I have been in my new job as a clinical psychologist for one month now, so it’s time for a update. I still can’t believe how fast the time has gone, it feels like the day is over before it even began. This is good, since it means that I am engaged. There is seldom a dull moment, and at the end of the day I look back and realize I have learnt something new. Already I have touching moments that I will carry with me until I take my last breath.
I have met many interesting people with a plethora of problems. Some with depressions, one with panic attacks, several with traumatized childhoods and also people with anger issues, AD/HD and personality disorders. Since I still see new patients, I haven’t had many conversations with anyone yet, and for many we are still getting to know each other. Finding the correct diagnosis is important, and we can’t move on before we have pinpointed what needs to be looked at more closely.
But even if we haven’t started on direct treatment yet, this first phase is hopefully already a step in the right direction. Although it’s necessary to go through some surveys and standardized questions, there is room for therapeutic work.
The first phase of therapy is often about stabilizion and education. By getting to know oneself better, the path for change is created. For traumatized victims, learning about how trauma effects the body, is crucial. For people with panic attacks, knowing the symptoms and normalizing them, helps a lot. If you understand what happens, it’s easier to start coping with it. In some ways, fear of symptoms is what many struggle with the most. When we face or monsters in a controlled way, we can finally watch them from afar and act like we want to.
Elizabeth Gilbert described in her book ‘big magic’ how she looked at fear: Fear is always with her, telling her that she should be careful. Prodding her to not take chances, because she might get hurt. She has learnt to thank her fear, because it wants to protect her. At the same time she also tells her fear that it can be there and monitor her surroundings if it wants to, but she must take command. She soothes herself by accepting that she will feel terrified and unsafe, at the same time as she assures herself that she can cope with what comes.
Many of my patients are still afraid. And that’s okay. We all are, often. I will not promise a rose-garden, but I want to explore the area they walk in no matter what is there.
My first week in my new job has gone really well. Already it feels like the day is over before it began, even if I’ve just had three patients. But there has been meetings, conversations with lovely new colleagues and learning new routines. It looks like the patients I will have a myriad of issues that will challenge me in a good way. Since my area of expertise is trauma, my training in treatment models not pertaining to trauma-treatment is somewhat limited. But it still is exciting and probably even necessary. Having just traumatized clients can be taxing, since they require your full attention. Containing their feelings can also affect therapists in the long haul, so treating clients with different problems is advisable. The three clients I’ve met so far, have myriad problems. The first is there for a diagnostic evaluation and treatment of anger issues, the second most likely has Asperger in addition to personality disorders and the third depression and a eating disorder.
I knew it would be good to finally do clinical work again, but it was even better than anticipated. In addition the clinic I am working in is excellent. The employees are highly skilled, and to my utter amazement they are especially interested in trauma. I don’t think it could get better, but my gut feeling is that it will be.
I’m back where I belong and it feels like finally coming home.
This is a reblog from Damon Ashworth Psychology! A brilliant post that I hope will be helpful and interesting.
When clients first begin their therapy journey, they often ask to be taught specific skills that are going to help them achieve their specific goals.
They believe that if they can be taught these skills, they will be able to overcome their difficulties, or the problems that led to them entering therapy, and they will have no subsequent difficulties or need for additional therapy going forward.
Cognitive Behavioural Therapy (CBT) is a short-term treatment that clients can easily understand. It is based on the premise that all difficulties arise from unhelpful cognitions (beliefs, expectations, assumptions, rules and thoughts) and unhelpful behaviours. CBT aims to help clients see that their cognitions and behaviours are unhelpful, and tries to teach them skills that can help them to replace these unhelpful cognitions and behaviours with more helpful ones. If this is achieved, the assumption is that clients will change and therefore improve.
I do believe that if a client is able to have more helpful cognitions and behaviours then they will have significantly improved psychological health and overall well-being. I’m just not sure if I agree that the process that is required to get to this outcome is the same as what many CBT clinicians would believe. In fact, focus on distorted cognitions has actually been shown to have a negative correlation with overall outcomes in cognitive therapy for depression studies (Castonguay, Goldfield, Wiser, Raue, & Hayes, 1996).
What actually leads to improvements across treatment?
My previous article “What Leads to Optimal Outcomes in Therapy?” answers this question in detail and shows that the outcome is dependent upon (Hubble & Miller, 2004):
- The life circumstances of the client, their personal resources and readiness to change (40% of overall outcome variance)
- The therapeutic relationship (30% of overall outcome variance)
- The expectations about the treatment and therapy (15% of overall outcome variance)
- The specific model of treatment (15% of overall outcome variance)
For cognitive therapy for depression, both therapeutic alliance and the emotional involvement of the patient predicted the reductions in symptom severity across the treatment (Castonguay et al., 1996). Many therapists are now aware of these findings, but clients are generally not.
What do clients view to be the most valuable elements of therapy once they have improved?
By the end of treatment, especially if it is a successful outcome, clients tend to have a much different outlook on what they think are the most valuable aspects of therapy when compared to what they were looking for at the beginning of their treatment.
In Irvin Yalom’s excellent and informative book ‘The Theory and Practice of Group Psychotherapy’, he goes into detail about a study that he conducted with his colleagues that examined the most helpful therapeutic factors, as identified by 20 successful long-term group therapy clients. They gave each client 60 cards, which consisted of five items across each of the 12 categories of therapeutic factors, and asked them to sort them in terms of how helpful these items were across their treatment.
The 12 categories, from least helpful to most helpful were:
12. Identification: trying to be like others
11. Guidance: being given advice or suggestions about what to do
10. Family reenactment: developing a greater understanding of earlier family experiences
9. Altruism: seeing the benefits of helping others
8. Installation of hope: knowing that others with similar problems have improved
7. Universality: realising that others have similar experiences and problems
6. Existential factors: recognizing that pain, isolation, injustice and death are part of life
5. Interpersonal output: learning about how to relate to and get along with others
4. Self-understanding: learning more about thoughts, feelings, the self, and their origins
3. Cohesiveness: being understood, accepted and connected with a sense of belonging
2. Catharsis: expressing feelings and getting things out in the open
1. Interpersonal input: learning more about our impression and impact on others
The clients were unaware of the different categories, and simply rated each of the 60 individual items in relation to how helpful it had been to them.
What becomes apparent when looking at these categories is that giving advice or suggestions about what to do is often not found to be a very helpful element of the therapy process, even though this is exactly what most of the clients are initially looking for. What is far more important is the client developing a deeper knowledge of themselves, their internal world, and how they relate to and are perceived by others in interpersonal situations.
The top 10 items that the clients rated as most helpful were (Yalom & Leszcz, 2005):
10. Feeling more trustful of groups and of other people.
9. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same.
8. Learning how I come across to others.
7. Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others.
6. Expressing negative and/or positive feelings toward another member.
5. The group’s teaching me about the type of impression I make on others.
4. Learning how to express my feelings.
3. Other members honestly telling me what they think of me.
2. Being able to say what is bothering me instead of holding it in.
1. Discovering and accepting previously unknown or unacceptable parts of myself.
Each of the 20 clients that made up these survey results had been in therapy for an average of 16 months, and were either about to finish their treatment or had recently done so. Obviously these items were in relation to group therapy, so the most important factors for change across treatment in individual therapy may be different. However, even with individual therapy, Yalom believes that in the end, it is the relationship that heals.
For more information, feel free to check out Chapter 4 in ‘The Theory and Practice of Group Psychotherapy’ by Irvin Yalom and Molyn Leszcz (2005), or any of the other studies out there that look into the outcomes or therapeutic factors involved in change across psychological treatment.
If you have ever wanted to discover and learn more about yourself, accept yourself more, express yourself better, take greater responsibility for your life, challenge yourself and develop more trust in others, a longer-term psychological therapy may be just what you need!
I have been listening to colorblind from glee cast a lot lately. Simply a beautiful song with lyrics that speaks to me. I am adding the video here and hope you like as much as me.