Symptoms, Education, Depth

     I'm coming more and more to the conclusion that therapy is less about what theory the therapist decides to employ overall, but move when he or she decides to use it.  Since I haven't written in this for a while, I forget about what I have previously written; my apologies if I repeat messages.  I think that a successful therapist is a journeyman of a couple of different therapeutic disciplines or orientations.  To practice otherwise would be to decrease effectiveness and the amount of clients able to be seen.

     It seems like there are three stages to successful therapy:  1) Symptoms, 2) Education, 3) Depth.  As I've previously written, one difference between the Wellness Model and the Medical Model is the fact that the former endeavors to make the person better than they were when they were normal.  I think that numbers two and three attempt to do this.  Number one adheres more strictly to the medical model, strictly controlling symptoms.

     Perhaps I should explain this progression first.  Number one is Symptoms, should be a therapy that helps immediately control the negative behavior that brings the client into the office.  The most base example of this is behaviorism.  Through behavioral techniques, controlling presenting symptoms would be possible.  If this were the starting point in therapy, it almost seems to me that the process of joining would be secondary to the work at hand.  The therapeutic relationship would stagnate until further along in therapy.  

     Number two is Education.  What I meant here is that a possible re-education may have to occur.  Two examples of this, depending on the presenting problem, would be CBT or emotion-focused therapy.  I think that both of these types of therapy attempt to teach skills to clients that they can use later in their lives.  Not only can they use specific skills, but I think that both of these theories would push the client to create new general means of thinking or feeling.

     The third step would be Depth.  Obviously this level of therapy would institute theories like existentialism or psychodynamics.  The main goal would be to really find the root of whatever issue is plaguing the client.

Normalcy or Being Abnormal in Therapy

     We keep on acting as if people are not normal.  I have already discussed normality and universality - two terms that halfway disprove total uniqueness (and adding "normal" back into the equation) - so I won't go into them.
     Should counselors be trying to change someone's personality?  Should an individual seek that sort of permanent alteration?  I'm unsure.  While actions show normality and universality, thoughts trend more into the realm of the unique (most likely because actions are bordered by physics, whereas imagination is infinite depending on the mind).  This being the case, that one does not translate into the other 100% of the time, should we try to construct further barriers to true unique thought by instituting outside action?
     An example is probably in order.  Sometimes I get skittish around people.  To a degree, it may be due to genes and a possibility of depression in my ongoing family and lack of sociability when I was a child.  This feeling might be detrimental to the counseling environment.  Perhaps a mood swing takes me in the middle of a session.  What then?  Should I not seek to reverse this trend and create inside of myself a feeling of calm and self assurance?  Would this not provide an inhospitable environment for mood swings?
     The answer:  perhaps.  But what would I be giving up were I to undergo such a change?  Would I lose part of myself?  Again:  perhaps.  This is a tangential thought adhering itself to the main purpose of this idea.  I don't know how to change myself in this manner.  What I want to figure out is how to live with my behavior and thoughts and feelings.  Generalizing this more:  How does a therapist advise on their presenting behavior?  Do we ask them to stop it?  Mask it?  Let it out?  Obviously this depends on the behavior and should be assessed on an individual-by-individual basis, but still . . .
     I think it comes down to this:  Good advice to a client (for me) might sound something like this:  "I hear what you're saying and really what comes to mind is the topic of acceptable consequences.  Are you willing to be responsible for your behavior?  If you are, then perhaps it is 1) not too severe and 2) worth the energy put into it.  If you are not, then perhaps we can look into some techniques that will allow you to act a little differently in certain situations."
     The counselor must also assess the behavior for himself also.  If the client enjoys killing people and is totally OK with the repercussions, the statement above is defunct.  We must stick to our ethical guidelines.  Personality disorders and irrational thought have the ability to destroy such a statement of consquences.

Universality Versus Normalizing

     Some of my classmates (and even some of my professors) confuse the terms universality and normalizing.  Both of these are terms that have to do with the understanding of one's problem or issue as normal.  They differ only in context, but it is this difference that makes them unique.
     Universality is an idea that promotes an understanding of one's problematic behavior through the idea that:  others have suffered in the same way, or similarly, in the past; are suffering in such a way in the present; and will most likely continue to suffer like they have in the future.  This promotes the feeling and idea that they are not alone and that others have either been "cured" or have learned to solve their problem/cope with it in a way that they can live a happy life.  This is one of Yalom's group theory therapeutic factors and makes a lot of sense when the immediate group can support the therapist or show their own similar behaviors/strategies on their own.
     Normalizing is more of an intrapersonal topic.  Instead of highlighting extrinsic factors, it describes the idea that the behavior itself is normal.  All behavior is normal.  Any mental illness is a product of all experiences of the past.  This means that the psychotic is normal because he or she is just performing the actions that make sense to them given what has happened in the past/what happens to them every day.  Carl Whitaker is very well known for accepting clients' behaviors as normal.
     While similar in intent, these concepts are dissimilar in context.  It is important not to mix them up because they are attributed to two different thinkers.

To a Better Approach to Finding a Therapist

     I am starting to think that the current model of psychotherapy initiation and execution is flawed and inefficient.  The current mode for client intake goes something like this:

1. Client searches internet/newspaper or asks advice from friends/family about a practice they know and trust.
1. If they search the internet exclusively, they forego knowledge of therapy jargon and choose based on the marketing skill and beauty of the site.  
2. Client calls therapist and hopefully asks some probing questions about means of therapy and history of the therapist.
3. Client agrees (or disagrees) with therapist, shows up (or doesn't), and is counseled. 
4. Client leaves therapy in relief of symptoms/presenting problem (could take time) or leaves therapy frustrated and upset that they lost money (or sanity).

     I think what irks me the most here is that the client dos not have the means to make an intelligent and educated choice about the therapist.  If a therapist works for Ralph, my friend's brother's boss, how do I know that the therapist will help me?  Word-of-mouth is inaccurate.  Looking over internet websites, while more accurate, is prone to folly when it comes to word choice, money spent, and therapist countenance.  It seems like there are too many factors with which a therapist could accidentally hang himself.

     There is a much better way to advertise counseling correctly/accurately.  It starts with understanding who the client is.  Steps three and four above describe the counseling process and any reaction afterward.  Any negative remark about therapy would be avoided if proper screening occurs at the front end.  I think there should be some kind of questionnaire that the client is required to take that shows what type of therapy might work best for him.  Therapists speak of "meeting the client where they are" - something that, I think, extends far beyond what questions to ask.  Certain clients might do better with a behaviorist while others could gain relief with an emotion-focused practitioner.  If such an exam could be constructed, it would be simple to match clients of a certain temperament to a counselor that would best fit them.

     There are two complications that come to mind here.  Other than the overhaul of the system (which no one likes).  The first is insurance and the second is accreditation.  I think that insurance companies would subsidize only the top nth percent of the therapists who provide care, based on the democratic process of choosing the ones who practice must.  This means that those practicing CBT would land insurance money while analysts wouldn't (this, of course, assumes that CBT would be matched to more people while psychoanalysis wouldn't)!  This would ensure that more therapists would train as CBT practitioners (and that schools would only teach CBT) and that fringe clients would have a mismatch when seeking treatment.  

     Accreditation here refers to the process through which a therapist gains the right to practice a certain orientation.  More schools would open up (probably called institutes, offering certificates) and more specialized training would be received.  

     I talked on December 24th, 2012 about abstract versus concrete practice.  I rather think that such a topic also has relevance here.  How constrictive would a therapist be in his practice?  Could they use techniques from other schools?  How is such a thing maintained?  Would therapists be required to amass further training in the future?

     This prompts yet another issue that would be the backlash to such a stunt.  If we made it normal to test clients on their "therapeutic temperament," would we not also require this of therapists?  If a prospective therapist is interested in such a study, would it not behoove him to take such a test to find out which speciality is best for him?  I am unsure of this.  To take it further, if a current student of existential psychotherapy takes the exam in the middle of his education and receives back an answer of behaviorism, would he then be required to change tracks or relocate his education?

     A huge part of this discussion is choice.  I think I put it on ice for awhile with this.  Should clients have the right to choose their therapists as they see fit?  Yes! Even if it doesn't help them?  Yes!  That's the beauty of choice.

Subjectivism and Objectivism

     When I talk to myself (which I think is very healthy), I keep catching myself being amazingly subjective.  Instead of saying something like, "The world is a beautiful and wondrous place," I say, "To me/For me the world is a beautiful and wondrous place."  I think that the distinction between the two is cavernous.  The first depicts a world as a truth inevitable.  There is right and wrong in this kind of world.  If, to fit the example, one would disagree with the notion that the world is indeed beautiful and wondrous, he or she would be incorrect without possibility of revision.  But all should ask themselves, is a sunny day beautiful?  To me, rainy and overcast days are beautiful.  So obviously total objectivism is not valid in this world.  At the other end of the spectrum, total subjectivism can't be correct either.  If we think of "correctness" as a morally acceptable (which opens up a whole bunch of cans of worms, but I'll take it here as an assumption), then those with antisocial personality disorder, who think stealing and killing are OK, are also correct (or at least not wrong).  Are their motivations really OK?  No.  Obviously either extreme end of the spectrum is a bit much.  Like most things, living or working somewhere in the middle is better . . .  it provides a level of comfort, adaptability, and safety that most people thrive on.

The Correctness of Psychotherapeutic Theories

     By trying to disprove previous theories of psychotherapy when there is documented proof that improvement has been made, are we really trying to help create better theories or just disprove old ones for abstract reasons?  I think that if there is documented proof of improvement, then something about the therapeutic relationship has helped them (if we assume that outside factors and time healing are not - or at least minimally-contributing factors).  Perhaps it is the case that psychoanalytic theory is wrong, but, again, something was going right.  Maybe it had nothing to do with the client's drives or motivations, but just the fact that someone is listening in a nonjudgemental fashion could be more of a common therapeutic factor.  So, by that logic, Freud did not have it all wrong (perhaps, even, psychoanalytic theory is 100% correct!).  He started everything that we do - sitting with clients, listening, etc.  He was the foundation.  Therefore, he was right, to a degree.

More on Religion (and Some About Science)

     Unfortunately this entry is going to be about religion again.  I still have some issues with it.  A doctrine built around a faith structure - a good idea?  I don't think so anymore than I did the last time I talked about it.  But is it a bad idea?  No.  At least, not when correctly philosophized.  What is religion more than rules about official conduct and beliefs about phenomena yet unexplained?  So, by that logic, is not science a religion?  It talks of proper behavior or etiquette - a certain level of sophistication and civility in this scientific age - as well as explanation of the unexplained - for instance, why does anything with a positive charge attract that with a negative?  I don't know . . .  They don't know, but we will give them names and observe them still.

     This brings me to to two points.  First, science is the obvious next step of religion.  And second, if science is indeed a religion, it is most likely not a good idea to listen to everything said.  If, by the stream of thought anchored from the first point, religion has spawned science and science is yet another religion unto itself, why are scientists not worshipping Reason and Logic?  Most likely in order to further themselves from formal religion and because practice, experimentation, and invention are they new praying, confessing, and sacrifice (and the former disallow the same attitude as the latter).  But, more to the point, I think that it used to be the case (and well still might be) that clergymen were the most educated men of their time.  This practically made them the scientists of their time (if such thought was not prohibited to begin with).  No, they did not experiment, for this was not their means/practice, but they observed, taught, and explained.  They did all they could with the resources they had.  Most likely it is true that most Renaissance thinkers were religious.  Many (thought not all, and the number is decreasing steadily) of our current scientists practice even while believing in more "old world" religions.  As technology progressed, and the fruits were received, it seems to me that the change in god figures only makes sense.  We could actually see changes and reasons for being through this new mode of understanding.  To a degree, just like the Greek/Roman gods are no more worshipped as they once were, technology and science are the new gods a la mode.  Old religions were in existence to explain the unexplained.  We now have "better" answers through this new apparatus.  The swift changeover from superstition to hypothesis is only logical.

     Could it be the case that science, like religious indoctrination, can lead to the closing of minds as much to the opening of them?  Yes!  Do we believe in the supernatural anymore? No, because it's not logical - even though there is plenty in the outside world that we don't understand.  It is very true that science has made the world/universe smaller; it has taken away some of its majesty through computation and through educated conjecture.  Science re-invents itself frequently as theories are proven to be false.  This means that everything we know is either a lie or an estimation (like modern physics).  Call me cynical, but it almost seems that creating astrophysics is akin to creating Demeter - another variant to explain another phenomena.

     Does this mean that science or any religion is bunk?  Absolutely not!  Far be it from me to take away someone else's meaning in life.  Should we all become Luddites?  Should we all throw away our science because we are afraid of what is to come?  No.  Indeed progress is very important.  Do progress and religion share every meal? . . . Maybe.  Very probably.  I think that we are only as un-evolved as our understanding of ourselves and our universe.  Science tells us a great deal about he latter, but the former?  Only we can know ourselves.  Only by really understanding who we are in this moment and understanding where we want to be in the future will we be free of all shackles of formal re-education.  A healthy dollop of personal understanding with a grain religion is, for me, perfect.  Goes down smooth, without worry of worry, cynicism, or self-hate.  The next question to answer is:  Who am I?  Were it that I could answer that question to its conclusion.  Unfortunately, I lack the cerebral skills and linguistic development that would allow an answer that is coherent and pleasing to read.