A Little Life – but a profound story

Hanya Yanigihara's A Little Life is an exceptional book, a harrowing story but one that all practitioners should read. She captures trauma – day in day out, for weeks, months and years at a time – and its impact on Jude, his friends and family, like nothing else I have read. At least nothing in our field.

Like a psychologist working with a client, the novelist focuses on a specific character, staying true to them as they evolve, suffer, thrive or succumb. The novelist's advantage over the psychologist is, of course, that their focus is limited only by their imagination. In our work we may attempt something similar, prioritising the experience of this particular person, yet we often come to the edges of our possibilities. It's not just the limits of our imagination that get in the way – other aspects of our work impinge on us too. Maybe we can't focus on one person as we are working with a couple, family or group; or it may be due to the fact that we don't set up services to cater to the needs of specific individuals, we prioritise developments that a range of people may use, individuals that may be subject to similar diagnoses yet may have come to these by very different experiences and manifestations of distress. The psychologist is duty bound to think beyond the individual, which can mean we have to adopt a more global view, prioritising 'objective' characteristics over subjective experiences.

Psychological research is an issue too; it cannot be everything to everyone. Research often overlooks experience as experience, instead listing different manifestations of a phenomenon, or explaining the needs across individuals. Unfortunately, this has meant that we often fit the client to what we offer, rather than adapting our services to what each client may need. Too much psychology prioritises trying to explain different forms of distress and, like psychiatry, ways to 'treat' it. And all this affects therapy. Instead of being able to offer the attuned engagement and knowing we so desperately want to, we can be straitjacketed, offering template interventions and explanations.

We didn't always do this, at least not to this extent. I remember broad referral criteria, a plethora of psychotherapeutic modalities being offered within psychology and psychotherapy departments, and these being welcomed as a sign of responsiveness. But this is no longer the case. Austerity, the closing of services, funding of research to fit the neoliberal view of people, and the constant and continuous underfunding of the psychotherapies all mean we are shackled in our attempts to work at depth and length with those that are courageous enough to approach us.

I do not mean to knock my colleagues, berate myself or discourage trainees. We try, and on many occasions, we do make valuable contributions to our clients' efforts. Indeed, counselling psychology, my own core profession, and existential psychotherapy, my psychotherapeutic specialism, have long advocated for a stronger engagement with clients as they are, encouraging a heartfelt and attuned exploration of the client, their world and the events they have experienced. It has been pleasing to see a similar focus receive sustained attention recently with the launch of the Power Threat Meaning Framework (Johnstone & Boyle, 2018). The better the world is understood, the more accurate a grasp we can gain of the person's psychology.

By giving us this visceral portrayal of what distress can actually feel like, Yanigihara reminds us that our responses to the traumatised have to go beyond a reliance on scripts and manuals. We can't expect everyone to respond in the pace we set, or even just to respond simply because X per cent of others have.

This is not to say that these aspects of our work are not without value, just that such an approach is limited, it can only ever be partial. To many, the cause of their distress is not a surprise; formulation is seldom 'rocket science'; 'factual' interventions only go so far. Jude isn't confused as to why:
…he woke with the names of people he had sworn he would never think of again on his tongue. He replayed the night with Caleb again and again, obsessively, the memory slowing so that the seconds he was standing naked in the rain on Greene Street stretched into hours, so that his flight down the stairs took days, so that Caleb's raping him in the shower, in the elevator, took weeks. (p.389)

Like many of our clients, Jude knows that traumatic events are traumatising, he doesn't need someone to tell him that. A Little Life is a timely reminder that the simplistic idea of distress being primarily a personal or biological issue cannot be right. Of course, as somatic beings, we are mind and body, and trauma can affect both. But for those who struggle to imagine the impact of abuse, deceit, stigma and violence… this story brings this home.

A difficulty psychologists often have in practice is evident in the pages of this book: How do we offer something useful? How do we practitioners offer something akin to what Jude's friends – Willem, Malcolm and JB – offered Jude, what his doctor-cum-friend Andy attempted and what Harold and Julia desperately yearned to create for him? How do we allow the person to express themselves authentically and at their own pace? Privileging hearing them and knowing them, as much as any educative, guiding approach we may also find useful?

We aim for such an engagement because our years in practice and generations of research have consistently shown that an attuned therapeutic relationship is central to effective practice (Gelso & Carter, 1995; Milton, 2017). Within such an approach, there is a chance in which the client can be seen, accepted and understood. And it's books like this that are an invaluable aid in us getting into the person's world, the real visceral experiences that traumatise us, the confusion we and our loved ones may feel and the terrifying experience of psychological dis-order (as opposed to disorder).

On literature more broadly

Much of our CPD is reading – we review studies for this problem and that, so that we might work with familiar groups and those we have not yet encountered. We trawl through journals that carry 5* ratings to help us enrich our knowledge and practice. But maybe this isn't enough? Maybe we should be reading novels, listening to poets, learning to write again?

We probably all have different books that speak to us, some more profoundly than others. A Little Life is one of the best fictional accounts of trauma and the long-term effects of it. Although it is a different genre, it compares to Immaculee Ilibagiza's 2016 Left to Tell, her terrifying memoir of experiencing and surviving the Rwandan genocide. It is one of a few books that I have read and re-read, and in that regard it is up there with van der Merwe's Moffie (2011; see also Milton, 2014). In reading these books I have learnt more than models of trauma… something approaching the experience of it, the feelings, physicality and gut-wrenching impotence that affects so many people and those around them.

A Little Life is a novel and as such is unapologetically not a template for any particular client. Novels are humanising and empathy-stretching experiences for the therapist. Yanigihara helps with this as she changes the point of view, making us work, so at times we are required to imagine Jude's world directly, at other times we have to picture his world through the sense-making of others. We experience Willem's suffering in the face of conflicting needs and opposing meanings; Andy's struggle to contain his upset at his impotence in curing Jude; Harold and Julia's desperation as they find 'doing the right thing' to be so excruciatingly painful… these are all emotions that we too might feel when engaging deeply with our clients and their distress.

In this way Yanigihara offers us the experience of first-, second- and third-hand trauma, the pain, the terror and the powerlessness that radiates far and wide from the hands of those that abuse. This powerful story captures the impact of trauma, over time and as it ripples out from the individual to others in their relational networks.

I can't help but think that in some ways fiction is far more effective in helping us understand the experience of the other. Scientific, theoretical and policy documents are all helpful and necessary adjuncts to our development as ethical and effective therapists, but good literature… there is no competition. We are transported into other worlds, they are not explained, we aren't told about events, we are invited to inhabit them. It is these experiences that can contribute to our own abilities to work with our clients, to hear about the horror of nights spent awake, with nothing but flashbacks to the faces of perpetrators. These experiences have to be imagined to be understood. Mere explanation only goes so far.

- Martin Milton is Professor of Counselling Psychology at Regents University London
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