Enough with the Questions!

Jay Watts, DClinPsy
27
202

A patient needs some extra support over the weekend. I suggest I get the Crisis Resolution Team to visit her every day. ‘What’s the point’, she says. ‘You know, they just ask the same questions again and again. It makes me worse’. I have no answer. I know this is true.

For several decades, since the days when I was a patient, I have seen and heard how an obsession with questions damages psychiatry. Many of us have been asked the same questions day after day, year after year: ‘Do your thoughts seem faster than normal?’, ‘Do you ever have thoughts in your mind which are not your own?’, ‘Do you feel anxious?’, and so on.

What does this feel like? As ever, my patients describe it best. One locates it as “like a machine gun into my brain”, another “an attack, an intrusion, a knife into my body”. A socially anxious man appeals “Did I say what I was supposed too? Did I perform OK?”. A woman with a long history of childhood abuse says the questions felt like “a penis going into my body, again and again”.

These type of descriptions are the norm not the exception. For the structure of being asked questions is a specific one: it places the desire of a powerful other (the nurse, the psychiatrist, the social worker) as primary. This echoes an interactional pattern so familiar to so many who have been bullied, shouted at, beaten, tortured, sexually abused. The feelings from these past times can return in the body – anxiety, paralysis, disconnection, anger – none of which are articulated to the professional, trumped by the desperate life or death task of getting out of the room in a vaguely ‘together’ way. So the doctor gets thanked for his time and doesn’t learn any better, and it is the student nurse on the ward, or the parent at home who sees the person in bits. Hearing only what a patient says under questioning when frozen by paralysis, or subject to the hyper-arousal of anxiety, the professional misses the opportunity to hear the threads of something new, the possibility of weaving with the patient a narrative of hope and recovery.

To be with someone in real distress can be incredibly difficult, and we can perhaps empathise with the professionals unconscious desire to cling desperately to the diagnostic manual, to the crib sheet of mental state assessment questions, as someone drowning clings to a rock. Hearing a person’s real history, rather than the history of their symptoms, makes explicit the limits to what psychiatry can do – the drugs don’t often work, and they rarely get rid of what triggered the problem in the first place. As both parties have some awareness of this, they can only perform  ‘the doctor who asks questions’ and ‘the patient who answers questions’. This is deeply depersonalising and means neither party will quite be there, both alienated by a set of rules of how they should be, as Tom and Jerry are obliged to perform Cat and Mouse. Yet, it’s perfectly possible to rip up the implicit rule book, and have a real encounter. It doesn’t mean the psychiatrist can’t check in on any risk questions right at the end, it doesn’t mean no medication to dampen down the physical, but it does mean the patient gets to dictate what the space might look like for the overwhelming majority of the time.

The need to fight for space so something of one’s distress can be heard becomes ever more important as even psychotherapy spaces becoming colonised by form filling, much of which is a response to the professionals internal judge who screams ‘show you are doing something!’ as opposed to a task related to patient care. For a barrage of questions about symptoms obliterates the possibility of the joining patient and professional to explore: ‘symptom of what’.  This is especially tragic when going mad can unconsciously be a way to try to communicate something that hasn’t been put into words. Mania can be a desperate attempt to flee hopelessness, voices the still heard words of an abuser, rage an understandable response to being downtrodden, depression unspoken grief for a baby, lost. The ‘what’ here is not connected to anything that can be found in one of the heavy diagnostic manuals, or got rid of by a small change in medication dosage. Every meeting that fails to explore this ‘what’ solidifies the psyches defences – it repeats what is often a common theme in a patients life ‘you are alone with this’.

How, then, can we construct a space that isn’t dominated by colonising questions? Both parties may think anxiously of the comic blind date sketches that originate from the horror of being asked outright ‘What do you want to talk about?’ Instead, professionals need to learn how to carve out an open, space in a gentle manner. This must involve thinking about how power, emotion, and social conventions may be present in interaction. Consider the question ‘How are you?’. A health professional will often ask this before proceeding to do a mental state exam, taking a simple response as meaning its time to start on their agenda. However, in any scenario, ‘How are you?’ nearly always needs to be asked twice. For at first, we tend to give a smudged response (‘ah you know, so so’) to allow us to ask the questioner how he or she is, the rules of normal discourse. We do this so often it’s automatic, so if a professional asks it we default into the same pattern.

Yet, if we ask someone ‘how are you?’ a second time, and really mean it, something more singular always emerges. The text of the person’s response nearly always provides some clues we can pick up on. So, if someone says “I’m alright, you know, things aren’t always easy”, we can repeat “things aren’t always easy” with a questioning tone and we’ll get an elaboration on how present the voices are, how impossible it is to open the post, or whatever it may be. Or we might pick up the ‘you know’, insisting perhaps with a dollop of humour, that its actually the patient who knows. And then we hear how tough its really been. We ask one simple question and then position ourselves as subservient to the discourse of the patient, attending to the silences, and pauses, and body language. It is this which gets to direct the conversation. Questions only become useful when they are about something idiosyncratic that has slipped into the conversation – an interest in a particular band, an old dream to be a footballer. Curiosity on this can often allow new expanses of our experience to reach discourse, can remind us of things its worth getting better for.

Rather than the dominance of the voice of the most powerful person in the room, we need a psychiatric practice that privileges and gives real space to the service users voice. It is madness to expect healing to occur if a space is colonised by standard often heard psychiatric questions, with the service user only asked what they wish to talk about in the snatched last few minutes, expecting them to express their needs whilst a professional shuffles their notes and makes to leave the room. Though psychiatry brings up metaphors of the brain to justify its practices the whole time, the evidence base actually supports such an approach. The diagnostic system is being revealed left, right and centre as an unscientific system still waiting 100 years on for evidence, the promised improved wave of new atypical antipsychotics now revealed as no more effective than the ones that went before, and the talking therapy beloved of the market place, CBT, is shown to be no more effective than befriending for psychosis . In contrast, the best outcomes in the world, using the most rigorous randomised controlled trials, are from a Scandinavian programme called ‘Open Dialogue’. With this approach, when someone becomes acutely distressed, everyone involved meets within twenty four hours – the patient, their family, any neighbours or friends, and professionals. They talk about what may be happening. The professionals do not ask questions, they are more there to witness what emerges, and make sure everyone’s voice is heard. The professionals talk about the power their titles may seem to bring, and how it is is dwarfed in the face of the lived experience of those present who know what’s been happening. All the professionals do is listen for the truths, the islets of hope, the forgotten traumas and dreams, which inevitably leak out in the act of speaking.

I write “all the professionals do is listen for the truths” but the ability to do this, to stay with distress, is something that has to be cultivated through gently guiding the professionals hand away from the book, so they can actually be with the person in front of them. If the professional can stop using questioning as a way not to be there, they will be able to join with the patient to hear something new and emerging in the conversation that may be a surprise for all. It is when we have the space and safety to surprise ourselves with hidden knowledge of where we are, and where we have been, that the seeds of recovery are sown.

 

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27 COMMENTS

  1. The person asking questions is the one in control of any conversation (psychotherapy, family relationship, business deal).

    A salesperson at a car dealership:
    “Let me ask you a question…”

    A barrage of questions, back-to-back, is the ultimate power grab.
    And someone who is not anxious to relinquish their own autonomy is likely not going to allow another human being to dominate the dialogue by responding to each, over-and-over.

    Sometimes I’m not sure if we would have more healing taking place if there were more equals and fewer professionals. I’m not down on therapists or counselors, but I wonder how many are good at just listening and being with a person who is deeply suffering – in a matter they would like if they were in the same situation.

    Good post.
    Thanks.

    Duane

  2. Great piece, Jay. As a former mental health counselor, I can totally relate to what you’re saying. I had the privilege of becoming a mental health counselor with almost no training at all (for some reason, they all thought an MS in Education qualified me as a counselor – go figure!) and learned most of what I know about therapy from my clients. The most fundamental truths I learned were that 1) me being real and genuine and vulnerable and willing to “sit” with their discomfort when they told their stories was far more important than any “technique” I ever learned, and 2) that no matter how crazy someone’s behavior seemed to me, if I listened well enough, there was some reason why that behavior made sense.

    The main reason the DSM drives me around the bend is that it interferes with both of those two points I learned to be so important. Having a diagnosis allows the clinician to distance him/herself from the patient and avoid having to deal with the feelings evoked from real empathy. It also allows them to avoid working with the client to seek a context to explain the behavior or emotion, as the behavior or emotion are identified as the problem rather than the indicator of something more fundamental.

    I bet you’re an awesome therapist and your clients are lucky to have you. But of course, what you do should be the actual minimum standard for therapists. We have to have our own shit together well enough that we don’t dump it on our clients. The rest becomes kind of obvious once we get rid of the need to have “clinical distance” and “evaluate our patient’s symptoms” and start dealing with them as one vulnerable, emotion-laden, spiritually seeking human being to another.

    —- Steve

  3. Yes, many patients may provide answers because they’re supplicating. An article on childhood trauma discusses supplication in terms of physical contact, like too much hugging. It says supplication is socially inappropriate. (bottom of page 8 – http://childtrauma.org/images/stories/Articles/attcar4_03_v2_r.pdf ) This could be true of other types of supplication as well. It’s unhealthy to go along with a structure that doesn’t best promote mental harmony.

    It’s healthy when interactions are harmonious. This occurs when people’s own inner harmony is reflected back to them. Technology that does this relieves symptoms of disorders, for good, and pretty quickly (http://www.brainstatetech.com/videos/introduction-brainwave-optimization – I’m not paid to share it). Questions whose underlying focus is on finding mental problems do the opposite. They reflect back inner disharmony. Technology now proves that’s unhealthy, which is needed to prove that so much social momentum in looking for personal problems is misguided.

    What kinds of activities reflect back people’s inner harmony? Honestly, it may be healthier if people played games like pictionary together. It’s harmonious when someone appreciates what one has created, by noticing how it’s effective to help succeed in a shared objective. Just as psychiatrists are going to have to embrace neuro-technology, so will therapists and their related colleagues. Computers can be perfect, unlike people, at reflecting back only someone’s harmonious brainwaves. People are subject to a lot more disharmony than that, but we can be harmonious enough to realize what helps us do better.

  4. Thanks, this was a great post! I finally got fed up with answering the same 45 minutes of questions (and the eight different diagnoses that were handed to me over the last couple years by different doctors, after answering them all the same way!) So last week when I had my first meeting with my new psychiatrist, I typed up a list of the questions, their answers, told him to spend a few minutes reading it, and then we were going to discuss the real problem. It was the first time I ever walked out of one of these intakes where I felt like the doctor actually understood what was going on.

  5. Thanks for explaining very well the hazards of “too many questions” and too little caring for the person being asked the questions, and welcome to Mad in America as a blogger!

    One fine point I would disagree with you on though concerns the value of CBT for psychosis compared to “befriending therapy.” Despite the success of befriending therapy, and the fact that it sometimes, as in the article you linked to, shows as good a result as CBT for psychosis, I think it is important to note that when looking at all the studies overall CBT for psychosis appears to have a benefit in addition to befriending. See http://www.apa.org/pubs/journals/releases/pst-49-2-258.pdf for one summary of the data.

    I recently heard Doug Turkington, one of the lead CBT for psychosis researchers, talk about some of the studies comparing “befriending therapy” with CBT for psychosis. He said lots of things happened in the befriending therapy that weren’t at all planned by the therapists, who were just trying to create a friendly relationship. People would do things like decide to explore trauma that happened in their past, trauma that hadn’t been dealt with at all by the mental health system up to that point. This demonstrated how people sometimes really know what they need, and therapists just have to let the person take the lead so that the healing can happen.

    There are other times though that people really want ideas about what to do about what is troubling them, and they are really disturbed by therapists who just want to listen and have little to offer! So I think the best therapists have flexibility and really try to figure out what the person wants and is ready to benefit from – they have ideas to offer, but also know how to simply be a listening friendly person when that is what is likely to work.

    • Ron,

      I agree whole-heartedly. The benefit of ‘befriending’ therapy for psychosis is quite limited. I found ‘befriending’ to be a role better fulfilled by actual friends (i.e. via people met in peer support groups). The point of going to a therapist is to learn and practice coping skills.

      By the way, I also wanted to say thanks to you personally for the fantastic website you put together on CBT skills for psychosis. It was my ‘de facto’ digital therapy for the first few years, while I was trying to get adequate health insurance and then on the long wait list to get into a CBT clinic. I am not sure I would have survived the first years of this without it; keep up the good work!

      Alexa

      • Hi Alexa, I agree with your point that in general actual friends are in general of more value than therapists who are doing nothing other than being friendly, though there are some exceptions. One is if a person doesn’t have friends they can trust to talk with about certain subjects: then having a therapist to talk with about those subjects can make a huge difference. Sometimes the problem is that within a given culture, too many people don’t know how to function as a friend in relationship to certain events, in that case the most important skill of a therapist might be to just continue to engage in a friendly way in relationship to experiences lots of people might over-react to.
        Oh, and thanks for the feedback about my website – I’m glad some of the content was helpful to you!

        • There will always be a need for paid and unpaid supporters [be they professional or non professional] because even the best friends in the world have work, kids, maybe a lack of space to accommodate someone in crisis. Even when people love us dearly that doesn’t mean they can automatically relate to us on all issues. I don’t talk to my parents about my voices because that’s not something they can relate to, not because they don’t care, everyone has their strengths and limitations.
          I can think of one friend who has the space to accommodate someone for weeks, even months [and has done so] but how many of us have that as an option? Sometimes we do need to speak with someone outside our friends and family, sometimes we do need to be physically somewhere else but there’s no non-psychiatric crisis/respite facility.

  6. A wonderful essay which to me seems to be exploring the “core” issue of “arousal?” Is arousal about the brain and mind, or essentially about the heart and the innate orienting responses we cal primary emotions? As you say;

    “Hearing only what a patient says under questioning when frozen by paralysis, or subject to the hyper-arousal of anxiety”

    The questions address the person’s cognition as a function of the cortex (higher brain function) yet arousal of our core orienting responses to life, like fear, anger, joy, etc, are sub-cortical functions overwhelmingly concerned with the body and movement, and setting the “tone” of our cognition. Imo being with someone in distress involves an ability to observe the “unspoken” language of the body and “feel” the emotional arousal of the another person. Hence you write;

    “I write “all the professionals do is listen for the truths” but the ability to do this, to stay with distress, is something that has to be cultivated through gently guiding the professionals hand away from the book, so they can actually be with the person in front of them.”

    Beyond the headline debates about the DSM-5 and professional turf wars, with jealously guarded territories, is a slow education process happening beyond the ivory towers? Beyond assumptions about brian diseases and pecking orders of rank and status, is a somatic approach to emotional distress gaining ground after decades of cognitive misunderstanding? Please consider;

    “Toward a New Paradigm of Psychotherapy

    For the last two decades, I have argued that no theory of human functioning can be restricted to only a description of psychological processes; it must also be consonant with what we now know about biological structural brain development. Three other themes that continue from literally the first paragraph of the first book are that the early stages of life are critical to the development of all later evolving structures and functions, that emotion is central to a deeper understanding of the human condition, and that unconscious processes lie at the core of the self, throughout the life span. The book thus also attempted to reintegrate psychoanalytic ideas of the unconscious mind into developmental science. Affect Regulation and the Origin of the Self— which is now in its 14th printing— was the first book to document not the cognitive development, but the social-emotional development of the infant.

    Now it is true that the current surge of research is being fueled by advances in a variety of cutting-edge neuroimaging technologies that can observe and document ongoing brain structure– function relationships. The reader should note there is a major limitation to current in vivo imaging techniques— their limited temporal resolution does not allow them to capture the real-time dynamics of brain function. But even future advances in technology would not be enough. We also need an integrative psychoneurobiological theoretical model that can not only generate testable hypotheses but also conceptualize the vast amount of research and clinical data in a meaningful way.

    And we need an interpersonal neurobiological perspective that can account for brain-to-brain interactions. As editor of the Norton Series on Interpersonal Neurobiology, I see this quantitative leap and qualitative shift in emotion research as a powerful source of updated models of psychotherapeutic interventions that are grounded in developmental, affective, and social neuroscience. It is now clear that psychotherapeutic changes in conscious cognitions alone, without changes in emotion processing, are limited. In fact, a clash of psychotherapy paradigms can currently be seen, especially in the treatment of more severe disorders that present with a history of relational trauma and thereby a deficit in affect regulation. In such cases emotion more than cognition is the focus of the change process, and so CBT is now being challenged by updated affectively focused psychodynamic models, including ART. In his most recent book my colleague Philip Bromberg (2011) also describes the paradigm shift in psychotherapy:  

    Interpersonal and Relational writers largely have endorsed the idea that we are in fact confronted with a paradigm change and have conceptualized it as a transformation from a one-person to a two-person psychology. I feel that this formulation is accurate, and that three central clinical shifts are intrinsic to the conceptual shift: A shift from the primacy of content to the primacy of context, a shift from the primacy of cognition to the primacy of affect, and a shift away from (but not yet an abandonment of) the concept of “technique.” (p. 126)

    The current radical expansion of knowledge and paradigm shift has wider implications beyond the mental health professions to the cultural and political organization of societies. In my 2003 volumes I argued that the right hemisphere nonconscious implicit self, and not the left conscious explicit self, is dominant in human adaptive survival functions. Offering data at the neuropsychological, cultural, and historical levels, McGilchrist (2009) echoes this principle:

    “If what one means by consciousness is the part of the mind that brings the world into focus, makes it explicit, allows it to be formulated in language, and is aware of its own awareness, it is reasonable to link the conscious mind to activity almost all of which lies ultimately in the left hemisphere” (p. 188).

    He adds, however, “The world of the left hemisphere, dependent on denotative language and abstraction, yields clarity and power to manipulate things that are known, fixed, static, isolated, decontextualized, explicit, disembodied, general in nature, but ultimately lifeless” (p. 174). In contrast, “the right hemisphere … yields a world of individual, changing, evolving, interconnected, implicit, incarnate, living beings within the context of the lived world, but in the nature of things never fully graspable, always imperfectly known— and to this world it exists in a relationship of care” (p. 174). Indeed, the “emotional” right hemisphere “has the most sophisticated and extensive, and quite possibly most lately evolved, representation in the prefrontal cortex, the most highly evolved part of the brain” (p. 437).

    An essential tenet of McGilchrist’s volume (2009) is expressed in its title: the right hemisphere is the master, and the left the emissary, which is willful, believes itself superior, and sometimes betrays the master, bringing harm to them both. Offering interdisciplinary evidence that spans the sciences and the arts, he convincingly argues that the left hemisphere is increasingly taking precedence in the modern world, with potentially disastrous consequences. I agree that especially western cultures, even more so than in the past, are currently overemphasizing left brain functions.

    Our cultural conceptions of both mental and physical health, as well as the aims of all levels of education, continue to narrowly overstress rational, logical, analytic thinking over holistic, bodily based, relational right brain functions that are essential to homeostasis and survival. It is ironic that at a time when clinicians and researchers are making significant breakthroughs not only in right brain social-emotional models of optimal development but also in right brain models of the etiologies and treatment of a wide range of psychopathologies, strong economic and cultural inhibitory restraints and cutbacks are being felt by practitioners. How can we understand this? We are constantly told that the reason for this lies in objective economic factors. But the paradigm shift in psychology and neuroscience suggests subjective unconscious forces are at play here.

    Listen to McGilchrist’s (2009) description of what the world would look like if the left hemisphere were to become so far dominant that, at the phenomenological level, it managed more or less to suppress the right hemisphere’s world altogether. He imagines that this left-brained world would lead to an increasing specialization and technicalizing of knowledge, as well as the following: increased bureaucratization, inability to see the big picture, focus on quantity and efficiency at the expense of quality, valuing technology over human interaction, lack of respect for judgment and skill acquired through experience, and devaluing of the unique, the personal, and the individual. Even more specifically; 

    Knowledge that came through experience, and the practical acquisition of embodied skill, would become suspect, appearing either a threat or simply incomprehensible.… The concepts of skill and judgment, once considered the summit of human experience, but which come only slowly and silently with the business of living, would be discarded in favor of quantifiable and repeatable processes.… Skills themselves would be reduced to algorithmic procedures which could be drawn up, and even if necessary regulated, by administrators, since without that the mistrustful tendencies of the left hemisphere could not be certain that these nebulous “skills” were being evenly and “correctly” applied.… [F] ewer people would find themselves doing work involving contact with anything in the real, “lived” world, rather than with plans, strategies, paperwork, management and bureaucratic procedures.… Technology would flourish, as an expression of the left hemisphere’s desire to manipulate and control the world for its own pleasure, but it would be accompanied by a vast expansion of bureaucracy, systems of abstraction and control. (McGilchrist, 2009, p. 429)  

    Sound familiar? I suggest that this “imagined” left brain worldview now dominates not only our culture but also the current mental health field in the following forms: an overemphasis on psychopharmacology over psychotherapy, an undue influence of the insurance industry on defining “normative” and “acceptable” forms of treatment, an overidealization of “evidence-based practice,” an underappreciation of the large body of studies on the effectiveness of the therapeutic alliance, a trend toward “manualization” of therapy, a training model that focuses on the learning of techniques rather than expanding relational skills, and a shift of psychotherapy from a profession to a business.

    Can we reverse this current imbalance of the hemispheres? The paradigm shift has generated a quantum leap in our attempts to understand a number of fundamental questions of the human condition that can be elucidated by recent discoveries of the early developing right brain. A prime example is the surge of deeper explorations of our human origins by contemporary developmental science. In 2005 Insel and Fenton articulated this widely held principle:
    “Most mental illnesses … begin far earlier in life than was previously believed” (p. 590). More recently Leckman and March (2011) are asserting that “A scientific consensus is emerging that the origins of adult disease are often found among developmental and biological disruptions occurring during the early years of life” (p. 333).

    We need, now, to use recent knowledge in order to reflect more deeply and act more directly on what is required— at levels of the individual, family, and culture— to provide an optimal human context for both mental and physical health. In addition to culturally supporting the development of intellectual and cognitive abilities, we need to foster the individual’s adaptive capacity to relate socially and emotionally to other human beings via the right brain functions of intersubjective communication, affect processing, empathy, and interactive stress regulation. The large body of studies on the critical survival functions of the right brain can be applied not only to individuals but also to cultures (Bradshaw & Schore, 2007; Schore & Schore, 2008).

    Here in the United States, how are we reacting to this crisis at the core of our culture? And if we are not responding, why not? In clinical models we speak of individuals having intrapsychic defenses against uncertainty, stress, and painful negative information. But defenses such as denial, repression, and even dissociation are collectively used by the culture to avoid more directly confronting the serious stressors that lie at its core. Forty years ago Jacob Bronowski offered the trenchant observation, “Think of the investment that evolution has made in the child’s brain.…

    For most of history, civilizations have crudely ignored that enormous potential. In fact the longest childhood has been that of civilization, learning to understand that” (1973, p. 425). In a current attempt to overcome that resistance and bring this problem closer to the forefront of cultural consciousness, my colleagues and I are producing two multiauthored volumes: Evolution, Early Experience and Human Development: From Research to Practice and Policy (Narvaez, Panksepp, Schore, & Gleason, in press), and The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic (Lanius, Vermetten, & Pain, 2010).

    Grounded in recent developmental neuroscience, psychiatry, and developmental psychology, these books cast light upon a number of serious psychological and social problems underlying our cultural blind spots. But more than that, contributing scholars from multiple disciplines offer practical thoughts about what types of early-life experiences are essential for optimal development of human brain and body systems— in order not only to generate greater understanding of scientific research and theory but also to promote informed public policy.

    In a recent overview of contemporary developmental neuroscience, Leckman and March (2011, p. 333) conclude, “our in utero and our early postnatal interpersonal worlds shape and mold the individuals (infants, children, adolescents, and adults and caregivers) we are to become.” At this point in time there is converging evidence that we can maximize the short- and long-term effects of our interventions by concentrating on the period of the brain growth spurt— from the last trimester of pregnancy through the second year. Whether or not our governments will fund such sorely needed efforts remains to be seen.

    Fifteen years ago, A. Schore outlined the essential role of attachment in the regulation of affect and emotional development. In his seminal 1994 volume, he integrated a large amount of existing interdisciplinary data and proposed that attachment transactions are critical to the development of structural right brain systems involved in the nonconscious processing of emotion, modulation of stress, self-regulation, and thereby the functional origins of the bodily based affective core of the implicit self that operates automatically and rapidly, beneath levels of awareness. In 2000, within an introduction to a reissue of Bowlby’s (1969) classic volume, Attachment, A. Schore proposed, “In essence, a central goal of Bowlby’s first book is to demonstrate that a mutually enriching dialogue can be organized between the biological and psychological realms” (p. 24), and argued that attachment theory stresses the primacy of affect and is fundamentally a regulation theory. This linkage of the theory with affective dynamics was mirrored in Fonagy, Gergely, Jurist, and Target’s (2002) Affect Regulation, Mentalization, and the Development of the Self. Indeed, Fonagy and Target (2002) concluded “the whole of child development to be the enhancement of self-regulation.” In parallel work on attachment from the social psychology perspective, Mikulincer, Shaver, and Pereg (2003) have offered extensive work on “attachment theory and affect regulation.” The current shift of attachment theory from its earlier focus on behavior and cognition into affect and affect regulation reflects the broader trend in the psychological sciences. In a recent editorial of the journal Motivation and Emotion, Ryan (2007) asserts:  

    After three decades of the dominance of cognitive approaches, motivational and emotional processes have roared back into the limelight. Both researchers and practitioners have come to appreciate the limits of exclusively cognitive approaches for understanding the initiation and regulation of human behavior. (p. 1)”

    Excerpts from “The Science of the Art of Psychotherapy” by Allan N. Schore.

    Have we become so “conditioned” to understand ourselves as a “thinking” being, that we literally cannot see unspoken body language, or feel the the true meaning of emotional expression, because we are oblivious to how we “distance” ourselves from our sens-of-self, with layers of “rationalized” defence?

    Enough with questions, that are essentially about “self-defence,” and the health care professionals NEED to remain as unaffected by another’s emotional state as possible. Hence the “visceral” term “shell shock” used after world war one, has been transmuted into a less emotionally resonant PTSD label. Thus allowing the observing intellect a comfortable distance from the HEART of its own arousal.

    Best wishes to all,

    David Bates.

  7. Thank you for this post. I have been a student and practitioner of Narrative Therapy for a number of years now, and I found the sentiments reflected in your piece deeply resonant with the tenets I have learned from the NT tradition.. Narrative inquiry emphasizes the importance of co creating therapeutic dialogue with a client in a manner that does not shut down his/ her ability to see beyond the “problem saturated story.” In that vein, questions that investigate “sparkling moments” where individuals have come out from underneath their problems, challenges, distresses and disasters are just as important as the “what is wrong” investigations. Without this balanced approach to questioning, we risk remaining oblivious to the fact that individual we are working with may actually possess the very qualities s/he needs for his/her own healing. To paraphrase Heidegger “Nature is that which is exposed to our method of inquiry.”

  8. I know someone who got asked lots of questions by a psychiatrist in an, “Assessment.” He asked the psychiatrist to stop asking so many questions. The psychiatrist didn’t, so the, “Patient,” kicked him.

    Round of applause, tut tut – dear me, that’ll learn ya, Oh dear, serve him right….no comment.