Therapy Termination Blues

I’m coming to an end of my work at the mental health centre that I work with. As I do short-term therapy many of the clients I see I will be discharging or passing on to another therapist (if I lobby hard enough).

Endings don’t get much attention in therapy conferences, workshops and literature.

It can be hard for therapists as well as clients.

This is especially the case when a client without explanation, or via a supervisor says they do not want to see you anymore.

This happened to me the other day.  Without warning.  This kind of event evoked in me a feeling of discouragement, inadequacy, and sadness.  As a beginning therapist these feelings may be based in some fact: I’m just new in the game and have a fair ways to go in learning how to be a skilled therapist.

Nothing significantly different had happened between us.  However, this comes in advance of us needing to call it quits (a planned termination).  His diagnosis is complex, with significant personality issue. Nonetheless it is a person I had spent a lot of time supporting.

This feeling of “counter-transference” is to be expected and acknowledged as therapy is at its core a relationship.  It can be hard to bare and to let it be known to other therapists.

It’s humbling too- knowing that a “good” termination/discharge is something I desire for my own reasons, as well as something we as therapists aim for so that the client can leave with a sense of finality, closure, and accomplishment.



CBT Thought Record Challenge Follow-Up

So it’s been over a week after I began this CBT challenge and I thought I should give an update.  I did the thought record a total of three times using situations of high emotion.  That is kind of a miserable number of times considering I am a therapist with no clinical depression or anxiety.

Nonetheless I will share my experiences.  Like most clients I dreaded doing it.  I begrudgingly scribbled in my journal a couple times.  During the experience I found it fairly easy, to put the words down but like others in my group who have done it did feel kind of hallow/fake.  I wasn’t sure what difference it did make.

What I did notice is that my high emotions tend to centre around embarrassment or shame.  This was helpful as it exposed a sore spot for me.  A negative core belief that still nags me that “I always make mistakes/fail”. I have a tendency to believe or fear that people think that worst of me.  This seems to be connected to feeling exposed when I err or make mistakes, so in response I may become defensive or fearful in those situations.

The advantage to doing this exercise more than once is that you can begin to see some dominant emotions and thought patterns that reoccur.  This is something I had never thought to mention to my clients or ask.

One drawback to doing this thought record is that there is little cathartic emotional release in thinking rationally about the situation.  It doesn’t have that same feeling as when you journal about pain or hurt or anger.  The analytic nature just wasn’t that much of an enjoyable experience; perhaps that’s why we tend to think more emotionally than logically and we end up with distorted beliefs.

I don’t think the lesson of this exercise would sink in without emotionally processing (which I’m doing right now and one would hope would happen within the context of individual therapy).

In this way I think more emotional expression through art or otherwise would be a complementary activity to this one.

So all in all, this exercise gave me some perspective, helped me enter into the experience and let me see the limitations as well as some unexpected advantages to doing this.

So reader: what experiences have you had with CBT personally (and in particular thought records) that you would add?

CBT “Thought Record” Challenge

I have been mulling over Cognitive Behavioral Therapy techniques and what it is like for clients to engage in this therapy.  If you are in healthcare as a therapist this is a mainstay of therapy.  One of the cornerstones of this techniques is the assignment of  “thought log” or “though record” or “thinking report” as homework assignments.  In these exercises you ask clients to identify a trigger (situation), an emotion (and intensity level), actions, and the automatic thoughts that are experienced.  After these “hot thoughts” are identified you ask people to find alternative realistic thoughts and/or behaviors.

When used these can be very effective.  When is the operative word.  Like any homework given to a depressed or anxious person they often are not completed and trigger a whole wave of feelings and avoidance.  Some therapists choose to discard this type of homework all together as it creates “resistance” that they deem unnecessary.  Others embrace this not doing homework and ask clients to examine this action using a thought log in session, or do a chain analysis to understand this behavior.

I have been thinking about these two views.  Mostly I have attempted to use these logs, examined the not doing them, and sometimes concluded after discussing with the client that they just do not work for the client at this time.

To gain a new perspective I want to delve into this experience personally.  I want to commit to doing a daily thought log for the next week and see how it goes.  How effective is it?  How much do I want to avoid it?  What will I learn about what a client goes through.  Granted I will not have the same experience as I’m not dealing with a dyadic therapeutic relationship, but I bet you I will still feel some guilt and pressure to doing it just by making this post here and knowing that a few lone souls will check back and see if I actually did what I endeavored to do.

Wish me luck!

The Sins of our Fathers..

In the bible there are numerous passages in the old testament that reference later generations bearing the iniquity of their fathers (Exodus 20:5, Deuteronomy 5:9, Exodus 34:6-7).  When I first read these passages I thought this was especially cruel and unfair.  Why should those who have done nothing suffer because of the sins of others? 

What I realized recently while working in mental health is that this is not an order of divine punishment but it is the unfortunate effect of sin.  When a father sexually abuses his daughter she will likely suffer greatly in this life through the destruction of her self-image and sense of safety. She may have lifelong depression, borderline personality, an eating disorder, or post-traumatic stress disorder.

Other verses point that one should not be punished for the sins of their abuser (Ezekial 18:20) in this present world.  Justice should be fair- the victim should not suffer further or be blamed.

Unfortunately blaming the victim has been part of our world for some time, even in Jesus’ time people were looking to understand suffering and illness and pinpoint to a person’s sin.  For example Jesus is asked whether it is the sin of the blind man or his parents that caused him to be blind from birth.  This seems so foreign today to us as we know that blindness is a generally a genetic condition. 

However mental illness is a good comparison: even counsellors find ourselves asking is it this person’s “negative thinking pattern” or “lack of motivation”,or  “personality traits” that keeps them ill or is it “genetic” or due to childhood abuse/trauma.  We want to know the why because we think it can free a person from its trap.

Jesus does not buy into this dualistic thinking as he simple states that “Neither this man nor his parents sinned, but this happened so that the work of God might be displayed in his life.” This statement alone would seem to mock the person’s plight and suffering if Jesus did not continue to bring miraculous healing and restore the man’s sight.  In this instance Jesus not only cures the sight of one man but brought new perspective to the discliples, the man’s family, and the larger society on illness, sin, and God’s restoring love for broken and wounded people.

Judging from the last few posts you may start to understand that I am starting to feel the weight of trauma, hardship and suffering that I am beginning to witness in my work.  I grieve the sins of fathers, neighbors, mothers, grandparents, wars, and societies that have hurt children; I wish that children did not have to bear that heavy burden as alluded in the old testament.  I have clients that say they cannot remember anything from their childhood and call it “horrible” and “awful”.  Although Jesus does not join in the condemnation of parents or the blind man in the aforementioned story he does have strong words for those who harm children. 

 “If anyone causes one of these little ones—those who believe in me—to stumble, it would be better for them if a large millstone were hung around their neck and they were thrown into the sea. ” (Mark 9:42)

For all those affected by the sin of their fathers that I work with I hope to develop Jesus’ view of seeing them as instruments of God’s grace and restoration, rather than just as people I am “helping” or providing “psychoeducation”. I hope that Jesus’ promise for freedom could be experienced by all like the woman who had bled for twelve years. That those who have been hurt and metaphorically bleeding out could courageously reach forward to Jesus and receive these words “Daugther[son], your faith has healed you. God in peace and be freed from your suffering”.  (Mark 5:34).