Appreciation (28) … taking care and giving care challenges

Appreciation (28) … taking care and giving care challenges
Torrey Orton
Sept.27, 2010



To my co-workers in psychotherapy:


I noticed recently that caring is an important core part of therapy…not because I had not been being caring. The research on therapeutic effectiveness shows a 30% contribution from the therapeutic relationship alone, regardless of therapeutic paradigm or technique(s). The core of effective relationship is perceived care, arising from relevant therapist attention, interest, etc. 'Relevant' means felt by clients as directed accurately towards their needs at the moment.


Certainly I vary / waiver in my caring at times, but underneath all is unconditional positive regard as I understand it. My patients should feel, not always at the same moment, that I am caring about them and taking care of them. They need both to be taken care of adequately. If my care taking is not felt as caring, as specific to them and personal, it will not work in therapy.


If you have not been in therapy, you may have experienced care-taking from personal trainers, nurses, doctors, and other health providers which felt careless in the personal regard sense – as emerging from an automaton, or worse, someone who really doesn't like being with you. The effect may be to make you doubt the technical quality of the service provided, and that may inhibit its effectiveness, even if declared to be 'best practice', best of class, or similar marketised appreciations.


Unmarked detour: I did not expect to come to the following observation here but this is how writing goes. It is already noticed in Australia that the increase in non-native English speakers in aged care and some standard nursing is leading to a decline in perceived care because some care givers cannot communicate adequately with their patients. Similar is sometimes noted in general practice, and certainly the written competence of some NESB* medical practitioners is well below local high school graduation level.


This is not to impugn the intentions of care-givers. Rather it is to highlight that care – given and received – is expressed and expected differently in different cultures. Learning these differences and being able to produce them naturally is often a more than one generation's efforts away from an immigrant. The first level of that learning is linguistic, but not sufficient by itself. Many NESB immigrant groups in Australia have long had aged care facilities for own community patients for this reason.


Back on the road again. Herein lies a primary psychotherapeutic boundary issue – that taking care and caring seem inextricably intertwined. Taking care is analytically separable from the personal connection of caring / being cared for, but for the patient it is not. Nor is it separable for therapists, though efforts to do so by adopting certain distancing attitudes to patients suggest it can be. Care taking feels like it is caring, lacking which it feels mechanical (you're giving me a treatment rather than treating me) or experimental (you are using me / seeing me as an object of study). Even behavioural interventions for eating disorders, panic, phobias, etc., require a caring relationship to be effective because patient motivation is the key variable in interventions aimed to bring certain behaviours like binges under control.


People in treatment for such visibly behavioural troubles are there precisely because their self-control has fallen into the hands of a destructive habit. Habits are behavioural recipes for achieving aims without thought. They systematically solve recurrent problems with systemically repeatable solutions. They embody recurrent motivations (energy to achieve needs / wants). Motivation, in turn, stands on the back of self-confidence, self-worth, self-efficacy – all products of appropriate developmental challenges and relevant, timely appreciation by others, parents first among them. The therapist's task is to rehabilitate the injured selves. The first step is care for the patients. Doing so both suggests more or less explicitly that the patient is worth rehabilitating and that they have some of what's required already in them – their worthiness!


The danger of care, however, is its personal character and the potential for it to feel or be extended outside the therapy space and time. The boundaries for constraining care to the spacetime of therapy may constrain it out of reach for some clients…that such boundaries are needed is certain, but how they should be configured is a case by case, and often moment by moment, therapeutic task. Their importance is reflected in the articulation of professional guidelines for boundary construction and typical dangers of shoddy construction. Breaching some of these is a matter for de-registration. Case by case, moment by moment caretaking is delicate work.

Linguistic note: we speak of care givers and caretakers as if they were the same thing, though 'caretaker' has a more manorial, landed sense to it, while in ordinary usage 'care givers' are workers in respite or aged care country. How did those two usually opposed verbs come to signify the same action? Perhaps, the 'take' suggests a focus on the worker, an attitude necessary to effective care giving; the 'give' focuses on the receiver – the patient or client.

*NESB – non-english-speaking background