The Gift of Empathic Witness (MH2)

In the video I talk about mental health versus mental illness. This can be thought of as a spectrum where mental health is at one and mental illnesses at the other end. Also presented are the three treatment prongs in mental health; which are medications, counseling and having a wellness routine. There a brief discussion about the services of counseling versus coaching versus consulting. And lastly about how to find a professional in relation for your needs versus wants.

The Spectrum Wellness, Mental Health to Illness.

This post is to present a simple way to look via descriptive aspects of the spectrum. Looking at the spectrum vertically from bottom to top; Starting with the bottom and then rising to more complexity and a larger picture, which is a developmental view. Notice that this is basically the “wellness” structure. It is a simple descriptive approach of evaluating the functional integrity of a person. It is a simple yet effective to way see how a person is to how a doing. There are no clear boundaries, but one can get an overall sense and also identify areas where a person could improve their functioning.

Spiritual: Pondering the larger questions in life.

Psychic: Meaning and purpose, world view of the self, world and future.

Intellectual: Mental, rational, coherent, education

Emotional: Affect, mood,

Relational: interactive or social,

Energetic: Energy exchange,

Physical: DNA, biological, bio-chemistry, diet, sleep, physical exercise and maybe medications.

The Story:

When I ask “what’s up or what’s going on?” The intent is listening to their story and checking off or noting areas of concern relative to the above wellness spectrum list. This will give a “snap shot” of their present state, clinically known as the Mental Status Exam (MSE). This includes appearance, speech, affect, behaviors, thought content, thought process, awareness and understanding of their situation, judgement, insight, etc. It also reveals their general sense of themselves, their world and of their past and future.

Reviewing the reports and information from medics, police, family and hospital staff gives a good indication of other contextual factors and recent dynamics that result in their current presentation. Such as drug, alcohol, medical information, family, living situation, education level, type of work, recent and chronic stressors or traumas and so on. From this larger view, I’m looking at “risk factors.” The risk factors are historical, social, personality, dynamics, contextual/environmental and fluid, i.e., what has contributed to the person showing up today. Also what are the positive (beneficial and supportive) factors in their environment; whether it is a job, supportive family, activities, lack of drug and alcohol, lack of a history of violence, etc. In crisis work, often the presentation is raw, in your face and quite obvious. In comparison, outpatient therapy, the issues are more subdued. And the therapeutic issue is more focused, contained and subtle in how it affects the other areas in the client’s life. Last and perhaps most important is the client’s subjective story. It is what the client experiences as their most pressing issues and factors and reveals the underlying dynamics and premise of their experience of their “crisis.” This is the key. The spectrum gives clues as to why something is not working. But it is the client’s experience, i.e., “story” that provides access to their inner workings of their subjective world.

The Gift:

Listening to the client is one of the most obvious things to do. And yet one of the most over-looked and under-appreciated. Basically, the client is telling you what they need help with. Their story may be all over the place. But often that is because of their feelings and thoughts are all over the place. It can be noted as a pressure to tell their story and have someone listen to and understand it… from an empathic standpoint. The challenge is on several levels. First, to just listen, attend to what they are saying, how they are saying it, their emotions and making sense of their tale by listening between the lines. Second, is for the therapist to suspend their judgment as to morality, believability or veracity about the content, the emotions and potential consequences of the client’s story. It can be quite difficult to suspend your values, opinions and judgement of the client and their story. Realize that it’s the client’s story and as a professional you are merely a witness.

Pro tip: Clients know that a therapist can’t really do a thing for them. And for a therapist to pretend or operate as if they can has detrimental results. Primarily the client recognizes it’s therapeutic BS and can smell it miles away. This results in the client not trusting you and you are perceived as disingenuous.

It is a rare gift when someone listens deeply, without interruption, judgement, or to question the other’s experience. It is creating a sacred space to be a witness to another’s pain and suffering. A person’s pain and suffering isolates the person. The client is afraid to tell their story, it’s unbelievable, they will be ostracized or ridiculed, surely it will reveal that they are indeed crazy, only to be told to just buck-up … it’s all in your mind, that family and friends will argue with them, etc. Often what is happening is the client is putting themselves into a small box of questioning their existential meaning and purpose… “wtf why is this my life. ” When the gift of listening occurs, the client feels heard, respected and validated. It becomes a sharing of their burden. However, for the therapist, the trick is not to pick up their burden and carry it for them. But to offer the idea that they can drop their load or at least find a wheelbarrow in which to carry burdens until they are ready to let go of them. Ultimately, for each person, it is their lesson, their discovery and their sovereignty to decide what to do. The professional is merely there to help them clarify what they need and want and what they will do for themselves. (NOTE: If the therapist picks up the client’s burden, it does several things. It robs the client of the opportunity to learn and continue to discover their path. It tells the client that you as their therapist; that you don’t trust their ability as a client/person on their own path. AND then there is also the therapist’s being co-dependent on and intermeshed with the client. Likely at some point the therapist will become a hot mess and burnout.)

The experience opens an opportunity for an interaction of integrity. It becomes an experience of deep interpersonal connection for the client. And in this gift, it is the therapeutic relationship or connection, which for some is the central healing component that is beyond the therapeutic theory, skills or technique. In a nutshell, an individual’s interpersonal relationships are part of the client’s personality and experience that is not to be overlooked. (see Harry Stack Sullivan – Wikipedia and Thomas Szasz https://en.wikipedia.org/wiki/Thomas_Szasz

In a therapeutic interaction, the “gift” provides the experience and opportunity to interact with integrity, compassion and gracefulness. For example: I was called to the ER to evaluate a male in his 40’s who had brought himself in because of his thoughts and feelings of suicide. His basic story was that for the past 10 years he had been doing well; working full time as a welder, had his own apartment, friends, etc. He had worked hard to attain this life after having been released from a six-year prison sentence. However, about a year ago, in an incident of drunkenness and with poor judgment he ended up breaking the law, was found guilty and for the past three months had been awaiting the date to begin a 1.5-year sentence. And during the past two months, he felt his life had fallen apart. Subsequently he was feeling isolated, depressed and thinking “what the hell I might as well ended it all.” He was not fearful of returning to prison and noted that he could easily do his prison time.

After the telling his story and listening intently. I blurted out… “It sounds like you are just fucked!” To which the client immediately burst out laughing and crying at the same time. It was quite odd to see someone cry and laugh at the same time. The client noted he appreciated my honesty and felt the same way. And he noted I was the first person “that got it.” This connection enabled us to move on to an open discussion based on an integrity of understanding his experience.

This client was not suicidal. But he had put himself in a small box and didn’t know what to do. But by listening and being honest, it released his built-up anxiety and pressure. And now he could gather his wits. The rest of the time became a discussion of how could he use the impending 18 months of prison to better his lot in life. He was able to remember that during the past 10 years he had built himself a new life from his first prison experience. That the next 18 months would be relatively easy. He actual began to look forward to the prison time as an opportunity to plan and prepare for a better life when he would be released. He began to feel that the 18 months were a blessing in disguise to get his life back on track. By the end of our encounter, this client was hopeful, confident and had a direction/plan.

I’ve seen frequently and countless times where well-meaning and well-educated professionals, including docs, nurses, therapists, social workers have difficulty offering the gift of creating a sacred space for their client or patient. Often professionals comes in with an agenda, a list of questions (a diagnostic or informational algorithm) and cannot get out of their own way. Here is the thing: most people, when questioned, are going to tell the professional what they think the professional wants to hear. This is a simple “set and setting” expectations. Or the client presents their story in a manner so that the professional will be motivated to give them something that the client “wants.” The result is the professional ends up hearing the answers to a bunch of questions they have asked. This can end up being a wild goose chase and may not indicate what the client needs to benefit their wellbeing. The professional ends up missing the client’s actual reasons and the driving dynamics for their behaviors or presentation. This missing or misunderstanding, results in the client becoming frustrated, angered and feeling like we have not heard them. You can see the client’s think “OMG what a professional idiot.” Sometimes a client does not know what they need but is focused on what they want.

Another example: One morning I was in for a dentist check up; whom I had seen for past 20 years. She inquired how I was able sort through crazy cases? I noted, that she could take a brief 30 second look in her patient’s mouth and could easily know if the person had been flossing, drinking coffee, chewing on ice, etc. And what would likely happen in the future of a patient’s teeth. This was because of her being an expert with many years of experience. And the same is true for any experienced professional whether a mechanic, plumber, house painter or ski boot fitter. You don’t have to ask all the detailed questions; it’s much simpler and more focused to ask what they need, listen to the story (reasons) of what brings them in to see you and make recommendations or point out factors they might want to consider to prevent future issues.

A more efficient and accurate understanding of the client is by merely asking, “what’s up?” And then shutting up and listening. This approach creates a vacuum or a space which is generally uncomfortable. The normal response is for the client to fill that space. The first part of the client’s story is what they think you want to hear. But then their story morphs into what is actually the central issue for them. It is actually quite difficult for most folks to tell a cogent and coherent story for manipulative purposes. So, as a professional, you already know the questions that you need answered because you have memorized or are at least aware of the information to be collected. And you can easily recognize or observe what is there or should be there. The question is, what is your professional style? Is it the machine gun questioning for information, read off a computer screen while you frantically type their response. Or is it listening to the client’s story and then mentally checking-off or making a note the information gathered from their story. In short, you don’t have to ask the questions. It’s often easier, more efficient and accurate to listen for the answers in their story. And you will discover the underlying dynamics of the what’s and why’s of their presentation. The tip is to organize your method of taking notes. Also, the typical interview kind of questioning does not lend to establishing a therapeutic relationship in which can be later leveraged in moving the client from crisis to opportunity. The result, is that it will take a bit more time to listen to the story. But in the end, it saves overall time, work and allows for a more effective movement from crisis to opportunity.

The point is, we all connect more easily with folks who have integrity, compassion and gracefulness. Thus, if we are able to create a sacred space in which to listen to another soul. We will all be able to have open honest conversations with integrity, compassion and gracefulness … and thus help each other grow.

Blessings

Tim

Next Post: Diagnosis, Dynamics and Treatment MH3.