Dr Liz Burns

Psychotherapist West Cornwall

A letter from Cornwall

This article is published in 'Context' the news magazine of the Association for Family Therapy.


In this edition of Context devoted to what is happening in the South West, I thought perhaps a letter from Cornwall, accompanied by some photographs might help to convey a feeling of place, a sense of context, which would, I hope, add depth and meaning to our contributions.

Dear Context Reader,

Writing from the edge


Many people have a picture of Cornwall in their minds, derived from holiday visits from the past. In no way do I want to interfere with these, especially if they feature more sunlit happiness than driving rain misery. We have our share of each, and I want to make some connections between where I find myself geographically and socially, and where I am in my career as a Family and Systemic Psychotherapist.

Many (even most) people stop off in Cornwall before they reach West Penwith, so cannot have a clear picture of this beautiful rugged landscape and the nature of the people who live here. To get here you have to continue beyond what seems the final destination which Penzance presents to rail and road passengers alike. To get here professionally, I have seen fit to push beyond retirement to create another mini career and a different life. To some (including me sometimes) this seems like a step too far but, like it or loathe it, here is a letter from about as far west as you can go.

‘You don’t need a weather man to know which way the wind blows’ Bob Dylan ‘Subterranean Homesick Blues’

I am writing to you on a pretty average day for the time of year, which is late January. I refer mainly, of course, to the weather. There has been sunshine, rain with a bit of hail, then sunshine again. There is a strong wind blowing, though happily from the West, in contrast to last year when the prevailing winds were from the North and East. This means that it is significantly warmer (no frosts for us!) and although evergreen trees are burned brown, early flowers are alive and well. Last year, when north and east winds predominated, early blooms were slaughtered.

You may think that I have become very preoccupied with the weather and, more particularly, with the peculiarities of the wind. This is an inescapable part of living on an exposed piece of land sticking out into the Atlantic. High winds, rain and giant seas, such as we have recently experienced, mean that flooding is likely, fishing boats can’t be launched, beaches are left denuded of their sand and the runway at Lands End Airport is waterlogged for the second winter running. Economic consequences affect everyone in a small community, and it also means that, for weeks at a time, families cannot make it from the Isles of Scilly to Penzance for Family Therapy. The Scillonian does not carry passengers in the winter, the all weather helicopter service has been scrapped, its old location now sporting a new, unwanted and very obtrusive Sainsbury’s, and the only transport link, a light aircraft, cannot land at Lands End because the grass airstrips are unusable. The round trip using Newquay airport is too long to allow for a FT session to be held in Penzance CAMHS and for the family to return to Scilly the same day. Time, you might say, for the FT team to think: ‘How can this family and their social/professional networks be involved in a therapeutic experience which is relevant to their needs?’ and even ‘what would we do if we were trying to work in Lapland or some other place short of normal travel links?’. Years ago, when I was leaning to be a systemic family therapist, I was taught that every problem or crisis can, and perhaps should, be re-framed as an ‘opportunity’ and there is indeed plenty of scope here for therapeutic letter writing, group-talking on the speaker-phone, or skype, given the facilities. Heroism in battling to obtain, or provide, services may be admirable, and we hear routinely that Islanders are proud of their independence and stoicism, but this situation feels very singular to me, and not in a good way.

When wider social systems impinge, as they are doing everywhere in this time of austerity, we may wonder how to approach our responsibilities as systemic thinkers and doers. In Cornwall, mental health services are painfully (chronically and acutely) short, not only of designated FT posts, but also of clinicians trained at any level in Family and Systemic Psychotherapy. I must remember to tell you here that I am but a volunteer in the public service, working on an NHS honorary contract, so my qualifications and experience do not ‘count’ in an organisational sense. I quite often find myself, as if in a time warp, thinking back to earlier times in my working life. In the 90s, when we were busily professionalizing and trying to get FT posts established in public services, and the NHS in particular, we needed to be ready to take risks and do a hard sell on our skills. I remember resigning from my social work post (I worked as a family therapist, so wanted recognition of that, and at that time I also wanted an NHS post) and on the day that my notice period expired, being offered a health service family therapist post in the same team, on the understanding that I could bring a certain amount of work and funding into the Trust. Does this seem the same? That was a time of optimism and confidence, at least where I was, and there could be rewards for taking risks.  I think the situation here and now (and perhaps in other places too) feels much more like the 70s when things were very tough indeed, there seemed few options, and many of us thought that political action was the way to go.

As an independent practitioner, I do also offer to work privately but the take-up is small, most people finding my geographical location rather too remote and windy; not normal, even for Cornwall. Besides, the tradition here is to make do and be independent and this has not hitherto traditionally involved going to a stranger to talk about intimate family issues.

In addition, very few people have much disposable income.

No wonder we are all obsessed with the weather!  



The ‘pattern which connects’ Bateson ‘Mind and Nature’ (1979) p.9

Since coming to Cornwall I have learned (or perhaps re-visited) a few valuable lessons about practising as a Family and Systemic Psychotherapist in lovely, but sometimes inhospitable, contexts. I’m not saying that these lessons are not equally applicable elsewhere, and I’m not saying they have necessarily got me where I want to go, but coming to Cornwall has certainly foregrounded them for me. I don’t know how it would have been different if I had been taking up paid employment, but as an independent practitioner I have been learning how important it is:

•    To meet people where they are
•    To revisit regularly the fundamentals of my craft
•    To look after my tools – predominantly myself.

These items may seem very obvious to you, so I’ll try to illustrate with a West Cornwall flavour and the help of a metaphor or two:

Meeting people and situations where they are.  
Go with the Flow '...You need to get to grips with and understand the particular conditions of your coastal site and soil, so that you will be sure to give up any uneven struggles early.... rather than fight, decide to grow what will succeed in the circumstances of site and weather.'  Segall, B (2002) 'Gardens by the Sea' p.139

Gardens are a big deal in Cornwall and it is possible to grow beautiful exotic plants here because of the warm winters – if they don’t blow away first, that is. Sheltered valley gardens like Trengwainton are the best for this but there are also stunning clifftop plantings like the one at the Minack theatre, where seaside flora cling to rocks high above the water. The motto for these gardens, and for my own, is ‘go with the flow’.

A first step in knowing what to grow is to immerse yourself in local gardens, observe what does well and the style with which it is done. To use the analogy with systemic practice for me, an important part was to return to home visiting, something familiar to me from my very early days working first in Family Service Units and later in Social Services. The impetus was largely practical, with geography dictating what would be possible. I learned again what it was like to go to an entirely unfamiliar place, sometimes in the dark, and contend with the many challenges posed by location and domestic arrangements e.g. too many granite walls where I try to manoeuvre my car; the TV in the corner; mobile phones; a dog on my head! I will always be grateful to the clients I met early in my days in Cornwall for welcoming me (usually!) into their localities and their homes and showing me how things were done where they lived. Plenty of advantages then, but later I felt obliged to think more about the financial implications of home visiting over a wide rural area. The costs of travel to a therapy session do have to be borne by someone and, if I charge an economic rate for mileage and travel time, which could easily be 2 hours in addition to the meeting itself, a family session at home can turn out to be an expensive item. I aim now to negotiate this with clients up-front whenever the question arises.

To return to the gardening analogy, the next step has been to make a tentative start on seeing what plants will ‘take’ and what is destined to disappear within a season. ‘Tentative’ is important and there is really no alternative to trial and error. For example, I was accustomed to work with a team and a one way screen, using a ‘live supervision’ method in my previous job, and a good deal of my time was taken up in that way. At the CAMHS in Penzance, where I am based, an up to date video link was installed, which was used for a training clinic for the Intermediate Family Therapy and Systemic Practice course in Plymouth. The clinic ran for a season, using my resources and those of the trainees, essentially as an extra to the work of the CAMHS team. The FT team used the video link but actually favoured a ‘reflecting team in the room’ method.  I came to see the training clinic acting rather like an architectural plant (maybe a Cornish Palm tree?) adding style and focus to the Family Therapy function. When the course was over, and with it the need for a training clinic, the FT team continued with reduced numbers for a few months. Eventually, however, local conditions demanded reduction to a pair of therapists, including me, offering family therapy fortnightly, using a ‘co-therapy with reflections’ type of intervention. This made it more difficult to maintain the profile of systemic practice and family therapy in a hard pressed clinical team.

Cornwall is not represented currently by any students in systemic training, in either of the local centres (Plymouth Intermediate or Exeter MSc) and so there will be no call for a formal supervised practice clinic in Penzance attached to a training institute for at least a couple of years. Sadly, but inevitably, ‘grand design’ has morphed into something more like maintenance, weeding or making compost, valuable activities in themselves but not providing a focal point.

Times are hard all round and, whilst I emphatically do not consider systemic practice to be an optional extra or a luxurious exotic, prudence suggests I now put some energy into producing a few tasty, healthy, metaphorical vegetables. I think the most useful thing to do with my very little time is to offer to work alongside other clinicians on an ad hoc basis, and bring a systemic view to case discussions wherever possible. Clinicians are preoccupied, but they will occasionally find time to chew on a nice systemic carrot, and find that it is genuinely worth consuming.

The training situation is worrying with its negative implications for the future. In the far south west it seems difficult to achieve the ‘critical mass’ I remember working so hard to achieve when we were ‘pioneering’ the introduction of systemic perspectives in the 80s and 90s. National austerity measures are not helping, especially where family and systemic psychotherapy already has a low profile, and other priorities are pressing. Arising out of this concern, I decided last year to nurture some nice strong seedlings to help keep systemic ideas alive and interesting, even if people are not in formal training. This is how the systemic practice groups (open to all with some grounding in systemic thinking and practice) came about. The format is informal, out of work hours, 2 hours long at roughly monthly intervals, and offered as cheaply as possible. The beginnings are small as yet, but this may be a plant which grows quite well in this particular patch: the armeria maritima (thrift), perhaps, of the systemic world.

Just one more gardening analogy: if we do not improve the soil and do the basics of horticultural husbandry, then richness and diversity will decline and the quality of life for all will be reduced. Gorse and bracken will be the only things to flourish, and there won’t be any more vegetables and food crops either!
         
Revisit the fundamentals
If you can’t explain it to a six year old, you don’t understand it yourself’ attributed to Albert Einstein
‘A child of five would understand this. Send someone to fetch a child of five’ Groucho Marx

What is the essence of a systemic approach? When you have removed all the dressing which pertains to particular brands, what is left that cannot be reduced?
For me, this question has been an important one, helping to clarify what is negotiable and what is not. This can be very energising, if strenuous, like throwing superfluous items out to keep the boat afloat, to use a nautical metaphor.

Accordingly, I have concluded that three words characterise a systemic approach for me: relational, interactional and contextual. ‘Relational’ means always focusing on more than one person and looking for the patterns which connect them with others. ‘Interactional’ refers to how the patterns (behavioural sequences, narratives, attachment patterns, circularities of all kinds etc.) operate, and ‘contextual’ indicates how situations become imbued with meaning according to the context in which they occur. Of course there is always more to be said and I have found this to be a good invitation to the ‘not-yet-convinced’. It has also been important to adopt and model these basic systemic descriptions in all I do (meetings, case discussions, team development days etc. as well as therapeutic situations) and to take every opportunity to explain what I am doing and why. Forgive me if this seems obvious!

I have made a conscious effort to remember what I love about the way I work, what excited me when I learned it and what I have found to bring about the effects I care about. Keeping abreast of what we know as a developing ‘evidence base’ is vital and relatively simple, thanks to the AFT website, but it is also important not to neglect what our own experience tells us is efficacious. A combination of both makes it easier to take a position and argue convincingly for it.

We know that jargon is aversive, but sometimes it is difficult to sort the jargon from ordinary shared language. This is another place in which I have found an interactional disposition useful. If the person I am talking to begins to look as though they would like to leap out of the conversational boat, then it is time to respond to feedback, and review the language being used. In the same way, it is important to be able to recognise commonalities in the jargon of others, and this is a situation in which a little curiosity is worth a whole heap of pronouncements. This basic principle applies well to all conversations, be they clinical or, more generally, about the price of fish, the style of planting suitable for a garden in Pendeen (viz. ‘we Cornish people don’t have trees’), Cornish tin/tin mining, or the nature of a sunset. Coming to a new place is a chance to refine this skill in social situations every day and to discover what it is which will float your common boat.
 
Look after your tools

‘Look out there’ he said pointing at the horizon. ‘Do you see the spot where the ocean meets the sky?... that is where you must put your mind, that place where air and water meet.’ Tan Twan Eng ‘The gift of Rain’ (2007)

I feel very privileged that the tools of my trade can’t be stolen out of my car, or while my back is turned. I do know, though, that they can be lost or can deteriorate for all sorts of reasons. This concern takes on a special piquancy when one is a. in an unfamiliar setting and b. becoming daily creakier and nearer one’s sell-by date. It is both a comfort and an anxiety that the most valuable, and arguably the only, tool is one’s self. It is a happy discovery, however, that age can be a positive advantage, handled carefully and steering clear of unwarranted assumptions.

Many years ago I decided to accept the profound intertwining of my personal and professional lives. I have not retreated from that, although there was a moment when I did wonder whether I would use my time in West Penwith, a place I had never known previously, to do quite other things; to write, to read, to garden, to follow a countrywoman’s pursuits (yes, at one point I was in the W.I) and to enjoy free time in a location I had chosen for its beauty, wildness and difference. It didn’t work out like that, and I have realised very clearly how life-enhancing being a psychotherapist is to me. The work I did a few years ago on literary reading and family therapists’ development shaped my life profoundly. One of the real answers to the question ‘whatever made you move here then?’ is that Virginia Woolf  had reflected so magnificently, movingly and with such human  relevance on the lighthouse just up the coast from our own. I was left with a deep interest in reading and writing, how they enrich and mediate lives. One of the ways this happens is through the strengthening of intuition through emotional and imaginative connections. Coming to Cornwall to live was a big step, and one that was taken intuitively. It remains to be seen how the lived metaphor unfolds.

To return to the practical, I think it is important to practise as much as possible. A systemic stance is an inclusive one and it is good and refreshing to say ‘yes, I’ll see what I can do’ when others may be saying ‘that’s not our remit’. I have learned to value my UKCP registration afresh, and the discipline involved in keeping it up as a kind of scaffolding within which to experiment. The honorary contract in CFT CAMHS, performs a similar function. After all the years spent in similar services, it is a kind of secure base for me but also one in which a ‘liminal’ position, half in and half out, offers a degree of freedom and a  perspective not easily viewed from elsewhere.

It has been good to help bring CPD activities closer to home for people in the far south west. The Cornwall and Plymouth branch of AFT (CAP AFT) is an excellent way of getting national and international figures to a venue near us. Being far away does not mean out of touch, but there is an urgent need to nurture skills and knowledge in ways which are both under clinicians’ control and local.

Cornwall is richly supplied with artists, poets and writers of all sorts and it is possible to feel spoiled for choice as to how to link up with them in productive ways. I find my poetry reading group, facilitated in Falmouth by poet Penny Shuttle, very rewarding and good for expanding my horizons. Lapidus (Words for Wellbeing) is alive and well, promoting ‘literary arts for wellbeing’ and I contribute when I can. One lesson I am having trouble with, however, is how to abandon the urge to fit more and more into a day. The pace of life here is mercifully slower, and I can’t help noticing how many people take time from the working day to park up and look at the sea or drive to certain spots to look at the sunset. Surfing is a passion for many and always seems to me to be largely a meditative activity, waiting for perfection in the shape of the moving water. My new home is a place of wonderful food, beautiful moorland, sea and beaches, fabulous cauliflowers, daffodils, early potatoes and dog-friendly pubs everywhere.

Where I live, the sea surrounds us on three sides. When I wake in the morning the horizon is the view from our window. It is hard to overestimate the impact of that, although its influence is subtle. I have felt for many years that therapy is something that happens in the spaces between words and actions, and I think this view is gaining from neuroscience in ways we could not have been sure of in the past. I have realised how much I value being able to work with a team, albeit a team of people trained differently from myself (nurses, psychodynamic and CBT therapists). The conversation and opportunities to think together are irreplaceable for me, as is the interchange of ideas and perspectives. A couple of weeks ago, I was ‘hot desking’ (not something I enjoy much) when I found, laid there as if for my attention, a copy of a chapter written by Alan Schore entitled ‘the right brain implicit self: a central mechanism of the psychotherapy change process’ (Schore 2010). Serendipity or what? It is too late in this ‘letter’ to say more, other than to recommend it, the process of being open to what happens to turn up, and the will to incorporate it.

Thinking of the right brain, psychotherapy and the horizon, linked together in the world, and in my mind, T.S. Eliot’s observation speaks to me about the relational ‘dance’.  

‘At the still point of the turning world. Neither flesh nor fleshless;
Neither from nor towards; at the still point, there the dance is,……

                                               ….Except for the point, the still point,
There would be no dance, and there is only the dance.’

                                                                      T.S.Eliot ‘Burnt Norton’ in ‘Four Quartets’

Cornwall has its own famous dances, the Floral dance which transforms the whole of Helston on Flora Day, being closest to home. I’d like to think that systemic practices can take their place as fully as possible, in ways which enliven the step and raise the spirits in characteristically Cornish fashion.
References

Bateson, G. (1979). Mind and Nature: A Necessary Unity. New York: Bantam Books.
Eliot, T.S. (1944/2000). Burnt Norton , Four Quartets. London: Faber and Faber.
Schore, A., N. (2010) ‘The right brain implicit self: A central mechanism of the psychotherapy change process’ in (ed) Jean Petrucelli, ‘Knowing, Not-Knowing and Sort-of-Knowing: Psychoanalysis and the Experience of Uncertainty’ . London: Karnac
 
Segall, B (2002) 'Gardens by the Sea' London: Frances Lincoln.

Tan Twan Eng (2007) The Gift of Rain. Newastle upon Tyne: Myrmidon