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.)