Monthly Archives: October 2013

Why the concepts of mental strength and weakness make me feel uncomfortable.

We are not mentally strong or mentally weak. We are mentally human.

dumbell

How many times have you heard someone say ‘S/he must be so strong to cope with what she does’? Or how about ‘some people are just weaker than others’ – how many times have you heard a statement like this or something similar?

These statements suggest that the way in which each of us reacts to different situations in life is dependent on how ‘strong ‘ we are. If we believe this then by association we must also buy into the idea that those who become extremely distressed by certain events, to the point of clinical depression, anxiety or psychosis are ‘weak’. I don’t know about you, but that sounds wrong to me.

We are all here, not of our own choosing, we just happened to be born. We did not choose our individual genetic makeup, the parents we would be born to, or the socio-economic situation we would be in. Some psychologists believe that we are born with a certain set of personality traits, some more dominant than others. For example I am an extrovert, there is no getting away from it, but I did not choose to be that way.

Rather than thinking about the way people respond to distress as being a sign of strength or weakness, I think it is much kinder to think of the way people react as being  somewhere on a continuum of resilience. For example the chemicals, neurotransmitters, hormones and structure of my brain perhaps do not predispose me to schizophrenia or psychosis. Does this mean I am ‘stronger’ than someone with schizophrenia? I don’t think so. I think I am lucky, that my particular anatomy means that I do not develop psychosis.

Let us consider depression. If I were to lose my job, feel down about it for a while and then feel optimistic about finding a new one, does that mean the person who is made-redundant and becomes extremely depressed, with feelings of hopelessness about their future is weak. I do not think so either. Perhaps that person does not have a close support network of friends and family around them, or perhaps they know that if they cannot pay their rent they will end up homeless. Even if were to take two people who have exactly the same life experiences and encounter a difficult life situation, and one becomes extremely anxious whilst the other remains calm, does it mean they are ‘weak’. I don’t think so, perhaps their particular set of hormones, chemicals and all the other physical parts of their humanness mean that are more biologically geared to respond with anxiety. So for whatever reason, I think that in different situations we all have different levels of resilience when we are faced with a potentially distressing situation. Our levels of resilience are often influenced by elements that our out of our control; biologically, socially and economically. I hope this makes you think more kindly about others and yourself. We are not mentally strong or mentally weak. We are mentally human.

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What really goes through my head when I make a self-disclosure

How can I expect my client to trust me, if I am unprepared to ever appear vulnerable?  How can I expect my client to comfortably explain a missed session or extended absence from therapy, if I am unprepared to do the same?

In a clinical context self-disclosure refers to the act of revealing personal details about yourself to your client.  I think self-disclosure in a therapeutic sense can be broken down into two different types;

  • self-disclosure in order to aid the process of therapy
  • self-disclosure when my personal life impacts on my work as a CBT therapist

For me, both types of self-disclosure are equally important as part of effective cognitive-behavioural therapy and are wonderful tools to build trust within the therapeutic relationship. In my experience many therapists are frightened of self-disclosure as in our training the importance of ‘boundaries’ is consistently drummed into us, from lecturers, clinical supervisors and academic literature.

However, I believe that whilst cognitive behavioural therapy is evidence based,  (which I strongly believe in, and support) there are some aspects of any type of psychological therapy and many medical interventions that make it an art. It is well-known that it is very difficult to measure empathy and the strength of a therapeutic relationship.  Measures of such things are highly subjective, and necessarily so, we do not have a better way of measuring (apart from extremely expensive neuro-imaging equipment) such intricacies other than self-report. Nevertheless, just because we cannot accurately measure something it does not mean it is not essential or unimportant.  For example, try to describe and measure love…… very difficult.

As a  scientist-practitioner and a social scientist the art of the therapeutic relationship is built upon trust. How can I expect my client to trust me, if I am unprepared to ever appear vulnerable?  How can I expect my client to comfortably explain a missed session or extended absence from therapy, if I am unprepared to do the same? It’s all very well saying to a client “I’m ill” and not expanding on it, but I find clients then often ask questions. Turning round and saying ‘I cannot tell you what’s wrong with me because it may affect our therapeutic relationship and would break boundaries’ sounds reasonable enough. However, clients are then likely to feel rejected (after all they haven’t studied the science and research behind boundaries) and moreover, worried. They may think, ” does she have a life threatening illness?”, “has she got an illness that gives her pain so it means she can’t concentrate during out sessions?” etc… In instances such a these I find truth is very powerful. By telling my client about my illness, I am given the opportunity to reassure them that my competence is not affected (otherwise I would not practice) and it also says to them, “I am a vulnerable human being just like you and that’s ok.”. Clients are so grateful for my honesty and it invariably builds mutual understanding and trust.

The other type of self-disclosure works slightly differently. This is useful for therapeutic gain by demonstrating to your client that in some situations you can personally relate. This communicates that as a therapist you are also vulnerable and imperfect but also shows that you practice what you preach. For example I am happy to tell my clients that struggle with insomnia that I have struggled with this in the past and still do from time to time.  Certain CBT techniques work better for me than others and I appreciate than sleep hygiene is not an overnight cure (pardon the pun) and that it can be tough and sometimes take perseverance before benefits are to be had.

I will not bore you with what are and are not appropriate self-disclosures, as this is very much down to personal discretion and a matter I have (and all therapists should) discussed in clinical supervision. I guess my message is this: Self-disclosure is a beautiful thing, therapists need not fear it as long as your intentions for self-disclosure are always in the best interests of your client and are not damaging to your own mental or physical health and well-being.

How I feel about perception polarisation and parity of esteem

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This photograph demonstrates nicely the vast difference between the way physical and mental illnesses are viewed and interpreted by ourselves and others. The depth of shame some of my clients feel about having a mental health issue saddens me greatly. As one of my heros, the wonderful Paul Gilbert says, ‘none of us choose to suffer’. To find out more about the work of Paul Gilbert please visit http://www.compassionatemind.co.uk/. In the same way that we do not choose to have agonising tooth ache, we also do not choose to feel frozen with anxiety, hopeless with depression or terrified by hallucinations. A fantastic article by psychiatrist Alex Langford, in The Guardian today, conveys how pervasive the polarisation between services for emergency physical and psychiatric care is.  To read Alex’s article Why mental health bed cuts make me ashamed to work for the NHS click here. To read Alex’s blog The Psychiatry SHO* click here.

Daily I encounter another demonstration of perception polarisation. Most people think nothing of telling their friend/colleague/relative that they have physiotherapy every week, but how many of us would feel comfortable telling those same people that we see a psychological therapist every week. Makes you think doesn’t it. We all need to strive for parity of esteem – making sure the same provisions are in place for all types of illness, physical and mental. However, more than that we need parity of esteem in the way we judge mental and physical illness in relation to ourselves and others, because until we shift our own perceptions, how can we expect others to change theirs?

I describe my excitement at meeting a new client, how I am rubbish at imagining what people look like, my belief that people should always be treated as humans – not statistics and how I wish I had a magic wand.

I always feel very excited before I meet a new client. I get butterflies in my tummy. I am aware of the anticipation in the air from both myself and the new person I am meeting. The overriding thought in my head is always ‘Will I be able to help them?’. I imagine clients often think ‘Will she be able to help me?’ (Although when they actually see me they probably think ‘Wow – she is really short!’). I think my excitement comes from several things

  1. I just really love people
  2. I really love my job – the prospect of being able to use my skills to support someone.
  3. I genuinely get excited during an initial assessment, if from what a client is telling me, I think CBT will be helpful for them in someway. If I don’t think CBT will benefit them I feel a bit sad, though I’ll always sign post them to somewhere/someone who I hope will be able to help them in a different way.

When I first physically see a client, I am always fascinated between the difference between the real person and the image I have built up in my mind of what they look like. I am invariably wrong!

I feel incredibly privileged during our first session. This person is trusting me, who is a complete stranger to them with some of their innermost thoughts and fears. Yes, I have formal qualifications, but I hope that right from the start I emit compassion and reassurance. I have met some people with so many qualifications in therapy and mental health that they are almost coming out of their ears, but they give off an air of what I can only describe as ‘clinical coldness’. Sometimes arrogance accompanies this too. Whilst I want to inspire confidence in people, I would be so upset if I ever seemed cold or disinterested. This is a human being, not a subject, participant, product, statistic or unit.

I aim to create a space of safety and trust and hope I to convey this very quickly to a new person.

I feel such a surge of empathy when my client first tells me their story. I wish that I had a magic wand and could take their pain away. I totally believe in cognitive-behavioural therapy, but there is no getting away from it; therapy is hard work. I sometimes feel angry when I hear stories of injustice, abuse or violence. In spite of these feelings, ideas of possible helpful techniques start flowing through my mind. I mostly leave first sessions with people the same way I felt before – excited! I’m excited about the work we are going to do together to help them (even if I do still wish I had a magic wand).

Why do I have clinical supervision, and how do I feel about it?

Firstly let me explain exactly what my understanding of clinical supervision is, for those of you that would like to know. I will then describe how I feel about clinical supervision, before, during and after a session. 

What is clinical supervision, and what do I understand it to be?

Clinical supervision is different to the general concept most people have of the English word ‘supervision’. In a nutshell it isn’t supervision in the sense of having a manager like you might in a job, giving you orders. Your clinical supervisor is not someone you are accountable to for your work, you are accountable for your own practice  (however when you are a student the relationship is slightly different). Clinical supervision is there to support therapists in their work, it is not therapy for therapists.

I can only talk about my experience of cognitive-behavioural psychotherapeutic supervision. To me, my clinical supervisor is someone who helps me look at my clients problems and goals from different perspectives when I need an alternative way to support someone. They also make sure I keep on top of my clinical skills, and help me improve them where necessary. This can be done in various ways, for example by listening to recordings of sessions (recordings are only ever made with the consent of my client and I always tell them that my supervisor is much more interested in what I am saying than them, which is true!), or role playing different scenarios during supervision  My supervisor also helps to monitor how my own thoughts, feelings and behaviours may be influencing my work, positively and negatively. For example, a clinical supervisor, from their external perspective may be able to notice if my stress levels might be interfering with my work, before I am able to notice myself. Or perhaps they may identify that the themes I am discussing with a client are too emotionally relevant to me for me to remain objective. In other words, in would not be appropriate for me to support a client through a bereavement if I was still grieving profoundly myself.

How do I feel before, during and after a supervision session?

When I was a student, and first started my training, I felt very nervous before supervision. I was worried that I wouldn’t be good enough and that I would be constantly criticised. Well I was right! I wasn’t good enough, but how could I possibly expect to be, I was learning! However I soon began to be accepting of my inexperience and my wonderful supervisor would constantly remind me to ‘allow myself to be crap’! I was also constantly criticised, but in a very constructive way, with both positive and negative comments.

Nowadays, before supervision I am invariably aware of one strong emotion. Excitement! To be honest I am a bit start struck by my current and previous supervisors. These are CBT practitioners with far more years experience than me, and are aware of so many more different resources and useful books/workshops/exercises than I am, and frequently point me in the right direction. I am also eager to get ideas from someone else about how to help a client, when the client and I are struggling with something. I often have light bulb moments in supervision along the lines of ‘of course, that would be so helpful, why didn’t I think of that?’ or ‘ Wow, that sounds really interesting, I am not familiar with that way of doing things and I really want to learn more about it’.

During supervision I feel inquisitive. I always want to know how I can do things better, and of course I feel warmed when my supervisor compliments me on something I have done well ( I have a tendency to be very hard on myself). Sometimes, being a therapist can be a lonely profession. Nobody else is in the room with you (at least in individual therapy) except the client. Of course clients often say lovely things to me and express their gratitude, which feels great (although I genuinely think the hardest working person is my client; therapy can be hard work). However, when a client is really suffering or things are rather difficult, you don’t have a colleague alongside you to say ‘it’s ok, you are doing a good job’. It is only in supervision where you can describe a difficult situation and get someone else’s opinion on what you decided to do.  After supervision, my overwhelming emotion is feeling inspired. I come away with lots of new ideas, different ways to help my clients and new exercises, and concepts to learn about.

At this stage in my career, supervision provides me with someone to give me a fresh perspective on things, to help me recognise my strengths, or make improvements where needed, and to metaphorically and sometimes literally give me a pat on the back.