What is in a case?
01 October 2007 at 12:00
A student homeopath preparing for a session with her supervisor writes about receiving a case:
“ I worked hard in this interview to not get caught in my own feelings about sexual abuse situations. At first I was worried that she might not tell all, so to speak. But at one point, I could feel her open up and the case start to take shape. At the end, I struggled some with how to talk with her about the risks involved in her decision to stop taking a seizure medication she has been prescribed by her doctor. I felt I had to re-state, at least, that I am not a doctor etc. and did all that at the same time that I was personally wanting to hug her for not using this medication as a suppression. It was a difficult spot for me; to speak as the homeopath and feel as the mum but I feel satisfied with how I handled it. “
As she starts out in practice, this student experiences some ‘work’ and ‘struggle’ before ‘satisfaction’ with how the consultation went.
In this next extract from her reflections at a later date, she is developing confidence in herself and the process. Anxiety, struggle and work are giving way to trust, interest, and observation. When the learning edge arises, for example, feeling in the thrall of or ‘fascinated by’ the patients story, she again works at watching.’ She writes:
“I am learning to appreciate and respect the simplicity of this process. I began by trying to direct the process more than necessary whether by my questions or by the outlines given in various texts about what information to cover. I’ve learned and continue to marvel at the simple way people find to show you exactly what you need to know. It’s both amazing and tender, and I’m practicing my ability to be quiet with each person and to be open enough to offer the space the story needs. I’m gaining confidence here and feel more able to trust that the case will come with little help from me other than providing the space and staying focussed. I’ve seen that patients condense their message in different kind of ways to give it again more clearly and strongly if the remedy given the first time isn’t close enough.
I recognize that sometimes I simply get too interested in the person’s story i.e. fascinated by some aspect of it…and then I can get sucked into it or start conversing as a friend might without really paying attention to what’s happening here…something I’m working at watching. I’ve been extremely moved at times with the amount of suffering there is in the world…and the tender and difficult ways people cope with their lives. “
‘A ‘case’ is the sense we make of a person’s original story. People come to see us. They become patients. We, as homeopaths, take and receive their story. We weave a case from it according to our arts and respond to the sese we make of it. There are many acts of translation involved. There are many stories to be heard and retold, refined and revised in the quest for the more elemental one, the one that will tell what the matter is and literally move the person on. Ryan 2004
As we develop in practice, we become more at ease, more of ourselves. We make the role of homeoapth more our own. At the beginning, when difficulties arise, we tend to fall back on the responses we know best so that a patient may get the ‘tea and sympathy’ of the friend or the investment of the mother, rather than the space to reflect and discover anew. In turn, a supervisor may revert to their primary role of homeopath and try to ‘remedy’ the supervisee rather than give them the space to reflect and learn for themselves about their practice.
At the School of Homeopathy we know that as a learning community we are all, students and faculty, engaged head, hand and heart in an inquiry into homeopathy. It is through my work with the School ,as well as in practice, that I have come to realise the importance of a holistic view of practice itself and of the role of supervision in maintaining the wellbeing of the homeopathic community.
In this article I will introduce you to a systemic or holistic model of practice which extends to relationships and roles and does not confine itself to the case, the method and the remedy. The model includes the relationship we make with the supervision of practice as well as that between patient and practitioner and the environments in which we meet.
In this model it is not just the ‘case,’ stuck, difficult or interesting that we bring to a more experienced practitioner for advice, guidance and assessment ( the supervisor) but rather a growing awareness of ourselves in practice, our learning edges, our prejudices, talents and interests.
Supervision, based on a trusting enough and risky enough relationship between peers can be a reflective space in which life long learning is faciliatated. It can be the unit upon which whole learning communities are based. A place of genuine inquiry, a space to be ourselves, an experience of vulnerability without being shamed. Instead of only being a developmental stage in a student’s path to practictioner staus, supervisied practice can be a means by which we all participate in an inquiry into homeopathy; into what it means to patient and practitioner, into how effective it is, into what actually occurs. If we do take the time and effort to make such relationships then we may also make a strong, vital learning community of homeopaths. This is important to what is a curently marginalised practice. Put simply, we need each other.
In order for any model to work, it takes time to get to know it and to practice it. If you don’t already keep a version of a case top sheet with space to record, not only the dynamis of the case and the responses, but your reflections too, then one practical suggestion is that you fire up your computer and get started on one. Without reflection there is no new learning from clinical practice.
The purpose of supervision is to learn from what we do.
The model is intended for use in self supervision and in supervising each other. It is a teaching aid in that it keeps in view the field of practice, alerting us to what we need to know about the process of becoming and being a homeopath.
The systematic manner in which supervision is applied is called a model. Leddick G.R. (1994)
A model is a framework or map which incorporates both process and function. Page S. and Wosket V (1994) p.29.
The purpose of making a model of what it is we do is to make it accessible to ourselves and others. It helps demystify the process. (While healing is a mythological project this is not to be confused with mystique which only disempowers the patient and aids the omnipotence of the practitioner.)
According to this model, personal growth is integral to professional development. Put another way, if we are not becoming more insightful about ourselves and our relations with other people as a result of practice, we are like loose cannons waiting for that patient to walk in and light the fuse!
I call this model of practice CEP. It is Based on a cycle of relationship. It is simple actually and in writing it down it seems to fall easily into two parts.
Part One: The elements
Ist consider four elements we bring to relationship:
Competence, Confidence, Creativity and Compassion ( The 4 ‘cs’ Brigid Proctor)
2nd consider the Expecations we have of the relationship.
3rd look to see how these ‘cs’ and expectations change and develop in the process of being in the relationship.
By competence I mean the adaptation we make to life. Disease is an adaptation, a competence. As homeopaths we bring our personal competence and that which we have learned and unlearned while studying and practising to be a homeopath.
Practicing beyond our competence is an ethical issue. Not acknowledging how competent we are could be a confidence issue.
Over confidence could be an ethical issue. Lack of confience could reduce our autonomy and effectiveness.
Creativity issues could be to act with little genuine inner guidance or discipline or else to use little creativity in making of homeopathy our own art.
Compassion can mean being stuck in empathy or burnt out through lack of self care. It can also mean to see patients as case objects rather than fellow human beings.
Of expectations we can ask how realistic are they? It includes diagnosis and prognosis and goes on to ask ‘Who am I as homeopath for this patient or practice?’ ‘Who are they for me? ‘ and ‘ What do I expect from being in practice?’
Process questions include ‘What is happening? And ‘ What is changing and in what direction?’ ‘what is moving and what is stuck?’
Part Two Relationship
We meet as people.
We get in role, as patient, homeopath, prover or supervisor for example.
We make the case together.
We respond, more or less, homeopathically and are restored, more or less, to ourselves.
Taking each of the four aspects of relationship in turn:
I - Thou: We meet as people.
Before the working alliance between patient and practitioner is made, before the case is given and received, before the remedy is given or responded to, there is the potential for healing. Paying attention to what it is we bring to the encounter and to the quality of our presence in the meeting begins the process. The case begins to move and we are rewarded by insight into the deeper, motive springs of self and other.
We bring values, predjudice, our former experience, projections, hopes and fears to the encounter. If we also bring compassion then we risk healing us both.
Rogers (1994) says of this unconditional love: it respects the other person as a separate individual, and does not possess him. It is a kind of liking which has strength, and which is not demanding.
What do we expect in doing homeopathy? With this patient? To heal? To be healed? Learn? Teach? Rescue? Reflect? Restore? Fix?
We are present when we actively listen, observe, be with the other and also with ourselves, listening to our own ‘felt senses’ at the edge of our awareness. Val Wosket (1999)
The competence needed is a mix of personal quality, characteristics and skills developed through practice.
This practice is inclusive; moving from self, to other, while paying attention to the space in between. It is central to clinical wisdom.
Unpacking what happens here is the field of supervision.
Martin Buber (1923) conceived the idea of ‘inclusion’ in relationships. He differentiates between ‘I’ - ‘It’ relationships in which the other is object and ‘I’ - ‘Thou’ relationships in which love as respect for separateness and difference is made. Inclusion allows us to move in and out of emapthy with the other, being with the other at one moment and seeing from our own perspective at another. Bringing awareness to the interventions we make and the effect of our presence on the other as well as their effect on us.
Looking at the model, the case is a mirror of the person when they are received in this inclusive way. The person only becomes an object when viewed as an objective case rather thsn a reflective process. We have an ‘I’- ‘It’ relationship with a case. This is why it is so important that we begin in a real relationship, in order to fulfill the purpose of homeopathy, to restore us to health that is to more of our humanity. If we begin by ‘taking a case’ or ‘receiving a case’ instead of meeting another with love, we are working with objects rather than other people.
We are very concerned at the moment with homeopathy as a profession. I should like to see us blur the distinction between amateur and professional in one important way: Profession as meaning that which we profess or believe in is quite congruent with amateur as that which we do from love.
Where now is the line between personal and professional development?
We develop our roles together.
Some thoughts about the importance of role:
We meet as people. We develop our roles together. A person becomes a patient, homeopath, prover or supervisor. The role itself demands its own competence, qualities, characteristics and skills. Some we have naturally and some we develop through practice, reflection and feedback. Some people appear born to the role, being naturals. The rest of us learn from our mistakes.
Why develop roles when meeting as people is what counts?
Formal space is elemental to the therapeutic relationship and to supervision. In the creation of ritual place and role, strangers can meet in great intimacy, making meanings and remaking their lives, without the consequences of personal involvement. Staying in role is an ethical issue.
The formal relationship is sometimes referred to as a working alliance. This is helpful in that it reminds us we are here for a special purpose and that we are doing it together.
Val Wosket (1999) develops the idea of becoming more of ourselves in our role so that role itself becomes invisible. She points to research into psychotherapy which repeatedly indicates that it is the person of the therapist who is more important than their theoretical school in determining outcome of therapy. Of course, we know that as homeopaths, it is the homeopathicity or not of the remedy that determines outcome. However, that remedy choice emerges from the patient - practitioner relationship.
Irvin Yalom ( 1999) in his tales of psychotherapy, Momma and the Meaning of Life recounts an heroic five year encounter with a client in a state of ‘grief rage.’
According to her, I had helped most by engaging her, by shrinking away from nothing she said or did....I bridled at such simplification. Surely my approach to therapy was more complex and sophisticated! But the more I thought about it, the more I came to see that Irene had it quite right. (p147)
Staying in the ‘here and now’ of the consultation, allows us to perceive the energetic case. Talking about something is nowhere as powerful as being and doing it! The patient - practitoner relationship is just as powerful a resource for the homeopath as the client - therapist relationship is to the psychotherapist. Being free to be oneself in the role of homeopath is a mature practice. We first have to experience in practice the power of formal and ritual space itself and to develop a sense of the roles involved.
In order to do a proving, we must become a prover. In order to give our case we must be patient. In order to receive it we sit as homeopath.
Sometimes the case is ‘stuck’ because we have difficulty with some aspect of the role we are in. Perhaps the person coming to us is not yet patient. We may have phoney ideas about what a homeopath should be and feel uncomfortable in our role. The remedy may not have been proved yet or well due to lack of people in the proving role or those in it not entering into it fully enough.
Abuse is common in therapeutic relationships. It happens when love as eros is mistaken for the unconditional love that does not burden or obligate the loved one. Kahn M. (1997)
Maintaining role makes for the right kind of loving!
‘Role Shadow’ is a term used to describe the way we seem to banish aspects of ourselves when we become counsellors because they dont fit our initial view of the role. Page S. and Wosket V. (2001)
Examples of my role shadow include my bluntness, sense of the ridiculous, capacity for making mischief and impatience...Page (1999)
These refelctions seem just as applicable to us as homeopaths.
Many examples come to mind, a brief one; a homeopath who adopts the role as if she herself has no needs. Personal response is consigned to the shadows. Seven years of listening to others without so much as a whisper from herself. Then, Bam, Take that! I am ANGRY. WHAT ABOUT ME!?
The question arises ‘Who are we for our patients?’
We make the case together
Making the case is an ongoing project, one in which both people bring their own inner world to the encounter in a continual flow of reciprocal mutual influence Stolorow and Atwood (1992)
Brian Kaplan in his lovely book The Homeopathic Conversation (2001) shows how the art of receiving the case is there, in essence, in the Organnon. He quotes Hahnemann aphor. 83:
This individualising case of disease, for which I will only give in this place, general directions.... ( aphorism 83)
kaplan then goes on to elaborate on these general directions given in aphorisms 83 to 99. He explores through his study of modern psychotheraputics and philosophy as well as his own clinical practice, how to receive the case within a healing relationship.
He comes from an ‘expert’ tradition as a doctor to reflective practice and so plots a fascinating journey along this continuum.
He quotes Buber saying:
Man defines himself in a way through the quality of his relationships.... (p90) The homeopath, adds kaplan, also has the joy of seeing the effect on patients of correctly prescribed homeopathic remedies. (p92)
Kaplan throws down a personal challenge when he writes: It may be a lifetime’s work but I would invite you to ask yourself whether you have something better to do with your life than to improve your relationships with your family, beloved friends, patients and fellow man in general. (90-91)
Implicit in this is the injunction to improve the relationship we have with ourselves.
In another modality, Paul Klee wrote in his diaries ( 1925)
The work of art is first of all genesis; it is never experienced purely as a result. In the same way the case as art is always becoming, being co-created in the relationshhip between homeopath and patient.
In The Thinking Eye ( 1961 translation) he wrote;
Form as movement, as action, is a good thing, active form is good. Form is bad; form is the end, death. Formation is movement, act. Formation is life.
Likewise, the case as still life is dead. Dis-ease is ‘stuckness.’ We talk of ‘stuck’ cases. The case as form moving between two people, is capable both of transforming itself and those who create it.
Notice the practitioner as well as the patient is healed in the encounter. How else do we practice?
We notice in supervision very often that a ‘stuck’ case is so stuck because the practitioner as well as the patient is stuck in it. Instead of a compassionate observation achieved through an inclusive practice, is the practitioner clothed in the garb of the case. This may be called ‘echo’ or ‘parallel process’ in the literature.
The patient may for example not be expressing anger directly. She may be repeatedly missing appointments, turning up late or forgetting her cheque book. In response, the practitioner may feel, not unreasonably, some irritation or frustration with the patient.
The suggestion is we engage with our own responses to patients, to see what light they throw on the case and indeed on ourselves as co-creators of the case. The Mumbai school for example implicitly recognises the art of taking the case in all its manifestations with its focus on perceiving the vitality of the case in sensation, gesture, delusion, doodle etc rather than a hierarchy of symptoms only.
Creative ways of receiving the case and of supervising the case come into this. The narrative being only one element of the case receiving. . Most meaningful communication being non verbal. How do we stay open and expect the unexpected?
Information is suprises as Roger Schank says. (2000)
Engaging in the moment with the other rewards us with insight. A lot happens we can’t catch at the time of course.
Supervision and reflective practice is all about the riches we find when we remember what happens in practice.
Just try a few minutes free form writing about any moment in practice that has caught you in some way today and see for yourself!
If the case is truly received then by the time the acts of translation are complete, it will look like an abstraction of the ‘ I’ - ‘Thou’ relationship. Hence on the model ‘the case’ is placed in continuum with ‘person’.
It means too that it can be written on a case top sheet so that it looks both uniquely characteristic and well rounded while being entirely confidential as it is abstract; a homeopaths’ professional record. The case may be recorded as a mappa mundi diagram ( Norland ) or as a set of essential rubrics or a vital sensation or gesture.. It can be sent to colleagues, by email, taught in class and shared in conference without compromising confidentiality.
The full case notes record the patients’ narrative and the homeopaths observations. Only a video recording of both patient and practitioner record the case fully and only such video and audio recording as well as live case receiving under supervision can show us to ourselves as case receivers.
In this way we can re-visit the ‘here and now’ encounter and see what we could not see at the time precisely because we are engaged in being with the patient, ourselves and the space in between. A tall order and a lifetimes’ practice to do. So we re-visit the encounter on reflection, in supervision and with the help of rewinding the tape.
Very often in supervising the case, there is incongruence between the patient seen or described and the case presented as ‘stuck.’ There is a problem in translating the person into the case. The missing translation is most often the unspoken narrative of the patient themselves, the unlistened to narrative of the homeopath in response to the patient and the unsaid or unrecorded dialogue between the two. It is the task of the supervision to bring the ‘there and then’ encounter into the ‘here and now’.
It should be clear from this description of supervision that education and practice in the role of supervisior is as important for a good quality clinical supervision as the development of a trusting relationship.
The response: More or less homeopathic.
This means that all theraputic interventions; the things we are, say and do during the consultation, as well as the remedy, can be more or less homeoapthic. A homeopathic response is an individualised one, it is a minmal one and it is an energetic one; it captures the vitality of the dis-ease.
The ‘response’ is placed in continuum with ‘ role’ in the model, as one end of a continuum, in the same way as ‘case’ is opposite ‘person’ in the model. Whether the response is more or less homeopathic depends in part on the development of the roles: As the person becomes more the patient, entering the process more fully, and as the homeopath is more fully realised in their role, the energetic case is received and the response will be more homeopathic.
As klee says of art, the response is partly genesis, never purely result.
If the response is more homeopathic, the patient tends towards restoring their humanity and the cycle goes on. If a patient does not do as well as is expected on a remedy, is ‘stuck,’ we can explore what is happening. Has the case been received? Where might the clues lie in this encounter? ( the 4 ‘cs’ Does it reflect the person met? Is the case synthesised and analysed properly? Are the patients expectations realistic? Are the homeopaths? Do they concur? Is their a working alliance? etc.
In this way, the process keeps moving, in a spirit of enquiry rather than demoralisation. This is the gold in attending to process: We are encouraged by it to stay in practice and to stay well in practice.
Bringing it together
As a cyclical model, a case or issue can be approached from any point. If your perception is that you are stuck in one way, you can shift your focus to another, moving point, and have a look at it from there. Very often the perception is that it is the ‘case’ that is stuck, perhaps the analysis, some issue with repertorization or differential. As Brian Kaplan points out, (2001) we can’t synthesise or analyse a case that hasn’t yet been adaquately received. And so we shift the focus to aspects of the case receiving or to what is happening in the relationship, or to the working alliance between patient and homeopath.
The role of supervision is to restore us to independence and relationship to ourselves, our patients and the wider environment. This is a holistic, or we could say systemic or ecological approach to practice and supervision.
At the centre of the circle, where all aspects meet, are the ethics of practice.
These are the elemental questions: Where is the compassion? The competence? Confidence? creativity? What do I intend and expect? What is actually happening?
Ethical questions put us in touch with the wider context in which we practice. As a relational model, both the minutae of practice and the wider environment are connected.
Who benefits from our practice? How accessible is our homeopathy?
Do we foster autonomy or dependence in patients? For example.
Fish and Twinn (1997) define practice as a complex, dynamic, social activity underpinned by sets of values and beliefs, traditions and theoretical perspectives, and with a moral dimension.
All the professional judgements we make have an ethical dimension.
Self knowledge is at the heart of ethical practice.
It sorts out our ‘shoulds’ from what is, and as Jung said, that’s wisdom!
The student at the beginning of this article is also at the start of her practice. She shows us, in her reflections, that what is in a case, is the tenderness of a true meeting between people.
I hope this article gives voice to something of your experience of practice and supervision and that the mapping introduced here of what is in a case proves useful.
Feedback is warmly invited.
Sheila Ryan September 2007
Sheila is Clinical Supervision Principal of the School of Homeopathy where she works with Misha Norland
She is a Fellow of the Society of Homeopaths and director of Sea Change homeopathic supervision
She has written many articles on practice and supervision. An earlier version of this article first appeared in The Homeopath No 85 in 2002
She is author of Vital Practice Stories from the healing arts The homeopathic and supervisory way
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