Friday, 22 November 2013

What Do Therapists Actually Do? Views from a Trainee

Part of my job is to sit in a room with people regularly and talk to them. We talk about what is on their mind, what is going on with their lives and how it all causes them distress. It is a strange and humbling sort of thing to do because even more than with reading, teaching and writing (the other components of my training) there is contention over how to do it successfully and limited information available about what it looks like when I do. I get little immediate feedback and some unknown proportion of that is necessarily misleading. Supervisors are amazingly helpful but they don't have the benefit of hindsight or unbiased vision, and can't be there in the room. Improvement I see in someone I work with may be a self serving illusion on my part ("of course they improved after I helped them") or may be attributable to something else.

In conversation, people ask me about "delivering therapy" with a hint of bemusement and incredulity. "What are you actually doing in there" is the implicit question underlying these queries. It is a very pertinent one. People who work in most jobs can describe almost everything they do with greater or lesser success. Therapists hover around in a weird hinterland, doing something which threatens professional vertigo and demands constant re-evaluation. I realised the other day that I think about it nearly all the time.

It is easiest of all to say what I don't think I am doing. I don't view myself as "healing" people, that is too Christ like. In matters psychological "healing" is a metaphor. Wounds heal when scabs form and bones start to re-grow. Subjectively experienced minds are what it feels like to be conscious and so when people say that their mind feels healed, although I have no reason to doubt it, I leave that sort of language to their discretion. Maybe someone might speak to me sometimes and feel healed. I would even hope for that to be the case, but it isn't my prerogative.

If I don't think I heal, I certainly don't think I "cure". People are cured of illnesses-to my mind-when the body has overcome an internal pathogen successfully. I might think someone seems better, but how do I know if the unseen underlying problem doesn't remain in some meaningful sense? Some forms of sadness may never leave us. "Cured" is what we say when we can be sure we have banished an affliction. I don't think I can confidently say I cure people.

I don't think I can generally be thought of as "training", "coaching" or "teaching" people, though I might talk in a pedagogical register from time to time. It seems useful to deliver information in an educational way under certain circumstances ("you know lots of people lose their appetites when they have been through what you have") but I don't feel knowledgeable enough to be a teacher, and I reserve a special distaste for the portmanteau "psycho-educational". I don't think I specialise in helping people to "find themselves" or to "self-actualise". In America's hyper-speed therapy-marketplace I see people describe themselves as "self-actualization consultant" or "life coach". Life and the self are huge and baffling ideas. I wouldn't want to shy away from talking about them, but the quasi religious quality of "self-actualisation" (as though one had found a higher purpose) seems an unlikely fit for the sort of thing people generally manage to do simply in order to be less miserable (or be miserable in less self-destructive ways). However, like "healing" I would still be very happy if someone felt they had been "self-actualised" (see, it doesn't even seem to be a transitive verb-phrase) after meeting me.

With ever increasing numbers of descriptions rejected, I find myself left with only quite workaday verbs to talk about what I do. I certainly try to listen sympathetically, to reserve judgement, and to speak a little bit from time to time. This seems insufficient though. Those things aren't therapy, that's just what we call "having a conversation". Therapy is a conversation, but it isn't just a conversation. When I sit and listen and speak, I do so in a more structured way than I do when I'm not working. I try (if working with someone in a psychodynamic way) to point out things that seem interesting to me about what the other person has said and how they've said them. I hope that in so doing I will call to their attention things that inform us both about what they are avoiding, or find themselves unable to say. Other sorts of things I might notice (when working within the framework we call "CBT") are over-generalisations or abstract statements whose accuracy we can both agree may be contestable. We can never successfully put our lives entirely into words, and finding new ways to systematically describe them can thus be very helpful. I could list other helpful ways of talking, but it would detract from the purpose of the post, and I would never be able to be as comprehensive as I would like.

These different sorts of conversational style sound easy and organic here, but I can't claim to be undertaking them this smoothly in person. There are instructions about how best to make these kinds of comments effective. We practice them in a more or less structured way depending on whom we are working with and what we set out to achieve. They get gathered together into manuals and books about "technique". Different styles and combinations of them are labelled with the notorious Three-Letter-Acronyms (TLAs). This is a necessary way of trying to find out which sorts of conversation help more than others, and we need to bunch styles together to try and keep understanding what works, when and for whom. However words like "technique" and, even "therapy" itself, can easily distract from the reality of what is going on, giving it an undeserved and magical power.

Whenever we say that we are "delivering therapy" we are always talking about two (or more) people having a conversation in a room. We hope the conversation will be helpful, and there are ways of talking that have been shown to be more helpful than others. If they get bottled and marketed as "cures", conversations can acquire a mysterious sense of magic, which may be unwarranted. It is better to remind ourselves that we can only ever be people who talk sensitively and intelligently with others. This is not to deny conversations their power; they can be very helpful indeed, but our claims for them should not strain the limits of credibility. Conversations can even be unhelpful too, perhaps devastating. You don't need to have had one with a therapist to know that.

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