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.