Part 3: Foundations for re-certifying in therapy

In Parts 1 and 2, I presented the case for re-certifying for therapists and presented my own experience as a case study. In Part 3, I invite you to consider an array of practices that informed the approach I took in facing my significant life crisis in its acute and ongoing phases. My ability to access these in vivo, in real life conditions, showed me that I was able to practise what I preach, when needed. I propose these practices as the foundation of any re-certifying process.

Socratic questions as a power tool

As a therapist, I’m trained to ask my clients questions aimed at getting them to:

• question their own unhelpful thinking
• see how their past experiences may be colouring their view of a situation in an unhelpful or limiting way, and
• invite them to consider current challenges from new perspectives.

This style of questioning, sometimes referred to as Socratic questioning, invites the person to momentarily step outside of their deep conviction that something is as they think it is, or they are who/what they take themselves to be, step back and reflect on the situation/moment from a different perspective. In loosening the person’s identification with their world view (that’s not helping them at the time), this can often open the person’s mind to new ways of seeing, thinking, feeling about their circumstances and about themselves.

In navigating my experience of temporary disability, I made use of Socratic questions daily.

In seeking out and receiving the aid of others just to go about my daily life, I confronted my own need to control (manifesting as frustration) as things were done differently to me, in ways I didn’t like and in time frames I found restrictive and irritating. I tried to remind myself don’t sweat the small stuff, be grateful – at least, it’s getting done! In a moment of intense frustration, I found such homilies just added to my fury. At that point, I would switch to asking — is it really that important that things be done in this way/time? Is it the end of the world that it will happen later than I’d prefer? 

Sometimes, I was able to stave off a major catastrophe from happening. Mostly, when I caught myself insisting on wanting to get a task done in a certain way, within a certain time frame, and thinking I could do it myself, logic clearly showed this to be a foolish if not dangerous course of action to follow. At those times, I found I had attached my sense of worth, pride, or shame to a myriad of utterly unrelated tasks and metrics in my life. From opening the manual lock on my garage door with one hand and nearly giving in to the impulse to involve my broken wrist in wresting the thing open, to stripping my queen bed myself to wash the bed linen in ‘an efficient time frame’. It’s of genuine curiosity to me —how did I come to attach so much baggage about my dignity and worth to so many tasks in my everyday life? Tasks that have nothing inherently to do with my worth just because I cannot do them, might need help in completing them, need more time to complete them, or need to have someone else do them for me?

My family of origin conditioning raises its ugly head continually as I negotiated tasks in the present day. In my childhood, to need help was to be mocked and ridiculed for being seen as needy, a baby, weak, incompetent, inadequate, or disingenuous. No allowance was made for context. I learned to do things to myself, to do them for myself and just push through.

In that situation, I would constantly ask myself….

Marie-Pierre, 

Does it have to be done now?

Does it really have to be done by you?

Will it really mean you’re worth less as a person if you let the other person do it?

Will they really think less of you if they do this for you?

Is it possible that you’ll potentially injure yourself if you try to do something when you’re not physically able to do it right now? 

How will you feel afterwards if it all goes wrong and you’re in a worse place than you already are, knowing you brought this about through your own doing? 

In those moments, I became the loving, limit-setting parent I so needed but didn’t have as a child. Asking these questions over and over gave me a chance to address my circumstances in new ways that were more realistic, compassionate, and constructive than what I internalised growing up. In doing so, I changed my view of myself, of others, and of the world.

Socratic questions helped me remember the bigger picture, remember I’m a capable person, and remember that, mostly, things eventually work out okay.

Is there an adult in the house? Well, find one!

Living alone means that, most of the time, there is no external person to whom I can outsource my adult faculties. I can’t just indulge a fit of the sulks, a tantrum, a wave of panic, or wallow in overwhelm indefinitely. As a dear friend (who also lives alone) told me: ‘You can go ahead and smash that plate. Just know you’ll have to pick up the pieces one-handed.’ Consequences. 

Ultimately, I must decide which part of me is going to ‘run’ whatever situation I’m in. Whether I act from my more adult side or my more child aspects, there will be consequences. There will be consequences either way. I get to choose which consequences I’d prefer.

Going through each day when I was impeded by my loss of an arm, I would find myself constantly toggling back and forth between a more adult, calm, flexible, reflective part of myself, and a more impulsive, reactive, rigid, controlling child part. I came to accept that I can’t pretend to be more adult than I am, and I will hate letting the rigid, impulsive, reactive, childish part of my nature take over. Plus, there will be consequences. If I chose the impulsive, childlike path, consequences would likely involve having to do even more work at a time when I was already feeling stretched and depleted.

I learnt to reason with myself and apply self-compassion. I worked to hit the pause button early to quickly assess and reassess situations midstream. I practised breath techniques. The pain and extensive restrictions on my movement reminded me to practise embodied mindfulness far more than I usually do. When I remembered, I regulated my spikes of emotions, challenged my unhelpful thoughts. When I was too deep in it, lost in a dark tunnel of pessimism I would find a way to pull myself out of the pit. Or turn to a dear friend, or trusted practitioner, who reminds me that I’m more than the cartoon version of myself I’ve momentarily morphed into, the conditioned reflexive patterns I’ve defaulted to. And sometimes, there’s nothing I can think to do to get myself out of the pit—so I would read, surf the net, lose myself in social media, stare at the wall. 

And there was always the dog. I reached for him, petted and cuddled him, fed him, walked him, talked to him. Sometimes, I responded to his invitation to play—and I felt better. Sometimes, I projected my wiser adult self into him, and followed his advice.

Wash, rinse, repeat.

Cut-through – which bucket list of shit smells less?

When I get stuck and can’t seem to make a choice between what feels like two seemingly equally hard options, I use this question as a way of cutting through the illusion of equal validity. 

I’m allergic to the idea of a perfect anything, an ideal anything. In my view, there is just life in its variety, its complexity. I observe that, when we get caught up in seeking perfect or ideal, we invariably don’t achieve it. Typically, people who use ‘ideal’ or ‘perfect’ as their metric by which to gauge how well reality meets their expectations say, ‘It’s not ideal, but…’ as though justifying why they’re opting for that option and not holding out for better. I think it’s a recipe to resist and resent reality, rather than learn to live with, work with, and sometimes learn to be content or make peace with it.

On the first night after my injury, the doctors and I decided to see if the bones might set without surgery. Three and a half weeks in, and a substantial amount of discomfort later at the wound site, I was booked in for corrective surgery. I practised telling myself—yes, it’s not what I preferred. But I tried, and that didn’t work. I adjusted my attitude towards surgery quickly: the bucket of risking the medical complications was countered by the bucket that involved lifelong pain and restricted movement for the rest of my days. Surgery won. 

I assessed the surgeon and decided he would be a good option—he was courteous, present, respectful, collaborative, experienced, had a non-defensive response to my questions about his skill level and complication rate, and he was empathic. I was on board. Two-and-a-half days later, on the day I was booked to have surgery, he called to say there was a more extreme case he had to operate on. He offered to operate on me the following week (I saw increasing pain and two more days of work lost), or I could keep my place on the surgery list and see his senior registrar. Which bucket to choose? In a few moments, I let go of having to have him for my surgeon, and I went for weighted pragmatics. I reasoned that I had already lost a day’s work, all the arrangements I needed were already in place, I had readied myself psychologically to have surgery the next day, and I’d have the weekend to regroup. I chose the bucket of risking surgery with someone I’d never met, but of whom he thought highly.

Every time I face a new choice, I remind myself—it’s just a choice. My goals are to:

1. own whatever choice I make
2. track if it’s doing what I need it to do
3. commit to addressing it if it’s not
4. back myself up with whoever I’m dealing with, and
5. pursue a better option promptly should emerging data suggest that it’s needed.

I engage in an active choice process that is a continuous feedback loop that I constantly monitor. Backing myself also means not re-opening options and destabilising myself by second guessing something that’s still working. The surgery choice was a case in point of acting this way. 

Over and over, I weigh up presenting options according to a balance of values and priorities. As long as core values and principles of integrity, dignity and self-respect, and respect for others, aren’t compromised, I find the buckets usually distinguish themselves fairly clearly.

Over time, I’ve found that, if the choice in one bucket compromises my core values or principles, it’s not the right choice — even if it appears to be more expedient or advantageous in the immediate moment. History has shown that I turn on myself when I make choices I don’t respect — it’s not worth it. 

Can I emotionally finance this choice?

In the same way that we need to carefully assess whether we can afford to take on a loan if we want to make a purchase, significant choices in life need to be ‘emotionally financed’. By that, I mean: every choice will cost (time investment, effort, other activities foregone).

Costs also involve risks. We risk rejection by significant others; we risk judgement or loss of status/esteem in the eyes of others; we need more courage than we feel we have access to.

We might need to have a certain grasp on information we don’t currently have; we might need to have learned certain skills we have not yet learned or practised enough to be effective in acting on our own behalf.

We might need to come to terms with allowing ourselves to be or be seen a certain way — we might feel that making a certain choice will cost us our sense of ourselves as a certain kind of person, either as a loss (e.g. generous, easy going, relaxed, independent) or in a new (possibly unfavourable) way (e.g. demanding, vulnerable, needy, ruthless, uncaring). We might need to be willing to give up a certain status altogether in our own sense of how we see ourselves, in our relationships, or our community. 

Whatever the emotional toll or costs a choice might involve, we all need to weigh these up beyond and in addition to the presenting limitations of pragmatics, monetary costs, familial and community mores, short-term convenience, and pros and cons. And we need to weigh these costs up in terms of what we can ‘afford’ at the time and in the longer term:  humanly, physically, emotionally, socially and sometimes, morally.

Making a clear-eyed choice about what we are able and willing to emotionally finance in relation to whatever choice we make means we will likely reduce the extent of additional extra complications we will face as we go. This approach is a mature one that weighs up the various implications of the choices we make through life and accepts that everything comes at a cost. And accepts that part of the cost is sometimes not being able or willing to pay what something will cost or foregoing something else. 

The litmus test – would you treat someone you loved this way?

Often, I ask myself — what would I say to/ask of a dear friend I loved, respected, and cared for if they were to be in my exact predicament? I then challenge myself to follow my own advice rather than my impulse or compelling ‘driven-ness’. If I do, when I do, invariably, I find I get a better outcome and feel a sense of self-respect. 

Checking that I’m treating myself meets the standard of care I would offer others speaks to treating myself with self-compassion. In my expectations of myself, I can completely lose sight of context and attenuating factors — in other words, perspective. This can add an extra layer of pain to whatever I’m already dealing with. 

One other component, however, and one I have a lot more control over, is one that I’ve borrowed from Buddhism and choose to call optional suffering. 

Optional suffering is all the extra baggage I mentally put on top of whatever real, built-in limitations exist in my situation. Optional suffering involves thinking that things which quite obviously, presently ARE, shouldn’t be so, shouldn’t be happening, shouldn’t have happened at all. It involves fighting with reality by judging it, resenting it, insisting it shouldn’t be happening, looking to apportion blame, and wasting energy and emotion getting caught up in this part of experience. All that remonstrance only serves to impede our access to whatever coping skills we might have. No one thinks well under attack.

In these situations, I like to remind myself that this component of my distress does not have to be part of the experience. By taking a certain perspective (e.g. it’s not fair, it shouldn’t be like this, it’s wrong, I brought it on myself), I’m layering and adding a whole lot of additional pain and suffering on top of what the situation itself already comes with.

Optional suffering almost invariably lends itself to and leads to feeling like a victim, shame, and feeling hard done-by. Regardless of how hard something is, it invariably makes me feel more depleted, more helpless, and more overwhelmed and less able to cope. Apart from a transitory feeling of gratifying self-pity, indulging in optional suffering for too long doesn’t lead to anything good. In fact, it leads to the opposite.

Optional suffering is like a weed — best identified, monitored and ruthlessly addressed as fast as possible. In identifying its presence, I find it useful to expose how this perspective adds to my existing stress load. I remind myself that, unless I’m bored or short of problems, and there’s nothing interesting on TV, optional suffering brings no benefit whatsoever. It gets in the way of identifying resources, touch points of relief: the things that might make us feel better in the moment if we orient our mind to look for them and to allow their presence to positively impact us (for instance, the kindness of a stranger).

Optional suffering ties up much-needed mental and emotional resources when we face challenging circumstances and depletes and impedes our capacity for a creative response to our situation, thus increasing the likelihood of us getting ‘stuck’ in feeling bad.

My predicament of my broken wrist was a continuous invitation to discern and triage the real pain I needed to deal with, rather than what I layered on top — the optional suffering. 

When all else fails, remember it could be worse

One advantage of being French by birth, is that I grew up with an exquisite sense of the absurd. Despite our tendency to take ourselves too seriously and our world class reputation for arrogance, we have a cultural tendency to frame and celebrate things as absurd in even the darkest times. How absurd is that??

I almost always make use of humour and use my sense of the absurd as a coping mechanism. I used this trait routinely in a bid to unhook myself from unhelpful identifications (‘I’m an independent person!’) and divert myself from making certain choices which would likely have made things worse and harder for myself if I indulged them. I also used my humour as a salve after particularly spectacular examples of me not being my ‘best self’.

Internally, I wailed bitterly about not being able to pull up my trousers without doing the dance of St Vitus, hopping from foot to foot, gyrating my hips, contorting my body, as I used one hand to do the deed. I hated the fact it took me five times as long to complete the task. Then I reminded myself I could be a double amputee and pondered how they do things. In fact, how do they wipe their own bum? Perspective restored.

One caveat I feel must be said, as with almost any tool, the good that may be achieved is significantly dependent on the attitude of the person using it and how they apply it. Using any of the tools I’ve mentioned requires kindness and sensitivity to context and timing. The notion of optional suffering, for instance, can be used to deny oneself (or others) compassion and care in a really tough spot or when the person is in great distress.

All of what I’m saying can be delivered to oneself or to others in a callous, mocking, dismissive way, and it’s crucial to track whether any aggression or blame might be contaminating their use. If in doubt, don’t use this tool. Wait. Challenging ourselves or someone else about optional suffering can easily fall into the domain of mocking or ridicule. Nothing good will come of that, I promise. 

To reinforce the impact of what I pick up and notice, and to hold onto it, I write it out as a list. I keep adding to the list. The MC at the entrance—his care, presence, compassion, thoughtfulness. The staff’s level of care, interest, compassion and respect. My friends and their generosity. My neighbours, some of whom I only know by sight, others complete strangers offering to walk my dog, take him for a play date. The surgeon’s respectful clarity and care. My clients’ care, understanding, compassion and willingness to work with my own need for flexibility in our arrangements with appointments and times.

I find that mentally orienting myself to what’s good broadens my focus from one of problem-saturated and overwhelm-inducing anxiety, to one of possibility and greater ease and openness, as I recognise that options may already be there for me. 

This is consistent with the findings by Butler and Moseley (Explain Pain model) that show that having an increased sense of danger (about one’s health status, circumstances) increases pain, reduces pain threshold, and reduces responsiveness to pain medication. In contrast, cultivating an increased sense of safety raises one’s pain threshold, reduces pain intensity, and improves responsiveness to pain relief methods. 

In my situation, I noticed that indulging thoughts and feelings about my situation that engendered resentment, blame, catastrophising, isolation, and powerlessness, quickly induced overwhelm. I found it also demonstrably led to me experiencing increased inflammation and pain of longer duration. Shifting my focus to what’s working, who’s there for me, what I’m grateful for, and to options and wins, quickly calmed my mind and emotions, broadened my perspective and made it easier for me to find solutions, see possibilities and generate options. Plus, it definitely associated with lower levels of pain and discomfort. 

This is where I’d say that knowing some useful theory, and applying it judiciously, provided me with an enormous amount of support in dealing with my predicament.

Growth mindset vs fixed mindset

I’d say that having, cultivating and orienting towards a growth mindset has been one of the single most useful orientations I used in my predicament.

In a situation that is unpleasant, ongoing, and has no single solution, one has to learn to continually adapt to circumstances. Having a fixed mindset that insists on control and solutions, demands single outcomes and time frames, is a recipe for increased frustration, resentment, and optional suffering, while adding to an already complex and demanding amount of objective pain and associated challenges. 

Self-acceptance, self-compassion

Every day during my months of recuperation, I was reminded that I’m fallible, that I don’t know everything, that my best plans, my best efforts might still not work out or get me the outcomes I wanted. I was reminded that I’m stubborn and that this can sometimes work to my detriment. I get caught up in — being right, over relating; having things done my way in my time frame; outcomes over process; mistaking speed for efficiency. I can get very stuck in wanting something fixed, solved, sorted, so I can move on to the next thing, only to realise many things are not solvable and can at best be managed.

At those times, I can find it hard to just accept what’s happened and remember to show myself the same compassion I would show anyone else I cared about who found themselves in this kind of predicament. 

Self-compassion and self-acceptance go hand-in-hand. Each generates more of the other. Both require that we first stop fighting with reality as it is and accept it exactly as it is. I didn’t have to like it; but I did have to radically accept the plight I was in. The moment I could do this, I noticed that I began to see myself with compassion and accept myself as I was. I stopped expecting myself to be more Buddha than I am. And the moment I accepted myself, I stopped fighting with what is, dropped the demands that I be any different, and compassion for myself flowed in. 

Whenever I now default to chasing my tail and berating myself, when I find myself in a predicament I can’t seem to shift right away, I remind myself that it’s not a crime to be fallible. It’s just how things turn out sometimes. And lo! When I remember to apply the salve of self-compassion, I often seem to find a bit more capacity—whether to work with what I’ve got in the moment, to work out potential options, to manage pain, to tackle something I know needs doing. In taking a layer of optional suffering away, self-compassion helps me to re-open to whatever good might be available for me in the present. With that, there often comes a sense that I do have a tiny bit more capacity and I can take whatever next step needs taking. Even if that next step comes down to simply taking a breath. With acceptance comes a pause in the fighting inside my mind against how things are. With that pause comes respite, and a chance to regroup.

Re-certifying: where to from here?

Reflecting on my own fallible way of dealing with life and its vicissitudes as an in vivo assessment of my fitness to practise offered me an opportunity to refresh my training and really refine, hone, and embody the knowledge I draw on in my work. It also showed me gaps in my development. In doing so, I believe it gave me a chance to be a more authentic, more compassionate, and more skilled therapist. 

In closing, I consider that my reflections on my experience and how I managed it served as a valuable opportunity to assess the degree to which I have sufficiently internalised lessons learned in my own therapy and training to be a therapist. My ability to access these in vivo showed me that I could practise what I preach when needed; in doing so, I effectively ‘re-certified’ myself as fit to practise.

I consider that the therapy field would be well served by implementing some form of re-certifying process based on core practices discussed here. As a starting point, such a process could occur in supervision on a regular basis.

If you work in the field as an educator or therapist, and are interested in discussing the possibility of re-certifying, I’d love to hear from you.