Hindsight and reflection

When I watched The Usual Suspects, the twist at the end made me immediately re-watch the whole film. The extra bit of knowledge meant the same information from the earlier plot had entirely different meaning. The same things happens when you realise someone has lied to you, or manipulated you for some secondary gain – you suddenly need to reappraise all the prior interactions you have had in light of this new insight. It is inevitable as we go through life that we learn additional information that helps us understand things in more sophisticated ways. Just as we learn that our parents are flawed human beings, rather than always right and almost omnipotent, a lot of relationships transpire to be less perfect when the first thrill of connection wears off. It can be quite a challenging process to understand why you were fooled, what you should have noticed, and how you could have avoided the bad feelings that come with realising all was not as it seemed.

In one chapter of my book I talk about the poem “Holes, An Autobiography in five short chapters” by Portia Nelson. It is a nice summary of the patterns we can all fall into, and how it is only reflection and insight that lets us climb out, and eventually learn to avoid falling into similar holes in the future. I found it really helpful realising that there were certain “holes” that I recurrently fall into. In particular, I was susceptible to one when others seem to need my help and support, but keep on taking without recognition of the value of that help or any cost it has for me, until I feel exploited. An early example was a student who volunteered when I was an AP, who I supported to apply for similar posts and to get onto clinical training, before becoming aware she had presented some of my work as her own, and named me as a reference for a job she had been fired from (when I wasn’t her supervisor and didn’t work there, in the expectation I’d say only positive things).

Related to this, perhaps, is my sense of myself never living up to the high expectations I set myself. It means I often assume I’ve done something wrong, until I find out that the other person is getting me muddled up with someone else, or has put the wrong time for the meeting in their diary. I feel acutely guilty if I take too long to write up the notes from a consultation, even if I’ve had time off sick or other crises to deal with. And I always first reflect on my part if there has been a misunderstanding (eg if the builder is asking for much more money than the written quote, and implies that we agreed additional costs for changes to the design – even though I know I would have kept track of that). It also made for very difficult dynamics with an AP who appeared really hard working and humble until I wrote them a reference for training, then started being increasingly critical and undermining, blaming me for their lack of progress in any of the tasks they were employed to do until I felt quite upset. It was only when I shared my feelings with trusted advisors and peers that I was able to recognise that the problem wasn’t with me. I then started to recognise I’d been gaslighted, and that if someone else makes me feel bad, I have no obligation to kept bending around them until they are satisfied.

Sometimes it isn’t new information about what happened or the other person’s motivation, but a new perspective or frame of reference that shows past experiences in a new light. I’ve reflected in past blogs about how what seemed like normal teenage boy behaviours, that were a socially acceptable way for them to show their interest in me (and portrayed in my peer group as something I should be flattered by) were actually quite inappropriate – unwanted, overly persistent and at times clearly non-consensual. Likewise, I learnt the term “stealthing” meant the guy at university who knew my consent was contingent on condom use, and made a show of using one but transpired not have to used it after the fact, was not just a selfish scumbag (as I thought at the time), but had committed a form of rape. The new insight gave a different perspective on past experiences that helped to bolster my trust in my own feelings and ethical judgements. And helped make me even more determined that I wouldn’t be complicit with these patterns again even if it means I sometimes have to risk looking emotional or being seen as a “difficult woman” when I assert my position.

From these relatively small examples in my own life, I also gained a new respect for the task of reprocessing past experiences for those who have lived through abuse and trauma. If a tiny piece of new information, or a new way of looking at things can throw my certainty about my past experiences into doubt and demand a high emotional load to process, how much more demanding it must be for those whose lives were impacted by much more serious or sustained experiences such as childhood sexual abuse, coercive control in a relationship. It will take time and effort to reprocess their own story when they are no longer in the sway of the person who is normalising the abuse. But often we are also fighting against social norms (eg many women are socialised into accepting “grey rape” as being not the real thing, if they didn’t say a clear “no”, or were intoxicated, or went back to his place/invited him home/consented to kissing or prior sexual activity). The meaning of experience is very much in the eye of the beholder, and shaped by cultural narratives. And there are forms of cultural oppression that change our whole sense of self, such as messages from family or religious/cultural groups that lead to people not feeling able to show their authentic sexuality or gender identity (the latter issue somehow being co-opted by both TERFS and right-wing figures who see trans people as an easy target for their “culture wars”). Finding a safe place and social network in which to be your authentic self is so critical for our happiness. Even feeling okay about your body and appearance is a challenge for many people, and finding body positive role models and reaching acceptance of ourselves that isn’t conditional on weight-loss or conforming to popular beauty standards can be life-changing.

A similar shift of needing to reappraise the story by which I understand my experiences happened to me recently in terms of my own body and health. After some quite unpleasant side effects to coming off HRT, including excessive bleeding to the extent I ended up in A&E, I had an ultrasound that suggested I have adenomyosis – a thickening of the endometrium, where lining tissue is mixed in with the muscle wall. Reading up about adenomyosis I discovered that this could explain the nature and extent of the period pains I have experienced since adolescence. It might also explain my negative reaction to the Mirena/Jaydess coil (despite this being a recommended treatment for excess bleeding due to adenomyosis) and the problems I’ve had with menopause. It may also explain why I’ve been prone to gain weight, as excess oestrogen can increase fatty tissue and fatty tissue can increase oestrogen production. But the most striking new info for me was the fact it is associated with premature delivery – as I’ve carried a lot of guilt about not having managed to sustain the pregnancy with my twin daughters to full term, and I’ve never had an explanation for why this happened. So I’ve started to reevaluate what I thought were the truths of my own life and how my body operates. I’ll learn more as I follow up with the consultant gynaecologist next week, but it seems bizarre to have lived with something that has potentially had significant impact on me throughout my adult life without being aware of what it was. But women’s health has always been an area in which medicine has lagged, and for the most part when it comes to menstrual or menopausal issues we suffer quietly. I’ve blogged before about how we need to assert our needs, and yet here I am realising I haven’t done so, as I didn’t realise my experience wasn’t the norm until the symptoms became too intrusive to work around.

Health symptoms also remind us of our own mortality, and the privilege of being healthy and able bodied. Having to reappraise our plans in light of health challenges or functional limitations can be another trigger for reflective hindsight. As can the illness or death of a loved one – or a public figure like the queen. Health is not a meritocracy, and lifespan does not reflect the value of a person. We are not guaranteed to live the average lifespan. We may get more time, we may get less. If we knew today that our time was limited, would we look back and wish we had done things differently? If so, maybe it is worth reflecting on our priorities now, because time is always limited – even if I live another 50 years. I feel incredibly lucky to have spent over a quarter of a century feeling loved by someone I love, to have had the benefit of a supportive family, and to have wonderful children who I get to spend time with every day. So the big building blocks of my life are firmly in the right place. However, I’m sure that there are small changes that could help me to spend less time on work and trying to make the future opportunities we have better, and to focus on the joy available within each day. Reading back over this blog, which I started eight years ago, I can see progress in some areas (I’m much clearer about my values, and what I want to do professionally, and have a tighter focus in how I want to make impact in the world). But I also see themes where I identified the need to make positive change that are still pertinent in my life today. So I need to think why I haven’t been able to prioritise self-care more, or to get rid of the physical or metaphorical clutter in my life, and how I can make space to be creative, spend more time in nature and connect with like-minded others. Maybe I should get some more coaching or personal therapy to reflect on this.

Gaining insight about ourselves is a particular kind of opportunity to grow and learn. Whilst it can be challenging, that reprocessing of experience over time and with greater information is a core part of personal growth (and a key foundation of the scientific method – that as we understand the facts better, we look again at our working hypotheses and adjust them to fit the new information). Understanding ourselves better can help us reach greater happiness and self-actualisation, and also helps us to understand our place in relationships with others, and in the wider world. It is a key part of the journey towards both happiness and wisdom, and lets us hang onto our values, despite the storms of political decay, inequality and climate change raging around us, which could so easily lead to feelings of despair and helplessness. Maybe the key to happiness in challenging times like this is to reflect on the things that you can change, and find a way to not dwell too much on what you can’t.

I sometimes find it heartening to think about how each honey bee makes less than 1/12th teaspoon of honey in their lifetime, yet pooled together it is enough to ensure the future of the colony. It helps me to remember that to make the world better, you don’t need to solve the big stuff, just focus on doing your 1/12th teaspoon to help others. A bee won’t directly benefit from the honey she makes; instead, it will allow future generations to thrive after she is gone. This too is how we can change the world — by each doing the small things we can, and inspiring others to do likewise.

Between a rock and a hard place – when friendship and your professional role overlap

I’ve always tried hard to keep a clear distinction between work and non-work stuff in my life. I expect my friends to be able to offer, on balance, a similar level of support to me than they require from me. If the relationship is too skew then it will be meeting one person’s needs at the cost of the other, and that isn’t a friendship. Friendships are reciprocal, and allow me to trust enough to show facets of myself that I might not want to reveal in the context of work. In the safety of such a relationship I can have my own vulnerabilities. I can worry that I am less than a perfect parent, or talk about my relationships with other members of my family. I can joke, swear, drink wine, express opinions, or laugh at the contestants on The Apprentice without fear that this will tarnish my professional reputation. The rest of the time I feel like I have my professional hat on. I am in a position of responsibility and power, and I am bound by a code of conduct. When I talk or post online as a psychologist, I run the risk that my comments will be brought back against me when I’m in the witness box, or be taken out of context and misinterpreted by a present, past or future client or colleague.

I am friends with some psychologists and other colleagues from work and via the clinpsy forum. That’s a good thing. We share common values and experiences. We have shared stressors, and we spend time together. I am also friends with other professionals that know me as a psychologist, like lawyers, paediatricians, psychiatrists and social workers. Again, our work overlaps and becomes a topic of mutual interest. I also have non psychology friends. That’s a good thing, as they bring different ideas and perspectives. They let me relax, share other interests and remind me of the other parts of me outside of being a psychologist. We can cook, eat, play, exercise, explore, talk. We can play video games, make music or art, debate politics and current affairs. As a prior supervisor would say, we are people, partners, parents and professionals as well as psychologists, and we need to pay attention to each of those roles. What marks it out as a friendship is that there is trust, and that the relationship is enjoyable or nurturing.

The difficulty comes when you feel like you ‘click’ with someone who you are seeing professionally and feel that had you met outside work it could have been a friendship, as that makes it harder to stay within a work role and remain within the more neutral and guarded boundaries that a professional relationship entails. A therapist needs to respect their clients, be curious about them, accept them, hold them in positive regard and see their potential. The relationship may be very important for the client, who may idealise you and want to bring you into their life. But that doesn’t make it a friendship. The power balance is different in a professional relationship. Within therapy the client is expected to disclose a lot about their life whilst the therapist discloses little. It is not a reciprocal relationship, and the relationship is not there to be enjoyable or nurturing for the therapist. Having started from there it is not possible to reach a place of reciprocity (at least not without a lot of time and distance after the end of the therapeutic relationship). So if you find yourself acting too casually, sharing too much information, or wanting to step outside of your normal professional role, this is definitely something to discuss in supervision.

Likewise, if someone in your personal life starts to use your professional skills, this needs to be handled very carefully. Parents asking for advice about their child’s anxiety or poor sleep may not differentiate whether you are giving advice as a friend and fellow parent or as a professional. A friend who wants guidance how to access IAPT, or is feeling suicidal and needs to be taken to A&E needs to know you can support them as a friend, but not as their psychologist. We may well know the system and the right things to say, or the right people to approach, but it is important not to end up muddling the role. You can’t ring up someone you know’s treating clinician and say “Hi, this is Dr Silver and I’m wanting to ensure you understand my formulation about my friend Jane”. They are entitled to confidentiality in their therapy and trust within their friendship. But you may also feel a greater obligation to act on concerns about someone’s mental health, or a child protection concern, than a general member of the public.

It is all too easy to get sucked into an uncomfortable place in between. What of someone that approaches you in a way that appeals to both the personal and the professional? They just find you so easy to talk to that they tell half their life story, and next thing you are feeding back a formulation at a dinner party. Where do you go from there? Do you reciprocate and tell the ins and outs of your life, or give them a business card if they want to follow up the conversation with a formal session? Or the friend who just can’t get an assessment for their dyslexia, but is self-critical about how stupid they are, when you have the psychometrics needed in the office and your assistant has a spare hour on Friday. Surely that’s not so personal? Or the friend of a friend that never seems able to access the services they need. Do you step in and advocate for them? Its a very difficult decision to call sometimes. But in my experience it is these situations that are most likely to fall down around your head.

A colleague of mine was concerned that a friend of a friend (lets call her Sarah) was discharged from an inpatient stay without proper risk assessment or follow-up. He spoke to the GP and inpatient team to raise concerns, but nothing was done. Sarah later committed suicide, and my colleague was interviewed in the enquiry that followed. The coroner did not seem able to differentiate between a concerned friend who happened to be a professional, and someone with professional responsibility, and he got given a really hard time. This was on top of the guilt he felt for not having been able to prevent Sarah taking her own life.

Another colleague ended up having to drop everything to collect a friend from various complex situations all over the country as she had psychotic episodes, and would not trust professionals when she was not taking her medication and did not have a good support network.

I ended up writing to the GP of someone I shared an office with early in my career, to report an eating disorder, suicidal ideation and risky behaviour. I felt like there was little else I could do after a supervisor said it wasn’t their problem, because their actions were placing other people at risk. I wanted to be supportive, but at the same time I felt like it was unfair to burden me with the information without allowing me to act on it. I was very clear with the person involved that this was what I was going to do if they continued to confide this type of information, and they chose to write down the contact details of their GP knowing that I would share this information. Thankfully, they went on to get appropriate therapy.

When I first met my husband it was evident he was dyslexic. I did some informal assessments so that I was sure my hunch was correct and then pushed him to get formally assessed at university. This confirmed the diagnosis and enabled him to get concessions made about his spelling and handwriting in exams, and I learnt to help by proof-reading his course work. I felt like the assessment needed to be independent to have any authority, and that I could not take on this dual role.

A decade later, I started at a new post and started talking to the IT guy who covered CAMHS, who was concerned about his memory. It was clear he had a specific deficit that had never been assessed, and I owned the WAIS and WMS that were current at the time. With the consent of the directorate manager and my supervisor, I did a full psychometric assessment. We have gone on to be lasting friends, and he credits me with helping him to understand that he is a bright guy with a specific deficit, rather than a guy of mediocre intellect who has done well for himself. However he has never wanted to use the assessment formally.

More recently I spent 24 hours taking an acquaintance to A&E after they confided detailed suicide plans in the wake of a relationship breakdown. After a long time talking in the waiting room before they were seen, they asked me to be with them in the room and share some of their abuse history with the assessing clinician. I agreed, but I had to be very clear to identify as someone from the personal network. Whilst the assessing clinician was keen to make me part of the follow up plan, I had to set out clear boundaries and decline. I was not a professional to them, and I was not somebody who could take responsibility for this person on discharge as I lived in a different part of the country.

Each of these has been a learning experience and shown the importance of differentiating the personal from the professional, but it is something I will continue to grapple with both personally and through supervising others. The nature of our skills and knowledge mean that there will always be situations in which people want to use our professional expertise, even when we are not wearing that hat. Whether that is the GP that wants advice about a patient when you go in for advice about your own health, or the business coach that wants to talk about their concerns about their child, or the friend who is giving evidence to a child abuse enquiry. We need to find a way to be both compassionate and pragmatic about the capacity in which we can be involved, to keep ourselves and the individuals safe and ensure they get the right kind of support. The role of speaking to other people on the internet is one I will blog about at some future point, and brings with it a plethora of new and challenging ethical issues, not just the way that the informality of the medium makes roles blur more between personal and professional.