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?