Never Insight Alone: DBT Therapy

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In Doing Dialectical Behavior Therapy, Koerner (2012) asserts states that “You’d never consider insight alone to be enough to change your golf swing or paint with oils.  Yet we often think that insight alone is somehow enough to change the complicated, highly habitual maladaptive behaviors of regulating emotion.”  

 What this means essentially is that understanding that what you’re doing is not working is not enough to change what your doing; you need to be taught and practice a lot. 

Similarly, telling someone what to do without actively assisting them to act out new skills can set someone up for failure.  However, even the act of learning a new skill needs to be handled with care to provide validation for their efforts and inherent value, especially when techniques to handle emotional pain aren’t performed perfectly the first swing. To do this you not only need to have the right information but deliver it in a wise way, like an excellent coach. 

Growing up, many of you played team sports; more often than not the coach would be a parent volunteer.  However as most of us know, there were good coaches, there were bad coaches and there were excellent coaches.

I had an excellent soccer coach throughout my childhood.  A tall lanky British born man with a distinct accent; he had nicknames for all of us.  He was no softy, but always explained his rationale “If I’m yelling at you on the field, it’s not because I don’t like you or am mad, it’s that I need to you to hear and respond quickly”.  This explanation helped poor sensitive spirits like myself.  He had a way of honing on your particular talents and garnering enough encouragement to keep trying at something that you’d failed at 100 times. For example, he knew I had a knack for heading the ball, and always stationed me near the net at corner kicks, despite playing left defence.  It was because of his coaching I eventually did score that way in a provincial championship game.   I can’t say that I didn’t shed quite a few tears on the soccer field trying to learn how to punt, but I kept persevering.  He had high expectations and outlined what it would take to improve, but never used high-handed verbal threats.  I thrived under his excellent coaching which was solution-based corrective feedback , with firm constant validation. 

This is what our clients need to move forward; excellent coaches, trained in their craft, knowledgeable about how they can move forward, providing corrective feedback in a validating way.  Looking back, I think the key to the success of my childhood coach was that he knew everybody as a person, our nicknames signified our value and belonging.  His connecting with each person, not just the stars made the biggest difference.

I’ve found similarly with some of my clients, I work as a coach, sIowly working out alternate strategies that work for them, without the use of deeper emotional processing therapy. For example I worked with a client who engaged in self-ham activity and suicidal urges, which was always precipitated by binge-drinking.  I went through this creative problem solving and testing out with him until he eventually felt confident in his chosen strategy and even if he relapsed into old ways was able to provide self-talk to himself realizing it was just a “slip” and continue on.  Yet throughout this process, I always encouraged him to see that he did have choices in how to deal with the problem, but they held different consequences.  This process has taken almost a year, long slow work with setbacks and small steps forward. Important work in the playing field of life.

 

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Wrestling with God

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There is a story in the Bible where God wrestles with Jacob (Genesis:22-32). He is alone, anxious and facing death by his brother. He has sent all of his family over to the other side of the river and there he meets a man/angel at night with whom he wrestles with. Before the match is ended Jacob demands a blessing and states that he will not let him go until he gets one. He receives a new name, not Jacob but Israel “because you have struggled with God, and with humans and have overcome.”

Recently I was unexpectedly admitted into the hospital for a surgery because of a serious infection that had developed quite rapidly. It was there that I was alone, at times praying desperate prayers of healing from an unbearable fever, prayers that a doctor would come and announce that my surgery was no longer delayed, and then prayers to be released home.

The struggles people come to in therapy are equally formidable, like a gash or a wound that ceases to heal instead of languishing in their pain or ignoring increasing symptoms someone decides to enter the battle of inner pain. They may face the taunts that were said to them earlier in life, the pain of loss or abuse, and struggle through them as they sit with a therapist. This struggle itself may bring up strong emotions, including anger, resentment that have not before been voiced.

I always wondered at the story of Jacob. How could someone have the audacity to struggle with God? How could he win? How did he know to ask for a blessing? Similarly, how do we know when is the right time to face the hurt that lingers? How do some overcome quickly and others take years to feel healing emotionally?

I recently took a course in Emotionally-Focused Therapy for Individuals. One primary thing I learned was that behind every emotion is a need- sometimes we need to ask a part of ourselves- or God for this to heal, just like the blessing that Jacob asked from God. From fear we may seek safety and reassurance. From sadness we may want comfort or love. On each of our journey I pray that we have the will to engage in the struggle through hard emotions and hard times and the courage seek the blessing that we need to heal.

The Hazards and Joys of work in Mental Health

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One of the riskiest and most challenging aspects of working in mental health is that of suicide.  For those who are depressed, bipolar, and psychotic that risk is very high.  We do everything in our power to prevent such tragedies.

In the last two weeks at work I have witnessed two contrasting stories on the topic.  Firstly, a client committed suicide that was on the caseload of one of the case manager.  This client’s life was very hard, she suffered from extreme highs and lows and she had numerous previous attempts where she had escaped death. The case manager noted that on the weekend that it happened there was a hang-up message from that client.  So close to asking for help.  This was very hard for the case manager and for all those who had worked with the client over the many years.

The second story is one of miraculous grace.  A client of a different case manager told me that one of her clients told her that over the week-end her client had prepared to commit suicide and was ready to do it and at that very moment her phone rang and the client picked it up.  It was his daughter who he had not heard from in 10 years calling to say that she wanted to come and visit him shortly.  This stopped the man in his tracks and he sought out help.

I have never experienced the loss a client by suicide, but I understand that most people who work in mental health do so at some point in their career.  I know that likely I would struggle emotionally and feel guilt and wonder what I could have done.  I know it would be an incredibly painful experience.  Trusting in God, as a loving father, I know he loves that deeply wounded and through the second story see that he does miraculously use us weak human beings for his means of grace in this world.

I was interviewing and listening to a new client the other day as she told me her story of death of all of those close to her, parents who were not available or in jail, and chronic physical problems. I  also read the chart to see also that she had experienced abuse in foster case.  It is so easy to understand how people become so hopeless when they experience life as unhappy and without joy as this woman described.  I just wanted this client to experience the love of Jesus.  The story of the phone call reminds me that God moves in mysterious ways gently and unexpectedly through each person’s life.

My lenten discipline for this season is to endeavour to pray for each client before seeing them and ask that God would give me openness, patience, love and grace.

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).

 

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An Honest Look at Depression

I co-facilitate a depression group with a counsellor/social worker about 20 years my senior who has thought deeply on the the topic of depression.  He often challenges clients with the statement 

We “follow” a widely used psycho-educational CBT-based manualized program .  We start light on the topics of : goal-planning, stress, diet, exercise, and nutrition.  We encourage people to make SMART goals with their small successes as stepping stones to easing out of depression.  The manual also looks at social engagement, fun activities, assertiveness, and also negative thinking patterns.  Basically it looks at the whole of a person’s life that is affected by depression and works to gain understanding into how altering behavior and thinking, even in small ways, can improve mood and decrease depression.  

This is all fine and wonderful.  However this manual only dedicates about one session (if that) on core beliefs.  My co-facilitator thinks that depression is at its core about a couple main themes.

1. Hopelessness  

2. Worthlessness and

2. Isolation

 

Firstly, based on his model he sees a big problem with targeting the externals (social activities, exercise, etc.) as a real effective change agent for depression.  

As a person with depression at their core thinks they are worthless, hopeless and deserve to be alone even small successes of changing diet or exercise likely do not help in the long-term.  For example, someone starts to do well walking everyday, but still feels depressed.  We say “Fred great work, look you accomplished what you haven’t been able to do in 10 years”.  He then thinks “Oh God, I feel even worse, I must be really depressed, I should be feeling happy but I can’t even get better when I follow this program”.  When we solely focus on the externals of someone’s life, even their negative thinking about events or triggers, the core beliefs may persist.  

This is of course classic CBT, but often we as therapist may stay on the surface for some time or look solely at the environment or triggers or be quick to offer realistic core beliefs that a client “should” instead of staying and delving into the darker beliefs that sustain an individual’s depression and allowing the person themselves to acknowledge and desire alternative ways of seeing themselves.

My colleague insists that to begin to effectively treat depression we must start to acknowledge the true thoughts and beliefs that are plaguing the person.  For example, an honest statement to really get going on therapy would be : “I’m making all of these goals and getting out and being social, but I still don’t feel good, I really believe that I should be alone, that I don’t deserve to have friends”.  In a trusting therapeutic context we process that and then work forward and life improvements.

One thing that he says is that “Nobody wants to be here” [in therapy].  Most of us therapists find it hard to believe.  In saying this he means that the nature of the depression, while they are still depressed is that honestly most people find being in therapy further confirms their worthlessness.

Of course I like to think that people both do not want to be in therapy and also want to because the therapeutic relationship itself is an avenue of hope as they learn to act out and learn positive regard and new ways of relating that bring life instead of darkness and depression.  That having someone caring, yet challenging in their life is something people find incredibly difficulty but also crave.

Clients with depression carry a heavy burden, many have suffered a large part of their life.  They are experts in understanding themselves; what we can bring is empathy, acknowledgement of the depth of their pain and darkness, faithfulness, and a keen balance of questions and encouragement that can help them find their way to a more realistic view of themselves and the world.

 

What are your experiences with therapy for depression?

What has worked? What hasn’t?

 

 

One week

After one week immersed full-time in the world of mental health therapy I am in love and energized.  The day I arrived I had a dozen cases already assigned to me, including both initial assessments and clients who were already long-time clients of the woman I was filling in for.  

The experience of being with someone suffering from anxiety or depression and literally seeing relief and reduction of symptoms as the session went on was satisfying.  I really got to use my whole self in the process and be genuine. What an experience.  And on top of that to try and understand the complexity of people’s lives, thoughts and beliefs and how and when they manifest into “symptoms”.  

I have a fantastic supervisor who herself absolutely loves working with people and doing therapy and who has spend time with me to introduce me to clients and give feedback on the direction of my cases.

I feel as if it is an answer to a prayer I was almost too tentative to pray.