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?

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.

Psychodynamics: On the Other Hand . . .

     I think that one disadvantage to psychodynamics (and indeed psychoanalysis) is that the client must be taught or persuaded in the craft. To think psychodynamically is probably not normal for most people. Thinking about thoughts strictly comes somewhat naturally, especially to people of higher cognitive level. With this in mind, it is simple to understand the hesitancy of many clients to want to engage in such therapy. Additionally, the general fear of the unknown would disallow many people to expand outside of their comfort zone, in order to integrate such a method into their being.

On-going Thoughts About Psychodynamics

     The more I think about it, the more psychodynamics makes sense. I've read somewhere that psychodynamics is psychotherapy, because it takes all origins into account (thoughts, feelings, history, present, future, etc.). I think the push-back here might come more based on how the therapy is set out. The basic tenets of psychodynamics involve a clinician ready to listen, a free associating client, and deep topics. 

     I'm not sure why I didn't consider psychodynamics in the past. In fact, I think I pretty much disregarded it completely. There is a certain hesitance to like psychodynamics . . . partially due to its similarity to psychoanalysis and its depth-based methodology. It's pretty easy to get intimidated by that.

     In any event, depth-based psychotherapies definitely vibe with me more than not. While there is a place for skills-based therapy - including REBT and DBT - getting to the root of the issue is really useful in creating real change. One can cover up maladaptive behavior with other behaviors, but understanding the self, including increased awareness and insight, can lead a person to change themselves, if wanted. I think that just gaining insight and awareness could be a goal unto itself. And just think of the changes, such as increased motivation and deeper self-understanding that might occur due to depth-based therapy than could happen during a CBT session!

     A big disadvantage of depth-based therapies is the fact that there are many clients that cannot or will not  engage in such therapy. I have met both types of clients. There are some who do not want to be told that a "deeper issue" exists, possibly due to a notion that they are conscious of the fact that there actually is a deeper issue to begin with. There are some who do not think that a deeper issues is possible. There are also many clients who just are not capable of talking about their own personal depth or just are not of a cognitive level to engage in such conversation. This is, I think, a main reason why many other orientations have found such a footing in the field. 

Flexibility in Therapy

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

How Not to Run Out of Things to Say

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

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

In-Session Paperwork

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

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