Ambivalence

I wish they had taught me about ambivalence at medical school. It would have made my life immeasurably easier if I had understood it earlier. Instead I was quite a long way into my career before I really began to see how important it was both to my patients, and to me personally.

I was taught what to do for each clinical problem with the expectation that a person would be ready, and willing, to accept my advice. If he or she wasn’t, they were something of a nuisance, indecisive, unable to recognise what was good for them. ‘Oh she’s ambivalent about it,’ I would be told if a person was shilly-shallying around. Ambivalence as a concept was confused with indecision. But it isn’t. It’s something much more than that. It’s about wanting to have something at the same time as not having it. Wanting to be thin, but to eat a large slab of chocolate every day.  Wanting both the benefits of sobriety and inebriation. Even wanting to be both dead, and alive at the same time. I know from talking to people who have tried to kill themselves and failed, that they sometimes wanted to be both still here among the living, yet dead and out of their suffering too. Some of them changed their minds as soon as they had acted to end their lives and came to seek help. Ambivalence underpins so many of the problems people have brought to me, and my own difficulties too. I was an ambivalent medical student, and for many years an ambivalent doctor. I wanted both to belong to a profession and all the benefits that come with it, and not to belong because of the cost to me personally and emotionally.

If you haven’t read Kenneth Weisbrode’s recent short book on the topic, entitled ‘On Ambivalence’ I can highly recommend it.

‘Ambivalence lies at the core of who we are. It is something more subtle, and more devastating than human frailty. Weaknesses can be remedied. Ambivalence comes, rather from too much ambition. Desire begets dissatisfaction, and vice versa. Optimization becomes a fetish. Wanting the ‘best’ means that we must have both or all and are reluctant to give up any option lest we pull up the roots of our desire. That is why ambivalence is so hard to confront, understand. Or master. And why it can be so disastrous.  Most of us know this. Yet we continue to deny it.’ (p2)

 

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The person who is ambivalent about their eating, or drinking, or lifestyle ( add ad infinitum) is not only unable to choose the from the options they have in front of them, but refuses somehow to admit that there is even a choice to be made at all. It’s both a painful yet oddly pleasurable place to be. We cannot have it all, but still somehow  want to believe that we can. We don’t have to decide what to do, to change our lives, because there isn’t a decision to be made. Yet we suffer because we struggle to live what is an impossible existence, only we don’t admit how impossible it really is.

If I had understood this when I was younger, I might have been able to recognise how much suffering is rooted in ambivalence. I began to understand it when I worked in addictions, and later with people who had eating disorders.  I’ve talked to many people who have felt judged rather than helped by those they have consulted; who have been labelled as weak because they are unable to ‘choose to change their behaviour’, rather than essentially ambivalent about life and what they wanted from it. I was influenced by Bill Miller, who first described Motivational Interviewing in the 1980s. I remember reading about how the clients of the clinic where he worked were routinely asked if they were willing to accept the label of alcoholism and accept treatment. That was exactly what I witnessed as a junior doctor:

Consultant: ‘So do you think you are an alcoholic?’

Patient : ..’No… I don’t’

Consultant: ‘Are you prepared to attend AA?’

Patient: ‘Why would I want to do that.?’

Consultant: ‘Well, if you aren’t prepared to admit that, you aren’t motivated to accept help. Come back again when you are.’

We may say it doesn’t happen quite like now, but it does. A person who doesn’t see the need to make a decision about taking up therapy and attends only intermittently is rapidly discharged for being unmotivated.  Instead of trying to understand their ambivalence and empathising with the problems they are experiencing which make it impossible for them to contemplate a decisive response to their problems, we treat them as wasting our time. When he first described Motivational Interviewing, Miller emphasized the responsibility of the therapist in helping the client to acknowledge and explore their ambivalence. When the person is ‘unmotivated’ we are discharged, as therapists, from our responsibilities.

I was personally fortunate. I had a therapist who was prepared to engage me in acknowledging that I both wanted to succeed and to fail in my career, and ultimately to both to live and to die. I’m still ambivalent, but I don’t want to talk about that now. There isn’t time. My cat is currently driving me crazy, wanting to be on both sides of the back door at once. Now that’s ambivalence.

 

Making a connection

The young woman, we can call her Mary (let me say now she is not a real person), is sitting in the chair opposite me.
‘What is it like, at home?’ I ask.
‘Difficult, no forget I said that.’
I wait a moment, then take a risk and ask, ‘What’s hard about it?’
Mary picks silently at a scab on her left arm. I can see blood beginning to ooze from beneath the hard carapace as she worries away at it with what remains of her fingernails. On both of her forearms are marks where she has scratched herself repeatedly with a razor blade. The newer injuries are still an angry shade of red. The older ones look like the silvery trails a snail leaves on paving stones. She has told me already how she feels a strange sense of relief when she cuts. She doesn’t want to kill herself, but there are times when she needs to have some relief from her inner pain, and this is something which seems to help, albeit for a short while.
‘Can you tell me a little bit about home…?’ I try again.
‘I can’t say I hate it can I? I mean they care about me, I suppose. But I can’t be what they want me to be.’ She sobs and her tears drip onto the arm of the chair.
I push the box of tissues towards her. ‘Do you have to be what they want?’
‘I don’t want to be…different.’
‘So tell me about being different…what does that mean?
Silence.
‘Maybe…I don’t know… you feel different?’
Silence. No- a shrug. A response.
‘Maybe that’s okay,’ I try again, ‘… to be different. Or maybe it’s not…it can be hard.’
‘Why? Why should it be okay? Not fitting in!’ She sounds angry now.
I find myself backing off a little, ‘I don’t know. Sometimes people just feel different.’
She nods but still looks at her lap.
Encouraged I continue. ‘Sometimes they are, different I mean. That’s OK with me, but how about you?’
Mary looks up. I detect an uncertain, conspiratorial glance and the first flicker of a smile. I sense we have started to make a connection.

Psychological therapy is a topic about which there is a great deal of mystique wrapped up in layers of ever more complex jargon. Each approach comes with its own vocabulary, set of abbreviations and training course. I had some training in my youth in psychodynamic psychotherapy; I’ve been on the receiving end of quite a lot of therapy too. I’ve also spent much of my life trying to help health professionals communicate more effectively with people who are distressed.

From all of this I’ve learned a few lessons:

Asking endless questions about symptoms is not the way to connect with someone.

Being a good listener is essential but not sufficient. You have to show that you are listening, and this means saying or doing things helpful things during the conversation. Not too much, and not too little. You have to be able to pick up on important cues, which may be verbal or visual, and comment on them. These important cues are the ones redolent of emotion.

You cannot fake empathy. If you don’t feel it, don’t pretend.

You have to be ready to hear awful stories about the suffering that people have endured. If you are not ready to do that then you shouldn’t be in a position where a person may need to confide in you.

You need someone to talk to about what you hear. Supervision is essential and many people in the caring professions simply don’t get adequate opportunity to make sense of their experiences with patients and service users with the end result that they emotionally close down and become insensitive to the pain of others.

You don’t have to be trained in psychological therapy to be able to connect with a person, but psychological therapies are useless when no emotional connection is made. Some people who have been trained are still hopeless at connecting.

Having your own experience of emotional distress isn’t enough. It might help you to understand what it feels like, but that won’t necessarily be what this person feels like and your work is to connect with them, not make them connect with you.

Without a connection you won’t feel able to talk about how you feel, develop trust and share your worries. I know this because the professionals who helped me most wanted to find out who I was and made the effort to connect with me. I will never forget them, or those of my patients with whom I was fortunate enough to forge similar bonds.