Humility as a Healing Tool in Mental Health Care

This little broadcast caught my ear - as it says things that ought to be any clinician's basic tool box - but can be all too rare. Any comments?

Humility as a Healing Tool in Mental Health Care

Summary:

Neil Underwood is a Community Mental Health Nurse in South Australia and describes himself as a compulsive doubter and collector of old text books. He talks about some earlier approaches to mental health care which used to be very authoritative. Neil argues that those working in the mental health profession should be sensitive and open to the people they care for, take note of the history of mental health care and show some humility in their dealings with patients.

Transcript:


Robyn Williams: I wonder how many aspects of behaviour that now seem commonplace and even charming, would in years gone by have had you locked up or even burned at the stake? Today’s eccentric can be yesterday’s lunatic. As for deranged behaviour, what about those possessed by demons who danced and hallucinated as if high on LSD? It turned out they had eaten bread contaminated with fungus and were in the grip of chemical torment. If only the Spanish Inquisition had known this.

Some mental states are not simply explicable, yet, but there are plenty of cases to think about: one in a hundred Australians has schizophrenia of some kind and as for depression …

So what should be our attitude to treatment, when never enough is known about the nature of mental illness? Who better to ask than a nurse who spends his life with patients? Neil Underwood lives and works in Adelaide.

Neil Underwood: I like working as a psychiatric nurse. It’s never short of opportunities to find new perspectives. I’m a compulsive doubter; I can’t go for long before questioning my own beliefs. A related habit to this compulsion is my collection of old textbooks. It’s very interesting to read about the beliefs that once drove health care. In psychiatry, the time that a textbook takes to progress from authoritative to comical seems rather short. Picture a scene from one of these books: a sepia-toned gentleman looks out at us from the 1920s, a confident and handsome man. Turning the page we find a photo of him several years later. We are told in the text that his obvious deterioration is due to the ravaging effects of masturbation and that this poor soul will be lucky to avoid the asylum.

It’s undeniable that all medical and nursing practices have a shelf life. If they are not eventually discredited, they are certain to continue to evolve over time, changing into new forms and combinations. We have no reason to believe that history will reflect on our current practices any differently. It follows that we need to be very careful in mental health care. This care when exercised, will be most obvious in our choice of words. Along with the occasional prescription of appropriate medication, language is the material of which psychiatry is formed. Like the hammer and sickle of the Soviet flag, these two tools, talk and tablets, are the two basic elements of psychiatry. All treatments are variants of one or both, language of course being the constant. The words chosen by a clinician when speaking to a distressed person can resonate for a long time. We can all think back to times when the words of people around us have formed indelible memories and shaped our world view.

Some of the effects of our language we are aware of. Some of it, in the endless chain of cause and effect, we will not see. Like throwing a stone in a pond, the ripples pass out of our view. Edward de Bono points out that in some sense, ignorance of the mechanisms of cause and effect is something we all share. We may think a mechanic understands cars, for instance, but what they really know is that if they replace a spring, the car will go again. A physics expert will know how the load tension on the spring works, but may know little of the way the spring relates to the engine. A medical student friend described his view of knowledge to me in this way: all we can is pull down the onion skins of knowledge, but somewhere we will not know how something works, and we will not be able to explain the methodisms of what’s happening. In medicine, he said, you can examine what you are doing to a molecular level and beyond, but somewhere you will be confronting mystery. In some sense, all of us operate like this. Push the blue button, and the machine works. His approach was simple: to do what he understands to the best of his ability, while always being aware of the things that are beyond his field of vision.

Take the example of the personal computer. You may know someone who you think is computer literate, but in reality they may simply be adept at getting Windows working. Or perhaps they can program or repair circuitry. But no-one has the complete knowledge of how the thing works. It’s actually a range of people with distinct knowledge that allows the computer to have its place in our lives. At some level, there is an element of the machine that is a mystery to us. All of us have to come to terms with ignorance at some point. It follows that health care is no different. We will do some things because we have a clear, evidence based, structural knowledge. There will be aspects of practice though that fall beyond our ability to predict.

Other things we will do because, like pressing the blue button on the machine, we know that it works. Electro-convulsive therapy, ‘shock therapy’, is a prime example. In its present form, it is a safe treatment for the worse types of depression. It works. We are not really certain as to why, but we do it because it relieves pain. If history will frown on a good part of what we do, though, what does this mean for the mental health professional?

Before I go on, I should ask the forgiveness of listeners if this topic of humility seems a touch preachy. A friend once used to say I am, therefore I think; I think, therefore I am confused. As I go on in health care, I relate to his joke more and more. Like all health care workers, I need to keep up-to-date with the latest trends and information, and at times I have bordered on paradigm burnout.

So let me underline, that all am doing is describing a thought that I have found helpful to push me through my own frequent confusion.

I suggest that what needs to be sought is a healthy and profound sense of humility. Not a humility that is associated with a morbid sense of doubt about our abilities. Rather, a sober awareness of knowledge’s constant state of flux. All our senses bring us is new information. Frightening! Perhaps this is what TS Eliot was describing when he said ‘We will not have finished the journey until we arrive at where we started, and see it for the first time.’ The ability to observe the environment as it truly is, how it seems to us here and today, and as for the very first time, is maybe what Jesus was speaking about when he told of the need to have the qualities of children.

Artists represent a parallel group that need to learn to reconcile their inner ideas and images with what their senses are truly telling them. It’s almost as though those who are learning ways to represent the world in pain have to be re-taught how to see. Is that sky really blue? Or is it a dozen shades of yellow? Is the ocean blue or is it a vibrant purple? The aim being to trust yourself over your beliefs.

In mental health we can see this form of humility in a very different way. We can actually see it as a potent tool for healing. In this context, striving for it is not about being a better person, it’s about being better at what we do. I say this because it seems a common theme with effective clinicians that at times the minimal approach to treatments, Ockham’s Razor, is taken. It is natural for the clinician with a high degree of humility to be silent often and cautious always. They will prefer expending effort in understanding rather than changing the person. It’s ironic that in mental health care, where ‘techniques’ abound, the sessions that seem to attract many positive comments are those that are conspicuous by the therapist’s frequent use of silence.

I am not at all saying that there is no importance in method, but I do suggest that the clinician’s perception of his or her approach can make a critical difference.

Being a car driver is very similar. I have no facts to back up this notion, but my guess is that learner drivers are amongst the safest on the road. As they are learning technique, that sense of gravity of what they are doing keeps them alert, courteous and perhaps more receptive to new information than at any other time in their driving career. I once heard a driving expert say that the biggest danger for drivers is their auto-pilot, when we cease to be reacting to the information around us.

Put it this way: if you were to go and speak to consumers of mental health care services about their experiences, often I think you would find a consistency: the clinicians they find most helpful are those that simply seem to have heard what is being said to them.

It is a principle that underpins human interactions to an international level; this need to let the other party know that they are being heard. This quality is perhaps going to be more important in mental health care than other specialties, because it is based solely on the exchange of thoughts and ideas. A surgeon’s tools are their hands. In mental health care however, the self in its own right is used as a healing tool.

This idea of course is nothing new. The scientific model enshrines this idea perfectly. Socrates said it all those years ago: doubt of everything is the best way to truth. This scientific ideal is reflected in the current move towards evidence-based practice in all spheres of health care. The gold standard being to ensure all procedures and treatments are backed by the best evidence. I believe that in mental health care however, we potentially hit a bigger snag in trying to creatively doubt what we do. Why?

Well the history of Western saints and mystics, the sages of their time, clearly shows that humility was not cherished by them as a quality so much as striven for as a prized intellectual standards. It is tricky now, as it was then, as we all build mental maps of our world. These we carry around to help us understand. Indeed, one of the key aims of counselling is to help people recognise their outdated maps, and to be aware of those conceptions that are straying in from the past. It is sometimes hard for clinicians to return the favour and to see each client as completely unique. This is because the behavioural sciences are taught in terms of the trends of populations. More significantly, it seems that clinicians, after years of practice start seeing people in terms of archetypes of character and behaviour. Indeed sometimes this can be a helpful tool, the danger being when we stop seeing each person as a unique construction.

Another barrier is the fact that economic considerations overarch many of our decisions. With economic rationalism comes measurement. Qualities are not easy to measure in a way that informs more efficiency. The skill of generating and consuming empirical research and basing practice on the resulting evidence, is a critical one.

However, it must be placed alongside the striving for personal qualities, or else it loses all healing potency. Having an attitude that places all importance on the primacy of the best science can offer is inviting trouble. An example is the notion of eugenics, a painful memory in the history of science. The idea of selective breeding in humans was accepted in the early 20th century by much of the world. This is an idea that was taken to its horrific conclusion of course by the Nazis. We should not forget that this progression of evil was propped up by the German health care profession as much as any. Why? Because a common idea at the time was that the inferiority of some racial and genetic characteristics was a proven fact. Thus, the idea was that through such merciless acts as selective murder, the future wellbeing and prosperity of the human race was assured. Yes, the Nazis had more pernicious motives than placing primacy on science, however, certainly this rationale was a successful element of their propaganda, and many allowed their instincts to be discounted. Now of course the science of eugenics has been dismissed. Had the individuals concerned ranked personal qualities such as empathy, imagination and humility alongside their rational knowledge, well who knows what would have happened differently.

So perhaps the act of reminding yourself of the fluid nature of our knowledge can help mental health care workers towards humility, and this in turn towards fostering healing. This may all sound rather simple and obvious, but we form our behaviour out of very basic elements. Focusing on these is helpful when reflecting on health care practices. And isn’t helpful simplicity what Ockham’s Razor is all about?

Robyn Williams: Helpful simplicity, the essence of Ockham’s Razor. Neil Underwood is a psychiatric nurse who works in Adelaide.