Rethinking therapeutic practice
Wright, N. (2019), 'Turning Point - Rethinking Therapeutic Practice', Therapy Today, British Association for Counselling & Psychotherapy, Volume 30, Issue 9, November, p49.
An axiom of therapeutic practice is the notion that people can and do change. This change may come about as, for instance, a change in awareness, perspective, experience or behaviour. It’s often a change from a distressing, dysfunctional or debilitating way of being-in-the-world to a way that is more healthy, sustainable and life-giving.
Sandra was 30 years old when she first came to see me, yet she looked a lot older. She walked with a stooped, hunched posture, often had dark rings under her eyes and was very pale, sometimes with oddly green-coloured skin. She was frequently absent from work, especially if she felt anxious or stressed. She felt miserable.
With this type of encounter, it can be tempting to jump to a hypothesis, a diagnosis, a label; especially if we have seen, read about or worked with a similar pattern of apparent symptoms before.
The felt-need to offer a convincing diagnosis can be amplified if, for instance, we find ourselves distressed by the distress of the client, or pressured (as a professional) by ourselves, the client or other stakeholders to come up with a diagnosis and treatment plan. It may be that our organisation's funding depends on visibly being seen to ‘fix’ a certain numbers of clients within a certain diagnostic cluster, or a client’s benefits entitlements require that they are assigned a particular diagnosis.
Sandra felt perplexed by what she was experiencing and was deeply worried about its impacts on her life, work, relationships and future. I was aware that, if I offered her a diagnosis expressed as a condition, she might well feel a sense of relief. At least then she would have an explanation for why this was happening, and might thereby gain a greater sense of control and hope.
On the other hand, she might become deeply invested in and attached to the label. It could function psychologically as a source of security and, socially, as a defence any against criticism of her behaviour. “I’m like this because of X”. It could become part of her core identity, as if the label were her sole defining characteristic. It could leave her stuck and unwilling or unable to move away from it.
The ‘because’ dimension presents particular problems. First, it assumes an underlying condition or state that we are often unable to observe directly and, second, it implies a linear, one-directional, causal relationship: "You are X because of Y" (not, "Y because of X").
Sandra had, in fact, previously seen a mental health professional and had been given a diagnosis for her condition: "You feel anxious because you have anxiety, and you feel low because you have depression". I wondered, isn't this a bit like saying, "Your head hurts because you have a headache"..? (And, if you don't agree with me on this point, is it because you disagree?)
Could it be that we sometimes describe the same phenomenon in two different ways; one via apparent symptoms and one via a label that represents that specific cluster of symptoms, and then we inadvertently misinfer a causal relationship between them?
In terms of causality, how can we really be sure if apparent condition X is causing apparent symptoms Y and related behaviours Z, or vice versa, or both, and that there are no other critical influencing factors that lay out of view?
In this case, I stayed simply with what Sandra was aware of and experiencing in the here-and-now. I didn’t diagnose a condition. Over time, I noticed how her physical presence, appearance and posture seemed to reflect and resonate with her spiritual, psychological and relational stance in the world.
We worked on these latter areas together, using coaching, and Sandra experienced profound change. She now walks with an upright, relaxed posture and no longer has dark rings under her eyes or pale green skin. She looks much healthier and no longer goes off sick from work.
I believe this type of case example poses a number of important questions, risks and challenges for therapists, as well as opportunities for reflection and action. In a well-meaning, professional desire to label and address conditions, do practitioners sometimes:
Are we willing to change?
(This article appeared in the November 2019 issue of Therapy Today, which is published by the British Association of Counselling and Psychotherapy © BACP)
(For further reading on this theme, see also: Jo Watson (Ed), Drop the Disorder, 2019)