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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Borderline States, Counselling, Dragons, Dreams, Narratives, Reflective Practice, Religion, Spirituality, The Inner World, The unconscious, Ways of Being

Principalities and Powers

Saint Paul wrote that we wrestle not against flesh and blood but against principalities and powers,

This seems to be one way of thinking about the way values seem to get embedded. Whenever I assess a man for Anger Management there will be generations of men behind him sharing their values and instilling in him a view of how men behave and conduct themselves. Usually these values include emotional and physical abuse as a way of enforcing a power structure. These men then grow up with a view of themselves as needing to be ” hard”. Hard on their children and hard on their wives. Sometimes the control is physical, sometimes emotional. But always about control.

Similarly when I assess a woman who has come for help with anxiety or depression, there will be mothers and grandmothers who instil a view of a woman’s place and function. This will be that they are there primarily to serve their husband or children. ( To serve. Not to complement or share, but to serve. As one patient put it, her task was to help her husband become the man she saw that he could be!)

Saint Paul understood his battle to be with the spiritual forces that he thought lay behind everyday life and society. He saw these values as demonic and anti Life..

Looking at the Brexit decision, I’m almost inclined to follow him.

In broad terms, he had a point. Violence, rage, crippling anxiety and depression are anti Life. Which might be one way of characterising the demonic. That which is anti Life. Which begs the question of “Why?” Why does a man come to believe that violence is the only way to live? Where does he decide that hitting his wife and children are good ways to live?

Where does a woman decide that her task is to sacrifice all for her husband/ father/ family?

It seems that there is an alternative value system that ensnares us in its thinking. I recognise it in myself. My wife works full time in a job that she enjoys and which is demanding. I’m retired and work fewer hours. But if we run out of something at home, my all too frequent reaction is ” Why hasn’t Jenny done the shopping?” (I do try to remind myself that I am quite capable of going shopping.) And I consider myself to be a modern man. Some values run deep!

So how to understand the principalities and powers at work here? Much of the difficulty seems to stem from a sense of insecurity. I’ve yet to meet a man for whom Anger was a problem who was able to value himself very much. In all the men I’ve worked with, there was an underlying sense of low self worth. ” I’m just thick. I’m only fit to be a navvy” is how several of my men have put it. And even on the building sites, there’s no respite. Any comment on their work, justified or otherwise, is experienced as criticism. Any criticism wipes out their entire being, confirming their view that they are indeed ” only fit to be a fucking navvy.” Take this away and it’s hardly surprising that violence erupts in some form. If my self esteem is so fragile, then anyone or anything that threatens that will be met with an extreme response.

With depressed and anxious women self esteem also seems to be involved but in more subtle ways. We know how misogynistic our society can be. A woman’s place is still in the home. No matter how many important decisions she makes at work, a woman can still be undone if she forgets the milk! ( I wonder who does the shopping for Theresa May? I remember David Cameron shopping in Aylesbury. A large, black SUV parked illegally at the top of our street. No parking ticket was issued! His bodyguards got out first, followed by Cameron as he did a bit of shopping in Aylesbury. An everyday trip to the shops such as we all do.)

Women still see themselves as being subservient to men. The patient who told me she saw her task as helping her husband to be the man she thought he could be, was expressing a maxim from her mother and grandmother- which is usually as far back as records go. In this case all three generations had seen their marriages fail as the men they had chosen turned out to have agendas that didn’t match those of their wives. In each case the present generation managed to instil the message ” Do as I say and ignore what you see.” with no good outcomes.

We seem to be back to principalities and powers. Of powerful unseen forces shaping successive generations and influencing behaviour and values. Perhaps one way of characterising the work of the therapist is that we speak Truth to Power.

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

Containment 3

Two people suggested that the last two blogs about containment needed a third one to bring them together. This is an attempt doing that. Years ago we used to sing a lovely hymn, “Brother, let me be your servant” it ran thus

“Brother, let me be your servant

Let me be as Christ to you…

I will hold the Christ light for you

In the night-time of your fear.”

It was usually sung for someone who was finding life particularly difficult or painful. A kind of lullaby between the singers and the soothed. It offered a promise of containment. “We can’t take away your pain, but we will do our best not to leave you alone with it.” (A lovely thought albeit one that cannot be totally fulfilled. At some point we are all left alone in the night-time of our fear.) The most we can hope is that the night-time doesn’t last too long. And that somebody is there with us in the morning.

Effective containment is a balance. The child who is frightened of the monster under the bed can only share its parents’ bed for so long. At some point the child has to go back and look under the bed and face the monster. That way they learn to self care. Then, when the next child is scared the monster, they can comfort them.

I remember doing a role play in a workshop. I was playing a husband whose wife of 40 years had just been told that she had six months to live. The other participant was being a counsellor. They listened to me as I expressed my grief, my fury, my fear.  Nodded and made empathic noises. Then said “I understand how you feel.” At this point I nearly had to be forcibly restrained. How could this counsellor who was at least 30 years my junior begin to understand? How dare she have the temerity to say that to me? What did she know of grief, or loss, or suffering? Whether I was in role or out of it, I was furious. She looked ashen, having suffered an unexpected emotional mugging.  What she needed to have done was to demonstrate that she understood. And to show me what it was that she understood. So “You must be feeling very frightened right now” might have helped.  Or even “How are you both feeling at the moment?” I make a point of never telling my patients “I understand.” Because I probably don’t! I’ll ask how they feel. I’ll suggest how I think they’re feeling. I’ll ask “How does that make you feel?” But I won’t tell them I understand.

How does this relate to the previous pieces? My hope is that it highlights that good containment holds both the Light and the Darkness. The Love and the Hate.  When I was lecturing I worried about those students who were devoutly Evangelical. I interviewed one candidate, asking her for her responses to being threatened, verbally abused and generally intimated by a patient who might be severely psychotic. Her response “I’d let the love of Jesus flow into him” worried me. Here was someone who was unable to know her own hatred. This put her at risk. And her colleagues. We did not offer her a place.

I previously quoted Isaiah 45:7 “I form the light and create darkness: I make peace and create evil: I the Lord do all these things.” Containment allows these two to live together and be acknowledged equally. The psychoanalyst, Donald Winnicott wrote “What is a normal child like? Does he just eat and grow and smile sweetly? No, that is not what he is like. The normal chid, if he has confidence in mother and father, pulls out all the stops. In the course of time, he tries out his power to disrupt, to destroy, to frighten, to wear down, to waste, to wangle and to appropriate… At the start he absolutely needs to live in a circle of love and strength if he is not to be too fearful of his own thoughts and… imaginings…”  (Winnicott, Deprivation and Delinquency)

This is containment. This is care. This is nurture. The rest is just nonsense.

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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, Dreams, Hope, Narratives, Reflective Practice, Religion, Spirituality, The Inner World, The unconscious, Ways of Being

Cathedrals

 

I came across this comment by the Anglican mystic Evelyn Underhill. She is writing about beauty:

“So, too, all who are sensitive to beauty know the almost agonising sense of revelation its sudden impact brings – the abrupt disclosure of the  mountain summit, the wild cherry tree in blossom, the crowning moment of a great concerto, witnessing to another beauty beyond sense… when we take it seriously, it suggests that we are essentially spiritual as well as natural creatures.” (The Spiritual Life)

I find myself uncomfortable with this idea. I acknowledge the sense of the numinous that we meet at times and places. I remember being moved to tears the first time I saw Rodin’s sculpture of the Prodigal Son. But what moved me was its humanity. Nothing to do with the Divine. I can listen to a great concerto, see a moving play, look at a landscape and be  moved. And be challenged to think about my life, its purpose and meaning. But I do not necessarily intuit the Divine in this.

Speaking of religion, Freud noted that:

“The psychoanalysis of individual human beings, however, teaches us with quite special insistence that the God of each of them is formed in the likeness of his father, that his personal relation to God depends on his relation to his father in the flesh and oscillates and changes along with that relation, and that at bottom God is nothing other than an exalted father.”

I find Underhill’s view one that demeans humanity and our creativity. I dislike the gothic cathedrals that, in my experience, seek to dominate man and propagate a view that reduces us to nothingness in the face of the grandeur of the Divine. I have no wish to be involved with a God who subjugates humanity. Following Freud, one has to wonder at the forces and influences that shaped the  inner world of the architects of the buildings. Robert Louis Stevenson wrote  “I never weary of great churches. It is my favourite kind of mountain scenery. Mankind was never so happily inspired as when it made a cathedral.”    For the most part I disagree.  There are cathedrals that inspire. Liverpool’s Catholic cathedral is one. Its light, its space and potential offer me a feeling of celebration and creativity. I always  want to dance when I’m there. Gaudi’s cathedral in Barcelona has a similar impact.

My point here is not to criticise gothic cathedrals per se. Coleridge saw them as “infinity made imaginable”. Perhaps he was right. For me, I prefer the image of an exalted father to be one of a father who can sing and dance with his children and teach them to celebrate life. I do not want to exalt a father who is remote, distant and intimidating.

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Counselling, Dreams, Hope, Mindfullness, Narratives, Psychoanalysis, Psychotherapy, Reflective Practice, Religion, The Inner World, Ways of Being

Winnie the Pooh

This is a piece about Winnie the Pooh who lived in the 100 Acre Wood where he had lots of friends.: Christopher Robin, Owl, Tigger, Piglet, Eeyore. Kanga and Rabbit. (Have I forgotten anybody?) When they got in a muddle he helped them out and when he got in a muddle, they helped him out. And he needed his friends just as much as they needed him. Which is how all good friendships work.

I want to spend some time getting to know this group of friends and see what we can make of them. Starting with where they live would be a good idea. The psychoanalyst Donald Winnicott observed that “home is where we start from.” So, home for this group is the 100 acre wood. Woods are important places. They represent stability and protection. We all love walking through woods.

But there is also a darker side to woods. Things are killed in woods. Owls, foxes and badgers kill other creatures in order to survive. Along with “All things bright and beautiful” nature is also “red in tooth and claw.” The 100 acre wood will have been no different. And whilst nobody physically dies in Winnie the Pooh, the emotions are there. A depressive Eeyore has to live with the manic Tigger. The young and feckless Roo has to live alongside the elder statesman Owl. As with any family, conflict was unavoidable, and necessary. Much as Tigger would have exasperated Eeyore, the former’s optimism would have offered Eeyore the possibility of Hope. Reciprocally we might think that Tigger could learn that quietness need not always be feared. So the home of 100 Acre Wood was a containing place that could hold both light and shadow. Which is probably as good a definition of “home” as we will come across.

Having looked at the context for the story, it might be interesting to look at some of the characters. My own favourite is the lugubrious Eeyore. He isn’t going to be fooled into thinking that everything is automatically and necessarily going to work out well. This way he can’t be hurt when people let him down. In one of the stories, his house is blown away. He always knew this would happen. Didn’t it always? Yet despite himself, his friends always help him out. Most infuriating. It is as if someone had offered Diogenes a proper home.

Then comes Tigger, ostensibly Eeyore’s polar opposite. Tigger always seems to land on his feet- all four at once. And just as often treads on someone else’s feet in the process. At first sight, he has nothing in common with Eeyore. On a close look, however, he uses bouncing in the same way that Eeyore uses melancholia. Tigger just uses a manic defence to keep at bay his existential anxieties. They are much more alike than either of them might want to admit!

At this point it is worth considering the 100 Acre Wood so that it tells us something about ourselves. “To make conscious the unconscious” as Freud put it. We all have our Tigger moments and our Eeyore moments. We also have our Piglet moments and so on. Depending on many factors we will all have a dominant personality trait. We may be more prone to an Eeyorish depression; a Tiggerish mania or a Rooish dependency. The process of emotional growth is the work of integrating these parts of ourselves in the same way that families have to accommodate children with their differences but who are still part of one family – hard though that is to comprehend at times!

To finish I want to suggest that all these characters reflect Christopher Robin’s inner world. And these in turn all reflect A. A. Milne’s inner world, and ours. In psychoanalytic language they are internal objects and part objects. Or “bits of ourselves” to put it more colloquially. So, when we read Winnie the Pooh we are reading both backwards and forwards. We are reading “forwards” in that we can look at the inner worlds of the characters in the stories. how they relate to each other, their world, themselves. Then we can look “backwards” to Christopher Robin and his world. Then we can look at the world of A. A. Milne and his hopes and dreams. Which begins to make a complex picture seemingly a long way from the simplicity of the 100 Acre Wood. Yet as counsellors and therapists we do this work all the time. Our patients bring themselves to therapy. But they also bring their partners, children, work, friends etc., as well as their relationship with us and all that represents. It is a sort of 3D chess game. It is this dynamic that makes the work so rich and rewarding. Mostly! (Occasionally also deeply frustrating and confusing.)

Let me leave the last word to Winnie the Pooh who would have made a very good therapist. He observed “I am not lost for I know where I am. But, however, where I am may be lost”.

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