One of my clients is going through a period of uncertainty in several areas of his life. He's trying to determine whether or not to sell his business; he and his partner are trying to decide whether or not to try to adopt a child; and they are considering moving to another city. None of the issues are near resolution, and my client finds the uncertainty difficult to tolerate.
During our session this week, I suggested that he try to "rest in the not-knowing and see what happens." My comment startled me a bit because I don't usually say things like that. Rather, I'm likely to help clients weigh the advantages and disadvantages of each option, or to guide them in exploring the thoughts and feelings associated with each possibility. This time, I surprised myself even further by following up with "When we make space for not-knowing--rather than frantically trying to allevaiate our discomfort by settling matters immediately--possibilities that might not otherwise present themselves can bubble up to the surface."
As different as this is from some of my other therapy interventions, I'm confident that it's true. Last week I attended a six-day silent retreat, during which there was nothing to do but meditate. During this exceptional week, my mind and body were free from their usual tasks of working, socializing, shopping, cooking, exercising, organizing, planning, and scheduling. Thus liberated, my mind came up with a collection of new and helpful ideas and insights, none of which had surfaced over the course of prior months and years of stressful contemplation and rumination.
When I shared this experience with my client, he remembered that during his three-week vacation over Christmas, he had made a deliberate effort to limit his rumination over a work problem that had been causing him grief for months. He reported that the spaciousness of mind created by that decision had resulted in significant insights that allowed him to consider the situation with greater clarity, and to perceive options that hadn't been mentally available to him before. He concluded our session by assigning himself the therapy homework of tolerating not-knowing, rather than one of our usual CBT assignments like recording thoughts or making a list of pros and cons.
We can't go on a meditation retreat or take a four-week vacation every time we're facing a
big decision, so how is the idea of tolerating not-knowing applicable in everyday life? The answer is that even without a retreat or a vacation, we can create mental spaciousness by sometimes choosing to put aside our lists of pros and cons and our step-by-step plans for arriving at a resolution. This choice protects the mental real estate that, given the chance, could house an insight or a creative solution.
The next time you notice that your mind is caught in endless or unhelpful speculation and deliberation, see if you can instead create some mental space for yourself by tolerating not-knowing. What happens?
Showing posts with label Psychotherapy/Being a Therapist. Show all posts
Showing posts with label Psychotherapy/Being a Therapist. Show all posts
May 25, 2014
March 05, 2014
Unconditional Positive Regard
Unconditional positive regard is a term coined by influential American psychologist Carl Rogers. If you have unconditional positive regard (UPR) for someone, you support and accept that person regardless of his or her behaviour. It means that even when you don't respect or approve of what someone says or does, you maintain an overall attitude of acceptance and positive regard for him or her.
Rogers named UPR as one of three necessary and sufficient conditions for successful psychotherapy, along with therapist genuineness and accurate empathy. He believed that therapists who demonstrated UPR for their clients created a positive therapy environment conducive to client growth and development. According to Rogers, the demonstration of UPR allows clients to freely express thoughts, feelings, and actions without fear of offending or alienating the therapist. Therapists may still question clients' behaviour, but without condemning the client as a person.
What about outside therapy, though?
Unconditional positive regard can exist in parent-child or other family relationships, in close friendships, and in romantic relationships or marriages. It can't be assumed to be present but, if we're lucky, we have UPR in at least one of our relationships. Social psychologist David G. Myers referred to UPR in relationships as "an attitude of grace, an attitude that values us even when knowing our failings." He added "It is a profound relief to drop our pretenses, confess our worse feelings, and discover that we are still accepted... we are free to be spontaneous without fearing the loss of the others' esteem."
My experience is that that's exactly what it feels like. I can think of a handful of people who seem to have UPR for me, and the word relief accurately describes how it feels to spend time with them. I've told these UPR-extending individuals what I believe to be the most shameful and appalling truths about myself, and it didn't seem to change how they feel about me. I don't worry about my pride around them and even when I'm my worst self, it doesn't threaten the relationship.
I can also think of a handful of people for whom I have UPR. It's hard to imagine something they could say or do that would make me turn away from them permanently, or make me not try to understand their motivation. I love and/or respect them even when I dislike them.
Unconditional positive regard is lovely when it happens, but I think it's the exception rather than the rule. That is, I'd venture that most of our friends, and even many of our family members, could lose our esteem. There are usually only a select few loved ones for whom we really feel unconditional positive regard. It may be spontaneous or may develop over time.
For whom do you have unconditional positive regard? Who has it for you? What does it feel like?
Rogers named UPR as one of three necessary and sufficient conditions for successful psychotherapy, along with therapist genuineness and accurate empathy. He believed that therapists who demonstrated UPR for their clients created a positive therapy environment conducive to client growth and development. According to Rogers, the demonstration of UPR allows clients to freely express thoughts, feelings, and actions without fear of offending or alienating the therapist. Therapists may still question clients' behaviour, but without condemning the client as a person.
What about outside therapy, though?
Unconditional positive regard can exist in parent-child or other family relationships, in close friendships, and in romantic relationships or marriages. It can't be assumed to be present but, if we're lucky, we have UPR in at least one of our relationships. Social psychologist David G. Myers referred to UPR in relationships as "an attitude of grace, an attitude that values us even when knowing our failings." He added "It is a profound relief to drop our pretenses, confess our worse feelings, and discover that we are still accepted... we are free to be spontaneous without fearing the loss of the others' esteem."
My experience is that that's exactly what it feels like. I can think of a handful of people who seem to have UPR for me, and the word relief accurately describes how it feels to spend time with them. I've told these UPR-extending individuals what I believe to be the most shameful and appalling truths about myself, and it didn't seem to change how they feel about me. I don't worry about my pride around them and even when I'm my worst self, it doesn't threaten the relationship.
I can also think of a handful of people for whom I have UPR. It's hard to imagine something they could say or do that would make me turn away from them permanently, or make me not try to understand their motivation. I love and/or respect them even when I dislike them.
Unconditional positive regard is lovely when it happens, but I think it's the exception rather than the rule. That is, I'd venture that most of our friends, and even many of our family members, could lose our esteem. There are usually only a select few loved ones for whom we really feel unconditional positive regard. It may be spontaneous or may develop over time.
For whom do you have unconditional positive regard? Who has it for you? What does it feel like?
April 05, 2013
Friday Post-Mortem
This week I saw an exceptional number of psychotherapy patients in five days, and I noticed a few things:
a) It took a lot of energy and, even though I enjoyed many of the sessions, I was noticeably drained by the end of the week.
b) I joked around in therapy more than usual and told more quasi-personal anecdotes.
c) My patients didn't necessarily like it.
I've been thinking about how the first two observations are related and I think I've cracked the code: Therapy takes a lot of energy because you have to be thoughtful and mindful and helpful and insightful, but an additional element that takes considerable energy--for me, at least--is not being totally myself. It's not that I'm a blank automaton with my patients, but in therapy, I don't make express opinions or preferences, make jokes, seek support, gossip, compliment, or reassure, and I rarely give advice. If a patient is telling an anecdote and I've experienced the exact same thing I don't say "Oh my God, me too!" If a patient is recounting a dilemma, I can't tell him what I'd do if I were in his shoes.
I think the extra jokes and quasi-personal anecdotes this week represent a kind of resistance to the additional hours of personality suppression. When a patient mentioned that the hospital security guard made a weird comment to him, I said "Yeah, he's done that to me too a few times, he's kind of an 'unusual' guy," rather than "What was that like for you?" When a patient reported that she didn't work out this week, I said "Yeah, it's not always easy to get to the gym after work, I've had weeks like that," rather than "What were some of your obstacles?" These responses weren't particularly out of line, but they weren't particularly helpful either.
Finally, I think that this kind of over-sharing is confusing for the therapy relationship, and here's why: I'm particuarly likely to joke or to reveal glimpses of my personal life in session with patients who are similar to me--patients who have the same sense of humour or the same personal conflicts as me, who live in the same neighbourhood as me and have a similar lifestyle, or who share my cultural or academic background. But although I know that we have a lot in common, patients aren't aware of our similarities. So if I suddenly mention that I too am attending a Passover seder this year or that I too experience daily frustration with the ongoing construction at the subway station nearest both our homes, it comes out of the blue. It's also worth remembering that I've had therapists who shared personal details about themselves with me, and that I disliked it and preferred to maintain our one-way relationship. My own patients may not feel this way, but it's my responsibility to err on the side of reticence.
Reining in your own opinions and preferences and experiences isn't easy and explains why therapists can feel isolated despite interacting with people all day. For the therapist, psychotherapy doesn't meet the need for communication because it's not reciprocal. All the more reason to keep up my usual strategy of calling up a friend or family member for a brief chat when I have a break in my day, and why I like the idea of mixing private psychotherapy practice with other pursuits.
a) It took a lot of energy and, even though I enjoyed many of the sessions, I was noticeably drained by the end of the week.
b) I joked around in therapy more than usual and told more quasi-personal anecdotes.
c) My patients didn't necessarily like it.
I've been thinking about how the first two observations are related and I think I've cracked the code: Therapy takes a lot of energy because you have to be thoughtful and mindful and helpful and insightful, but an additional element that takes considerable energy--for me, at least--is not being totally myself. It's not that I'm a blank automaton with my patients, but in therapy, I don't make express opinions or preferences, make jokes, seek support, gossip, compliment, or reassure, and I rarely give advice. If a patient is telling an anecdote and I've experienced the exact same thing I don't say "Oh my God, me too!" If a patient is recounting a dilemma, I can't tell him what I'd do if I were in his shoes.
I think the extra jokes and quasi-personal anecdotes this week represent a kind of resistance to the additional hours of personality suppression. When a patient mentioned that the hospital security guard made a weird comment to him, I said "Yeah, he's done that to me too a few times, he's kind of an 'unusual' guy," rather than "What was that like for you?" When a patient reported that she didn't work out this week, I said "Yeah, it's not always easy to get to the gym after work, I've had weeks like that," rather than "What were some of your obstacles?" These responses weren't particularly out of line, but they weren't particularly helpful either.
Finally, I think that this kind of over-sharing is confusing for the therapy relationship, and here's why: I'm particuarly likely to joke or to reveal glimpses of my personal life in session with patients who are similar to me--patients who have the same sense of humour or the same personal conflicts as me, who live in the same neighbourhood as me and have a similar lifestyle, or who share my cultural or academic background. But although I know that we have a lot in common, patients aren't aware of our similarities. So if I suddenly mention that I too am attending a Passover seder this year or that I too experience daily frustration with the ongoing construction at the subway station nearest both our homes, it comes out of the blue. It's also worth remembering that I've had therapists who shared personal details about themselves with me, and that I disliked it and preferred to maintain our one-way relationship. My own patients may not feel this way, but it's my responsibility to err on the side of reticence.
Reining in your own opinions and preferences and experiences isn't easy and explains why therapists can feel isolated despite interacting with people all day. For the therapist, psychotherapy doesn't meet the need for communication because it's not reciprocal. All the more reason to keep up my usual strategy of calling up a friend or family member for a brief chat when I have a break in my day, and why I like the idea of mixing private psychotherapy practice with other pursuits.
February 26, 2013
R.E.S.P.E.C.T.
Lately I've been feeling impressed by the courage of my patients and my friends.
Once a month at the clinic where I work, two members of the team conduct a psychological evaluation with a new patient, while a group of medical residents and psych interns observes. Each time, I'm struck by the courage of the patient who sits before the group and describes in detail the manifestations and origin of the presenting mental health problem, the distress or impairment it causes, current and past relationships, and goals for treatment. How brave is that!
I was similarly struck a few weeks ago when a colleague told me that her patient with panic disorder willingly ran up and down the stairs inside the clinic, trying to expose himself to the terrifying breathlessness that triggers his panic attacks. I feel the same respect when a patient with chronic health anxiety successfully writes, records, and listens to an exposure scenario describing himself dying of cancer, or when a painfully shy patient reports that she successfully completed her plan to initiate a conversation with one of the other parents in her son's class.
It's not just my patients who are impressive: my friends are, too. A few months ago, one of my friends was diagnosed with schizoaffective disorder, a difficult-to-diagnose mix of depression, mania, and psychosis that neatly explains symptoms he's been experiencing for years. Following the diagnosis, he took his mental health into his own hands--seeking out a support group and tirelessly navigating the overwhelming bureaucracy of the health care system until he found a doctor who understood the diagnosis, prescribed medication appropriately, and addressed his concerns about side effects. Another friend recently began psychotherapy to deal with a procrastination problem that has plagued her for years. A third friend called me up for a referral for a couples therapist so that he and his partner could address some issues they were unable to resolve on their own.
My friends' and patients' initiative touches and impresses me. There's still a stigma attached to mental health care and there are still people who believe that seeing a psychologist or psychiatrist or taking medication is a sign of weakness. I'm pretty sure that acknowledging a problem and seeking help demonstrates the precise opposite.
Think about it.
Once a month at the clinic where I work, two members of the team conduct a psychological evaluation with a new patient, while a group of medical residents and psych interns observes. Each time, I'm struck by the courage of the patient who sits before the group and describes in detail the manifestations and origin of the presenting mental health problem, the distress or impairment it causes, current and past relationships, and goals for treatment. How brave is that!
I was similarly struck a few weeks ago when a colleague told me that her patient with panic disorder willingly ran up and down the stairs inside the clinic, trying to expose himself to the terrifying breathlessness that triggers his panic attacks. I feel the same respect when a patient with chronic health anxiety successfully writes, records, and listens to an exposure scenario describing himself dying of cancer, or when a painfully shy patient reports that she successfully completed her plan to initiate a conversation with one of the other parents in her son's class.
It's not just my patients who are impressive: my friends are, too. A few months ago, one of my friends was diagnosed with schizoaffective disorder, a difficult-to-diagnose mix of depression, mania, and psychosis that neatly explains symptoms he's been experiencing for years. Following the diagnosis, he took his mental health into his own hands--seeking out a support group and tirelessly navigating the overwhelming bureaucracy of the health care system until he found a doctor who understood the diagnosis, prescribed medication appropriately, and addressed his concerns about side effects. Another friend recently began psychotherapy to deal with a procrastination problem that has plagued her for years. A third friend called me up for a referral for a couples therapist so that he and his partner could address some issues they were unable to resolve on their own.
My friends' and patients' initiative touches and impresses me. There's still a stigma attached to mental health care and there are still people who believe that seeing a psychologist or psychiatrist or taking medication is a sign of weakness. I'm pretty sure that acknowledging a problem and seeking help demonstrates the precise opposite.
Think about it.
January 16, 2013
Capacity for Empathy
How come sometimes you can listen to a colleague complain or to a friend vent for hours on end, never wavering in your sympathy, empathy, or active listening skills--but on other occasions, your patience wear thin after minutes?
Last fall, I posted about our capacity for composure, suggesting that composure is a limited and fluctuating resource dependent on physical comfort, mindfulness and the intensity of our stressors. Since then, I've been thinking about empathy--the often (but not necessarily) sympathetic identification with or experiencing of another person's thoughts, feelings and experiences. Empathy is a key component of friendships and of patient-therapist relationships, and a resource that may also be fluctuating and limited in nature.
For example, consider the time I lost my patience with my friend who kept repeating herself and unwisely retorted "I get it, already!" Not exactly empathetic! In retrospect, I can identify that it was the last week before the Christmas holidays and that we were spending the evening together after a long day of back-to-back therapy patients. That is, my capacity for empathy was low.
I was once on the receiving end of a breach in empathy on the part of my own therapist: I was complaining about something I wanted but felt was impossible to have and my therapist lost his patience and snapped something like "Can't you see that what you're looking for is right in front of you? Open your eyes!" I was pretty taken aback at the time but when I later learned that he had received some extremely distressing news about five minutes before our session, I understood a bit better. My therapist's capacity for empathy was very low during our session; otherwise impeccably appropriate, he slipped up and said something unhelpful and out of place.
For therapists and lay listeners alike, capacity for empathy seems to depend on a few things. First, similar to capacity for composure, having your basic physical needs met is key. It's hard to listen helpfully to someone else's problems when you're starving, exhausted, or have a raging headache. Second, capacity for empathy suffers when there's too much demand: if your best friend's marriage is breaking up and your sister just lost her job, you might not be a very good listener for your colleague who wants to discuss his toddler's bed-wetting. Third, it can be difficult to have empathy for others if you're having your own problems. If you were just diagnosed with a serious illness, your capacity to empathize with a friend's existential angst is probably pretty low.
Therapists need a pretty endless supply of empathy. To maintain capacity for empathy, in addition to attending to our basic physical needs, we need peer support (i.e., don't work all alone all week in your private office with no one to provide social interaction or peer support) and should avoid scheduling too many patients in one day, or too many patients in a row without a break. Further, awareness of how our personal lives are affecting us will allow us to monitor and minimize the impact on our work. Keeping these tips in mind can help us avoid exhausting our empathy reserves.
For non-therapists, the tips for maintaining the capacity for empathy are no different: in addition to making sure your basic physical needs are met, don't spread yourself too thin empathy-wise (e.g., if you spent the morning consoling your sister over her job loss and your friend calls to discuss his relationship woes, you might want to limit the length of the conversation or call him back later). Remember that your empathy reserves may be low if you're dealing with your own serious problems, and feel free to hoard most of your empathy for yourself during those times. Keeping these tips in mind can help you avoid breaches in empathy and maintain your reputation as an empathetic listener.
Last fall, I posted about our capacity for composure, suggesting that composure is a limited and fluctuating resource dependent on physical comfort, mindfulness and the intensity of our stressors. Since then, I've been thinking about empathy--the often (but not necessarily) sympathetic identification with or experiencing of another person's thoughts, feelings and experiences. Empathy is a key component of friendships and of patient-therapist relationships, and a resource that may also be fluctuating and limited in nature.
For example, consider the time I lost my patience with my friend who kept repeating herself and unwisely retorted "I get it, already!" Not exactly empathetic! In retrospect, I can identify that it was the last week before the Christmas holidays and that we were spending the evening together after a long day of back-to-back therapy patients. That is, my capacity for empathy was low.
I was once on the receiving end of a breach in empathy on the part of my own therapist: I was complaining about something I wanted but felt was impossible to have and my therapist lost his patience and snapped something like "Can't you see that what you're looking for is right in front of you? Open your eyes!" I was pretty taken aback at the time but when I later learned that he had received some extremely distressing news about five minutes before our session, I understood a bit better. My therapist's capacity for empathy was very low during our session; otherwise impeccably appropriate, he slipped up and said something unhelpful and out of place.
For therapists and lay listeners alike, capacity for empathy seems to depend on a few things. First, similar to capacity for composure, having your basic physical needs met is key. It's hard to listen helpfully to someone else's problems when you're starving, exhausted, or have a raging headache. Second, capacity for empathy suffers when there's too much demand: if your best friend's marriage is breaking up and your sister just lost her job, you might not be a very good listener for your colleague who wants to discuss his toddler's bed-wetting. Third, it can be difficult to have empathy for others if you're having your own problems. If you were just diagnosed with a serious illness, your capacity to empathize with a friend's existential angst is probably pretty low.
Therapists need a pretty endless supply of empathy. To maintain capacity for empathy, in addition to attending to our basic physical needs, we need peer support (i.e., don't work all alone all week in your private office with no one to provide social interaction or peer support) and should avoid scheduling too many patients in one day, or too many patients in a row without a break. Further, awareness of how our personal lives are affecting us will allow us to monitor and minimize the impact on our work. Keeping these tips in mind can help us avoid exhausting our empathy reserves.
For non-therapists, the tips for maintaining the capacity for empathy are no different: in addition to making sure your basic physical needs are met, don't spread yourself too thin empathy-wise (e.g., if you spent the morning consoling your sister over her job loss and your friend calls to discuss his relationship woes, you might want to limit the length of the conversation or call him back later). Remember that your empathy reserves may be low if you're dealing with your own serious problems, and feel free to hoard most of your empathy for yourself during those times. Keeping these tips in mind can help you avoid breaches in empathy and maintain your reputation as an empathetic listener.
January 01, 2013
At Your Service
If I had a friend who began every sentence with an apology, I might eventually point it out and ask her to knock it off. If a colleague told the same anecdote three times over the course of one lunch hour, I might tell him to quit repeating himself, or else intervene and change the subject.
But what if these things happened with my patients? What's the difference between conversations with friends and conversations with patients?
The difference is that with patients, everything I say or do should be in the service of the patient. With the friend and colleague in the examples above, I'd speak up to save myself from boredom and crankiness; with patients, my personal feelings are expressed if and only to the extent that expressing them would be helpful to the patient.
Example: Say I had a self-effacing patient who was driving me crazy by beginning every sentence with an apology. By the end of a session, I might want to snap "Quit apologizing!" but that would be a mistake. A better intervention would be to gently say something like "I've noticed that you frequently begin your sentences with an apology." Whereas the former comment expresses personal irritation, the latter is a simple and therapeutically relevant observation; the latter comment also allows for follow-up questions such as "Is apologizing something you also do with other people?" "How do you think your habit impacts your conversations?" and "How might you perceive someone who apologized all the time?" If later the patient and I were hypothesizing about how other people might perceive his constant apologizing, I could ask him for ideas (e.g. "People might think I have low confidence; they might think I'm being fake"), and then maybe add something like "Some people might find it endearing; others might find it frustrating." But my personal impatience would not be relevant.
Second example: Recently, I recently expressed frustration with a friend who kept repeating herself. She was struggling with the decision to move her elderly mother into residential care; despite my validation of the struggle and the decision, my friend continued to repeat just how much she loved and respected her mother, what a good parent her mother had been, etc. Finally I lost my patience and exclaimed "I get it, already--you love your mom!" This wasn't very helpful for my friend; a more helpful response would have been something like "Yes, you've mentioned that a few times. It must be really important for you to make that point clear."
With a patient, this kind of neutral comment is even more important, and often elicits useful information such as "I didn't know if you heard me the first time I said it because you just nodded but didn't say anything" or "I guess I feel guilty, like I'm just getting rid of my mom now that she's become a nuisance, or worried you'll think I'm a bad daughter" or "Really? I already said that?" With patients, these answers can prompt valuable conversations about validation, guilt, and social skills, respectively.
In therapy, comments like "Quit apologizing!" and "I get it!" are not appropriate because they imply a responsibility of the patient toward the therapist (e.g., to not be boring, to not waste my time), and because they express therapist feelings in a way that isn't relevant or helpful. But are there occasions when a therapist should express her true feelings? The answer is yes, but the same rule applies: only in the service of the patient.
Example: A depressed patient tells me he's bad at communicating and I respond that I've noticed that he's actually quite forthcoming and articulate in our sessions.
Example: A panic disorder patient tells me that he felt silly jogging on the spot in my office to try to induce panic symptoms for an exposure exercise, and I tell him that I was just thinking how brave he was to engage in an exercise designed to bring on symptoms that terrify him.
Example: A socially anxious patient reaches over in the middle of our session to pluck a stray hair off the arm of my sweater and then immediately asks, "Was that weird? Should I not have done that?" and I respond that her act didn't seem out of the realm of normal social behaviour, but that the timing was surprising and the gesture had taken me a bit off guard.
In each of these example, my comment is authentic and is designed to validate, bolster, and/or reflect reality to patients whose perspective may be unhelpfully distorted.
But what if these things happened with my patients? What's the difference between conversations with friends and conversations with patients?
The difference is that with patients, everything I say or do should be in the service of the patient. With the friend and colleague in the examples above, I'd speak up to save myself from boredom and crankiness; with patients, my personal feelings are expressed if and only to the extent that expressing them would be helpful to the patient.
Example: Say I had a self-effacing patient who was driving me crazy by beginning every sentence with an apology. By the end of a session, I might want to snap "Quit apologizing!" but that would be a mistake. A better intervention would be to gently say something like "I've noticed that you frequently begin your sentences with an apology." Whereas the former comment expresses personal irritation, the latter is a simple and therapeutically relevant observation; the latter comment also allows for follow-up questions such as "Is apologizing something you also do with other people?" "How do you think your habit impacts your conversations?" and "How might you perceive someone who apologized all the time?" If later the patient and I were hypothesizing about how other people might perceive his constant apologizing, I could ask him for ideas (e.g. "People might think I have low confidence; they might think I'm being fake"), and then maybe add something like "Some people might find it endearing; others might find it frustrating." But my personal impatience would not be relevant.
Second example: Recently, I recently expressed frustration with a friend who kept repeating herself. She was struggling with the decision to move her elderly mother into residential care; despite my validation of the struggle and the decision, my friend continued to repeat just how much she loved and respected her mother, what a good parent her mother had been, etc. Finally I lost my patience and exclaimed "I get it, already--you love your mom!" This wasn't very helpful for my friend; a more helpful response would have been something like "Yes, you've mentioned that a few times. It must be really important for you to make that point clear."
With a patient, this kind of neutral comment is even more important, and often elicits useful information such as "I didn't know if you heard me the first time I said it because you just nodded but didn't say anything" or "I guess I feel guilty, like I'm just getting rid of my mom now that she's become a nuisance, or worried you'll think I'm a bad daughter" or "Really? I already said that?" With patients, these answers can prompt valuable conversations about validation, guilt, and social skills, respectively.
In therapy, comments like "Quit apologizing!" and "I get it!" are not appropriate because they imply a responsibility of the patient toward the therapist (e.g., to not be boring, to not waste my time), and because they express therapist feelings in a way that isn't relevant or helpful. But are there occasions when a therapist should express her true feelings? The answer is yes, but the same rule applies: only in the service of the patient.
Example: A depressed patient tells me he's bad at communicating and I respond that I've noticed that he's actually quite forthcoming and articulate in our sessions.
Example: A panic disorder patient tells me that he felt silly jogging on the spot in my office to try to induce panic symptoms for an exposure exercise, and I tell him that I was just thinking how brave he was to engage in an exercise designed to bring on symptoms that terrify him.
Example: A socially anxious patient reaches over in the middle of our session to pluck a stray hair off the arm of my sweater and then immediately asks, "Was that weird? Should I not have done that?" and I respond that her act didn't seem out of the realm of normal social behaviour, but that the timing was surprising and the gesture had taken me a bit off guard.
In each of these example, my comment is authentic and is designed to validate, bolster, and/or reflect reality to patients whose perspective may be unhelpfully distorted.
November 29, 2012
Psychoeducation
Psychoeducation is a core feature of cognitive-behavioural therapy--and any good therapy. The term refers to information that a therapist provides a patient
about the patient's symptoms or disorder, about the therapy model, and about how treatment will proceed, among other things. A lot of psychoeducation occurs in the first few therapy sessions, but psychoeducation also involves explaining new concepts and providing a rationale for in-session exercises or homework assignments over the entire course of therapy.
As a therapist, I sometimes forget the importance of psychoeducation. Particularly when I feel an urgency about helping a given patient, I make the mistake of cutting short the education part to try to jump ahead to a more "active" treatment phase. To avoid this error, I have to remind myself that good psychoeducation is part of the treatment: patients consistently demonstrate great interest in the information provided, express relief to learn that their symptoms are normal, and show greater commitment to therapy following psychoeducation. In fact, often when therapy doesn't seem to be having the intended effect, it's because I went too quickly and failed to psychoeducate sufficiently.
I had an experience today that reminded me just how powerful psychoeducation can be: I have a patient who suffers from obsessive compulsive disorder (OCD), an anxiety disorder characterized by intrusive thoughts and by repeated compulsive actions designed to eliminate the anxiety generated by the thoughts. During our session, we were discussing the nature of OCD and I emphasized the fact that intrusive thoughts* (e.g., I could jump in front of this bus; what if I had sex with my best friend's partner; my hands could be contaminated from that weird meat at lunch; I could drop the baby off the balcony) are normal and common, and that most almost everyone--OCD or not--experiences them. My patient was so happy and relieved to hear this that he kissed my cheeks when he left my office--not our usual way of saying goodbye!
My patient's reaction reminded me that psychoeducation is an important part of my job. Here are some examples of information that can make a big difference for patients:
* NB: Everyone has intrusive thoughts, i.e., thoughts that seem to come out of nowhere and are inconsistent with our real feelings and values (e.g., we don't really want to jump in front of a bus or have sex with our best friend's partner). The difference is that someone who doesn't have OCD treats the intrusive cognition as an annoying but passing thought and lets it go, whereas someone with OCD perceives the thought as both realistic and dangerous, and needs to perform a compulsive behaviour to alleviate the anxiety generated by the thought.
As a therapist, I sometimes forget the importance of psychoeducation. Particularly when I feel an urgency about helping a given patient, I make the mistake of cutting short the education part to try to jump ahead to a more "active" treatment phase. To avoid this error, I have to remind myself that good psychoeducation is part of the treatment: patients consistently demonstrate great interest in the information provided, express relief to learn that their symptoms are normal, and show greater commitment to therapy following psychoeducation. In fact, often when therapy doesn't seem to be having the intended effect, it's because I went too quickly and failed to psychoeducate sufficiently.
I had an experience today that reminded me just how powerful psychoeducation can be: I have a patient who suffers from obsessive compulsive disorder (OCD), an anxiety disorder characterized by intrusive thoughts and by repeated compulsive actions designed to eliminate the anxiety generated by the thoughts. During our session, we were discussing the nature of OCD and I emphasized the fact that intrusive thoughts* (e.g., I could jump in front of this bus; what if I had sex with my best friend's partner; my hands could be contaminated from that weird meat at lunch; I could drop the baby off the balcony) are normal and common, and that most almost everyone--OCD or not--experiences them. My patient was so happy and relieved to hear this that he kissed my cheeks when he left my office--not our usual way of saying goodbye!
My patient's reaction reminded me that psychoeducation is an important part of my job. Here are some examples of information that can make a big difference for patients:
- For patients with panic attacks: It's normal to think you're going crazy or to think you're having a heart attack during a panic attack. In fact, both are listed as panic symptoms in the DSM.
- For patients who feel guilty about being depressed: It's normal to feel guilty when you're depressed. In fact, guilt is one of the DSM criteria for diagnosing depression.
- For patients who fear their depression is making them stupid: Poor memory and difficulty concentrating are listed as DSM diagnostic criteria for depression.
- For patients with generalized anxiety: Worry and anxiety are maintained by intolerance of uncertainty.
- For depressed or anxious patients: Depression and anxiety can be maintained by beliefs about depression and anxiety (e.g., anxiety makes me productive; only stupid people are happy).
- For patients with insomnia: Many cases of insomnia can be cured through simple sleep hygiene (e.g., always going to bed at the same time; not eating, drinking, or exercising right before bed; eliminating noise and light in the bedroom).
- For mindfulness meditation clients: Meditating doesn't mean clearing your mind of all thoughts. Practicing mindfulness doesn't mean you'll be Zen all the time.
- And my favourite, for everyone: Thoughts aren't facts. Not everything you think is true.
* NB: Everyone has intrusive thoughts, i.e., thoughts that seem to come out of nowhere and are inconsistent with our real feelings and values (e.g., we don't really want to jump in front of a bus or have sex with our best friend's partner). The difference is that someone who doesn't have OCD treats the intrusive cognition as an annoying but passing thought and lets it go, whereas someone with OCD perceives the thought as both realistic and dangerous, and needs to perform a compulsive behaviour to alleviate the anxiety generated by the thought.
November 20, 2012
Anecdote: Parallel Therapy Universe
In September, I explained how psychologists are just like other professional that you might consult--with a specific set of skills, knowledge, and training. Today I had an experience that demonstrated the remarkable similarities between two very different types of therapy:
Before work this morning, I had an appointment with an athletic therapist. I told her my problem: "One of my knees hurts when I run." After asking some questions to understand the background and history of the problem, she maneuvered my legs around, testing muscles and ligaments to determine a diagnosis. Then she educated me: "Sometimes when you have surgery on one knee, that leg never fully regains equal strength; over time, the discrepancy between the two legs forces the muscles and ligaments to compensate--pulling in weird directions and resulting in pain." Next, she guided me through a few exercises that will strengthen the weaker leg. Once she was sure I understood how to do them, she prescribed a few for homework and made sure I wrote them down. She took notes during our session and put them in my file.
After my athletic therapy appointment, I went to work and met with my first patient of the day, a socially anxious man in his late twenties. He told me his problem: "I have to give a toast at a friend's wedding this weekend and I'm so anxious about it I can barely breathe." After asking some questions to fully understand the situation, I asked him to write down some of the thoughts and feelings that come up when he imagines giving the toast. His thoughts included "I'll go blank and won't be able to give the toast," "The other guests will laugh at me," and "If that happens, I'll be humiliated and devastated." Then I educated him: "Often people who are anxious both overestimate the likelihood of a feared event and underestimate their ability to cope with it."
Next, I guided him through an exercise that involved rating the probability of each thought: Given his ample preparation and the notes he planned to bring to the wedding, he rated the probability of forgetting his toast at only 15%. Given that most of the guests were friends of his, he rated the probability that they would laugh at him at only 10%. Given that he had experienced embarrassment during public speaking in the past--but allowing that humiliation and devastation were probably exaggerated predictions--he rated the probability of humiliation and devastation if he forgot his toast at 60%. Together we did the math (15% x 10% x 60% = .009% chance of his feared outcome occurring) and explored the impact of calculating the probabilities on his anxiety. Once I was sure that my patient understood how to apply this strategy, I assigned the use of probabilities in other anxiety-provoking situations as homework for next week. I took notes during our session and put them in his file.
There you have it! Regardless of type, it seems that therapy involves explaining the problem, testing and diagnosis, education, introduction of a new skill or exercise, practicing the skill/exercise, and homework.
Before work this morning, I had an appointment with an athletic therapist. I told her my problem: "One of my knees hurts when I run." After asking some questions to understand the background and history of the problem, she maneuvered my legs around, testing muscles and ligaments to determine a diagnosis. Then she educated me: "Sometimes when you have surgery on one knee, that leg never fully regains equal strength; over time, the discrepancy between the two legs forces the muscles and ligaments to compensate--pulling in weird directions and resulting in pain." Next, she guided me through a few exercises that will strengthen the weaker leg. Once she was sure I understood how to do them, she prescribed a few for homework and made sure I wrote them down. She took notes during our session and put them in my file.
After my athletic therapy appointment, I went to work and met with my first patient of the day, a socially anxious man in his late twenties. He told me his problem: "I have to give a toast at a friend's wedding this weekend and I'm so anxious about it I can barely breathe." After asking some questions to fully understand the situation, I asked him to write down some of the thoughts and feelings that come up when he imagines giving the toast. His thoughts included "I'll go blank and won't be able to give the toast," "The other guests will laugh at me," and "If that happens, I'll be humiliated and devastated." Then I educated him: "Often people who are anxious both overestimate the likelihood of a feared event and underestimate their ability to cope with it."
Next, I guided him through an exercise that involved rating the probability of each thought: Given his ample preparation and the notes he planned to bring to the wedding, he rated the probability of forgetting his toast at only 15%. Given that most of the guests were friends of his, he rated the probability that they would laugh at him at only 10%. Given that he had experienced embarrassment during public speaking in the past--but allowing that humiliation and devastation were probably exaggerated predictions--he rated the probability of humiliation and devastation if he forgot his toast at 60%. Together we did the math (15% x 10% x 60% = .009% chance of his feared outcome occurring) and explored the impact of calculating the probabilities on his anxiety. Once I was sure that my patient understood how to apply this strategy, I assigned the use of probabilities in other anxiety-provoking situations as homework for next week. I took notes during our session and put them in his file.
There you have it! Regardless of type, it seems that therapy involves explaining the problem, testing and diagnosis, education, introduction of a new skill or exercise, practicing the skill/exercise, and homework.
September 14, 2012
Career Justification
In my very first post, I wrote about the difference between psychologists and psychiatrists. Recently, I started thinking about the difference between psychologists and laypeople (i.e., non-psychologists) after a friend asked me why anyone would consult a psychologist. His argument: If I'm a smart person and I know what my problem is, why wouldn't I just work on it on my own? What can a psychologist do that I can't?
This is a reasonable question and it got me thinking about the advantages of consulting a psychologist versus working on your issues on your own. Here are some reasons you might want to consult:
a) Psychologists have fifty minutes per week to dedicate to your problems. This may seem short, but it's a devoted and concentrated period. Left to your own devices, you might ruminate for hours or discuss with friends for weeks, but you're unlikely to sit down to undistractedly confront your issues or problem-solve.
b) Like any professional, psychologists have specialized knowledge, including knowledge of the DSM criteria for validated psychological disorders. Psychoeducation is a huge part of psychotherapy, and you might be relieved to learn that your gruesome intrusive images are a common symptom of obsessive-compulsive disorder, or that during a panic attack, it's normal to feel like you're going crazy.
c) Psychologists have experience working with people whose problems are similar to yours, and so have a good idea of what might and might not be helpful for your issue.
d) A psychologist is someone to check in with. Even if you already know what your problem is and what to do about it, it's not always easy to stay on track. A weekly meeting with a psychologist can act as a strategy session, a check-in, and a one-on-one support group.
e) Psychologists are trained to notice avoidance, incongruence, and behavioural patterns, and to not let you get away with your BS. So if you never do your therapy homework, giggle when you talk about your suicidal thoughts, or abruptly change the topic every time the topic of your parents comes up, a psychologist will notice and gently address it.
f) Psychologists know techniques and strategies that you don't know or might not have thought of, such as activity scheduling and the what went well exercise for improving low mood; behavioural experiments and cognitive restructuring for testing dysfunctional beliefs; Socratic questioning to ferret out cognitive distortions; mindfulness meditation for cultivating attention and awareness; and exposure hierarchies for addressing phobias.
Psychologists aren't just wise listeners who dispense advice; rather, like any professional, we have specialized skills and training. So in the same way that you might hire a lawyer, a carpenter, or a dentist instead of defending yourself in court, building your own back deck, or giving your kids a fluoride treatment, many people find it helpful to consult a psychologist. Not every problem or every person needs a psychologist, however, and while I've encouraged many friends, family members, and acquaintances to consult, I wouldn't recommend it to someone who prefers to seek help from loved ones or to deal with their issues on their own.
It's your call.
This is a reasonable question and it got me thinking about the advantages of consulting a psychologist versus working on your issues on your own. Here are some reasons you might want to consult:
a) Psychologists have fifty minutes per week to dedicate to your problems. This may seem short, but it's a devoted and concentrated period. Left to your own devices, you might ruminate for hours or discuss with friends for weeks, but you're unlikely to sit down to undistractedly confront your issues or problem-solve.
b) Like any professional, psychologists have specialized knowledge, including knowledge of the DSM criteria for validated psychological disorders. Psychoeducation is a huge part of psychotherapy, and you might be relieved to learn that your gruesome intrusive images are a common symptom of obsessive-compulsive disorder, or that during a panic attack, it's normal to feel like you're going crazy.
c) Psychologists have experience working with people whose problems are similar to yours, and so have a good idea of what might and might not be helpful for your issue.
d) A psychologist is someone to check in with. Even if you already know what your problem is and what to do about it, it's not always easy to stay on track. A weekly meeting with a psychologist can act as a strategy session, a check-in, and a one-on-one support group.
e) Psychologists are trained to notice avoidance, incongruence, and behavioural patterns, and to not let you get away with your BS. So if you never do your therapy homework, giggle when you talk about your suicidal thoughts, or abruptly change the topic every time the topic of your parents comes up, a psychologist will notice and gently address it.
f) Psychologists know techniques and strategies that you don't know or might not have thought of, such as activity scheduling and the what went well exercise for improving low mood; behavioural experiments and cognitive restructuring for testing dysfunctional beliefs; Socratic questioning to ferret out cognitive distortions; mindfulness meditation for cultivating attention and awareness; and exposure hierarchies for addressing phobias.
Psychologists aren't just wise listeners who dispense advice; rather, like any professional, we have specialized skills and training. So in the same way that you might hire a lawyer, a carpenter, or a dentist instead of defending yourself in court, building your own back deck, or giving your kids a fluoride treatment, many people find it helpful to consult a psychologist. Not every problem or every person needs a psychologist, however, and while I've encouraged many friends, family members, and acquaintances to consult, I wouldn't recommend it to someone who prefers to seek help from loved ones or to deal with their issues on their own.
It's your call.
May 15, 2012
Personality Disorders, Part 2
A personality disorder is a recurrent and pervasive pattern of maladaptive or inappropriate behaviour that causes significant distress or causes impairment in social, interpersonal, or professional functioning. People with personality disorders repeatedly think, feel, and react in ways that cause problems, and often elicit consistent reactions from the different people in their lives. Think of someone whose friends and colleagues all take advantage of him, someone whose romantic partners always leave her because she is so dependent, or someone who keeps getting fired because he refuses to work on projects that he considers to be beneath him. These are examples of enduring and problematic behaviour patterns.
How can you tell if someone has a personality disorder? A clinical supervisor once told me that when a client inspires an unusual or strong reaction during therapy, that's a big clue. After all, what happens in the psychotherapy office reflects what happens in the client's larger world; if I have a certain intense reaction during my limited contact with a client, changes are good that other people in his or her life do too. Example:
I have a new client who has a physical injury subsequent to a car accident. The injury is minor--something that doesn't usually disturb functioning for more than a month or two--but it has taken over the client's life. He remains significantly more disabled than what is expected at this stage, and family life revolves around his disability: The client's wife and children have put their regular weekend activities on hold to accompany the client to an outpatient rehabilitation centre an hour from home every weekend; the client's wife drastically cut her hours at work in order to care for him; and the client's children and extended family wait on him hand and foot. The client reports some tension as a result of his disability, but for the most part, his family members are extremely accommodating.
In a recent session with this client, I felt myself becoming intensely frustrated as he described his resistance to his doctor's proposal of a progressive return to work. However, despite my frustration, when the client wistfully expressed the wish for our sessions to be longer than the standard fifty minutes, I extended the session an extra fifteen minutes, keeping my next client waiting. When I looked at my schedule to book our appointment for next week and the client's preferred afternoon slot was unavailable, I accepted his proposal that I stay late at work and see him at suppertime.
After the client left, I felt unsettled: I don't usually spend more than an hour with any client, nor am I in the habit of extending my workday! I took a few minutes to explore what happened: Unusual client behaviour (asking for longer appointments; asking for an evening appointment)--check! Intense emotions (frustration) and unusual reactions (prolonging the session; rearranging my schedule) on my part--check! Probably replicating the client's family's behaviour of alternating between frustration and excessive accommodation--check!
It was fascinating to observe myself and the client replicating in therapy what I suspect is his dynamic wherever he goes. The client may or may not have a personality disorder, but my reaction to him tells me that it's something to explore. Clinically, it's not that important to establish whether or not the client has a personality disorder or which one he might have. What's essential is that we identify his maladaptive behaviour patterns so that I can help him by a) addressing the pattern in therapy, and b) making sure not to continue replicating/reinforcing the behaviour.
How can you tell if someone has a personality disorder? A clinical supervisor once told me that when a client inspires an unusual or strong reaction during therapy, that's a big clue. After all, what happens in the psychotherapy office reflects what happens in the client's larger world; if I have a certain intense reaction during my limited contact with a client, changes are good that other people in his or her life do too. Example:
I have a new client who has a physical injury subsequent to a car accident. The injury is minor--something that doesn't usually disturb functioning for more than a month or two--but it has taken over the client's life. He remains significantly more disabled than what is expected at this stage, and family life revolves around his disability: The client's wife and children have put their regular weekend activities on hold to accompany the client to an outpatient rehabilitation centre an hour from home every weekend; the client's wife drastically cut her hours at work in order to care for him; and the client's children and extended family wait on him hand and foot. The client reports some tension as a result of his disability, but for the most part, his family members are extremely accommodating.
In a recent session with this client, I felt myself becoming intensely frustrated as he described his resistance to his doctor's proposal of a progressive return to work. However, despite my frustration, when the client wistfully expressed the wish for our sessions to be longer than the standard fifty minutes, I extended the session an extra fifteen minutes, keeping my next client waiting. When I looked at my schedule to book our appointment for next week and the client's preferred afternoon slot was unavailable, I accepted his proposal that I stay late at work and see him at suppertime.
After the client left, I felt unsettled: I don't usually spend more than an hour with any client, nor am I in the habit of extending my workday! I took a few minutes to explore what happened: Unusual client behaviour (asking for longer appointments; asking for an evening appointment)--check! Intense emotions (frustration) and unusual reactions (prolonging the session; rearranging my schedule) on my part--check! Probably replicating the client's family's behaviour of alternating between frustration and excessive accommodation--check!
It was fascinating to observe myself and the client replicating in therapy what I suspect is his dynamic wherever he goes. The client may or may not have a personality disorder, but my reaction to him tells me that it's something to explore. Clinically, it's not that important to establish whether or not the client has a personality disorder or which one he might have. What's essential is that we identify his maladaptive behaviour patterns so that I can help him by a) addressing the pattern in therapy, and b) making sure not to continue replicating/reinforcing the behaviour.
May 03, 2012
There's an App for That
Cognitive-behavioural psychologists encourage clients to not believe everything they think. One way to apply this suggestion is to imagine your mind as an email inbox and some of your thoughts as spam. In the same way that you don't take seriously every email informing you that you've just won £20,000,000, maybe you don't need to take seriously every thought that runs through your mind.
When you believe everything you think and react to your thoughts as though they were facts, you're experiencing what psychologists call cognitive fusion. Say I have a tough session with a client and I have the thought "I'm a bad therapist." If my heart sinks and a knot of shame forms in my belly, I'm fused with my thought--that is, I'm reacting as if the thought were a fact, rather than a mere string of words my mind created. What's problematic about fusion is that we can get so wrapped up in a fused thought that we fail to notice or incorporate any information that disconfirms it. For example, say a depressed client were fused with the thought "Life is hell." Cognitive fusion would maintain his grey-coloured glasses and prevent him from noticing anything pleasant about the world around him.
Cognitive defusion is used in psychotherapy to help clients unhook from painful and stressful thoughts. A lot of defusion techniques involve using mindfulness to see thoughts and emotions as transient external events, observing them in the same way you would observe a bus drive by or a pen fall to the floor. You might picture your thoughts like leaves on a stream, each one just floating into and then out of consciousness, or you might add the words I'm having the thought that to the beginning of your sentence, so that instead of saying to yourself "I'm an idiot," you would say "I'm having the thought that I'm an idiot." In so doing, you acknowledge that your thought is just a thought, not a fact.
Other defusion methods include saying the fused thought out loud over and over until it loses meaning, saying it in a silly voice, and singing it. I went to a conference a couple weeks ago where I attended a workshop on cognitive defusion techniques; the presenter showed us an iPhone application called Songify that he uses to help his clients defuse from thoughts. The app records you speaking, analyzes your speech, organizes it into a chorus and verses, and maps it to your choice of melody, adjusting your pitch and syncing your words with the beat. He played us a demo of a client saying "I'm a loser." It was impossible not to laugh at the electronic but melodic "I'm a loser" song and it really made the words seem like just words. Apparently the client felt the same way.
I tried Songify recently with colleague, testing some of the thoughts we sometimes find ourselves fused with. It worked! Not only did we have a good laugh, but hearing our thoughts sung out loud to a melody gave us some distance from them, letting us see them for exactly what they are--mind spam, rather than literal truths.
When you believe everything you think and react to your thoughts as though they were facts, you're experiencing what psychologists call cognitive fusion. Say I have a tough session with a client and I have the thought "I'm a bad therapist." If my heart sinks and a knot of shame forms in my belly, I'm fused with my thought--that is, I'm reacting as if the thought were a fact, rather than a mere string of words my mind created. What's problematic about fusion is that we can get so wrapped up in a fused thought that we fail to notice or incorporate any information that disconfirms it. For example, say a depressed client were fused with the thought "Life is hell." Cognitive fusion would maintain his grey-coloured glasses and prevent him from noticing anything pleasant about the world around him.
Cognitive defusion is used in psychotherapy to help clients unhook from painful and stressful thoughts. A lot of defusion techniques involve using mindfulness to see thoughts and emotions as transient external events, observing them in the same way you would observe a bus drive by or a pen fall to the floor. You might picture your thoughts like leaves on a stream, each one just floating into and then out of consciousness, or you might add the words I'm having the thought that to the beginning of your sentence, so that instead of saying to yourself "I'm an idiot," you would say "I'm having the thought that I'm an idiot." In so doing, you acknowledge that your thought is just a thought, not a fact.
Other defusion methods include saying the fused thought out loud over and over until it loses meaning, saying it in a silly voice, and singing it. I went to a conference a couple weeks ago where I attended a workshop on cognitive defusion techniques; the presenter showed us an iPhone application called Songify that he uses to help his clients defuse from thoughts. The app records you speaking, analyzes your speech, organizes it into a chorus and verses, and maps it to your choice of melody, adjusting your pitch and syncing your words with the beat. He played us a demo of a client saying "I'm a loser." It was impossible not to laugh at the electronic but melodic "I'm a loser" song and it really made the words seem like just words. Apparently the client felt the same way.
I tried Songify recently with colleague, testing some of the thoughts we sometimes find ourselves fused with. It worked! Not only did we have a good laugh, but hearing our thoughts sung out loud to a melody gave us some distance from them, letting us see them for exactly what they are--mind spam, rather than literal truths.
March 01, 2012
Therapy Gold
Some clients come to psychotherapy because they are entirely non-functional and need help establishing the basics--routine eating and sleeping, and a reasonable degree of physical comfort, financial stability, and social support. Other psychotherapy clients are already highly functional and fairly content, but want help tweaking their life to achieve better relationships, a more meaningful career, or less stress.
Which type of client is more rewarding to work with? Is it better to slightly improve the already-good quality of life of high-functioning clients or to work with low-functioning clients who improve more slowly but whose progress, even if minimal, constitutes a huge improvement in quality of life?
I've always been partial to the idea of tweaking--of helping high-functioning clients meet their potential and achieve their stretch goals. But last week I had a therapy gold (term I made up in my post about friendship versus therapy) moment that changed my thinking somewhat:
I had a session with an extremely depressed client with a serious chronic medical condition. He was going through a flare-up in his condition and I expected him to report that his mood had plummeted correspondingly; however, when I asked him about mood, he replied that it was stable, good even. He reported that he had been using some of the strategies we had discussed in therapy and then said (and this is the therapy gold part), "I have more control over my situation than I thought I did."
After he left, I practically jumped up and clicked my heels! My singular therapy goal with this client been to improve his mood by instilling a modicum of hope and personal control; the serious joy I experienced at seeing this happen diminished my conviction that working with high-functioning clients is more rewarding.
NB: My cup of therapy joy ran over when, before the client left, I assigned him the What Went Well exercise.
Which type of client is more rewarding to work with? Is it better to slightly improve the already-good quality of life of high-functioning clients or to work with low-functioning clients who improve more slowly but whose progress, even if minimal, constitutes a huge improvement in quality of life?
I've always been partial to the idea of tweaking--of helping high-functioning clients meet their potential and achieve their stretch goals. But last week I had a therapy gold (term I made up in my post about friendship versus therapy) moment that changed my thinking somewhat:
I had a session with an extremely depressed client with a serious chronic medical condition. He was going through a flare-up in his condition and I expected him to report that his mood had plummeted correspondingly; however, when I asked him about mood, he replied that it was stable, good even. He reported that he had been using some of the strategies we had discussed in therapy and then said (and this is the therapy gold part), "I have more control over my situation than I thought I did."
After he left, I practically jumped up and clicked my heels! My singular therapy goal with this client been to improve his mood by instilling a modicum of hope and personal control; the serious joy I experienced at seeing this happen diminished my conviction that working with high-functioning clients is more rewarding.
NB: My cup of therapy joy ran over when, before the client left, I assigned him the What Went Well exercise.
February 19, 2012
Friendship versus Therapy
A friend called me today to ask for advice about a conflict in his relationship with a mutual friend. After listening for five minutes, I told him exactly how I thought he should handle it. He was grateful and I was pleased; I joked that I wish that I could do the same thing with my clients--that is, tell them what to do and make everyone happy. After we hung up, I started thinking about the difference between friendship and therapy. In both cases, I provide support, give advice, and, to varying degrees, facilitate insight and personal growth. So what's the difference?
One of the biggest differences is that, for two reasons, I rarely flat out tell a client what I think he or she should do. Why not?
1) It's risky. I know my clients in a very limited context. I've never been to their home or to their workplace and I haven't met their partners, children, friends, or colleagues. If I tell a client how she should, for example, discipline her daughter, handle her overbearing boss, or respond to learning that her partner reads her personal emails, it could easily backfire, causing significant distress for which I would be partly responsible. Further, my client and I may have very different values, and a solution that seems perfectly appropriate to me may be completely out of the question for her. I know most of my friends much better than I know my clients and we share a lot of the same values, making it less likely that I would give bad advice (and if I did, there would be no question of professional liability).
And the more important reason:
2) It's kind of like "Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime." The goal of therapy is to render the therapist obsolete; I want clients to gain enough insight into their behaviour and develop enough new skills for problem-solving and for managing stress and distress that they no longer need a therapist. Telling clients what to do does not facilitate learning, and so a client who asks for straight-up advice will often get the answer-a-question-with-a-question technique. For example, if a client asks "Do you think I should take antidepressants?" I'll ask "What are some things that helped last time you were depressed?" If a client asks "Should I leave my partner?" I'll say "What are some of your options?"
It can be challenging to not tell clients what I think they should do--especially if it seems obvious--but it's much more powerful if they figure it out on their own. And when clients surprise me by demonstrating that they learned exactly what I was hoping they'd learn (e.g., "None of my avoidance habits really work. I guess it's time to try something different," or "I notice that when I force myself to be active, even if I don't feel like it, my mood lifts"), it's therapy gold.
NB: There are two situations in which I would tell a client exactly what to do. The first is if I have a tip the client can use to solve a practical problem (e.g., If you're suffering from insomnia, don't get into bed until you're tired; if you keep falling asleep during your relaxation exercises, try doing them before instead of after lunch). The second is a suicidal or other serious crisis (e.g., "When we hang up the phone, call your husband; if he doesn't answer, go to the ER").
One of the biggest differences is that, for two reasons, I rarely flat out tell a client what I think he or she should do. Why not?
1) It's risky. I know my clients in a very limited context. I've never been to their home or to their workplace and I haven't met their partners, children, friends, or colleagues. If I tell a client how she should, for example, discipline her daughter, handle her overbearing boss, or respond to learning that her partner reads her personal emails, it could easily backfire, causing significant distress for which I would be partly responsible. Further, my client and I may have very different values, and a solution that seems perfectly appropriate to me may be completely out of the question for her. I know most of my friends much better than I know my clients and we share a lot of the same values, making it less likely that I would give bad advice (and if I did, there would be no question of professional liability).
And the more important reason:
2) It's kind of like "Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime." The goal of therapy is to render the therapist obsolete; I want clients to gain enough insight into their behaviour and develop enough new skills for problem-solving and for managing stress and distress that they no longer need a therapist. Telling clients what to do does not facilitate learning, and so a client who asks for straight-up advice will often get the answer-a-question-with-a-question technique. For example, if a client asks "Do you think I should take antidepressants?" I'll ask "What are some things that helped last time you were depressed?" If a client asks "Should I leave my partner?" I'll say "What are some of your options?"
It can be challenging to not tell clients what I think they should do--especially if it seems obvious--but it's much more powerful if they figure it out on their own. And when clients surprise me by demonstrating that they learned exactly what I was hoping they'd learn (e.g., "None of my avoidance habits really work. I guess it's time to try something different," or "I notice that when I force myself to be active, even if I don't feel like it, my mood lifts"), it's therapy gold.
NB: There are two situations in which I would tell a client exactly what to do. The first is if I have a tip the client can use to solve a practical problem (e.g., If you're suffering from insomnia, don't get into bed until you're tired; if you keep falling asleep during your relaxation exercises, try doing them before instead of after lunch). The second is a suicidal or other serious crisis (e.g., "When we hang up the phone, call your husband; if he doesn't answer, go to the ER").
January 14, 2012
I'm Watching You
One of the best things I've learned in my clinical training is that everything is information. Everything a client does provides data, and I can use it to generate hypotheses, even before the first session. For example, it's telling when a client asks the receptionist four times how much longer he'll have to wait, even though I'm only ten minutes behind schedule. It's interesting and useful to notice that a middle-aged client is dressed like a teenager, or that a client keeps his coat and hat on when he sits down across from me.
What can I hypothesize about these clients? The client who repeatedly checks with the receptionist might be anxious, entitled, or both. The middle-aged client dressed like an adolescent might be emotionally immature or fear aging. The client who keeps his coat and hat on might be emotionally guarded and unsure about seeing a psychologist. These are only possibilities, but they allow me to start generating a conceptualization of the client--one that will be reinforced or corrected during the interview.
Naturally, the habit of observation extends outside the therapy office. I notice if an acquaintance is usually on her phone when she enters a party, and I wonder if it's important to her to look busy or if she's socially anxious about greeting people. I notice if a colleague starts every sentence with an apology and try to guess if it's just a verbal tic or if he believes that his contributions to conversation have no value or that others aren't interested in his opinion.
You don't have to be a psychologist to notice behaviour and make hypotheses, and there are benefits to this kind of observation. Say a friend tells you that she's thrilled about her new job, but you notice that she's biting her nails and doesn't smile once during the conversation. You can gently point out that she seem more stressed out than thrilled, and give her a chance to reflect and to discuss her true feelings. If you notice that a friend often busies himself with drinks and hors d'oeuvres and spends most of his time in the kitchen during weekly games night, you can hypothesize that he's unsure of his place in the social group, and--without necessarily saying anything--make a particular effort to include him.
Next time a friend or stranger does something interesting or unusual, or you notice a pattern in a colleague's behaviour, make a hypothesis. You might learn something interesting!
What can I hypothesize about these clients? The client who repeatedly checks with the receptionist might be anxious, entitled, or both. The middle-aged client dressed like an adolescent might be emotionally immature or fear aging. The client who keeps his coat and hat on might be emotionally guarded and unsure about seeing a psychologist. These are only possibilities, but they allow me to start generating a conceptualization of the client--one that will be reinforced or corrected during the interview.
Naturally, the habit of observation extends outside the therapy office. I notice if an acquaintance is usually on her phone when she enters a party, and I wonder if it's important to her to look busy or if she's socially anxious about greeting people. I notice if a colleague starts every sentence with an apology and try to guess if it's just a verbal tic or if he believes that his contributions to conversation have no value or that others aren't interested in his opinion.
You don't have to be a psychologist to notice behaviour and make hypotheses, and there are benefits to this kind of observation. Say a friend tells you that she's thrilled about her new job, but you notice that she's biting her nails and doesn't smile once during the conversation. You can gently point out that she seem more stressed out than thrilled, and give her a chance to reflect and to discuss her true feelings. If you notice that a friend often busies himself with drinks and hors d'oeuvres and spends most of his time in the kitchen during weekly games night, you can hypothesize that he's unsure of his place in the social group, and--without necessarily saying anything--make a particular effort to include him.
Next time a friend or stranger does something interesting or unusual, or you notice a pattern in a colleague's behaviour, make a hypothesis. You might learn something interesting!
December 22, 2011
Too Much Empathy
Judging from reactions to my two recent posts on the subject, most people believe that some form of empathy (cognitive or emotional; innate or learned) is a key characteristic for healthcare professionals such as doctors and psychologists. But is it possible to overempathize? A recent experience suggests that it is:
Last week at the chronic pain centre, I had the opportunity to see two therapists consecutively interact with the same patient, with two very different outcomes. The therapists were co-conducting a psychological assessment of a new patient who was extremely and visibly depressed. The patient walked into the office slowly and hunched over. He didn't make eye contact during the introductions, and slouched in his chair, tears falling unchecked even before the interview started.
The first therapist was shaken by the patient's appearance, and unsure that he was in a condition to answer three pages of questions about pain, mood, and functioning. She began the evaluation anyway, but the interview rapidly went nowhere. The patient spoke slowly, softly, and infrequently, and continued to cry. The therapist felt insensitive probing someone in such obvious distress, and spoke to him more and more slowly and softly. As palpable despair crept into the room, the therapist started fumbling her words, and within ten minutes, she too was slouched in her chair, feeling helpless.
The second therapist took over. She obtained the patient's consent to continue the evaluation and then, sitting up straight and speaking at a normal volume, she continued the interview. When the patient stumbled or got stuck, the therapist rephrased the question to make it easier. Her attitude and questions expressed empathy, but she maintained composure and didn't behave as though her questions were an imposition.
How did the patient react? He sat up straighter. His tears gradually stopped. He raised his voice to a normal volume and made more eye contact. He joined the conversation and the second therapist was able to obtain the information necessary to formulate a treatment plan.
What happened here?
In a fit of unhelpful overempathy, the first therapist had fallen head first into the patient's emotional world, taking on his hopelessness and helplessness. The second therapist didn't take on the patient's mood; instead, she maintained her own competent and upbeat manner, and her energy spread to the patient. Her composure conveyed a message of strength: whereas the first therapist's behaviour communicated "You (and I) are too fragile to complete this interview," the second therapist's attitude said to the patient something like "I see that you are in immense physical and emotional pain, but I believe that you have the strength to communicate your situation and participate actively in your treatment."
In the therapy room, part of the therapist's job is to be in control, to model competence and mental health, and to convey appropriate optimism to the patient. To do so effectively, the therapist needs to strike a balance between empathy and some degree of emotional separation. In this case, the first therapist's excessive emotional empathy maintained and propagated the patient's despair, and prevented the therapist from doing her job. The second therapist's appropriate empathy allowed her to maintain composure, do her job effectively, and propagate hope. The patient's reaction made it clear which attitude was more helpful!
Last week at the chronic pain centre, I had the opportunity to see two therapists consecutively interact with the same patient, with two very different outcomes. The therapists were co-conducting a psychological assessment of a new patient who was extremely and visibly depressed. The patient walked into the office slowly and hunched over. He didn't make eye contact during the introductions, and slouched in his chair, tears falling unchecked even before the interview started.
The first therapist was shaken by the patient's appearance, and unsure that he was in a condition to answer three pages of questions about pain, mood, and functioning. She began the evaluation anyway, but the interview rapidly went nowhere. The patient spoke slowly, softly, and infrequently, and continued to cry. The therapist felt insensitive probing someone in such obvious distress, and spoke to him more and more slowly and softly. As palpable despair crept into the room, the therapist started fumbling her words, and within ten minutes, she too was slouched in her chair, feeling helpless.
How did the patient react? He sat up straighter. His tears gradually stopped. He raised his voice to a normal volume and made more eye contact. He joined the conversation and the second therapist was able to obtain the information necessary to formulate a treatment plan.
What happened here?
In a fit of unhelpful overempathy, the first therapist had fallen head first into the patient's emotional world, taking on his hopelessness and helplessness. The second therapist didn't take on the patient's mood; instead, she maintained her own competent and upbeat manner, and her energy spread to the patient. Her composure conveyed a message of strength: whereas the first therapist's behaviour communicated "You (and I) are too fragile to complete this interview," the second therapist's attitude said to the patient something like "I see that you are in immense physical and emotional pain, but I believe that you have the strength to communicate your situation and participate actively in your treatment."
In the therapy room, part of the therapist's job is to be in control, to model competence and mental health, and to convey appropriate optimism to the patient. To do so effectively, the therapist needs to strike a balance between empathy and some degree of emotional separation. In this case, the first therapist's excessive emotional empathy maintained and propagated the patient's despair, and prevented the therapist from doing her job. The second therapist's appropriate empathy allowed her to maintain composure, do her job effectively, and propagate hope. The patient's reaction made it clear which attitude was more helpful!
December 18, 2011
Pain Psychology
In September, I started an internship at a chronic pain centre. The pain centre is a multidisciplinary hospital clinic that employs various types of healthcare professionals, including doctors (e.g., rheumatologists, anesthesiologists), nurses, a physiotherapist, and a team of psychologists. About two thirds of pain centre patients see one of the psychologists at some point during their treatment.
Why do chronic pain patients need psychological help?
Pain patients need psych help because chronic pain often impairs functioning significantly, creating considerable distress. Imagine not being able to go to work, walk around the block, or lift your child. Imagine going from playing competitive volleyball to walking with a cane, or from working construction to being unable to stand for more than fifteen minutes at a time. Imagine explaining to family, friends, and colleagues that you have constant pulsating pain shooting down both of your legs, or that you wake up every morning with what feels like a 100-pound weight pressing on your spinal cord. Then imagine years of this--sometimes without a clear diagnosis--and you can see why some pain patients need psychological help.
When pain centre doctors refer a patient to the psychology team, the first thing the psychologist does is a complete psych assessment. The goal of the assessment is to get a global portrait of the patient, and to answer the following questions:
a) What is the state of the patient's mental health? For example, the patient may be depressed, anxious, suffering from post-traumatic stress (e.g., pain onset subsequent to a work or car accident), or self-medicating with alcohol.
b) Did the patient's psychological problems develop before or after pain onset? For example, a depressed pain patient may have been psychologically healthy before pain onset; a patient with a personality disorder has probably had interpersonal problems all his or her life.
c) Do the patient's psychological problems exacerbate, maintain, or perpetuate the pain? For example, an extremely anxious patient may focus excessively on every tiny sensation in his body, fearing increased pain with every movement; his hypervigilance exacerbates the pain, reinforcing his fear of movement and creating a vicious cycle. A severely depressed patient may stay in bed all day for months; her decreased strength and flexibility maintains her pain.
d) Does the patient's psychological state present a barrier to treatment? For example, an extremely depressed patient may need to start taking an antidepressant before he would be able to benefit from therapy. The patient with a dependent personality may rely heavily on pain centre staff and, at some level, fear getting well enough to be discharged. The occasional patient is receiving good worker's compensation benefits or enjoying receiving care and attention from loved ones, and has little interest in getting better; this is a clear barrier to treatment and is important to assess.
We use this information, as well as information about pain history, family history, and work and relationship history, to formulate a treatment plan. The number one goal of psychological treatment at the pain centre is always to increase patients' functioning and improve their quality of life. In individual and group therapy, we help patients increase the number of pleasurable activities in their day, implement a healthy sleeping and eating schedule, and start exercising again if possible. We teach them how to manage stress, and how to communicate effectively with doctors and loved ones about their pain. Most patients' pain is only manageable, not curable, and many patients' pain isn't even diagnosable. Lack of diagnosis is understandably difficult to accept, and a big part of our job is helping patients adjust to this reality. We help them move from grieving their former activities and abilities ("I used to be able to...") to considering available adapted activities ("Now I can...").
Chronic pain eats away at quality of life, and our objective is to increase patients' functioning, restore some level of activity, and help them live better with their pain. When patients start to make some of the changes described above, they often find that their physical health improves and their mood lifts. Pain doesn't go away, but if fades somewhat or feels more manageable.
NB: Psychology is a key element of a multidisciplinary approach to pain, but psych treatment doesn't replace medical intervention--rather, most patients receive concurrent medical and psychological help.
Why do chronic pain patients need psychological help?
Pain patients need psych help because chronic pain often impairs functioning significantly, creating considerable distress. Imagine not being able to go to work, walk around the block, or lift your child. Imagine going from playing competitive volleyball to walking with a cane, or from working construction to being unable to stand for more than fifteen minutes at a time. Imagine explaining to family, friends, and colleagues that you have constant pulsating pain shooting down both of your legs, or that you wake up every morning with what feels like a 100-pound weight pressing on your spinal cord. Then imagine years of this--sometimes without a clear diagnosis--and you can see why some pain patients need psychological help.
When pain centre doctors refer a patient to the psychology team, the first thing the psychologist does is a complete psych assessment. The goal of the assessment is to get a global portrait of the patient, and to answer the following questions:
a) What is the state of the patient's mental health? For example, the patient may be depressed, anxious, suffering from post-traumatic stress (e.g., pain onset subsequent to a work or car accident), or self-medicating with alcohol.
b) Did the patient's psychological problems develop before or after pain onset? For example, a depressed pain patient may have been psychologically healthy before pain onset; a patient with a personality disorder has probably had interpersonal problems all his or her life.
c) Do the patient's psychological problems exacerbate, maintain, or perpetuate the pain? For example, an extremely anxious patient may focus excessively on every tiny sensation in his body, fearing increased pain with every movement; his hypervigilance exacerbates the pain, reinforcing his fear of movement and creating a vicious cycle. A severely depressed patient may stay in bed all day for months; her decreased strength and flexibility maintains her pain.
d) Does the patient's psychological state present a barrier to treatment? For example, an extremely depressed patient may need to start taking an antidepressant before he would be able to benefit from therapy. The patient with a dependent personality may rely heavily on pain centre staff and, at some level, fear getting well enough to be discharged. The occasional patient is receiving good worker's compensation benefits or enjoying receiving care and attention from loved ones, and has little interest in getting better; this is a clear barrier to treatment and is important to assess.
We use this information, as well as information about pain history, family history, and work and relationship history, to formulate a treatment plan. The number one goal of psychological treatment at the pain centre is always to increase patients' functioning and improve their quality of life. In individual and group therapy, we help patients increase the number of pleasurable activities in their day, implement a healthy sleeping and eating schedule, and start exercising again if possible. We teach them how to manage stress, and how to communicate effectively with doctors and loved ones about their pain. Most patients' pain is only manageable, not curable, and many patients' pain isn't even diagnosable. Lack of diagnosis is understandably difficult to accept, and a big part of our job is helping patients adjust to this reality. We help them move from grieving their former activities and abilities ("I used to be able to...") to considering available adapted activities ("Now I can...").
Chronic pain eats away at quality of life, and our objective is to increase patients' functioning, restore some level of activity, and help them live better with their pain. When patients start to make some of the changes described above, they often find that their physical health improves and their mood lifts. Pain doesn't go away, but if fades somewhat or feels more manageable.
NB: Psychology is a key element of a multidisciplinary approach to pain, but psych treatment doesn't replace medical intervention--rather, most patients receive concurrent medical and psychological help.
October 29, 2011
If You Don't Understand, Ask
Therapy Policy: If you don't know what your client is talking about, ask.
I learned this lesson during my first doctoral internship, which was my first experience conducting therapy in French. Over the course of eight years living in Quebec, I've achieved considerable fluency in the French language, as well as in the nuances of Quebec slang, politics, and culture. However, everyday French conversation and conducting therapy in French are not comparable, and the learning curve during that first internship was steep.
At the beginning, wanting to prove myself as an Anglo therapist in a Francophone environment, I opted for the "it's no big deal" approach and ignored the language issue. To avoid drawing attention to my Anglo-ness, I didn't ask clients to repeat unfamiliar terms or to explain comments that weren’t clear to me. This strategy was not effective. In supervision, I learned that my comédien client was not a comedian but, rather, an actor. When I expressed surprise in supervision over a client’s shocked response to a rude, but not out of character, comment from her partner, I learned that choqué means angry, not shocked. When I asked a colleague what my client might have meant when she said that her mother was "the kind of person who watches Occupation Double” (a Quebec reality TV show), my colleague wondered why I hadn’t simply asked the client.
In discussion with my supervisor, I realized that I was worried my clients would reject me for being an Anglo imposter who could never understand them. But my solution--pretending to understand when I didn't--was hindering therapy. When I consciously shifted to a more open and curious approach, my clients responded positively. They appreciated my acknowledgement of our differences and enjoyed the opportunity to explain their cultural references. Who knew!
Now I'm in a new steep-learning-curve internship--at a chronic pain centre. I'm not used to working at a non-psychiatric hospital; I hear unfamiliar terminology used every day to describe pain, medical procedures, medications, etc. What's more, I've never worked with pain patients before and many of their experiences are unfamiliar.
I'm doing much less pretending this time around. One thing that helps is seeing my superiors--physicians and psychologists alike--do things like Google a medication they've never heard of, right in front of patients! They don't seem worried that patients will think they're incompetent because they admit to not knowing everything. A second thing that helps is noticing that patients want me to really understand their experience; they're not annoyed when I say "I'm not quite sure I understand; what do you mean by...?" Rather, they appreciate it.
I'm doing much less pretending this time around. One thing that helps is seeing my superiors--physicians and psychologists alike--do things like Google a medication they've never heard of, right in front of patients! They don't seem worried that patients will think they're incompetent because they admit to not knowing everything. A second thing that helps is noticing that patients want me to really understand their experience; they're not annoyed when I say "I'm not quite sure I understand; what do you mean by...?" Rather, they appreciate it.
This time, my policy is "If you don't understand, ask" (and, where medical terminology is concerned, "if you don't know, look it up").
So far, so good.
October 10, 2011
Empathy
A good therapist should be empathetic, right? Most people, myself included, would automatically agree--but what is empathy, anyway?
Until recently, my loose and unexamined definition of empathy was the capacity to put yourself in someone else's shoes and feel as he or she feels. So when in clinical case discussions, colleagues mentioned how awful they felt about a given client's situation, or that tears came to their eyes during a client's particularly moving story, I called that empathy. And when other colleagues reported that this never happens to them--that they never vicariously experience clients' pain or take clients' problems home with them--I called this lack of empathy. I figured that the former group were the more sensitive, more human, and all-around better psychologists, and that there was probably something wrong with the latter group.
However, subsequent to a conversation on this very topic, a friend pointed me to the Wikipedia page for empathy, which lists definitions of the term by various theorists. To my surprise, many of them were not consistent with my definition. Rather, several referred to a cognitive component of empathy, that is, empathy as the ability to understand another person's thoughts, feelings, and motivations, without necessarily experiencing them.
Examples of this type of definition include "the ability to put oneself into the mental shoes of another person to understand her emotions and feelings" and "a complex form of psychological inference in which observation, memory, knowledge, and reasoning are combined to yield insights into the thoughts and feelings of others." These definitions involve perception and appreciation of how the other person is feeling, but don't imply stepping into his or her shoes.
Other definitions suggested that empathy has both cognitive and emotional components. For example: "There are two major elements to empathy. The first is the cognitive component: understanding the other's feelings and the ability to take their perspective. The second element to empathy is the affective component. This is an observer's appropriate emotional response to another person's emotional state." Another definition proposed that empathy is "the capacity to a) be affected by and share the emotional state of another, b) assess the reasons for the other’s state, and c) identify with the other, adopting his or her perspective."
Reading these interpretations changed my personal definition of empathy and eliminated my judgment of therapists who don't feel their clients' pain. The more I think about it, the more I believe that, in combination with warmth, compassion, and therapy and problem-solving skills, cognitive empathy is enough.
What do you think? Would you appreciate seeing your therapist wiping away tears when you describe your troubles, or is it enough if he or she can understand where you're coming from and why, and can use that knowledge to help you move forward?
Until recently, my loose and unexamined definition of empathy was the capacity to put yourself in someone else's shoes and feel as he or she feels. So when in clinical case discussions, colleagues mentioned how awful they felt about a given client's situation, or that tears came to their eyes during a client's particularly moving story, I called that empathy. And when other colleagues reported that this never happens to them--that they never vicariously experience clients' pain or take clients' problems home with them--I called this lack of empathy. I figured that the former group were the more sensitive, more human, and all-around better psychologists, and that there was probably something wrong with the latter group.
However, subsequent to a conversation on this very topic, a friend pointed me to the Wikipedia page for empathy, which lists definitions of the term by various theorists. To my surprise, many of them were not consistent with my definition. Rather, several referred to a cognitive component of empathy, that is, empathy as the ability to understand another person's thoughts, feelings, and motivations, without necessarily experiencing them.
Examples of this type of definition include "the ability to put oneself into the mental shoes of another person to understand her emotions and feelings" and "a complex form of psychological inference in which observation, memory, knowledge, and reasoning are combined to yield insights into the thoughts and feelings of others." These definitions involve perception and appreciation of how the other person is feeling, but don't imply stepping into his or her shoes.
Other definitions suggested that empathy has both cognitive and emotional components. For example: "There are two major elements to empathy. The first is the cognitive component: understanding the other's feelings and the ability to take their perspective. The second element to empathy is the affective component. This is an observer's appropriate emotional response to another person's emotional state." Another definition proposed that empathy is "the capacity to a) be affected by and share the emotional state of another, b) assess the reasons for the other’s state, and c) identify with the other, adopting his or her perspective."
Reading these interpretations changed my personal definition of empathy and eliminated my judgment of therapists who don't feel their clients' pain. The more I think about it, the more I believe that, in combination with warmth, compassion, and therapy and problem-solving skills, cognitive empathy is enough.
What do you think? Would you appreciate seeing your therapist wiping away tears when you describe your troubles, or is it enough if he or she can understand where you're coming from and why, and can use that knowledge to help you move forward?
September 29, 2011
The Suicide Question
The other day, a research participant questioned me about the usefulness of asking clients whether or not they feel suicidal. He was completing the Beck Depression Inventory (BDI), a popular research and clinical measure of depressive symptoms, including suicidal thoughts. Question 9 of the BDI requires the respondent to choose from the following:
a) I don't have any thoughts of killing myself,
b) I have thoughts of killing myself but I would not carry them out
c) I would like to kill myself
d) I would kill myself if I had the chance
My participant wanted to know, who would actually admit to wanting to kill himself or herself? Given all the stigma surrounding suicide, wouldn't most people just lie?
Good question: Is it effective to ask clients flat out whether or not they are considering suicide?
The answer is yes. Doctors, psychiatrists, and psychologists are trained to ask the suicide question, without hesitation and without euphemisms. We ask it in a sensitive but straightforward manner, and clients invariably respond honestly. They either express surprise and say "What? Oh, no, I'm not at that point," or admit that yes, they've thought about it, at which point we empathize with their suffering and follow up with questions to determine whether or not they have a plan or a timeline.
I've never witnessed or heard of a client who reacted to the suicide question with shock or anger, and I've never heard of a client who lied (i.e., said he/she wasn't suicidal and then committed suicide). Rather, clients are relieved to be able to address the issue candidly. When a health care professional asks about suicidal thoughts in the same tone of voice used to ask about sleep and appetite, it removes the stigma, allowing the client to bring the dark, scary secret out into the open. To this end, some psychologists have their depressed clients complete the BDI at every session, providing a weekly measure of suicidal ideation, as well as of mood, sleep, appetite, and activity level.
Frequently asked question: Won't asking about suicide plant the idea if the person wasn't already considering it? This is a common fear, especially for non-professionals who aren't sure whether or not to broach the suicide question with a loved one. The answer is no. If someone isn't contemplating suicide, he or she won't start considering it because you asked; and if someone is thinking about it, he or she will probably be relieved that you brought it up, even if it's uncomfortable.
If you think that someone you know is contemplating suicide, ask the question.
a) I don't have any thoughts of killing myself,
b) I have thoughts of killing myself but I would not carry them out
c) I would like to kill myself
d) I would kill myself if I had the chance
My participant wanted to know, who would actually admit to wanting to kill himself or herself? Given all the stigma surrounding suicide, wouldn't most people just lie?
Good question: Is it effective to ask clients flat out whether or not they are considering suicide?
The answer is yes. Doctors, psychiatrists, and psychologists are trained to ask the suicide question, without hesitation and without euphemisms. We ask it in a sensitive but straightforward manner, and clients invariably respond honestly. They either express surprise and say "What? Oh, no, I'm not at that point," or admit that yes, they've thought about it, at which point we empathize with their suffering and follow up with questions to determine whether or not they have a plan or a timeline.
I've never witnessed or heard of a client who reacted to the suicide question with shock or anger, and I've never heard of a client who lied (i.e., said he/she wasn't suicidal and then committed suicide). Rather, clients are relieved to be able to address the issue candidly. When a health care professional asks about suicidal thoughts in the same tone of voice used to ask about sleep and appetite, it removes the stigma, allowing the client to bring the dark, scary secret out into the open. To this end, some psychologists have their depressed clients complete the BDI at every session, providing a weekly measure of suicidal ideation, as well as of mood, sleep, appetite, and activity level.
Frequently asked question: Won't asking about suicide plant the idea if the person wasn't already considering it? This is a common fear, especially for non-professionals who aren't sure whether or not to broach the suicide question with a loved one. The answer is no. If someone isn't contemplating suicide, he or she won't start considering it because you asked; and if someone is thinking about it, he or she will probably be relieved that you brought it up, even if it's uncomfortable.
If you think that someone you know is contemplating suicide, ask the question.
May 09, 2011
What is CBT?
We often say things like "I don't know why I feel anxious," or "All of a sudden, I felt so mad... out of nowhere!" or "I don't know why I acted the way I did." Here's a question: what were you thinking at the time?
Cognitive-behavioural therapy (CBT) is a psychotherapy approach that emphasizes the role of automatic thoughts in feelings and behaviour, and suggests that our feelings and behaviour aren't caused by people, situations, and events, but are instead caused by our thoughts about people, situations, and events.
Example: say your parents call three different times in one evening. How do you feel? If you think, "They're always trying to run my life," you might feel irritated or indignant and avoid returning their calls; if you think, "They love me and are excited for my upcoming trip home," you might feel warm and fuzzy and call them back the next morning; if you think "They're trying to reach me because something bad happened," you might feel worried and call them back that night even if it's late.
Another example: your work colleague walks by in the hall and doesn't say hi. If you think, "He thinks he's awesome now that he got that promotion," you might feel insulted and gossip about it with your office mate; if you think, "He's probably distracted; I heard his daughter's sick," you might feel sympathetic and send a quick email to ask how he's doing; if you think, "He's still mad about that mistake I made last week," you might feel anxious and avoid running into him again. In each of these cases, your reaction isn't the direct consequence of the event, but is the consequence of your thoughts and your interpretation of the event.
CBT is based on three principles: thoughts affect behaviour; thoughts can be monitored and altered; and changing thoughts can change behaviour. Learning the CBT lesson that emotions and behaviour don't come out of nowhere can help people who experience a lot of upsetting emotions or who are unhappy with certain elements of their behaviour gain some control over their feelings and actions. Cognitive-behavioural therapists first teach clients that a lot of distress is created by distorted or unhelpful thoughts, and then help clients adjust their thinking by teaching them to evaluate the validity of their thoughts and generate possible alternative thoughts.
CBT has proven to be an effective treatment for a variety of anxiety, mood, sleep, personality, substance use, and eating disorders, as well as for problems like chronic pain, stress, anger, and relationship issues. As a CBT student, client, and therapist, I'm here to tell you that it works. I believe in it and I recommend it.
Up next: examples of specific CBT concepts and interventions.
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