On the Couch
Vol#1
Retrospective look at some of my therapeutic views By Jason Ross Sigmund Freud Museum Vienna
Photo by: Emily Ruth @ FlickR
What is “Therapy” Anyone who believes that they have a definitive answer to this question is most probably lying. I am sure that I am not the first person to say that therapy comes in as many forms as there are therapists. For me, therapy is about having conversations that are aimed at understanding the influence of problems on a person’s life. It is about mapping out an understanding of the “fabric” of a problem: where it came from; how we were introduced to it; to what memories, people and places it is connected; what keeps it in place and what supports its influence in our lives. This puts us in a position where we are more likely to separate ourselves from the problem and are able to stand up to the influence of the problem in our lives. Therapy also involves talking about aspects of our lives that are not influenced by the problem and honouring these moments. Written: 26th September, 2006
The Language of Psychology I have come to understand that our thinking is influenced (in ways that we often don’t recognise) by certain “cultures of understanding”. One of these “cultures of understanding” is psychology itself. In my conversations with people about their problems, I have begun to witness how ‘psychology’ seems to have influenced us into thinking that if we just chastise ourselves enough then we will “get better”. As an undergraduate student, each time I learned a new pathology, with strange excitement I would point out all the traits I had that approached mental illness. Somehow, pointing out my own pathos to myself became, what I believed to be at the time, a form of self-growth. Some clients seeking help tend to do the same. They arrive with a barrage of criticisms about themselves in the hope that with enough criticism they will find ‘growth’. To make things worse, psychology has come up with an entire dictionary of categories and terms to support this process. Terms like anorexic, borderline, bipolar, histrionic, depressed, narcissistic, and the list goes on… Such terms and descriptions do not invite qualities like resilience, bravery, ingenuity or resourcefulness. Furthermore, when psychological language like this is used to describe a problem, such descriptions are very “sticky” and do not leave much room for change. I must, however, make note here that there is a difference between selfcriticism and accountability. Therapy, or any other relationship for that matter, is made very difficult to sustain unless there is the preparedness for genuine accountability for how one contributes to a problem. Unfortunately, when accountability comes smeared with the language of guilt, shame and self-depreciation it is of little use to us.
Written: 26th September, 2006
Photograph by: Theodora @ Flick
Madness, in me or upon me?
I
I have more recently come to respect the idea of mental illness. It does seem possible that we can become involved and even stuck in lasting patterns of deeply destructive thought, behaviour or realities. It also seems possible that pharmacological support for such difficulty can be helpful. Furthermore, I must confess that I have even become aware that many people might willingly embrace the illness labels that they are given by professionals. For instance, understanding relatively destructive and habitual sexual behaviour as a “sexual addiction” might help in gaining some sense of control over it, avoiding the behaviour in future and encouraging support from partners in dealing with the behaviour. Similarly, the understanding of oneself as “bipolar” might help to finally acknowledge deeply destructive aspects of ones life, gain a sense of “ok, this is what I am suffering from and why I was capable of this”, and help one take predictable steps towards avoiding, or at least coping with, such difficulty in future. However! Do such categories have any fabric of truth woven into them? Can ones character be said to have a “pathological” structure to it? Although I have learned not to dismiss ideas of pathology and psychiatry altogether, what if the answers to these questions are less important than the practical implications of such illness based understandings of peoples’ difficulties? What if the most important question was not whether mental illness exists or not, but: “When do the professional practices associated with these illness categories have constructive or destructive implications for those struggling with such experiences?” Kenneth Gergen (a leading social psychologist) speaks critically of the psychologist as heroic scientist who is supposedly able to step outside everyday influences and “carve truth from nature”. From this position we can supposedly measure, predict and treat what people bring to us (a position arguably adopted from medicine). You tell me a story about your experience, from this story I identify symptoms, these symptoms lead me to a diagnosis and upon this I base my ‘treatment’ of you. In other words - you bring me an experience and from it I carve out what is wrong with you. Your pathos allows me my heroism. My treatment of you relies less on your own interpretations and more on my professional versions of you. The questions that I then ask myself are: What happens to your personal power? What becomes of your knowledge and personal versions of your life when you take on a medicalised label in attempting to understand your difficulty? In other words, along with my respect for the idea of mental illness come cautioning questions: How does the idea of “mental illness” contribute to peoples experiences of themselves, in both positive and negative ways? Does it lead to a sense of empowerment, value and sense of control over ones life? There is growing concern that medical approaches to peoples experiences lead to a loss of personal narrative - the potentially interesting and elaborate stories I have for myself are replaced by a more generic and limited clinical one. In conclusion, in many circumstances it might be important to acknowledge “mental illness” but the ways in which this mental illness is acknowledged has significant implications for the position from which we can try and deal with these troubles. A new psychology attempts to provide a different experience of illness by viewing the illness as something acting upon us, and the people close to us, rather than something that is an intrinsic part of us. Written: 26th September, 2006
I, reluctant Freudian Freud, reluctantly postmodern It is part of my post-modern identity to distinguish the kind of therapy that I do from that of more traditional forms, especially psychoanalysis. However, if I am really honest with myself, Freud’s vocabulary is so imbedded in the language of psychology that I might often be using it without realising it. But, what would make the insights of a single man have such a revolutionary and lasting impact on how we treat and understand ourselves? Reading The Writer’s Voice, by Al Alvarez, he comments on how writers don’t just hold a mirror up to reality by creating an imitation of life, “they create a moment of life itself”. Alvarez also likens the process of psychoanalysis to that of imaginative writing: “Freud, with his interest in archaeology, laboured to dig up the past and re-create it, almost as a work of art.” He goes on to describe psychoanalysis as a “dual storytelling”, the patient telling their story and the analyst retelling it back to them in a different language. He suggests that what sets Freud apart from other, more modern, analysts is that he had a distinct appreciation for the art of writing, making him a pleasure to read. Hence, his eloquence in storytelling (in the form of case histories) is “one of the many reasons why he remains a powerful figure.” I would like to take this analogy of comparing imaginative writing and psychology a bit further: Through creating moments in life itself (through writing) Freud was not so much reflecting on the reality of our minds but, rather, actually (re)producing a reality of mind. At the very least, he was producing a convincingly eloquent version of it. Perhaps, as psychologists, we don’t only investigate client’s realities, we actually help them to produce a reality through the stories we tell about them. If you come to me with the idea of ‘depression’, we don’t only investigate it, we produce a story about your life based on that theme. So it is possible that Freud saw his patients, just like a postmodern therapist might, as storytellers. However, he endeavoured to retell their stories through the lens of science, in very articulate and, ironically, imaginative ways. Not all writing can be ‘therapy’ and not all therapy makes for good writing, but perhaps the creative process of writing should be fully
appreciated as inherently related to the act of psychology! Written, November 7th, 2007
I must confess of
my chief fetish
:
I cannot resist the impulse to buy books. The inclination to read them seldom lasts and if it does, I seldom find the time or patience to read them in their entirety. Despite this, a book with an appealing title will call to me from its crowded space on a booksale table. It will lure me with promises to improve my intelligence, make me a better person or at the very least entertain me. Not to take it home would mean that I was choosing to be less than I could be. Usually, following a brief struggle with myself, I surrender and before I know it I am leaving the bookstore with a packet in hand, already feeling more intelligent. Yesterday, when I spotted a poetry collection by Don Maclennan, “Grahamstown’s gaunt doyen of poetry”, there was no struggle with myself to be had. The fact that I only had to pay sixteen rand for this rarity is nothing short of sacrilegious. His work has managed to keep me fully interested for more than a decade and I can read and re-read the same poem for years. For me, Don Maclennan is volumes of philosophy neatly packed into the shortest of verse. Words, mundane details and profound wisdom are crafted together into beautifully succinct melody….
What was he saying? ‘People must learn to love before they die,’ said Freud. But we’re too scared to throw away our reticence like old vegetables, or books we no longer need to read. People still ask, ‘So what’s he telling us?’ Sit in your chair in the winter sun. You’ll think of something. in Reading the Signs, 2005. Carapace Poetry Magazine.
I did think of something [even though it was not in the winter’s sun]: What if we are largely mistaken about love? It seems as though we think of love as something that we stumble across, find or even “fall” into. This might be somewhat true. But, what if the love that Freud is alluding to is one that we have to “learn” to do? If so, Don seems to be suggesting that learning to love has something to do with discarding of our “reticence”. Perhaps there are some things we should rather not hold onto if we want to learn how to really love? What idea, dream, identity, fear, habit, expectation, belief…do you have to discard to truly allow yourself to love the ‘someone’ in your life? Written: February 15th, 2008
Artwork by: sine_so_cold @ FlickR
The Unspeakable Choice A call for a different ‘morality’ I decided to write this following a conversation with a colleague who asked me about my work with women who have had endured an abortion. She was particularly interested in why women might put themselves at risk of having a repeat abortion. I think there are almost as many answers to this question as there are women who have had more than one termination. What did come to mind for me, however, is how society’s approach to these topics might contribute to the problem rather than help alleviate it. South African Society can perhaps be accused of being ‘morally immature’ when it comes to the topic of sex. There is a strict moral code that everyone is supposed to keep up, to save face, but in reality is seldom lived up to. As a result, there is a considerable gap between what is privately practiced and what is preached. We begin to engage in private sexual practices that we try to hide, even from ourselves and we end up behaving in ways that we ourselves feel ethically at odds with. My concern is that a conservative moral approach to sex causes sexual behaviour to live in secret, hidden and less manageable ways. This is true, I believe, for the way that we deal with the topic of abortion. What are the reasons for putting yourself at risk of a repeat abortion? For a woman to take responsibility for contraception requires planning. Do we live in a society where women are allowed to actively and openly plan to have sex? What does it say about a woman if she openly intends on having sex? What if the conservative audiences in our society compel her to pretend (even to herself, perhaps) that she does not intend having sex. Therefore, she puts herself at repeated risk through the need to keep up this pretence? Despite popular assumption, sex is not an isolated physical act that happens behind the closed doors of a married couple’s bedroom. Some people do make the decision to have sex only after significant commitment in a relationship, but ‘Sex’ is not an isolated action that is separate from the rest of our lives. We cannot pack it away in a cupboard until we are ready to use it. Sex is entwined in who we are, from infancy. A woman who is haunted by feelings of not being “goodenough”, under pressure to be in a ‘committed’ relationship, or does not feel free to be in control of her own body; might find it difficult to make responsible choices about sex. For example, by negotiating to use contraception she might risk ruining a perfectly good romantic moment. Or, insisting to use a condom might require her to find an assertive voice that she is not used to having in a relationship. Sex is entwined in our every day lives and we need to be open to this fact in order to be equipped to manage its role in our lives.
When I enter into conversations with women about their decisions to terminate a pregnancy it is like entering into a secret world where we start to speak about the unspoken. Every woman who is reluctantly faced with the difficult decision to terminate a pregnancy has a unique story to tell. The details of this story are what lead to having to make this choice. There is almost always a societal audience (even if it is an imagined one) that places judgments on this story. This audience judges whether the story is sad, traumatic or desperate enough to make an abortion ‘morally justifiable’. The same audience compels individuals to feel shame about their decision and to avoid openly telling their stories. Therefore, any attempts to actively deal with the events of their life surrounding the decision to terminate are undermined by such an audience. How would things be different if women (and their partners) where invited to be open and honest about abortion? Surely it would empower them to be less likely to find themselves in that situation again?! My work with women who are considering having or who have had a termination attempts to make room for a different morality: It is a morality that appreciates open dialogue about our sexuality; that helps them explore the individual stories that have led them to this point; respecting these stories as significant and worthy of a concerned audience; and attempting to privilege their voices above those of a judging societal audience.
Perhaps there is a myth that openness about abortion will lead to an immoral and complacent reliance on it, like; the use of it as a form of contraception). In reality, I have witnessed that the decision to terminate is never an easy one to make and that it is possible to choose abortion and still have ‘ethics’, spirituality and integrity. My hope is that all women are never faced with having to make that decision but I am also quite sure that abortion is unlikely to be used as a form of contraception. Is it not unfortunate if taken-for-granted moral codes, such as abortions as “shameful and secret practices”, deny the opportunity for control over ones own wellbeing? [for more info on termination, contact www.safersex.co.za] Written, March 10th, 2008
Temple to the human spirit
Every Monday I work at a Hospital for post-injury and illness rehabilitation. It is a place where many lives have been shattered by sudden and unexpected tragedy. People’s lives are brought to a literal standstill through stroke or injury. Cold corridors link rehab units, filled with dedicated therapists, to wards of scattered beds, populated with unflinchingly brave patients whose lives have been stripped of everything familiar to them. I soon realised that the confusing network of bland concrete corridors that make up this hospital are, in fact, the main arteries to the [less tangible] heart that beats at the centre of the ‘human spirit’.
If this hospital was a temple to the human spirit, then its patients are the high priests from whom we all learn…their resilience and determination the central teaching. Written: April 16th, 2008
Shackled by Lust? Out of the many reasons that people seek out a psychologist, it is often because they find themselves at odds with their own behaviour. We live in a society where our relationship with our own desires is changing: where masturbation is considered a healthy aspect of our sexual development; homosexuality is no longer considered a disorder; and there is open public discourse about sex. We are living in a society where lust is becoming less understood as one of the “seven deadly sins of man” and more as a celebrated human experience. However, it is possible that ‘lust’, if gone completely un-checked, can be a chief cause of being at odds with ourselves. As the contemporary philosopher Simon Blackburn writes, “Living with lust is like living shackled to a lunatic”. This lunatic is often named “Sex Addiction”. Although there is much debate about the appropriateness of associating sex (a normal part of human behaviour) with “addiction” (a destructive affliction), the term can be a very helpful metaphor when dealing with sexual behaviour that we have very little control over.
Sex Addiction is a rather sticky problem that slowly creeps up on you. Out of shame and denial it keeps itself secret, refusing to be addressed. Although it is by no means a strictly male problem, the popular understanding that “men are just like this” is a convenient excuse for the problem not to be addressed in men’s lives. The internet is its ideal breading ground, allowing the sexual behaviour to live hidden and separate from the rest of your life. With a double-click you have access to an abundance of explicit pictures, videos, and chat lines. Much like a lunatic, it has little control over itself and even less insight into the consequences of what it is doing to you. It can take the form of compulsive masturbation, paying for sex, continual affairs or an unusual preoccupation with sexual pleasure. Despite its destructive nature, most people only seek help after they have been “caught out”.
Sex can definitely be a mood altering experience and medical researchers suspect that we have neurological-pleasurepathways that provide for this experience. Sex addiction might therefore feed on a neurological “fix” and over time these pathways develop an increased sensitivity to experiences that promise this “fix”. The need for this fix can get so strong that you will put your work, family or self respect at jeopardy in order to get it. Ironically, the outcome is normally not as pleasurable as you would have liked. This leaves you with a need for more. However, to think of the problem as simply “looking for pleasure” is a limited view - the “fix” varies for each person, and could be allowing for a variety of experiences such as: escape, fantasy, relaxation or stimulation. In the end, it only tends to make you feel shame, guilt and disappointment with yourself.
Lust is more than just a good sexual appetite when: it is uncontrollable and interferes with your daily life; gets worse over time, becoming habitual, even though less pleasurable; and is hidden and separate from the rest of your life, promising to go away “tomorrow”. Steps to dealing with it: acknowledge the hold it has over you; map-out how it started, what it does for you and what makes it worse; realise that it is not separate from the rest of your life; consider the person that it is forcing you to be [i.e. deceitful]; consider serious measures to avoid opportunities to get your “fix” [i.e. net-nanny, disclosing the addiction, or trying periods of celibacy]; and lastly, try and see the problem through your partner’s eyes. Although disclosing the addiction to your partner is risky, it might help explain behaviour that he/she is already concerned about. Disclosure might be an opportunity to address related problems in the relationship, such as: a lack of intimacy or unusual pressure on your partner to have sex. Realise that you might need support in dealing with the hold that the addiction has over you. Written, March 10th, 2008
All photographs in this article by Michelle Brea @ FlickR
Often, in an attempt to avoid the discomfort that these extreme moments of sadness might bring (for me, my client or both of us) I might not always allow the ‘grief’ the room it needs in the conversation. Yesterday, upon revealing itself again, I decided to give it a bit more room and had a more deliberate conversation about it. Ironically my client had mentioned how her friend had lost her mother the other day and she “did not know what to say to her”. We used this as the basis for reflecting on her own grief and I would like to draw on my conversation with her to suggest some guidelines when it comes to ‘grief’: Grief differs from person to person and the nature of the grief is very dependant on the relationship you had with this person. …an unexpected conversation with ‘grief’ Working with grief is not necessarily considered one of my specialisations. But, when you work with people’s life experiences on a daily basis, grief becomes an inevitable theme in many of your conversations. A young woman has been meeting with me for several weeks and, from time to time, the subject of her father’s death arises. Her father’s death was not necessarily the central reason for her coming to see me and it has never been her dominant concern in our conversations. To put this in context, although I do believe that psychodynamic ideas like “defensiveness” and “denial” have their merit, I am not a therapist who chooses to relate to clients’ utterances in these terms. In other words, when she does not bring up her father’s death, I do not start to think that she is in denial and that it is my job to convince her that her grief for her father is the “real issue” in her life that we need to address. Nevertheless, without me purposely directing the conversation there, ‘grief’ tends to make its self relevant from time to time. One thing that you have to become comfortable with in this career is open (although, often reluctant) displays of intense sadness. Furthermore, the very idea of therapy, the atmosphere of the therapy consultation room and the questions a therapist might allow himself to ask a client – seem to open up a door for this sadness to reveal itself. I must stress here that this does not mean that therapeutic success should be equated with how easily a therapist gets his client to cry.
We assume that in order to properly grieve, to prove our love for the person, our lives must be destroyed. Sometimes you even feel guilty when you are visited by excitement or happiness. We misconceive that ‘grief’ disallows happiness of any form. Grief changes you. When you lose a significant person in your life, you are not the same person. As my client so poetically puts it, “I live in my old shoes, but I am a different person”. It is as if your life stands still while everyone else’s moves on. People close to you might share your grief at first, but soon they move on, while you are left behind, in the company of grief. Grief does not move on, you cannot just let go of it. It stays with you for life, although forever changing through time. People can help you by not being scared to talk about the lost person. Not out of pity, punctuating their sentences with “ag shame”, but in positive terms. There will always be events, birthdays, wedding days, where their presence will be sorely felt. Even though it might seem easier to just pack them away and pretend they were never there. It might help to find a way of honouring how they would have wanted to be present. Just because they are physically absent, does not mean that the influence that they had on your lives; the things they introduced you to, what they taught you, how they changed your life, has to disappear.
It is important to ask how you can continue to honour the character of the person you have lost and how you can keep a legacy of them alive in your life. This may not be true or useful for everyone who is in pain due to loss. But, so far, many of the conversations I have had about grief with many of my clients suggest that these statements bare relevance for how many people.
Some guiding questions could be: How can you honour the lost person in your life? How would they want you to be living? If they where present, what would they have to say? If there is something that they introduced into your life, how can you keep this influence alive? Written, April 18th, 2008
Photograph by Flex @ FlickR
Cohabitation From perfect strangers to living imperfectly
Photograph by Amsterdamned @ FlickR
In a 20th century western world it is not uncommon for 2 perfect strangers to meet in a bar and in no time at all, find them selves sharing a flat in suburban JHB. Up until more recently, the ‘heteronorm’ has been for couples to make the commitment of marriage before co-habiting. In fact, I could say that many of my clients have often passed the comment that, in retrospect, they got married at an early age in order to escape the confines of their parents’ home. However, in contemporary western society, more and more people are living meaningful lives - that involve love, care and intimacy - outside of conventional family life. In our contemporary society it seems possible that significant bonds can be made without the assistance of convention. Perhaps the popularity of programs such as Will & Grace or the Friends series are testimony to this. Recent statistics indicate that in the US and UK, 4/10 babies are born to un-wed mothers. I must caution here that one must be careful how you read such statistics. This does not necessarily translate to 40% of children living in families where parents have actively chosen a life of cohabitation. But, nevertheless, it points to the fact that the way our lives are organised emotionally, is changing. In some cases you even find successful “transactional parenting”, where two people agree to be parents to the same child but do not share a longstanding intimate relationship. The bad news for cohabiting couples is that research has argued that such relationships are prone to be more volatile, and if the goal is ultimately marriage, do not always lead to better marriages. This is contrary to popular assumption and the one reason for this may be that it is easier, in moments of discord, to put the entire relationship in question when not bound by the convention of marriage. The commitment of marriage is allot more difficult to break. Another possible reason is that cohabitation, if seen as the synapse between living together and inevitable marriage, is always in waiting of something more to happen – making room for tension. Furthermore, co-habitation might be a way of avoiding marriage and therefore when finally forced into marriage (as the “next inevitable step”) it doesn’t work. Cohabitation that is not a “marriage in waiting” could, however, be quite successful. Hence, co-habitation and marriage should perhaps be treated as separate arrangement not arrangements that lead from one to the other. In both cases it is easy to start to take each other for granted, for the passion to subside and for both people to get lost in the routine of life. Married couples are more likely to stick to this trajectory whereas those co-habiting might choose to move on. Ultimately, we all long for at least some stability and emotional comfort. But, in a society where we are starting to value individual choice over cultural norms, stability might be more easily given up in pursuit of ones own fulfilment. Living together through marriage involves a series of rituals that officialise the arrangement. You go through the predictable steps of engagement, marriage and then childbearing. Whether these are considered good or bad rituals, they do in some way manage to organise the living arrangement - allowing for some order. When it comes to cohabitation it is easy to stumble into the arrangement without much conscious thought or official agreement on the “nitty gritties” of shared living. Perhaps the most risky aspect of co-habiting is that we are still at the point where, in most areas of society, not to be married is to fall into the margins of societies “worthy” citizens. As a woman, to be un-married is to be un-chosen and as a man it is to be un-tameable. Luckily, despite the inclusion of marriage for Gay partners, portions of the gay community are at the forefront of campaigning for alternative living arrangements that do not have to mean an absence of mutual respect, love, intimacy and caring. In short, what if marriage is not the only arrangement in which love and intimacy find sincerity, respect and legitimacy? Written, August 26th, 2008
The following forms part of in-service training given to a Neuro Team in a Rehabilitation Hospital
What do I do with a patient in Distress?
Photograph by Delire Lucide @ FlickR
What patient experiences contribute to distress?
might
What are our responses to this distress informed by?
When people become seriously ill and debilitated, they often feel isolated. They become part of a small group of “outsiders” for whom most of their suffering is silent, not understood or largely unnoticeable. Perhaps any actions that attempt to bridge this chasm might help give the suffering a voice. Any signs of concern, understanding or simple indications that their suffering has not gone unnoticed, can be useful. Illness and injury often leave people feeling shameful, undignified, useless and helpless. Discomfort, from patients or care-givers, with open displays of emotion often risk exacerbating these experiences.
As professionals there is the expectation to always be in control, sometimes extreme displays of emotion are personally moving and uncomfortable. In an attempt to stay in control, we often disregard the emotional. Although it is not the role of all practitioners to actively address the distress of patients, patients already feel like a ‘burden’ to those around them and we need to avoid creating the impression that they are burdening us even further with unwelcome displays of emotions.
“Critical illness leaves no aspect of life unchanged…Your relationships, your work, your sense of who you are and who you might become, your sense of what life is and what it ought to be – these all change and the change is terrifying. Twice, as I realized how ill I was, I saw these changes coming and was overwhelmed by them.”
Patients are left isolated by shame and helplessness. This shame and helplessness are cemented by loss in ability, of significant roles in family or work, or difficulty with bodily functioning. Simply noticing the suffering might help limit this sense of isolation. “Human suffering becomes bearable when we share it. When we know that someone recognises our pain we can let go of it. The potential of recognition to reduce suffering cannot be explained, but it seems fundamental to our humanity.”
A traditional approach to psychology views Sadness as an internal condition to be “treated”. A person that displays symptoms of an internal condition is then referred to someone who can then “treat” this condition or psychological illness. However, such an approach sets the psychologist up as a kind of mental mechanic that repairs a break down in the mechanics of the patient. This also risks implying that emotional displays of emotion are a sign of breakdown in the person and that referral to someone is confirmation of this. This often leads patients to portray their distress as having been a “moment of weakness” or a “bad day” that they are now over. Therefore, they tend to resist any genuine attempts to notice and understand their distress. Patients might even conclude that distress or helplessness in the face of illness/injury (even if only momentary) is inappropriate. The ‘discursive turn’ in psychology has brought about a change in approach by counsellors to individuals’ illness experiences. The basic premise of this approach is to avoid objectifying the person being treated. People are not problems, problems are problems and the practitioner’s role is to help in “standing up to the influence of the problem”. Therefore, signs of distress are not necessarily symptoms of an internal condition but an invitation to participate in the patient’s illness experience. The focus is on connecting and caring rather than curing. Sadness due to loss is then not an inner mental state to be cured, but an experience that the patient (and those around him/her) is in a relationship with. The practitioner’s role is to notice this relationship, and show a curiosity for how the illness-experience
influences the patient’s life. Where possible, the practitioner might be able to help investigate ways of limiting this influence. “I couldn’t even read the newspaper headlines – the words made no sense, I enjoyed nothing and could not imagine anything that could make me happy again…when I was awake, I would cry or eat ravenously. The smallest task demanded great effort, and when I thought about killing myself, it loomed like an insurmountable mission.”
What might be helpful responses to this distress? Occupational, Speech and Physical therapists are the first professionals a patient starts to interact with and build a relationship with. Patients often come to rely on these people to make them feel better. These therapists are therefore the foundation to the community of care that the patient is involved in as they endure moments of distress. In the context of neuro-rehabilitation, this might be a bit trickier as illness or injury might influence the ability to display appropriate emotion, comprehend ones own emotion or communicate emotion effectively. For myself, I try to distinguish between an observing self and a doing self. Neurological illness/injury can arguably influence both. The doing self is the one that is able to function effectively in the world and is always affected by neurological illness or injury to some extent. The observing self is the one that is able to understand what it is doing, how it is doing it, and clearly reflect on this. The observing self is influenced to varying degrees by injury or illness. This effect is sometimes devastatingly insignificant. From my experience, there is perhaps almost always an inkling of the observing self in the majority of these patients. It is this observing self that we need to invite into interaction and help feel noticed in moments of distress.
“The incremental demands of age, the steady pickpocketing that happens to us all, seemed like nothing compared to the robbery that had been performed on my body.”
The following steps might be helpful responses to distress:
1. Listen to the patient. Rather than making professional assumptions, try to really listen for what the distress is attempting to communicate.
2. Listen to yourself. What is this doing to me and how do my own feelings influence my response? Often family members find the distress too painful and unknowingly disallow moments of distress.
3. Reflect on thoughts, feelings and behaviour. Find a way of letting the patient know that they are being heard and that you are making a genuine attempt at understanding their distress.
4. Affirmation & respect. Try to make the patient feel that their displays of emotion are welcome and no cause for shame.
5. Empathic curiosity. Try to show a non-expert curiosity in what their distress is communicating.
6. Summarize/paraphrase. Give a sense of the overall impression that you have of the concern and clarify it with the patient.
7. Make a plan. This step is not always needed and sometimes inappropriate, but in general, action will help make the patient feel more in control.
8. Offer Follow-up. Follow up on their situation at a later stage. This will help to let them know that your concern is authentic and that their openness is invited. Written, August 26th, 2008
Photograph by Teresa-M @ FlickR
Jason Ross is a Counselling Psychologist who focuses on communication, related to: health care; sexual matters; family dynamics and relationships. He has a fervent interest in the role of text and metaphor in Psychology. At present, he practices from his home and a local physical rehabilitation hospital, in Johannesburg. jasontross@mweb.co.za