When it comes to mental health, the best strategy can be to have no strategy

“I think they’re trying to send me a message,” the patient said, certainly trying to send me one. He was panicky, hadn’t slept for a long time, felt watched and told me it was like living in wartime and hiding something, but he wasn’t sure what. The enemy was approaching, the punishment death. Apart from his palpable panic, he looked shattered and his pleading eyes begged me to make it stop. “Talk to the non-psychotic bit,” I remembered a supervisor saying, so I said it sounded exhausting living like that and he agreed. By the end of the session he was falling asleep, which I took as a sign that his anxiety had lessened a bit. 

Two colleagues and I have just launched a service providing long-distance therapy for aid workers, journalists and others who need, but traditionally don’t seek, therapy. People in the field are witness to all kinds of horrors, their lives often in actual danger, and their own problems can pale into relative insignificance when compared to the plight of the people they’re out there to help. Bravado, booze, black humour and being generally hard-bitten often mask serious (and very possibly pre-existing) problems and stop anyone from asking; “Are you okay?” Our therapists are all former journalists or aid workers themselves. 

Someone from a big US health insurance company asked me what our strategy is for dealing with traumatised patients (she called them clients) who may be in unsafe situations. She asked me about my goals. Strategies! Goals! Help! (I’m English.)

Pondering this I recalled the words of my old seminar leader, who would tell his first-time therapists, “All we can do is listen and try to understand.” It is easy to get sucked into treatment plans and strategies, to be seduced by some new model promising a cure in only a few sessions. But life just isn’t like that. I thought of my patient, who, although he lives a middle-class life in a Nordic country famous for its safety, feels desperately afraid. I suppose my goal for that one session was to help him feel calmer and my strategy was to understand him. That doesn’t sound very impressive though.

But wouldn’t it be a grandiose fantasy to imagine that we might make someone in a war zone actually safer or instantaneously less traumatised? “I suppose the strategy of psychotherapy is always the same really. We’re only ever trying to grasp the unconscious communication and bear the material without entering into the panic and trauma the client is trying to express, or perhaps to offload,” I babbled to the US health executive. 

If a patient comes in being seductive and you get seduced that would be acting out the patient’s game rather than understanding it with them. If a patient comes in panicked and you spring into some sort of action, you’d surely be missing the point. Therapy can’t stop atrocities (unfortunately), but it can hear about them and try to understand their effects.

“Anyone promising certainty is lying, so perhaps the strategy is to try to bear there being no strategy,” I found myself saying to this efficient woman on the screen with a head set on and an impressive view out of the office window behind her. She rapped her fingers on her desk, and I went all meek, shrugged and said, sincerely: “Sorry.”