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.)

Terrible, Terrible movies, Clinical Modesty, and Pondering a Ponder

This is my seventh post and it is 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 was quite happy with the ending of the “Prudence” chapter in Doherty’ book. He describes his work with a couple who were always going to have problems, as the husband has a chronic case of “ambivalence” about his life, meaning that his long term relationships were always going to have a tinge of doubt and restlessness. Doherty responds, as a mature therapist, with acceptance, and he moves the conversation towards a consideration of whether or not the couple can accommodate his feelings and towards a discussion of his coping with those feelings (as opposed to acting on them).

Doherty writes of this couple:

They taught me something important about the wisdom of accepting what cannot be changed, without a sense of tragedy or failure. If they had had the misfortune to come to me as a therapist early in my career, I might have insisted on teaching them a lesson about not settling for a care whose engine is not fairing on all pistons (180).

This is a particularly complicated situation, and we will see many like it. When we consider our goals for our clients, how good is “good enough,” and when should we think that they should consider drastic changes?

In the case of couples counseling, the “drastic change” that might be something for us to consider is obvious, but all of our clients face similar choices. How good is “good enough”? The bottom line truth that we might lose sight of is that our clients’ circumstances provide constraints. The bottom line truth is that being a human being, unless one is extravagantly successful and miraculously well regulated, provides constraints.

I am not a religious person (replace that phrase with whatever term you prefer. . . I’m not “spiritual” or some other vague concept either), but I have found tremendous importance in the Christian tradition, particularly when it considers grace, original sin, and suffering. People suffer. People do not get "well," but then can get better. We, in the behavioral/ metal health world have limits.

Very successful people experience trauma when life stages do not work out ideally. More to the point for us, many people do not see the orderly progression that Erickson describes in their life stages. There are SES and cultural differences, to be sure, but there are also challenges that people dealing with psychological problems, a lack of support, or economic challenges will encounter.

Even people with every advantages do not go through something like Erickson’s life stages smoothly (and to his credit, he describes them as challenges). How to negotiate thinking about compromises, alternate framings, and different ways of living is what we do. I have (and will be) guarded about my marriage and divorce, but I, in retrospect, understand it as a life cycle issue. I am glad I am divorced, but I can imagine an alternative world where we learned to have a compromised relationship and stayed together. I am happy about my how my life has ended up, but what was the other path? (I am happy with our choice, but I can see another. What would be the compromises? Other people might have chosen those.) How does a therapist consider these challenges? How does a therapist do so without keeping the client’s autonomy first in mind? We are already understanding (I gather from supervision) what our clients should do while remaining out of the fray. Or are we?

I will leave you, dear reader, with a sample of the idiocy that popular culture tells us about romance. I have had a very good time laughing like an idiot at this movie.


https://www.youtube.com/watch?v=PeaguDB-v_c

In which I consider different perspectives and think about Neo-Southern Rock

This is post number six, and it is 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.

Skimming around after having read the book in a few binges, I continue to enjoy Hollis’ playing about with the connections between evil and “civilized society.” For me, that is the best part of the book. We too often say that people who commit awful crimes are somehow other. They aren’t. I have used the word “banal” a lot in these posts, as it is appropriate. The motivations that underpin atrocities, whether systemic or notable, are ordinary bits of self-preservation and identity. The book gets fairly repetitive (and inconsistent, as “the Shadow” is sometimes a neutral term for something like “the unconscious” and sometimes a term that means “evil”), but that central observation is particularly valuable, particularly for the well intentioned sort that trains to administer therapy.

Skimming about this week, I was drawn to this quote:

“What surely must make all of us shudder is the recognition that not all of our institutional religion, not all of our humanistic and scientific training, not all of our collective mores could keep perfectly civilized, highly educated souls from murderous possession by the Shadow.” (pg. 180)

This passage is the central insight in the book, and the central problem with it. On one hand, being a “civilized” modern human, whether we fundamentally embrace liberal values or tradition, will not save us from being a monster. On the other hand, any sort of value system might, in fact, nurture something monstrous within us.

(I want to be fair to Hollis here, and acknowledge that I am probably pointing out sophistication with the places his concept goes. He has not resolved what he means, but in some ways he is pointing toward challenges that are messy. Our unacknowledged feelings do not necessarily fit in with some sort of “selfish subversion of values vs. evil undercurrents of society” paradigm. Some of the challenge is the messiness of psychoanalytic theory, which I understand as a sort of structuralist intellectual project more than anything else. That opinion has more to do with literary theory, which has borrowed heavily from psychoanalytic theory, than anything.)

I want to ramp down the rhetoric from “evil” towards something more tangible here. What do we do with perspectives that, when at their best, might point people toward social responsibility and health, but that are also connected to big ugly social histories? As usual, my artifact is music, and in this case, I think about my heritage as a Southerner. One of my favorite bands is The Drive By Truckers, who established themselves writing songs about what their frontman described as “The Duality of the Southern Thang.” The issue at hand is the pride of being a part of the American underclass, but identifying with an ugly history. I (and the Drive By Truckers) have navigated our own peace with cultural pride and progressive dissent, but the conflict inherent in the duality of the Southern Thang is similar to one that many of out clients, who might have repressive ideas about gender, race, or class while having their own idiosyncratic ideas about personal pride and rebellion from dominant discourses.

What do to with that? I can imagine, when I understand someone’s perspective to some extent, a path forward, but doing that (let’s face it) literary work is not what therapy is. At the same time, I do have a responsibility, according to Doherty, to introduce new perspectives to my client and to have my own moral point of view when I am in session.

This is not at all a hypothetical dilemma. I was working on my case conceptualization and it was a useful exorcise for thinking about the differences between my perspective and that of a client. I suspect that we will all have situations where we can imagine a nuances of a case that our clients might struggle to find and we will be puzzled about what our role is in terms of sharing our perspective.

My own little example of dualities is below. I had resolved this a long time ago, but this is pretty good. 

https://www.youtube.com/watch?v=k84lMPX_Kjg