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.

CBT for Personality Part 2: From a Christian Perspective

After reflecting further on my original post on CBT for personality, the New Paradigm for CBT I noticed some interesting parallels between my Christian faith and this therapy that may be relevant for both therapists and people seeking help for personality disorders that are also Christian.

In her new paradigm what I noted is that she explains old behaviour and beliefs that were held/used for “good reasons”.  Instead of challenging the old system she introduced a “new paradigm” in a very experiential manner.

It made me think of how Jesus taught about being born again to Nicodemus and how he offers the gift of eternal life to the woman at Jacob’s well.  He does not challenge the old system of sin, but acknowledged it openly and assumed that a person is already understood how the old system did not work and instead they are looking and seeking a new paradigm, this living water, or spirit life that is not based in place or a set of laws but “in spirit and in truth ” (John 4: 24).  Jesus is continuously offering images, and stories to activate the imagination of people to create a “new paradigm” to enter the kingdom of God that is “here but not yet” (common term from Kingdom theology).

Some of the people Jesus encounters, like those with personality disorders have been suffering for many years, like the woman with continuous bleeding.  Those with these physical ailments were also consequently excluded from relationships and the acceptance of society which is similar to the interpersonal difficulties and invalidation that those who have personality disorders experience.

However, unlike CBT personality that reconceptualizes  the world Jesus challenges us to imagine a new kingdom of God that is loving, beautiful, and a place for the broken.  This kingdom of God is not the world- the world is fallen- whereas the kingdom of God is good and allows people to live fully in love.  Paul for example would likely not approve of imagining the world as a good and loving place, but challenges followers to “not conform any longer to the pattern of this world, but be transformed by the renewing of your mind.”.(Romans 12:2).

Jesus does not want us to idealize ourselves in positive terms but to hold a dialectic together of both sinner and a new creation in Christ.  Loved deeply by God, though rejected by others.

We have an initial belief or experience as followers of Christ but that does not always mean that our old beliefs and habits die completely.  We struggle between paradigms slowly through steps of faith and in acting out our faith in obedience (behavioural experiments of sorts) we learn to walk in this new way. 

Ultimately what anchors us in this new life are not just the word and promises of the bible on a page (the challenging of our old system of belief through words and reason) but the discipline of living out faithfully this new life.

In this new system- or more accurately through a God that is who loves us, who is greater than ourselves – we gain the strength and new resources to cope in a new way with the struggles we face in this world.  Our old ways are no longer necessary as we live more deeply into the new way of Christ.

So if I was to use the new paradigm for CBT for personality from a Christian perspective I might initially focus the old as she does on the view of self, others and the world but conceptualize the new through replacing a focus on the world to the Kingdom of God as the new realm to live in.  This new kingdom paradigm could also be anchored through visualization, and experiential elements- encouraging one to actively enter God’s presence using imagery.

Then introducing interpersonal difficulties into this new kingdom/paradigm makes total sense because you are inviting someone to little by little start living in the kingdom of God (“let your kingdom come on earth as it is in Heaven”). For example you could say “If you are living in this new kingdom of God where God loves you, you are forgiven, you have joy, and are special…what happens when someone insults you…?” .

This new Christian interpretation of Padesky’s paradigm doesn’t just apply to those with personality disorders but I can see how it would be useful for each one of us to conceptualize in our imagination what it is like to live more fully in the kingdom of God.  It might also be helpful for those who struggle with deep shame, despite intellectually accepting that “God loves me” or “I am deeply loved”.

Kind of exciting!

Questions? Comments?

CBT for Personality Disorders Workshop

I recently attended a workshop by Christine P., a well-known CBT therapist who has authored  Mind over Mood.

The workshop I attended was about her “New Paradigm for CBT” for personality disorder treatment.

CBT focuses on the relationships between thoughts, feelings and behaviours and specifically targets changing thoughts and behaviours as dysfunctional thinking is thought to be at the core of problems such as depression.  Automatic thoughts are challenged through thought logs and behavioral experiments to test core beliefs or “schemas”.  Behaviour is challenged through behavioral activation, skill building (assertiveness, for example) The premise is that as behavior and thinking are changed so mood will also change as a result.

This is the standard protocol treatment for most conditions as there is a lot of evidence backing up its use with many different issues (anxiety, depression, etc.).  However for personality disorders research shows therapy take a lot longer to treat, and are treated most effectively by a variety of therapies.  For example according to research, Borderline Personalty disorder is best treated by mentalization-based therapy, transference-focused therapy, dialectical behavioral therapy, and schema-focused therapy.  Classic CBT was not listed among those in a review in 2009 by Zanarini although the last two therapies are in the CBT tradition and the first two are psychodynamic in their roots.

Her new Paradigm, is meant to treat those with personality disorders after they have already addressed Axis I issues (depression, bulimia, etc.) using evidence-based methods.

It departs from traditional CBT in a couple of ways.

1. It does not challenge core beliefs  eg.”I am unlovable”.  This is because she had come to the conclusion that in those with personality disorders lack positive core beliefs to fall back on. Instead of challenging old beliefs the majority of time is spent on building a new system, a new set of beliefs is imagined and dreamed that are tested out through behavioral experiments.  

Core beliefs are notoriously difficult to challenge and VERY hard to dislodge in most people.  I question the need or even ability to fully challenge in general in CBT. I do not agree that those with personality disorders do not have positive schemas- I believe they do but to enact them would be feel threatening and “unsafe”, and is likely something that has not been done for a long time without getting hurt badly. 

2. Similar to attachment theory, which many people say is a major factor in personality issues, she affirms the adaptive nature of people’s strategies to get through earlier struggles and uses the phrase people do things “for good reason” .  This is fantastic and really does well to not pathologize people who are labelled and judged greatly by the psychiatric/medical system.

3. Christine P. ventures into right brain territory by capitalizing on the power of positive affect (see Diane Fosha AEDP) to encourage smiling and warmth when imagining a new “system” for new beliefs and strategies. She also uses imagery to activate the “experiential” mind (see Epstein, 1998) (rather than just the rational mind that traditional CBT focuses on) to allow a person to construct a new system.  She asks people to imagine a scene, be aware of the body sensations, a memory from the past, and a metaphor/song/image as “anchors” to engage this new system.  This is completely new territory for traditional CBT.  It seems to be crossing boundaries with a lot of experiential therapies (and EMDR) that focus on the emotional experience to create and instill change.  I love the integration myself and have been wanting to focus more of the experiential but wondering how to fit it in to my theoretical framework.  This workshop gave me an opportunity to continue ot integrate ideas together that previously appeared very separated.

4. To test out these new beliefs and strategies she uses behavioral experiments- this is not new.  But the rationale is different: to continue ot create safety and protection in this “new system”.  This really fits well with the idea of defenses in traditional psychodynamic theory; defenses are constructive for protection although they may seem extremely counterproductive on the outside; just getting rid of defenses will be futile.  I think what Padesky has conceptualized is important in that she focuses energy on building new defenses so the other ones aren’t necessary.  Like CBT in general it does not focuses on the past but on the “here and now” and immediate future.

As you can tell, I quite loved the workshop and how it seemed to breathe new life into my understanding of CBT and different theories and practices that I’m using.  Padesky’s workshop gave some solid reasons and some evidence to use some practices that I have started to use outside the usual CBT box, but that seem to work well for people along with some of the classic CBT strategies.

Trauma and Psychosis

I just attended an interesting seminar on trauma and psychosis and CBT. 

Psychosis is almost exclusively explained as a biological vulnerability.  Trauma is often assumed to be linked to depression and anxiety but causality is not openly as linked to psychosis.

One researcher and psychiatrist Dr. Bill MacEwan, found that among those in the Downtown Eastside of Vancouver in a population that is highly addicted to substances there is a higher comorbidity of psychosis and childhood trauma than anxiety and childhood trauma.  One explanation is that drug use mediates/masks the anxiety symptoms that trauma can produce and that increased drug use can trigger or exacerbate psychotic symptoms.

Notably Tony Morrison of the UK reported a study that found that in one study institutional care was especially significantly associated with paranoia and rape was associated with audio-visual hallucinations.  Physical abuse alone was significantly linked to both paranoia and audio-visual hallucinations.  Numerous other studies found the same link between psychosis and traumatic events, especially those in early childhood.  Also: people can experience psychosis itself as traumatic and may go on to develop PTSD after having PTSD from the psychosis or institutional care.

This is particularly significant because it means a couple of things.

1) Preventing abuse of children could diminish those who experience psychosis

2) Understanding this link can help someone gain insight into their illness  and through addressing trauma.

3) Our care should acknowledge this and seek to diminish further trauma and increased sense of safety.

For me going starting into a field working with people with psychosis and also with a huge passion for helping people with trauma this brought a new meaning to my work with those with psychotic illnesses and more perspective and ideas on how to understand those of my neighbors in the DTES with psychosis.