Learner therapist (3) What's a person…
March 27, 2011
… an agent, with potential authority?
What are we trying to help patients 'fix' or to repair in themselves? For me it is essentially their agency, their ability to act or to influence their worlds. Psychic injuries, like physical ones, inhibit our power, render us weak where we could, or used to be, strong. The help we need is to restart our motivation (value) and improve our action competence(s) (behavioural repertoires). Notice I've slid from patients to 'us'. We are them, but they are usually not us, when in the room. For what follows, we are them, too.
This is a vignette to hang a theory of agency on. The theoretical connections are made through numbers in parentheses – eg (6) – which refer to examples of agency in the first paragraph after the vignette.
One day alcoholic D, about 40, walked in with his whole self on show. His hands were fairly damp for the first time in a while. He asked for tissues to dry them (6) as he noted the fact in passing. It was the first time in 16 months work that he had been fully present, though not for lack of trying. That he could be present was always on display (7) in his ambivalence about being here. He could talk about that easily, and did so every session (1). "I really don't have anything to say today" he would announce on arrival, while always being almost unclothed his defences were so slight.
He has a lot to defend – a lifetime's actual and threatened violence from a still living alcoholic father. One thing in particular: the fiercely vivid memory of repeatedly over his primary years having to lie silently in bed in feigned sleep to avoid his just-home-from-the- pub father's attention, consciously effacing himself by containing his terror from the senses of his terrorist. He has the finest detectors of non-verbal expressions I have ever met, attached to a capacity (2) to precisely test those perceptions.
...a glass of whiskey
But that day he arrived in such ambivalence that he had skolled a glass of whiskey from a local provider on the way over. His conflicted feelings (anger and hope, riding on the energy of interest) had bounced him back and forth in the bus on the way here, just as they do every day for him. But in the room they were visibly so as he shifted in the chair, giving and withdrawing eye-to-eye contact like a chimp in a cage. What he had to say this day, after briefly having nothing as usual, is that he was here with his fears blazing and his hopes leading (8). This is the motivation that brought him into the room.
We stepped from his present into its origins through the gateway of D's defences, a set of behaviours which mark his coming to the end of bearable exposure of his pain. These gestures all happening together – breathing out, shaping up to fight or fly (in the shoulders), scrunching up his face – lead to a visible / audible stop signal (4) from D, if I haven't already got their implication. When I use his name, D, it always elicits this expressive set, as if I called out from the end of his bed to waken him into the expected paternal violence. It is this set of behaviours which expressed his being in that life space while in the room and how he controlled his exposure to it.
Control the terrorist father within…
We worked on that space to reduce its terror. I explained that this was a normal approach for engaging traumas of many kinds. Through it he could learn the threat was no longer present in its embodied way, and that he could control the feelings. As we finished a few minutes exposure, he queried, "You've done this before haven't you?"(5) And, he was ready to consider starting (3) the reconciliation trip through which he might get final control over the terrorist father in him. We had approached it 6 months ago but it had seemed way over his horizon then. Now it's in view; feels possible and desirable (1).
When I'm working with D, I have an implicit model of a person in the near background of my approach. I listen and look for certain indicators of how he is. (1) Can he say what they want, (2) interrupt to clarify a meaning, (3) propose a direction for discussion (at the beginning or in the middle of a session), (4) request changes of time or place for sessions, (5) offer feedback on how it's going for him, (6) notice what his body tells him about how he is, (7) how he presents overall, or (8) have an inner sense of truth or direction which tells him what's right and not (often expressed as feeling unfairly done by), etc.…? These are access points to his growth potential, present motivation(s) and levels of need(s). They apply to everyone.
…anyone can grow
When I first had the idea of presenting my underlying therapy assumption it seemed easy because it is so obvious to me, revisited daily in my conduct of therapy. The foundations extend back to my past as a teacher, trainer, coach where my assumption always was, and remains in every new encounter in therapy, that anyone can grow if they are compos mentis.
This is not a value statement. It's one about our nature (to which our nurture may or may not add!). The value aspect arises in making the choice to apply this assumption to everyone I encounter, professionally or personally. This is our professional responsibility.
I have worked with this assumption in the US, France, China, Singapore and Australia. You probably have your own version of favourite indicators and there's probably a thousand books proposing various right or correct answers to 'What is a person?' For me, my version allows me to approach EVERY patient from the same foundation – that they all have an identifiable set of needs, core functions and basic necessities for effective living in their world(s). I find the details of their needs, functions and basic necessities arguable, but a lack of them is the boundary between human and android. At another time a full underlying theory of a person may be usefully added to my entry assumption.