In which we ride off into the sunset

This is my tenth and final blog entry, and it is about considering our ability to be ethical when working with the constraints of our workplaces. My ninth post was about acknowledging ugly feelings and P.T. Anderson movies. My eighth post was about trusting our clients and empathy. The seventh was about the ethical challenges of assessing for functioning. Post number six was about ethical differences and new Southern Rock. Post number five was about imaginary devil worship. Number four was about Public Enemy and my contrary ways. Number three was about the blues, number two was about feorabros, and number one was about Scandinavian heavy metal.

We have, at last, reached the end of this semester’s blogging assignment (and we are but a few weeks from the end of the semester). One of the biggest challenges that this semester has presented for me, and two that have come up a few times in the discussions of ethical dilemmas my peers have experienced, is that we must work within logistical realities and we must work in the uncertain terrain of human behavior.  

I think back to some of the stories my peers have told about working in hospitals. They have encountered several situations where other people, and people with more power, have behaved in ways that are ethically suspect or have put my peers in situations that strain at the limits of their roles as medical family therapists.

I also think about the financial challenges that our clients might face. At Mercer, we use a sliding scale, and so cost is no barrier, but in our futures we will be working in situations where non-abandonment might become a real challenges. I know that we have some clients in the clinic who were referred by faculty members who could no longer see them because of insurance issues. In these cases our faculty were able to stay involved, at least peripherally (or even as a co-therapist) because the client could be shifted from the therapists own caseload to the clinic’s. What to do when you are not a supervisor at a sliding scale clinic (that shares the same office space as your own practice)?

I also think about the challenges of risk assessment and safety contracting. We have been given instruction and provocation to think about our duties to prevent people from inflicting physical harm on anyone in at least four different classes, but the details of safety remain murky and scary. I have done suicide assessments and safety contracting already, and I feel that I did fine, but those conversations always have a twinge of uncertainty. (I, or course, got backup from the on call therapists to make sure I had done everything right.)

Certainly, when faced with an inherently difficult ethical situation (not a dilemma exactly, but a situation where living up to our responsibilities is difficult) want to live up to the standard of CYA, but any therapist worth his or her salt should take those responsibilities much more seriously than merely to understand them as mechanical obligations. The “correct” courses of action for the three circumstances mentioned above are fairly obvious, but the nuances of carrying out those duties in ways that honor the spirit rather than merely the letter of our responsibilities are difficult.

Of course, the even thornier problems of self as therapist come into play whenever we encounter a difficult to carry out ethical obligation. Do we want to face the challenges of dealing with someone with more authority who is not cognizant of his or her responsibilities? Do we have the confidence to make difficult judgments about client safety? Do we have the patience and concern to make sure our clients are being taken care of when they are not in our therapy rooms?

As we reach the end of the semester, the intersections of personal and logistical issues has become increasingly clear. A psychosocialspiritual perspective applies not just to the presenting issues our clients struggle with, but to our own ethical reasoning, and we must be vigilant to find the connections between where we work and who we are if we are to carry out our duties responsibly.

In Which I Get All Deep and Stuff and Allude to Hollywood

This is my ninth post and it is about acknowledging ugly feelings and P.T. Anderson movies. My eighth post was about trusting our clients and empathy. The seventh was about the ethical challenges of assessing for functioning. Post number six was about ethical differences and new Southern Rock. Post number five was about imaginary devil worship. Number four was about Public Enemy and my contrary ways. Number three was about the blues, number two was about feorabros, and number one was about Scandinavian heavy metal.

One of the strengths of the literary, psychoanalytic perspective of Hollis’s book is that often prefers murky ambiguity to straightforward cause and effect explanation or simple psychological explanation. The end of the book has, for me, one of his stronger summative passages, and it exemplifies the strengths of his approach:

“When we to [Shadow work], we do it for more than ourselves. When we do this work we find, in the end, that the light is in the darkness itself. We will find that no feeling, even the most turbulent, most contradictory is wrong, although we are wholly responsible for how or whether we enact that feeling, for felling is not a choice. Feeling arises from soul autonomously; ours is the choice to acknowledge and honor that feeling, or not, without literalizing its meaning. So what if an old concept of ourselves has to go?” (pg. 237)

This “acceptance” aspect of his understanding of the shadow is probably my favorite aspect of the book. What is dangerous is when we try to rationalize our behavior, not when we acknowledge that we will have feelings that are troubling or socially unacceptable.

I would quibble somewhat with the passage, in that we can have a certain amount of control over our feelings, but that kind of mastery begins with acknowledging and understanding them. We do not like to consider that we are selfish, entitled, hostile, or insecure, but if we are going to get better, we have to let go of the self-image we like to maintain that does not include those sorts of feelings.

This line of thinking led me to consider some of the films of P.T. Anderson (Boogie Night, Magnolia, Punch Drunk Love, The Master, etc.). 

The stories in his film often involve broken characters who manage to connect to other people only when they go through some form of surrender at a very low point in their lives. “Hitting bottom,” is the term usually described for these moments in people’s lives. (Well, his characters who “get better” often go through some version of that journey.) A pivotal moment in Magnolia, a movie with a very prominent soundtrack, features an Amy Mann song with the lyric “It’s not going to stop till you wise up/ so just give up.”

The kind of surrender P.T. Anderson has some relationship to religious concepts that have been used in literature like Joyce’s idea of “epiphany” or Flannery O’Connor’s idea of grace, except that these moments are starting points for people to rediscover themselves rather than transcendent moments that are important in and of themselves.

This discussion, of course, has its dangers. We romanticize “hitting bottom,” which is not even a concept that addiction research supports. (Substance abuse is the topic when people use that term in a literal way.) Also, we can, perversely, use some superficial acceptance of our darker selves to excuse bad behavior. There is a difference between accepting that we are not the idealized people we imagine ourselves to be and accepting that we have feelings that are ugly and becoming complacent.

The tightrope walk describe in this post is one that people must sometimes do if they are to get better. As people who want to be better therapists, we have to attempt it. Similarly, some of our clients will have to walk the same path if they are to get better. We might never be the people we want to be, but we will not get a step closer without acknowledging who we are.

Country Music and Not Knowing and Other Stuff

This is my eight post and it is about trusting our clients and empathy. The seventh was about the ethical challenges of assessing for functioning. Post number six was about ethical differences and new Southern Rock. Post number five was about imaginary devil worship. Number four was about Public Enemy and my contrary ways. Number three was about the blues, number two was about feorabros, and number one was about Scandinavian heavy metal.

I have found myself, in looking for starting points for these reflections (I raced through both books earlier as a strategy to cope with the demands of the semester), increasingly drawn to Doherty’s perspective, even though some of the liberal underpinnings of it are problematic for me. (Refer to earlier posts to watch me process my reservations.)

In skimming about to see what my mind landed upon as being particularly prescient this week, I was drawn to the following passage:

I knew a therapist who, when challenged about whether his approach to therapy was sufficiently caring, would reply that, or course, you have to show clients warmth and caring at the beginning in order to ‘pull the strings’ later in the therapy. This difference between ‘showing’ care and ‘being caring’ illustrates well the difference between the virtue of caring and technique of showing caring behaviors. (132)

The challenges suggested by this passage are substantial, and this passage speaks quite directly to a lot of my experiences in the program during the past few days. The presentation Saturday, today’s clinic meeting, our midterm exam, my experience in our research methods class, and my group’s experience in supervision today are quite directly relevant to this passage.

A lot of the conversation I have been exposed to this week hinges upon the tension between being a technician and being a humble interlocutor.

Much tension exists in the oft used term “clinician.” “Clinical” suggests assessment, diagnosis, and planning. These are necessary technical skills involving coaxing information from clients so that we can perform billable, proven treatments to help people to overcome specific symptoms.

At the same time, being a good therapist involves a lot of modesty, and a lot of learned comfort with ambiguity, and a lot of faith that our clients can, with the support and the perspective that careful conversation can provide, can help themselves.

These two ideas of being a good therapist are always in tension. For me, identifying a tension is the path toward wisdom. I do not take sides in the implicit (and sometimes explicit) conflict between these two perspectives, but I do not believe that synthesizing them is easy.

As usual, the artifact that comes to mind that illustrates this issue comes from music. This tension brought to mind some of the extreme empathy and mythologizing that I am familiar with from contemporary American Roots music (also referred to as Americana or Alt-Country). During my life, I have fallen under the sway of an awful lot of beautiful music that celebrates outsiders, even to the point of celebrating behavior that a responsible therapist would work to move a client away from. My favorite songwriter (aside from Duke Ellington, who mostly didn’t write the lyrics anyway) is probably Townes Van Zandt, whose lyrics are often specific meditations about living outside of social norms. His work finds the beauty and meaning in what most responsible people would regard as irresponsible dysfunction. Townes Van Zandt’s work grew out of his own struggles with mental illness and addiction, and it is gorgeous, life affirming stuff. If it also terribly fatalist and awful. His characters find fragile happiness, or die beautifully.

I understand, of course, that nobody coming to therapy understands their problems as poetic tragedy, but the defeatist (even that word tips the scale in a particular direction, when understood in the light of the tension described above) thought processes that maintain destructive behavior. We have to acknowledge these aspects of our clients’ lives and respect them. Motivational interviewing, for example, asks us to locate our inquiry in what addiction (or non-compliance with medication, or non-compliance with diet advice, or some other behavior that might be labeled as pathological) as a starting point to explore willingness to change. An underlying idea is that we should have faith in our clients. That faith can be, of course, hard to come by sometimes.

My artifact is actually not by Townes but about him. When he died of complication of alcoholism, his close friend and fellow addict (now recovered and still alive) Steve Earl wrote a tribute to him that celebrates the beauty of his life, addition and all. I am reluctant to dismiss sentiments like Earl’s, but our goals are to help people in situations like Townes’ to change. This, of course, is not a dilemma when we consider what changes our clients should make, but empathy, along with our responsibility to avoid manipulating our clients, can make navigating the emotional waters of change difficult.

  https://www.youtube.com/watch?v=p4WOys7sWvU

(I do not mean to suggest that there is anything wonderful about addition. I mean to acknowledge that what we might sometimes label "symptoms" have functions, and that the complexities of empathy can be difficult. I take it for granted that my audience knows me better than to think  I meant otherwise, but let us be explicit about this. Let us also be explicit that empathy might mean deeply understanding and identifying with behavior that is unhealthy.)