Multisensory: An intimate, embodied and holistic process of painful clinical decision-making: Applications for practitioners
That evening, when she got home, it was hard to open the front door. She realised she was not only pushing the door but the slumped body of Viking. It looked like he’d tried to get out of the cat flap, and it was too much. With tears on her face, Val phoned the vet. She should have had the courage to do this yesterday, not leave him to collapse on his own while she went off to do work she didn’t want to do but had to because her stupid trust in market forces had led to the loss of her pension.
Overview: October 2023
This month’s fiction is: It is time for you to go
This month’s application posts are:
Researcher positionality: Grandmothers are other-with: Applications for researchers
The fiction this month is, for me, about the painful process of clinical decision-making when that decision-making is under pressure from market forces to be ‘effective and efficient’ from a manstream perspective.
As a practitioner, when I make decisions about ‘what to do’ in therapy, I am at the interface of being absorbed in the intense application of my tacit internal knowing process and the outward facing process of moving towards fixed knowledge and then moving into action. At this interface of the maternal and external, it feels easy to lose caring connection to the lived experience of being with the people who have come to seek my help to alleviate their distress. Instead of the person in need being at the centre, it becomes too early to be caught into the challenge of navigating the tension filled gap between that maternal and the external, expected manstream, just as Val was automatically about to put Viking on the vet's examination table when he was comfortable on her lap.
At one level, writing about the Theraplay core concept of working in a multisensory way is straightforward as it is such a physical way of working with sight, sound, smell, taste, and touch. In terms of practice, Theraplayers, as well as other practitioners, are more aware of the deep embodied and sensory aspects of what we do (Hong et al., 2023; Lloyd, 2016; SAI, n.d.), but my reflection on the importance of this core condition by engaging with writing the fiction and then wondering about the fiction took me less in a direction of how do we do multisensory practise, but why? What are the philosophical and theoretical underpinnings to this aspect of our clinical practice?
In these blog posts, I have been putting forward an argument that we use tacit maternal knowing. In my doctoral research, the focus was specifically on uncovering my use of this in my therapeutic practice with children experiencing the effects of relational and developmental trauma. Since I have moved beyond sharing that doctoral research with you, and moved into new territory, each of the new fictions has placed Val in a world outside the deep immersion of complex clinical practice. This absorption in meeting the needs of the people we work with is essential. My thinking about where the fiction is taking me in uncovering my tacit knowledge has left me considering that there is also something protective for the therapist in this hyper focus on one dyad (therapist-client in standard therapy, parent-child in Theraplay).
Absorbed in clinical work, the tacit knowledge being used is contained within the process of endeavouring to find ways to make therapeutic relationship. By allowing ourselves to be guided by our tacit knowing, we are inevitably working in a multisensory way because tacit knowing and tacit knowledge is developed through the innumerable bodily actions that lead to skilled practice (Polanyi, 2009). Tacit maternal knowing is one form where what is drawn on is the skilful practice of motherhood, which has often been unnamed and unacknowledged as skilful practice.
Maternal knowledge is in our theory. Bion talked about containment. Winnicott talks about primary maternal preoccupation. Milner talks about the need for artistic space (Caper, 2020; Wright, 2009; and Halton-Hernandez, 2023 respectively). But I would argue that in all of these theorists, the lived experience of the maternal absorption has not been sufficiently embedded and valued and so has been viewed from the realm of the manstream with the potential for Othering rather than valuing ‘the other’.
I have presented this removal of the power of the lived experience of mothering as a facet of misogyny and patriarchy: the manstream. However, this month I've been more preoccupied with just the inherent difficulty of moving tacit knowing processes into action; that challenge of making clinical decisions that are profoundly embedded in the intimate embodied and multisensory relationship between two beings relating at the preverbal, non-verbal, and right-brained level (yes, another core concept of Theraplay not yet explored in these posts). This form of relationship is represented by Val and Viking.
There are moments when relationship must move on. Cats age faster than humans. The infant grows. Tacit maternal knowing is not a static thing. It is a process of adapting to the developmental needs of the other, using one's power in the service of the other. Viking is ready to go. Each step of development involves loss as a necessary part of progression. This is hard to do if you are so utterly absorbed in the connection to the person being cared for that it is as if you are one. To allow growth and change, you have to accept the loss of both something of the person you are caring about, and something of yourself.
Val is in a very different aspect of her tacit maternal knowing in this fiction. In August, she, rather gleefully I thought, accepted her Othering as a batty old woman, as it gave her space to disrupt violence. But she got hurt. In September, she displayed her tacit maternal knowing, her desire to connect in an engaged, challenging, and nurturing way, in the wrong place at the wrong time. This was a misattunement to an externally imposed structure, and she is deeply wounded.
This month, she retains her connection to the embodied multisensory experience that is symbolised by Viking, and so her decision-making, although heart-breaking, is sound. There is no traumatising injury in this fiction. There is development with its inherent loss. This enables progression. It takes us back to our roots, with the potential for even those roots to be changed by the experience.
The progression is that of an integration of masculinity in a form that can see, value, and enable the importance of the maternal. Graham spots that Val is about to fall into an old pattern of manstream practice, moving Viking from the comfort of her lap to the examination bench, and can structure a different way of meeting Viking's needs that combines both maternal and paternal forms of knowing.
If you have been reading previous posts, you know that I have been wanting to move beyond raging at the manstream. The part of me that does know is saying that this integration will come, and give solidity to decision-making, when the logical and the verbal is used, alongside tacit maternal knowing, in the service of the more vulnerable other (represented by the computer that Graham moves to serve Viking’s needs).
I don't think this is any different to what Bion was exploring in his own theory, as elaborated by Caper (2020, Chapter 10, penultimate paragraph): “if we simply equate the theory of the container with the maternal model, we lose sight of the elements in the psychoanalytic situation that require a paternal function. This function defends the analyst's maternal linking and synthesis from the patient's attacks on the analyst.”
Winnicott, elaborated by Wright (2009, Chapter 8, page 2), talking about the notion of holding says, “whereas theories of interpretation are relatively detailed and coherent, operational accounts of holding and containing are harder to come by. Constituting and an unobtrusive background to the analytic frame, they have seemed to have eluded clear description”. “Transitional functioning allows an emotional experience to be ‘held” (contained) within a sensory form or concrete object…Thus, an observer can see that the baby’s comforting bit of blanket is like the mother's skin in being soft and warm” (Chapter 1, page 10). This observer position is what I relate to Capers’ notion of paternal containment and what I called ‘logical and verbal’ in the previous paragraph.
The connection of these theorists, that I have deeply valued in my training and practice, with my internal process of recognising, valuing, and theorising my own tacit maternal knowing as a powerful part of my clinical practise leads me to become other-with these theories rather than being Othered-by them (Garcia, 2021).
This feels a significant and useful step in accepting how I describe my clinical decision-making process. It gives a theory to how my practice is “guided by the adult” (as we considered last month) in a way that does not detach itself from the intimate deep relationship that is created through the physicality of tacit maternal knowing. It facilitates tacit maternal knowing to be present in the hard places of decision-making. Holding awareness of the core concept of being multisensory, not just in Theraplay practice, but also in theorising how I use tacit maternal knowing, ensures that clinical decisions are congruent with my commitment to working relationally and using my power in the service of the more vulnerable other.
As with everything that emerged from a heuristic inquiry, I can only say, this is my learning, and ask, is it like that for you too? Does that make sense to you when you think about your embodied, intimate therapeutic practice?