Sunday, June 19, 2011

Blogging as an Adjunct to Therapy:An Experiment.

I began this blog partly as a gesture toward establishing a more productive relationship between my clients and myself in my professional practice; a practice customarily referred to as psychotherapy or counseling. I'm not especially comfortable with either name. Counseling is often seen as psychotherapy-light and has a surface connotation akin to advice-giving (think of Star Trek's Counselor Troi); while psychotherapy invokes a paradigm of mental health. Despite those reservations, I tend to use both interchangeably, while preferring to see what I do as having a special sort of conversation; a "conversation" because what is involved is an exchange between two, less often, three or more, individuals. What I hope to bring to that conversation is an attitude of openness and acceptance of the person, a curiosity and interest in what he or she has to say and the training and experience that can help the person understand and articulate his or her thoughts and feelings more fully; ideally moving toward a preferred and less troubled sense of self.

More traditional, especially, medical models of psychotherapy, posit the therapist as a blank screen; while the patient is expected to share the most intimate details of himself or herself, the therapist is supposed to maintain a neutral stance; enabling the patient to project whatever he or she wishes on the therapist, which then becomes grist for the analytic mill. The extreme being classic, Freudian analysis; having the therapist sit behind and out of sight of the patient lying on the couch. A relationship in which there is a marked difference between what one person is privileged to know about the other is inherently unequal; typically, the person in a position to know more has more power. Quite apart from the question of the desirability of such a model, there is the question of its achievability. Humans have an uncanny ability, even more so than they are consciously aware, to perceive how someone responds to them. In the smallest facial movements, movements of the eyes, changes in posture or breathing, we unconsciously and necessarily communicate approval and disapproval, liking and disliking, interest and boredom, amongst many other responses. It has been shown that even with the most classic of analytic postures the dreams reported by patients begin to resemble more and more the interests of the analyst.

I'm neither comfortable with that traditional approach nor with the terminology of patient and doctor; implying one person is passively acted upon by another; the doctor knows best model.  I prefer seeing therapy or counseling as an active collaboration in which the focus is on the issues and concerns of the person who has requested the meeting, while the therapist or counselor openly responds to those concerns to the extent it is helpful; being at ease with the reality that his responses will probably be communicated, even when not specifically intended. I see the other as a client who has engaged me; hoping, through the process of our interaction, to become more comfortable with what discomforts him; not as a patient to be acted upon with my expertise or bag of tricks.  If someone shares with me a horrific experience, I'm comfortable with showing that I feel how difficult it must have been. If I sense that the client finds my response disturbing or quite different from his own, I encourage him to share his response to my response in order to deepen our conversation together.

The traditional injunction to keep the therapist's private life and values unknown to the client or patient is one that could only have arisen in an urban setting. Anyone who practices in a rural or small community is likely to be known in that community, as are his friends and family; the same is true of a therapist serving a small, minority community in an urban centre. A corollary of that fact is that the therapist is likely to know a considerable amount about his clients before meeting them in therapy and to interact with them outside of the context of therapy. Working largely with an anglophone clientele within the gay community in Montreal, a minority within a minority, I would frequently encounter clients in social settings and know some of the same people who form their friendship network. Once I was in the particularly awkward position of having two clients, who weren't aware they shared me as a therapist, begin dating one another. I couldn't inform either of them of that fact without breaking confidentiality nor could I figure out any fair way of stopping to see one or both of them. I was quietly relieved that their relationship was short-lived.

The weakness of the medical, psychiatric approach to emotional well-being is shown through the construction of the Diagnostic and Statistical Manual; a process through which interest groups and big pharma continually lobby, first to a recommending committee of experts, then to members of an association, which votes on what disease entities to recognize and which to remove from the Manual; a process far from what is recognized as real science. Physicists don't determine what entities exist in the universe by taking a vote amongst other physicists. The DSM is put together the way natural scientists catalogued nature in the Nineteenth Century; with the even less scientific method of changing their designations of disease entities based on social change in the particular parts of the world in which they practice and pressure from various interest groups. As many have observed, the classifications contained in the DSM have most to do with providing designations for conditions enabling drug companies and therapists to be paid for their products and services through insurance companies and governments; they are more instruments of profit than science.

The one, significant, caveat to that critical perspective is in the treatment of psychosis, which doesn't lend itself to talk-therapy and can be somewhat controlled by medication, though with considerable negative side-effects to the sufferer; the same seems true of severe instances of depression and anxiety. However, for the less severe complaints of anxiety, depression and the ordinary, human conflicts related to relationships, desires and identities, research seems to indicate that talk-therapy is more effective.  Medications have been shown to be no more effective in relation to those ordinary, human discomforts than placebos; which can, nevertheless, be very effective for many individuals. Perhaps, severe emotional disturbances are more likely to be accompanied by distinct, neural anomalies, and, hence, are more effectively targeted physiologically through medication; while the disturbances and discomforts that result from being a reactive human in an imperfect world are accompanied by the usual, natural spectrum of neural interactions; accessible as much or more through changes in environment and behaviour, including talking with a therapist, as through chemistry.

My approach to therapy or counseling is, not surprisingly, very much a part of my background in philosophy; it embodies a sort of Socratic method in which an engaging curiosity can lead to a better grasp of the concern or issue being addressed; that better grasp of the issue usually leading to paths of approaching or understanding the issue differently. The particular sort of conversation I aim to have with a client is not to be confused with a discussion that one might have regarding values or ideological orientation; it has nothing to do with right or wrong or with convincing someone what I think is right or wrong; it is about elucidating how a person thinks and feels. I don't feel it is important to me if a client has very different values than I, as long as those values don't entail harm to himself or others. Even if they entail harm to himself, as long as he is clear about that fact and comfortable with it, I would, probably after sharing my reluctance, acknowledge the sense it makes to him. Some might find my stance to be a destructive form of relativism; perhaps we can discuss that perception at a later time.

The background I have in philosophy is strongly related, as well, to my interest in narrative therapy, which I have described and applied in previous postings; for me narrative therapy is intimately related to my understanding of Wittgenstein. His philosophy that our language, perceptions and approaches to what we consider to be reality construct our world views forms the core of narrative therapy; a world view which we reveal and perform in talking about ourselves and our relationships to our environment. In my conversations with clients I listen for their stories, through which they have come to script their lives; paying special attention to events and experiences in their lives which don't seem to fit within those stories. Often those stories emerge as constraining or negative in their implications, and the client can be assisted in constructing different, more inclusive stories within which his view of himself and the world becomes less distressed.

One more influence from my studies of philosophy that has carried over into therapy is found in the writings of Aristotle. His belief that reasoning-well, in some ways a highly articulated form of common sense, is a key to happiness or living-well, is, to my mind, closely associated with cognitive-behavioral therapy. The theory that cognitive distortions are at the heart of much emotional distress is quite congruent with the therapeutics of Aristotelian ethics. If people value being reasonable, and I find most people at least feel they ought to endorse that value, indicating in a therapeutic conversation the manner in which certain distortions have an impact on their moods and behaviors can prove quite productive. It is intriguing to realize that some distortions in our thinking, such as magnification and either/or thinking, can in themselves have a clear, negative impact on our feelings and behaviour.

Interestingly, despite the hype around particular techniques that can be used in therapy, study after study has shown that it is personal characteristics of the therapist himself or herself in interaction with the client that most accounts for successful outcome; characteristics, such as nonjudgmental, positive regard, active curiosity and focused, empathic attention, consistently emerging as the most predictive of positive change. An insistence on the use of particular, "evidence based" therapy techniques, often has as much to do with securing payments from insurers as securing a productive outcome between therapist and client. I happen to be impressed with some of those evidence-based techniques and I make use of them; however, I like to think it is my self in interaction with the client that has the most efficacy in producing positive change.

The role that I hope my blog will play in my understanding of the particular conversation that is therapy is consonant with the perspective I am describing. First, it discloses to clients something about the person with whom they are in conversation and in doing so establishes a certain basis for equality; I'm not expecting them to share intimate details of their lives with me without being willing to do the same, should that be important to them; they can see in my own life conflicts that might resonate with their own. Secondly, in writing my blog as an attempt to come to a clearer understanding of my self, I've used the same theoretical approaches that I use in conversation with my clients; providing them with an illustration of the sort of reflection I find helpful.

Recently, I ran out of business cards and decided to add the address of my blog to new cards; making the blog more a part of my practice. So far I haven't given any of those cards to clients, as I'm somewhat anxious about the results that might have. For example, if a client or potential client found some of my values or approaches very much at variance with their own, would they engage with that difference, or simply withdraw? I had an opportunity to give a new card to a client I just began to see and found myself deciding not to; he was from a Moslem family and I was concerned about his reactions to my being gay, before we were even able to form a relationship. On the other hand, would it have been more respectful for him to have had access to that information at the outset in order to make a more informed decision as to his comfort with me as a therapist? Thus far, only two clients have managed to find their way to the blog on their own and have commented on similarities between some issues in their lives and mine; they found that helpful and I find it hopeful. I'll let you know how my experiment evolves.


  1. Several readers have told me of an article published today in the New York Times that approaches some of the same issues as my blog:

    Living the Good Lie by Mimi Swartz

    Thanks for letting me know.

  2. Without invalidating your main point, I think you under-estimate how often "voting" (formally or by consensus) plays a part in classification. You stack the deck a bit by choosing physics as your example, but even there voting sometimes determines what will represent reality (q.v., the recent demotion of Pluto from full planetary status). In biology, a discipline more relevant, such debates over classification abound. Is this organism a separate species or just a variant of an old? Where does this fossil fit in evolution? The list is endless, and so are the debates. Often they are eventually decided more by which partisans outlived the others than by rational conclusions.

  3. I agree with you in your observation that in choosing physics as a "real" science with which to compare the process of putting together the DSM I made a stronger case against the scientific nature of that enterprise than would have been made if I had chosen another science. I acknowledge that in all sciences what comes to be regarded as fact or truth is to various extents the product of consensus that develops over a period of time and, sometimes, is influenced by factors quite extraneous to the science itself. However, I don't believe that in any other "science" what is
    or is not accepted as some sort of truth or fact within that "science" (the DSM is often referred to as the "Bible" of psychiatry) is decided by a vote of the members of a professional association; nor do I think that in relation to any other "science" there are advocacy groups and profit-making organizations that play an active role in influencing such decisions.

    I really appreciate the time you took to make the precision and there's no one more qualified than you to speak of the process of determination of knowledge in biology.

    Thank you, John.