Parenting Parallels to Therapy

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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).

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.

 

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.

Rabbit-holes, Land Mines, and Red Herrings

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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.