Category Archives: What really goes through my head when…..

Daily or Weekly CBT insights. What do you think? 

It’s been a long time since I’ve blogged. I’ve really been missing it. I am thinking of doing a series of regular blog posts sharing how I am using CBT in my own life each day. I’m hoping this will serve as a reminder to those who have already received some form of CBT or introduce new people to the benefits of cognitive behavioural therapy.  Being a Mummy to a 10 month old baby means that committing to blogging every day probably isn’t realistic, as much as I’d like to. I might manage a daily insightful tweet but even that can be a chore with a baby.  Instead I was thinking of doing a weekly blog post sharing in which ways CBT has enhanced my wellbeing for each preceding week. I’d be really grateful for any feedback or suggestions anybody has about this idea. I’m really looking forward to connecting with my followers and a wider audience again.

How it feels to be bullied on twitter

 “Thank you, I’m glad you told me the truth, I would have worried you were terminally ill otherwise”. This statement is indicative of why I will continue to self-disclose despite being bullied on twitter.

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The other night I was taking part in a really great scheduled mental health chat on twitter about CBT. Obviously I was really excited, I participate in this group chat most weeks and I was so pleased that this week’s topic was one so dear to my heart. I was talking about how I find self-disclosure to be an effective therapeutic tool. After the chat two other mental health professional people started saying; it was a fact that self-disclosure was never appropriate, that my behaviour was unethical, unacceptable and that I must be youngish, inexperienced and ‘done a course in CBT (inferring I was not properly trained)’ and were worried. These people know absolutely nothing about my clinical practice, and have no right to make assumptions about me as a person or my professional conduct. I am not sure which professional body they belong to, but raising concerns on twitter and making defamatory statements about another clinician is breech of the British Psychological Society’s social media policy. Of course it is ok to have differences of opinion, I frequently have differing views to those of other professionals on twitter. However, differences in opinion should always be expressed in a respectful way and never become personalised or accusatory, especially in a public forum.

I usually regard myself as a confident and assertive person, but to be harassed in this way and have my professional integrity attacked was extremely upsetting. If someone as usually resilient as me can feel so hurt, then it begs the question as to how severely affected those that are at a particularly vulnerable time in their life could be when on the receiving end of such nastiness?

The other side of the situation is this. So many mental health services users, psychologists, therapists and other mental health workers publicly and privately gave their support to me, and nobody condoned their behaviour. I am so touched by all the support I have received, I sincerely thank each and every one of you.

These tweeters took issue with the fact that I tweet about my medical problems and posted a photo of myself in a hospital gown. I feel very strongly that having long term health conditions are nothing to be ashamed of, and I never hide them from my clients. In fact the frequency of which I sometimes need to apply eye drops means it is impossible to hide from clients, and why would I need to anyway? I simply explain to clients in the first session why I need them. I believe telling people the truth, especially vulnerable clients, is much preferable to what people may imagine. For example, one client said to me “Thank you, I’m glad you told me the truth, I would have worried you were terminally ill otherwise”. How can I expect my client to learn to manage their long term or permanent health condition if I am actively trying to hide mine? I believe being open sends out a positive message, I have several chronic health conditions but I have learnt to manage them well, so I believe others can too. My health problems shape who I am. There is no doubt they influence my therapeutic practice, but I believe for the better. For those who are lucky enough to be healthy they cannot possibly understand how it feels to have a permanent disability or illness, how it feels to have an unpredictable illness, or live with chronic pain. That is not to say that therapists need to have personal experience to deliver effective CBT, but the added lived experience and personal insight I can offer is sometimes very powerful for clients, an added bonus of having me as therapist if you like.

So I will continue to tweet photos of me looking fabulous in my hospital gown, and raise awareness about eye health and adverse reactions to medication by sharing my own publically! If people do not like it, they do not have to have me as a therapist. There are plenty of therapists out there that will reveal absolutely nothing about themselves, and that is fine – I see no reason for me to criticise them, we simply have a different approach. I refuse to shy away from public media for fear of criticism. I have blocked those two individuals on twitter, I no longer respect or have any interest in what they have to say. My wonky spine and I (shhhhh I have scoliosis don’t tell anyone!) will be tweeting for a long time to come. I am chronically ill, but I am also chronically fabulous!

What really goes through my head when I get dressed for work.

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What do you wear when you are working as a therapist? Read on to find out how I choose my clothes, and why I wear the things I do. Fashion and CBT not the most likely of topics, but a subject that I find quite intriguing. 

When I first started my CBT training, I asked my clinical supervisor ‘what should I wear when I start to see clients?’ He looked at me puzzled and replied ‘Clothes, Alieshia!’. ‘Very funny’, I said but seriously, I said, ‘how do I know what to wear?’. He looked at me again and could see I genuinely wanted advice. He said ‘as a woman you don’t want to wear anything that is too revealing, simply because it is too distracting for clients’. I said ‘yes, I had already thought that, I have never worn anything that shows my cleavage or is too short whenever I have worked in the caring profession. I agree. But apart from that how do I know what to wear?’ He looked at me again, surprised that I still was not satisfied with his answer. He looked down at himself and said, ‘I just wear this’. He was wearing a pair of jeans and a polo shirt. I looked at him and said ‘Yes, that is fine, but you have many years of experience and look your age, I don’t’.

My issue is that I look very young. Only the other week my new cardiologist started asking my Mum about my usual energy levels at home. My Mum had to turn round and say, sorry Dr S****** but Alieshia lives with her husband, she is actually 29. He turned round and apologised to me, he had thought I was still a teenager, living at home.

I feel that if I turned up to meet clients in a polo shirt and jeans that I would look so young that they may doubt my clinical capability and lose confidence in the therapeutic process, which would be counter-productive. For me personally it’s important for me to dress in a way that looks professional and choose an outfit that makes me look at least 20, I mean this sincerely, I do not jest. I have discussed clothing with some other therapists. My colleagues do not have the age issue to contend with but are honest with me, and can understand why it is important for me to dress in way which enhances my age.

So aside from the age issue, what other factors are there to consider when I dress for work?

For me I think it’s great that my first clinical supervisor wore casual clothes. On one level, I believe what you wear should not matter, CBT is a collaboration and not a platform for power dressing. By wearing jeans, it could convey the message that ‘I am relaxed, it’s ok for you to be too’. I can particularly appreciate how this might be great when working with children and young people. Business attire can sometimes be intimidating. However for me personally I believe that dressing smartly (not a three piece suit or anything, but smart trousers, top and shoes) conveys to my client ‘I respect you and have made an effort to dress this way. I am a professional and I want you to have confidence in that from everything, from the way I speak, the content of what I say, the way I conduct myself and what I wear’.

Some therapeutic approaches discourage from any personal expression and therapists will wear exactly the same outfit, or extremely similar clothing to each session. CBT is not like that, I have never come across any literature that discusses proper work attire! I still feel able to express my personality through my clothing and make-up without being distracting to my clients, whilst still being professional. What do you think about what your therapist wears? Are you a mental health professional, have you ever considered your work attire? Let me know in the comments below, or send me a tweet.

On a final note I shall leave you with this memory…… I wore a yellow top one day with matching yellow nail polish. In the morning my client said to me ‘Alieshia, you look like a ray of sunshine’. The next day my supervisor said to me (I had a different top on, but the same nail polish) ‘Alieshia, that is the most disgusting colour nail polish I have ever seen. It’s horrible’. Make of that what you will!

What really goes through my head when I break confidentiality

I have been asked my quite a few people to write a post on how I feel when I have to break a client’s confidentiality.  Read on to see how I have felt in this situation, and why it’s good for other professionals to be pedantic.

To date I have never had to break the confidentiality of a client who I am seeing for cognitive-behavioural therapy. In all the situations that I have encountered where it has been essential for me to inform my client’s GP (or somebody else) about something, I have been able to discuss it with them first.

However, In previous roles working in mental health I have had to break my client’s confidentiality either without their consent, or without attempting to gain their consent in the first place. Breaking confidentiality only ever happens (or should only ever occur) when the client or others are seriously at risk. Whenever I have had to do this, it has been my client’s health and life that could potentially be threatened, because if I had not taken immediate action and/or if by asking them for consent I would have put them at further risk. I will not discuss individual cases on here, for confidentiality reasons (I mean this sincerely, no pun intended). More to the point, this post and blog is about my own thoughts and so it is not even necessary.

There is no doubt that when I have broken someone’s confidentiality I have felt guilty. Although I have always felt very confident that my actions were essential and definitely within my client’s best interests, there is no getting away from the guilt. The clients I have worked with, I have built good long standing relationships with, over many months and in some cases years. Sometimes I have been the only person they have really trusted, and to go and do something that puts that trust in jeopardy is so difficult. I have been lucky, my clients have always understood the reasons for my actions and we have come out on the other side, but for other professional-client relationships this is not always the case. I can only speak for myself here, but I have only broken my client’s confidentiality when I have felt that if I did not, their life may have been at risk or they were  likely to become seriously unwell. Although in all good therapeutic relationships your client is always told that in exceptional circumstances there confidently may be broken, it still does not mean this is an easy thing to do. The thought of somebody doing it to me – no matter how good their intentions, makes me feel vulnerable, scared and almost invalid as a person. It’s horrible to think I may have made other people feel this way at some point or other.

I have had positive experiences when I have needed to obtain information about my client without their knowledge. Other professionals have thoroughly checked me out and my reasons for wanting the information before releasing it. Good. This is the way it should be. I would not want somebody to tell me private details about someone else, without them making sure I was who I said I was first, and that it was essential for me to have the information. In these situations the more pedantic someone is the better.

Breaking confidentiality is never nice, should never be unwarranted, but at the end of the day, sometimes it is necessary to literally save somebody’s life – so I’ll take the guilt any day.

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

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

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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.

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).

What really goes through my head when I care too much for a client or dislike them.

Cynics sit down to read this. In brief I care about all my clients in equal amounts, but the way  in which I think about them and approach them in therapy can be qualitatively different.  Read on to find out why disliking myself is much more of an issue for me than disliking a client. Thank you to @SecretSchizo for suggesting such a great topic.

This question was posed to me by @SecretSchizo on twitter (thank you for such a great topic suggestion). For ease of reading let’s split it into two sections. Firstly I will talk about what goes through my head when I care too much for a client. Ok, brace yourselves (especially the cynics amongst you). I genuinely care for each and every client I have ever had. I can honestly say I have never encountered a client in any of my different roles within mental health care that I have not cared about.  So what about those I care for too much, or like more than others? For me I can’t write about this without considering what happens to my thoughts about clients after work. I have always been very lucky in that I can always switch off very easily after work, no matter how distressed clients have been. I believe that the reason for me personally is this; I know that during my time with my clients and any time spent working for them (even when not in direct contact with them), I know that I have done my very best for my client and everything within my power to help, support and safeguard them. I suppose having this resolve means that whilst I still have a healthy concern over their well-being, I am at ease with my own conscience as a professional and more importantly as a caring human being. So in this respect I never ‘care too much’ about any clients, as I care a lot about them all! Of course, just as in everyday ordinary life, there are some clients that I build a rapport with more quickly and that I have more in common with (although they probably do not know that, as I do not disclose much about my personal life) and it is easier to relate to them. However this in itself is dangerous: if I think I ‘know how they think’, I am more likely to make assumptions about them, which could be inaccurate. This is something I try and be aware of at all times.

In terms of how I respond to clients in terms of anything other than the actual therapeutic process, I have a fierce dislike of injustice (even though I understand that life cannot always be fair) and so I always treat clients the same in terms of missed sessions, abusive behaviour etc. Boring, but true.

Ok, so on to what happens when I dislike a client. Again, make sure you are sitting down. I have never encountered a client who I do not like. Now, that is not to say I don’t deal with clients whose behaviour I do not like, or their attitude, but I essentially believe that all humans are good. I may not like the way a client ‘presents’ i.e. their behaviour towards me, their actions, the severity of their problem etc, but for me I see this as an opportunity for me to learn how to build a good therapeutic relationship in circumstances that may not be the easiest. Also in these situations, I am less likely to make assumptions about ‘what they think or feel’ if their behaviour or attitude is very different to that I may have experienced personally.  For me the biggest problem, and something I have explored in clinical supervision, is that with certain clients I dislike myself. I have a tendency internalise situations, so if a client isn’t reaching their goal, the negative automatic thoughts that go through my head are ‘it’s my fault’, ‘I am not a very good therapist’, ‘I bet Joe Blogs (insert the name of any other therapist I respect) would have dealt with this much more effectively than me’, and so I have to work at challenging these thoughts and assumptions in exactly the same way as I teach my clients to. Above all I am learning to accept that I am an imperfect, flawed human being. Ultimately whether I like a client or dislike myself when with a client, I am eternally grateful to my strong sense of self in that I always know that I do my very best for my clients – from the moment of first contact, until our last contact, and what more could anyone (including myself) ask from me than that?

What really goes through my head when a client is late.

In brief, when clients are running a bit late, I can often be found sharpening my non-mechanical pencils (read on for my feelings about different pencils and an analogy featuring a roast dinner). When clients are consistently very late, it is an indicator to me that there is a big practical issue or a psychological barrier, and these things can be worked through together.

When clients are late, the same thoughts go through my head as in my personal life, if a friend was running late. Typical thoughts I have are ‘the traffic might be bad’, ‘perhaps they have finished work late’. Nothing much more exciting than that really, I am sorry if it is a disappointment. I don’t take lateness personally; the modern hectic lifestyle of today provides so many obstacles to punctuality. The main emotions I feel are frustration and sadness, not directed at my client, but at the situation, and the reason is this: When my clients are late (regardless of the reason) it means our time together is shortened, which means less time for therapy, in turn leading to reduced opportunities to work on their goals. If a client’s lateness is something that is within their control, then this can often be used as tool for discussion and implementing cognitive-behavioural techniques.

More often than not clients will tell me why they are late without me asking. If they do not, I do always enquire as to the reason to try and understand whether it is merely a practical issue (such as a traffic jam) or whether it may be more directly linked to their emotions, i.e. perhaps they are nervous about something we might discuss in the session. If a client is more than around twenty minutes late, it is often not appropriate to start a session as there is not time to cover and properly review the necessary items and it is much better to reschedule. To put this in an analogy, you wouldn’t begin eating a roast dinner only eat half of it, stop (even though you are still hungry) and then leave the other half until a week later would you? However, eating a roast dinner, and missing a roast potato or two isn’t the end of the world (the couple of roast potatoes representing being 5 minutes late).

It’s great when clients are able to let me know they are going to be late, often they will text me and let me know. That being said I would much prefer it if clients who are driving and running late, do NOT to text me and put themselves and others in danger. I am quite content sharpening my pencils (I have a healthy stationery obsession, how I love a freshly sharpened pencil, mechanical ones just don’t do it for me), chatting to reception staff etc.  Ultimately, when clients are late for their session, it is them that is missing out, not me and so I don’t get my knickers in a twist. In fact I have the upmost respect for clients that manage to get to therapy every week, despite often leading incredibly busy lives, sometimes with others dependent on them. What a wonderful commitment to themselves and a huge compliment to me that they see me as a therapist that is worth investing their time it takes to travel to see me. Yes, it would be wonderful if clients could always be on time, but as soon as my client arrives, whether it be early or late, my aim is always to make the best of the time we have together. I guess I have mainly talked about lateness in terms of being 5 or ten minutes late. If a client of mine is consistently very late, I always address this quickly. If it is a practical problem, we try to find a solution to this. If it is psychological in nature then this is explored too.

I think it is worth noting that being late and missing sessions are two completely different things in my view. This post is about lateness, if you are interested on my thoughts about missed sessions please comment and let me know.