. (It is always an uncomfortable moment when I bring together the stories my patients tell me about their blissful childhood and the biography they tell me week after week. Two worlds collide and tears often follow.)

The original sense of “History” was not of a recording of events per se. I “did” the Tudors and the Stuarts at ‘O’ level and learned almost nothing that seemed important about them. I don’t know if Henry VIII was a good man or not. I have no idea what kind of man James 1st might have been. I learned the dates of their reigns but nothing much else. This kind of history seems soulless to me. The original meaning of “History” is that of a narrative, a story. This meaning in its turn is linked with the idea of a wise man using stories to discover a truth – much  more akin to stories in counselling. There is rarely one overarching story in therapeutic work. One can say “Yes. That was abusive” or “That must have felt unfair.” One cannot give an overall meaning to a history. Any event has to be visited and re-visited to begin to come to terms with it. This then has to fit into the rest of the story of my patient’s life. This is the benefit of long-term work. One can work through the issues that are problematic and resolve them.

How do these two blogs fit? I said that I found the idea of History being written as His Story problematic. It imposes one overarching interpretation on history. History as God working His purpose out. God is behind the major events in our world and is using them to teach and train His people. (I’m not sure how one is supposed to react if one doesn’t see oneself as fitting into this category.) As I said earlier, if I was a displaced [person living in a refuge camp I’m not sure how much comfort I would draw from a fantasy that this was, somehow, the will of God.)

So I think I’ll carry writing and thinking of History as just that. History. Not His Story. It means more uncertainty. More muddles. But that’s where I think I’ll find truth along with my patients.

Counselling, Madness, Religion, The Inner World, The unconscious, Ways of Being

History or His Story? 1.

We were sitting chatting in the pub last night. It was the monthly meeting of our A&E group. A&E standing for both Accident and Emergency and Ale and Exegesis.The name came out of the idea of a casualty department which deals with crises because there was a feeling that the church is in crisis, needing some interventions fast.  Plus the idea of good beer and good conversation out of which might come some ideas for local interventions. That, then, is the history of the group. At some point we began to talk about the state of the world-  as one often does after a few beers. We looked at the ebb and flow of power and influence held by different groups at different times in history. It seems hard to grasp the ways in which power shifts. (This is one of the drawbacks of living with 24 hour news. Something happens in one part of the world and the rest of us are bombarded with images, opinions and commentary with so little time to think.) Groups appear for a time, hit the headlines and then disappear from the media because something more exciting has happened.

The conversation moved on and we began to talk about justice, leadership, power, democracy etc. The big ideas. The question was asked about how God fitted into this process. “Well” said someone “the bible says that rulers are appointed by God. One way of saying that is to write ‘ History’ as ‘His Story’.God is in control.” I have numerous problems with this view. I love in the UK in a parliamentary democracy. I have work, a house, a circle of friends. I am not persecuted because I belong to the wrong tribe. Or because someone else wants my land. When the General Election finally arrives I shall not have to worry about armed soldiers implicitly threatening me. On this basis the idea of the government etc being appointed by God seems fine. Move me a few thousand miles East and my world looks very different. I could be living in a refugee camp with 10,000 others. If I was a woman in this context I would fear being raped. My children would not go to school each day. My husband would not have work. Why? Because God has appointed ruler who despises my tribe. Or my race. Or my religion. Or all three. I’m not sure I find that kind of God very appealing. Still less His appointed representatives.

In part 2 I will link this to the personal, inner world.



Counselling, Madness, Psychosis, Psychotherapy, Reflective Practice, The Inner World, The unconscious, Ways of Being

Power proves the Man

SolonThe quote is from one Solon who lived in Athens in 638 B.C. I know little more than that about him.  The comment was posted on Twitter and caught my attention – as Tweets do occasionally. I began to play with the idea of power in a counselling relationship. As a counsellor i can hide behind my therapeutic anonymity to some extent. This is particularly true in psychoanalytic work with its emphasis on the therapist as a blank screen onto which the patent may project whatever they choose. (Although I find it hard at times to be this anonymous .”I” keep on breaking through! Fortunately my patients don’t seem to mind.) This anonymity is a kind of power. My silence or interpretation or comment carries a lot of weight .Far more than a casual conversation in the pub.  As I have discovered to my cost ,my words can make or break the therapeutic alliance. Which is one reason why good therapists try to say few words and allow the patient to do the talking. It’s their session, after all.

To take up this stance comes at some cost, particularly if one is being attacked.I have ended sessions feeling as though I have been in the ring with Mike Tyson. Yet to defend myself would have been to rob my patient of a valuable experience. To be able to be hateful and do it safely. I still remember a dream when I was in analysis. I put my analyst in the electric chair, fitted the cap etc and pulled the switch to kill her. I did it dispassionately. It was nothing personal! We spent some time talking about my envy of her and my hatred of her. Painful but very helpful for me to be hateful without having to make reparation. To allow ourselves to be hated requires a certain kind of power. There has to be a good enough sense of who we are to allow us to survive the attack. (I wear an artificial eye and have done for many years. I remember on a ward one very angry patient calling me “a fucking cyclops” because we had interrupted her attempting to have sex with another patient. That comment hurt. It was meant to. But my task was to hold her anger and survive the attack without retaliating.To have retaliated would have been to misuse my power as a nurse.

So, power proves the man. I agree with Solon. But like any proving, it can cost us dear.

Counselling, Mindfullness, Psychotherapy, Reflective Practice, Religion, Spirituality, The Inner World, The unconscious, Ways of Being

The hands of the living god

The unknown writer of the New Testament book of Hebrews offers this warning “It is a fearful thing to fall into the hands of the living God.” (Heb.10:31) The psychoanalyst Mike Eigen comments “It is a worse thing not to fall into the hands of the living God.” He has a point! I’ve been musing about Eigen’s comment for a while.

The idea which most struck me was that the god into whose hands it is fearful to fall is a living god. One sees and hears much about those whose god seems dead .Or seems to be linked to Freud’s Death Instinct (Thanatos) rather than his Life Instinct (Eros). One only needs to see or hear the News to see the working of these drives in numerous groups.Religion is the most conspicuous example where Eros and Thanatos are clearly in evidence. At a micro level go to any school playground and watch the results of these drives. My point is a broader one that just Freudian theory. It is about our god being a living one. I’m aware that this piece could so easily morph into a “Thought for the Day” wannabe. Bear with me. That is not my intention. I have no plans to launch a religious polemic of any kind. My intention is to think about our relationship with that which we call “God” Paul Tillich and others talk about God as “the ground of our Being” which seems a broad enough definition to give plenty of room.He also talks about God as that which is left when everything else has collapsed. Which gives a good few options. Friends, family, hobbies, career. The point being that these should be alive and generate life in us -Eros not Thanatos. The living god.

In clinical practice I meet many people who are stuck in a dead relationship with themselves and those around them. (Frequently stemming from childhoods that did not give them the right kind of care and support-for a variety of reasons.) My patients will complain that nothing is ever quite as they want it to be. their marriage doesn’t quite fit. They don’t feel fully at home in their work. Friendships never seem to last. They are caught in the hands of a dead god rather than in a relationship with something that nourishes and nurtures them – and which they in turn can nourish and sustain. Thanatos not Eros. Death not Life. That is one of the hoped for outcomes of counselling. that my patients who are in thrall to Thanatos can change. They can develop a relationship with a living god. It takes time but it is a pleasure to watch when it happens.blake

Counselling, Psychotherapy, Reflective Practice, The Inner World, The unconscious, Uncategorized, Ways of Being

Prayer after birth

The analyst Mike Eigen wrote “The ‘ I know who I am’ moment’ can, at times, be more destructive than doubt or confusion.” (The Analytic mystic) Those people who come to see me with ready-made life stories are often those who find  therapy the most difficult. The patient who comes in and says “My life is a mess. I’m a mess. What can you do?” is already some way along the road to insight and help. The patient who presents me with their “Happy Ever After” picture book is more difficult because they have chosen this story with good reason. I have yet to meet a patient who tells me this story who hasn’t, in fact, had a thoroughly miserable childhood and adulthood. They tell this story to protect themselves from the pain of what they did experience. (This is not say that all my patients bring stories of appalling abuse. They don’t. But many of them bring stories of neglect. Of unreasonable expectations. Of gross unfairness. Sometimes these “abuses” were intentional. Sometimes not. It doesn’t much matter. Their impact is felt across the years and is expressed in bad marriages; in unhappy relationships; in an inability to be genuinely intimate.) They bring their own Prayer after birth. It is a prayer they would like to have been answered-by someone. The pain comes with the acknowledgement  that those who could or should have heard their prayer couldn’t or wouldn’t respond. Thus their adult life is spent setting up repeating situations where their prayer remains unanswered. As a counsellor it is painful to point out what it is they are doing. (It’s not a route to popularity!)

It is never possible, I realise, to predict who will stay and who will go in therapy. Those whom I was certain were committed to me and the work often are those who leave most unexpectedly. Money is the most common reason given. “I’ve had to move house; buy a car; get married; get divorced… so I can’t afford to carry on seeing you. I’m sorry but …” These are the people, mostly, who find the work too difficult. The story they have told themselves is too important to have it challenged in therapy.The fear is that all that will be left is a huge void.(That is why the most valuable part of a therapist’s training is their own therapy.If I have never looked at my own resistances ,my own “No go” zones, I will be unable to help my patients work through their difficulties.)

So, where does Eigen’s quote take us? I think it takes us to a place where we need to find courage. It is a difficult process, this thing we call therapy. It upsets many of our ideas about our selves and our world. It can challenge our assumption that “I know who I am”. It invites us to be seen and to stay with that being seen.It also allows us to consider our prayers – before and after birth.

The link is, of course, to a reading of Louis Mc. Neice’s poem.