Directions of Travel

I expect you know this, and I expect that I should have known this, but we live and learn.

I am working with someone who has done some fairly nasty stuff and during the process of assessment and formulation we identified that there were some fundamental issues that likely were involved in this behaviour. One of these was his own traumatic experiences. As part of our plan, we had a hierarchy of addressing these issues, in part informed by him and in part informed by my attempts to try to keep the stuff that I thought would be harder for him until closer to the end. Sometimes hierarchies have to be adapted so they are no longer the hierarchy that you initially identified.

The work was tough for both of us. He’s someone who struggles to concentrate, struggles to see the point of the work (because he says he’s fine), but is a mostly amenable fellow. His attendance could best be described as sporadic.

One fine day as I arrived to meet with him, he was telling me that he was in good shape and ready for a session, which filled me with optimism, and we started off well. It didn’t last. We had got quite far in our hierarchy over the months and were getting close to the trauma, and I think this was uppermost in his mind. For no clear reason he got angry and said that he didn’t need psychology, accused me of forcing him to do it, and made it clear he wanted to be gone. I try not to get into fights with the people I work with so I said we could finish for today and if he really felt that he didn’t want to continue then we would stop, and both of us could discuss the situation with his RMO (NB, this was not presented as a threat, just as something that we both should do so the RMO understood the situation). He agreed and left the room. I sat for a bit feeling a bit rejected and useless, wondering what I might have done to stop us getting to the point where he wanted to end things. That thought plagued me for quite some time.

I do take my own advice, and part of that is the importance of being seen on the wards, so that there is a degree of “transference” (in a forensic sense, not a psychodynamic sense), so I would continue to be on the ward and if I saw this person, I would acknowledge him, and if the opportunity arose, I would say hello. At no point did I raise the issue of work. I thought that perhaps if he got the sense that I still cared, was still there for him, could be trusted to not cause him trouble because he had decided to withdraw, maybe he would choose to come back. I like this idea, but do note, my belief in it is a little tenuous given that never in the history of my fairly awful dating history has this approach ever resulted in the rekindling of a romantic relationship. So, I have no evidence for it.

Weeks passed.

I would still turn up, be around, if he was there said hello, but never with the intention to monopolise him or steer him towards re-engaging. The fact that things had come to a juddering halt still plagued me and as I had supervision on the near-horizon I decided I need to have a plan as not everyone shares my view about the value of transference. I suspect that hardly anyone has ever read it. By trying to analyse what I had been thinking and had been doing it became clear to me that I was approaching the work a bit like a miner, gradually digging deeper and deeper, with the idea that if we could free the “coal” in his psychological mine then we could explore it, analyse it, and then to keep with the metaphor, throw it on the fire and watch it burn. If you have ever dug then you know it is hard work and the deeper you go the more the substance through which you are digging puts up resistance and the sides cave in to refill the hole. But what if rather than taking my client down into this mineshaft as we went digging, we thought about it as more bringing him up to the surface, from the darkness, from those fears of trauma, into the light? Few things remind me of Westlife, but this did (https://www.youtube.com/watch?v=9bxc9hbwkkw).

What would be his light? He wants to be released; he wants to get back to his life. Doesn’t it make sense that rather than driving someone towards their fears we support them in achieving their goals? It seems really simple, that change of direction, but I hadn’t seen it, given it any thought, as my intention was to protect him as we got closer to the trauma, rather than having a positive goal and help him plot a route towards that light. The niggle is, do we still need to address his own trauma? If he brings it up as a barrier to his success then he has opened the door, but what if he doesn’t? Is it possible that personal trauma can be dealt with or buried successfully enough by the individual that it never comes back to cause distress? We can’t really test for that as those people who have successfully done it are less likely to present themselves for investigation.

I will have to let you know, as this is in vivo, the work is ongoing, the risks are being taken, and the future is yet to be written. However, now that I have seen this it feels right and sensible and respectful. Just having written that sentence makes me wonder how dim I might have been to not think that trauma-informed care can also mean you can care by being informed enough not to threaten someone with the idea of an exploration of their trauma. To err is human. Perhaps one day I will be forgiven.