Process: Negative Direction or Positive Direction?

Ask clients what they want out of therapy, and initially they often have difficulty nailing it down. “I don’t know.  Feel better?” They may have come to therapy because their discomfort has simply become too great. “I’m in pain and not coping well, so I’ll go to a therapist.”

What we need is some sense of the path out of the pain. What does the client really want? A reduction of 50% on their Beck Depression Inventory score is a nicely operationalized definition of “less pain,” but pain is what they don’t want, not what they do want.

Stand in a large field next to a live grenade. You want to get away, and it doesn’t much matter which of the 360 degrees available to you is the direction you take.

In therapy it matters, because there are other grenades in the field.

At the start of therapy I’ll often ask clients to create a list of all the things in their lives they don’t like. This is a bit risky, because it can imply that we are going to deal with all 183 problems.  In fact, this would never work.

But every one of those problems is a direction marker. Turn and face that problem straight on. Then look behind you, over your shoulder. Opposite the problem lies a possible goal. We can mention these to the client and see how they react.

• You are completely out of shape? Perhaps fitness is a goal.
• You hate your marriage? Maybe enhancing it is the goal. Or leaving it. (The client may not know which, pointing to exploration and decision-making as a possible goal for therapy.)
• You are in the wrong career? Perhaps exploring new options is the goal.
• You have no sense of meaning and purpose in your life? Then cultivating meaning and purpose may be the goal.

The negative direction can lead us to a positive direction. But it is only once we have at least an initial positive heading that we can get started. The goals may change as we go. “Maybe I don’t want to save this marriage after all.” Fine. But we need at least one goal anyway.

Process: The Path to Change

Last week I mentioned David Burns’ argument that one of the main causes of treatment failure is the therapist’s overeagerness to help. This leads the clinician to leap into the fray before the client has fully embraced the idea of change, creating an oppositional relationship in which the therapist is pulling for change and the client is backpeddling.

Once both client and therapist are on the same page, however, we still have to figure out how to get to the goals the client has specified. The client may have ideas about how the process will take place.

It’s useful, then, to distinguish between two types of resistance, a topic that Burns is eloquent about.

Outcome resistance is directed, not surprisingly, at the outcome of an intervention. Anyone giving up alcohol, for example, can think of good reasons not to succeed: I’ll give up my best coping strategy, I’ll be more anxious, I’ll have to face what I’ve done to others, and so on. Overcoming a fear of heights will mean that I’ll be in high places more often, and I hate high places. Overcoming my elongated bereavement reaction will mean letting go of someone I loved, which seems like a betrayal of their memory.

Process resistance is directed at the path toward the outcome. Dealing with my public speaking anxiety might involve doing some public speaking as part of the therapy, which I am reluctant to do.  Working on my depression might mean taking up an exercise program, which I have no energy to do.

Once a client has identified a treatment goal, we can feel tempted to race in (yet again) and seize control. We are supposedly the big experts, after all. “Right, so you want to overcome your anorexia.  Great!  Here’s an eating program for you.” The client has bought into the goal but not the path, and again resists.

Process resistance often occurs because the therapy will involve doing distasteful things – like exercise, or public speaking, or challenging long-held ideas, or sniffing alcohol without drinking any. But sometimes it occurs because the client has a clear idea of the path toward the destination that differs from the vision of the clinician.

I once saw a person beset by a hoarding compulsion who had had decades of unsuccessful psychodynamic intervention. S/he had learned the importance of investigating the circumstances of his/her upbringing in order to find the key that would unlock the problem. S/he hadn’t found it yet, but was reluctant to abandon the search.

My suggested approach had little to do with the past, and instead emphasized behavioural rehearsal (bringing in bags of stuff that we would actually throw the contents in the dumpster together) and cognitive work (noting and evaluating the thoughts that occurred when it was decided to save something or contemplated throwing it out). Before s/he could do this, however, we had to explore the therapeutic options and it had to be the client's decision to give this seemingly nonsensical strategy a try. It worked well, but it would never have done anything if s/he hadn’t chosen it.

So once we have an idea of the client’s destination, we should ask the client how he or she envisions reaching that goal. They may or may not have a picture of this. If they have a picture that doesn’t match what we can do effectively, or that is simply more of a strategy that has been tried for years with little result, we can discuss the issue. We can present our own ideas as well. But until we’ve had the discussion and agreed on a course of action, we are on the road to certain treatment failure.

Process: The Dangers of Therapeutic Altruism

I saw David Burns speak recently about the problems that impede therapy.  I’ll paraphrase something he said that resonated with me a great deal but hadn’t put into words.  (Burns is quite precise by what he means and how he says it, so doubtless my paraphrase won’t live up to his standards.  I’ll give it a shot anyway.)

The inimitable Dr Burns.

In effect, he stated that one of the biggest handicaps therapists face is their desire to help.  They assess a client, figure out what’s going on, settle on their own idea of what needs to be fixed, and race in to try to fix it.

The client almost inevitably resists, and therapy runs the risk of devolving into a power struggle in which the clinician attempts to impose his or her will on the hapless client – who is supposedly the customer/employer in this whole enterprise and whose life it is.

For example, we might learn that the client drinks more than is, strictly speaking, a good idea.  We decide that it would be a good idea for the client to cut back, and obviously they came to see us, so they must expect us to do something.  So we begin mapping out a reduction plan and the client doesn’t cooperate.

I’ve seen this pattern repeatedly, and notice that the usual consequence is that the client gets labeled as resistant, and possibly as a passive-aggressive or self-defeating personality disorder (neither of which are real DSM diagnoses, but they serve the important function of preserving the therapist’s ego).  A better consequence would be for the therapist to be labeled as “meddling and intrusive.”

Burns points out that clients are perfectly entitled to drink as much as they want, stay at home due to agoraphobia, live a socially isolated life, or be dysfunctional at work.  It is, after all, their life.  It isn’t the business of the therapist to decide what needs to be changed and to push the client into conformity.

Of course, none of us went into this racket for the money, so obviously we all want to help people.   But this honorable intention can lead us astray by ignoring the fact that the client gets to decide what they want to change, when they want to do so, and how they’d like to go about it.  All we are is advisors.

In recognition of this basic principle, we need to hear the client’s story and resist the impulse to race in with our toolkits.  We need to ask the client what they would like to change.

I do this by having the client imagine a good outcome to therapy.  “What would be different?” Sometimes I’ll have the person imagine someone following them around with a video camera for a week.  “We can’t see what you feel or how you’re thinking.  All we can see is what you are doing.  What do we see in this movie that would tell you things are better?”  This helps us specify concrete change.

But we’re not done.  We still have to ask the client HOW they imagine getting to that goal, and what might hold them back.  Let’s save that for future posts.

Upcoming Talks: The Canadian Psychological Association, June 13-16 in Halifax

It's June, and that means it's time for the annual meeting of the Canadian Psychological Association, this year in Halifax, Nova Scotia.

Beautiful Atlantic Canada

I'll be presenting two talks this year, and there will be much more to see (most of which will be more interesting than listening to me, I'm sure).  Here are my topics:

Preconvention Workshop June 13

Process Made Simpler: A Behavioural Guide to the Therapeutic Alliance.

Therapists are encouraged to be warm, be supportive, be empathetic - but most of these suggestions are phrased in terms of the reaction that we hope to evoke in the client. We seldom discuss exactly what it is we are supposed to do to bring about these reactions. How do we establish a good working alliance? What is that, anyway? And what can we do to make the therapeutic experience more powerful, more effective, and more rewarding for the client?

This full-day workshop emphasizes specific behavioural strategies for enhancing the so-called nonspecific factors in therapy. It will be presented the day before the regular convention opens, so there is an extra charge.  Register through CPA, here.

This workshop will also be offered in Vancouver BC on October 18 2012.  Registration information for the Vancouver program can be found here.

Convention Workshop June 14, 12:30 - 2:30
Creating an Effective Internet Presence: Strategies for Psychologists.

Once, long ago, a telephone was an exotic curiosity employed by early adopters - but it rapidly became a business essential. The same progression has now occurred with a web presence for professionals: If you are not on the net, how do prospective clients know you really exist? This workshop provides specific recommendations about the development of an effective website for the mental health professional, from selecting and registering a name to measuring and enhancing site usage by visitors. Topics include: the respective roles of site designer and site owner; how to select content for posting; why everything you ever learned about writing will get in your way; how not to waste the time of your visitors; the critical importance of the "above the fold" region of your homepage; and how to maximize in-person business via a practice website. We will also discuss strategies for tracking visitors, using online advertising options to promote a site and practice, and some suggestions and concerns about using social media. Finally, the question of whether practitioners should have a blog is considered - and, if so, how to design it, content to include, and ethical issues.

This two-hour workshop is part of the regular convention program and is free of charge for convention registrants.

Hope to see you in Halifax!

Private Practice: Your Burnout Warning Signs

This is it! The Friday series based on my book Private Practice Made Simple (available from Amazon.com and Amazon.ca) has been going on for several months now, and we have come to the end of the adjunct documents supplied at www.changeways.com.  

Summer: Time to get outside.
For example: hiking Stawamus Chief in British Columbia.

It's also summer, so I'm going to call a halt to the Friday post and continue with a weekly posting schedule  at least until September.

This week, however: A topic that almost anyone can relate to, and a form that anyone can use, whether you are a therapist or not.

The burnout continuum

All or nothing thinking pervades our world. We use it without thinking, without noticing. One of the places it comes up is when we talk about burnout.

• "I'm burned out."
• "I'm not burnout out."

Burnout, then, is something that either happens or it doesn't. There are two slots, and you always fit into one or the other. Supposedly.

In fact, of course, burnout is a continuum that runs from "no burnout symptoms at all" to "completely incapacitated." It's like height, or shyness, or physical coordination. Everyone has some, so we are always on the continuum. It's only a question of where. 

If burnout was an all-or-nothing dichotomy, there would be few warning signs. One moment we'd be in one category, the next we'd flash over to the other. 

The fact that it is a continuum means that we flow along it, day by day and hour by hour, rising and falling with the circumstances of our work, the quality of our sleep, and dozens of other variables. One day we feel a little more exhausted, a little less enthusiastic, the next we feel better. 

We hope that we will never migrate fully over to the "burned out" end of the continuum. We can use the small shifts as useful and indeed welcome cues to make adjustments and take care of ourselves.

As therapists, we do precisely the same thing with our clients. We suggest replacing the "depressed or happy" dichotomy with a mood continuum, and invite a calm appraisal of shifts along it, welcoming signs of increased symptoms as useful and nonlethal cues to take better care of oneself.

In the case of burnout, of course, this begs a question. What are the subtle changes that happen as you shift toward the burnout end of the spectrum? What are your cues? What will signal you to take action?

Some sample signs of burnout

At the Private Practice Made Simple workshops I ask therapists to share the changes that they notice when they are becoming just a bit more burned out. Everyone seems to experience the phenomenon in a slightly different way, but here are some of the warning signs they report:

• Not wanting to go into the office.
• Getting behind on administrative work such as billing.
• Snappish at home.
• Thinking more about clients when not at work.
• Not preparing enough before sessions.
• Feeling too tired to exercise.
• Poor sleep.
• Tempted to have an extra glass of wine with dinner.
• Not calling or emailing friends as often.
• Putting off report and note writing until the next day.
• Reluctance to return phone messages.
• Feeling rushed all the time.
• Feeling impatient with clients.
• Talking too much in session.
• Attempting to take control of clients' lives / tell them what to do.

Needless to say, there are many more.

An exercise sheet

There are many forms accompanying Private Practice Made Simple that are posted for free download at www.changeways.com. The page with the complete list of them is here.

Here's a brainstorming sheet to help you identify your own signals of impending burnout:

Your Burnout Warning Signs (pdf)

The form invites you to think of two occasions when you have felt somewhat closer to burnout than usual. Then it asks you to identify the risk factors that seem to have led you there. It starts with external factors: time pressures, too many clients, trouble at home, and so on. Then it invites you to think of internal factors, like physical ailments, difficulty sleeping, little exercise, or seeing clients that mirror your own problems a bit too closely. Once you have your list, the form invites you to rank the importance of these factors from 1 to 10.

Then you are asked to consider how you managed to get your energy back. Chances are, it wasn't just the passage of time. You did something, or something happened. What helped? What brought you back closer to the "not burned out" end of the continuum? It also invites you to consider strategies that you have never tried. Many of these are discussed in Private Practice Made Simple.

The idea, obviously, is that you want to reduce the threshold for becoming aware of impending burnout, so that you notice there is a problem before it gets out of hand. Then, rather than simply hoping the issue goes away, you can consult your list of strategies and actually put some of them into practice.

That's it for now!

Over time, I anticipate that there will be additional posts about private practice issues. But that's the end of the series for the moment. Whether you buy the book or not, I hope that this series of posts and the accompanying exercise sheets prove useful in making your work as a clinician more rewarding and effective. 

Posts on PsychologySalon will continue to appear on a weekly basis through the summer and into the fall.

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Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple, available at bookstores and through Amazon here.

Vancouver Workshop November 29 2013

Click here for information and registration for the one-day workshop Private Practice Made Simple being held in Vancouver Canada Friday November 29.