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A desire to change

One of my favourite papers is by Dr Sebastian Kraemer, called ‘Something Happens: Elements of Therapeutic Change’.  This blog helps break down what therapists and clients set out to do, as they sit together in a therapy room both hoping that change can be immobilised from a stuck situation.

This is first of eight short blogs exploring the eight elements of change identified as:

1. A desire to change

2. A primary task

3. A theory of mind and a method of treatment

4. Courage and honesty

5. A specific narrative

6. Neutrality and reflectiveness

7. A tradition

8. Something happens

 

A desire to change: As the client and therapist sit face to face in their first session progress has already begun  – the desire to change has been acknowledged and acted on.  The request for help to a therapist has been made and the therapist has accepted this. 

However long a therapist has been practicing – having collected skills, theories and techniques along the way – each new client brings a unique story and request for help.  They bring their stories of strength, courage and endurance alongside their stories of distress, confusion and pain.  Just turning up to the appointment is an act of bravery, it is our role as therapists to acknowledge and respect the clients vulnerability; walking alongside them as they take action to change.

On first meeting, many clients report that they have noticed shifts in their thinking, changes in behaviour and an increased sense of hopefulness that things can be different – this is before the first session.  This could possibly be a placebo effect or could be understood further in the context of the research around models of change.

In the early 1980’s Proschaska and DiClemete set out five stages of change. Upon arriving at their first session clients are already in transit between Stage Three and Stage Four 3 of this theory – monumental shifts in awareness and readiness have already taken place:

Stage One. Pre-contemplation – the ‘I’m not ready’ stage

I am unaware or under-aware of a problem and have not got plan to change – leave me alone.

Stage Two. Contemplation – the ‘I’m getting ready’ stage

I am aware I have a problem to address but do not have the motivation or commitment to change my behaviour as yet. – leave me alone but watch this space.

Stage Three. Preparation – the ‘I am ready’ stage  

I have researched and planned a way to change.and my initial goals are clear – no time to talk I’m busy!

Preparation is considered the most important stage of the model – relapse is considered to be 50 per more probable if the preparation stage is not undertaken

– ON YOUR FIRST SESSION YOU ARE HERE –

Stage Four. Action – the ‘I am implementing my plan’  

I am making changes to my behaviour, my environment and my choices. I have sought help in this process and am being encouraged to feel more hopeful about the future

Stage Five. Maintenance – ‘I have changed and I want to keep it that way’ stage.

Work and effort is still required to maintain positive changes and prevent relapse.

A desire for change is important to begin the work however sometimes it becomes clear change may bring difficulties and risks that had not been contemplated originally.  Resistance to the change may then come into play and the work takes a different turn as goals are reviewed.

 

Sharon Spindler is an experienced Systemic Family Therapist with twelve years experience within the NHS and private practice.  Sharon is available at the Brighton & Hove Practice.

 

Further reading by Sharon Spindler –

Covid 19 – Talking with children in uncertain times

Family Therapy for Beginners

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Why psychotherapy sessions should end on time

Boundaries are critical not only to a psychotherapeutic relationship, but, as many clients learn through therapy, are essential to healthy adult-to-adult relationships.

In a good psychotherapeutic relationship, there is a solid contract between client and therapist such that clients know what to expect and when.  And part of this knowing by the client is knowing what time the session ends; most psychotherapy sessions last for a ‘therapeutic hour’ or 50 minutes.

Door-stop moments

Every clinician has encountered what are known as ‘door-stop moments’ with clients – they happen in the moments leading up to the end of a session where a client suddenly blurts out something emotive and important that can throw the therapist and lead them to extend the session by some further minutes.

Unconsciously, door-stop moments have much significance and represent a relational process between the client and therapist.  Yes, the content may be important, however, why is it being brought into the room (and relationship) in the final moments?

The client may unconsciously want to control the session by ensuring their therapist has no time to explore the content in detail; they may wish to ‘leave’ something difficult with their therapist to hold for a week; and they may be testing whether the therapist will hold the boundaries.  Or all of the above and more.

On hiding an being found

Donald Winnicott, esteemed 20th Century British analyst famously said “it is a joy to be hidden, and a disaster not to be found”.  Winnicott was making reference to the children’s game of hide and seek, which, is only enjoyable if we imagine that someone is looking for us.  If the other game participants give up and leave, we are left hiding with nobody holding us in mind – a disaster.  In this quote, Winnicott is talking about many concepts, but amongst others he is making reference to boundaries and holding others in mind.

Even though in the game of hide and seek the winner triumphs by not being found, they paradoxically only win if the other(s) are still searching for them – the game therefore is profoundly relational and based on an agreed set of rules.

Psychotherapy is also relational at its core and based on a set of rules (boundaries).  One of these is that sessions end on time.  Clients will find all sorts of ways to ‘hide’ from their psychotherapist, however, this is only ‘joyful’ if they believe that they will be found (seen and contained).

When a client presents a door-stop moment to us, it cannot be allowed to derail the boundaries of the relationship or the rules of the game.  Otherwise the client gets what they think they want (more time) but feels omnipotent and thus unsafe with their psychotherapist – in other words, the client has hidden so well the psychotherapist has forgotten about them.

It is never about the client even though it seems it is

Extending a session due to a door-stop moment is never about the client’s needs and always about the psychotherapist’s.  The client relies on their psychotherapist to ‘hold them in mind’ and thus hold their best interests in mind.  It is the latter that gets lost when a session is extended.

How can it be in the psychotherapists interests to extend a session?

Unconsciously the psychotherapist has also ‘got lost’ and is unable to remain separate from the client’s needs.  They thus extend the session to try and ‘please’, or appease the client, which fundamentally is about avoiding the client’s anger’ rage and disappointment.  And the job of a psychotherapist is precisely to survive these feelings in their client and what it makes them feel.

Don’t become a psychotherapist if you want your clients to like you

Psychotherapy is only happening when a client feels either positive or negative feelings towards their psychotherapist (and vice-versa).  If the relationship is neutral, nothing is happening.

It is easy to bask in the glow of a client’s adoration but beware, a fall will come.  And so it should.  As psychotherapists we are not there to be liked – we are there to remain constant in the face of our client’s emotions.

And being constant means ending the session on time.

 

Mark Vahrmeyer, UKCP Registered, BHP Co-founder is an integrative psychotherapist with a wide range of clinical experience from both the public and private sectors. He currently sees both individuals and couples, primarily for ongoing psychotherapy.  Mark is available at the Lewes and Brighton & Hove Practices.

 

Further reading by Mark Vahrmeyer –

How being ordinary is increasingly extraordinary – On the role of narcissistic defences

Can Psychotherapy or counselling be a business expense?

The difference between Counselling and Psychotherapy

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So what actually is a Psychologist?

It’s important to note that the term ‘psychologist’ is not actually a protected title.  So, anyone can technically call themselves a psychologist.  If someone claims to be a psychologist, then the question to ask is, what kind of psychologist are they, and perhaps more importantly, what qualifications do they have.

Undergraduate degrees may be undertaken as either a Batchelor of Science or of Arts.  Completing an undergraduate degree in psychology gives a good basic introduction to a wide range of psychological theories and applications, but not necessarily expertise in any one area.

The British Psychological Society describes psychology as:

‘the scientific study of the mind and how it dictates and influences our behaviour, from communication and memory to thought and emotion.  It’s about understanding what makes people tick and how this understanding can help us address many of the problems and issues in society today.’

There are many areas of both theory and application within psychology; health, educational, forensic, counselling, occupational, clinical, sports and exercise, and neuro.  Becoming qualified in one of these fields requires post-graduate study.

In the example of Clinical Psychology; the current route for training is a 3 year doctoral degree (after the undergraduate degree) which involves both university teaching days and days on placement with the NHS.  In order for someone to call themselves a Clinical Psychologist, they must have completed an approved training course, and be registered with the Health and Care Professions Council (HCPC).

The HCPC regulates all applied psychologists within the areas above. The below are protected titles, which means people can only use them if they have completed an approved training course and complete ongoing appropriate Continuing Professional Development.

  • Practitioner psychologist
  • Registered psychologist
  • Clinical psychologist
  • Forensic psychologist
  • Counselling psychologist
  • Health psychologist
  • Educational psychologist
  • Occupational psychologist
  • Sport and exercise psychologist

Any other titles, such as Media Psychologist, Celebrity Psychologist or TV Psychologist, such as are often seen in the media, say nothing about the qualifications or expertise of the individual.  Understandably this is often misunderstood by the public.  As a Clinical Psychologist it concerns me that people may put their trust in, or even pay for services delivered by, unqualified people.  In addition it is concerning that the reputation or credibility of the profession may be damaged by unqualified people providing a poor service.

It is a very confusing area, however, probably the most important thing to remember is if you are considering working with a psychologist in any of the fields above check that they are registered with the HCPC on www.hcpc-uk.org

 

Dr Emma Stevens, HCPC Registered, is an experienced Clinical Psychologist. She has an integrative approach drawing on Cognitive Behavioural, Systemic and Psychodynamic models, as well as Attachment Theory. Emma sees individuals primarily for sort-term work. Emma is available at our Lewes Practice.

 

Further reading by Dr Emma Stevens

Using the body to calm the mind

Emotional Well-being

What is EMDR?

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Online Therapy

We spend much of our lives online these days and increasingly more services are available online that traditionally would have been conducted face to face. This is the same with psychotherapy and counselling, and there is a growing availability of online therapy services around on the internet. So, is online therapy for you?

There are many ways to engage in therapy online, but for the purposes of this blog I’ll be considering online therapy that uses live video. This can be done with apps such as: Skype, Zoom, WhatsApp, FaceTime, BotIM etc. Whatever app is used, the most important thing to consider is the security. Only use an app that has a secure and encrypted connection.

There are many benefits to having therapy online and the most obvious might be the convenience of it. Rather than having to spend time travelling to a clinic, you can be at a location of your choice where you feel comfortable. This might be at home, in a private office at work during your lunch break, or anywhere where it is confidential and you won’t be overheard or disturbed. However, you will need to consider what you will do after the session has ended. Do you have time to compose yourself before you step outside the room and back to the office or family life?

Another benefit of working online is that you might have a greater choice of therapists available to you. Rather than having to choose those in your local area, you can work with the therapist of your choice wherever they are in the country. This can be particularly beneficial if you live in a remote area, or live abroad and want a therapist who speaks your native language. Additionally, if you travel around a lot, it can make it possible to access therapy wherever you might be.

Another advantage of online therapy is that it can make it easier to engage with therapy if you are anxious about going to a clinic in the first place, or have any difficulties with leaving home or accessing certain locations. Being able to engage with your therapist online can remove any of these potential barriers and you can get the support you need.

A lot of people wonder if online therapy is as good as face to face therapy, and that is an important point to consider. Certainly, there is a big difference. The rapport and connection you have face to face with a therapist will be different to what you build online. Some of the non-verbal clues to communication can be lost online so it’s important to be able to tell your therapist if they haven’t understood you, or if you don’t understand them. However, once you get used to working online with a therapist, the distance and technology can ‘disappear’ and you can feel very connected with your therapist.

Here are a few points you might want to consider if you want to access therapy online:

  • You will need to have a good, stable internet connection for the duration of your session.
  • It is best to have a few connection options available – such as wifi and data, and a couple of different options of apps – such as Skype and Zoom, to allow for tech difficulties.
  • You need to be comfortable working online and familiar with the tech you are using. It’s a good idea to turn off any notifications for the duration of your session as these are very distracting when you are trying to work with your therapist.
  • You need to ensure that the location you are in is private and confidential.
  • You should check the credentials and qualifications of your therapist before you engage in any online therapy. There is a growing number of people setting up online as ‘therapists’ with little or no training. Make sure your therapist is registered with a professional body such as UKCP.

Dr Simon Cassar is an integrative existential therapist, trained in Person Centred Therapy, Psychodynamic Therapy, Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), and Existential Psychotherapy. He is available in our Hove and Lewes clinics and also works online.

Further reading by Dr Simon Cassar –

Student mental health – how to stay healthy at university

Four domains – maintaining wellbeing in turbulent times

What is an integrative existential therapist?

What is Existential Psychotherapy – Video

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The Therapeutic Relationship and the Unconscious

Therapy is often referred to in terms of it being relational, or as a relationship, albeit a particular type of relationship, one that has very specific parameters, particularly around money, time, touch, and about whose inner life is there to be explored.

Despite this, in some ways, very one-way relationship, an awful lot of what goes on is a kind of relating. The therapist will encourage the client to speak as freely as possible and through a careful listening to the client’s words and to what is evoked in themselves, through this listening, they will try and relate as closely as possible to the clients experience and will feed this understanding back via their own comments, or interpretations.

What makes this different from other listening conversations, is that the therapists understanding and feedback will be influenced by the therapists training, specifically their own therapy and their learning of theories, which provide maps of mental structures and types of human experience and distress.

The therapist as well as listening to the stories, will also listen for patterns, for words, they will try and be attuned to what is going on emotionally for the client and also pay attention to the actions of therapy, to the how the client goes about relating to the therapist. When the therapist feels something useful has been understood, they will share this.

Sometimes this may not have been consciously known by the client, and this is why it can be useful. However, it can also be unnerving, as we like to believe we are the masters of our own houses, independent and not in need of the help of another.

Freud said there have been three great blows to man’s ego, the Copernican discovery that the solar system didn’t revolve around the earth, Darwin’s discovery that we are descended from animals, and share an essentially mammalian brain structure and Freuds own discovery that we have a dynamic unconscious, that the rational beings we like to believe ourselves to be is only one part of the story.

Part of this unconscious is the repressed unconscious, the place where we store the things we don’t want to know about ourselves, however these things are known at some level and we can expound a great deal of energy trying not to know them.

Getting to know and understand these parts of ourselves although often frightening to begin with, can actually be a huge relief as we come to know and accept these parts of ourselves, parts of ourselves that may seem like monsters under the bed and cast scary shadows but are usually essentially human characteristics.

 

Paul Salvage is Psychodynamic Psychotherapist trained to work with adolescents from 16-25 and adults across a wide range of specialisms including depression, anxiety, family issues, self awareness and relationship difficulties. He currently works with individuals in our private practice in Hove.

 

Further reading by Paul Salvage –

A Nation Divided

Adolescence: the trials and tribulations

Does the male mid-life crisis exist?

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