Avoiding Advice

Something I’ve been struggling with in my Psychological Wellbeing Practitioner training and clinical work so far is that we are told that the ‘therapy is in the materials’ rather than in ourselves as clinicians. Our role is to guide our clients through self-help material that is appropriate to their psychological distress, and help them to problem-solve any difficulties that they might have along the way. Rightfully, due to our lack of training in delivering any kind of therapy proper, we are told to concentrate on the CBT-based tools and techniques that we are supposed to be imparting to our clients. It is (also rightfully) emphasised to us that the focus should be on ‘collaboration’ rather than any kind of didacticism in our delivery.

However, it feels that by focusing so much on the content and tools that we are providing our clients with, I too easily slip into ‘offering advice’, which I think is usually so antithetical to any kind of meaningful therapeutic intervention! I really do try not to do it, but find myself on occasion saying, ‘What about trying this…’, when discussing how to change a sleep routine, for example. (I feel no temptation to offer any more significant life advice, thank god). One way around this that our supervisors have recommended is to ask questions based on the materials/information you’ve given your client, for example, ‘Why do you think I asked you to read that Booklet?’, ‘Can you explain to me the rationale behind Behavioural Activation?’. But I think those questions can be useful to check or consolidate learning, rather than genuinely encouraging the client to arrive at their own conclusions and answers…

I think this is related to my major qualm with CBT-based approaches in general, the fact that though they profess themselves to be less hierarchical than psychoanalytic or psychodynamic approaches are seen to be (in that old-fashioned idea of psychoanalyst having all the answers but remaining silent), they can end up being more unequal in power dynamics. In the psychoanalytic approach, regardless of whether the analyst thinks she has all the answers, she at least gives the patient space to think things through in their own way, following their own patterns of thought, rather than shoving tips and tricks down their throat in a limited number of sessions. The CBT clinician can end up asking patronising questions (like those above, ‘Can you confirm that you’ve understood all the information I have imparted to you today?’), rather than genuinely engaging with the client’s way of understanding the world, and taking it on its own terms. The CBT clinician is Wise Teacher, who benevolently takes on board the patient’s particular life circumstances to adapt the techniques to them, but nevertheless remains the one with all the information the client needs to live a better life. I guess these power dynamics risk becoming problematic in all kinds of therapies, because essentially, the client is coming to a trained ‘expert’ for help. But I think it’s important that we remind ourselves of the pitfalls of this kind of imbalance as often as possible, and do everything we can to stop offering advice. I’m mainly speaking to myself here.

Book Review: ‘Man’s Search for Meaning’ by Viktor Frankl

This book is divided into two parts. The first part is an autobiographical account of Viktor Frankl’s time in concentration camps during the second World War, and the second part is a more academic exposition of the type of psychotherapy that he created, Logotherapy.

He begins the book with an admission that ‘This book does not claim to be an account of the facts’, which is an interesting start, given that I think most people opening a book about the Holocaust are going into it prepared to be smacked in the face with some cold hard truths, and (hopefully) a willingness to take the survivors’ at their word. My comment isn’t to suggest that Frankl is painting a fictional picture, but he is reminding us that even factual accounts of events, especially those involving immense suffering, will always be shot through with the strong emotions colouring a first-person account. Which makes it then all the more surprising, and initially disorienting, to find in the pages that follow an absence of emotion, to the point where it can feel quite like watching a scientist observing the facts. This is soon explained however, when Frankl writes that: ‘Cold curiosity predominated in even in Auschwitz, somehow detaching the mind from its surroundings, which came to be regarded with a kind of objectivity’ (29). He describes this as a self-preservation mechanism, and we come closer to understanding just what happens at the limit of human cruelty and suffering experienced in concentration camps all over the world.

What the book goes on to teach us, is that positive transformation can be achieved even through the most horrendous experiences of suffering. This is a hard idea to take. Our immediate reaction might be to reject that kind of inhumane suffering forthright as an absolute evil (which it is), but what Frankl pushes us to confront is the possibility that so long as someone is still alive, there is still hope. Something can be made of the situation, even if it is only a kind of ‘spiritual’ and inner transformation. And what he wants us to take from that fact, those of us so far from having any comparable kind of experience of hardship, is that our experiences of difficulty can also be transformed into something meaningful and positive. This is another surprising move of the book – as we might feel uncomfortable trying to place the two different kinds of suffering side by side in this way – especially when ours might feel trivial in comparison.

But that is exactly what he asks us to do, to use his experience as something we can learn from to live our lives in more meaningful ways. And this is how we arrive at Part 2, on Logotherapy, which is a therapy designed to help the individual discover, and live by, the unique meaning that they can create for their lives. Frankl explains that there are three different ways we can discover meaning: ‘(1) by creating a work or doing a deed; (2) by experiencing something or encountering someone; and (3) by the attitude we take toward unavoidable suffering’ (155). (Note the importance of the word ‘unavoidable’ to qualify suffering here, Frankl is adamant that self-inflicted suffering is masochism, without the potential for self-actualization). Where logotherapy differs from Freudian psychoanalysis is that according to Logotherapy, ‘man’s search for meaning is the primary motivation in his life and not a “secondary rationalisation” of instinctual drives’ (105), and this has close links with Nietzsche’s idea of the will to power – but Frankl edits the phrase to will to meaning.

The first way we discover meaning, ‘creating a work or doing a deed’, is fairly self-explanatory and well-established, so Frankl doesn’t dwell on it. The second, ‘experiencing something or encountering someone’, Frankl explains by delving into the meaning of love: ‘Love is the only way to grasp another human being in the innermost core of his personality … by his love, the loving person enables the beloved person to actualise these potentialities’ (116). I think it is still an open question as to whether this kind of ‘therapeutic’ love can exist within a psychotherapeutic relationship (my inclination is towards the negative), but that’s something I’ll write about in a future post. It sounds like Frankl is talking predominantly about real-world love experiences here, so maybe he’d agree with me. The third way to find meaning, ‘through suffering,’ is what Part 1 had described for us, as he was somehow able to transform his experience of suffering into something with meaning. However, I would like to tentatively suggest that perhaps point 1 (‘creating a work or doing a deed’) also has a role to play in what enabled Frankl to find meaning through suffering (point 3). From what we learn in the autobiographical part of his book, it seems as though Frankl’s role as a doctor towards the end of his time in the camps was at least partially what helped him survive, both physically and psychologically. At one point, given the chance to escape, Frankl decides to stay in the camp hospital and tend to his dying patients.

I like the idea of life as guided by those three ways of creating meaning: Works and deeds, experiences and relationships, and the strength to try to step back from our suffering to see what good can come of it, even if that might only be an increased ability to empathise.

I’ll finish by sharing some of my favourite quotes from the book:

‘Yes, a man can get used to anything, but do not ask us how.’ (30)

‘An abnormal reaction to an abnormal situation is normal behaviour.’ (32)

‘A thought transfixed me: for the first time in my life I saw the truth as it is set into song by so many poets, proclaimed as the final wisdom by so many thinkers. The truth – that love is the ultimate and highest goal to which man can aspire.’ (49)

‘This intensification of inner life helped the prisoner find a refuge from the emptiness, desolation and spiritual poverty of his experience, by letting him escape into the past.’ (50)

‘Humour was another of the soul’s weapons in the fight for self-preservation. It is well known that humour, more than anything else in the human make-up, can afford an aloofness and an ability to rise above any situation, even if only for a few seconds.’ (54)

‘Suffering completely fills the human soul and conscious mind, no matter whether the suffering is great or little. Therefore the “size” of human suffering is absolutely relative. It also follows that a very trifling thing can cause the greatest of joys.’ (55)

‘No man should judge unless he asks himself in absolute honesty whether in a similar situation he might not have done the same.’ (58)

‘The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity – even under the most difficult circumstances – to add deeper meaning to his life.’ (76)

‘It is a peculiarity of man that he can only live by looking to the future – sub specie aeternitatis.’ (81)

‘Thus it can seem that mental health is based on a certain degree of tension, the tension between what one has already achieved and what one still ought to accomplish […] What man actually needs is not a tensionless state but rather the striving and struggling for a worthwhile goal, a freely chosen task. What he needs is not the discharge or tension at any cost but the call of a potential meaning waiting to be fulfilled by him.’ (110)

Book Review: ‘The Adolescent Psyche’ by Richard Frankel

This book is filled with wisdom, and I think it would be helpful for any mental health professional working with adolescents (regardless of their preferred brand of therapeutic approach) so I’ll attempt to summarise its main points:

The Freudian psychoanalysts were wrong to treat adolescence as primarily a return to infantile id drives/impulses (only with different conflicts against a more strongly developed superego), and instead it should be seen on its own terms, as a distinct developmental period. We should take the transformations of puberty and the tumultuousness of the experience as meaningful in itself, and with its own progressive functions (telos), rather than as some kind of a backward step. And to do this we should use a phenomenological approach, staying close to the actual experiences of adolescents, rather than theoretically hypothesising what we think is happening…

The best starting point for understanding adolescence is seeing it as time of paradox and conflict – the adolescent is pulled in both ways at once: back towards its childhood, but also towards adulthood and the wider social world (beyond the family unit). This paradoxical position, or point of tension, defines what it is like to be an adolescent. Adolescents are both a child and an adult at once, and they are constantly negotiating between the archetypes representing these: the puer (youth) and the senex (older adult). What I think Frankel takes from Donald Winnicott is also the idea that the boldness and bravery of adolescence is something society needs as a creative and refreshing force; we should appreciate their ‘fierce and stubborn morality’ and their way of refusing ‘false solutions’. Winnicott wrote somewhere that ‘Infinite potential is youth’s precious and fleeting possession’. What typically society tends to dislike about adolescence is something that we should rather appreciate and value in itself – ‘Could we imagine that the instinctual turmoil of adolescence creates a special sensitivity and receptivity to the world and that this can manifest in the pleasure with which ideas are entertained, engaged and undertaken?’ (98)

Adolescents in our era have a particularly difficult time also because there are no, or few, community-organised initiatory rites designed to mark the transition period. Primitive societies usually did have some kind of ritual/initiation designed to mark the young person’s entry into the adult world, which meant that it could be a fairly quick and organised process. Frankel quotes Michael Ventura here: ‘Tribal adults didn’t run from this moment in their children as we do; they celebrated it. They would assault their adolescents with, quite literally, holy terror: rituals that had been kept secret from the young till that moment – rituals that focused upon the young all the light and darkness of their tribe’s collective psyche, all its sense of mystery, all its questions, and all the stories told both to contain and answer those questions’ (69). Because these initiatory rites are an ‘archetypal human need’, our adolescents can’t just skip them, but rather must invent a kind of replacement for these community-organised ones on their own, and evidence of their attempts can be seen in youth gang culture, self-mutilation, substance-abuse, and impulsive/risky sexual behaviour.

Frankel offers Jung’s insights as more helpful and relevant to working with adolescents than Freud’s, primarily because Jung sees the self as a ‘self-regulating system’ (5), in contrast to Freud’s Id which is always in need of externally-imposed prohibitory forces. If parents and clinicians of adolescents remember that the best way to stop someone – particularly an adolescent – doing something unhelpful is to speak to with their own ‘inhibitory’ sense, and get them to arrive at the desire not to do it themselves (rather than simply acting as that external prohibitory force), then they’ll be better able to help them.

Final point that I want to share is Frankel’s suggestion that art and cultural artefacts should have a much larger role to play in clinical work with adolescents. In connection to the idea that inhibitory forces must be engaged with adolescents having a particularly difficult time, Frankel writes that: ‘The inhibition of action produces imagination. Experiencing an inhibition is feeling into the imaginative pattern that contains the impulse towards action. Engaging an instinctual impulse imaginally, feeling where it is rooted in the body, may reduce the need literally to take action. Thus imagination is one of the most effective tools we have in working with adolescents who are prone to impulsive behaviour.’ (169) In order to connect meaningfully with adolescents, we must be prepared to meet them on their own level, which might not necessarily be the ‘literal’ adult world. We must instead stay empathetically attuned to the deeper meanings in their narratives – and art might provide that fruitful meeting-ground.

Book Review: ‘On Becoming A Person’ by Carl Rogers

This book could be summarised into one paragraph, and while it has some good ideas, it is far too repetitive as a book.

Carl Roger’s came up with what he refers to as ‘client-centred therapy,’ which today sounds like something that goes without saying, but in its own time was a fairly radical and novel concept.

His argument is that each individual has innate, self-actualising tendencies towards growth and development. We all want to be the best version of ourselves that we can be, and, given the right environment and support, will strive towards becoming it. We all have a general sense of what is good for us to do, what we want to do, and how we should go about doing it, or becoming it.

This reminds me of a soft understanding of Nietzsche’s ‘will to power’ – that inner, individual will towards growth in things that feel meaningful for us. We all want to improve and ‘actualise’ ourselves as individuals with power and agency over our own lives and becomings.

Since postmodernism, however, the idea of ‘the self’ has received criticism, and it no longer feels so simple to suggest that we are all bounded individuals who know what we want. ‘The self’ is now a much murkier concept, which is made up of bits and pieces of others, our environment, the things that happen to us… So Rogers’s argument that we all just need to allow our ‘true selves’ to develop and grow seems a bit optimistic and simplistic. What exactly is that ‘true self’, and how would we go about finding it?

Anyway, Rogers says that people suffer psychological distress, and come to therapy, when they encounter problems with self-actualisation. Something has prevented them from either getting in touch with their inner self, or from realising its potential for various other reasons.

Therefore, he argues that it is the role of the therapist not to teach the individual how to live, but rather to create an environment in which the individual feels safe to know, listen to, and then act on their inner wants and needs. A fundamental catalyst for helping the individual to do this is an empathetic and non-judgemental relationship with the therapist.

The therapist must be honest and open about themselves and their own feelings (what Rogers calls ‘congruent’, or authentic), which in turn facilitates a trusting and non-judgemental relationship and allows the individual to themselves become open about their inner experiences. After openness comes acceptance, and with acceptance comes fewer defences and therefore more flexibility and responsiveness to the real world and others.

What I liked most about this idea is the emphasis it puts on the special relationship between therapist and client, as one which can be totally free from evaluation. In our other relationships with people in our lives, there is usually some kind of mutuality – we expect things from each other, there is a balance and reciprocity. Therefore, we hold each other to certain standards. Because the relationship between therapist in client is not one of friendship, there is also no real need to evaluate (according to our own standards) the other person’s motives or feelings. The therapist might completely disagree with everything the client says, but because they aren’t friends (or even potential friends), this doesn’t matter at all, and the therapist can, and should, accept entirely whatever it is that the client is saying. This is quite an unnatural relationship, and one that probably wouldn’t arise outside of the therapeutic environment, but it is one that I believe all of us would benefit from. To have someone who can listen to us, and accept us, completely without judgement.  This kind of space and freedom to air our ideas would do all of us a lot of good. It lets us see our ideas without any need to present or sell them to anyone, and thus lets us be truly honest with ourselves. Only when we can be totally honest can we then look at our thoughts objectively, and only then would we be in a strong position to critique them.

Too often when we speak of ourselves or our thoughts and feelings, we are trying to present them in a certain agreeable way, and we might end up persuading even ourselves that these are the best ways forward. When we don’t feel any pressure to ‘sell ourselves’ to even our loved ones or friends (or perhaps especially to those individuals important to us), we can see ourselves as we ‘truly’ (?) are.

Uhoh, I just fell into the ‘true selves’ trap. Which I myself find a little wobbly as a concept… So I’ll probably need to work out that thought in a blog post to come…