Coming back down the hill I met a girl taking her mother for a walk. There had been several couples along the way, and several with dogs (mostly overexcited dogs intent on providing everyone with a nice slobbering), but this one was walking her mother.
The mother confided in me as I passed. I’ll not say what she confided, because this really did happen only long enough ago for me to get home, make a cup of tea and turn the computer on, and although what she said was not in any way personal, she said it in a sort of confiding tone of voice that activates some kind of Top Secret mode in my brain and makes me feel I cannot ever reveal it.
But in her nervous excitement (and I don’t want to draw any parallels with the dogs, really I don’t) I could see her delight in being taken for a walk by her daughter.
The daughter had a map, which she was consulting as they stood under the tree. She seemed shy…nervous perhaps…annoyed perhaps at my intruding on a private outing.
I’m afraid I was dismissive of the map, and directed them straight to the best place without telling them what to expect there. I hope they found it. After a couple of minutes I looked back and they were just reaching the top of the first little rise — on the right track, I was glad to see.
Because a little stream makes it muddy around the gate, you always arrive watching your feet. So it’s only as you find the path again that you look up, and then it’s as if you have stepped into another world, a magical, peaceful glade.
The magical place
Mother and daughter have already found a magical place, of course, a place in their lives where they can share times like this as two adults, neither one the other’s carer. It doesn’t always work out that way.
For a proportion of CBT patients, although by no means all, understanding past events involving parents is part of the whole process of making sense of things that is CBT. Approaching past events like that in therapy can go one of two ways.
Usually, what makes a past relationship significant is that it’s unresolved in some way. There’s a lingering tension. For example, perhaps something bad happened long ago, but it is never spoken of. Or perhaps there is a simmering misunderstanding that is too often spoken of.
One way it can go is release — the patient released from childhood, parents released from having to parent. Then everyone can get on with their lives. They might never speak to each other again. There’s no rule that says parents and children must go hand-in-hand through life forever.
The other way it can go is resolution — the patient coming to understand what really happened, looking back on it now with an adult understanding. So this understanding is like a map. Now the patient can approach the parents again and say, “You don’t know me. I grew up. But look, we can go here together.”
Sometimes this works, and sometimes it doesn’t. Parents don’t always take it well. Sometimes much forgiveness is needed, map or no map — sometimes too much is needed.
It annoys me when I hear of therapists who have tried to evade issues of the past and issues of relationships, missing the point of their patient’s story and making the patient seek therapy again elsewhere. Being a CBT therapist is like being a map-maker in a complex ecosystem, diagramming how things fit together and rely on each other. This grew from that. This depends on that for nourishment. This is in the way. That needs more light.
It’s not enough to treat a symptom. It’s almost but still not quite enough to treat a patient as a whole person. No one is a whole person in isolation. Both past and present relationships are frequently interwoven with therapy.
On the other hand, it annoys me, too, when therapists try to cover all the angles by slavish adherence to lists of factors that must be taken into account. Then they miss the point by drowning it in irrelevant detail. So how do you get it right? How do you know?
The answer is that you don’t know until you get there. You wander down a path and see where it goes. You might think that it looks like a dead end. Wander down it anyway. By the time you reach the end, another path will often have opened up, as if the world you are mapping is responding to your presence by making paths for you.
It sounds like this wandering around should take a long time. Not if you allow the path to show you where to go.
(This is all getting very zen-like, and I suppose I should throw in a quote from some Buddhist master at this point, but I’m not in a Googlish mood to find one.)
The point is, the world works. You don’t have to fight it. Patients want to be cured. They will tell you what is wrong. You just have to go where they take you and see the connections, so you can make the map with them.
The technical term for this map-making is formulation. What you’re after in a formulation is a common-sense explanation for what is going on.
So as you wander around in the story of your patient’s life, what you want to find are the things that don’t make sense, the things that either have no explanation at all, or the things whose explanation doesn’t ring true. Those things will always be the cause of the problem. Always. The world works.
What doesn’t work is if you ignore the world, and ignore your patient, and focus instead on the “shoulds”, “don’ts” and “musts” of some abstract theoretical model of therapy.
If you’re getting it right, what you’ll find is that the successful formulation you end up with is often quite surprisingly different from the initial presentation of the case. And what you’ll also find is that your successful formulation takes into account other people apart from your patient, very often including your patient’s parents, grandparents, children, lovers. The map you make together with your patient is a map they can all share.