Tag Archives: Mental health

CBT – Why some people might not like it.

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.

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!

Why do people become therapists?

There are academic research studies published about the various reasons why people choose to become therapists. Have a Google, it is rather interesting. If you would like to know why I became a therapist read on…….

whyAged 19 I had a very promising career in opera and classical music ahead of me. The pleasure I got from singing gradually reduced over time as the pressure increased. I became more and more disillusioned with the classical singing world and eventually decided that despite my talent, this it was not what I wanted for my career anymore. I was then at a loss. Even if I had wanted to pursue a musical career it had started to become apparent that it was too physically demanding for me (I now know this  is due to Ehlers-Danlos Syndrome although I was undiagnosed at the time) My life had revolved around music from the age of six. What on earth was I going to do now?

I remember getting out a piece of paper and a pen. I thought that if I made a list of all the things I enjoyed, that it might be helpful. The first two things I wrote down were;

  1. People
  2. Animals

I briefly entertained the idea of becoming a veterinary receptionist, but did not know where my career would go after that. I then realised I was more of a dog person than an animal person.

I was then left with just people. I love people. I really do. I have always been fascinated by why people behave or think in certain ways. Just for my own pleasure I would watch anything to do with psychology on television and read anything I could get my hands on. I don’t remember but apparently when I was in infant school, before I started studying music, I would tell people I wanted to be a psychiatrist. People very close to me had experienced psychosis and depression, so I was also aware that mental health problems were very real.  One of the main issues I had with my career as a classical singer, is that I did not find it meaningful. Although I greatly appreciate the benefits of entertainment for others, I was so wrapped up in my own performance nerves that I could not appreciate it. I had this urge, and still do – to help people. I did not feel I was helping people with my singing voice.

The next natural step was to find a way to combine psychology with my love of people. I did some career research and decided that I would like to go into psychological therapy. I did not feel that a counselling course would provide me with enough depth or breadth to enable me to make informed decisions about which type of therapy I’d like to study (that is not to say I do not think counselling can be helpful for others. I sometimes refer people on to counselling if I feel it may more appropriate for them than CBT, and during my career in mental health I have met many people who have found counselling beneficial). It was very important for me to become and member of the British Psychological Society and so I enrolled to start BSc Psychology. Ironically before beginning my degree I became very depressed. This was before IAPTs existed and I saw a psychologist within the NHS and had what I now realise was CBT based therapy. I then went on to have cognitive-behavioural therapy to try and help manage chronic fatigue. I kind of fell in love with it (CBT not the fatigue!). People close to me had also had CBT. Whilst it is not a miraculous cure, it really had a meaningful effect on my life and my nearest and dearest. I wanted to offer the same support to others, with a therapy grounded in a solid evidence base. I still kept an open mind and studied many different perspectives during my degree.  I graduated and worked in different roles in mental health. I got to witness the impact of CBT on lots of different people. My love and respect for CBT only deepened, so I took the plunge and trained did my post graduate diploma in cognitive behavioural therapy –  and the rest as they say is history!

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.