A decade after retirement, I remain preoccupied with some basic issues pertaining to psychotherapy. I believe it is important to express some of the misgivings I have about the general training and preparation of therapists, based on the experience I gained over 40 years as a psychiatrist.
After one graduates with a basic medical degree, the training to become a psychiatrist lasts for several more years. There are usually pre-medical school studies of basic science or humanities that one takes before embarking on subjects such as anatomy, biochemistry, physiology and psychology. But, somehow, the positive factors relating to healing and restoring individuals to wholeness are not discussed. They may be implied but they are not specifically engaged. Factors that directly influence the work of a therapist are usually not mentioned, the two key ones being hope and compassion. Perhaps they are regarded as self-evident and therefore not in need of exploration but, by failing to focus on them, therapists are not guided to consider their importance or trained in how to put them into action.
The fundamental message of compassion exists in every religious tradition I have encountered. It is an essential practice for many Saints in the Christian tradition; it is one of the principal teachings of the Buddha; and it is the most used word in the Koran. Clearly, the importance of hope and compassion transcends sectarian differences. In the absence of religious traditions, most individuals express their common humanity through kindness and compassion.
It is kindness, the active component of compassion, the instills hope. Hope offers a path back to a sense of possibility in our lives when all, or almost all, seems lost. It’s about relief and restoration. There is a Chinese proverb that says, “Beyond the dark willows and bright flowers, there is another village.” A western proverb says, “A dark cloud has a silver-lining.” These can give sustenance to us going forward, strength to continue putting one foot in front of the other. They communicate the opposite of despair, the opposite of a “dead-end street.”
As a therapist, it is worth considering a few questions concerning hope: how important it is to instill or invoke hope it in your client; how does one engender and nourish hope; what might undermine hope in a patient; what does it feel like for you, as a therapist, to hope; and, crucially, what does it feel like when you, as a human being, lose hope – even briefly. While everyone’s answers are different, asking the questions is critical for one’s own understanding of the role hope plays in your work and life, as well as specifically they might apply to individual patients.
We all should, or are presumed to learn, these positive attributes of hope and compassion though the love and nurturing we receive from our primary caregivers. Generally speaking, they are learned from our parents, or perhaps our teachers in kindergarten and/or Sunday Schools. But, this is less and less the case in modern life. For patients, those positive attributes may not be accessible following trauma – particularly repeated early childhood trauma caused by primary caregivers.
All of therapy is built on a foundation of hope. Hope that things can change: habits, behaviours, emotions, outlooks, relationships and even people themselves.
For those who do not find inspiration from religious texts whether it be the Bible, the Bhagavad Gita, the Koran, the Buddhist sutras or others, let me point out that hope is associated with life itself. The organism knows best. Just as plants grow towards the light, the human organism intuitively knows a healing path back to well-being. A good therapist can point out the light to a patient, but part of therapy is getting to what is blocking this intuitive understanding. Perhaps it is our chaotic day-to-day struggles, perhaps it is confusion that is the result of early traumatic experiences.
To properly provide a therapeutic container, a place where the light can shine on a patient, the therapist must be clear about their own internal obstructions. Therapists are prone to depression and negative mind-sets, just as their patients may be. Many therapists, unconsciously, are drawn to the profession as a way to work out their own psychological issues. Some may simply become overwhelmed by the intensity of their patients’ suffering. Others may survive by becoming inured to it.
A depressed therapist tends to be bogged down by the client’s problems perhaps because they are wearing glasses with that same tint. A therapist may also become depressed as a result of vicarious re-traumatization though their empathic listening. Trauma-fatigue is common for the therapists who have neglected their own mental health in the past, and/or fail to maintain it under the stress of their profession. My training was primarily in British institutions, where professionals are expected to keep a stiff upper lip and maintain one’s dignity as a professional regardless of any internal turmoil. The risks of vicarious trauma and trauma fatigue were never mentioned in my training.
Looking through the case files of successful suicides, I have come to the conclusion that the common element was that hope was missing. There was a failure by the therapist in that critical goal of instilling a sense of hope in the patient. Hope is the predicate to reversing the suicidal path. Sometimes the right medication, or even electro-convulsive treatment, was able to slow down and perhaps reverse the progress towards self-destruction, but not always and certainly not in a majority of the cases I reviewed. If a therapist is honest in their self-reflection, consider the possibility that one if one gives a subtle signal of giving up on the patient, that can and often will be seen by the patient as a message of “permission” to end their life.
To put this in a practical context, when a therapist faces a patient who is imminently suicidal, the first response is to determine, by knowing the patient’s personal circumstances and/or through truly deep listening, how serious the risk is for that patient to act out on their suicidal ideation.
In my previous post on the importance of hope, https://www.engagingmultiples.com/the-importance-of-hope/, I discussed briefly a particular patient who was suicidal. She was the last appointment in my day’s schedule. I know that many therapists would decide that immediate hospitalization would have been the correct response to this situation, and in many cases, if not most, they might be correct. However, this was a DID patient and I did not see hospital admission as likely being helpful to reverse that decision.
Hospitals can be a negative experience for the patient, especially when the treatment team or the ward milieu is not suitable for DID patients. One must remember some mental health professionals do not even acknowledge DID as a legitimate diagnostic mental disorder regardless of its inclusion in the DSM. Hospitalization in this particular case would have meant a cop-out for me as the therapist as it would not address the actual triggering issue or the loss of hope. So, I decided the only way to approach this was to see if I could actively instill hope in her.
The key was that I took her words of hopelessness as a simple direct statement rather than a threat of any kind; empty or genuine. Her decision to end her life was averted once hope was instilled in her. I am confident that hope was what saved her.
