Therapeutic approaches

On forgiveness

I have been thinking a bit about forgiveness recently. It has been a recurring theme in therapy over the past few months, which is hardly surprising when you think of some of the things that have happened to my patients. It’s something that seems to come up more when I do family therapy, which perhaps makes sense – there will be times when the tormentor, or the one who failed to protect, will be there in the therapy along with the tormented and unprotected. In individual work the tormentor is always there, of course, but only in a metaphysical sense; tainting everything but with no potential for real resolution.

In addition, today The Guyliner, whose writing I think is tremendous – by turns arch and acerbic; painful and true – posted a link to a blog on the school bullies who try to apologise twenty years later. You really ought to read it but the long and the short of it is that frankly, you’re not compelled to show any kindness to someone who made your life hell when you weren’t able to defend yourself. His timeline today is hard to read – the kids who picked on the one who was different; the teachers who did stuff like this:


I wasn’t bullied at school and I am eternally grateful for that. I never had to dread going to school in the way so many people do, but even aged ten I didn’t believe your school-days were the best of your life. School – even my school, which was ‘good’ and which churned out droves of Russell Group-types – was tough for many and I suspect lots of people hated it and were simply trying to survive; waiting desperately for the day they could leave and acquire some kind of freedom. I feel guilty writing that, because when you go to a ‘good’ school and you come out with decent results and you swan off to a fancy university and get a good job and achieve some kind of success it can seem disloyal. But that’s part of the problem – bullying is always so insidious; so hidden; and loyalty to an institution is I think, often  faintly suspect. And of course most of the ways in which we hurt others are insidious and hidden; usually with the person being hurt left wracked with shame and fear and self-loathing and, if they don’t find a way out, quite possibly a lifetime of mental health and substance problems and relationship difficulties and heaven knows what else.

Anyway. The fact is that I now spend my working life with lots of people who have been bullied and terrorised and persecuted to an almost unholy degree. If I have learned one thing working in mental health for the past ten years it is this: life can be almost unbearably cruel and it is almost always other people who enact that cruelty. Rarely is it pure bad luck which breaks people; far more often it is people who break other people.

I never quite know what to do with all the after-effects of such experiences. Lots of people talk of forgiveness, often from a religious perspective, and there’s a raft of literature out there on the healing, restorative power of forgiving those who have hurt you. It all sounds lovely – they say sorry; you forgive them; everything is solved. Third parties – well-meaning third parties, in general – often advocate forgiveness; occasionally telling you should not only forgive but also forget, as though we’re living in Hollywood.

Sometimes – and please indulge me here, dear reader – I wonder if it isn’t all nonsense.

Don’t get me wrong – it takes a big person to forgive someone who has intentionally caused you harm; it shows a remarkable humanity and a strength that not everyone possesses. But that doesn’t mean that to be unable or unwilling to forgive makes you inhumane or weak. Tell me, how can I possibly ask my patients to forgive the parents who beat them or neglected them; the people who abused their power and molested them; the systems which took their children or incarcerated them? What right do I have to placate them with talk of ‘healing’ when they are angry; when they are emotionally and physically shattered; when they want revenge; when they want to be believed, vindicated, listened to?

So many of the people I see only talk about these terrible abuses late in life, for the simple reason that there was no one to listen at the time. They carry these scars for decades and they have an absolute right to be angry and hurt and want some justice. And that’s one of the problems, I think – when someone well-intentioned talks of forgiveness it’s often without a visceral understanding of the anger and the pain and the betrayal that the one being asked to forgive is battling. I often think that in circumstances such as these it’s the person who committed the crime who gets off easier, because it can be so very easy to say ‘sorry’, and once you’ve done that you have the moral high ground because the person you’re apologising to is expected to be gracious and accept it and if they don’t they become the bad guy; the one so caught up in resentment and themselves that they can see no further. Saying sorry is not necessarily indicative of taking responsibility for your actions; it’s frequently a get out of jail free card. Saying sorry means nothing; not if there’s no attempt at reparation. And of course making attempts at reparation is great, but that doesn’t mean your offer has to be accepted. You don’t have the right to terrorise and victimise people weaker than you; you certainly don’t have the right to tell them how they should react when you want to assuage your own guilt years later. And I know that many of the people who are cruel to others were damaged long before, but, when it comes to my patients, I have to work with the damage I see in front of me. I know that damage perpetuates damage but it’s not my job to defend the person who hurt my patient; it’s my job to protect my patient because other people haven’t, and sometimes that means loyalty to my patient regardless of other aspects of the story. It’s not always that simple, of course; I also have a responsibility to stop my patients perpetuating that damage in any way I can, but I think that still counts as doing your best by the people you see therapeutically. I am categorically not there to side with the aggressor, the abuser or the tyrant.

I’m not sure what some of my colleagues would say about this. I suspect some would be more circumspect, but I’m afraid  I can’t be – or at least I can, academically; I can think about the physiological impact of long-term anger and the effect of stress and resentment on well-being; but I can’t, not in my guts, which is where the stories I hear hit me. The things I read and see and hear don’t have an academic impact on me; they have a human impact on me, as they do on every clinician who cares about their patients and their stories.

Perhaps with time I will have more or a philosophical approach to forgiveness, but for the moment I think any attempt on my part to encourage it in people who are not that interested in doing so would be patronising and would diminish them and their stories of survival. Because most of the people I see have survived and often only through grit and a refusal to drown in the mire.

And so, when I see someone who has survived, against all the odds, and who has retained courage and strength and humanity and who is actively trying to change their life through therapy, how can I possibly tell them that forgiveness is key? Because the truth is, dear reader, when I hear stories like that I’m never sure if I would be able to forgive. But then I look at some of the people who manage it and I am awed. And when I realise that I remember what I have always known: that our patients are often bigger and better people than any of us who have the temerity to think they need our help.



On boundaries

A day or two ago, I found myself discussing the notion of ‘boundaries’ with my supervisor. It was an unusual discussion to have in some ways as I am currently working in neuropsychology. ‘Boundaries’ is one of those terms bandied about freely by mental health types and it usually refers to what you do/do not reveal about yourself to patients. So you might tell someone you’re gay if you think it might be useful therapeutically, or you might tell them that you’re not immune to black moods (it’s interesting how revelatory something like this can be). I don’t expect many people would tell their patients that they were HIV-positive, however, or that they were going through relationship difficulties or that they drank too much. Even when we speak of our real selves, we’re very boundaried about it.

The idea is that therapy is for the patient and that you, as the therapist, shouldn’t turn the therapy into your space. Some people believe in the ‘blank canvas’ therapist, who tells nothing of their life and simply absorbs what the patient has to say. Typically, this is the case in psychodynamic psychotherapy. In neuropsychology, where I assess people’s memory and attention and visuospatial skills and discuss the impact that multiple sclerosis or a stroke have had on them, there’s rarely a need to say anything about myself. It’s something that’s discussed much more frequently with supervisors and colleagues when you’re doing more typical therapy.

To my mind, boundaries are a funny old thing and I sometimes watch with wry amusement as we try to work out what is (in)appropriate to disclose. I have known people to tussle with telling a patient they are gay, but few people have reservations wearing wedding rings. Lots of people refer to their opposite-sex partners, unashamedly disclosing that they at least tend towards heterosexuality. I know clinicians who talk about their children; some who will, in certain circumstances, show patients photographs of them. I have no especial issue with any of this because all therapy is different. I have bonded with some patients over taste in films; others with my reasonable knowledge of 1960s rock music. When you do short-term work, which is increasingly the case in the NHS, you haven’t the luxury of building a relationship over months or years. You have to do it quickly. Successful therapy (I accept the vagueness of that term) is almost always accompanied by a good therapeutic relationship. For me, that is based on a common humanity.

But boundaries are about more than what you say or don’t say about yourself. They’re also about how you behave. This has been on my mind a lot recently, probably because, as I creep ever-closer to the end of clinical training and attain the dizzy heights of qualified status, I am trying to work out what kind of clinician I would like to be. I’d like to be a good one, obviously, but I don’t know how that’s defined. Is it based on whether my patients like me? Is it based on whether they turn up? Is it about whether they feel ‘better’ (more vagueness) or self-harm less often? Is it based on my assessment of my capability? Is it based on my flexibility?

Often in MH we focus on problems and therefore therapy is aimed at making problems smaller. That’s reasonable, but I have come to view that rather blunt measurement with some skepticism. As I said, a human science. The truth is that, post-qualification, I might not have the flexibility to do what I think the patient might benefit from, or the time to do the things they want to. The last thing you want to do as a psychologist is open up a can of worms, get a really good idea of the person you’re seeing, and then fail to address most of it because you can only see them half a dozen times. There’s a notion that there are no side effects from psychology; that we can do no harm. We can do harm very easily and it takes a lot of thought to try to avoid it. So perhaps as clinicians we need to focus less on doing ‘good’ and more on ‘not doing anything bad’. If we take that view, clinical practice might look very different. I might make my patients cry less because I focus less on the things that make them cry. I can still have a good relationship with them: we can chat, go to lunch, take walks. There’s evidence that these things can be therapeutic and, as we know, having someone simply sit and listen and give a damn is enormously beneficial to most people. Perhaps giving someone a lift to the dentist if they can’t use public transport is more help than asking them how many times they left the house last week. Maybe taking them to the CAB to complain about their crap housing is better than telling them to drink less. Maybe giving them the bus fare so they can see you again is better than telling them to only buy ten cigarettes. Is it the end of the world if I go to a coffee shop with someone and buy them a cuppa from my own back pocket? I don’t think it is. I think it’s a gesture of kindness and humanity. It’s more equal than the ‘I buy mine and you buy yours’ mentality that often pervades these things. Yes, there’s a symbolism to spending your own money on a patient, but two quid on a hot drink is hardly the same as a tenner on the horses. And why shouldn’t we? We often earn more than our patients; it’s unlikely to be financially catastrophic. As to the symbolism, perhaps it suggests that you think your patient is worth £2. It’s a gesture; it doesn’t need to become a habit.

It’s a mark of how entrenched the concept of boundaries is that this, to some, seems radical. As far as I’m aware, there’s no evidence which suggests that not buying your patient tea leads to better outcomes than buying it. Similarly, I doubt there’s anything out there to suggest that getting them to scrabble around for the bus fare is beneficial compared to driving them yourself. Maybe it’s less about ‘the patient’ and more about ‘the psychologist’. Having a patient in your car makes the division between work and personal life less clear. But to think that it’s set in stone is absurd: when you see a patient you’re probably also thinking about the fact you’ve misplaced your diary, or that you need to book a hotel for the weekend, or that you rowed with your partner that morning, or that you shouted at your kids or that the insurance needs renewing. The divide between personal and professional is more often drawn in sand. Given that, then, perhaps there’s room to reconsider ‘boundaries’ and whose benefit they’re really for.

On therapuetic evangelism and why we should employ professional skepticism

Occasionally, when I am at a loose end, I think of three-letter acronyms and try to think of a model of therapy which might use that acronym. Amusingly (for a psychologist-type, anyway), more often than not, you come up with something that does indeed refer to a therapy which exists in the psychological literature. Despite stating over here  that there are three basic models of therapy, over the years, psychology has evolved and we are now in the situation where we have therapeutic models coming out of our ears. For the unitiated, here is a brief rundown of the main models we have at our disposal:

Acceptance and commitment therapy, Attachment-based psychotherapy, Behaviour therapy, Compassion-focused therapy, Cognitive analytic therapy, Cognitive behaviour therapy, Dialectical behaviour therapy, Emotion-focused therapy, Eye Movement Desensitisation and Reprocessing, Functional analytic psychotherapy, Intensive short-term dynamic psychotherapy, Interpersonal therapy, Mindfulness-based cognitive therapy, Mindfulness-based stress reduction, Mentalization-based treatment, Narrative therapy, Person-centred therapy, Positive psychology, Rational emotive behaviour therapy, Rational living therapy, Schema Focused Therapy, Solution focused brief therapy, Transference focused psychotherapy, Wilderness therapy.

And those are just the ones I am familiar with and which didn’t seem too left field. I haven’t included adapted models such as CBTi (for insomnia) or CBTp (for psychosis). It is, it would be fair to say, mind-boggling.

Lots of psychologists just rub along doing whatever seems to work for our patients. Whatever the clinical guidelines may say, one person with depression is rarely the same as another person with depression because they exist in a different family, with different experiences and goals, so the overwhelming majority of clinicians adapt their approach to fit the person.

Increasingly, however, there seems to be a slight culture of evangelism around particular models. There has always been debate, of course; I have a bit of a soft spot for family therapy, but I wouldn’t consider myself exclusive to any model. But more and more, there seems to be an air of exclusivity amongst some clinicians. This is easily observable via social media, where CBT for psychosis seems to be the current topic of (interminable) debate. I don’t object to the discussion of these things on Twitter (although you have to admit that 140 characters is hardly the best medium for it) but what irks me is that the majority of those involved in such discussions seem to have no intention of changing their view and are simply content to hammer away at the same points over and over again. That’s not debate, and I would suggest that trying to persuade people who are as certain in their views as you are in yours is a bit of a waste of time.

But I don’t write this purely to grumble about Twitter debates. My concerns are a little bigger than that, and perhaps the best illustration is mindfulness. Mindfulness is very much in vogue at the moment and was the topic of a very good piece in the Guardian recently. Mindfulness derives from Buddhist meditation but its proponents are very keen to point out that it ‘doesn’t involve any religion’. Disclosure: I (attempt, often unsuccessfully) to meditate, but I do it firmly from the Buddhist point of view. I like some philosophy to back up my inner serenity. Mindfulness spurns the philosophy and adapts the practice and it is often used with depression and anxiety. I have attempted to use it with patients, with varying degrees of success.

I happen to own a well-known mindfulness book (I took part in some research purely to get this book) and recently I was flicking through it. I was stunned by the language, not because it was offensive or profane, but because it seemed like the sort of blurb you would find in the sacred book of some new-age cult. I shall not, for reasons of professionalism, identify the book or quote passages, but the general thrust was that a) you need mindfulness; b) mindfulness will, without a shadow of a doubt, change your life. And though I may be paraphrasing, I am not exaggerating. And I am worried that statements such as these are being made because there are people out there who will take them as Gospel.

Let me be clear: mindfulness, like any other therapy, will work for some people with some problems. It is not a magic wand. It is an unfortunate truth that in psychology, there is no magic wand. I cannot promise that I will help you to rid yourself of your difficulties and I make that apparent with every person who comes to see me. We can try something and see if it works. If it doesn’t, we’ll try something else. It is constant trial and error, combined with clinical experience. It’s not magical or mysterious; it’s simply having a go.

The problem is that virtually every therapy in that list was invented by someone. Someone, somewhere, developed it, tested its efficacy and wrote a book. They probably run training courses and charge for accreditation. They may well be earning a fortune from it. Obviously, they are hugely invested in that therapeutic model. I don’t think that’s great for science or for our patients. There has been much in the media (partly thanks to Ben Goldacre) about the corruption, falsification and suppression of clinical trial results and psychology is not immune from such things. If you have built an entire career from a therapeutic approach, you need it to work. You also need people to apply it and for it to remain credible. This means that you might promote it more than it deserves or that you might claim that its scope is wider than it really is. Lots of therapies might be of some use in some people with some problems; I challenge you to show me a therapy which works for all people with all problems. If that is too hard, show me one which works for all people with one problem. I doubt you’ll be able to. But some theoretical models are being funded more than they ought and are being pushed more than they ought and the result is that clinicians are being forced to work in ways which may not fit the patient, and that is no good for us or for our patients. I never promise anyone a cure, but the very least I want to do is offer them something which might have a decent chance of helping them. The only way to do that is to remain open-minded and to remain skeptical. There is no panacea for psychological distress. If you develop your own theory or model and the evidence suggests that it can work, that is all to the good. But you really owe it to your colleagues and your patients, not to mention to yourself, to consider that model critically, to accept its limitations and to admit it when something better comes along.