Learner Therapist (64) … Test myself, test my patients

Torrey Orton

Oct. 06, 2015

Feedback Informed Therapy (FIT)

It is claimed, with reason, that the most effective therapists are those who seek constant and consistent feedback on patient experience of their therapy provision. The International Centre for Clinical Excellence offers research backing for this claim and tools for feedback informed practice. I find them sensible but unremarkable, being an obsessive self-doubter about my therapeutic effectiveness, which springs a little from my tendency to self-denigration and a lot from my constitutional scepticism.

My skill at feedback seeking and giving has been fashioned and refined during years spent in various educational roles ranging from teacher to instructor, coach and, drawing up last, therapist. I became accustomed to checking if things were working well enough from both my and the other’s viewpoint. During my first two years’ high school teaching in 1966 to ‘68 I kept a teaching diary daily for five classes a day assessing the appropriateness of my teaching plan and implementation over year levels 9 through 12 in English and year 12 in philosophy. For the latter course, I invented a student reflection process which has flowed on into later life teaching/learning settings. Both have a life today when patients take up diary keeping as a path to self-clarification.

As a result of these sources, I am inclined to see my therapy skills as applicable in a wide range of learning settings and roles, though most obviously in therapy, coaching and teaching. The process of testing patient / participant purposes or needs morphs naturally into testing learning processes and outcomes, and shifts emphasis from testing me to testing them – testing their confidence in their grip on themselves in whatever ways they are seeking in our work. One could say competent confidence in one’s ability to self-correct is the signal attribute of a professional or high performing amateur of any kind.

8 critical feedback opportunities

 

There are at least eight critical junctures for testing what patients / participants are working on, whether in therapy or training group:

1.      Preferably first, some kind of pre-session needs assessment before the moment of first entry, which may be a proforma tick-a-box, open-ended questions or a quick inquiry by phone at the initial contact for an appointment like “what’s your concern?” or similar.

2.      On arrival for the first session, the opening test is reconfirmed in this hello: ‘What are you here for?’ or its slightly more pointed sib ‘What can I do for you?’ In a group this is usually formalised in a group needs chart cobbled out of individual contributions.

3.      A little way into the first session (and many sessions thereafter), I propose this: ‘So, what concerns you is…? Am I right?’ This is a test of me, not the patient / participant, though they often hear it as a test of them.

4.      One step beyond mirroring is framing a chunk of patient / participant input into slightly different language and at a slightly higher (or lower!) level of generalisation, which does double duty of checking my grasp of their material and testing their capacity to generalise or concretise it.

5.      I pretty consistently check progress in session by inviting patient / participant assessment of the clarity and relevance of almost anything I offer beyond mirroring their contributions: “Is that clear?” “Does that make sense?”

6.      Towards the end of a session I seek a general assessment from the patient / participant like: ‘Are we on the right track for you here?’

7.      Over multiple sessions I check how the work is fitting their original and emerging objectives’ prediction of its direction and process, sometimes pointing out a new candidate for objective of the day, or week, for which I have evidence in their behaviour. Such “pointings” are raised as queries with explicit room for patient disagreement. Almost no patient / participant arrives at the end of therapy without discovering some learning objectives they did not start with.

8.      And, at the end of the learning process (in therapy there seldom is a complete closure, just as there is no closure to learning in life except the closure of life itself) we may look back by looking forward to see what new pathways have been unveiled by the work and what vulnerabilities have now been raised to the level of self-correcting consciousness.

5 in-session reflection ‘tests’

1.      Phrase completion test – there are a number of ways to signal I am paying attention to a patient / participant: This is a normal conversational move not just a therapeutic one and has the same effect – the person feels attended to, recognised, understood and shows this by continuing their conversational flow. For example,

a)      Add the word which comes next in a run of expression when the person pauses

b)      Punctuate chunks of expression with ‘Uh huh’, etc.

c)      Ask the patient to repeat what they’ve just said in other words, or give an example

d)     Encourage them to stay on a track they’re on with a rolling hand signal, not words.

e)      Stay silent when they reach a natural pause in their talk to make space for them to continue

2.      Feeling awareness tests, often repeated especially early in the work to authorise using feelings and help discover them.

a)      Mirror back a non-verbal, usually embodied, or say back a particularly striking expression

b)      Invite reflection on where in body they are feeling something: ‘’what body feeling is happening with this experience you are describing?’

c)      Invite an example / trigger of a particular feeling.

3.      Conflict engagement test

a)      Suggest an alternative perspective for a situation they are exploring – ‘I imagine you could look at this matter in other ways. For instance…’

b)      Propose an alternative interpretation for a situation – e.g. ‘Another way you could interpret at this is…’

c)      Assert they are wrong about a perspective or interpretation of theirs, with an appropriate degree of certainty in the truth claim involved. Use ‘perhaps’, ‘probably’, ‘possibly’, ‘certainly’ (as appropriate) to show your level of confidence in your assertion.

4.      Emerging theme identification test

a)      Repeat back a word in their conversation which suggests the patient / participant is evaluating something, especially them self – words like ‘value’, ‘care’, ‘like’, ‘avoid’, ‘worth’, etc.

b)      Invite an example of a particular evaluation, especially those where ‘could’ can easily replace ’should’ or ‘must’ in their speech.

5.      Objective description test – have they covered the what, who, when, where, how and why of their concern concretely?

NB – all of these ‘tests’ are feedback opportunities for both patient/participant and therapist/coach.

Learning to learn is the primary objective of therapy (and training and coaching!!)

A useful model for thinking and acting about adult learning is experiential action learning which comes out of workplace development needs arising from unexpected circumstances which out-date existing business operating constructs and competences.

 http://www.leeds.ac.uk/educol/documents/00001260.htm

I roughly work with this kind of framework in all learning settings where local design is necessary to fit specific conditions - a typical therapeutic requirement. The above ‘tests’ of both patient / participant and facilitator / therapist can be applied (should be applied) in any such setting for optimum effectiveness.

Learner Therapist (53) … Revisiting an abuse to clear it

Torrey Orton

January 28, 2015

Guilt and trauma

 

I’m going to stretch a concept a bit here. Abuse has a well understood content in therapy, characterised by a range of behaviours which distort personal development at any age. The distortion I’m concerned with – guilt – is especially inculcated (a word I have never used out of disapproval of its implications for learning, but here is where it speaks its truth) by religions and cultures to establish internal controls meeting externally sponsored and sanctioned behaviours and values.

 

This social use of guilt as control is most notable in matters sexual and procreative of all descriptions. The controls (the abuses in question here) are aimed at ensuring that historical narratives of sexuality are sustained, in the process sustaining historical inequities and iniquities along with them. These are fought out daily today, within cultures and between them. They reflect transitions from normals to new normals in the most foundational areas of life.

 

So, what to do with such a historical distortion carried by a patient as part of her present stress overload burden (marriage / relationship breakdown, betrayals of various sorts, retrenchments, illness, etc.)? I’ve had a number of these patients, and in two cases resorted to the following strategy for deflating the guilt which drives their self-oppression: I suggested they go back to the beginning, back to their guilt’s self-acknowledged origins in their Catholic girlhoods.

 

There were two reasons for this suggestion. First, the origins in the Church entailed its own forgiveness through confession and, second, their present guilts from those origins are in a much changed socio-cultural context from that in which they grew up – notably the collateral sins of sexism in particular are on display, backed by the Church’s leaders’ failure to command right behaviour of its agents, the priests and nuns. Some of the things they had been taught to feel guilty about are no longer on the guilt feeding horizon, at least of everyday practitioners of Catholicism.

 

 A relevant example of the changed cultural context of the Church appeared in the NYTimes as I was starting this post. It exemplifies the results of the struggle against the guilting forces of the mid-20^th century, especially the Sixties. Columnist Frank Bruni, writing in the New York Times on 26 Jan. 2015 says,

“At my request, Gallup did a special breakdown of its “Values and Beliefs” survey from last May and looked at how the principles of people who identified themselves as Catholics diverged (or didn’t) from those of Americans on the whole. Catholics were only slightly less open to birth control, with 86 percent of them saying that it was “morally acceptable” in comparison with 90 percent of all respondents. But Catholics were more permissive than all respondents when it came to sex outside marriage (acceptable to 72 percent of Catholics versus 66 percent of Americans overall) and gay and lesbian relationships (70 percent versus 58).”

 

Finding an appropriately modern priest was a challenge in one case, but once found, the reduction in guilt was sustainable from that experience of a now unnecessary confession. Interestingly, the priest in question was also mature enough for the Church to want not to hear from him much anymore. The other example is still in the works.

 

What surprised me, for a while, was that such an idea should come to me so easily and offering it to the patients came equally easily. Priests, of course, play a role like therapists in being bound by a personal and institutional code of silence, and so when not in the role of judge as when preaching, they are safe carriers of ‘sins’. That’s a simple transferential equation.

 

The underlying reason, which I discovered by taking action, is that acknowledgment and apology from relevant authorities or authority figures, is an essential step in trauma recovery. It frees the traumatised of the self-critique which paralyses them in their trauma. Confronting the traumatising authority (something the patient has to do for themselves) lifts the lid on one of the traumatic dynamics.

Learner Therapist (52) … Fear of losing the edge

Torrey Orton

January 22, 2015

 

For the second time in a week I ran into a patient from a traumatised background fearing that if he recovered from his defences against the trauma he might lose his life energy, drive and motivation…that his strength would be diminished or undermined, that he would lose his edge. I remember a very similar feeling myself five decades ago when I was interrupted in my life’s progress by depressive episodes. At the time I argued (to myself of course) against finding some help with the notion that I would lose my quite clear edge in my chosen activities, while in tandem advancing the view that my worries were nothing compared to person X or Y, whose troubles were so obviously more deserving of help than mine. At the time I thought my appreciation of the needs of others was a unique moral insight. I’ve since found an enormous company of helpers and fixers espousing my mantra all on their own. Another edge dulled by normality.

 

This second aspect – unworthiness of help, or much of anything for that matter – is what our hyper-vigilant defences keep from our view. The edge of our defences, their energy, focus and sharpness, is sustained by a largely unconscious apprehension that it is being dulled by the engine of unworthiness.  So, if we deconstruct our defences we will slide back into the sludge of unworthiness and its helpers - hopelessness and helplessness. The actual experience of trying new thoughtfeelingbehaviour is one of re-entering the traumatising world and self – a world of danger which a lifetime’s defences have been designed to prevent. The twister here is the often recognised fact of the abused re-exposing themselves to old and new abusers over the life cycle. Why? Because the defence is more comfortable than the promise of freedom from it, which can only be obtained by daring to behave in new ways!!

 

I think this kind of experience is especially prevalent for the “high performing” among my patients. It might be difficult for them to tell the difference between their injured self and their competent one – all the more so if their high performing self is clearly and unarguably publically acclaimed. It may appear to the therapist as ‘resistance’ to therapy in various forms. An ally of the preference for the edge is disclaiming victimhood, which is encouraged by the pop psych “move on”, “just get over it”, “changing your thinking will change your world” ideology.

 

The third side of the edge is an over-developed competence, which may create an unbalanced self but does not qualify for Medicare funding. A fourth cut of the edge is that it will never wholly disappear, that the wound which it expresses will always be with the wounded to some extent. It is, with respect, called character. The wearing away of our visible person into the wrinkled one of old age is one mark of our learning experiences of all kinds.

 

A sign of therapeutic success for trauma patients is the capacity to hear that they will never get over it in some important senses, one of which is having an edge. Another is seeing our scars as honours. That this is extremely difficult is modelled for us in daily life by the struggle of our defenders – soldiers, police, firies, paramedics… - to handle the traumas of their defence of us and the denial of their experience demonstrated by our social unpreparedness to care for them on return from our wars. Therein lies one of the most obvious sources of intergenerational violences, and around it goes again!

 

Those two patients I mentioned got over it. They were enough into the therapeutic work that they could acknowledge their temptation not to do the work for a tangible reason – that getting better might make them even less well, or so the loss of edge might feel to them. Their edge is among the most reliable of their feelings of being in the world, of existing, and reliable about keeping them in the world in the face of various pressures pushing or pulling them out of it!! But they are successful enough to know that their edge is now constraining their full development, usually in the relationship sides of their lives, either intimate or collegial, or both.

 

Learner Therapist (49) … How much is a performance failure worth?

Torrey Orton

October 19, 2014

“A misunderstanding can be a good place to start….”

…I wrote to a prospective client 19 years ago in concluding my response to her justifiable irritation with my proposing to charge her for something she had not imagined was chargeable. I went on…

“I am sorry that we have a misunderstanding about fees, though on reflection I am not surprised. Please accept my apologies for my contribution to that misunderstanding.”

 

It has been a principle of mine to acknowledge mistakes, even perceived failures, in my professional life (and personal, too, often enough). In therapy, it seems to me essential to do so since relationship failures are the stuff of mental health matters and those failures often thrive on unacknowledged misdeeds by the more powerful over the less. Learning to acknowledge and ask for acknowledgment of perceived mistakes / failures is an essential capability outcome of useable therapeutic development. It cannot be learned when the pressure is on not to fail and not to acknowledge.

 

I concluded that

“The only charge for a service that has not been perceived to be rendered can be nothing at all.”

I have occasionally run into colleagues who explicitly counsel non-acknowledgment of perceived errors or missteps in therapy, and I gather my professional organisation counsels that as well (perhaps an infection of negligence suit paranoia in both cases?). It seems to me that counsel is a recipe for a paranoid process which is the enemy of professional development. The latter depends on conducting real practice undertaken for real purposes and discovering that my judgment failed the patient’s need(s) at a certain time. And the repair of failed efforts is usually a matter of slight adjustments of tone and timing, which can only be practiced in real time.

So I added that

 

“Therefore I am returning your cheque.”

One of my colleagues, my professional supervisor, has with reason proposed that I do not make mistakes. That I do what I thought best at the time and so they cannot be mistaken. An interesting line of approach since it recognised that I do do what I think best at the time, and not lightly so. Perhaps a call for more acknowledgement of successes?

And I closed with

“I look forward to working with you at any time you may find useful in the future.”

 

This may seem a strange offer, but I still feel it stands up to my understanding of best practice. This aspect has to do with not assuming that an error is a death notice to a relationship. I have insisted on making similar offers at times since then, even where the patient who bore my mistake(s) was more mistaken than I.

My founding assumption is that it is always my responsibility to ensure that all the relationship Ps and Qs are dotted and crossed. It is my capacity for relationship design and execution that is what patients are buying, and in that sense any mistake is mine first, even if it was theirs. When their mistake is unexpected or, the reverse, it is perfectly expected as a result of a design and /or implementation malfunction, it’s my mistake.

By the way, the cost was only $80 lost income. A small price.

Learner therapist (46)…… Uplifting thoughts in times of down

Torrey Orton

Sept. 19, 2014

A cream pie in the mind

I’m working through very complex lifelong injuries with a very willing and able but psycho-spiritually compromised patient. At the moment we are picking apart an eating/body-image distortion which expresses a lifetime of deprivation of affection by family and schooling and….as we get closer to the core structure of the eating distortion, unguarded by its automatic functions (bingeing, constraining, etc.), the pain of sessions increases and cannot always be nicely balanced within the session timeframe. That is, we cannot often end on an upswing, or even a bit of flat earth.

 

The 42 year old female patient started introducing what have come to be known as cream pie diversions in the last minutes of a session still in its down (appreciating the pain of the past in the present) phase. She developed this tactic by chance a few weeks ago and it has become a signature skill for self-management around the hardest parts of our work. She can now confidently shift her mood out of obsessive / dark places in a few minutes before the end of a session.

 

The effectiveness of the pie in the face move initially arose from the summoning up of an image of pie smushing a face, but found enduring perceptual legs through my general vulnerability to desserts and ignorance of fine details of their contents. For instance, what really lies below the cream in a cream pie? Once opened, this doorway led into matters of cultural ownership of dessert types, with potential for pleasingly simpleminded explorations about what a real apple pie is, which naturally degenerates into memories of childhood pies, and we’re back in the lap of our mothers again. Which is where it all starts for her (and me in my way, of course)…

Learner therapist (16)……What’s a good enough therapist

Torrey Orton

August 3, 2014

I set myself the goal for my CPD tasks two years ago to design a generic therapist competences framework. This is the first cut. It begins with the name – the good enough therapist – which intentionally borrows from Donald Winnicott’s ‘good enough mother’. We could do with a bit more good enough these days, and maybe I was thinking the same for therapists. My objective is to use this framework as a template for self-assessment, with elements of professional assessment added as possible – that is, as I can succeed in finding colleagues who are prepared to judge.

I have enquired around the formal psych fraternity – especially the APS and some of its associated colleges – to find so far that no one has a generic, or a context-specific, competence framework for therapists, even the CBT squad. So there is no agreed framework for evaluating anyone’s performance, apart from the “clinical psychologist” qualification standard of CBT masters and similar. Anyone with a slight degree of program evaluation experience knows that quals are only the starting place. It is therapeutic processes and outcomes that count for patients.

 And as for the processes and outcomes of therapy a few things are clear. First, the nature of the therapeutic relationship from both points of view is a major contributor to perceived therapeutic effectiveness. Second this effect stands without regard to the therapeutic system, modality, theory or fantasy which a therapist brings to the relationship. Third, therapeutic improvement can best be achieved by constant checking with patients about their continuing perceptions of effectiveness of the experience of being in therapy with one. Fourth, the generic therapist must be able to engage with any presenting patient, even if only long enough to identify that a referral to a specialist of some sort is appropriate (and have a resource of such specialists on hand).

 

Here are some competences, knowledge and skills: no special order. I am seeking all and any suggested additions to the following first. Then, I’ll entertain alteration or deletion suggestions to the items listed.

1)      Intercultural communication, which includes knowledge of relevant cultural differences affecting application of preferred treatment(s) and the capacity to negotiate the treatment process. The key test of this competence is the capacity to understand and accept that the suite of assumptions and practices which constitutes Anglo psychotherapy will not be wholly shared by cultures like Chinese, fundamentalist religious practitioners (Jewish, Christian, Moslem, Hindu….), etc. In the end this competence would be exhibited by not working with some cultures rather than assuming one can work with all which one doesn’t know enough to know they are immutably different from one’s own.

 

2)      In vivo, person to person negotiation of the therapeutic process, including review / evaluate each session with patients, without shielding oneself by a diagnostic stance presuming the therapist knows best. A test for this competence might be the holding of a patient who experiences themselves as sometimes ‘crazy’ or out of control and demonstrates that self-perception in the room.

 

3)      Knowledge of a full range of therapeutic approaches, techniques and work styles, including how these approaches integrate with each other at different times in the therapeutic engagement. E.g. – CBT, IPT, dynamic therapies, behavioural therapies, ACT, Mindfulness, etc.

 

4)      Experience being in therapy oneself, not just supervision, so the more permeable boundaries of one’s self are in view and acknowledged as such – as being in flux – and how affecting that flux is of one’s availability to patients under various personal circumstances and conditions.

 

5)      A theory of the self which is holistic, embracing at least the biopsychosociocultural paradigm’s domains, with awareness of the spiritual and economic.

 

6)      A theory of life span learning stages and the processes through which they are experienced by people, including micro learning processes and their integration into life span learning.

 

7)      A human needs construct like:

Elements of well-being (basic human needs)

*From: The Treatment of Sex Offenders: Risk Management and Good Lives.

Tony Ward, University of Melbourne, Claire A Stewart, Deakin University, 2005

 

Without specified needs we cannot decide how we are doing and what trade-offs are required to improve well-being. One approach to defining basic needs is this:

 

Needs	Wants specifications of needs
1) Life (including healthy living and functioning)	Adequate sleep, food, exercise
2) Knowledge	Knowing that…Knowing how to….knowing why…etc.
3) Excellence in play and work (including mastery experiences)	Play an instrument, a sport; Practice a profession, trade, art, hobby…
4) Excellence in agency (i.e., autonomy and self-directedness)	Cooperative activities; enlisting others in our activities
5) Inner peace (i.e., freedom from emotional turmoil and stress)	Meditation, martial arts,
6) Friendship (including intimate, romantic and family relationships)	Appropriate care, affection, connectedness….
7) Community	Authentic membership, identification, …
8) Spirituality (in the broad sense of finding meaning & purpose in life)	Relevant belief, imagery, contemplation….
9) Happiness	In my view this is not a need; it is one  outcome of well-being
10) Creativity	Opportunities to invent at whatever level or domain of life activity (also a doubtful need)

 

8)      Understanding of social systems and the individual’s place in them, especially family systems, workplace systems and social systems generally.

 

9)      Capability in leading patients through actual or virtual reconciliation cycles, including creating and sustaining the power to be heard within those systems.

 

10)   Ability to hold and contain intense feelings, with a view to building patient authenticity and authority about those feelings. Confronting high risk subjects: suicide, violence to others or self, crime, abuse and how to contain an emotional outburst of any kind.

 

11)   Ability to recognise and admit own mistakes appropriately as they happen…..be a continuing learner with specific development aims and goals.

 

12)   Understand what makes research good enough and what important emerging evidence-based research shows about good enough psychological processes. Neuropsychology presents as a must appreciate emerging field.

 

13)   Capacity to make good enough judgments in the room about:

Talking about possible need for medication

Knowing where patients are at, or up to

Managing exposure therapy at the right pace / depth

How far to pursue a patient who is loosely engaged in therapy

Appropriate self-disclosure

Quantity of therapist input required

Boundaries of contact: in the room only?

 

14)  Having workable definitions of the main therapeutic entities: person, couple, family….

 

15)  Knowing at least one therapeutic paradigm in depth and a number of others to level of workable confidence

 

16)  Supervision - peer and professional; one-to-one and group.

 

17)  Knowing when to refer and being free to do so

 

18)  Having a collegial support network

 

19)  Having had an ordeal to prove you’ve got the commitment to do therapy; mastery of personal suffering and success

 

20)  Wider life experience: jobs, vocations, volunteer work, etc.

 

21)  Having a workable theory of contemporary life: it’s challenges, rewards, distortions and distractions