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.

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.

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.

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.