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.

The Headclutcher Strikes Again

In May I posted this about the peculiar tendency for newspapers to run a "headclutcher" image with any story about mental health issues. Silly though these pictures are, their use raises some interesting questions. How do we see people with mental health problems? Who are the acceptable faces of mental health in the mainstream media? What representations of distress are we prepared to look at when we scroll through the news? These questions are linked to the issue addressed in this pertinent New Statesmen article by Glosswitch, that not everyone with mental health problems will fit into a comforting "normal" image.

Today there has been a brief flurry of activity around the headclutcher below, which was originally used to accompany this article about voice-hearing by Charles Fernyhough and Eleanor Longden. Though still certainly a headclutcher, this lady has a more aggressive, scary presentation than usual. She is trying to block her ears in a flamboyant over the top way and appears to be shouting in anger or distress. We may note that the Guardian chose a red-head, perhaps seeking to bring to mind the lazy associations people have about their being tempestuous or hot tempered. 

Fernyhough immediately expressed discomfort with the Guardian's choice of image on Twitter, and he and Longden appear to have had words with the article's editor. The piece is now garnered with a tasteful screengrab from Longden's recent TED Talk.

Though they may sometimes seem a mere distraction from the main event, the media's use of illustrative pictures is important in the public consumption of mental health stories. Stigma is a huge problem and recent experiences with Asda's "mental health patient" halloween costume and Thorpe Park's "Asylum" have shown that it takes sensitive and thoughtful people to notice the implicit messages that are finding their way through to us. Headclutchers are not stigmatising in the same way as tasteless Halloween products but they are embarrassing and lazy; a form of journalism that is subtly derogating its subject. It's time the media thought a little harder about what images they used to accompany such important stories. 

The Scientist and the Practitioner: Some thoughts on A Vexed Relationship

The first thing I ever knew about clinical psychology was that it was based on the "scientist-practitioner" model. This paradigm, dating from a conference in Boulder Colorado in the 1940s (just as clinical psychology was taking off after the second world war), has largley defined the profession on both sides of the Atlantic ever since.

However, despite the fact that the science of psychology has expanded wildly since 1949, the scientist practitioner model seems ever less central to the profession. There are instances of outright disregard for the "scientist" part evident in many quarters and I find myself in interesting debates with psychologists and other therapists, trying to figure out how to define the role of "evidence" in that cumbersome phrase "evidence based practice". For many I detect a current of hostility to thinking in data and a general preference for using common sense and seeing the person with whom you are working. Data, by some accounts, is the kind of thing upon which we can become "hung up". Perhaps people are wary of becoming cold hearted Spocks:

"I'm Listening"

Although I have previously been scornful of the woollier arguments used against evidence in psychology, I have sympathy for some of what people are (I think) trying to express in these reservations. This post is an attempt to persuade them there is less disagreement than they fear.

Basic Problems:

Let's put our hands up right away and get a few things straight about the science of therapy. First, what gets called "evidence based practice" is not necessarily always (or even most of the time) living up to the lofty ideal of the name. For some institutional bodies, the existence of plausible seeming figures in some journal is good enough to plough ahead and recommend a therapy. I have even seen people make quite important decisions on the basis of a single pie chart (of unknown provenance) in a promotional brochure:

Even Data Can be Meaningless

Equally, much research is compromised by financial interest and driven by large pharmaceutical companies. Furthermore, the terms under which research is conducted are largely defined by political considerations of what is in vogue or popular. CBT gets more attention than any other modality, especially ones that don't sound snazzy or mysterious (like ordinary "befriending" or "supportive therapy").

Empathy and Therapeutic Skill:

There are definite limits for the role of science in the practice of therapy. The skills and considerations of an effective therapist can probably be determined by data, but perhaps their cultivation is a separate thing. I am sure there is no contradiction between being an empathic, kind and effective therapist and being statistically competent to assess efficacy, but I am aware of no reason to believe that proficiency in one automatically helps with the other. Whatever it is we do to cultivate kindness and empathy (an empirical question), it seems pretty clear we should do it.

The Role of Values and Outcomes:

The question of what kind of society we wish to have cannot always be answered empirically. A neat example of this is in a debate I recently had with a friend. In New York, unlike London, people have to pay to get into museums. In a basic way this doesn't feel right to me and I was trying to articulate why. "Societies just seem better when their art and culture is accessible to anyone" I argued. "Can you prove that?" asked the friend, and of course I couldn't. There may exist some quantitative indications that free cultural activities are good for people, but I doubt they are very robust, and in any case I am not interested in them. Even if you couldn't show conclusively that free access to culture improved people's lives, I would still maintain it was a social good. This is because it is not a question of tangible effects, but of what kind of society I want to live in.

To transpose this onto the field of mental health and social care; at least some proportion of what is at stake in the debates cannot be settled by data. Walking onto a mental health ward for the first time, I was struck by a sense of how cold and cruel it seemed. Apparently abandoned residents walked about in distress and staff members callously (so it seemed to me) bossed and condescended to them. Leaving the place behind felt like a palpable relief. Who knows how you would begin to quantify what it is like to live in such places; what kind of impact it would have on your sense of self. This is not to say that we shouldn't try, nor that we can ignore good quality data, but we can't depend on quantitative data to know everything we feel to be worth knowing. Sometimes the feelings that philosophers call "intuitions" are worth listening to. Debates outside of science, about what we should value are worth having too.

Rapprochement:

However, none of these readily acknowledged limitations is straightforwardly an argument against the centrality of the scientist practitioner position. I see a definite tendency to martial the limitations of science-based practice and attempt to assemble them into a case against data, but that way danger lies. One line of attack is to identify a scientific persuasion as a kind of arrogance. The logic apparently being that the scientifically oriented are vulnerable to using data to somehow over-ride the immediate experience of the service user, perhaps by steadfastly maintaining that they continue to do something (take a pill, undergo a form of therapy) when it is not working for the individual. This is indeed a risk of following evidence-based recommendations blindly, but it would in fact be a deeply unscientific thing to do. Reasoning from samples to individuals is probabilistic, and even if an intervention worked for 95% of cases, there are still 5% for whom it won't. The rational scientist-practitioner treats every case as a new instance of reality and pays attention to what is and is not working. This is what Jacqueline Persons (here) calls "Treatment as Experiment".  People who say that therapy is an "art" or that clinicians need to "be confident enough not to need to know all the answers" can, I hope, see a direct parallel with what they are proposing. 

Therapy, like most complex human behaviour, can probably be described as an art, but that doesn't mean it can ignore science. Is architecture an art? Plausibly yes, but if architects ignore the principles of engineering and physics, their buildings will kill people.