Parenting Parallels to Therapy

emotional-portraits-paintings-by-michael-shapcott-07

As a parent I have noticed there are a number of different camps in parenthood literature: ones that espouse behavioural modification shaping (i.e. cry it out in terms of sleep) and others who espouse attachment/ child-led philosophies that tend to emphasize the child’s innate ability to know what they need and face natural consequences. As a parents I have found wisdom in both of these camps.

Similarly in working as a therapist I have found competing theories in working with clients with what psychiatrists often call “behavioural issues”, or “personality disorders”.

These are clients who for whatever reason (often poor attachment growing up, but not always) employ coping mechanisms that keep them stuck in a negative emotional state over the long-haul and often involve intensive contact with the psychiatric system. Some approaches demand a very rigorous and structured approach, and others espouse a focus on the creation of re-creating an attachment relationship over many years in therapy.

In working with these clients, you are often presented with dilemmas familiar to being a parent to a child who has temper tantrums, misbehaves at school, or directs anger inwards at themselves. How do I respond to problematic behaviour and strong emotions in a way that shows love and respect ? How do I respond so that I do not inadvertently make the problem worse rather than better ?

However, unlike parents, I do not have the same amount of time, nor even trust with such clients; I might see my client one hour per week, rather than working with them 24 hours a day. In addition, the clinical situations I face require decisions that force me to balance the risks between encouraging positive change in the long-term, and short-term safety risks (i.e. suicide). I am usually the most recent therapist of a long list of helpers and caregivers that have tried to help them and have given up, left for other reasons, or passed them on to another care provider.

I am by no means an expert in helping these complex clients, but I do care about them and would aim to work therapeutically for their benefit and recovery.In my effort to try and be a contributing force for good in the my work I hope to actively process reflections from various books on this blog, beginning with “Doing Dialectical Therapy” by Kelly Koerner (2012).

Advertisements

Working Creatively in Mental Health Case Management

As mentioned in a previous post, I have been working in the area of case management for the past 6 months, with some therapy with a handful of clients- for example with a caseload of 50-60 client I may do more regular therapy with 5-10 of them.

There is a movement to adopt “recovery” oriented language and outlook but to date I have seen only glimpses of it in case management, but when things get tough (hospitalizations, etc) this language of looking at someone’s strengths, good reasons for their actions and own abilities gets thrown out the window in lieu of mechanisms of control.

In times of crisis and challenge it seems more common to start the see the client as problematic in our conversations together as professionals. For example very often people are described in the following ways: “she is very dependent”. “she is non-compliant” “requires redirection frequently”. This paternalistic lingo evolves in part by being a “manager”, rather than a therapist or a supporter.

It has become rarer now since becoming a case manager that I share with my colleagues with amazement of accomplishments that my clients have made or the amazing insight that they arrived at in session that day. Even if they are doing well it may also be attributed to the role of medication, which may be true in part, but also denies the client the victory of their own self-accomplishment.

As a case manager I spend so much time on medication refills and psychiatrist appointments that it seems like a big switch of gears to put on a therapeutic lens in each conversation. Many other professionals try to assure me that this is too much to expectof myself. However, I yearn to give the same attention and curious wonder to my clients I only see half an hour per month (or more frequently when medication changes are being made or person is unwell) as those I see every two weeks for therapy.

Part of this is beginning to think creatively, more visually and outside the box. I would like to dream to find new ways to engage their strengths and goals. This involves taking the time in each conversation to wonder out loud with someone about the future, about the ideas, about what is going well in their lives.

I have tried to have the lenten practice praying for my clients as I see them. I would also like to take time, even 15 minutes a day to think openly and creatively about one of my clients and think and plan a way forward. A therapist I used to work with used to set aside a day a month to plan and think about the work she was doing with her clients. In my work a blank calendar would definitely not go unnoticed, so a little bit integrated in would be the best strategy.

I’m curious to here about strategies of working creatively with long-term and chronic clients that you have used as a fellow therapist or ideas you may have from those outside the field. For those in mental health and case management how have you managed to refocus on recovery and strengths. Please share!!!

Happiness is…

Image

I recently attended a workshop by a well-known local psychologist on the topic of CBT and mindfulness. He mentioned that from talking to clients he has found that most people are searching to for “happiness”. For example we toll away at jobs that we do not enjoy for the end result of retiring comfortably and being “happy”. Of course, these culturally prescribed routes rarely produce happiness and sometimes people find they are the opposite of happy even while pursuing happiness. Depression is widespread in our culture(and among those who follow Jesus) and is characterized by hopelessness and lack of will to live and isolation/withdrawl from relationships.

For those who follow Christ I wondered if we too are aiming for happiness? The teachings of Jesus surprisingly do not seem to advocate for the goal of happiness and when happiness is spoken off it appears in an upside-down manner. For example in the beatitudes (Matthew 5:1-12) Jesus speaks of being blessed or in some translations “happy” when we are poor, mourn, meek, merciful and persecuted. It seems that happiness, instead of a goal, is a by-product of a lifestyle of both weakness and righteousness. In all of this we are called to “rejoice and be glad, because great is your reward in heaven…” (Matthew 5:12). Somehow we are supposed rejoice- celebrate – an action- not a mood stated- with the challenges in this present life with the insight and hope that God will reward us in heaven.

I have been meditating and memorizing Philippians 4:4-13 for the last month. Philippians was written by Paul from prison to the community in Philippi. He too is advocating a joyful/happy action “Rejoice in the Lord always I will say it again Rejoice”. It is in this passage that he explains that he has learned to be content in any and every situation (Philippians 4:11). This goes counter to our cultural “quest” for happiness through the usual route.

However, unlike mindfulness which aims to find inner peace through the moment Paul emphasizes that we are content in the Lord, who strengthens us. We rely on God’s strength to renew us and give us the “peace of God, which transcends all understanding”.

Being and feeling happy is cherished for a reason- it renews our spirit, we can keep on going in this hard challenging world. Can followers of Christ really hope to be happy? What can we say to clients who hope to be happy? Is it even an achievable goal?

Rabbit-holes, Land Mines, and Red Herrings

alice-in-wonderland-rabbit

I just ‘picked up’ (i.e. downloaded) a new book called Principles of Counseling and Psychotherapy: Learning the Essential Domains of Nonlinear Thinking of Master Practitioners by Mozdzierz, Peluso, and  Lisiecki.

I’ve been slowly working away at this text book sized volume.  I bought it because my framework for my previous job does not seem to fit as smoothly as I thought it would.  I need to refocus my understanding and am doing this by returning to basics- but with an emphasis on nonlinear thinking.

I have been in my new role as therapist/case manager for the past 4 months now.  I have to remind myself that in my work with more chronic clients that change is very slow, if not, in a haphazard mix between relapse and realization.

One phrase that really hit home was encountering “rabbit holes, land mines, and red herrings.”   Red Herrings- what may seem like real issues but don’t really have to do with the client’s needs.  Land mines- “so emotionally explosive you will not want to step on it twice”.  Rabbit-holes the long eternal struggles or stories that people extoll that do not produce forward movement.

Many of my clients have indirectly said “no” “I’m not ready” or “not that” by these tried and true human strategies of rabbit-holes, red herrings, and landmines. I’m slowly gaining understanding and experience to navigate these waters.  Landmines are my challenge right now: I feel challenged and frustrated when clients who tell me  the same story each time, with little improvement in resolution.

This book categorizes “rabbit-holes” as situations where you need to listen for absence.   Absence is not only when little is said but also evident when too much is said.

I feel that I have not been that successful in effectively working with “Rabbit-holes”.  To counteract I have asked the client about other stories other than the one described (distraction to focus on building anxiety coping skills, CBT, mindfulness, etc.).

This book later describes using a nonlinear response.  The authors note that sometimes not responding is the best approach, whereas at other times it is a matter of timing in stopping the client to reflect.  When avoidance is brought up it should be done tactfully, and with kind curiosity (Columbo Approach).  For example “I could be wrong but…” , “I’m confused could you help with with this”.  These comments are best placed on the process rather than engaging the content.

This approach requires a lot of patience, understanding, and true curiosity with compassion.  I admit, that I need some more fine-tuning in this department to walk that fine balance between avoiding the avoidance of the client by continuing to listen without intervening, addressing it in a tactful way, and gently changing topic.

What is your experience with rabbit-holes, land mines and red herrings?

The debate about Positive Core beliefs

My colleague and I presented the information from the Padesy workshop I recently described to one of our therapy teams.

The debate was electric.  People were intrigued by the integration of different ideas in CBT.  It came to a raucous debate surrounding Padesky’s emphasis on clients to develop positive core beliefs; the “new system”.

We are so used to asking clients to think of realistic alternative thoughts that we almost frown on positive thoughts.  One colleague that introducing the possibility of building new positive beliefs was dangerous as it would definitely disappoint clients the world is not “safe” all the time- why would we encourage someone to think that?  He felt this was just as dangerous or more than negative beliefs; in fact I got the sense that the negative beliefs seemed safer to him. 

It got me thinking on my bike ride home regarding the role of “positive schemas”.  When we are working with those in distress we do not ask them to think of a “so so” place for a “safe place”- the place they invoke is usually one full of positive feeling.  This is an internal positive image that they begin to build inside them; in some sense it is a new internal model they can draw on- it is not the real world. 

When we are motivating people to change our goal must be something worthwhile- something worth striving for.  What the positive core belief is an alternative to the negative belief on an internal level that can stand in competition with the old belief that judges every situation, regardless of whether or not it applies (an overdeveloped strategy).  It is not a representation of the world as it is- if that makes sense. The core belief is an ideal that can find a home in someone’s mind.  Her theory is that strong experiential affect (negative and positive) make a considerable mark ; they are hotter than a hot thought.  Realistic thoughts don’t necessarily have that edge to carry someone into something new.  To give someone the courage to try an underdeveloped strategy in a new situation the hope is that positive affect and memory associated with the new system will do that.

Padesky’s behavioural experiments and new strategies allow someone to carry this into the world with them to access to begin to explore the possibility of something new and promising even if it is just a few moments of the world.  I’m not sure this makes total sense. I’m still grappling with that.  It’s a fascinating topic to contemplate.

Challenging therapy clients : Psychosis

When most people think of challenging clients in therapy they immediately think of a few different labels: one of which is borderline personality clients- few think of those with schizophrenia.

Today I’m weighing on a challenging client group: those with psychosis/schizophrenia.  I find these clients tricky to figure out if and how to do therapy. 

Historically in the psychoanalytic schools of thought some people thought it was inadvisable to do therapy with those with psychosis, as classical psychoanalysis (going back to childhood) can be indeed in some cases cause more harm than benefit for someone with psychosis.  (However- this is not to say that it is never helpful- please see Elyn Saks’ book- The Centre Cannot Hold a story of a woman with schizophrenia who found medications and psychoanalysis helpful). Jung however, formed his theories by observing those with psychotic illnesses and worked directly with them.  Currently there are numerous articles on CBT for psychosis, some of which I’m trying to wade into.

Here are the challenges:

1) For  psychotic illnesses the first line of treatment is medication management with antipsychotics.  For many when this is accomplished they have nearly eliminated positive symptoms of hallucinations and voices- although some have residual symptoms. For those folks for whom medications are working therapy seems unnecessary however even those successfully on medication relapse sometimes due to stress and other times because they go off their medications.   Do you do CBT for psychosis for those in remission?  Or just educate about warning signs?  Mostly we just check that people are sleeping well and not getting too stressed out. 

2) Those with residual symptoms of paranoia, voices, and delusions can be hardest to engage personally due to fixation on ideas, or fear of their voices.  Some with delusional ideas it seems that their connection to the ideas are so strong that it can be hard to find a window of uncertainty to introduce doubts are hypothesis testing around their beliefs.

I’m struggling to offer my clients some therapy but end up offering a conversation here and there and am uncertain how to and when engage these clients.

I’ve been reading a lot about psychosis these days to help and finding various models in addition to the purely biological vulnerability model that is espoused that help me think of windows to address psychotic illnesses.  I think for clear-cut cases of schizophrenia with an average onset age and classical symptoms that there is likely a strong biological component.  However, there have been numerous other studies that have linked mood disorders, anxiety, and experiences of trauma with psychosis.

If you are a therapist what have you found works in therapeutically working with those with symptoms of psychosis?

If you have experienced psychosis yourself and attended therapy or had psychiatric treatment, what helped and what didn’t help?

From therapy to case management

In my new job I’ve switched from doing therapy with people 100% of the time do now doing 80% case management and about 20% therapy in my new role working with adults with chronic mental illnesses mostly those with psychosis of some sort, and also those with bipolar or longstanding and complex mental illness of varying sorts.

Some would call it a fall from grace other people would call it a chance to directly impact people’s lives.

The work I do now puts me squarely in the medical model as I work closely with the psychiatrists monitoring medication adherence and tolerance, as well as working together with the client on a movement to recovery in their mental illness. 

One positive aspect of my job is now working more closely with Occupational Therapists at our centre who do a wonderful job of connecting people with activities, socialization and even housing.  The job of the OT and case manager overlaps at times as I may be actively working on some areas that OT’s may also help with (housing for example).  The OT’s run groups at some of the community mental health clubhouses and by doing this they introduce the clients to a new community support network.

Because of the short-term nature of my previous job doing therapy I did not usually refer my clients to these resources as they were not appropriate supports, or the person was independent enough to connect individually.

I miss doing therapy greatly.  I have a number of clients I have offered to do therapy.  For example, one client with schizophrenia (now under control with meds) and OCD.  We will be working on the OCD together in therapy.  This will be a new challenge for me as I have not worked with someone on OCD before and because of his also having a diagnosis of schizophrenia. 

Working in therapy on this team is generally harder for a couple of reasons.  Firstly my caseload is at least double and almost triple what it was before- so I am caring for more people with the same amount of time in a week- so in this model I cannot do therapy with everyone but with somewhere between 5-12 people at a time.

People come to our team because they have had a mental illness for some time; this can make therapy harder as they and those around them have accepted that this is how life is for them.  Therapy can feel threatening as if to challenge the equilibrium they may have found.  Most people have had case management for a long time (usually meeting once a month for a 1/2 hour) that they are accustomed to the care they have. 

Other people benefit so much from medications and are well-supported by family and involved  in their community (many of my clients are christians who go to church regularly) that the focus is much different; on relapse-prevention planning and re-enforcing and maintaining good support.

 What I have noticed is that in some people with psychotic disorders there is  a strong anxiety component.  For example, a cleint may  have had hallucinations and delusions in the past but they are now managed by medication but still they have significant fear and worry in their lives, and have difficulty handling difficult emotions, like shame or embarrassment.

These are the folks that I would like to do some basic therapy for anxiety.  However, given their chronic nature and how negatively their mental illness has impacted their ability to function in basic areas of their life they may have a harder time engaging in traditional CBT therapy- some of them are just not interested as well. 

This is the challenge ahead.  I hope there will be some encouragement in undertaking this work with those who are ready and providing support to all of my clients in meeting their goals and needs wherever they are on their road towards greater wellness.