On becoming a therapist: choosing your ground

As I wrote in my previous article, the therapeutic process starts long before the client knocks on our door – it starts when we adopt our professional and therapeutic stance.  Therapeutic stance begins to crystalize at early stages of the professional training, but some of its underpinnings might be traced even deeper in our personal history, where the roots of many of our values lie. All therapists go through this phase of professional development as we can’t work without adopting any stance. It’s a ground on which we stand while doing our work. The question is whether we are aware of our professional ground and to what extent it is a result of a conscious choice. In other words: do we as professionals play the role we’ve chosen or the role we were assigned to by circumstances.

The term therapeutic stance is sometimes used as a synonym of therapeutic relationship, but I use it in a much broader and more fundamental sense. For me therapeutic stance is a more or less coherent system of the therapist’s attitudes towards own professional role, clients, therapeutic relationship and to mental health generally. The importance of those core attitudes for therapy can be compared to the importance of the basement for a building: the whole construction rests on it. Our stance impacts the way we build the therapeutic alliance, our choice of conceptual models and formulation of treatment goals, the style in which we deliver treatment and the way we relate to outcomes. The lack of coherence between these fundamental attitudes is like a loose fundament, it makes the upper construction unsteady and its elements may easily fall apart.

Of course, the therapeutic stance may change and evolve in the course of our career, but at a given point of time it is quite stable. Otherwise our professional identity would swing from client to client and from session to session.

Like many topics I write about, the therapeutic stance could be a subject for a book. However, in my blog I’ll limit the scope to focusing only on two of its aspects: worldview and allegiance (in the next article).

Worldview

Have you ever tried to look at something from no place? It is literally impossible, isn’t it? We always view things from a certain perspective, and when that perspective changes the view changes too. A worldview is a general perspective from which we explore and try to understand the world, including human beings and their mental health. How does it work in clinical practice?

Imagine going to a concert and choosing a certain seat in the audience. From this place you can clearly see the lady in a black dress playing violin and a front part of the piano. But then, when you move to a seat on the opposite side, your view changes. Looking at the stage from the other chair, the lady with violin is almost completely hidden behind other musicians. You can no longer see the front part of the piano, but you can see its back. And now you can clearly see a man playing saxophone, who was hidden behind other musicians while you looked at the stage from your previous seat.

The music is the same and sounds equally good from both places, but the picture you can see differs dramatically between the seats. What is interesting: both views are correct and equally “true”.

I often use this metaphor to illustrate the way we view mental health. What is true and correct depends always on the perspective from which we look.
Some of the clinicians I encounter believe that there is one truth that is more true than other truths, and which must be discovered and agreed upon by clinicians. This illusion is dangerous as it may lead us to absolutizing own points of view and to sticking to unworkable concepts at the expense of results.

Like picking seats in the audience, we can adopt different point of views on mental health. And like watching a concert from different places, our choice of a certain point of view will impact what we see in the therapy room.

There are no maps of clinically relevant points of view, so you have to explore the terrain on your own. However, in the book “World Hypotheses: A Study in Evidence” (1942) philosopher Stephen Pepper suggested that all philosophical and intellectual systems may be clustered into a few core worldviews: formism, organicism, mechanism and contextualism.

Among the four main worldviews mentioned by Pepper, two seem to capture well some major divisions in our field: mechanism and contextualism.

The mechanistic worldview approaches humans as if they were machines/mechanisms – a combination of parts that interact together. A natural consequence of viewing our clients through such a lens is normative thinking, because only by having norms we’re able to say whether a certain machine works properly or is broken. And only broken machines are to be fixed up, aren’t they?

Nosology, one of the pillars of mechanistic psychiatry, is just another natural consequence of approaching human beings as if they were machines. From this point of view, we need a classification of all possible breakdowns in order to choose proper repair procedures when a machine is broken.

And finally, once a machine is broken, we search for the failure within the machine. Where else? That’s exactly what a mechanic does when I drive my car to a garage. So, clinicians look at the brain, genetics, hormones, cognitive schemas, core beliefs, defense mechanisms etc.

When we move over to the contextual chair, the view on human beings becomes very different. First of all, what we primarily see from this point of view are whole human beings and their behaviors in all relevant context. This implies searching for causes of client’s problems both within and beyond the boundaries of the organism – in its interactions with the environment. Those interactions may be both current and historical. And what is important, an interaction means a mutual impact on each other.

Furthermore, when we view symptoms as behaviors, the prerequisite to predict and change them is to understand their functions. Classifying behaviors into syndromes and comparing behaviors of different individuals can’t help us with that task, because identical behaviors may have different functions, depending on the context. So, both norms and diagnoses are of little use from this perspective.

Finally – and this makes a huge difference between both perspectives, contextual treatment goals can’t be formulated in terms of symptoms, because symptoms may have different functions. What from the mechanistic perspective might be viewed as a core problem, from the contextual seat might be viewed as a mastering strategy and the client’s attempt to achieve legitimate life goals.

Social withdrawal in a depressed client may serve as protection against public shame and ostracism. How changing the serotonin level would help with that? Or exercising? And what if the client’s beliefs about the world and the future were realistic, what would you restructure? What if self-compassion would be the only available response to being in hell? Which perspective would help you to see that, mechanistic or contextual?

From a mechanistic point of view self-injury (“abnormal” behavior) may be viewed as a problem and its reduction as the goal of the treatment. But what if the client uses self-injury to regulate emotions, which she views as an obstacle to having satisfactory relationships? Would Olanzapin or Lamotrigin be a better solution for achieving her goals? Well, drugs may be more effective and less harmful than self-injury in regulating emotions, but equally ineffective in regulating relationships. Perhaps emotion regulation skills learned in the interpersonal context may be more helpful. Perhaps something else… Anyway, when clients are able to achieve their goals with other strategies, symptoms (and drugs too) may just lose their function. Thus, for a clinician the difference between mechanism and contextualism may equal to the difference between searching for a less harmful or a more helpful solution.

Now, take a look at a client suffering from an eating disorder. From a mechanistic chair you may view someone who is completely controlled by her anorexia. However, from a contextual place you may see someone for whom weigh is the only thing she feels she can control in her life. You may see someone living in a family where not giving in to hunger may be the only available mastering experience.

As said, what we see depends on where we stand. I have seen many heated discussions about diagnostic categories: whether they are real or not. Well, no concept is real in itself. When you sit on the contextual chair diagnostic categories are invisible, because they would only blur your view of the stage. However, when you move over to the mechanistic chair, they become very real and you have them right before your eyes. The concert hall is just built this way.

The choice of our professional ground is not only our personal issue. Clients learn to view their own problems through the therapists’ lenses and they quickly adopt our perspective on themselves, whether we want it or not.

So, after reading this article I’d like you to take a little break and reflect which seat you would like your clients to look at themselves from. And if you were the one who seeks help, which ground you would like your therapist to stand on.

My next article in this series will discuss another aspect of the therapeutic stance: the therapist’s allegiance. Stay attuned and consider subscribing to my blog.

Readings:

• Pepper, S. (1942). World hypotheses. Berkeley: University of California Press
• Malicki, S., Dudek-Glabicka, J., Ostaszewski, P. (2013). “Towards functional-contextualistic understanding of health problems.” Advances in Medical Sciences, XXVI, 1/2013.

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