Flexibility in Therapy

     I am coming to a crossroads in my practice, I believe. Perhaps this is not a choice, not a path that leads to some separate destination. Rather, I am coming to realize the balaance on a spectrum between operationalizing therapy and keeping the practice flexible. As I have discussed once or twice before, a moderate approach to such dichotomies are almost always justified. But how does one choose when and how much to keep flexible or stick to some kind of stricter or regimented question/answer session.
     At the very least on the side of operationalizing, there are some comments/topics that require certain answers, reflections, or questions. The default topic here is suicide. When suicide (or any kind of harm: homicide, child abuse, elder abuse, self-injury) is brought up, a risk assessment must be completed, comprised of a plan assessment capability, type of harm, etc. But there must assuredly be other "canned responses" to certain issues.
     Continuing with familiar ground, there are certain responses that are appropriate for clients who present with issues involving drugs and alcohol. When a client mentions that he or she has used in the past week (or is "confessing" use to the therapist for the first time when the use was in the distant past), it is important to ask as many questions as possible to ascertain the setting, amount, feelings, impacts, and plans pertaining to the use.
     As examples:
     - Setting: Where did you use? Were you with anyone? Was it a safe environment?
     - Amount: What did you use? How much did you use? What symptoms did you experience                     during/after use?
     - Feelings: How do you feel about the experience? Are there any lingering positive or negative               feelings associated with it? Do you think you're going to continue to use in the future?
     - Impacts: What have been some consequences of your using? What has changed/What is the                 same for you?
     - Plans: How might this change things for you? How might this change your valuation of yourself?

How Not to Run Out of Things to Say

     Another name for a therapist is counselor. A counselor learns counseling. In counseling, there are many different styles that, when matched to the appropriate clinician/client relationship, can yield positive responses. I think that we sometimes forget that there is more to therapy than these theories. In fact, no new counselor is trained in any theory, really. We forget that counseling itself has its own questions to be asked and is a support that any clinician of any theoretical orientation can fall back on when their theory is not working.
     One of my own faults has to do with "seizing up" when I realize that I don't know were to go during a session. Frequently, I find myself running out of things to say which puts both parties in the uncomfortable situation of awkward silence and can undermine the relationship as a whole. I think that there are important questions that need to be answered: These could be:

• What are you looking to get out of counseling?
• Why did you choose therapy?
• Do you have any supports in your life?
• What are some advantages/disadvantages of that situation?
• How are you feeling about that now?
• What are some changes you can make to meet your goals?
• How did that affect you?
• What is your biggest concern?
• What changes between then and now?
• What's that like for you?

In-Session Paperwork

     Therapists talk a lot about having an idea about where they should be going with therapy. We should know why we are questioning the client as we are. Random questions should not be discouraged, but should be minimized so as not to confuse the client (or ourselves, for that matter). To some degree, we want the client to see where we're going; we want the client to be able to understand the topic enough to foresee where the conversation is headed.
     Therapists need to be able to have their end idea in mind and ask questions in order to sustain, or to throw out, their hypothesis. 99% of the hypotheses will be incorrect and that's OK. Even incorrect hypotheses give one at least two pieces of information: 1) They allow a clinician to rule out that idea and 2) they allow more information to be gathered that could lead to the genesis of a new hypothesis. Of course, there are some phrases said by clients that require a specific response at that time, even if it is not a question or a statement that lends itself to the hypothesis.
     It can be easy for a clinician to become fixed on a certain hypothesis. This could happen in any number of ways, I suppose, but two come to mind at present. The first is that the clinician believes that their hypothesis is the only correct explanation for the behavior that exists. This means that whatever signals the client sends are discarded by the clinician and the client saying, "THAT'S NOT IT AT ALL!" might be seen only as denial. The second type of hypothesis fixation is when any outside comments are not taken into account and will not dissuade the clinician in finding out if this hypothesis is correct.
     A good note sheet could look something like this:

_________________________________________________________________________________
|
|     Client's Name                                                                                      Working Hypothesis         
|     Date                                                                                                     New Hypothesis                
|
| -------------------------------------------------------------------------------------------------------------------------
|     Topic:                                                                      Intervention:                                                  
|     Information:                                                                                                                                   
|                                                                                                                                                            
|

Working With the Client in All Ways

     I have been rather stupid in the recent past. I have talked a lot about meeting the client where he/she is, yet I threw out the importance of theories such as CBT to the theoretical framework of a practicing therapist. Thoughts are a part of the person. A therapist cannot just deal with emotions, behaviors, and beliefs. Even if this works 99% of the time (which it wouldn't) a therapist is failing clients due to a faulty knowledge base.
     I must say that I am rather disappointed in myself for denying such an important are of knowledge. I will say that I am no CBTer. I still don't see it as an end-all, be-all type of therapy . . . but it does have some merit.

A Fourth Stage to Therapy

     I've briefly discussed my ideas before relating to a way of engaging in therapy that allows symptoms to be addressed first in order to decrease the minute-to-minute pain that a client might be feeling. Behaviorism is the best therapy to use here, because its call to action only treats the observable. Next is a slightly deeper therapy that would target the thoughts. This would allow the client to understand the relationship that thoughts have with their behaviors. On the way to some form of "normality" or "therapist-assisted self-actualization," understanding one's own thought patterns and being able to identify positive and negative thoughts are very important and can only help the deeper therapeutic levels.
     Previously, I have added in a portion after symptom regulation about education. This portion is to provide the clients with more information about their suffering and to add more normalizing language into their world. I still agree with this approach, but I could see it being a very interspersed "stage" in that it could pop up really at any point it is needed. Education is important in therapy and is not a stage or method that should be eschewed just because people don't want to deal with it.
     Next, we start engaging in more depth-based work. This is an interesting transition. Many clients may want to stay with surface work, but the problem therein has mainly to do with recidivism/relapse. It is very simple for anyone to re-engage in their past behaviors if they have never gotten to the root of the problem. A popular example is cutting off the stem of a very lively weed only to find it growing back next season because the roots were never dug up. Another good example is seeing a rogue iceberg int eh water and blasting the visible part, but being hit by the non-visible portion laying in hiding just under the water's surface.
     Depth-based work takes the form of many different types of therapy, including, but not limited to, psychoanalysis, psychodynamics, Jungian analysis, existentialism, Gestalt therapy, etc. There are many different types of therapy styles here and the foremost similarity is that the therapist is adding in his or her own "interpretations" into the mix in order to guess at the underlying issue(s) facing the client and disallowing their full "recovery." Perhaps another way to group many depth-based therapies together is to say that depth psychotherapies require a counselor or psychotherapist in order for therapy to continue. Practices involving theories like behaviorism or REBT could be learned from a book and applied without the use of another person.
     I do think that this progression is a positive one. Clients who go through such a system could be changed (if such a thing is needed) fundamentally and never need the help of a therapist ever again. After all, it is the aim of the therapist to make himself or herself obsolete by guiding the client toward his/her ideal self.
     Oddly, there is a stage that is deeper than really any depth-based psychotherapy can go. This stage is a realm that requires no techniques or theories. This stage is realized most likely at the end of the real "change phase" and consists of the therapist talking not as a therapist, but as a fellow person. The therapist uses the "power of their personality" (Kottler, p unknown). This means that the therapist and client are so comfortable with tone another that the client's own anxieties in session are almost nil, allowing the therapist to help them to simply identify problems and solve them (or create possible solutions) in sessions.
     This stage supposes a couple of things. The relationship itself must be deep enough that any personality traits seen as deleterious in earlier stages are now seen as endearing. The client must also remember previous stages and be able to use some of them in his/her own life.
     I think that very few therapy dyads come to this last stage because a client gets some instant gratification from the first step or two and then quits therapy, happy with their progress. On the other end of things, it's possible that the last stage is never engaged because this can herald the end of the relationship altogether (and ends up with the client understanding their own power over themselves). There is no moving past this stage and going to a previous stage. This stage most likely sees a lot of work done because the trust required for it is already there and the styles of both parties are so in-line that observations, advice, and interpretation are organic.

Thoughts on Countertransference

     I've always found the concept of countertransference difficult for some reason. The basic definition is pretty clear: countertransference is the expression of the therapist's own experiences, thought, beliefs, emotions, drive, etc. in the therapy session due to something having to do with the client. This could include what they say, how they act, how they look, or really anything that has the ability to set off a reaction in someone else. I think that normally this coutnertransference is seen as negative - mostly due to the fact that many therapists do not identify their own countertransference and act on it, much to the detriment of one party or the other (or the relationship itself). But it doesn't have to be negative, especially if that person can recognize their reaction for what it is and use it positively.
     This is not he reason why I write this, though. I have found countertransference difficult in the past because it is difficult to use in metaphor. I think that this is an odd statement and do not really know how to put it any other way. I have come up with a metaphor that really helps me to describe it now. I look at it like every person omits a "noise" - some kind of psychic communication that has to do with everything that has ever happened to them (sort of  like the sun emits light or people emit pheromones). These rays of communication push out and interact with the rays of others. Perhaps an even better image would be spherical constructs that are around everyone's head.
     When a client's own sphere engages or interacts with someone else's - meaning that their own communication, style, look, etc, has overlapped - certain constructs can clash. For example, a client is coming to a session because of a divorce. They communicate that want. The therapists's own sphere shows that he or she is going through a significant rough patch with their significant other. These two spheres rub each other the wrong way, creating friction, which can inform the thoughts/emotions/reactions of therapist. Frequently this friction occurs in the client and is pushed back toward the therapist (transference). Then the therapist, in order to push this negatively-charged psychic energy away, converts it into verbal or physical communication. This can be pushed back onto the client. When it is, a clash normally ensues and the client might leave the relationship.
     As mentioned, when friction occurs, an experienced therapist can identify it and use it to further positively treat the client. In fact, going on with the metaphor, the energy created through the friction of the spheres can be use as a type of energy that recharges the therapist and/or the relationship; this might be use for fodder for good conversation with the correct client.

Disease Model of Addiction

     Working right now in drug and alcohol, I hear a lot that drug abuse and dependence is a disease. I have to say that I am very conflicted with that statement. Perhaps in the past I was more conflicted, but I still get negative twitches when someone calls their substance abuse condition a disease. I plan on talk about: 1) When the disease emerges after the behavior; 2) Why I didn't like the word disease; 3) Why behavior or disease might be better than the other; and 4) What I've heard from clients recently on the subject.

     I think that it is difficult to pinpoint a moment when the behavior of drinking/doing drugs turns into a disease. A behavior is something that involves thoughts, feelings, beliefs, etc. There is some level of choice involved and, as such, there is some level of control over the circumstance. A disease is different in that choice or motivation has nothing to do with it. Instead, a disease progresses seemingly without the consent of the victim and proceeds, sometimes, to rob that person of any further ability to stop it, through the destruction of relationships, communication, logical thought patterns, and positive expression of feelings. But the question still stands: When does the behavior turn into the disease?

     I guess that the logical answer, given the definitions, is that behavior develops into a disease when there is no more control over the action. When there is real chemical dependence, meaning that withdrawal symptoms are either bad enough to kill or distressful enough to inhibit normal or safe functioning, the person must continue or risk such consequences. Of course, there is no clean delineation between behavior and dependence here; in fact, it is possible that there is a middle stage where chemical dependence is starting to take root, but a strong enough verbal or psychic burst (whether coming from inside or external, though certainly an intrinsic shock would yield better results) might allow the person to kick the habit.

     There is some power in semantics, using certain words can either preclude or assist a client in gaining active recovery status. I think that words like "behavior" and "disease" themselves have power. Each one has positives and negatives. Behavior is positive in that it denotes a changeable variable, as most, if not all, behavior can at some point be altered for good or ill. Behavior can be a negative word here if we paralyze the client for not changing or for "mis-diagnosing" a disease as a behavior. Disease, likewise, has both positives and negatives assigned to it. Disease is positive if diagnosed correctly because it correctly describes the inability of change by choice. Disease is negative in that it can easily be seen as a crutch - a way to eschew responsibility off of the self and on to something out of their control.

     It is very much this last example that pushes me away from the word disease. At one point in the life of the addiction, there wasn't a disease. There was a repeated behavior. The person chose, for whatever reason, to continue the negative action until the consequences were so deeply embedded that a change in action was either impossible or inconsequential. I think that part of my issue with the word disease comes from the belief that these people deserve their predicament. This belief, of course, is shameful and without evidence. Logically, could we say that the first behavior was their fault? Logically . . . yes. But do they deserve to suffer? No, they do not. 

     I know that a lot of my current clients mention that they have a disease. For them, as long as they are no using the word as an excuse, its use is fine with me. I think that a happy medium, perhaps, between the two terms could be "condition." A condition has the dual meaning of being treatable and a little easier on the ears than the word disease. It's different from behavior in that it shows a certain amount of seriousness or semi-permanence than behavior can inherently imply. I don't think I'll be pushing the work condition in sessions, but I will think it to myself. 

     I think it important to mention that the recovery process from addiction is both behaviorally treated and medically assisted. To treat the "disease" through detox and medically-assisted rehabilitation methods and not to treat the behavioral issues that go along with it doesn't add up. It's kind of like balancing an equation. One side is the behavior and the other is the disease.