People often write about change in psychotherapy. Fewer people seem to write about how changes are noticed and acted upon, especially in clinical teams. This piece is written for people working in teams and tries to suggest a few things about accountability among clinical groups.
When you see something that you believe someone has missed it can feel alarming. (I’ve heard it can also be gratifying.) There’s a kind of noticing which can either be constructive or divisive, depending on how it’s approached, and it goes like this: someone (a therapist, a counsellor, a nurse; let’s not get too hung up on titles right now) is responsible for a client, perhaps something goes wrong or a situation deteriorates, or nothing seems to be happening, and another person is invited in (hopefully by the first person) to take a look at that client as well. I’ve experienced this from both sides.
At worst, the person being called in might see what they call negligence. Negligence happens and is probably as likely as ever to happen now, although I won’t get into that here (if you’re interested, I imagine all would be revealed rather quickly if you watched Ken Loach’s latest film and then read some Adorno on administrative culture). More often I imagine that what might be regarded by the second person as having been ‘missed’ by the first person has actually been subject to one of, broadly speaking, three kinds of process.
The first person may have been aware of what has been ‘missed’ but chosen to approach it in a way that does not seem immediately obvious to the second (process one); or it could have been seen and not considered as important as the second person believes it to be (who may or may not be right in believing this – either way, this is process two); or it could have been become perceptible as a result of the way the first person has worked, but remained undetectable, immediately, to him or her, such are the defences at play (process three).
There’s much I would say about the first two categories of process listed above. It’s the third, however, that I want to say some more about here. If you have some kind of affinity to what’s usually called ‘psychoanalytic’ work then the third category is possibly one that you never let slip out of mind. But I think any experienced clinician, in fact anyone who’s had the regular experience of joining in with work someone else has begun, might recognise that some things will never be immediately perceptible to the people who begin to make them knowable.
Good clinical work is work from which something emerges over time. This calls for a kind of continuity in which accountability is isolated, as far as possible, from blame – where it’s sought after by the person accepting it, rather thrust upon them as part of a move to account for what apparently hasn’t happened, with no acknowledgement of ‘yet’.
The idea that clinical work can predictably happen in the time we would like to allocate to it is of course most seductive. Given the ways in which clients live their lives, how treatment is paid for, and how therapists work it’s almost too much to bear, to think that the most useful thing in someone’s treatment may be happening only unrecognisably so. But holding onto the idea that perhaps something hasn’t happened yet, and that some clinicians are going to complete what they see as their work without perhaps feeling with their client the greater sense of achievement that comes with a life ‘turning around’ calls for a rare and special kind of collaborative work.
Supervision and cooperation must hold strong without starting to become steely. Experience needs to be contained without being restricted or constricted; growth needs to happen while being shaped as little as possible by containing forces (directive work needs at some point to give way to a client finding his or her own direction).
Plato (the Timaeus), Heidegger (Was heißt Denken?, 1954 [What is Called Thinking?, trans. 1968]), Bion (Container and Contained, 1962) and Derrida (Sauf le Nom, 1993 [On the Name, trans. 1995]) wrote about this. Still, it seems somehow to so often become forgotten.
And of course I am not suggesting that certain other important things be forgotten, like looking closely at what is evident to everyone involved and making sure certain parameters are not exceeded: the ones written into the ethical codes we subscribe to and the bottom lines relating to the forms of treatment or engagement we begin. It would be a mistake, however, to believe these things are always decided beforehand, in another place, such as a room inhabited by a UKCP ethics committee. Things begun in those places have a life of their own, too.