On being uncertain in certain places

I recently started my specialist placement: children’s neurosciences incorporating paediatric sleep and a complex motor disorders service. It has been fascinating so far, working with new client groups and in a hospital setting, which is novel to me. It has also been a culture shock, hence the title of this post.

Throughout my clinical psychology training, I have been encouraged to explore and grow more accustomed to certainty. This is a central part of what I now believe to be the role of a psychologist: to resist grabbing on to a sense of certainty, when faced with the complexity our clients bring. It is tempting to leap towards more certain, explanatory answers, but when done too soon, this can shut down the exploration which is intrinsic to the process of potentially helping people find meaning in their distress, and prevent people formulating their own ways to work with it, hopefully preserving a sense of their own agency.

Certainty can be seductive. In my earlier work as a low-intensity IAPT worker, I was taken aback to find myself being admonished for suggesting that someone might be drinking an amount that could be to the detriment of their mental and physical well-being. I was told that in so doing, I had assumed the expert position. I had thought that I was being helpful, and that indeed it was part of my duty of care as a health worker. The possibility that this might not be an appropriate part of my role was new information for me, and led to my reflecting on the ethical dilemmas it implied: by remaining with someone in the uncertainty, perhaps it would have allowed a healthier therapeutic alliance to develop, rather than potentially shutting the alliance down with what might have been construed as advice-giving on my part.

Thus the intervention could be viewed as a balance between short-term and long-term benefit: by not intervening so soon, the benefits over time might be better. Indeed, in the situation above, it was later protocolised that this type of information-giving should be standard practice at the reported level of drinking. However, if I had not been picked up on it, leading me to reflect on the benefits of intervening soon rather than waiting, as well as whether I was unhelpfully taking an expert position more widely, I would not have learned so much from the situation.

This could be seen as analagous to the urge to move towards a certain position, which could shut down curious explorations and dialogue. I took this approach forward with me, and it has been cultivated in my clinical psychology training. A core paper has been “Towards positions of safe uncertainty” by Barry Mason. It has been invaluable in my transition to the role of a trainee clinical psychologist, and has helped me to resist the urge to try to explain or label things people bring, and explore complexity with people. This was initially a very difficult place to occupy, but it has become more natural, to the point that to move to a position of (psuedo-) certainty often seems quite alien to me.

When I started in the hospital environment, and saw the way things tend to be conducted, I was surprised to find myself experiencing another culture shock, but this time in the other direction: the certainty that clients tend to be presented with jars with my current professional identity. People are given clear answers and explanations for why things might be happening, and whilst these might be one explanation of many, it often feels like they are presented as the sole explanation. This feels awkward and somewhat simplistic, but it makes sense in the hospital environment, where people are seen irregularly for relatively focussed interventions. I have seen how helpful people seem to find the answers they are given, but find myself wondering where the role of a clinical psychologist fits into this. I was reminded of the scene in U-571 where Harvey Keitel admonishes the acting captain for revealing that he does not know what to do, and the potential paradox this introduces to the role of a clinical psychologist: how does one balance sitting with uncertainty with the pragmatism needed in leadership?

I have been reflecting on how much uncertainty I can realistically show and communicate, without perhaps positioning myself as outside the team, which could be problematic. I feel that at this early stage, I may have to tread relatively carefully, and sound out the ideal position where I can still be acceptable to the team, whilst still being positioned at a distance that opens up, in the words of Gregory Bateson, the difference that makes a difference.


Photo – Hakkoda’s Summit by Charlie Tyack