Tuesday, December 22, 2015

Theoretical Orientation Research

     I would like to take a little time to write some about a research project I would like to undergo. This research has to do with the selection of a theoretical orientation. The aim of the research is to find out whether there is any statistical relationship between personality type and theoretical orientation. I would like to add in a questionnaire about when field clinicians think they chose their orientation and whether they have experienced any changes in their orientations throughout their careers.
     The tools to be used here are manifold. There is a good theoretical orientation sorter out there that I have use in the past call Selective Theory Sorter - Revised. It is from a book by the name of Developing Your Theoretical Orientation in Counseling and Psychotherapy. This tool asks the user questions and grades their reactions, in the end giving them a numerical output for twelve well-known theories for further research.
     The next tool is a shortened version of the Myers-Briggs test call the Myers-Briggs Preference Sorter. This tool is much shorter than the Myers-Briggs and can be taken in about ten minutes, rather than the multiple-hour exam that is the normal evaluation.
     The third part to this study would be a questionnaire for both current students and professionals. This questionnaire, which I hope to elaborate on later, has demographic questions as well as questions about their current place of work/study and their own ideas about theoretical orientation.
     There are some limitations of these tools that must be mentioned. The first is that both of the non-questionnaire tools are short. I have less confidence in the Myers-Briggs Sorter than I do the other, as the former as a long and much more version. The theories sorter is mildly concerning, as the book in which the sorter finds itself has other ways to find one's clinical orientation.
     I would like to more succinctly detail the reason for this study. I am testing the relationship between personality and theoretical orientation. I am not wanting subject to take only the Myers-Briggs test or the orientation sorter, as, independently, these tests mean nothing. Were I to just give out the Sorter, I would only be gather information on this population's theoretical preference (which are not necessarily generalizable). On the other hand, giving out the personality test would at least give some kind of viewpoint as to common personalities of budding and established therapists. Doing both hopefully will connect not just personality type to therapy (which has already been done), but rather personality type to a specific theory. This might aid in decreasing search time for budding counselors or at least some possible borders for research after mastering basic counseling techniques.
     As far as questionnaire questions are concerned, here are some:

  • Name
  • Credential/License information
  • Number of years in the field
  • Level of schooling achieved
  • Current theoretical orientation
  • Previous theoretical orientations
  • Is your current TO based in your current area of work?
  • Current area/type of work?
  • Do you ind TO important in your work?
  • Did you start out practicing  a certain method/theory and go on to change your desired theory (1), alter how you practiced the first method/theory (2), or add additional skills/techniques/theories to become more "eclectic" (3)?
  • Did your clinical educational program adopt a theoretical orientation that was then taught to all students? - or - Was your education more generalist, in that you were presented with multiple theories and then recommended to choose one?

Monday, December 21, 2015

Counselor Versus Therapist

     I have written before about the difference between counseling and therapy/psychotherapy. A similar question is What is the difference between a counselor and a therapist? While I think that one is still more developed (or higher) than the other - specifically that being a therapist is higher than a counselor - my reasoning for the difference between the two are different. I don't know if my new reasoning is correct - perhaps that is why I am writing all this down. My thought has to do with level of training and how a clinician practices. Could it be that a therapist is an experienced counselor (perhaps of a couple of years) who has created their own, or implemented an existing theoretical orientation that increases the effectiveness of therapy.
     I have raged against the need for implementation of theoretical orientation in the past. I still don't think that theoretical orientations are the most important things in therapy, but they do have their place. It is important here to discuss when to implement a theoretical orientation and to what degree. A counselor should stay a counselor for a significant time, studying theories of course, but primarily practicing the basic skills of counseling that provide a positive bedrock off of which to build a theoretical orientation. Echoing what I have said in previous entries, my opinion on this subject is that every clinician should review much relevant literature and then create their own orientation that works for them. The "when" is a difficult question here. When does a counselor graduate to therapist? Who graduates them? How does the counselor know that he or she is ready?
     These are amazingly challenging questions, for sure. I am not sure that there are absolute answers to these, but I will still give it a shot. A counselor, as said, should be constantly researching different theories and techniques. Perhaps the moment when a counselor becomes a therapist is when he or she becomes so comfortable with the base counseling skills that he or she hits a ceiling in practice or that they feel stuck where they are. At this point, the logical response is to change something. Sometimes, the change is to review the basic counseling techniques (like Rogerian/client-centered therapy or motivational interviewing, if one bends that way). Sometimes, the change is to add more: in this case, we would add theoretical techniques more strongly into therapy.
     Such a graduation comes about in different time periods. Different clinicians take different amount of times to do things. This does not necessarily mean that one clinician is better than another, because he or she takes less/more time to learn things; I think the opposite might be the case, as frequently the clinician who pushes the learning process learns less.
     It is important for the budding therapist to gain supervision when creating and implementing his/her own therapy. In my opinion, a serious therapist should show proof of their learning through writing or reading texts. Just because a therapist thinks that something is a good idea doesn't mean that it is. Generally, if a clinician finds something in the literature, especially seminal literature, normally that is OK to use right out of the bag.

Wednesday, December 16, 2015

What Is the Role of a Therapist?

     Why go to therapy? What do you hope to achieve? Why can't we just do therapy by ourselves? What function does the therapist serve? Why can't a person just talk themselves into a better state? Why can't they talk to their mother, friend, or a stranger and be in a better state? What about a real therapeutic encounter helps people? Again: What is the role of the therapist?
     To some degree, I see the therapist as a "nudger." In a perfect therapeutic situation, the therapist's job is to course correct with the client, identifying  negative behaviors, thoughts, and expressions with the client and discussing more positive behavior. Instead of giving advice, the clinician is tasked with taking information given, evaluating it with the client, and coming to a good conclusion as to its validity and place in the client's life.
     The therapist provides outside perspective. That is one of the main reasons to go to therapy. As such, a therapist must ensure that he or she is very unbiased. While we have previously thought that children are tabula rasa, in this case, it is the therapist who must shut off his or her previous actions and become a reflective surface, on which the client might see the person they are and make corrections needed.
     I think that I have said this before, but part of the significance of the therapeutic encounter is the setting in which it occurs. Just as the therapist must be ultimately objectively subjective, the space in which therapy finds itself should allow for minimal distractions or means for negative transference. Some decoration, or course, is needed, but not so much that the client thinks that he or she is impeding on someone else's territory. That said, I don't think it horrible for the clinician to provide some kind of backsplash on which a client might throw their personal dirt. That is having some objects in the room(s) that create conversation might push deeper understanding on both sides.
     A note that I would like to make is to say that therapists do not say what is correct and what is incorrect. That decision is fully on the client's shoulders. It is the clinician's role to help the client to figure out what is correct and incorrect of them. Of course there is an objective right and wrong and the hope is that a client's subjective right and wrong are similar. When the two are strikingly dissimilar, coordination between the two parties must occur, sometimes requiring a more directive or psychoeducational session on norms of right and wrong, consequences on actions, or a very MI-based discussion on ideas behind these thoughts.
     Were someone to say that a therapist is a guide, I would not wholly disagree with them, but rather ask them to qualify the parameters of the word. That is a therapist is a guide to a person's inner self, not a guide to the outside world. That latter work is the work of a skill-builder specialist. A therapist's bread and butter are a person's inner-most ideas, motivations, feelings, and thoughts. Frequently, a person's own self gets in the way of their path forward and it is the therapist's job to help a client to figure out the possible paths and then their choices. They are not a guide in that the therapist does not do much (if anything) for or to preempt the client.

Tuesday, December 15, 2015

Some Clinician Responsibilities

     I've been thinking a lot recently about why therapy works (or doesn't) and what each individual's role is in therapy. I've also been thinking about how to ensure that individual knows what their role is and how to address the situation in the moment.
     A good therapy session requires a good therapeutic relationship. This almost goes without saying, but I think that it continues to be a statement that must be reiterated from time to time for personal clarification. I don't want to go into this subject, as I have talked about it earlier. I do think that both sides have certain roles that need to be present and acted-out for the session to be called a success. Upon writing this, I am thinking that the last sentence was somewhat directive. I do not want to continue that thread, as all I am saying is that there are certain things to do and certain things not to do in therapy on both sides. I guess the first thing to say here is that each side has certain roles to fulfill that will increase the chances of a good therapeutic effect.
     So what are these rules, roles, or obligations? I would like to start to talk about this topic on the side of the clinician, as that is where I am currently. What are the clinician's responsibilities? I ask the question because I am looking around me and seeing multiple avenues of practice. Some of these avenues are directive, others are not so directive. It is my view that a clinician is not necessarily a teacher. A clinician is more a guide. As such, a clinician is not present to instruct the client on what to do, but is rather there to help sift through all probably options with the client and create an atmosphere in which a client can come to their own conclusion as to their course of action. It is not the place of the clinician to add new knowledge to a client (normally), because I think that many clients already have an over-abundance of information, which can lead to their anxiety or depression.
     It must be said that sometimes teaching must occur. Some clients do not have a set of skills or an understanding of their situation that is helpful. In this case, it is more the how of the teaching that is the key to the situation, rather than the why. Giving a client options is a very good way for them to learn positive skills. Better said: Giving a client a buffet of choices will lead to hearty discussion about the positives and negatives of each option, why the client chose a certain option, the evaluation of that option with the help of the clinician, and a creation of a plan to implement that skill, if desired.
     The client gains much when a therapist does not choose their path for them. They learn the skill of decision-making and some self-confidence. Understand that a client will want to engage in a path/plan that they have created themselves. It means more to them (hopefully), thus making them adhere to it more than if it were created by the clinician. When a client creates some path, it is the therapist's job to help the client to ensure that the path is going to a positive place, that the end result is a therapeutic one. A path, being made out of stones or objects of some kind, should be examined by both members. Each stepping stone is another sub-goal or experience that must be processed by both members. It is the client's place to attempt to process; it is the clinician's place to encourage such processing and, if it deviates from a positive path, to attempt to correct it. The therapist does not exist to create and maintain this; such a thing is more in the realm of the client
     Some clients do not know how therapy should work, so it must be the role of the clinician to guide them.

Tuesday, November 10, 2015

The First Interview

     Let's talk a little about the start of the interview and the client working relationship. How does a good therapeutic relationship start? First impressions being what they are, I think that it is important to come up with a way to greet clients that is relatively standardized, because this will allow the clinician to be comfortable in that setting, hopefully transferring that state of ease onto the client. It might be important to note that different clinicians are going to proceed through the first session differently. Also, where a clinician practices might make the decision for the clinician, as to how that first session operates. Let us start with the greeting.
     The very first contact with the client can be a crucial make or break point. I think that an appropriate greeting involves a warm smile, a healthy handshake, and an introduction involving identity. While I am not partial to the smile, I think that it does calm the client and gives them a positive first image to be remembered later on. The handshake very much depends on the client: some clients are touch-averse. Frequently the clinician can gain this information from the assessment, which can happen over the phone or from a previous appointment. The introduction should probably  entail name and any degree-related formality (Dr. and such). I'm not sure that there should be too much talking about self at this point because there could be a walk back to the office or a "settling in" period that separates the greeting from the formal introduction.
     There is much more to do in the first interview, obviously, than the greeting. The next step would be the "setting in" period. After that is the introduction phase, which is a complicated phase, full of sub-phases that I hope to talk about shortly. After the introduction, depending on the reason for therapy and the setting, first-session questions should be asked in order to gain a baseline understanding of the client. I hope to go over some of these questions here. I also wish to explain the end of the first interview and what should be discussed then. This includes possible avenues of therapy going forward, talks about the frequency of care, the length of each session, the length of treatment in general, etc. I realize now that I forgot to talk about discussion points in the introduction. The introduction is the time to talk about payment/insurance, clinician degrees/certifications/licenses, specialties, and any relevant experience of the clinician. Client concerns with therapy can be dealt with here or could be discussed in the baseline questions. I think that there are more questions in that section that I have forgotten, so I will hope to explain them further later.
     The greeting having been covered already, what does one do during the "settling in" phase? Normally some small talk may occur here. This is a good time for the therapist to introduce the space, asking whether the configuration is good for the client and, if not, how the pattern of chairs, desks, and tables might be more agreeable. This is also the time to get any water or tea that the client or clinician would want. This stage is very much the "hemming and hawing" between stage. After the settling in in comes the formal personal and professional introductions.
     I think it is important to note that the introduction is not only a space for the clinician to "awe" the client with his or her credentials, but also to ask some important questions about the client. Introductions, as such, should be mutually presented. This time is the chance for the clinician to inform the client about the clinician's work experience, including some history on where and how long the therapist has worked. This may bring up some points of similarity between the two parties, possibly strengthening their bond from the beginning. It is also the clinician's job to expound on the proficiencies and deficits of the clinician's practice. What do I and what don't I do well? This talk might include the therapist's orientation to clinical work and their expectations of the client (and themselves). As previously mentioned, insurance information and payment should also be discussed early on (rather than later on in the session. I would like to mention that session rules should also be discussed. Perhaps these are the same as client/therapist expectations or perhaps not. Obviously any special degrees, certifications, and licenses should be quickly introduced for the edification of the client.
     Between introductions and baseline questions, there might be a good opportunity to ask clients about their previous counseling experiences, including quantity and quality of treatment. This is important because the clinician can know what worked and did not work with the client. He or she can also know what not to do or how not to act - possibly just as important as the prior point.
     There are other questions that must also be asked in the first interview, including more assessment-based questions, these include:

  1. Full name/nicknames
  2. Address, phone number
  3. Employment/job/occupation + feelings about it
  4. Family growing up + feelings about them
  5. Family now + feelings about them
  6. Religious background (what type/denomination)
  7. Psychiatric symptoms
  8. SI/HI
  9. Why are you here? 


Friday, November 6, 2015

The Basic Counseling Skills

     A word of caution: No good therapist exists who does not have basic counseling skills. Why do I bring this up? I realize that I have recently been focusing overmuch on the higher-level therapy skills, having not really strengthened my core skill set yet. I guess what I want to illuminate here are the skills that a therapist needs to be successful, were any kind of orientation stripped away. It is on this foundation that a good practice can be built. What are these elementary skills?

  1. Listening skills
  2. Empathy
  3. Positive regard
  4. Appropriate silence
  5. The "go on" skill
  6. Unpacking
  7. Appropriate self-care
  8. Introduction
  9. Gaining feedback
  10. Balance self versus clinician
     I'm going to comment on these ten items. I think that they are a good beginning, but are also nowhere near what any good therapist needs to be successful and helpful.
     The first three items are very Rogerian. It is my belief that Rogers was a good practitioner of basic counseling skills. Listening - specifically active listening - is a much-needed skill because it pushes the clinician not only to really hear what the client is saying, but to react in an appropriate way. Both of these skills allow the client to feel comfortable telling a stranger some of their darkest truths. Listening should start from day one in order to accustom the client to that level of deep interpersonal acknowledgment. This skill is difficult because it takes a high level of composure and compartmentalization on the part of the counselor to ensure that such listening can occur. Because every counselor is still a person with his or her own hopes, dreams, thoughts, beliefs, motivations, prejudices, loathes, etc, we must all ensure that our outside (or inside) stuff does not preclude us from this most basic and important of techniques. 
     Now let us talk bout empathy. I find myself with much internal conflict about this, specifically as to the ability to develop it versus being born with it. The reason I waiver has both to do with my own personal level of empathy and neurological science behind empathy and personality. I think, for myself, that I have a certain amount of empathy inherent in me, but that there could be more (but who couldn't say that?). It is better in this business to have more empathy, as it is the main connection of caring between the client and the clinician, though too much may lead to a difficulty in engaging in appropriately high-level self-care. The other argument, to get back on track, is saying that brain structure decides empathy. To take it to an extreme, those diagnosed with anti-social personality disorder are said to have no empathy. Taking it a step further, we can say that to this population, empathy cannot be taught; perhaps put differently, empathy cannot be "bought into," meaning that it might be taught and understood academically or mechanically, but cannot be truly believed in by that person. So what does all this mean for the therapist? Empathy is something that, at best might be taught and developed in someone that has the seed for it. Empathy, being one of these core criteria for a counselor, is something that a good counselor MUST have. 
     This next subject is one that I don't quite agree with Rogers on. Rogers touted unconditional positive regard. This seems very difficult and tiresome to me, as, like empathy, it almost seems to be something one must be born with. I also think that unconditional positive regard is almost a lie to the self and unrealistic in practice. I will talk about the latter first. Unconditional positive regard is not something that exists naturally in the world. It seems to me that everyone has an internal list of things that, if violated, would break this type of positive regard. Also, we need to make sure that we are reality testing here with our clients . . . Now that I am thinking about it, I guess that there really is a difference between unconditional positive regard for the client and unconditional positive regard for the client's actions and choices. The latter does not deserve such regard, whereas the former is difficult, but perhaps possible. The reason I changed my mind is that a client will not work with a therapist who thinks that he or she is a scumbag or a dumbass. I guess this one is both an interpersonal issue as well as one that could effect the clinician's case conceptualization. 
     Appropriate silence can be a difficult topic. I think that it can be every new counselor's instinct to fill in the conversation completely. A problem here is that frequently such dialogue is inane chatter, which only serves to confuse the client and tire the clinician. Sometimes clients must sit with a problem and think about it, while in the presence of a therapist. In these moments, it is not therapeutic to tell the client an answer or a philosophy. Rather, allowing them to piece out a problem might be exactly what they need in that moment. Silence is also a guard measure taken against over-functioning. Of course, there are some clients who disallow silence, so for those cases a clinician must be able to act in the opposite way in order to be effective.
     The next skill is a difficult one to make sound genuine for me. Frequently clients stop their dialogue, looking for something. From my own time in therapy, I would say that clients stop in order to ensure that the clinician is still with them, that they are not sounding crazy or stupid, that they started to hit on a topic that they would rather not talk about, or that they are looking for more encouragement to continue (for whatever reason). it is in this case that the clinician employs this skill to "allow" the client to continue. The therapist needs to give some kind of verbal or non-verbal cue to the client. Sometimes, a simple nod of the head will do. Frequently, a vocalization is fine (such as "mhm" or "hmm" or such). Now and then something like "yeah, "yup," "I hear you," or some such can be used. I think that this skills is quite dramaticized and romanticized in movies and books, to the point that the clinician says something like, "Talk/Say more about that," or, "Tell me more." For the reason that these terms are used so frequently in major media, I myself feel awkward in using such lines. Still, they might be useful.
     This next skill is a pretty advanced one for this list, but is one that requires a lot of work on the part of the therapist. I think that "unpacking" can lead to a clinician getting to know themselves better as a therapist, to a point that they might be able to learn their own theoretical orientation. Anyway, unpacking is the ability to break apart what a person is saying into different parts, consisting of narrative, problems, thoughts, feelings, complexes, etc (or the lack of any of these attributes), in order to highlight the important aspect to a client that can be explored during therapy. As previously mentioned, what a clinician chooses to unpack - or perhaps better put - what a clinician chooses to discuss after unpacking is a good indicator of that clinician's end "theoretical orientation." Unpacking is important because a clinician can gain much information from one sentence. At this time, I do not have a great example of such a sentence. While unpacking, a clinician can make connections and hypotheses that will allow them to continue a conversation if it starts to stall later on in therapy. My level of unpacking at this point is still somewhat basic, meaning that it takes me longer to do it and that it is difficult for me to do it in my head - meaning that I frequently have to be writing things down. This can get in the way of truly active listening and engaging with the client, but it is a positive for good and accurate case conceptualization. This is a skill that must be continually used and perfected if the clinician has a hope of being a master therapist in the future.
     Good self-care is essential to any therapist. Not engaging in proper self-care leaves one open to "psychic viruses" such as sarcasm in the office, compassion fatigue, a grand case of the fuck-its, and depression or anxiety. Good self-care can take the form of pretty much anything - being as changing as the subjective person.
     The next two skills frequently occur at the beginning (for the first) and at the end (for the second) of the relationship. The first is the introduction. I have elaborated on this portion many times, especially when discussing the documentation that occurs at the beginning. I will most liley be updating that section soon. This has more to do with how one acts at the beginning of a clinical relationship and at the start of all sessions. Confidence is key here, as it starts the relationship off on good footing and allows the client to see the clinician as someone who might actually help them. It is important in the first introduction to talk about fees, credentials, past history in psychotherapy, experience, orientation, and any paperwork that must be completed. It is important to ask for questions and concerns throughout, as airing these might allow for good discussion topics and make the client as comfortable as possible. That work - comfort - is very much something that is highly important in the first session. I think that making the client as comfortable as possible can only echo well throughout the rest of therapy. Every session also has some kind of introduction, which can change very much based on the clinician and their therapeutic approach. A clinician could create a set agenda or start out with a general question, such as "So, what's going on?" or "What would you like to talk about?" I guess comfort is just as important to the clinician, but in a different sense. The clinician is supposed to be relatively comfortable in the chair, so the introduction is just as much for him or her as it is for the client to ensure that there is a good fit or match between the two parties.
     This next one seems to, again, be an issue that is frequently regulated based upon theoretical orientation. This is unfortunate, as feedback is good for both parties and very good for future discussion and planning. Oddly, I think that most theories could easily accept the feedback rule and integrate it into themselves. Bringing the conversation back to the present with a feedback question is very existential-focused. I think that a behaviorist can get behind this question as well in their constant search for feedback and numbers-based results. Feedback allows the client to give their thoughts on the conduct of each party as well as the discussion and give good insight for the clinician as to what is important in current therapy to them and figure out what they are getting from therapy. Clinicians are on the receiving end of this and use the feedback to alter their own case conceptualization and change now they are engaging in therapy with the client. I'm not sure that it must be a rule as to when the feedback question is asked. I can see wisdom in sometimes asking the question during the middle of the session, especially to check whether an intervention has landed, though I would say that ending the session with the question might be a good idea to write good notes and track milestones in the client's treatment.
     The last point that I will mention here is a sometimes difficult balance that any counselor has to make between showing self and not showing self in session. This can be better said. Many counselors have to deal with this question: How much of myself do I show in session versus showing a more generic therapist self? This is a very good question that can easily affect how a clinician behaves in session. Some therapists have an innate ability to add themselves genuinely into the conversation. They can highlight their own behaviors subtly and model what a healthy individual might act like. Some clinicians use the role of clinician as a foundation or base to act in a way that they find appropriate. I can't say that one is necessarily better than the other, though I do think that there should be a balance because clients can tell when a clinician is hiding things and/or not being up-front with their feelings. 

Thursday, November 5, 2015

Some Criticism of MI, CCT, and Existential Psychotherapy

     It seems to me that a reflective statement (a la motivational interviewing) is inherently revealing of the orientation of the clinician who states it. A complex reflection - one that is not just a rephrasing of the client's own words - adds to the client's statement by switching words out and adding in a small interpretation. This interpretation can vary wildly between therapists. Some will talk about the client's thoughts; some, their motivations; others their core values and meaning in life.
     It bothers me that some people call motivational interviewing their "theoretical orientation," because, as I have written previously, it is not one; it is more a technique. The reflection that MI uses really shows the underlying theories that the clinician holds dear to them. I do think that we should not discount MI, though, because it does operationalize how to actively listen to clients and is, in my opinion more of an offshoot of client-centered therapy than anything.
     In this light, I guess it would be difficult to call even client-centered therapy a complete psychotherapy, because its practitioners mainly use only one technique (active listening). When only one techniques is used, it seems to me that theory is pretty much technique-less and is more an avenue for a theory than a theory unto itself. In the same way, I guess that many people would point the finger at existential therapy and say that it is only theory and has minimal technique (I would like to say that CCT is a good personality theory, but in the realm of therapy, falls somewhat short because much of the theory falls flat when used in session; hence the minimal technique). My rebuttal here is that existential therapy's technique is both very present and invisible. It is present in being present-focused, critical, and always thoughtful. It is willing and able to explore all the subjects that the client would like to understand. It is invisible in that the technique is so parallel to the theory that it is often difficult to understand that it exists, especially apart from other theories. I also like to view it as a pair of eyeglasses that one forgets he or she is wearing but one that constantly informs his choice of phrase and approach to an issue brought up.

Tuesday, November 3, 2015

When Is Therapy Finished?

     What is the end result of therapy? I really struggle with this question. I think that different therapists with different orientations would, surely, have wildly different answers. Allow me to map this out so that I might better describe the issue later on. There would be a difference between what a directive and non-directive therapist would say. There would be a difference between what a therapist and a client would say. There would be a difference between what an insight and a more behaviorist clinician would say. Different venues would have different goals here. Diagnoses would entail different approaches and result in varied goals. A psychologist, a psychiatrist, and a therapist would describe different goals. A practitioner from the past would detail a different result from a therapist from more recent times. Similarly, a client from years ago and a client now would surely expect an end to therapy at different times.
     I think I will start this short essay with answering these questions/topics and, if I remember, go into my own ideas as to the result of therapy and knowing when therapist is "done."
     A directive therapist versus a non-directive therapist is the first topic I brought up. The locus of control for a true directive therapist would obviously be with that therapist, so the burden of result would be more with the clinician. Now, it must be said that most clinicians are not summarily directive, so this might be a moot point. A non-directive clinician, on an opposite note, will, at their core, leave the client to find the end of therapy. I think that the question here still stands: What is the end result for these two types of psychotherapy? Perhaps this is a confusing question. A better one could be: When does therapy end? or How does one know that therapy should be concluded? Referring back to the example of directive versus non-directive, I think that a directive clinician will halt therapy (if they think that a discharge is positive) when all goals on a treatment plan have been dealt with. This clinician is one that is doing more of the "executive functioning" of the dyad. On the other side of the equation is the non-directive therapist. When is therapy done in that situation? This is a much more difficult question. A client who is ready to release himself or herself from that type of therapy is one who has the skills, confidence, and reason to do it. Either that, or he'she just stops coming to therapy (which, while here being a jab at non-directionalism, is very true of most therapy types).
     What about a each person in the relationship? When would a clinician be able to say that a client is ready to leave therapy and when would a client know that they are done with it? I think that the first question is much easier to answer than the second, as I can speak through the lens of orientation or general counseling theory, while the latter has only a lens of personality or subjectivity. I would like to get into theoretical orientation later, if I remember, so I think that at this time I can speak from a more general viewpoint. In general, a counselor knows that a client is ready to leave if he'she shows a marked decrease in distress in their lives and can deal with situations in such a way that leads to minimal discomfort and no psychiatric disorders. As mentioned, it is difficult to adhere to an idea of an individual client (and his/her ideal self post-therapy) because each client is very different. To some degree, I think that the end result that a client is looking for is probably very similar to the generic counselor in his comparison. Frequently, in my short-lived experience, clients tend to disengage from therapy before their therapist intends. Barring bad match-ups and negative dialogue, clients seem to frequently want more instant gratification therapy; that is, clients want tools to help them decrease their stress immediately with minimal insight. In my opinion, it takes a special client who really wants to look deeply into themselves and reveal (as well as sometimes combat) what is there. These clients are looking for self-development and understanding and frequently only leave therapy when they have found that. Some want to undergo very intense therapy and frequently require little of the therapist outside a gentle nudge or permission/validation to continue their talk, needing more of a safe space to discuss themselves with themselves.
     Going on with this subject in a slightly different manner, an insight therapist and a more new-age symptoms-based therapist would have very different ideas as to what constitutes a "recovered" or "cured" client. I think that an insight- or depth-based therapist looks for a client, to some degree, to self-assess their own condition. This is in contrast to the more behavioral therapist who operates based on scaling and other more quantitative measures. It must be said that the former clinician will most likely have their client for longer than the latter therapist.
     It is important to look at where the client is being helped. If the client is at a clinic attached to a hospital, I think that the former scaling rules used would very much inform when a client is discharged or when they choose to leave treatment. Depending on the topic of treatment, a "cured" client is most likely one who shows minimal to no behaviors that plagued them before and pushed them to enter some kind of treatment to begin with. In a private-practice setting, it is possible that the client stays very long in that setting - which depends much on the client's identified concern(s) and/or the orientation or plan of the therapist. There are, of course, many different venues for therapy to occur, and each one has myriad different variables to take into account when this essay's question presents itself.
     I think that the next section is probably both the most interest academically, as well as the easiest one to talk about. Because this part has to do with diagnoses, there is an already set framework upon which to work, specifically symptoms and diagnostic criteria of the DSM 5. This section is easy because we are looking at set criteria. If these criteria dissipate, then we can easily make the case that the client should be discharged. Again, in my opinion, it is always good to check-in with the client to ascertain their viewpoint on the subject. Many venues, such as progressive private practices, might not diagnose or use diagnoses at all, so this venue cannot use symptoms, as such, as a criterion to discharge or recognize a client as able to leave treatment.
     Let us look at differences between what a psychologist, a psychiatrist, and a therapist would deem an appropriate as an end to therapy. I must preface this by saying that I am talking through my own lens and cannot completely see nor understand the intricacies of the other jobs (nor, indeed, all of them in my chosen field). A psychologist, in my opinion, uses many numerical measures. They might scale, as previously discussed, in order to ascertain whether a client is finished with therapy. There are many psychologists who act more like therapists and I would understand them more through the lens of a therapist. A psychiatrist, especially a more new-world one who is more interested in medication than true therapy, might see a reduction in certain symptoms as a basis for an end of therapy and a proclamation of a cured client. An unfortunate issue here has to do with the many medications from many psychiatrists being taken for a lifetime instead of being tapered off (when possible) and replaced with a strengths-based talk therapy regime. I believe that I already have revealed my own thoughts about how I see counselors acting in this frame and will ask the reader to refer back to those words rather than repeat them.
     The last two points have to do with the past: How would psychotherapists from the past know when/if a client is done with therapy? and How would a client from the past know this?  I will answer this in one paragraph as a I think that the latter question is very dependent on the former. It is my opinion that many clients in the further-flung past (early 1900s) held their therapists in such high esteem that their therapist was the one to end the relationship, frequently whether or not the client agreed. In Freudian terms, a client was in denial when resisting treatment, something he saw as a great step forward in treatment, as it signaled that the client was avoiding the clinician due to issues being uncovered that were uncomfortable and, therefore, important. These therapists (and I am speaking specifically of analysts) frequently kept clients for years, so an end to therapy was very infrequent for them.

Wednesday, October 7, 2015

Buy-In From Client and Therapist

     When a therapist and a client take on a problem, both parties experience buy-in. I am not sure that this is a term in the vernacular of the field yet, but it should be. Both parties experience varying levels of this state, which to define it, might sound something like: "The idea that a person will get something out of the experience that will benefit them in the long-/short-run . . ." I'm sure there is more to it than that, but that is just off the cuff, as it were.
     As stated, the level of buy-in varies and depends very much on many different factors. Just a few are the client-clinician match, pre-conceived notions of therapy and its uses/structure, how the experience starts, and similarities or differences in communication styles. A client can come into therapy wanting to use the session(s) to complete good work that will change something in his or her life. Similarly, yet completely opposite, a client might enter therapy without their consent. A clinician can have the same bipolar situation going on, one day entering a session with relish and an attitude of "stick-to-it-ness," but show a very different side of themselves later.
     This entry is not about the on-going buy-in of clinician or client, but rather the resolution felt by either party at the end of a span. I did not know the correct word to use, so "span" it is. By this word, I mean to signify the end of a certain issue, whether that be a problem going on in a client's life or the end of therapy with that particular client. Obviously, a client gets resolution during therapy; that is what successful therapy is all about. I would like to look at the theme of resolution at the end of a span on the part of the therapist. Does the therapist need resolution as well? What does therapist resolution mean and look like?
     These are very difficult questions. I would say, even at this early point in my career, that a therapist's resolution is fleeting and transparent when in existence at all. Frequently, the client leaves therapy or moves on to a new subject before therapist resolution can occur. Does this not weigh on the therapist? Does this not decrease future general buy-in for the therapist in the same and different clients? Possibly. Probably. I would say that true resolution - getting past the phenomenological idea that resolution looks different for ever single person, which is true but unhelpful when writing about it - is the knowledge that something was gained by the client due to the time that was spend in the company of the therapist. This is what should be - and I use that word sardonically.
     I think that a therapist frequently wants to get into many issues that a client deems unworthy or not as important as another at a given time. This, I think, can plague the therapist with a case of the "I wish"es, "I should have"es, or give him or her a general sense of not being challenged or stretched in their practice. These are issues that can bring a therapist to his or her knees without good supervision or the help of a therapist's therapist.
     Allow me to talk about these ailments and their specific impacts on the therapist. The first "ailment" is a case of the "I wish"es. Perhaps better said, it is the case of the "If only"s or the "I wish I had"s. When a certain span ends, it is rather simple for a counselor to wonder whether something more should have been done (to be honest, this is the same as the "should"s) to seek a better or different conclusion. The therapist thinks that they did not do a very good job, or could have been better. This can lead to a long-term case of second-guessing, especially when the end to the span was not good for the client and/or ended badly for the therapist.

Tuesday, September 29, 2015

Honesty in Therapy

     Therapists must ask themselves an important question very early on in their practice: How honest do I want to be with my clients? Honesty can be either an important building block in the relationship between therapist and client or a stumbling block that sends the duo into disarray. I think that there are positives and negatives to honesty in therapy. I would like to talk about the advantages and disadvantages for each side, the long-term and short-term outlooks of each, and what it says about the clinician to use stark truth and/or white lies.
     I will talk about white lies first. Are they every appropriate? Sure, depending on the state of the client, a white lie might be a good bet. Just like with a client, though, white lies can be slippery slopes, increasing the chance of this "intervention" in the future, especially if the lie is never found out. A good question to ask here is When is it appropriate to use this? The therapist must always keep in mind that a white lie might be found out and that consequences could ensue. So, the lie should be as white as possible, be explainable by the therapist, and, taking those two into account, should not be so hurtful that they fundamentally injure the relationship. If the issue at hand is life or death (it could be a trauma case, a client with SI or HI, etc.) and a very small white lie can help that person to endure their situation and possibly survive until they, or someone else, can ensure their safety, then the answer is a non-idealistic and pragmatic "yes." I think that white lies have to be monitored closely because, just like normal lies, they can multiply quickly if one is trying to cover them up, and they can be detrimental to any relationship, as mentioned. In the end, after giving this some due thought, I think that lies in general should be avoided - after all, it is the place of the therapist to screen behavior and call clients on maladaptive thoughts, emotions, and beliefs.
     When it comes to honesty, there are, of course, times when the therapist must care to soften a blow and use more of an opaque honest (versus a clear honesty). I do think, though, that honesty really is the way to go. As previously mentioned, a crucial effect of honesty is trust. Without trust, a client would get nothing from therapy. I don't want to belabor that point as I think that it is relatively self-evident. I do think that one good topic for discussion is how to go about being honest.  A good velvet-wrapped brick approach seems appropriate here. I think that this is a good metaphor because being honest can be pretty traumatic and blunt. Wrapping it in velvet (a.k.a. saying it in a way that is softer than merely blurting out the truth) can go a long way. No client wants their therapist to tell them the honest truth outright that they are absolutely wrong, absolutely screwed if they continue their current actions, etc. No one wants to hear that. What good therapy allows us to do is to hear the client, their reasons for saying their piece, and then discuss their choices. A declaration of incorrectness can be just as hurtful to a therapeutic relationship as a found-out lie could be.
     Is one theory more honest than another? I'm not certain that this is a particularly fair question and is not one that I am prepared to answer. I think that it is less the theory and more the therapist that is the final answer to the question.

Thursday, September 17, 2015

Client: Know Thyself?

     Some theories look at the deep-seated issues in any specific person. We call these theories "depth" or "insight" psychotherapies. These theories attempt to crystallize, in some manner appropriate to that theory, what makes a person tick, where it came from, why it exists, and perhaps even how to change this for the future (this last point is one that I hope to remember to bring up at the end of this small essay). 
     The main issue I would like to understand in this writing is whether people are meant to know their deepest, darkest motivations, desires, and dramas. I think that both sides to the debate have credible viewpoints. Going along with this question are some important sub-questions that I hope to discuss more. They include these: Does fully knowing one's self open the door to over-reviewing the self and becoming neurotic? Are people simple creatures without the needed neurological tools to cope with such deep understanding? Are there certain groups of people out there who can and should explore the dark recesses of the mind and soul?
     Depth therapies require the client to enter into a type of contract with themselves. This contract states that he or she will be open and willing to plumb their own depths, no matter what they find there. To be willing to do this is a big deal because it shows that the client wants to get to know themselves better. So let's get down to it.
     Is it good or bad for a person to truly know themselves? Allow me to start by saying that we all hide things from ourselves. We hide negative reactions, unsavory opinions about people or ideals, and sometimes our own impulses in a given direction. The Freudian unconscious is a good method of illustrating this point, but one that comes much more naturally to me is that of a bubble bath or a dark barrel full of water. Our negative, and, to be honest, sometimes even positive attributes are pushed below the surface to a place that is invisible from where we normally operate. One must ask himself: Do we do this for a reason? Is the reason a good and adaptive one? I guess another good metaphor for the place we stash our deepest motivations could be an unlit and dank basement. Such a basement is frequently neglected, has some major disrepair, and smells awful. We can bring down a flashlight, but that flashlight only illuminates a small spot on a wall, a corner, a floor. A therapist can help by adding a second flashlight to the search. It is only with true self-analysis (for lack of a better phrase) that we can turn on a gas lamp or install an electrical system to see it all at once. 
     I like this last metaphor best, I think, because a basement has movement that can be heard, felt, and feared from the upper floors. Our lamps/flashlights can hit a corner and show, perhaps for a second, the movement of some small and skittering something before it crawls out of view to be swallowed by the darkness, which it finds more comfortable, assuredly. Sometimes, a therapist and his or her client can shine their lights on one of these creepy-crawlies and blind it long enough to examine it. Doing this can be (and is) uncomfortable for the client and the creature will scurry away in time. 
     I have definitely gotten off track, but I really like that metaphor and will continue to use it. The main point still stands and is amazingly difficult to answer. To some degree I think that it comes down to what a person has on their figurative/psychic tool belt that will allow them to cope with any shocks that they might incure in the process. It is pretty easy to understand how much the fundamental pillows on which a person has founded their meaning in life can be put at risk, damaged, or even toppled because they have dared to gaze into their own eyes. If this person has the education or natural grit that allows for quick positive reaction and repair, then they might come out of this encounter unscathed. Everyone will have scars showing their ordeal. 
     But can a person be driven insane because of their peek into themselves? Probably not. I think that someone can be shaken to their core, as described above, but, especially with the help of a qualified therapist to help them, they should be able to recover from any and all shocks and be a stronger person in the end. We must also take into consideration the fact that one doesn't only find negatives in their basements, but also bright spots including memories, unknown strengths, and other sources of positivity. I think that much of this is found when reacting to a negative critter, but some of it can be uncovered when free associating strictly or not. 

Monday, September 14, 2015

The First Three Movements in Psychotherapy and Their Places in History

     Does psychotherapy change with the fashion of the day? It seems to me that it might. We can look back at Freudian analysis and see that Freud himself was a product of his time (a time of sexual repression in Victorian Europe) and the citizens of the culture took it on (perhaps, at first for the novelty of the idea). If we look throughout history and the development of such theories, I think that we can map the changes with the changes in culture. The movements in psychotherapy are good ways to look at the movements' effects on culture and the culture's effect on therapy. I will also be taking into account the chicken or egg factor with each movement.
     The first movement in psychotherapy was, of course, Freudian analysis. As mentioned, the people of this time repressed their own sexuality. Freud's theory was, to some extent, an essay not only on sexual repression, but also on general repression and other concurrent psychological concerns. Repressing one's own innate sexuality as well as bad memories (through the "stiff upper lip" doctrine, especially) led to the fame of this theory. One reason, possibly, that this is considered the first movement in psychotherapy is that it is the first time that therapy was named such and operationalized as such. The novelty of therapy was high at this point and critique of it came some time after its inception. This critique originated from within and without. Two of Freud's own proteges broke off to create their successful theories. These include Jung and Adler (there were, of course, many others, including Freud himself). Jung's theory especially seems to have taken advantage of a certain mysticism inherent in those days, concurrent with similar study of mysterious phenomena in science and medicine.
     Freud's popularity started to wane as the scientific nature of his theory was questioned. The second wave of therapies started. This wave included the other end of the spectrum from Freudian and Jungian analysis: behaviorism. It ames sense to see this as a direct result of Freud's work. Skinner himself eschewed  the quasi-mystical nature of Freud's theories for the purely visible and quantifiable nature of a more behaviorist agenda. Science, at this time, was gaining a more consistent quantified requirement. It follows that psychotherapy, still performed mainly by doctors and/or psychiatrists (with the addition of psychologists) would try to mirror such changes.
     The pendulum seems to have swung back, as it does, toward a less quantifiable realm to admit the third movement in psychotherapy: humanistic/existential theories. To some degree, I think we can see that this movement or wave, upon examining the positive and negative factors of the first two, tried to expel some of the very negative portions (namely, the psychosexual fixation of Freud and the strict and neutral stance of behaviorism) and celebrate the positive ones (such as, in Freud's theory, the use of the unconscious, general developmental theory, and patience and feeling in talking to the client and, as in a Skinnerian model, a shorter therapeutic session need and a certain "go with what works" feel), in order to gain some ground and create a more viable and user-friendly theory. I am not sure of this, but i would say that with the modernization of education - which is to say the quasi-requirement of it in today's college society - that many more people were opened up to "high-order" anxieties such as existential depression, anxiety, guilt, and terror. Perhaps there is a less interested viewpoint on the more patient-related or medical model (the "talk down to" model). I think that both of these points really do create the need for a theory that both takes existential crises into account and works with, rather than above, a client.

Saturday, September 12, 2015

Is All Psychotherapy Depth Psychotherapy?

     To a degree, all psychotherapy is depth psychotherapy. I say this to mean that every therapy is going at least slightly beneath the surface in order to bring to the client's attention that there is something going on that is affecting their behavior negatively. What the therapist is looking out depends on their orientation, but all at least go beneath the surface a little.
     We can, though say that some are deeper than others. Some theories, such as pure existential theory is 100% depth-oriented. There are, of course, advantages and disadvantages to this. I believe that I have talked about this earlier and do not wish to rehash that topic. What I would like to talk about is a non-depth-oriented theory here. It is funny to me when therapists guffaw in the face of depth-based therapy.
     It seems to me that going beneath the surface to thoughts is good, but not enough. It almost seems lazy. One can infer much from thoughts and belongs in a deeper therapy than CBT because the therapist is inferring much from the thoughts (it also goes to show how difficult it is to be a raw CBT user). It behooves the client to get to know themselves on a deeper level. Only at this point, in my opinion, is it possible to truly identify normal or maladaptive behaviors and then change them in the moment.
     I must say that there are therpies that do not go beneath the surface. I personally would not call these psycho-therapies anyway. These include (but are not limited to) behaviorist therapies and neurological/medical therapies. Neither of these care to go beneath the surface or engage in a meaningful relationship with the client.

Thursday, September 10, 2015

Creating a Unique Psychotherapy

     There is some wisdom to the teaching assertion that counseling/therapy students should have a theoretical orientation. I think of all the theories out there, especially the well-known and most authored ones, and do agree that it can be difficult and often intimidating to try to research and incorporate some or many of them into a coherent practice. I imagine all these theories as dark boxes lined up in rows and columns on the floor of a large, non-descript, vacuous room. A student must open boxes, peruse (in the true meaning of the word) their contents, and then move on to another, always trying to find a perfect match. He or she might feel some large stress due to the search and need for personal identification with/through the theory.
     Now, I must admit that this is mostly auto-biographical (as if anyone thought any differently). It is probable that many students do not have the drive, patience, or tenacity that I do in finding different theories and techniques and attempting to integrate them into my own practice. I do feel a sense of need to create something for myself . . . something that is mine exclusively. I've always had this urge. I think I've written this before, but it seems to me that every clinician should have their own theory. For many, perhaps most, this means that they make combination theories: theories that add whole sections of different psychotherapies together to create a chimera or hybrid theory. I'm thinking that this could work when the particular cogs in the created theory (cogs are the specific techniques or the general orientation of the theory) really do work with and for one another.
     For some reason for me, such a combination theory is unattractive. It still has too many restrictions that exist in the component parts. It is best, for me, to create something from scratch that I can believe in and that seems to be useful in session. So it seems to me that a good clinician really does base psychotherapy off of themselves; after all, when we take a look at the progenitors of different psychotherapeutic means, can we not see a glimmer of themselves in their output?
     I don't know . . . the more I talk about creating a theory from scratch, the more I think about not only how difficult such a thing would be, but also that I have already been influenced by so many established ways of thinking.

Wednesday, September 9, 2015


     There are many pseudo-therapies out there. These are psychotherapeutic techniques that seem to masquerade as theories, but are in fact, not. The list includes such modern staples as motivational interviewing and cognitive-behavior therapy. It is important to note why those, in my opinion, are not theories/therapies unto themselves, but are, rather, techniques only.
     Each one of these methods has one thing in common: they do not go far enough. It's not necessarily that they don't go deep enough, for I don't want to make this an issue of depth versus non-depth therapies; I think that this merely has more to do with the fact that motivational interviewing and CBT seem to me to be natural segues to other therapies. Talking about thoughts is all well and good, but where did they come from? What is their impact on the client and others?
     Now that I am thinking about it . . . yes, the problem is really that these two methods don't go deep enough. It seems irresponsible to me to stop early when there is most likely much going on in the client's life that needs examination.

Thursday, September 3, 2015

The Simplicity of the Person

     The more I think about it, the more I am convinced that people are simple AND deep. People can be both. People are simple in that they (we) all have pretty basic motivations that push our actions and thoughts. Even our more advanced, seemingly mysterious, behaviors often have common origins.
     I am not trying to belittle the "mystery of our existence" or anything. I am of the rather conventional opinion that each man makes his own meaning in life. That in and of itself is somewhat mystical. Rather, I think, when it comes to therapy, people share more concerns than differ in them. I think I am painting in somewhat broad strokes here (because, as we all know, if we get down to the minutia of motivation and will, there are myriad reasons as to why we act the way we do), but it seems to me that this might be a good way to start out.
     What I am hoping does not happen is an increase in a feeling of futility in writing on this subject because people are "simple." I think that even mentioning it shows that certain cogs are spinning to this tune. Out of self-preservation, it seems to me that stopping this train of thought holds great merit. But is that just lying to myself? Should I be pursuing this further?
     Were I to really believe this, it would be a somewhat bold and fantastic claim. It would signal my belief that this is the correct and only logical or true and to quasi-scientific/philosophical inquiry into the subject. It would signal that I am correct where so many others just as, and much more, talented than myself have failed. That is some kind of hubris. With that conclusion, I think that I must say that the belief is wrong. I say this for two reasons (other than the aforementioned). One: I need this line of inquiry. It keeps me questioning and developing in the craft of psychotherapy. It keeps my mind limber. Two: I don't think that there is any one answer to the question of "What is the best form of therapy?" or "What is the only form of therapy?". Such an end result, in my opinion cannot exist. To create such a balm would end therapy. We could then program a computer to do therapy. Because of the dynamic, intra- and inter-psychic forces between a therapist and client, depending on the therapist and client, it cannot exist. Personality is just as diverse as all the hues we can, and cannot discern. So, two personalities working close with one another increases those hues even more.

Thursday, August 27, 2015

The Value of Writing and Reading as a Student

     I have discussed, prior to this date, the importance of reading the seminal articles and books in psychotherapy in order to truly understand the meaning behind the theorist's words. This allows the student to learn, as it were, directly from the teacher. I think that many texts frequently dumb down the information to make it simpler or "more accessible" to understand. This is unfortunate, as that information, since it was gleaned first from that source, will forever be remembered in that tongue or voice. 
     To read the work in the voice of the master is to be able to hear it through only one degree of separation. The more it is repeated, the greater the chance exists to alter, simplify or incorrectly translate the work. A student who reads Rogers's Client-Centered Therapy can read and then take that information as he or she sees fit.
     This may lead to a false conclusion, however. I am by no means introducing the idea that teaching should not exist. Some works, such as Perls's Gestalt Therapy, are inherently difficult to understand and need some instruction in order to truly capture the minutia  of the thought. I think that a lesson should be learned with the assumption that the text has been read. This assumption - which hopefully proves correct - means that the student has read, digested, studied, and questioned the material. This will lead to a class discussion that centers around the thoughts of the student and their questions on the text.
     The reason for this entry, though, has really nothing to do with reading the material. I have already covered that and allowed myself a couple of paragraphs to expound on the idea. I would instead like to talk about writing. Why is (or isn't) writing important for a student? That is: What does a student get out of writing? how often should a student write? What should the topics be? How critical should the advisor be? I will attempt to answer at least some of these questions in the following paragraphs.
     Writing, like reading, should occur because it gives the student knowledge. Reading gives the student knowledge of others' ideas that can then prompt their own. Writing frequently comes of this. Writing itself, though, has the ability to open up the client's own history, ideas, motivations, desires, and reasons for certain thoughts, emotions, and/or behaviors. Writing and reflection brings the student on-par with the theorist, allowing them to work side by side and pushing the student to further the work of her or she would went before. Writing also provides a way for a clinician to work out some of their own problems in a very understanding medium.
     I think that writing should occur with as much frequency of reading. If a student is reading anything of value (and I certainly hope they are), then writing is almost the next logical step to help them chronicle their own thoughts. The student or clinician will get things wrong and change their own ideas. Such a deed is more the norm than not and can be expected and encouraged. Indeed, a change in thought is healthy; I would be much more distressed were I to see that a student changed none of their ideas than some or most. More reading will lead to more changes of mind. It's hard to see a true intellectual ever being comfortable in one idea. He or she would most likely constantly be taking in information that would lead to different opinions. And when or if such information ceases to exist, should it not be the intellectual's job to create a stir and write something that causes people to think again? Because we are dealing with the phenomenological here, there will always be more, newer, and different things to read and write about.
     I think that topics should vary widely with students and clinicians. Theories, media, ethics, case studies, applications, "what-ifs" . . . they are all fodder for writing. I think that a big topic that all students should have to deal with (I could see pros and cons to early and late) in their schooling is ethics. Knowing where one comes down on a certain difficult topic permits a student to think deeply on a topic that may or may not ever really occur to them. They can create a script to be used in such a crisis, which is invaluable  and could mean their job or even the life of a client.
     The advisor of the writing should not be critical, per se. The advisor should be challenging. It is his or her job to ensure that thought keeps on going. He or she should push in the opposite direction of the student. He or she should push the student to strive for more information and a broader, as well as deeper, view on the topics at hand. The advisor should recommend books, times, to meet with the student, and opinions to allow the student to continue their writing and reading. 
     As my las not for this entry, I think that it is important to talk about ignorance wiring. This is writing about a subject without really knowing a lot  about it. Ignorance writing can be either positive or negative. It can be negative if written without any knowledge of the subject and with unhelpful intentions. This is not to say that education on the subject is necessarily needed. Indeed, many new thoughts have come without schooling. Perhaps truly negative ignorance writing can truly be identified after the fact. Positive ignorance writing comes by when a person writes on a subject he or she knows little or nothing about and turns out to be able to contribute. This happens infrequently and takes an exceptional person - a person who can intuitively understand fundamental concepts of a field and build on them using  his or her own thought structure. 
     Rather than writing from the bones of a theory, I think that students should write with knowledge of fundamental concepts and write in ignorance of some of the finer points. This way, a student can write their own thoughts and either "get it wrong" or "get it right." The wrong means that the student didn't quite write it as the textbook, not that that is necessarily incorrect. The right means that either the student has complemented the original work or has written something of value. 

Wednesday, August 26, 2015

Assumptions in Therapy

     In any therapy, assumptions must be made. Cognitive-behavior therapy would assume cognitive distortions. Person-centered therapy would assume some deeper meaning (technique is scarce with the theory . . . the theory itself can use multiple). Psychodynamics uses interpretation, which is an assumption about innate, subconscious, preconscious, or unconscious motives that the client most likely cannot understand or identify.
     Assumptions, though, are inherently tricky. The clinician has data from different sources: the client, the clinician's own ideas, and the clinician's study. Two of these three sources do not come from the client; they come, instead, from books (experiences of other counselors) and the clinician's own experiences. Neither of these can ever be 100% accurate, as neither have the knowledge about the client that the client does. So, it is important to use the client as a consultant to themselves.
     Blundering through an interview can hurt the relationship and set back any positive change. A blunder, in this case, is meant as an interpretation that is either incorrect and offensive to the client or correct and improper at the time. The former occurs when the client knows the interpretation's matter and the clinician does not. In this case, the client is not consulted on the meaning of their behaviors and is offended by the clinician's view of them. The latter can occur when the interpretation breaks previously indicated (or perhaps not) norms in past sessions.
     So, before any assumptions are made in a session, the client must be consulted. Simple questions, such as : What do you think here? Or an even more personal: I'm wondering what you're thinking about this. More data is always better when making an interpretation. Indeed, theories like person-centered are founded on the subjective, the phenomenological; ideas that respond more to working with a client - indeed interpretation is not needed here, as the client has the lead on their own case. If the clinician has perfect data, meaning that the client knows all their information and can plan out their own treatment (to some degree, treatment would not be needed with perfect information).
     Continuing with this thought, a client would not enter therapy with perfect information. Perfect information would make therapy useless - it would not be needed because a problem would not exist. Perhaps a problem would exist, though, if the issue (or the solution) is outside the client's possible realm of understanding. In this situation, a therapist is needed. Indeed when incomplete information is had, a therapist is needed. It is possible that perfect information cannot exist if defined as total information - omniscience. No client, or anyone, knows everything. So, does this not mean that 1) a therapist is needed as a side consultant, 2) interpretations (of some kind) are needed, and that 3) pure person-centered therapy can almost never work completely unless interpretation is used in some way.
when they are made. An assumption of a client should never be made on the first session. The first session should be joining and information-gathering. Assumptions come much later in the process, once a clinician has a good idea of the client and his or her issue.

Tuesday, August 18, 2015

The Unconscious as a Depth Error

     As I've previously discussed, I think that it is pretty easy to get behind the idea that the unconscious exists. This, I think, is the moderate view along the spectrum. one end is the aforementioned idea that the unconscious does not exist. The other is the frame of mind that holds that the unconscious is everything.
     Moderation, rather a moderate view on any idea, is, in my opinion, probably the wisest choice between two extremes. I have already talked about the "no unconscious" extreme. I think that the other can be just as negative.
     It is imperative to avoid the idea that the unconscious is a black box. Everything goes into the box, including our passions, drives, motivation, emotions, and thoughts. We are not sure what happens in this box, but what exits the box are our actions. If we take this point of view, one can easily attribute anything to the unconscious. This makes a therapist both lazy and ineffectual. It gives a therapist a demeanor of "well, we can't figure that out" or "let's dive into this," possibly resulting in another depth error.
     We need to be critical with what we attribute to the unknown unconscious and what we try to see through the lens of some other theory. The unconscious is not designed as a way out for a clinician - a way to attribute meaning where there might be none. I think that it is important to seek out other avenues of meaning before the unconscious attribution is made.

Sunday, August 16, 2015

Author and Therapist

     With the success of Irvin Yalom's novels and the general critique on literature that any good author has the ability to find the "inside voice" of any character they have created, as well as his or her deepest, darkest motivations, a broad statement could be made that a writer could be a good therapist, or perhaps be a satisfactory therapist as a second job. 
     Frequently when I read good fiction or literature, an author will lead me down a rabbit hole of thought and emotion, lighting up side alleys of inquiry discussed perhaps later on in the work. I have been very often surprised by the depth that many good authors have entered to convey the real motivations of their characters.
     It makes me think that we should be training more English majors as therapists. Alas, this might not work for myriad reasons. First of all, I'm guessing that most English majors would like their careers to have something to do with English insofar as teaching or studying it further. I'm not sure that we would necessarily want every would-be author rooting around in the back channels of their unfortunate clients' heads.
     A clinician must be willing to work with the client, not in spite of them. This is tricky for me, sometimes, as I would like to delve into the topics that clients would not necessarily want to cover. I think that many authors-turned-counselors would ride down the client's path, making assumptions about their feelings and thoughts, possibly because they themselves are use to having the helm in their work. 

Wednesday, August 12, 2015

How Do We Help a Client?

     Is it the place of the therapist to help the client solve their problems in session or is it the clinician's duty to bring up so many questions in the client's life that they must choose to answer them or go insane?
     As with all dyadic arguments, each side has both advantages and disadvantages inherent in their methods as well as outside their application. We must take into account here that I am speaking, of course, in generalities, as the quite phenomenological part of me disdains such gross thought. We must also take into account here that there are some schools of psychotherapeutic thought that deal mainly with the issue of solving problems with/for the client. CBT, frequently, does this, while some therapies, such as solution-focused therapies to it exclusively.
     I think that it is frequent that clients want the therapist to come to a conclusion for them. Many therapists do this, giving out advice and educating a client on what to do. It must be said here that explaining how to do something is quite different than describing what to do. The latter burdens the therapist with deciding the issue, one way or the other. I think that it is quite clear that it should be the client's decision to make a change. But, seeing the issue from the outside, how much does the clinician push? Psychoanalysts would say that little to no guidance is best. DBT practitioners would say the opposite, possibly.
     So is it the therapist's place to say, "You are having an issue with ________."? To some degree, I think that that burden lays only on the shoulders of the client. To be forced or coerced will not lead to a positive prognosis and says little about the future good of the therapeutic relationship. When a client looks back on their goals and treatment plans, might it not be best if the concerns tackled were theirs? Obviously here I predicate the argument on these clients being intelligent enough to be able to perform such a cognitive task.
     So, so far, without answering, or even alluding to an answer to the central question and reason for this entry, I have masterfully come to the conclusion that clients would be able (when at all possible) to determine their own problems. How much prodding by a therapist in one direction is appropriate here? As previously mentioned, voicing personal opinions on a client's hidden presenting concern may not be the most skillful one. As all clinicians are taught in school, it is fine to (indeed preferred to) operate under a hypothesis, even if that hypothesis is in direct violation of the client's own presenting issue. This is where the expert role of the clinician may come into play.
     An analyst will frequently refer back to his/her hypothesis, even if thrown out by the client. He or she will still see a kernel of truth in it (due to their own training and past experience) that the client may refute brazenly. A client-centered therapist might approach things differently, taking their assertions as gospel, or at least remaining mum about the continued hypothesis. The clinician's theoretical orientation is the main sway in this argument.
     When it comes to actively solving a problem with the client, what are the gains and harms? A huge gain is that a clinician can supervise the problem-solving process, deterring a client from violence (to self and/or others) or other negative outcomes. A harm that comes with that has much to do with the finite knowledge and experience of the clinician. It is possible that a clinician could steer the client down a wrong path, leading  to one of the not-so-positive outcomes aforementioned. A positive may be the efficiency with which the clinician can fulfill the client's needs in therapy. A subsequent advantage here would be the speed which a session can get on to the new - possibly more important - topic or the clinician can schedule a client in more dire need of therapy. A big negative could be that problem-solving methods do not necessarily yield information about personal history or motivation that might reveal the true nature of the concern or the true concern itself. Another negative is that the client may leave treatment, thinking  that his or her work is done, without reaching into himself or herself for another important topic.
     What about the second approach? Is it more effective for a clinician to deny the topic of helping a client to solve his or her problem and instead search for the deeper meaning behind their plight or plea? Frequently, a client comes in with a certain problem: this could be anything from pain in their head to an existential angst about death. A therapist can choose - in the sense of the first approach - to find the reason for the pain (which might be very dynamic of them, depending on how they go about it and how deep they endeavor to delve) and/or talk about different, normally cognitive or behavioral methods that could help the client in the short run. A therapist of the insight persuasion might do this, but also bring to light some other issues that the client is having. To put it another way, the clinician does not see the presenting problem as such, rather sees this concern as an avenue to the real, or just other deeper, issues that the client is facing.
     One strategy that this therapist might use is to identify so many issues that the client shows distress with, that there builds up in said client a certain level of anxiety. This is a critical point that can show the difference between the seasoned and the amateur therapist. The immature therapist may stop too soon in this process, allowing too little anxiety to show in the client, before working with the client on some of the problems. The immature counselor may also go too far, not identifying the client's anxiety and working with the client to increase their own intrinsic motivation for change. This could lead to many more violent concerns, such as self-injurious behavior, suicide, or an outward explosion onto others.
     The seasoned therapist, quite on the other hand, will allow the client to feel his or her anxiety, reinforcing their own strengths - particularly their strength for changing themselves. This will allow the client to come to an intrinsic change much quicker that will last longer specifically because it came (in the client's mind - which is what matters here) from the client. I think that the seasoned therapist in general (obviously) has more techniques and skills built up that will allow the therapist to operate in a way that is best for the client.
     So the end question is: which approach is better? Perhaps the better question is: Which approach is more skillful? I think that the answer here would have to be the latter choice. But this is not to say that the former is not all bad. Rather, this is to say that the former is just an immature expression of the latter. The skillful therapist will test out how to gain experience enough to move to the next level in their own practice.

Sunday, August 9, 2015

Depth of Errors and Clients

     There is such a thing as a depth error. Normally a depth error is one that is made by a therapist and is comprised of finding an issue with a client that does not really exist and is in fact most likely more projection (or countertransference) on the part of the therapist. Depth errors occur because a therapist tries to assume too much from a relatively innocuous set of circumstances or a turn of phrase that a client uses.
     I personally vacillate something fierce on the depth of humans to begin with. Part of me does think that there has to be much more going on under the surface of our conscious mind than what we are immediately aware of. I do not think that we can say that humans are only stimulus-response animals. To say this would rule out values, convictions, and opinion. These three things, I think frequently live in the unconscious or the preconscious are, unless they are brought up in the environment and are the main topics of conversation. Reaction is one of the best examples of the unconscious. If this didn't exist, then everyone would react the same (or similar) in most situations. When an external stimulus is provided, we "choose" our reaction after searching or files based on our values, convictions, and opinions. Due to the sheer variability in different reactions, it shows that there is more to a person than just their animal instinct.
     The other side of the coin is the argument not necessarily against the unconscious, but rather a more shallow conscious. I have to confess that I get frustrated sometimes with how shallow people are; that is, I get frustrated with how similar people can be. Sometimes it seems like there really is a lack of thought with some clients that makes a depth error rather frequent.

Saturday, August 8, 2015

Strategies to Change

     We must ask ourselves as therapists when change occurs. Obviously this depends on the client and their situation, but in general the question still stands. Specifically, I would like to focus on a topic I brought up in my previous rant: What is the main point that a client "chooses" to change? Is it after a particularly involved stratagem by the therapist pays off or is it when the client has cast off all of his or her baggage and has become receptive to change? The answer is an obvious "both."
     My personal opinion on the first choice is somewhat bold: I am not a big fan of using "strategies," Sure, that unto itself could be seen as a strategy. But I think more what I am trying to say here is that I don't necessarily think that one strategy provides an "aha!" moment for the client. Very experienced therapists can set up a scaffolding of doubt in the current behavior/thought structure/motivation and subtly provide hints as to better possibilities to be used in the future. This can be a course of action that is enacted over weeks, months, or years, but it is not he one that can be executed on one minute in one session. The idea that one strategy is some kind of magic spell that will allow the client to change is silly; this is especially true for "shock clinicians" who employ tactics used mainly to surprise their intended victims into change. This won't work and will definitely not head to long-term change.
     That being said, the use of properly-timed strategies can be invaluable to a clinician. When the client is ready for change - meaning that a lot of work has been done to help facilitate it - then I think it is absolutely possible for a single intervention to produce an "aha!" moment. It is important for me to note here that that is not where the therapy should end. Clients frequently need help figuring out their plans for change and learn to monitor their own needs to help facilitate it. So, in the end, such magical intention with many therapists is not a valid way of practicing: one successful intervention will not sustain a client's own personal growth forever!
     The second choice has more to do with the client's entrance into therapy - their "casting-off" of surface-based problems, and, when this venting/complaining stage is through, engaging in real, meaningful therapy that will allow them to overcome challenges in their lives. To some degree, this must happen before the first choice may occur. That being said, this stage or choice will build much trust between client and clinician.

Friday, August 7, 2015

Is It Too Much to Ask a Client for a Fundamental Change?

     As with any theory, there are pros and cons. The same occurs with psychoeducational psychotherapy. I think that a main con that is difficult to see as otherwise with this modality is its use of convincing. I'm using the word here to denote the need for teaching rote skills to a client. Obviously, for a client to really take these lessons, they must be convinced that the material is worth enacting. True, some clients won't need this, but some do.
     It is this convincing that quickly leads to a certain type of (hopefully positive) indoctrination. This, frankly, scares me a little and is the main topic of this entry. I think that there has to be a certain level of buy-in to any psychotherapeutic meeting. This goes along quite intimately with Rogers's views on the strength of the therapeutic relationship being the most important factor in positive change in the client. Aside from this, thought: Are we not asking our clients to change/adapt a new philsophy, lifestyle, or state of mind? Is this not a lot to ask of anyone?
     If we were to really think how groundbreakingly catastrophic this could be to someone, would we do it? Sure, we start small, making/facilitating minor changes, hoping that the client sees the light and starts advocating for themselves in their personal lives. We need to be very careful in how we go about this process. Push too much and, yes, we might lose a client; but think about the significant impact that this could have on their lives!
     Take, for instance, a client who is having a relationship issue. This clients is unsure of his spouse's/significant other's reactions and his/her own proper reactions. If the therapist deigns it worthy, she might go deeper to find some history of spousal abuse in the parents that is replaying itself out in the client's current life. While the client's behavior is assuredly maladaptive, changing the behavior is tricky. The behaviorist would ask the client to simply practice new skills. He or she would assume that the old behavior would extinguish itself in time and the new behavior, if properly maintained, would take its place. The humanistic practitioner would work with the client, avoiding conflict and setting up scaffolding to prepare the client for positive change. The CBTer would dispute negative cognitions when heard in order to activate the client's "logic function" and give them an "aha!" moment. The depth-based practitioner might look at the client's own past, motivations, resentments, etc. All of the clinicians are looking for some "in" that will allow them (or allow them to help the client) to make some kind of quasi-philosophical change in his or her life.
     Such a change is huge! It can cause the client's whole life (in their subjective experience) to fall to tatters. It is, then, the therapist's job to help the client to rebuild their worldview (again, only if such a reaction were to occur . . .  with very existential clients/clinicians, the probability of this occurring is a tad higher). Frequently what is required here is the adoption, by the client, of a new lifestyle. THIS is one of the most important and most difficult steps in therapy. Identifying the problem is relatively simple. Encouraging the client to see that issue is the problem that is somewhat harder. but to convince them to change their general outlook?. . . very very difficult. To even take it one step further: changing their outlook in a manner that does not require them to re-examine every single aspect of their lives . . . this can be very difficult. I must warn that the issues that I am discussing here are not skills-based ones. These are more depths-based ones, such as trauma, race-issues, religion-issues, and communication problems.
     This last part of really convincing the client that what they are doing is wrong/unskillful/maladaptive can be difficult. It frequently takes many sessions for this to occur. Some clients never quite get it. It is important here not to get too frustrated. Sometimes all a therapist can do is to help the client see a glimmer of who/what they could be and hope that they change themselves when they are in themselves during the week. I think that many clinicians get very frustrated with clients not listening to them. They reframe, redirect, and coach, hoping against hope that their words, methods, and strategies stick. But is it the strategy or the relationship that is the grounds for change?

Tuesday, July 21, 2015

Theoretical Orientation Research Idea

     I think I may have come across an idea that could prove for some fine research in the future. Frequently, students in counseling programs, or even students of psychology looking to go into PhD or PsyD programs, are tasked with discovering their theoretical orientation. I have complained about this process in the past, but perhaps the choosing of the theoretical orientation can be cushioned by administering a personality exam and then encouraging research into a specific theory or group of theories based on the four-letter code. As a note: I have not checked the literature as of yet for this idea and it would not surprise me if it has previously been researched. Still, I see this idea as mine and would like to follow it, even if only for the academic exercise.
     There would be two phases to the research: the first phase would consist of polling established clinicians or advanced students as to their personality and their chosen orientation. The second part would be to use this information to suggest possible avenues of advanced theoretical study to beginner/intermediate students and gain an idea as to their level of "match" from the first part's data.
     The first part would consist of a Myers-Briggs-style type indicating exam. This exam would have to be both reliable and valid (if such an exam could be valid to begin with). There are some good exams out there, but the validity of the whole research is linked with every step! Every participant would report their current personality (mine is INTP, currently) as well as some additional information. This information can be quite varied. Some thoughts at this moment include: What do you see as your theoretical orientation (note: choose a specific theory when possible)? Is there a theory that you never use in your practice (possibly better put: Is there a theory that you do not see influencing your practice?)? What integrational strategy do you see yourself adhering to (Add in a description of theoretical integration, technical eclecticism, common factors, and post-modern approaches; see The Basics of Psychotherapy, page 32)? Here you received specialized training in any theory or group of theories? If so, in what and what type of training was it? I think that many more questions could (and should) be asked here, but I caution my future self to keep them on the subject at hand.
     The second part would consist of a student learning more about a theory that coincides with a recommendation from the research, one that is chosen at random (or perhaps one that shows minimal correlation), and one that shows negative correlation. From this a student can rate which on they gained the most from. Of course, every student would have to take the personality type exam before gaining their prescribed theories.
     So what is the goal of this research? This is a tough question. There are most likely multiple possible uses for this research. The working hypothesis would be something like: If a student shows (insert personality type here), then can we show that there is a meaningful correlation to end-result theoretical orientation? Perhaps this research could help a student to come to their theory faster, instead of writhing in a pit of theories that might not work for them. The end result could be a clinician who comes to their "best" theory quicker. This would ensure that they have a more accelerated process, putting them in the shoes of the theorist, allowing them to make important decisions as to general theory before burnout starts or the joy of thinking ceases.