Working towards What?

Do you know what your goals are? And if so, are you certain that if you achieved them you would be happier, or more satisfied, than you are now?

I think many of us might answer negatively to at least one of those questions, and I’m surprised that CBT thinks that most of us know what our goals are, but that we just have difficulty working towards them.

I’m closer to thinking that most of us would be able to work towards goals that we have identified that are meaningful to us (they would be inherently aligned with us and therefore more likely to be motivating), but our difficulty is more often rather in identifying what is important to us.

So while CBT sounds like it’s a therapy that believes in the agency of the individual, I think more exploratory approaches like psychoanalysis or psychodynamic approaches have more faith in the individual’s agency to achieve their goals.
CBT assumes that we know what our goals are, just need help achieving them with a boost of willpower.
Psychoanalysis assumes that we are pretty good at going after what we want, but we often need help clarifying and unearthing those ‘truer’ or more authentic values and goals.

What sparked this thought was a guilty feeling, because I have recently started twice-weekly psychoanalysis, whilst clinician-me delivers six 30-minute sessions of Low Intensity CBT to clients suffering from similar (if not far more debilitating) mental health difficulties than patient-me. I know that if I switched roles, if I approached myself as PWP, and was told by PWP me to identify ‘Goals’ to work towards across 6 weeks in ‘therapy’, I’d be stumped. It would be totally meaningless, and potentially even distressing. What I am beginning to identify – slowly, tentatively – in psychoanalysis, is that sometimes seeking and going after goals is a blind race towards, or perhaps more accurately away from, something else as-yet-unidentified. And we don’t necessarily know what we should be striving towards or moving away from until we have stopped for a moment to reflect, and I don’t mean for a matter of moments or even days, but a stretched-out kind of reflection that happens best in the presence of a non-judgemental other. I think I am learning that healing (sometimes) can come from a moment of pause, or stillness, where for a couple of times a week you don’t need to press forward towards an unending improvement.

Admittedly, this will not apply to everyone. Despite my belief to the contrary, many of my clients say that they have found our sessions helpful and they even seem to ‘recover’ as according to the PHQ-9 and GAD-7. So, clearly, the approach taken by psychoanalysis as opposite to CBT is not for everyone, sometimes we do just need that boost of motivation, or a few handy techniques for stopping worrying so much. But maybe it’s a question then of time of life, sometimes we need CBT goal-oriented help, and at other times we need just a space to think and speak.

Brief Interpersonal Dynamic Therapy

 

Though working in IAPT, a CBT-dominant mental health service, if you have read any of my posts before you’ll know that my temperament aligns far more naturally with the dynamic, interpersonal and exploratory therapeutic modalities. This means I often find myself in unpleasant moral dilemmas where I worry that I am short-changing my clients by sticking faithfully to the ‘Behavioural Activation Protocol’, but have zero other training that could better guide me with my clients.

So, I’ve started to read the textbooks of other psychotherapies, for some pointers of what kind of approach I have a better fit with, and to inspire ideas as to where my career path goes next…

The first book I’ve finished is Alessandra Lemma, Mary Target & Peter Fonagy’s Brief Dynamic Interpersonal Therapy: A Clinician’s Guide (2011), and it felt like balm to my CBT-crushed soul. The book is a treatment manual for practicing clinicians to deliver short-term, focussed, psychodynamic therapy for complex cases of depression and anxiety. (And they define short-term as 16 sessions! What would they call my 6 thirty-minute IAPT sessions I wonder?).

This is an interesting concept, because psychodynamic clinicians are usually allergic to manuals and time-constraints, seeing the complexity and variety of human nature as bound to doom any standardised approach to failure.

There are three key points about this kind of therapy that make it far more appealing to me than CBT.

Firstly, the importance given to interpersonal processes, both past and present. DIT structures itself around an Interpersonal-Affective Focus (IPAF), which it does by identifying one dominant and recurring unconscious interpersonal pattern. For example, an individual might find that, for whatever reason, they tend to see themselves as ‘a flawed woman’ and significant others as ‘critical and superior’, which, played out enough times in various relationships, would quite naturally lead to depressive symptoms. The logic behind this is the idea that because we are social animals that depend so strongly on others, most forms of psychological distress will likely be caused by, and then maintained, in some disrupted interpersonal functioning. Maybe we experience some form of interpersonal trauma, which then makes us fearful of getting emotionally close to someone, so we withdraw, but then feel lonely and depressed. From my limited clinical experience thus far, it does seem like the vast majority of psychological distress is usually due to, or resulting in, problems in relationships. Because of this focus, a key DIT technique involves working within the transference relationship, as this is a ‘live’ relationship in which those patterns are likely to surface, and hence can be a useful place to begin exploring those patterns in a safe and non-judgemental space.

Second, the attention to affect. To most fruitfully use the transference and countertransference processes that occur within the therapeutic relationship, DIT takes a far more detailed and exploratory approach to the individual’s affect on a moment-by-moment basis during the sessions, as these affects are likely to give important clues about their interpersonal patterns. The thought here is that the better able we are at identifying our affects, the more control we will have over them in future, as we might be able to shift the perspective and not get so wrapped up in the more automatic/unconscious affective patterns that might otherwise control us.

And third, the move away from symptoms and towards a more holistic view of what makes a life worth living. (The absence of symptoms does not a meaningful life make!) DIT understands symptoms as existing further along the line from where the problem started. Symptoms, such as anxiety or panic, might be manifestations of faulty interpersonal/affective patterns as they are enacted in situations that are not well suited to them, so are more like the tip of the iceberg. CBT approaches tend to treat panic symptoms as if that were the only thing going on in that person’s internal world (they might well be), whereas psychodynamic approaches are more interested in why and how that symptom started. They attend more to an individual’s underlying personality structure, which typically might not even bring a person into therapy in the first place (most of us take our personality as a given). The idea here is that by working at the deeper levels of human psychology, the therapeutic benefits will hopefully be more long-lasting, as the anxiety or panic won’t just pop up later on in another form. I think this narrow attention of CBT on presenting symptoms only, especially the low-intensity CBT in IAPT, might explain the 50% relapse rates (within a year) of the clients who ‘recover’. And we must not forget that those clients who ‘recover’ are only ~50% of those ‘completing’ treatment.

I’ll finish this post with a quote from the book summarising the main aims of DIT, being to:

  • ‘Identify what he/she feels, encouraging the patient to stay with a current feeling as it emerges in the session.
  • Communicate what he/she feels more effectively.
  • Build greater facility in connecting his/her feelings, thoughts, and actions, and how these relate to others’ internal states and behaviour.

The therapist thus strives to help the patient to identify the way in which his/her feelings are guided by the particular self and other representation that is activated in a given relationship. The patient’s conscious affect, though important given that this is what the patient feel’s troubled by … may yet conceal latent affect that may be even more disturbing to the patient.’ (pg. 158).

Avoiding Advice

Something I’ve been struggling with in my Psychological Wellbeing Practitioner training and clinical work so far is that we are told that the ‘therapy is in the materials’ rather than in ourselves as clinicians. Our role is to guide our clients through self-help material that is appropriate to their psychological distress, and help them to problem-solve any difficulties that they might have along the way. Rightfully, due to our lack of training in delivering any kind of therapy proper, we are told to concentrate on the CBT-based tools and techniques that we are supposed to be imparting to our clients. It is (also rightfully) emphasised to us that the focus should be on ‘collaboration’ rather than any kind of didacticism in our delivery.

However, it feels that by focusing so much on the content and tools that we are providing our clients with, I too easily slip into ‘offering advice’, which I think is usually so antithetical to any kind of meaningful therapeutic intervention! I really do try not to do it, but find myself on occasion saying, ‘What about trying this…’, when discussing how to change a sleep routine, for example. (I feel no temptation to offer any more significant life advice, thank god). One way around this that our supervisors have recommended is to ask questions based on the materials/information you’ve given your client, for example, ‘Why do you think I asked you to read that Booklet?’, ‘Can you explain to me the rationale behind Behavioural Activation?’. But I think those questions can be useful to check or consolidate learning, rather than genuinely encouraging the client to arrive at their own conclusions and answers…

I think this is related to my major qualm with CBT-based approaches in general, the fact that though they profess themselves to be less hierarchical than psychoanalytic or psychodynamic approaches are seen to be (in that old-fashioned idea of psychoanalyst having all the answers but remaining silent), they can end up being more unequal in power dynamics. In the psychoanalytic approach, regardless of whether the analyst thinks she has all the answers, she at least gives the patient space to think things through in their own way, following their own patterns of thought, rather than shoving tips and tricks down their throat in a limited number of sessions. The CBT clinician can end up asking patronising questions (like those above, ‘Can you confirm that you’ve understood all the information I have imparted to you today?’), rather than genuinely engaging with the client’s way of understanding the world, and taking it on its own terms. The CBT clinician is Wise Teacher, who benevolently takes on board the patient’s particular life circumstances to adapt the techniques to them, but nevertheless remains the one with all the information the client needs to live a better life. I guess these power dynamics risk becoming problematic in all kinds of therapies, because essentially, the client is coming to a trained ‘expert’ for help. But I think it’s important that we remind ourselves of the pitfalls of this kind of imbalance as often as possible, and do everything we can to stop offering advice. I’m mainly speaking to myself here.

Are We Fudging IAPT Data?

In my PWP training today we were taught how we are supposed to record our targets and recovery rate data, and I think I’ve just realised one way that IAPT services might potentially be overestimating their success rates…

We were told that if, by the end of the 6 Low Intensity CBT sessions we offer (outcome measures for depression and anxiety are taken at each session), the client’s scores on the two main measures have gone to ‘recovery’ (meaning below caseness, so scoring below 9 for the PHQ-9 or below 7 for the GAD-7) then we mark the final session as a ‘treatment session’, the system will count that client as ‘recovered’ – which makes sense, and that’s all fine and well.
But if we arrange a ‘follow up session’ with them in a few weeks time, and find that their scores have risen to now above caseness, then we are told to mark that session as a ‘follow up session’, and it will not count towards our recovery rates. So, we would have learnt that the person has not in fact really benefitted from the sessions that we have given them, or at least not in any lasting way, but on the system that rise in scores will essentially be ‘invisible’, so ours, and our companies recovery targets, will be unaffected. It will look like IAPT did its job and was successful in ‘curing’ the individual, even though the benefits of our treatment have actually not had too much of a lasting impact, and so weren’t so good after all.

We were also taught another way that might overestimate IAPT’s success rate. If, at the end of the 6 sessions the client’s scores have not lessened enough for them to count as ‘recovered’, but at the follow up session a few weeks later we find that their scores have dropped to below caseness, we are told to mark that extra session as a ‘treatment session’ (not a ‘follow up session’ as in the situation that I’ve described above) so that on the system it will count as thanks to our treatment, and so count towards our recovery rate. If we’re feeling generous to IAPT, we may say that our sessions and support just ended up having a bit of a delayed effect – maybe they were a bit slow to apply all the ‘tools’ we gave them and so we do deserve to pat ourselves on the back. But, you could just as well argue that maybe their life just improved slightly (nothing to do with us), or it was a purely natural recovery (generally consistent low mood does tend to improve over time even with no treatment). So basically we’re allowing natural recovery to count as IAPT-caused, when there is no true measure as to whether this was actually the case.

Neither of these situations are explicitly fiddling with the data – we are still trusting and taking at face value someone’s scores (this is to say nothing of the problems that may inhere in using the outcome measures that IAPT services do, for more on this see Levis et al. 2020), but it’s easy to see how they might lead to a slight bias towards favouring IAPT Guided Self-Help treatments which may not reflect their actual efficacy…

Would be very interested to hear people’s thoughts on this!

Coaches or Clinicians?

I’ve recently started training to become a Psychological Wellbeing Practitioner in an IAPT (Improving Access to Psychological Therapies) service, and what that means is that I will soon be able to deliver Low Intensity Cognitive Behavioural Therapy to ‘clients’ with mild to moderate common mental health problems such as depression and anxiety.

The training is delivered 2 days per week by lectures and seminars from University College London, and the remaining 3 days per week I spend working at my IAPT service doing assessments and low-intensity treatments.

One thing in particular that we learnt in the first week threw myself and my fellow Trainees: the fact that we should not think of ourselves as therapists or clinicians, but as coaches. We didn’t do so big-headedly, but in our previous role (when we were doing Triage Assessments and offering people Step 2 Guided Self-Help, or Low Intensity CBT), we always thought that Step 2 was a sort of CBT-lite, and so the Step 2 clinician was therefore a sort of therapist-lite.

Also, when I was learning about IAPT as an outsider, I was wrongly led to believe that the program is training ‘therapists’ not coaches. David Clark says so himself in his ‘IAPT at 10: Achievements and Challenges’ post, he writes (under the dramatic title ‘A revolution in mental health’), that to overcome the shortage of psychological therapy available to people suffering from common mental health problems, ‘the NHS has trained over 10,500 therapists and deployed them in new psychological therapy services’ (emphasis added). This is misleading, and I often find evidence of IAPT’s main advocates (usually people with a stake in the game), claiming more for the service than it deserves. I think Clark and others should be more cautious in over-selling IAPT, because it will eventually lead to disappointment when people’s expectations aren’t managed.

Thanks to that misinformation, when I used to allocate people whom I had triaged to Step 2 treatments, I always sold it as a ‘guided cognitive behavioural therapy over 6 weeks, for 30 minute sessions’. But now that we are training to be those Step 2 ‘clinicians’, we find that we are not that at all, and what we offer isn’t Cognitive Behavioural Therapy, but rather a life-coaching session.

But – I agree with this. We shouldn’t think of ourselves as clinicians or therapists because we don’t have those skills – we aren’t taught about what happens within the therapeutic relationship, and how to more supportively guide our clients through more long-lasting psychic change. I think it also serves to prevent us from feeling also like counsellors, whose role is to sit and listen to the client as they talk about whatever they feel like getting off their chest. By reminding us that we are there to encourage behaviour change (and that’s essentially it), it makes a lot of sense to call us coaches.

Having said that, however, it’s now clearer to me just how difficult I’m going to find this year in how it jars with my fundamental values and assumptions as to how psychological therapy should be. It’s odd, and I must try to check it, but I have an almost instinctual aversion to CBT and the phrase ‘evidence-based treatment’. Aaron Beck (the founder of CBT), gives me an uncomfortable feeling, I can’t help but think he’s getting something terribly wrong, or turning something complex into something robotically simple (to its detriment). I don’t have enough learning or experience to quite put into words what exactly I distrust about Beck’s cognitive approach, and I know that it has changed and improved a lot since his day so I’m probably being hugely unfair to modern practitioners of CBT, but I have read a couple of things recently that have started to confirm my uncomfortable feeling about it…

The first was a blog post by philosopher and clinical psychologist Richard Gipps, on how Beck’s turn away from psychoanalytic psychotherapy was caused by his own misunderstanding of the theory, rather than with any fundamental flaw in the approach itself.

And the second was a journal article by Michael McEachrane on the flawed assumptions that Cognitive Therapy is based on to do with what it really means to ‘think that p‘.

I’m tempted to share these two articles with the other Trainees on my course to see what they think, but I don’t want to be the bad, critical one in the bunch.

And, I do understand why IAPT uses the CBT model so religiously. The aim of IAPT is to ‘democratise psychological therapy’ – it wants to make it accessible on the NHS, and this I fervently agree with. Unfortunately, however, CBT is the only kind of therapy that can be made ‘efficient’ and ‘wide-spread’ in this way, because it’s less about the relationship that the client has with their therapist, and more about the ‘tools’ that they learn from them. So, the therapists can be quickly and inexpensively trained, because it’s not really about them and their skills.

Research has shown that this can be effective (with about a 50% recovery rate; not bad, not good?), but the jury’s out as to how long those benefits last for, and I have a feeling that the main function of having Step 2 low-intensity treatments available on the NHS isn’t so much for the good they do, but as a sifting mechanism for finding out who are the really serious cases on the waiting list who need longer-term therapy. Without Step 2, we would have one big, long waiting list for CBT Proper (Step 3), and that wouldn’t be good for anybody.

First Day as a Mental Health Support Worker

Yesterday I had my first shift as a Support Worker at a Recovery House; it was both exhausting and fascinating.

I arrived for 8am, which was when the night staff give us the hand-over on each individual staying at the house, how their night went, etc. so that we know how everyone is feeling in the morning. Then myself and a colleague went around each room at 9am to say hello to everyone, even if that’s just a sleepy grunt, and give some people their morning medication. The rest of the day was spent checking various inconsistencies (one lady had much less medication left than we would have expected given how much she is supposed to take), or issues (to do with housing, mis-remembered doctors appointments…). We also keep regularly checking-in on everyone, and take notes throughout of everything that happens so that we can then hand over that info to the night staff that will follow us when we leave at 9pm.

One of the most interesting parts of the day for me was shadowing a 1-on-1 chat between my colleague and a service user who had only recently come to the house, and listening to how we first get a sense of the individual joining us – what they are struggling with, what they hope to achieve, what particularly distresses them, and general background information…To be totally honest, the conversation was heartbreaking. What seemed to be the major problem for the service user, apart from her mental health difficulties (which were being relieved somewhat by medication, I think), was her lack of social networks. She said that she had no friend or family member who was there for her outside of the house. The only person ‘in her life’ was her Care Co-Ordinator. That must be so frightfully painfully lonely and horrible. I don’t think many of us can even imagine what it must be like to have literally no one that we could turn to if we were ever in a difficult situation (aunts, friends from school, neighbours…). And, in a cruel turn of fate, it is as if having that support network there is even enough to prevent us from actually needing them. I think that the very fact that we know that they are there, is enough to comfort us and stop us slipping into a spiral wherein we really need to rely on them.

In talking to this woman I suddenly realised how powerful those invisible support networks (and, of course, the less invisible ones that we get joy and love from on a regular basis) are to our mental health and stability. Her affect felt completely hopeless, and I really felt and shared her suffering as I listened to it.

Since the ‘social networks’ box that my colleague ticked seemed to be the major problem, (I must add that I really didn’t like the very obviously ‘structured’ interview style that we were doing, I understand that it is useful to quickly measure and compare over time, but it felt inhumane and insensitive when discussing such intimate difficulties.) – she tried to suggest ‘ways to improve’, such as to hang out in the lounge or kitchen more, and get to know other service users, or join one of the activities that the house runs like yoga or a film night.
These are all great ideas, but, to me it almost felt too soon to ask this lady to ‘get out a bit more’. I would have wanted to talk to her a bit more personally first, try to understand what kinds of things she as an individual could imagine enjoying doing, get a little bit more of a sense of herself first, so that she wouldn’t feel overwhelmed and incompetent while trying to socialise. I say this because she really struggled to even look either of us in the eye during the conversation. Though, actually, trying to socialise could probably only help, and maybe she would be pleasantly surprised by the ease with which everyone seems to get along in the house. So, both efforts could be used at once, I think. And of course my own presence probably didn’t help the conversation, as I was just awkwardly sitting there watching. A genuinely 1-on-1 conversation would have been easier for everyone involved.

So, those were my first day thoughts! I am very very much looking forward to getting comfortable with all the admin-stuff of the house, the millions of forms to fill, and which keys open which doors, etc., so that I can concentrate fully on providing the best possible service to the residents. Will keep you updated.