Clinical Applications
A
woman wanted help with her confidence. She was having
difficulty speaking with her child’s parents at school
functions, and was beginning to have trouble conversing
with workmates. I listened to her situation, and concluded
that lack of confidence fitted the problem, and that if she
had more confidence, her life would continue more
satisfactorily.
After 2 or 3 sessions, she was aware of enough improvement
to not need more assistance. As she was preparing to leave,
she told me that she had had 2 “psychotic episodes” after
the birth of her second child. Rather than accepting her
diagnosis, I asked for details. She said that she had felt
overwhelmed, trapped, nowhere to go for help, and had lost
touch with reality.
I asked her is she recalled a fire engine which had
disrupted our first session, informed her that a
house had burnt to the ground because of some electrical
fault, and expressed my speculation that if a fuse had
blown, the house might have been OK. I then asked her if
she had had a “psychotic episode” or if she might have
“blown a fuse”. She was thoughtful, then profoundly
relieved as she stated that she had blown a fuse.
She was indignant that she had been labeled so unhelpfully,
and had been carrying that stigma, with its associated
fear, for years. I asked her what she might do if she
became overloaded again in the future, and she was
delighted to say that she would make sure she “blew a
fuse”.
Even though I haven’t seen her since, I would anticipate
from her mood as she left that this re-labeling allowed a
tremendously important shift in her, and that instead of
fearing another “psychotic breakdown” with its
associated terror, she might be able to “blow a fuse”
and be OK.
We are
never
dealing with anxiety, depression, phobias. We are
never
dealing with clinical conditions. We are
always
dealing with people. Remembering this keeps us connected to
the client as a uniquely individual human being living in
their uniquely individual worlds of experiences and avoids
any drift towards theoretical
abstractions.
If
we look for an emotion that is being expressed – fear,
insecurity, uncertainty, confusion – then what’s missing is
likely to be another emotion – comfort, security,
certainty, clarity. If the problem is expressed
somatically, we can ask what other somatic sensations might
be preferable. If the expression is behavioural, we can
investigate alternative behaviours. This further matches
the client’s solution to their own personal style of
experience and add to the effectiveness of the process. By
dealing with the experience directly, we can avoid the
unnecessary, time-consuming, and sometimes harmful path of
labeling pathologically.
We
have learnt to gather as much information as possible, so
we can make a map, and then we are ready to start. But so
often we only discover what information we need after we
have already begun.
On
a teaching trip to Cøpenhagen, I was unable to use the
automatic teller at the bank because there were numbers and
no letters on the keypad, so my pin number was useless. I
only discovered this when I was there, as I would never
have thought to find such information before I left home.
When we are going on a holiday, is it best to pack for all
eventualities, running the risk of not fitting everything
in the boot of the car or on the plane, or should we pack
almost nothing and risk the consequences? No matter how
thoroughly we research the weather patterns of the
destination, we only discover how the weather is after we
arrive.
Because
individual clients are individuals with individual
differences, the therapeutic conversation can be most
effective if we allow it to unfold so that as a client
responds to our questions, we can respond with questions
that emerge in a way we couldn’t have predicted. Without
this conversational flexibility, we might as well hand our
work over to a computer.
Instead
of working with the diagnosis of “anxiety”, “depression”,
etc., we can begin by unpacking the label for each
individual client. We can ask “What other words could you
use instead [of the label]?” or “How could you describe
your experience?” and this will lead us to addressing
“What’s missing”. A theme can emerge which will inform and
shape the therapeutic conversation and guide it in a
relevant, helpful and healing direction.
Cloe
Madanes wrote an article “Rebels with a Cause – Honoring
the Subversive Power of Psychotherapy” in the July/August
1999 Family Therapy Networker in which she warned about the
dangers of pathological labels such as in DSM IV. She
reminds us that if normal human suffering is approached as
a disease to be “cured” by drug therapy, there can be
shocking consequences. She writes of a man who was still
grieving for his father 8 weeks after his death, was
diagnosed as suffering from depression, prescribed
antidepressants, and when his grief persisted was
hospitalised which only added to his distress since he was
now separated from his family. Cloe advised that he be told
that his experience was a normal response and to let the
healing happen, perhaps over a year or two. He was mightily
relived to be told that he wasn’t suffering from a mental
illness, and was able to return home and go back to work.
While
there is no doubt that the label of depression is helpful
for us to manage some situations, we should always remember
that the label has been created by us, and for us, and has
no existence outside of the labeling process. Also no-one
would doubt the usefulness of antidepressants, but to
assume that they are the cause of improvement, or even a
source of “cure” is an unfortunate and demeaning assumption
which runs the risk of damaging the dignity of such
clients.
We human beings are naming, labeling beings. We name every
object we encounter and label every experience
automatically, mostly without being aware. When we hear a
noise, we want to name the noise, so we can either attend
to it or ignore it. When we listen to someone speaking
their problem, we are automatically assessing, naming,
labeling their experiences as normal, weird, familiar,
dangerous, funny, disgusting, etc..
Given this unavoidable tendency, how can we use it to the
benefit of someone seeking our help?
In AA, there is a requirement that someone assumes and
permanently owns the label of “alcoholic” and when AA
succeeds, this is an important first step. The woman I
mentioned earlier was labeled as “psychotic” and the man
Madanes wrote about as suffering from “depression” provide
disturbing examples of labeling being actively harmful.
If someone has trouble sleeping, then they will not benefit
from also carrying the burden of a label of “insomnia”.
This added burden is even worse, since it make the
experience seem more severe, and needing the help of
experts. If someone is worried about their approaching
exams, it is enough to cope with them without also having
to cope with “stress” or “anxiety”. These labels serve no
useful purpose to the sufferer, in fact only add to their
troubles. Anyone who has been through a disaster, doesn’t
need the additional disaster of a label such as “PSD” –
much more helpful to reassure them that any normal who had
been through such an abnormal event would be expected to be
as they are.
By labeling their response as normal in the face of
abnormal situations, they themselves are validated, and so
more able to begin to deal with their personal horror. This
sort of labeling also links the sufferer with their own
everyday resourcefulness, as compared with the jargon of
pathology which only serves to distance them from these
precious and healing potentials.
If the label is useful to the client, or if it is helpful
to us, then there are two very different processes
happening. If the client asks for a label, and we can give
it – whether it is optimistic or pessimistic, then this can
allow a wonderful relief. When Ian Gawler discovered that
his sarcoma had a prognosis of nil, he realised that “I
needed to do something different” and this awful diagnosis
gave him something solid to deal with. In “Change”,
Watzlawick, Weakland and Fisch write about a man who was
dying of an unknown condition, and told that if a diagnosis
could be made, then he would be OK, was able to suddenly
begin this recovery when a visiting diagnostician made the
pronouncement “moribundus!”. It was the labeling, not the
label that was helpful, and it was helpful to the listener,
not the speaker.
A newly married woman was upset by difficulties with her
husband - she was frustrated with herself, and particularly
her bitchiness which she felt powerless to stop – she loved
her husband, and wanted the marriage to continue. In
general conversation, she recalled that she had a recurring
tendency to sabotage anything she wanted – her education,
her workplace, her friendships. When we speculated together
about where such behaviour might have come from, she
recalled that her mother had said on one occasion that she
was “a poisonous child”, and somehow that label had stuck
and contaminated so many of her experiences. This poisonous
label, once recognised as a label, could be seen, and put
aside, and we were able to find another experience – one in
which her mother held her close and told her how much she
loved her – and we were able to label this experience as
the antidote to the “poison” and she could use this herself
any time she wanted.
It is when the label is used for our benefit, our comfort,
to guide our actions, that they can be so destructive. I
once heard a comment that chilled me to the bone. “I woman
came to see me suffering from manic depression. When she
first came to see me, she did not know that she was
suffering from manic depression, but after I had treated
her for 2 years, she came to recognise that she was”. For
me, this is an abuse of authority and labels and verges on
the criminal.
The main characteristic of a label is that it limits
options. This ca assist us in a complex situation, and in a
person who is overloaded, this can be so helpful, but the
limitations persist, and can become outmoded, and if the
problem is one where options are already restricted, this
can add to the trouble. Anyone with a work-related
disability is open to added insult if they dare to show
anything but immediate and full response to the help that
is offered. They can be labeled as malingerers, making it
up, wanting a pay-out, or suffering from a psychosomatic
disorder. How often are these labels used to tranquilise
the provider of such help, to help them cope with their own
inadequacy? I have seen such sufferers weep when their pain
and suffering is acknowledged and validated, and labeled as
a normal response to a series of extremely abnormal
circumstances.
This process of creating labels that are of maximum benefit
to the client also adds to the therapeutic relationship by
engendering a mood of trust and expectancy, and is so much
more satisfying to the practitioner. Thankfully, the days
of experts handing out diagnostic labels and technical
treatment is being replaced by an approach that recognises
the primacy of experience over explanations, of future
possibilities over past damage, of clients’ autonomy and
authorship over control and predictability – the primacy of
concern for a fellow human being over a limiting taxonomy,
of appreciation of the mystery of existence over scientific
certainty.
