Conversing With Uncertainty

Practicing Psychotherapy in A Hospital Setting

Rita W. McCleary, Rita Wiley McCleary

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134887538
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Conversing with Uncertainty is a unique chronicle of why therapists must use theory while resisting the allure of theory, maintaining a double vision that allows them to appropriate theory only to break it open to enlarge the interactive and interpretive possibilities of therapy. But McCleary offers far more than a vivid experiential rendering of this insight. She argues persuasively, here in conversation with the writings of Irwin Hoffman and Lawrence Friedman, that a narrative case study - such as her case study of Kay - offers a unique window to comprehending the type of reflection that culminates in psychotherapeutic knowing. It follows, for McCleary, that case narratives are especially relevant to psychotherapeutic training, and by implication, to the way in which therapists acquire expertise.

Framed by a foreword by Stephen Mitchell and an afterword by Glen Gabbard, Conversing with Uncertainty is the premier volume of the Relational Perspectives Book Series. It also introduces a gifted writer of rare therapeutic sensibility. For it is McCleary's achievement, finally, not merely to convey with arresting candor the stress and uncertainty of clinical training, but to use her encounter with Kay to probe with fresh insight perennial questions about the narrative structure of therapeutic knowledge, the experiential foundations of theory choice, and the use and abuse of theory in clinical practice.

FIRST WORDS

Life can only be understood backwards, but it must be
lived forwards.
Søren Kierkegaard, Either/Or

When I first saw Kay, she looked larger than life, and she scared me. She was dressed all in black and outraged. Her hair was black and spiked up on her head, she had rimmed her blue eyes with black, her tight jeans and tee shirt were black, and her mood was black. I felt pale, if not invisible, by comparison and scurried past her room without stopping to introduce myself. Kay was shouting at the milieu worker with her that she had no need for hospitalization, that the “state system” had victimized her, and that she was goddamned if she could not smoke. I would have sworn at the time that she was wearing chains (she was not). Back in the nurses’ station, I tried to minimize my nervousness as I listened to staff members grumble that this kid had an awful lot of baggage to sort through and that her nose-ring was disgusting. I did not know what to think or say.

This case study is as much about myself as it is about the adolescent girl whom I treated for nine of the ten months she remained hospitalized at the State Psychiatric Hospital. To tell the story of Kay’s intensive, and often intense, psychotherapy is to reconstruct a relationship that was at least as significant for my personal and professional development as it was for any improvements in her behavior and capacity to live civilly with others. Our relationship occasioned, for me, a continuing series of reflections, formulations, and interventions, each of which informed and transformed my appreciation of what the relationship was about and what role I played within it. What I hope to convey, by way of my own example, is how thoroughly and inevitably therapists ground their ideas in the nitty-gritty exigencies of working with patients.

When I began my psychotherapy practicum at State in July 1985, I was relatively inexperienced as a therapist, but not without intellectual commitments and fairly strong convictions about how I should do therapy. More than a decade before, as an undergraduate, I had read Harry Stack Sullivan’s (1953) The Interpersonal Theory of Psychiatry under the tutelage of Eugene Gendlin, and since that time had pursued a passionate interest in how notions of “self” and “other” mutually defined themselves. Before deciding to seek clinical training, I had also studied philosophy, writing my thesis on Merleau-Ponty’s (1945) conceptualization of intersubjectivity. I subsequently explored related topics in the areas of biography and fiction. Once invested in my psychotherapeutic training, I gravitated toward interpersonal formulations of psychoanalytic treatment, as represented by Edgar Levenson (1972, 1981, 1982), Merton Gill (1983, 1985), Irwin Hoffman (1983), and Greenberg and Mitchell (1983), in addition to Sullivan (1940, 1953, 1954). In short, my personal predilection and studies came together in a dream of a future as a psychoanalytic psychotherapist with an interpersonalist bent.

In important respects, this case study owes a debt to the psychoanalytic theorists I had embraced and can be read as an appreciation of their relevance to clinical practice. Curiously, however, during that first panicky moment when I glimpsed Kay, and for many weeks thereafter, their collective wisdom escaped me. Instead of sagely appreciating the subtleties of the interpersonal encounter, I tried out this or that idea or intervention, almost blindly at first. Only very gradually did I gain a more reflective sense of what seemed to work and why, and at no time, with the exception of occasional conscious efforts to “analyze the transference,” did I apply directly the concepts of interpersonal psychoanalysis. Still, as I have examined and reexamined my experiences at State, I have come to regard this narrative as exemplary of an interactive “structure of inquiry,” akin to what Sullivan, borrowing from anthropology, called “participant observation.”

Edgar Levenson (1972) captured a therapist’s experience of participant observation—and its difference from more exclusively academic efforts—when he wrote the following:

It is not the therapist’s uncoding of the dynamics that makes the therapy, not his “interpretations” of meaning and purpose, but, rather, his extended participation with the patient. It is not his ability to resist distortion by the patient (transference) or to resist his own temptation to interact irrationally with the patient (countertransference) but, rather, his ability to be trapped, immersed, and participating in a system and then to work his way out [p. 174].

At one level this case study illustrates the particularities of getting caught up in an interpersonal system and what it means to work one’s way out. At another level, as I will argue more fully later, I think that writing—and reading—such a case study represents a unique form of reflection on clinical practicing that has especial relevance for psychotherapeutic training.

Because she proved to be so controversial, demanding, and dramatic, I was particularly immersed in my work with Kay. Her baggage, of course, was figurative as well as literal, and several pieces had preceded her arrival. We learned that she was 16 1/2 years old and had been a ward of the state for several years. Her parents (who had divorced by the time she was six and who shuttled her back and forth between them) had physically and emotionally abused her as a child. She had run away from her father repeatedly until he finally gave up his custody of her.

In leaving her father’s house for a Children’s Aid Society (CAS) group home, it seemed that Kay had jumped from the frying pan into the fire: a child prostitution ring operating out of her placement conscripted her into service at age 14. This fact, which shifted in significance and prominence throughout her hospitalization, lent Kay an exceptional, if not favored, status from the start. Following a successful suit against CAS for mistreatment, the court legally mandated CAS to assume full responsibility for Kay until her 21st birthday, a situation many CAS workers resented. Kay’s anger and frequently proclaimed sense of entitlement chafed them, yet they could not dismiss her. As I will recount in greater detail in chapter 2, Kay had spent a year in a prestigious private institution prior to arriving at State, but her length of stay there was always in question. I had the impression that more than one worker took grim satisfaction in her “demotion” to a state hospital, as if now Kay had gotten what she deserved.¹

The most shocking piece of information about Kay, received the day before she arrived, on September 29, was recorded by the chief social worker as an entry, called a “passalong” or “PAL,” in the unit’s informal log. Everyone who worked on the unit, from psychiatric aide to unit chief, relied on this clipboard of handwritten notes to learn up-to-the-minute information about patients, to communicate with one another about unit procedures, and sometimes just to complain. Thus, within hours, everyone on A-2 had read: “Kay Z (new patient) has a lawyer, Katherine Q, who might call and arrange a time to see her. She should be allowed to come—she’s defending Kay on charges of sexually abusing minors.” An abusive delinquent elicits far less sympathy than a child whom others have abused. Confronted with the ill-defined task of treating this girl, with no empathic identification with her predicament, I felt rudderless and alone.

I think that the nursing and milieu staff also felt overwhelmed by Kay’s arrival, but for different reasons. For them she threatened to be the proverbial straw that broke the camel’s back. An obnoxious and morally repulsive sex offender brought in through political channels, from far outside the unit’s catchment area and at a time when the unit chief had promised—impossibly—to keep the census low, was the last thing the staff wanted. They bitterly complained about being a “dumping ground” for “unmanageable” cases. That Kay was not blond and pretty, as a CAS worker had told us, only made matters worse.

With the distance of time and subsequent developments, I have come to reevaluate the staff’s anger at my patient, along with everything else. I have come to recognize that beneath the resentment and disgust (curiously focused on the nose-ring) was enough of a sense of challenge and of pride in the unit’s work to keep them minimally engaged. That Kay had previously received treatment on a well-known private adolescent unit spurred the State staff to prove they could do better. When Kay first arrived, however, what I was aware of and reactive to was the staff’s antipathy to a case that (for better or worse) I had claimed as my own. It was only a matter of days before I became angry as well.

Needless to say, Kay was not the only one with baggage. I, too, had a history, albeit far less sordid, as did the unit staff, both collectively and individually, and the various agencies and institutions involved in Kay’s care. At the time of Kay’s admission I had been at State, on A-2, one of the hospital’s three adolescent units, for three months (out of an eventual twelve). I had inherited two patients from the previous year’s trainees, one now discharged and the other (my favorite) about to be. If I remember correctly, I anticipated Kay, sight as yet unseen, as my first real patient. Thus, for a variety of reasons, I felt remarkably possessive.

I shared my training on the unit with three third-year psychology graduate students like myself, a fourth-year full-time psychology intern, a string of medical residents, and an occasional trainee in psychodiagnostics, occupational therapy, and the like. After three months I knew my way around and my initial apprehensions about working with “crazy kids” had more or less abated. My early enthusiasm had also waned, however: I had had a run-in with the nurse supervisor that left me in tears, my relationship with my own supervisor seemed off to a rocky start, and the staff, while generally friendly, let me know that trainees were often irritants who hindered as much as helped the patients’ hospital course. Any exalted notions I had had of being a primary psychotherapist had faded, and I had fallen back to a more questioning and uncertain position.

In many ways Dennis McCaughan (1985) captured my distress and disorientation as a student of adolescent psychotherapy in his article “Teaching and Learning Adolescent Psychotherapy: Adolescent, Therapist, and Milieu.” He noted students’ typical lack of preparation for inpatient work; their uneasy, and sometimes hostile, alliance with the milieu staff; their increasing insecurity about their role on the unit; and, most important, their disheartening admission (weeks into the therapy) that “their” patient wants no part of their help:

The character-disordered adolescent’s need to act out as a defense against the recognition of a painful and often tormented inner world runs counter to the therapist’s reflective orientation derived from psychoanalytic models of psychotherapy. Many of these adolescents simply do not want treatment. They resist its frustrations, having organized their lives around the immediate gratification of drugs, promiscuity, and a range of anti-social acts. . . . Novice psychotherapists must contend not only with the emotional responses generated by the adolescent’s hostility and impulsiveness, but also with the devaluation of a psychotherapeutic orientation that they have come to prize both professionally and personally [p. 416].

When I first read McCaughan’s article, shortly before I began at State, it made me vaguely uneasy, but its accuracy and utility eluded me (not unlike the elusiveness of interpersonal theories of psychoanalysis that I mentioned earlier). When I read McCaughan again, six months later, it occasioned a shock of relieved recognition and, when supplemented by a directed readings course, introduced me to the wide-ranging perspective of milieu therapy. Although this case study is not primarily an apologia for milieu therapy, McCaughan’s viewpoint convinced me that the story I want to tell here has to include in its broad cast of characters the unit staff, the institutional politics, and my teachers and supervisors, as well as, of course, myself and Kay. In so doing, I am heeding McCaughan’s concluding advice that “it is necessary to develop a conceptualization that allows for the integration of the therapist, the adolescent, and the milieu. Without such a conceptualization, attempts at treating the adolescent and teaching the therapist are compromised” (p. 422).

The most exciting development in the midst of my enthusiastic reading of the milieu literature was a newfound awareness that formerly abstract, if attractive, ideas might finally pay off. Not only could I now conceive of a productive working relationship with the staff, for instance, but I could also begin to talk to them about it in a way that vastly improved our rapport. The work of Donald Schön, a professor of urban studies and education at the Massachusetts Institute of Technology, complemented and enhanced this realization. In The Reflective Practitioner (1983) and its sequel, Educating the Reflective Practitioner (1987), Schön wove together his own detailed examples of professional practicing, from fields as diverse as engineering, town planning, and psychotherapy, as a way of exemplifying and engaging his reader in what he called “reflection-in-action.” Schön’s characterization of the “push-me pull-me” of doing and thinking-about-doing has helped me enormously to articulate a sense to my work with Kay that neither discounts the contributions of various ideas I entertained nor glosses over the innumerable times I felt stupid and stuck. Given the extent of his influence on my story’s “plot,” I will present Schön’s thesis in some detail before turning to more specific introductions of the chapters that follow.

Schön (1983) began by inviting all professionals to really look at what they do, to recognize that, contrary to popular opinion, their primary activity is problem-setting, not problem-solving:

In real-world practice, problems do not present themselves to the practitioner as givens. They must be constructed from the materials of problematic situations which are puzzling, troubling, and uncertain. In order to convert a problematic situation to a problem, a practitioner must do a certain kind of work. He must make sense of an uncertain situation that initially makes no sense [p. 40].

A novice practitioner, of course, will be at a loss as to where to start. Quoting a master architect, a problem-designer par excellence, Schön (1983) advised, “You should begin with a discipline, even if it’s arbitrary . . . you can always break it open later” (p. 85). Using a discipline and making a move, the experienced practitioner, as well as the student, must then listen for “back talk,” the frequently surprising way in which a problematic situation responds to and influences our ongoing activity. Problem designing is a “conversation with materials” (p. 78) that Schön characterized more fully as follows:

At the same time that the inquirer tries to shape the situation to his frame, he must hold himself open to the situation’s back-talk. He must be willing to enter into new confusions and uncertainties. Hence, he must adopt a kind of double-vision. He must act in accordance with the view he has adopted, but he must recognize that he can always break it open later, indeed must break it open later in order to make new sense of his transaction with the situation. This becomes more difficult to do as the process continues. His choices become more committing, his moves more nearly irreversible. As the risk of uncertainty increases, so does the temptation to treat the view as the reality. Nevertheless, if the inquirer maintains his double-vision, even while deepening his commitment to a chosen frame, he increases his chances of arriving at a deeper and broader coherence of artifact and idea [p. 164].

For reasons examined more closely later, reading Schön, about three-quarters of the way through my year at State, at a time when I had already gained sufficient distance to reflect on my experience, dramatically reframed my earlier experiences of confusion and disillusionment. To put it simplistically yet honestly, Schön’s validation of the inevitable uncertainties of professional practice and the continuing, if unacknowledged, process of thinking-while-doing helped me to forgive myself for my ineptitude and to reconsider what I was practicing in a more constructive light.

What sets Schön’s epistemology apart from that implicit in the writings of interactive or interpersonalist clinical theorists such as Levenson (quoted earlier), is his central concern with how professionals learn. Not only does he decry the pitfalls of a professional’s believing that with the right theory he or she can find the right answers, but he models, in painstaking detail, the purposeful yet often bumpy course that a “conversation with problematic materials” may take. Analyzing the transcripts of supervisory sessions, he identified “knowing” and “reflecting-in-action” in a way that made them accessible to me in my own struggles to determine what I knew, what I was doing, and what I hoped to accomplish as a psychotherapist. More specifically, Schön helped me to recognize that my experience of Kay was of the greatest importance to my learning and thinking about her.

Kay always “talked back.” No matter what formulation or intervention I might hazard, she repeatedly surprised me....

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Dedication
• ACKNOWLEDGEMENTS
• CONTENTS
• FOREWORD—Stephen A. Mitchell
• 1 FIRST WORDS
• 2 NOISY WORDS
• 3 CONFLICTING WORDS
• 4 MAGIC WORDS
• 5 SHARED WORDS
• 6 CONVERSATION
• REFERENCES
• AFTERWORD—Glen O. Gabbard
• INDEX