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.
In this video I talk about some of the reasons I think people have a bad experience with, or don’t like CBT. It touches on various things such as the way CBT is delivered, people’s expectations and cognitive behavioural therapy for chronic pain and chronic illness. I’d be really interested to get people feedback on it, and wonder if anyone who has had CBT can relate to any of the issues that I address.
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!
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.
We are not mentally strong or mentally weak. We are mentally human.
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.
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.
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
- I just really love people
- I really love my job – the prospect of being able to use my skills to support someone.
- 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).