Borderline States, Counselling, Dreams, Hope, Mindfullness, Narratives, Psychoanalysis, Psychosis, Psychotherapy, Reflective Practice, Religion, Spirituality, The Inner World, The unconscious, Ways of Being

From certainty to certainty

Paul Tillich in his sermon Faith and Uncertainty comments “When we have left behind all objective probabilities about God and the Christ, and all subjective approximations to God and the Christ, when all preliminary certainties have disappeared , the ultimate certainty may appear to us. And in this certainty, although never secure and never without temptation, we may walk from certainty to certainty.”  (The New Being 1956)

Tillich’s sermon seems to me to be addressing the issue of containment. Something that as a therapist, is an integral part of my work. There are various “techniques” that help containment. Fixed appointment times, the same room, the same length of session time. All these help but what is central is that as a therapist one is consistent-both internally and externally. The external world can change a little without ill effect. But if who one is as a therapist changes, then the containment is threatened. But containment needs some flexibility if it is not to become a strait jacket. (The word “containment” has its roots in the idea of stretchiness or flexibility.) Tillich uses the word “certainty” which must  also allow for some flexibility. We’ve all met the fundamentalist of any shade or opinion whose certainty becomes a strait jacket rather than something more giving and flexible.

In my clinical practice 95% of my work focuses on containment. Or lack of it. (Or at lease a containment that somehow did not provide the balance between flexibility and fixedness.) The parent who was an alcoholic. Or the parent whom work was the all important aspect of their life. The mother who was terrified of her own sexuality and attempted to repress it in her children. The list is long. The mother who had an anxious mother and who herself passes on anxiety to her children. The list is long but all have in common a lack of holding or containing.

Compare these two images. Both show containment but done in such different ways. One restrictive and restraining, The other flexible and attentive.

Tillich suggests that we may have to let go of all our subjective and preliminary certainties in order that ultimate certainty may appear. It holds true for parenting. My mother was a Spock mother who read Spock as if he were the bible. She followed his advice religiously. My mother-in law also read Spock and found his advice useful, but found his assertion that, “Mother knows best. Trust your instincts.”  much more helpful and liberating. From here she could move from certainty to certainty- albeit never entirely without doubts and temptations.The same is true in clinical practice. I can say something important about what is happening in the room between me and my patient. But it is always tentative and equivocal. Which is the paradox at the centre of Tillich’s assertion that In order to find ultimate certainty we have to let go of many to our other cherished certainties. In T.S.Eliot’s words,”We shall not cease from exploration. And the end of all our exploring will be to arrive where we started and know the place for the first time.

This is what good containment offers us. “The chance to drive where we started and know the place for the very first time.”

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Counselling, Dreams, Hope, Madness, Narratives, Psychoanalysis, Psychosis, Psychotherapy, Reflective Practice, Religion, Spirituality, The Inner World, The unconscious, Ways of Being

Who are we?

W all love stories. We live in them and through them. Being Robin Hood or the Sleeping Beauty or Heidi.  That’s one of the reasons I enjoy a good radio play. It has better pictures, as somebody observed. Cinema is excellent-so long as I don’t know the story on which a film is based. Then I get cross because the director’s picture of a character is always at odds with mine!

In his book The Amber Spyglass,  Philip Pullman wrote,  “Tell them stories. They need the truth. You must tell them true stories, and everything will be well, just tell them stories.”  A true story was the means by which those in Sheol – (or its “Dark Materials” equivalent) — found their freedom. So many things and people shape the stories we tell ourselves about ourselves. Are we seen as  clever? Or sexy? Or stupid? Are we a “Good” boy or girl? Being “Good” can be quite a curse. I’m never able to be “Bad”. Or my “Badness” is felt to be unspeakably awful and shameful. Thus creating a self censoring super ego that rarely gives me a minute’s peace. (The same is true of “Bad” people. Even terrorists go home at the end of day and play with their children!

Niall Williams writes, “We are our stories. We tell them to stay alive or to keep alive those who only live now in the telling.” History of the Rain . We choose what stories to tell. When I was training to be a psychiatric nurse, I made a point of only telling funny anecdotes about my work. I rarely shared the darkness the so often haunts psychiatric patients. (Imagine spending all day, ever day with voices that only you can hear. Taking to you. Commenting on your actions. Telling you how worthless you are. Telling you to go and kill yourself. Or kill others. These are not the stories that are easily told. Or easily heard. There is a cost in hearing these stories.We might wonder, with Williams, who or what we are keeping alive here.)

So, stories. As a counsellor I spend much of my time hearing people’s stories. Frequently we start with a “What an awful person I am.” Over time it becomes possible to think about the origin of this story. “Well, my husband tells me I’m…” Or “My wife thinks I’m …”  Then we can challenge some o these  stories. I’ll sometimes ask something like “Well, are you lazy?”Or “Is it the case that you never help with the childcare?” Most times my patient reflects that,”No. That’s not entirely true.”

It takes courage to change our story. My story, after all, is Me. That’s who I am. Isn’t it? As part of my training as  a counsellor, I had my own analysis.(There were so many stories to tell! But that, as they say, is another story!) My wife was terrified. Terrified the I’d uncover a different story about her. One that ended with my discovering that I didn’t love her. After 30 years of marriage it is apparent that there was no other story. I loved her then as I do now. And will continue to do because that’s my true story. Which sets me free. And that is one way of understanding my work as a counsellor.To help people tell their stories. To listen to the telling. And to reflect on my experience of that story. My patients are always free to do with my listening as they wish. That is my blessing and my curse as a listener.

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Counselling, Dreams, Hope, Psychoanalysis, Psychosis, Psychotherapy, Reflective Practice, Religion, The Inner World, The unconscious, Ways of Being

Pain Management

Pain Management

I lay no claim to any particular skills in pain management. My experience has been of the past three months. In November 2017 I had planned surgery for a total knee replacement. I think I underestimated how difficult I would find it. There was the constant pain. Day and Night. I couldn’t find an effective pain killer. Then the inconvenience of not being able to drive. Or, much more of a loss, not being able to cycle anywhere. I became used to taxis for the shortest journey. The loss of independence was not something I managed well. At the time of writing it feels that I might be getting better. The pain is diminishing and I can drive- a mixed blessing!

The writer Henri Nouwen said “When we honestly ask ourselves which person in our lives means the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand.”

I was talking with one of my patients recently about what it means to be human. How did he know, he mused, that I wasn’t a robot programmed to respond in an appropriate way to his conversation. I don’t think I’m a robot but his question was interesting. My thinking is that whilst I try to respond empathically, I also try to link unconscious materials and make links between the past and the present. I also will bring the focus onto myself using my experience of my patient to think about how our relationship might reflect their other relationships. I like to think this is beyond a robot’s abilities.A large part of the work of therapy is achieved in the relationship between the therapist and their patient. if this is a good match, then risks can be taken; challenges made and help offered.

Nouwen talks about the value of feeling cared about( of knowing that one is valued. This is at the heart of all healthy relationships- including that of counsellor and patient. ( This is one difference between seeing me or answering an on line CBT questionnaire!)

So, what can I learn from my past months of pain? One lesson has been the value of feeling loved and cared for by my wife. And a great deal of sympathetic support from my friends. I also came to learn to appreciate and recognise the good things I have Inside me. My pain has not, mostly, been too awful physically. Emotionally it has been difficult at times.)I would not do well if I were seriously disabled.)

As a counsellor I see people who are in emotional pain due to any number of causes often beginning in childhood. My work here is to help them find a way of talking about things that have long been buried. For most of my patients this is a slow process. They begin with a sadrightforwad narrative about their life. “I’m married. I have 2 children. My husband loves me. So why do I feel so lonely all the time?” Another story is “My wife and i are separated at the moment. I love her to bits and our kids. i couldn’t bear it if anything happened to them. But i have problems with anger. A red mist comes down and i’ll lash out at anyone. The wife. The kids. It doesn’t matter who. She says she’s not coming back. i don’t blame her. But i miss her.” Tears often follow this introduction. From here we walk together quietly and carefully, trying to see the underlying story. An anxious and depressed mother and Grandmother so often leave the next generation as damaged as themselves. Violent father’s who “don’t take “no shit from no-one”all too often produce sons who have never learned how to expired need .Or vulnerability. So they lash out. With awful consequences. Then the work goes on and we talk about self worth. About allowing oneself to be vulnerable. i point out the ways in which they are taking a huge risk by coming to see me! And add that, so far, the risk has paid off. That in my room, they are seen and acknowledged in their own right as Persons.
So, just as being hugged, loved and held can help with physical pain so the same process can help with the healing of emotional paiPain Management

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Counselling, Mindfullness, Narratives, Psychoanalysis, Psychosis, Psychotherapy, Reflective Practice, Religion, Spirituality, The Inner World, Ways of Being

3D Jigsaw

I was talking to somebody recently and trying to describe my counselling work. “It’s a bit like ‘Hide and Seek'” I suggested. Or, at times, like ‘Russian Roulette’. Other times it can feel like ‘Pin the tail on the Donkey'”My friend looked a bit puzzled. I tried for another analogy.”It’s a bit like trying to build a 3D jigsaw. You have  to find a way to keep all the pieces intact whilst trying to build new things onto it.”I wanted to sound clever and quote Freud’s maxims “Where id was, shall ego be.” And that the aim of therapy is to make conscious the unconscious but I wasn’t sure this would help much. “It’s a complicated process that we try to make look simple.” I said. How to explain ideas like Transference and Counter Transference; Splitting; The Paranoid- Schizoid position; Projective Identification and so on. It took me years to get to grips with them ( and I still am)! But despite the complexity of my answer, it was a very good question. What does happen in the counselling room? How does one describe a task so simple and yet so complex?

At its simplest, counselling is all about a relationship. I see my counsellor and we talk to each other. And, hopefully, hear each other. (Not always guaranteed by either side.) Within that framework I then build a picture of my patients’ inner world. Of their early life, their childhood, school, university, work, relationships and so on. I look for the repeating patterns. This week my patient’s world is wonderful and ever more shall be! I remind them that two weeks ago they were suicidally angry and had decided to join a silent order of Buddhist nuns.”Oh! Yes, But that was then. Things  are better now.” My task is to hold both past and present, making a connection between them to help my patient make their own connections. (This is Freud’s “making conscious the unconscious.”) I might then wonder what my patient’s early life had been like. How did his parents relate to each other and to their children? I half know the answer but want to help my patient see their own presenting past ( the past being re enacted in the present). Plus I want to know for myself and my work if my musing is accurate. The idea of therapy is that the model fits the patient. Not the other way round. In this case, my patient came from a home where “today was always a new beginning”,which is less positive than it sounds. “Those who forget their past are doomed to repeat it.” as the philosopher George Santayana put it.

So in this conversation between therapist and patient, all manner of strands are being weaved together. Or, a 3D map of their world is being carefully and jointly built.

 

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Counselling, Dragons, Dreams, Hope, Madness, Narratives, Psychosis, Reflective Practice, Religion, Spirituality, The Inner World, The unconscious, Ways of Being

Containment 1

I’ve just had a short stay in hospital for knee replacement surgery. It’s  a disconcertingly quick process, once you’re admitted. I was admitted on Thursday and discharged home by the Sunday. Out with the old and in with the new. Literally. This was my third hospital visit over several years and the first one that was planned. The previous two had been crisis admissions. I don’t do well as a  patient – particularly as one who has been a nurse for most of his professional life. My overall recollection of my two previous admissions was of a gap between “hard” medical skills and the “soft” nursing ones. Between  the “male” skills of surgery and the “female” roles of nursing. I remember one nurse observing of me (to me) that “we’re all ill in our own way.” She was right. I’m not good as a patient. I’m far too impatient and independently minded. I hate being stuck in bed. I fear a loss of autonomy. My defence against existential anxiety is to become difficult and demanding. It’s a way of reminding myself – and everyone else –  that I will deal with this situation in my own terms. And if those terms don’t accord with your terms, well, so be it. Which means I’m never going to be “that nice man in bed 12”.

This admission was a markedly better experience. In part because I’d had a lot of time to prepare myself. I had a list of coping strategies. Chief of which was “Be nice to the nurses”! I was and it paid off. I could relax and allow myself to be cared for. Which created a virtuous therapeutic circle. I was content and contained.

The image at the top of this blog gave me a lot to think about. I Googled “Containment” expecting to find images of holding. A mother feeding her baby. A parent and child walking hand in hand.  Holding and held.  Instead I found a number of images like the one I chose. I thought about using another gentler image but opted to stay with the violent image that Google gave me. I wondered why? Partly on the basis of my two previous admissions. Partly on my own experience of being in analysis and also of my clinical work as a nurse and a therapist.

Psychiatric nurses don’t get many boxes of chocolates from grateful patients. In 25 years I got one box! I was reminded of this when I left Papworth hospital. I dutifully brought a box of chocolates. “Oh. Chocolates. How nice.” was the distinctly lackluster response. “I’ll put them with the rest.” It was a fair response. I was expressing my hate not my love.

“Damn”, I thought, “nice Adult nurses always get nice chocolates from grateful patients.” In  Mental Health this was not the way of things. We didn’t get “nice” patients nor did we expect to be “nice”. We expected to keep our patients safe. If that meant restraining them and forcibly medicating them, well then that was what we did. We contained them.

My two previous admissions highlighted this difference. The nurses expected to be liked. Why wouldn’t they? They were there to make us better and we were supposed to be suitably appreciative. So why wasn’t I being appreciative? I was being well looked after. My medication arrived on time and when I needed it. I was constantly monitored by a machine that bleeped if I even sneezed. I had drains, catheters, fluids and drips. All conspiring to keep me alive. So why my ingratitude? Mostly because I wasn’t contained. Nobody was asking me how I felt about having nearly died. Nobody asked me why I wasn’t eating or drinking enough. I was simply put on a fluid balance chart.

So the picture above sums up my first two experiences, My rage, fear, hatred couldn’t be borne. So I felt gagged. And murderously angry. Which I evidently conveyed. Powerfully.

 

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

Emotional etymology

I realise how often I will look up a word’s etymology when writing a blog. It seems a way in which I can ground my thoughts and my writing. A literary “ground of my Being”. It gives me a sense of starting from somewhere honest, which is the original sense of the word “etymology”. It has to do with true meanings. But words don’t remain static. Thankfully. They “slip, slide, won’t stay still” to quote Eliot. ( A friend wrote a brave and fascinating piece on the word “cunt” I’m not sure I would have been as brave!) My thoughts then wondered off to my clinical work and the idea of clinical etymology i.e. what are the origins of this symptom, idea, fantasy etc.  (Freud’s essay on The Rat Man is a classic example of the beginning of a symptom and the ways in which these symptoms changed over time. It is also an exploration of the creative uses to which we put our symptoms. It is also quite opaque at times with Freud making extraordinary jumps of understanding and interpretation. But why should this be a surprise? If language is full of hidden histories, how much more so our unconscious lives?)

To take this idea a little further, we can follow Lacan in suggesting that the unconscious  is  structured as a language. Which might give us access to wondering about what part of speech any given symptom m might equate to. Thus a symptom may serve several functions. It might work as a noun, having a naming function which also serves as a limiter i.e. it is this thing, not that thing. It is depression, not anger. A symptom may also  be a verb. a doing word i.e. I”do” psychosis. It is an active process that needs a subject and an object to fully make sense. (Which is why whenever we take a clinical history, we try to put a symptom into a context. When did this symptom first begin? How do you use it? There is really no such thing as an isolated symptom .Somewhere in the unconscious we will find the rest of its family.

And like any good piece of writing, I’m now struggling to find a satisfying way of ending my blog. I think M.Scott Peck sums it up beautifully when he writes, in The Road Less Travelled “The fact of the matter is that our unconscious is wiser than we are about everything.”

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Hope, Madness, Narratives, Psychoanalysis, Psychosis, Religion, Schizophrenia, The Inner World, The unconscious, Ways of Being

The enemy within?

Like so many others I’ve watched with concern Donald Trump’s attempt to ban certain groups from entering America. His argument is that they are  a threat to national security. I suspect that America is quite capable of producing home-grown terrorists without importing them. Psychologically his attitude is fascinating – albeit dangerous.

 

In psychoanalysis there is the idea of two states of mind in which we live. Technically called the paranoid-schizoid position and the depressive position. In the paranoid-schizoid position the infant has two mummies. The good mummy who comes when called, feeds me when I’m hungry, changes me when I’m wet and so on. I love this mummy.  Then there is the bad mummy. She leaves me too long, does not instantly respond to my needs and so forth. I hate this mummy. Eventually the child comes to recognise that the two mummies are one person. The bad mother is also the good mother. And vice versa. The child is faced with a problem. How to live with its responses to this mother. How do I reconcile my love of the good mother with my hatred of the bad one? What does this say about me? I have to live with my capacity for hatred as much as I live with my capacity for love. (R.D.Laing explored this tension brilliantly in his book “Knots”.) It is the problem Juliet faces in Romeo and Juliet when she falls in love with Romeo and laments that her only love has sprung from here only hate. Bringing these two positions together is what we call the depressive position. It takes courage to live in this place.

I think we are seeing something similar being played out with the rise of far Right political groups. The enemy is the immigrant who is taking our jobs, stealing our benefits and generally being parasitical. We then go to our hospital and are grateful to the Pakistani doctor who cares for us. The African   nurses who look after us. The Chinese Radiographer who scans our bones. These are good people! The bad ones are the other kind. (Whoever they may be.)

We separate good “mothers” from “bad” ones. Why? Because to recognise the split within ourselves would be too painful. We would be forced to acknowledge our own ambivalences. We see this splitting off in men who murder prostitutes. In women who will allow a dangerous partner to look after her children. In the killing of gay men by straight men who fear what they desire.And in the psychotic states of mind like schizophrenia where the denied part is heard as voices which can be disowned.)

It seems to me that this is Donald Trump’s agenda. In banning Muslims from coming to America he is attempting to banish split off parts of his psyche. And that of a segment of America. He can hate the poor, the needy , the vulnerable. In much the same way as some religious groups demand “modesty” from women. (If I lust after  a woman’s body, why is it that this is the woman’s fault? Why should she wear a burka and cover up all but her eyes? Why should some christian groups demand that wives are submissive in all things to their husbands?) In Trump’s terms, we might wonder what parts of himself he is putting into the poor etc-from whichever country they come. I suspect from his bombast that he cannot tolerate his own needy parts. His narcissism stemming from a profound insecurity. What makes him dangerous is, of course, that he has mobilised a part of America that feels dispossessed and unloved. Perhaps with some justification.  Brexit in the UK seems to me to demonstrate something similar.

As a counsellor, I have some idea about how I might work with a patient exhibiting these attitudes. Where does the hatred come from? What triggers the fearful self loathing? I would hope that, over time, we would build a strong enough relationship for my patient to let go of some of their fears. To come to a place where they could grow some self-love and nurture the parts of themselves that they so despise. (The despising coming from a fear of vulnerability and neediness)

But I am not a politician. Trump is not my patient. Nor are the Brexiteers.  Perhaps it is time for the clinicians and politicians to sit round the table together and share some insights. Then we could move the social narrative on from a split, paranoid-schizoid position to a more integrtated depressive position.

 

internal-conflict

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