In a Nutshell gives a very brief synopsis of various subjects of relevance to student and trained counsellors and psychotherapists.
Receiving Gifts
"Should a therapist accept a personal gift from a client?”. "It depends" is the short answer!
It depends on the agency policy you work for, the context of the work and the clients problems and history, previous experiences and the present relationship with the client and dynamics of the client; how they relate to others, issues therein and relational dynamics in the relationship with you.
How does offering me this gift fit into what I presently know of this client, and what they are working on? What's the potential impact (short & long term) impact on the client and the work we are doing if I accept the gift? what's the....if I don't accept the gift?
Your theoretical approach will also have an influence on your decision too. And also the nature of the 'boundaries' the therapist prefers with their clients. The gift may simply reveal your clients generosity etc. However If excessive and goes overboard may irritate others. Or client may expect to have special treatment or go easy on them i.e. avoid challenging. Or a boundary issue; wanting to have you be thier friend. Depends when given too and the size of the Gift!
Personally I usually accept the gift (unless excessive etc.) and use this experience to deepen my understanding of the client. I’ve rarely refused a gift but as you will see from reading chapter 9 cited above below their are some examples where we should. Most times a gift is given because the client is genuinely very thankful for what you have done for them.
Therapists rarely give gifts but a card with ending thoughts (letter) can be very therapeutic for the client at the end of the therapy relationship. This can mean a lot to the client and reinforce the clients process, learning, etc. An object could be given representing the changes the client has achieved or as a transitional object if the therapist is going on holidays or other break.
Further reading: Chapter 9 in ‘Standards and Ethics for Counselling in Action, Tim Bond'. Also read if any code of ethics and practice out there makes any comments on accepting gifts: IACP, IAHIP, PSI, UKCP, BACP.
Holding and Containmment
These are the most fundamental elements in the therapeutic relationship as they lead to trust and a sense of safety at conscious and unconscious levels. If you feel trust and safe in the relationship you feel able to share the unshareable. So what factors contribute to the client experiencing holding and containment from the therapist within the therapeutic relationship? Some of the same factors that are essential for babies to experience from their parents: Consistency, reliability, and good boundaries. From the start of therapy meeting the client weekly in the same room at the same time for the hour and naturally the therapist not being late or leaving early or answering calls and of course maintianing privacy so the client is not distracted by external sounds of people looking in (solid boundaries). All this contributes to the person feeling safe to be open at depth about themselves. The therapist has shown respect and is protecting and looking after the client as a parent does. Naturally face to face therapy provides the optimum conditions and online therapy a poorer substitute. If online is needed due to another pandemic arising then the consistency must be maintained and any ‘ messing' with the boundary creates anxiety, insecurity and distrust and openness is reduced along with increased poor atendance and premature endings. Obviously the reason I have made comparisons with the parent role and child position is that a client arrives into therapy feeling and experiencing similarities of feeling very vulnerable, out of thier depth with life’s challenges and entering a relationship where the other is in a much more powerful position. In addition of course we feel and act out aspects of the ourselves as a child at such times (patterns, schema’s).
Cognitive Behavioural Therapy (Part I)
Where's the evidence for your assumption? What possible explanations can account for her/his behaviour? Which one is most likely? How might you check your assumptions? How might you test out your assumptions? Note what you expect to happen, then engage in the situation or behaviour, then compare what actually happened with your original assumption.
CBT involves challenging our assumptions, opinions, thought patterns and beliefs, by examining the evidence and testing them out through experiments. Thus it follows basic science and 'common sense’, the same principles that have supported human survival for near 2 million years! and led to clothes that keep us warm, means of transport, medicines etc. By common sense I mean the joint and common proved knowledge of humans.
This approach is used continually by humans throughout history in many daily situations. You hypothesis that it would be beneficial to greet the stranger passing you by in your locality. You decide to greet them (experiment/test), They smile and greet you and you feel good to be acknowledged or having made positive contact thus confirming evidence of your hypothesis. Notice in your own daily living how many activities actually do involve this process. Imagine what would happen if this scientific approach had never been used! bikes would fall apart, houses collapse, boats sink, medicines would be ineffective.
A thought, a belief, an assumption, an opinion is just that! Once you treat any one of these as a fact without sufficient evidence well we know what happens from history and the recent Trump era! It is potentially very dangerous for an indivisual too to treat thier self criticisms as facts about themselves. A thought or belief is not a fact until proven by the evidence. Be suspicious of what you read and hear others say. Follow up with researching for the facts. Good research tells you if thier is bias in the researchers. The same principle can be applied to our own self defeating thoughts and beliefs about ourself or others. So thats the background to one aspect of CBT.
Structuring the Therapeutic Process
Integrative models can provide a map to guide us through the territory with work within. My favourite is B. D. Beitman’s in
his book ‘The structure of Individual Psychotherapy’ where he identified four stages: Engagement, Pattern Search, Change
and Termination. His book is well worth studying. After studying the major models and examing my own approach I found the central focus on the relationship was not emphasised enough and corrected this in my own personal model with the stages of: Building the Relationship, Expressing & Exploring, New Understanding, Developing Options (IACP journal, 1996, 1, 36). It goes without saying perhaps that no model should be taken too literally as the map is not the territory and a model should not be followed mechanically.
Brief Therapy (Pt I):
Dermot has been seeing a psychoanalyst for four years for help with his fear of monsters under his bed which has led to chronic insomnia. The psychoanalsis didn’t help so he stops seeing him and decides to try something different. A few years later Dermot bumps into the psychoanalyst who is very surprised to see his former patient looking so rested, full of energy and relaxed. On questioning Dermot says he’s cured and sleeps great. The analyst is amazed and curious. Dermot tells him "I went to see another therapist who called himself a brief therapist who cured me in one session". “ Wow!" the sceptical anaylst replied, “and how did he manage that?". ‘Oh easy, he gave me a saw and told me to cut off the legs of of my bed!
Brief therapy II.
There are many forms of brief therapy some use paradoxical approaches which are not encouraged nowadays. See ‘A Brief Guide to Brief Therapy’ by Cade and O’Hanlon for an interesting overview of brief therapy approaches. Solution focused brief therapy focuses the clients sharing on what has worked for them rather than talking about the problem. The therapist looks for exceptions to the rule where the client managed the situation better or when the depressed client had a good day or times when the alcoholic drank less and then encourages more of what did make the difference. (see De Shazers writings: The Keys to Solution in Brief Therapy; Clues: Investigating Solutions in Brief Therapy (1988) and Putting Difference to Work (1991). This approach can be helpful with ‘clients’ that are, as de shazer describes as just ‘visiting’ - a person who doesn't want to talk about their problems/isn’t there to work on them or change but may engage through an affirming approach and acknowledging what is going well - what is working for them.
Films on Psychotherapy
General release movies: 'A Dangerous Method' starring Keira Knightley, Michael Fassbender; 'What about Bob' (comedy); '50:50' (comedy & serious); ‘Help' TV comedy series with Paul Whitehouse and Chris Langham. 'The Simpsons' family therapy session. 'The Big Bang theory': Sheldon trains Penny. 'In Therapy' with Susie Orbach (BBC radio): https://www.bbc.co.uk/sounds/play/b070v8bn. Yalom: 'Yalom’s Cure', 'Understanding group psychotherapy' (out and inpatient), and 'Group supervision'. TA: Emily Rupert. PCT: BrianThorne with client, 'Journey into self' Rogers group therapy. Gestalt: Psychotherapy with the unmotivated patient' (Erving Polster), Perls with Gloria: https://www.youtube.com/watch?v=it0j6FIxIog. Christine Padesky - films on bore beliefs, panic, social anxiety etc. using CBT. Three approaches to psychotherapy with Gloria (1965) demos by Perls, Ellis and Rogers. Three approaches to psychotherapy with Kathy 1977 with Rogers, Shostrum and Lazurus (https://archive.org/details/threeapproachestopsychotherapy2dreverettshostrom). Many of the above are accessible on youtube. Contact me if you can’t find the one you want after googling it. Most of the demos are with ‘real’ clients not role played roles.
Co-Dependency
“It has been said that when a co-dependent is in danger of dying, the life experiences of their partner flash before their eyes!” Described as a pattern of painful dependence upon compulsive behaviours and approval of others to find safety, self worth and identity or a family member being unwittingly entwined with, and contributing to, the drinking or drugging habits of the chemically dependent person. The person may go onto fall into similar dysfunctional close relationships, especially with narcissists. Indications: Intense and unstable interpersonal relationships. Inability to tolerate being alone. Chronic feelings of boredom and emptiness. Subordinating one’s own needs to those of the person with whom one is involved. Overwhelming desire for acceptance and affection. External referencing (always checking outside oneself before making choices). Dishonesty and denial. Low self worth. Origins: “…women with an alcoholic parent will be especially attracted to people whom they perceive as having a style of interpersonal relating similar to the substance dependent parent…having become dependent on the esteem of a dysfunctional, dependent person, codependents will continue to seek self-worth from the same type of person.” Lyon and Greenberg (1991). The parent was therefore likely to have been distant, neglectful or had abandoned the child. The parent may not necessarily be a substance abuser. Karen Horney, a german psychoanalyst, was the first to write about co-dependency. She proposed that some people adopt a “Moving Toward” personality style, a defence, to overcome their basic anxiety (from dysfunctional parenting) and to meet their unmet needs through the other person, drove to obtain and preserve affection, even at the expense of engagement in a dependent, exploitive relationship. Reading: Karen Horney (1945) Our Inner Conflicts. Norwood, R. (1985). Women who love too much. Lyon, Deborah and Greenberg, Jeff. Evidence of Codependency in Women With an Alcoholic Parent: Helping Out Mr. Wrong. Journal of Personality and Social Psychology. 1991, Vol. 61, No. 3, 435-439.
Existential Psychotherapy
Existential psychotherapy is a philosophical method that operates on the belief that inner conflict within a person is due to that individual's confrontation with the givens of existence. These ‘givens’ include: the inevitability of death; freedom to choose; isolation; and meaninglessness. Existential psychotherapy emphasises how we apply ourselves to the world. The latin origins of ‘exist’ means to ‘step out’ - capturing the existentialist theme of active engagement with the world and responsibility for one’s destiny. As James Bugental (1992) put it: ”The purpose of the therapeutic process is to increase living awareness of the consciousness of one’s own being, one’s own powers and choices, and one’s own limitations…we must help our clients become aware of how they are constricting their lives and their awareness and of the possibilities that are latent for them.” And Emmy de Deuzen added: “[Existential psychotherapy]...seeks to enable a person to live more deliberately, more authentically and more purposely whilst accepting the limitations and contradictions of human existence”. Texts: Existential Psychotherapy, Irvin Yalom. Existential Psychotherapy, Emmy de Deuzen. Both have wrote many other books of interest that are recommended.Films: Akira and the recent series by Riccky Gervais: After Life. Also Yaloms Cure. Sartres ‘Bad Faith’ can be seen in the film: ‘the Remains of a day’.
Personality Disorders
Personality disorders are long-term patterns of behavior and inner experiences that differs significantly from the ‘norm’. The pattern of experience and behavior often begins in childhood and becomes clear by late adolescence or early adulthood and causes distress or problems in functioning. leads to substantial personal distress and/or social dysfunction, and disruption to others. Not diagnosed until after early adulthood and can be mild to severe in severity.
Borderline (emotionally unstable) personality disorder
Involves a pattern of instability in relationships, self image and affects, coupled with marked impulsivity. Others are regarded as dangerous and bad, and oneself as powerless and vulnerable (victim) as well as inherently bad and unacceptable to oneself and others. DSM Diagnostic Criteria for BPD: BPD is diagnosed on the basis of (1) a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and (2) marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by at least of the following
- Frantic efforts to avoid real or imagined abandonment
- Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- Markedly and persistently unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- Affective instability due to marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, or recurrent physical fights)
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Treatment & Prognosis: DBT programmes and General psychiatric and psychotherapy support though the work is most applicable for very experienced psychotherapists and psychologists who have training and experience in this area.
Remissions can occur but can also be lifetime. With support can learn to manage emotions, behaviour and thoughts better. There is some research showing that borderline personality disorder runs in families and individuals have a higher chance of developing BPD if experienced early sexual abuse or alcoholism in the family.
ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome)
ME/CFS is a serious debilitating chronic multisystem illness that can leave the sufferer house or bed bound. This condition is often misunderstood by many professionals (GP’s, consultants, physio’s, nurses) and lay people as 'all in the mind’ or viewing it as simply fatigue. This is despite having robust evidence showing it to be a biological illness. Affecting many systems of the body, symptoms include profound fatigue, post exertional malaise, sleep disturbance, cognitive impairment, postural orthostatic tachycardia, fibromyalgia type pain, sensitivity to sounds, smells, light, enlarged lymph nodes and IBS. It is diagnosed after having certain conditions ruled out through medical test such as Lyme’s disease, thyroid disease, anemia, Addison disease etc. It is crucial to obtain a early diagnosis from a qualified doctor and a consultant with an understanding of this condition. The hallmark symptom of ME/CFS isn’t fatigue at all: It’s a dramatic worsening of symptoms after exertion (which for some patients can be as little as washing themselves). Cognitive problems can be incapacitating whereby the person can’t talk or read; within half an hour of standing, their blood pressure drops or their heart rate soars; and sleep makes them feel no better. Given all the above many sufferers will, naturally, suffer from depression too. Associations: www.irishmecfs.org (frequent events with expert speakers). Reading: Living With M.E.: The Chronic, Post-viral Fatigue Syndrome by Dr. Charles Shepherd. For latest research: ME/CFS/PVFS An exploration of the key clinical issues (2017) from www.meassociation.org.uk. Investinme (research conferences). Article on M.E. (Myalgic Encephalomyelitis) in the Irish Times Tuesday Nov. 28th, 2019 (http://bit.ly/2ByC5zV) Many doctors, psychiatrists, physio's and other professionals lack accurate understanding of ME and it is often misdiagnosed and sufferers given inapproriate and potentially harmful treatment. The new NICE guideline 2020 draft for ME/CFS. Informative summary of updated guidelines. Link.
Dialectical Behavior Therapy (DBT)
Is a modified cognitive behavioral treatment that combines behavioral science with acceptance and mindfulness. It was originally developed by Dr. Marsha Linehan to treat chronically suicidal individuals diagnosed with borderline personality disorder. DBT involves the learning and practicing of particular coping skills such as self monitoring, emotion regulation and tolerance, mindfulness and interpersonal skills. Extended group based programs are available in the HSE which also include individual therapy and phone coaching session. Resources: http://behavioraltech.org.
Future topics: Countertransference, Gestalt, Transactional Analysis.