Therapy, Coaching, Agency

Autonomy

Maybe you’ve struggled to put the shattered mirror of yourself back together and you don’t want to unearth what you’ve been able to put to rest. Plenty of people decide that psychotherapy is not for them, and we are, as our own individual, sovereign self, the best judge of our need. As someone looking from the outside, we can only know a fraction of the depths of another person and what truly matters in their mind. This is a reality of decisions about medical choices too; we cannot know or understand the intricacies of a patient’s unique fears, anxieties, and priorities. This can be difficult to accept as physicians in the face of our depth and breadth of knowledge. But it is a critical skill to honor decisions we don’t understand, both for our work with patients in earning their trust, and for our own professional longevity. This can be conceptualized as a boundary skill, that ubiquitous term that describes a complex understanding of the borders of self and other and which applies to multiple facets of being. We are not tasked with making anyone choose our therapies but rather with sharing information to the best of our ability, and with beneficence. That last can be challenging, particularly if we feel our patient’s decision as our own personal failure, or even as an assault on our expertise.

But how does it come to be that we struggle to allow for our patient’s rightful autonomy and authority over self? This is a complex question. As physicians we are taught in an intensive environment that we uphold a responsibility, and we do, but perhaps we mistake this responsibility for control. If we had a capacity to hear our patients’ thoughts, feel their feelings, intimately know what drives their decisions, we would likely feel easier accepting choices as sovereign to their reality rather than as challenges to our intellectual authority. But we cannot read another’s mind, only what they choose to share, and so instead we trust and accept the limits of our influence, while still carrying out our duty to share information. Developing this boundary can potentially contribute to a sense of satisfaction in our work and lays to rest chronic anger, frustration, and sense of personal failure. This can be the work of therapy and of coaching with two very different approaches.

Art of Therapy

Speaking of choice, crisis-hopping describes one of the bigger misconceptions about the purpose of psychotherapy and its underlying mechanisms. It is not the case that one must have a crisis to discuss in each session, that crisis is the sum total of what drives someone to seek help, or that crisis is the sole legitimate focus of therapy. Sometimes a perceived lack of important things to work on leads to prematurely discontinuing therapy, and sometimes therapy is done. The former often reflects an underlying anxiety about the discomfort associated with change. Referred to as a “flight to health,” this concept describes latching on to a temporary sense of well-being with a decision to exit therapy prior to much work actually being accomplished. Not to be confused with brief, solution-focused therapy that seeks to resolve a single, simple issue, a flight to health might look like achieving sobriety for a few weeks after years of active addiction and conclude that goals are met. This might also be encapsulated in manifesting an effort towards change in relationship and terminating services prior to integration of new perceptions, expectations, and behaviors. As therapists we share information and insight, we create space to explore decision, and we honor the choices made. And then we process our own feelings about those choices which we honor.

There are many reasons for terminating therapy, and it is always the right of the client to do so. Perhaps the working relationship is just not a good fit, or change is moving too fast and feels overwhelming, or a change in finance dictates deprioritizing therapy. A flight to health results in termination due to intolerable anxiety reflecting the capacity of an individual. Not everyone wants to or can endure additional challenges in an already busy, challenging life. Not everyone wants to face the pieced together mirror. But premature termination can also reflect a therapist’s miscalculated pacing. The work of therapy does feel overwhelming at times, and it is part of a therapist’s responsibility to help move towards or away from difficult material in those moments. This might depend on the strength of the working alliance, client trust in the process, therapist sense for a client’s affect tolerance or ability to feel vulnerable, and a sense for how the client conceptualizes their circumstances. It is also a therapist’s responsibility to recognize and help contain feelings of overwhelm while making decisions about how to proceed. What is best called for in this moment, approach or retreat? As a client one should feel supported in the painful feelings that can arise during and in between sessions. Psychotherapy necessarily has very difficult moments and one should not feel alone while building supports in community. For those who choose to stay the course, building capacity to trust another person in one’s vulnerable moments moves the work forward.

Crisis-hopping not only reflects a common misunderstanding that the work of therapy must always engage some sort of crisis, but also that there is no work being done during moments of smooth sailing. The facilitating environment holds space for the acute work of processing and integrating grief, rage, shame, fear, anxiety, and it also holds space for a sense of accomplishment, peace, and joy. It invites a sense of personal pride reflected in stories of changed relating, altered expectations, identifying and questioning counter-productive assumptions. These are moments of therapy to relax into before new challenges present opportunities for growth and change, but they also anchor that change. Felt moments are an experience in which positive changes are solidified, integrated, made part of the structure of self, rather than a fleeting moment before reverting back to the comfort of familiarity. This reflects the deeper work of therapy, careful tinkering with troubling implicit assumptions and beliefs, as compared to coaching which is focused explicitly on skill building.

Art of Coaching

While sharing tips and tools in the context of a psychotherapy relationship helps to build a working alliance, in a coaching relationship this is the work. Understanding boundaries, how and when to apply them, what interferes with doing so, and practicing those skills does not seek to alter underlying assumptions that make up the structure of self. Deconstructing the variables of conflict in psychotherapy seeks to understand and alter unverbalized assumptions about the rules of engagement. By contrast, coaching goals include improving conflict management in a professional environment. It is by its nature less personal; it works with the scaffolding of self already in place. Coaching seeks to understand a client’s sense of value, esteem, confidence, and unique skill set to leverage these in advancing identified goals. In the practice of anesthesia, it might mean developing skills to navigate disappointed and sometimes angry patients, time constraints imposed on a schedule that disregards patient safety, discussing physiology with other members of an integral team. In our medical world in general it means identifying and prioritizing values in an often-hostile system. It means understanding and honoring one’s well-being as a clinician despite seemingly impossible choices. It means connecting with one’s own agency. If you decide to approach the shattered mirror on the other hand, this is the work of psychotherapy. At least, it is in my hands.