Positive Approaches Journal, Volume 8, Issue 1
Legare | 35-48
Volume 8 ► Issue 1 ► 2019
Positive Approaches & The Wisdom of Herb Lovett
In Positive Approaches & the Wisdom of Herb Lovett, the author, by revisiting an article written almost twenty years ago, explores how something seemingly so simple, listening, requires mindfulness, feedback, humility and ongoing practice. The implications from years of outcome research are shared and cannot be dismissed; the person you are trying to help is the engine of change. Simple and practical ways of getting regular feedback are discussed to help anyone interested in learning to listen, integrate the art and the science of being helpful.
“Of all tyrannies, a tyranny sincerely exercised for the good
of its victims
may be the most oppressive…those who torment us for our own good will do so
without end for they do so with the approval of their own conscience…
This very kindness stings with intolerable insult.”
– C.S. Lewis
It was exciting to hear that a group of people from the Office of Developmental Programs (ODP) and Office of Mental Health and Substance Abuse Services (OMHSAS) in Pennsylvania were working toward reviving the Pennsylvania Journal on Positive Approaches. Being invited to contribute and offer an occasion to revisit an article submitted almost twenty years ago as a way to reconnect with the spirit of Positive Approaches, is a wonderful opportunity to reflect on how it influenced my ability to listen over the years, how it helped me be present and helpful with others is simply great timing.
In one issue of the original Pennsylvania Journal on Positive Approaches in 2000, a good friend, Susannah Joyce and I collaborated on an article titled: Remembering Herb Lovett 1. Two years before in 1998, Herb had died in a car accident on his way home from work he was doing in New Hampshire at the time. Years before, when Herb was in Pennsylvania facilitating some workshops and working with small groups, supporting the work of dedicated people who were involved in supporting people with challenging behaviors, he was asked to give these events a title and he simply suggested “positive approaches for people with difficult behavior.” All of a sudden, Positive Approaches was born2.
It is impossible for me to think about Positive Approaches without reconnecting with the times I shared with Herb and what I learned from him. Like many others whose lives were touched and transformed by Herb, I believe that both Susannah and I were deeply impacted and transformed by Herb’s capacity for empathy and the way he could attune himself to and be with another person. At the time, as Susannah wrote, we discovered that even between ourselves it was not that simple for us to convey what we felt or all we had learned from Herb. We were simply hoping to share through some personal reflections and stories, some of the gifts and wisdom we had received from Herb and in turn try to stay connected with the spirit of Positive Approaches; to this powerful yet inhabitual way of being with others while trying to listen and help them.
Susannah described beautifully how Herb would try to listen to the person first, be present, even when people were very difficult, appreciating their experiences and the context of their lives. She also wrote about how Herb was constantly inviting others to connect first person to person, while providing respectful and effective clinical expertise to the team supporting that person when needed.
Although I could not articulate it clearly at the time we initially wrote this article as I believe I could do today, I had started to realize that developing a relationship with someone, one based on equality and mutual respect was, as Susannah wrote, the context and the true vehicle for any “help.” In sharing James’s story, someone who I found very challenging to support and help, I was focused on describing how Positive Approaches turned out to be a powerful awakening for me. I had first met James, a very smart, funny and cynical 43-year-old man in 1991. During the previous 25 years, he had been admitted more than 20 times to a large psychiatric institution in our community. Over a period of several months a group of clinicians were involved in developing with him the supports he needed to stay out of the psychiatric facility and successfully live in the community. Despite our best efforts to listen and support James, it became a frustrating experience for everyone involved, especially for James. Positive Approaches allowed me to reconnect with James in ways that I could not have imagined. When I finally heard James and realized I had unintentionally been getting in the way, it transformed the conversation I had with him and my ability to partner with James. What wasn’t as clear to me at the time was why it took me so long to hear him and appreciate something that then became so obviously simple.
In the foreword of Herb’s second book, Learning to Listen: Positive Approaches and People with Difficult Behaviors, Nancy R. Thaler3 who knew Herb well, described two important aspects of the work Herb was doing in Pennsylvania. She explained how he was introducing a new way of thinking and how he was fostering an openness to doing things differently. She also shared how Herb, through personal stories, reflections on his own thinking and actions, would gently expose the harm being done in the name of treatment. Herb would do so without demeaning our past efforts to help and allow us to face the truth about the possible impact of our actions without debilitating embarrassment or shame. Nancy went on to write: “Here the truth was we’d been hurting some people instead of helping them. In fact, we’d been hurting them in the name of helping them.”3
Herb was gifted at presenting the truth in ways that others could see and accept. He would often present information with humor and create an opportunity for the listeners to consider something important he was suggesting, something painful we were unintentionally doing, something we may need to change to be more helpful from the person’s perspective. In 1992 during a two-day workshop Herb was facilitating in New Brunswick, Canada, I heard Herb say something that really resonated with me: “The day I realized as a psychologist I was my clients’ biggest problem, they all started to do a whole lot better.”
At the time of his presentation like many others attending, I smiled and laughed when I heard him, appreciating his humor and wit. I thought about this profound and wise statement often the last twenty some years. I wish I could have a conversation with Herb about this, what it meant to him, how that realization actually happened for him and how he was able to use these lessons to help him learn to listen, be present and connect empathically with others. This would be I am sure, a fascinating conversation.
Similarly, I also have thought about James’s story over the years. I wasn’t, and am not a bad person, I was well intentioned, I was passionate about helping, about making a difference in people’s lives and I was just trying to assist James in having a stable and meaningful life in the community, away from the psychiatric facility he was so often visiting. I was not actively hurting James, but for seven months while I was simply trying to help him, sadly and painfully, I did not really hear him, and I had no idea that was happening.
It was a true gift to meet Herb years ago since it literally changed my life. Of all the things I learned from Herb, two in particular have stood the test of time. They are present in my mind every day, important reminders of what I need to be mindful of when I am trying to listen and hear someone. I have always believed these two critical lessons to be at the core of what Herb called Positive Approaches:
- Despite my best intent as a helper, I could unintentionally be dismissing someone and not knowingly, be doing something that the person is experiencing as frustrating, unhelpful or hurtful. This was a big part of what happened with James.
- To implement and practice what Herb was teaching, I would have to be humble, recognize and be comfortable with the fact that I am the one who will first have to change the way I am thinking and acting in order to connect more meaningfully with someone as a person, hopefully becoming more helpful with them. It is only when I started to look at James and his life differently that it became possible for me to consider another possibility.
I am truly grateful for the opportunity to share some reflections on Positive Approaches in the new version of this journal, to consider the art and science of being helpful with individuals we find challenging to support, share some thoughts on how Herb is still influencing my life today and how it has led over time to simple daily practices that are transforming me and others personally as well as professionally.
The Art Being Helpful: Learning to Listen
“The world as we have created
it is a process of our thinking.
It cannot be changed without changing our thinking.”
– Albert Einstein
If I were sharing James’s story today, the emphasis would be on helping others appreciate how much of a gift these kinds of experiences are and how transformative they can be if you take the opportunity to learn from them. James was one of the first few times I had that kind of humbling and transforming experience, but it wasn’t the only one, it was only the beginning of a long learning process for me. This journey the last twenty years has been surprising, sobering, exciting, sometimes painful, difficult, yet very powerful and always meaningful. Since that initial awakening with James, I have been interested in better appreciating why it took me so long, seven months, to hear something that was so obvious once I heard him. Ever since, I have been obsessed with the idea of learning to listen and curious about understanding why something seemingly so simple as listening is actually so much harder to do in practice. I started to explore the following questions:
- How can I be listening to someone without hearing them?
- How is it that in the name of helping him over a period of seven months, I also unintentionally created multiple subtle experiences where James’s identity, feelings, needs, preferences or experiential reality could also be invalidated?
- How could I unintentionally spend so much time with someone, simply trying to listen to and also unknowingly create an outcome where James could be dehumanized as a partner and fellow human being?
- How is that possible?
- What could I do differently?
It made sense at the time to continue exploring these
questions within the context of Positive Approaches since these powerful
learning experiences were possible because of the transformation I was
experiencing implementing it. As Nancy Thaler wrote2 the name Positive Approaches communicated a
stance, an attitude, a set of values that should direct what approaches we take
in supporting people. The approaches themselves were many.
A really good friend, Beth I. Barol, PhD offered an overview4 of Positive Approaches in the premiere issue of the Pennsylvania Journal on Positive Approaches, a quarterly publication created to help people with developmental disabilities and challenging behaviors live fulfilling Everyday Lives. Beth reminded everyone at the time that Positive Approaches was a worldview, one where everyone is treated with dignity and respect. She also introduced the Positive Approaches paradigm, an attempt to conceptualize and organize this worldview in terms relevant to all interacting and supporting individuals we found challenging. The paradigm was a helpful way to organize all these different approaches and perspectives into four major areas: Environment, Communication, Assessment and Hanging in There4.
For years I believed I simply needed to become more knowledgeable, practice, pay attention, be mindful and honor what I was learning. I spent a lot of time learning various helpful perspectives or approaches and what I eventually referred to as lenses. The goal was to develop the flexibility and knowledge I thought I needed to be able to explore multiple possibilities, to navigate the four major areas of the Positive Approaches paradigm competently so I could respectfully, based on need, look at things and people differently.
My hope was that all this knowledge would help me improve my ability and capacity to better appreciate someone else’s experience and connect empathically with them in a deeper way. It was important to look at someone’s quality of life; at how they are spending their days; at how lonely and disfranchised the person could be; at how little control someone might have over their life; at what they could be communicating; at how dual diagnosis, trauma, their biography and history could be impacting their ability to have the life they want; how sensory issues could affect someone, how pain or medical conditions could influence the person, etc. There was something very helpful in learning to appreciate how all these lenses were helping me understand various aspects of the person’s life. This indeed helped me assist teams and provide respectful and effective clinical expertise when it was needed.
What I also learned from people during those years is that all these lenses and approaches actually got in the way and did not really help me connect with people in a deeper empathic way. In fact, I started to realize that even though these lenses can help you focus, help you see something new, all these lenses, when you adopt them, come with some risks. It is important to know that they also limit what you can see and hear when you chose to use them. For example, when I start to think that the person may be showing signs and symptoms of a mental health issue, it is hard to focus on something else. It is also easy to forget that as human beings, we have a tendency to search for, interpret and favor information in a way that confirms one’s preexisting beliefs or hypothesis.
I became increasingly aware that when I was looking at, or listening to someone through these lenses, when I was trying to interpret, assess, evaluate or make sense of what I saw and heard through them, I actually was not listening to the person. I was busy thinking, trying to make connections but I was not present with them, not really listening to their experiences, especially appreciating how I could be impacting them in the name of helping.
The larger lesson I was learning was not just about the value of these lenses or approaches, but much more about how I was using them in the moment with someone. It became clear that I also needed to pay attention to my own thinking, I needed to become much more aware of the choices I was making in the moment when listening to someone. To be able to really move from control to empathy and true collaboration, I would really need to increase my awareness of how my own needs and thoughts (in the moment) could shape and influence what I saw, heard and understood. I needed to develop and practice the kind of mindfulness and presence that I could use to develop a deeper empathic connection with someone. So I started exploring different kinds of questions:
- What kind of practices could help me grow and become more attuned to others in the moment?
- What can I practice daily that would decrease the likelihood that I might unintentionally recreate that experience with someone I am supporting and trying to help?
- What kind of safeguards can I put in place to ensure I first really connect with the person?
- How could I make sure (as Herb would say) that I would never be or become the person’s biggest problem?
- More importantly, how would I know in the moment that I am listening, that I am helpful?
Looking back again at James’s story, seven months in and because I
felt frustrated and had no clue what else I should do, out of desperation I
asked James what he thought and asked him for help. Today I cannot help but wonder
how much sooner I would have been able to hear him, had I been present, aware
that I could be his biggest problem or if I had simply checked in and asked him
how helpful I actually was.
The Science of Being Helpful: Being Driven by Feedback
“Divorced from systemic, reliable, and valid feedback about
and outcomes (subjective experience of the person) for almost everything we do,
the field has become a jumble of competing, complicated and often
contradictory approaches to treatment, services and supports.”
– Institute for the Study of Therapeutic Change (ISTC), 2001
In the early 1990s, Mark Hubble, Barry Duncan and Scott Miller, three clinicians, got together and started to collaborate in an effort to share helpful information about what works in therapy based on the lessons learned from the important work of outcome researchers the last previous years. The Institute for the Study of Therapeutic Change (ISTC) was created. Eventually, their work led to the publication in 1999 of the first edition of The Heart & Soul of Change: What Works in Therapy5. The second and updated edition The Heart & Soul of Change: Delivering What Works in Therapy6 was published in 2010. As editors, they assembled the best outcome researchers and practitioners and summarized what works in psychotherapy and how to best deliver it.
The outcome research was challenging the prevailing view that to be an accomplished psychotherapist one must be well versed in evidence-based treatments (EBTs) or in those models that have been shown in randomized clinical trials (RCTs) to be efficacious for different “disorders.” In reality, the role of various models or approaches as a specific factor in the change turned out to be minimal.
The implications from years of outcome research are clear and cannot be dismissed; the person you are trying to help is the engine of change.5,6,7 Therefore, the person’s perspective and involvement in the planning and delivery of how we do what we do to help them, is absolutely critical. It suggests that as helpers we need to take our direction from the person, follow their lead, accept (when it is safe to do so) the person’s goal and also have a way for the person to confirm that what we do is actually helpful for them.
From this perspective there are no a priori assumptions about the person or challenging behaviors, or solutions, no special questions or series of questions that are best to ask, and no invariant or systematic methodology that needs to be followed. Rather, as a support person or a helper, you follow the person’s lead, listening intently and carefully. The person’s perception of the problem and what would be helpful is what really matters in all this.
Early on the Institute for the Study of Therapeutic Change (ISTC) developed the Session Rating Scale (SRS) and the Outcome Rating Scale (ORS) to help clinicians appreciate the person’s perspective on all this. Both the SRS and ORS are simple four item scales. They are actually soliciting the person’s perspective or feedback regarding factors proven to predict success, regardless of the population, treatment modality, or presenting problem. Both are simple measures a therapist could use to quickly get feedback from the person every time they met5,6,7,8.
Since then, these simple measures were implemented, tested, evaluated and eventually validated. They became part of a larger outcome management system: The Partners for Change Outcome Management System (PCOMS)9,10. The Substance Abuse and Mental Health Administration is now listing PCOMS as an evidence-based practice. It is different from what is usually considered evidence based because feedback is a theoretical and therefore something you can add to any therapeutic orientation or approach and it can apply to people and clients of all diagnostic categories11. The work being done to help someone is literally feedback informed and driven.
The use of these scales is helpful but the conversation that should ensue with the person once you genuinely ask for feedback is what has the potential to transform your abilities and effectiveness as a helper. Having the person rating how well you are doing as a helper and how effective you are can be scary and it is a powerful act. This brings the person’s voice back in the partnership as long as the helper you can receive the feedback you sought as a gift. Feedback is a gift since it allows us as helpers to adjust and correct what we do quickly, to attune to the person’s preferences, it allows us to focus on the quality of the relationship and maximizes the person participation in the partnership. Soliciting systematic feedback and the opportunity for real conversations it creates provides a transparent, ongoing interpersonal process that solicits the person’s help in creating the necessary partnership and collaboration to ensure a positive outcome.
Today, when I reflect back on the journey I embarked on since I first met James and the search for a way to ensure that I would not become someone’s biggest problem when trying to help, seems so obvious. The key was simply to be mindful and attentive to the feedback from James and be humble enough to simply check in with him to ensure that what I believed was happening was also what he was experiencing. Had I been able to do this at the time, it would have allowed me to appreciate the impact I had on him; it would have been an early-warning system, giving me a chance to adjust quickly, maybe chart a different course with him, minimize his frustration, increase the likelihood we were going to reach the outcome we were both hoping for sooner and in the process to boot, assist me in becoming a better helper.
We collectively as a system have changed a lot since Herb was last here in Pennsylvania. However, most systems of support or helpers still have a tremendous amount of influence or power over the people who need assistance and supports. This power can be visible and obvious, but it is more often hidden and communicated through assumptions, language, and expectations. Even though we mean well, we have learned that what we do in the name of helping often unintentionally creates conditions where the people we are trying to support also experience situations where their most basic human needs are not being met.
When most of us start in this field we are convinced that we have the best intentions when we are trying to help. Very few of us have had the opportunity to realize and appreciate that the person’s responses to what we do are often the only way they have to let us know that even though we mean well, our actions and what we do to help them, is actually not that helpful for them. Over the past twenty years I have often experienced that even with the best intentions to help, my words and actions often have unintended consequences. Examining how you might unintentionally be contributing to the person’s problems when you are convinced you are only trying to help requires a willingness to learn; it can be hard work, but it is also exciting and rewarding.
In the preface of his second book, Learning to Listen: Positive Approaches and People with Difficult Behaviors3, Herb was already recognizing that naming this attitude, this way of thinking, this way of speculating empathically or this way of life where one, as a helper, moves from control to collaboration was a mixed blessing. Herb understood that nothing named can hope to remain the same and that new names and phrases always run the risk of becoming spiffy euphemisms for “business as usual”3. What Herb feared is exactly what happened. Over the last twenty years from my point of view, it seems like we have gradually shifted towards a more clinical perspective in nature. We have unintentionally lost sight of the importance of truly being present with someone, of listening deeply to another and to fully appreciate the transforming power of empathy and collaboration. In the original article1, Susannah shared a powerful story about Herb at his best, listening, present and Michael, a young man who was living in a large mental health institution. Herb had started a circle of support a few years before to help Michael find a meaningful life in the community. She described how one afternoon while they were out with Michael, sitting at a picnic table in a park, planning how to best support Michael, sharing sodas and fries, Michael started to sob. In response Herb put his arm around Michael, held him for many minutes before they had to leave and bring Michael back to his ward. Herb offered him what comfort he could in an impossible situation; everything else Herb did trying to help, sprang from that center of compassion.
It is my hope that restarting The Pennsylvania
Journal on Positive Approaches will not only be an opportunity to explore and
celebrate best practices but more importantly, to revisit and reconnect with
the spirit of exploration; to honor the feedback the people are always offering
us about how helpful we are; to reconsider the possibilities we know exist
beyond a clinical lens and to continue getting better at working with – rather
than on – people.
- Legare G, Joyce S. Remembering Herb Lovett. The Pennsylvania Journal on Positive Approaches. 2000; Volume 3, Number 1, pp 10-13.
- Thaler N. The Beginning of Positive Approaches in Pennsylvania. The Pennsylvania Journal on Positive Approaches. 1997; Volume 1, Number 2, pp 1-2
- Lovett H. Learning to Listen: Positive Approaches and People with Difficult Behavior. Brookes Publishing, Toronto. 1996
- Barol BI. The Pennsylvania Journal on Positive Approaches: An Overview. The Pennsylvania Journal on Positive Approaches. 1996; Volume 1, Number 1, pp 1-3.
- Hubble MA, Duncan BL, Miller SD. The Heart and Soul of Change. American Psychological Association. 1999.
- Duncan BL, Miller SD, Wampold BE, Hubble MA. The Heart and Soul of Change: Delivering What Works, 2nd Edition. American Psychological Association. 2010
- Bohart A, Tallman K. Clients: The Neglected Common Factor. In B. Duncan, S. Miller, B. Wampold, & M. Hubble (Eds.), The Heart and Soul of Change: Delivering What Works (2nd ed.,) Washington, DC: American Psychological Association Press. 2010; pp 83-111.
- Miller S, Bargmann S. The Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). Integrating Science and Practice. 2012; Volume 2, Number 2, November, www.ordrepsy.qc.ca/scienceandpractice
- PCOMS Information: Better Outcomes Now - https://betteroutcomesnow.com. 2019. Updated October 1, 2018.
- PCOMS Information: Center for Clinical Excellence (ICCE) - https://www.centerforclinicalexcellence.com. 2019.
- Duncan B. The Partners for Change Outcome Management System (PCOMS): The Heart and Soul of Change Project. Canadian Psychology. 2012; 53, pp 93-104.