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There’s been a lot of noise lately about how awful the new version of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association is going to be. Virtually none of this drive-by criticism appears to be the least bit informed as to the goals of the DSM-V, much less the process by which it has been developed.

A recent critical article: Why Many Mental Health Professionals Are Ditching the DSM-V ‘Bible’. There are SO many problems with this article, yet most will completely elude detection by readers.

1. The title asserts that “many” MHPs (Mental Health Professionals) are abandoning the DSM-V. Absolutely NO evidence is given for this assertion. A cheap shot, nothing more.

2. The title refers to the DSM as a “Bible”, which it is not. The Bible is considered to be a revelatory document (by believers) or a historical document (by non-believer scholars). The DSM is neither. It’s a data driven, clinically validated, periodically updated classification scheme, and nothing more. That’s all it’s designed to be.

3. “major players in the mental health community say the book needs more research”. Who are these “major players”? The NIMH is mentioned, but that’s now old news, and not immediately relevant, anyway (see #4 below). Unnamed academics from Columbia and Rutgers are also referenced – complaining about the DMS’s lack of epidemiological perspective, and insufficient consideration of ancillary causal factors. As usual, these non-clinician critics want the DSM to be the kind of research review it never was intended to be. It’s for working clinicians, not researchers. It USES research, in several ways, but is NOT a research report, review, or even summary. Once again we see non-clinicians simply failing to understand what we in clinical mental health are actually doing in our work.

4. NIMH director Thomas Insel is paraphrased (correctly, I think) as saying the DSM lacks validity because it classifies disorders solely by their symptoms. Pray tell, what is the alternative? The DSM, in recent iterations, derived from a desire to diagnose not according to theory (for which, by definition, there was little or no formal research support) but according to actual clinical presentation – yes, symptoms. WHAT ELSE DO WE HAVE? This isn’t a mistake, it’s a NECESSITY. We’re playing the only game we actually CAN play, at this point in the evolution of our knowledge of mental illness.

Insel’s project is a research strategy, for an agency with a very strong commitment to basic (i.e., physical science and medical) research. But don’t expect it to answer all questions; it simply can’t

There is a vast amount of research – from studies of morphology in biology to the famed “Minnesota twin studies” in psychology – which supports the idea that what one sees in the real world is about 50% derived from genetic factors and 50% derived from environmental factors. The conceit that any study of genetics+environment will allow us to account for the spectrum of depressive disorders, anxiety disorders, and most particularly trauma disorders is either phenomenally ill-informed or gratuitously over-optimistic. The further notion that the results of such a effort will properly be considered “medical” presupposes that psychology can be reduced to physiology, at the least. Yeah, and while you’re at it, let’s reduce computer programming to mere electronics. This is sort of “reductionist” logical error one is cautioned about as an undergraduate. Such decomposition of a higher order field to one or more lower order fields has never, to my best knowledge, happened – outside of the realm of theory, not is it ever going to.

For how many decades has the search been unfolding for a “gene for alcoholism”? And the results: still looking…

“Further evidence and an approximate estimate of heritability – crudely speaking how genetic a condition is – can be derived from twin studies that yield figures of 50% for males and 25% for females…” (Ball, D. (2004). “Genetic approaches to alcohol dependence”, The British Journal of Psychiatry
185: 449-451 doi: 10.1192/bjp.185.6.449)

What this should make clear is that “medical” approaches to such things will ever only get us part of the way to our goal. The rest of what it will take has to do with behavior, learning, and a causal model that will contain a number of non-physical factors. And alcoholism is EASY, compared to anxiety, depression, or trauma disorders.

It is fundamentally misguided to think that psychology can be reduced to physiology or medicine. Yet, if awareness of this thinking error is not much in the minds of the general public, it is also significantly lacking in the minds of too many mental health professionals. Insufficient awareness of this error is at the heart of much criticism of professional clinical psychology by non-clinicians outside of the field. They just don’t get it. Clinical work is NOT research any more than research is theory. Different areas of thoughtful activity – different goals – different processes – different rules – different outcomes. So shall it always be.

I appreciate that several rather subtle considerations are touched upon in my remarks above, of necessity. This is ALL about explanatory and prediction strategies, and THAT topic isn’t seriously taken up by most students until graduate school. If this were an easy topic, it’d be covered in high school.

Biology is still actively arguing about species delineation and classification (a fascinating topic, by the way). It’s hardly surprising that we are doing the same in the nosology of mental illness. It’s part of the process by which science improves itself. We’re NOT in trouble; we’re just doing our job.

[based on a 2013.05.14 post to the G+ Trauma and dissociation: education and advocacy community]

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Many of the people I work with as a psychotherapist have been very seriously impacted by their life histories.They did not ask for this. It’s like a rock that falls out of the sky, striking them for no discernible  reason. It’s our task to go forward and make their lives work better. Sometimes rather simple tools yield powerful results, as I relate here.

The problem: getting control of intrusive symptoms

Many of my clients have Post-traumatic Stress Disorder. This is usually quite treatable, but success in treatment often isn’t simple. Sometimes I’m faced with a client whose symptoms interrupt their life so much that it makes ongoing treatment difficult if not impossible. This is (obviously) a show-stopper. We simply must moderate the impact of those symptoms if we are to get treatment launched (which will, of course, we expect to make the symptoms go away).

An example: I have a client whose depression, social isolation, high degree of distractibility, and intermittent flashbacks all result in their having real difficulties in remembering appointments, much less actually showing up for them. Symptoms of their disorder are effectively blocking treatment, so we must achieve real symptom management if we’re to accomplish anything significant.

The intervention: tracking symptom intrusion events

So, we recently started formally tracking commitments he makes – for phone calls with me (in which I do brief counseling), as well as psychotherapy appointments. We use an online Google Docs spreadsheet to track both individual commitments he makes AND, should he fail to keep a commitment, the disruptive symptom(s) which impacted him and caused the problem. The purpose of this is help us both focus on identifying and improving management of specific symptoms which are making his life dysfunctional. To both of us, this direct, straightforward, utilitarian approach appears to be working.

It’s about behavior change, not moral re-tooling

There’s also an important implicit message being conveyed here: when you don’t keep a promise, there’s a reason. Something’s happening in your brain which is not serving you well. It’s not about moral failure, or flawed character, or anything remotely related to that outdated, conceptually limited, seventeenth century way of thinking about human behavior. It’s just a programming glitch, pure and simple. We need to isolate the “bug” in the brain program, and fix it. Since we cannot directly access the program, we go at it indirectly, using known psychological principles[1]. This is indirect access is not ideal, but it’s the only access we have, and its good enough – it will get the job done.

So, looking at my client who has trouble keeping promises, we are not going to do a moral analysis of the situation. We’re going to use our best knowledge to make sense of it, and to change what’s happening. Since we understand (I hope – see note 1 below) that a psychological principle CANNOT be Mosaic (absolute or deterministic)  in nature, just what IS it? It’s a pragmatic description of what is likely to happen in a situation, to the best of our knowledge. It’s a probability statement, a kind of “bet”, if you will.

Watched pots boil faster – how the eyes of a group can help an individual

The key psychological principle on exhibit here is social facilitation.[2] It has been noted in psychology, for over 100 years, that people perform better when observed. Modern updates on this note that this is true, generally, with simple behaviors, but can be quite the opposite with complex behaviors.

What I’m trying to do with my client is increase his sense of being observed, both by me and by him (but not by anyone else, as the Google Docs spreadsheet is not accessible to the public), with the expectation that the mere fact of increased observation will improve BOTH his and my management of his intrusive symptoms.

For every intrusive symptom we’ve identified, I’ve suggested to him (IN the online spreadsheet) a simple cognitive-behavioral management intervention. Because the interventions are simple, they ought to be better utilized when his sense of being observed increases. It’s a reasonable bet. Whether the bet pays off or not will be tracked in the spreadsheet. Both he and I contribute to the spreadsheet. His participation is critical. It’s visible manifestation of his very real motivation to get his life in order. He defaulted on a promise last night, and he himself entered that fact into the spreadsheet (it was his first such default, by the way, since we started spreadsheet tracking).

So, this shared spreadsheet functionality make it possible for him to be more visible to himself, and we’re already seeing improved results – dramatically so. Awareness tends to confer increased choice (another practical psychological principle). Because his behavior is improving, his hope for real change in his life is growing. It’s all a simple thing to do, but has already had a  large effect on his life.

An event in progress

We are early in this intervention effort. It may yet fail, even if it surely hasn’t so far. If it does, we’ll simply assess the situation, redesign interventions, re-engage, and continue tracking outcomes.

Today, however, I’m totally pleased with our results. Our use of the Internet as a private computer network may be a little unusual, but…it’s working. and that’s no small thing – not to my client, and certainly not to me. I like to win. We’re winning.

Notes

1. I need to explain what I mean by “known psychological principles”. I am NOT referring to  “principles” that are Mosaic in nature (i.e., those which have the authority of Moses, of “Ten Commandments” fame). While the existence of such principles have long been asserted, to assert is not to validate. Saying that, I must clarify that in our times truth is NOT validated by reference to authority, but by demonstration in the real world. Obviously, not everyone accepts this, but the scientific psychology/psychotherapy community does, and it is from that point of which which I write.

In the nineteenth century, our best thinkers thought we’d finally located  principles of at least near-Mosaic quality –  in the magnificent Newtonian universe of mathematically describable mechanics and thermodynamics. But, with the emergence of Einstein’s relativity and quantum physics (with which Einstein never made his peace), that all fell apart. This new world-view, essentially in place by the early 20th century, is with us still.

Educated people now generally now that we live in a world imbued with uncertainty (probability), not principles (determinism) of the old sort. “Principles” exist only in the simplicity of casual speech and informal thought, the real world does not appear to offer such principles. One can certainly assert the existence of a “principle”. That’s easy enough. It’s demonstrating its validity – its truth – that always proves surpassingly difficult.

People who exuberantly talk about their “principles” and their “values” as if their veracity were beyond doubt are exhibiting intellectual dishonesty. They give us the conclusion of an argument (thought process), but not the argument itself. It’s as if I said, “I’m simply going to believe that what Newton described to us his Principia is true. Because I trust this document, I know that the world is inherently mechanical, because the Principia says so! Mechanistic determinism is true, else Newton wouldn’t have devoted so many pages to its description!” As a medieval philosopher might dryly say, “non sequitor” – nonsense.

The question here is not whether a mechanical view of the universe is good and true, but whether the assumption that Newton got it right in his Principia is supported (and it is not, in the argument I give here). The “values” crowd invariably makes a gratuitous assumption sabout some source document or idea, then deductively derive propositions from that assumption. It’s child’s play, and we’re not going to do that with real people in the real world. What we think has consequences, so we’d better get it as right as we possibly can – demonstrably right.

2. The referenced article is brief, but well summarizes the concept.

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I recently added the following section (notes are at end of the post) to the Posttraumatic stress disorder article at WikiPedia (see my next post, for more on this). The information is completely up to date, and rather interesting – although probably only to other MHPs who treat significant numbers of clients with PTSD, which is my specialty –

Proposed changes to current DSM-IV criteria

(Note: the “DSM” is the Diagnostic and Statistical Manual of the American Psychiatric Association – the compendium of established mental illness diagnoses which mental health professionals in the USA, and a few other places, use. The fifth major revision is in preparation, and will be published soon. It’s a Big Deal, at least for some of us.)

On February 10, 2010, the American Psychiatric Association placed online for comment the draft diagnostic criteria for mental illness diagnoses which are proposed for the upcoming DSM-V. After a public comment period closes on April 20, 2010, the criteria will be field tested for two years, prior to final revisions and publication in May of 2013.[1]

The draft PTSD diagnostic criteria contain some noteworthy changes:[2]

  • Criteria A (prior exposure to traumatic events) is more specifically stated, and evaluation of an individual’s emotional response at the time (current criteria A2) is dropped.
  • Several items in Criteria B (intrusion symptoms) are rewritten to add or augment certain distinctions now considered important.
  • Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This is especially evident in the restated Criteria B – intrusion symptoms. Development of age-specific criteria for diagnosis of PTSD is ongoing at this time.
  • Criteria C (avoidance and numbing) has been split into “C” and “D”:
    • Criteria C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in descriptions.
    • New Criteria D focuses on negative alterations in cognition and mood associated with the traumatic event(s), and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria.
  • Criteria E (formerly “D”), which focuses on increased arousal and reactivity, contains one modestly revised, one entirely new, and four unchanged symptoms.
  • Criteria F (formerly “E”) still requires duration of symptoms to have been at least one month.
  • Criteria G (formerly “F”) stipulates symptom impact (“disturbance”) in the same way as before.
  • The “acute” vs “delayed” distinction is dropped; the “delayed” specifier is considered appropriate if clinical symptom onset is no sooner than 6 months after the traumatic event(s).

Finally, the inclusion in the DSM-V of a Developmental Trauma Disorder is still under discussion, at the time of the draft publication.[3]

Notes

1. Gever, John (10 February 2010). “DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses”. http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/18399. Retrieved 10 February 2010.

2. “309.81 Posttraumatic Stress Disorder – proposed revision – rationale”. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165#. Retrieved 11 February 2010.

3. “Conditions Proposed by Outside Sources”. http://www.dsm5.org/ProposedRevisions/Pages/ConditionsProposedbyOutsideSources.aspx. Retrieved 11 February 2010.

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By at least a ten to one margin, the most read and commented-upon post to this blog is my August 1, 2007 End times: Coming to the end of psychotherapy. I had not expected this, when I published the piece.

Originally written to help one of my clients sort out their thinking as they came to the end of their time working with me, I had posted it because I did think others might find it useful. It appears, now, that it addresses a real and persistent problem. Well, such problems are what we deal with in psychotherapy, and sometimes in our blogs as well.

So, “what’s the problem”? There appear to be two of them: psychotherapy clients, and their therapists. That’s simply what the data appear to support. Let me address each, in light of the continuing comments to the blog entry, and in relation to one in particular (which was withdrawn by its author, so you cannot find it there).

THERAPY CLIENTS AND THEIR ISSUES

Clients appear to have trouble with leaving for several reasons, among which are:

  • They cannot decide if it’s time or not. They don’t know how to arrive at  a decision they can feel comfortable with.
  • They have to leave, and don’t want to, and it’s disturbing them.
  • They’re ready to leave therapy, but don’t want to lose contact with their therapist.
  • They want to leave therapy, but their therapist is objecting, or advising against it.

I think you’ll agree that that covers a lot of ground.

THERAPISTS AND THEIR ISSUES

From the report of people writing comments to my blog entry, it appears that therapists also have trouble with therapy termination for a variety of reasons, among which are:

  • They think their client is making a poor decision, and really isn’t ready to leave.
  • They think their client is being “resistant” to therapy, and is basically “fleeing” therapy.
  • They appear committed to a long term relationship with their client, for reasons which (to me) appear suspicious, and object to a client’s attempts to break free.

I want in this post to comment about therapists and their problems, mostly, since the clients’ side of the picture has been commented upon by me extensively in my original post, and in my responses to readers’ comments.

When therapists think their client is making a poor decision, and really isn’t ready to leave. In a hospital, if the doctor treating you isn’t ready to discharge you and you leave anyway, which is certainly your right, unless you’re being held there under court order, you’re advised that it will be noted in your chart that you’re leaving “AMA” – again medical advice.

In other words, it is customary to tell you that we think (I used to work in a mental hospital) that you’re making an ill-advised decision. Partly this is to protect ourselves legally, but it’s also a last chance to ask you to think things over. Warning you about an “AMA” discharge seems good practice for both parties, and it’s usual and customary practice.

Such circumstances certainly occur in outpatient practice as well, and the same justifications for voicing and recording objections of the treating professional to the departure of the client hold weight in this context. In other words, we are almost certainly remiss if we DO NOT give this warning.

So, clients, you do well to consider the larger picture when you find that your therapist does not support your leaving. The disagreement likely has in it an element of real concern for your welfare.

Yet some clients come to therapy with the expectation (which can escalate to a demand) that their therapists “support” them, period. This is both unreasonable AND reasonable, in the following senses:

  • Reasonable: Our first obligation to you is to support the promotion of your health. It’s the oldest admonition in the healing arts. This means that we need to be able to offer you an informed opinion about your condition, AND that we actually make you that offer. But…
  • Unreasonable: There’s no guarantee that you’ll like what you hear  when we offer you this kind of support. Making you immediately happy is not the purpose of such support. Assisting you to be healthy in the long run IS.
  • Reasonable: “Support” is a favorite word women use in talking about their close social relationships, and with good reason (men seem not to talk about this). It’s a high value for most women, and by “support” they mean what I would call the offering of emotional congruence. That kind of support is appropriate in therapy as long as it supports (in the other sense!) your health. Such support can very meaningfully help a client learn to value their own feelings and viewpoints, for example. But…
  • Unreasonable: Do not expect us to support you emotionally while you make what appears to us to be a bad decision. That’s like praising you for staying on road while driving, as you drive across a washed out bridge.

So, can we do both at the same time? Can we support your “personhood” while disagreeing with your decision to leave? Of course, and I think we must.

I think that at all points in the therapy relationship we need to support our clients’ thinking for themselves. This, fundamentally, is about self respect. But, we also need to MODEL this behavior, which is what I do when I disagree with a client’s decision to leave. How can I advise you to respect your own thinking if I do not respect my own? Therapists are in many ways like parents: they cannot be, or act like, “friends” or “buddies”. We are coaches,  sources of expert opinion and intervention, and most definitely models. Any other understanding is almost always ill-informed and ill-advised.

Basically, our being both supportive and unsupportive of a client, when we find that that is our true position,  is asking a client to be an adult. We’re saying “It’s important that you make your own decision, and do what you think best. Nothing else will really work for you, howsoever scary it may be at the moment.” And then we may also say “And I do not agree with your decision to leave therapy at this time. I think it’s ill advised.” And then, finally we say (at least I say this, because I think it’s very important): “Now you have to make a lonely decision. I’ve given you my best thought, and the most important part of it is that it’s up to you to decide, just as it’s your fate to meet up with the consequences of your decision. This is the way life really is, and I’m here to help you with this little piece of it.”

Some clients have trouble with this, in large part, I think, because we therapists don’t work hard enough making clear what our purpose is: not to make life easy, but to make it better. Often, that means “no pain, no gain”. Some clients really kick and scream about this. I consider that a normal part of their life development. We’ve all done it at one time or another, believe me! And we therapists must remain adult, hold our ground, and hold out for the overall improvement of our clients. We, too, have a lonely decision to make: just as you have to do what you think best, and no one can really take over for you, so do we. It’s part of our ethical commitment to you.

(I’m laughing to myself right now…recalling how many times I know of parents who truthfully told their kids “You’ll thank me for this some day.” What a day of true joy THAT is – ha!)

When therapists think their client is being “resistant” to therapy, and is basically “fleeing” therapy. Well, some clients ARE resistant, and they do flee. The “resistance” is typically based either on a failure to understand what therapy is actually about (“What? I have to walk TOWARD my pain? Are you NUTS?”), or on fear, or both. The “fear” is more serious, more complex, and more difficult to deal with.

Just to give one example: a client I had once basically had never, as a child, had an emotionally supportive, protective relationship with an adult she could trust. I was probably the first person who’d ever invited her to trust herself (AND me) as we looked back at the painfulness of that childhood. She’d thought that therapy would be like a magic pill, and that we’d quickly and permanently anesthetize large parts of her memory.

When I advised her that that wasn’t quite accurate, she simply couldn’t trust that I knew what I was talking about. I think that she also couldn’t trust that she could survive contact with her feelings. She ran, against my advice and in spite of my best efforts to calm and reassure her. I believe her departure was due both to her mis-perceptions about how therapy works and her fear of herself and all other adults. A tough story, for both of us.

On the other hand, some therapists call any client who want to leave before the therapists deems them ready “resistant”. I strongly object to this. First, I don’t think it’s helpful in any way. Second, I think it a poor characterization of what’s actually happening.

Resistance can be a very good thing. I will resist your picking my pocket, for example. But it also can be a completely wrong word. If I resist having a perfectly good meal with you, because if I do so I’ll miss my train, “resisting” your invitation is simply rational. So is it rational if my client evaluates her situation, listens to me and anyone else she cares to listen to, then decides that what she want to do is leave? In that case, her leaving is the only sane, rational thing to do, and I would strongly support her leaving for that reason.

I have in fact most certainly told clients who I thought were leaving therapy prematurely (I do get a few!) that I thought all in all they simply had to go, that not to go would be wrong because it would be an act of self-disrespect. And I said this after telling them that I was convinced that therapy would be good for them, and  thought they needed it.

Again I say: I know this isn’t simple. But it IS true, and telling the truth is my first interest and first obligation. The challenge of understanding this truth is a completely separate issue.

WORKING TOGETHER TO MAKE THIS EASIER

From the moment I began addressing this topic, over a year ago, I knew that often it’s a difficult one for all concerned. I have, at all points, felt most concerned about the difficulties clients have with ending therapy. They are the more vulnerable, less informed, less experienced of the two individuals involved. I think we therapists need to help them with this issue just as we do with others.

Therapists get in trouble with this issue just as do their clients, sometimes for the same reasons! Sometimes their troubles are of their own making, and sometimes they are due simply to the nature of the problem. A fundamental objective of my writing on this topic is to raise awareness by both therapy clients and therapists both of the pervasive existence of this problem and of its nature.

We need to talk more with each other about this matter, preferably from an informed point of view. We certainly also need to respect each others difficulties in dealing with therapy termination. All in all, this problem isn’t going to go away, and isn’t likely to get much easier over time. It will just be there, waiting for us.

When therapy termination time comes, we need to do with this what we do with other problems in psychotherapy, turn toward it, look it in the eye, see its parts, feel our feelings, talk to each other, and, while as fully alive and functional as we can be, simply walk through the fire. It’s what we do, and it’s what we’re good at – or trying to get good at! It’s just another part of a life which isn’t always easy but which IS manageable.

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As a graduate student in Honolulu, I had a friend – ex-Peace Corps (Ethiopia) volunteer – who shared with me a love of cycling, especially outside of the city. Not natives, we loved the local exotica we encountered cycling along the quiet roads outside Honolulu – sights and critters best seen from a bicycle. We also shared a common need to manage the stresses of graduate school. This led us both to meditate – a nice counterpoint to the intensity of cycling, which itself led inevitably to physical relaxation – always good for the mind.

He proposed to me one day that we drive up a route we would normally cycle: a lovely winding road close by the university, a route which ended at a high spot overlooking the city and the hilly country inland which was populated mostly by trees. We would do this, he suggested, so that we could sit in the quiet and wait for dawn -a dawn meditation leading into the day. A lovely idea, which required that we arise early, drive away from the familiarity of our little dorm rooms, out into the dark in anticipation of the coming light.

And so we did, one morning. That is how we encountered yet another marvelous dawn, sitting up above the city, in the cool air, waiting until our reward came, while the faint sweet scent of plumeria drifted over us. That day had a good beginning – quiet, calm, comforting.

As I write this I’m struck by the metaphor this memory embodies. A child well might not have understood what we were about, setting off to go sit in the dark. Children don’t really understand psychotherapy, either. It’s an adult idea. Children can experience, and benefit, but only adults (and mature children, in all fairness) can intend such things. Psychotherapy usually involves encounters with darkness – with negative views, ideas, and feelings, causes of distress in a person’s life. This encounter is taken up in the hope that light will dawn, which it usually does, but not always immediately.

On that morning, some years ago, we both could see the light – in our mind – before it gleamed in our eyes. This was helpful. It gave us reason to leave our warm beds and journey off into the dark. It’s good to know that light is coming. Belief in that possibility is at the heart of psychotherapy. Children are good at hope, if they are reasonably well cared for, but adults are better – they simply can see farther. Almost anyone can enter into psychotherapy, but only adults (and some mature children!) can intend to.

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[ Psychotherapy may end, but the popularity of this topic may well not. There’s a follow-up to this post, which you may wish to read: Leaving therapy – so what’s the problem? (2009.01.15) ]

Everything ends eventually, including psychotherapy. A grace-full, well managed ending is ideal, but, in reality, ending psychotherapy – leaving a psychotherapy relationship – is a problem for some individuals. Mental health professionals would do well to acknowledge this more often, and respond with some specific suggestions for our clients, before they start wondering whether it’s time to stop, and then how to do it.

PSYCHOTHERAPY AS AN INTIMATE RELATIONSHIP

Intimacy takes many forms. Most intimacy in life is familial. Some occurs in the context of friendship. And some occurs in psychotherapy. In all cases, it is true that intimates know things about each other not generally known by other people in their life.

Intimacy is not always between peers. We may know significant details of the life of our First Family (President, etc.). It’s unlikely that they know anything of us, as individuals. Mothers know more about their children than the children know of them. Psychotherapy relationships are similarly unequal, for in them therapists know more about their clients than clients about therapists.

INTIMACY AND VULNERABILITY

Intimate knowledge creates vulnerability. Where intimate knowledge is asymmetrical, vulnerability is also. Whoever is known most about is usually the vulnerable one, for multiple reasons. In psychotherapy, this vulnerable one is the client.

The specific vulnerability I want to address here has to do with the likelihood that leaving a psychotherapy relationship will be a distressing time for a client. I want to consider the possibility of reducing this distress.

WHY LEAVING PSYCHOTHERAPY CAN BE DIFFICULT FOR YOU

There are so many reasons why this may be so. Here a some of the reasons most immediately obvious to me:

  • You may never have done it before.
  • When the issue of leaving occurs to you, you may not feel finished with therapy.
  • Your therapist may not talked with you yet about leaving, at the time you begin thinking about it.
  • You may have real conflict about leaving.
  • You may not be the one who brings the issue up.
  • You may be aware that your therapist is more engaged in working with your problems than you are, and you don’t have any idea what to do about this.
  • You don’t want to hurt your therapist’s feelings.
  • You may have no idea how to justify your leaving.
  • Other people in your life who matter to you may want you to stay in therapy.

GETTING YOUR THINKING STRAIGHT ABOUT LEAVING

I want to take up here each of challenges I listed above, and possibly a few others that come up as I work things through.

You may never have done it before. First-time therapy clients have a lot of “firsts” to work through in therapy. Leaving is certainly one of them. If this is not your first therapy relationship you’re more likely to have some knowledge of the challenge of leaving, even if you don’t yet quite know how to do it well. If this is your first time leaving therapy, you really ought to talk about it with your therapist. They, after all, are not first-timers, relative to this issue, and just might be able to help you. If you find it a difficult topic to bring up, then the difficulty you’re experiencing needs to be the first thing you talk about. That difficulty may well be a legitimate “therapy issue”.

Your therapist may not talk with you about leaving before you begin to feel like the time is close. If we therapists don’t take up this problem and make sense of it, what chance do you have if doing it at all well? We’re interested in getting you into therapy, and keeping you there until we can get some real work done. And then what? We seem to have little to say about this.

When I brought up this topic to my very capable faculty adviser during my internship in graduate school, his reaction was that this concern was not for us to address. “The client determines when therapy ends”, he said. OK – there’s a very good idea in that sentence, but the problem remains. (And I suspect that if I’d asked the question better I’d have gotten a better answer!)

We have many ideas to offer you. How to leave therapy well seems not to be among them. I’ve never heard this issue seriously discussed in a professional context. We seem not to think about it. We should, because it’s too often a source of distress for our clients. As a client, you cannot fix this problem, but you can realize that part of the problem for you is that too often you’re on your own with the problem. You shouldn’t be, I think, but you usually are. There is a remedy for this, however, and it’s under your control.

You will probably not feel finished, when the issue of leaving comes up. It is rare for a person to have addressed all their problems when they leave therapy. There really isn’t a need to have done this. It’s better to take up focused issues, make progress (any progress at all is better than staying stuck), leave, and then return later if this seems called for. It is realistic to see life as a series of ongoing challenges – and to accept that you’re not going to run out of problems. Do you really think psychotherapy is going to fix this? I wish!

You may not be the one who brings the issue up. If you have to deal with “managed care”, or have a seriously limited budget, you know that external factors and people can have a real say about when therapy ends. Or…your therapist may be moving, or retiring, or going on vacation. Your situation then is one of feeling unfinished but having to leave anyway (see the paragraph above, concerning this). This can be difficult, but it can also be talked about, and learned from. See that this is how it gets handled in your case.

You may have real conflict about leaving – feeling like you want to leave AND you want to stay. This is very common, for many reasons. The best thing to do is to take up the matter of the conflict(s) you feel with your therapist (do you notice a theme in my remarks, here?). Such conflicts arise from the fact that our mind virtually always holds multiple points of view about critical issues. These conflicts are part of being human, so talk about it. It’ll help, and it’ll often work to actually resolve the conflict.

You may be aware that your therapist is more engaged in working with your problems than you are, and you don’t have any idea what to do about this. In a sense, this shouldn’t happen, but it often does, anyway. First of all, it’s probably generally true that your therapist experiences a degree of fascination with your problems – dealing with them is his/her chosen profession, after all. You, on the other hand feel something other than fascination, and in this there is an essential imbalance.

Nevertheless, the rule is that the client leads. We may invite you to go certain places, but when you indicate disinterest, that settles it. It’s YOUR opinion that counts. I hope your therapist doesn’t forget this, but if they do, you still shouldn’t. If your therapist appears to need to engage with your problems, they have matters to take up with their therapist. This kind of problem is actually common in psychotherapy. Freud talked about it, and we’ve been talking about it since then. What you should know is that it’s OUR problem, not yours.

Therapists are people, and they do have problems, at times, but that should not be your concern. In psychotherapy, you’re expected to be self-centered, and you should maintain this focus right on through the time of your leaving. Your therapist can take care of themselves. They have access to excellent resources for doing this.

You don’t want to hurt your therapist’s feelings. I see this issue come up most often with young women, who are often deeply in contact with their maternal side. Such instincts are one of the glories of humanity, but really don’t belong in the psychotherapy relationship. Your therapist does have feelings, and you likely will be missed. Your therapist also has experience with this problem, and can take care of themselves.

It’s good for you to notice that your therapist values you. You do have value, and we all need to know this. However, children leave home, clients leave therapy, and we all leave life, at some point. It’s the Way of Things. If this is a persisting problem for you, you owe it to yourself to bring this problem to therapy. Doing so is an excellent idea.

You may have no idea how to justify your leaving. Many people in therapy have a history of being disrespected, and thus have some trouble respecting themselves. They often feel defensive or in need of justification. Try to understand that this is a developmental problem which you don’t have to have, and really should not tolerate. If you DO have this problem, take it into your therapy as a topic.

The best reason to leave therapy is a very simple one: you want to. I teach assertion, and I’ll say it plainly: Your feelings are your best justification for anything. (You do well to see that your feelings are based on correct perceptions of course.) If you find this difficult, then you’ve just identified and area in which you need some work, and definitely some practice. Assertion skills definitely have to be practiced. I look for opportunities to practice mine. You should too.

Other people in your life who matter to you may want you to stay in therapy. Who? Parents, spouses, children, friends, employers…did I leave anyone out? While sometimes therapy may be mandated by a judge, in all other cases, it’s your call. People can have any opinion they want. It’s a free country. And you need to keep your own counsel. Participation is your decision. When someone else has feelings about your leaving therapy, take it up with them. Understand that THEY are having a problem. Talk with them to see what’s at the root of the problem (it’ll usually be some fear which isn’t well enough identified). This will help your relationship with them, and may even give you some useful information.

SOME THINGS I WANT YOU TO KNOW ABOUT LEAVING THERAPY

You may not be the only one distressed by the idea of your leaving. We often come to truly like and enjoy our clients. I know that in mine I virtually always see the essential problems of all of us as human beings. I usually develop a strong sense of compassion, and come to care significantly about each individual I work with. How can I look casually upon the prospect of coming to the end of our meetings? I don’t know how to do this, and I’m not sure I want to learn. So, that your distress is likely shared is a very good reason for taking up leaving as a topic, with your therapist. You both should talk about it with each other. Very often the problem is one of dealing with loss – and that’s a problem that challenges all of us, in various ways.

Some therapists are as puzzled by the “leaving” problem as you may be. Not all therapists grasp that clients will leave with some of the problems they brought into therapy. I can recall our being confronted with the necessary “unfinished client” problem, by one of our teachers in graduate school. I was already familiar with it, but some of my fellow students had not thought of it, and found it troubling. If your therapist has not grasped this reality, and the fact that it’s not necessarily a problem, you still can. You must, in fact, because everyone leaves unfinished. We’re all a work-in-progress. You think this is a problem? Wait until you face dying, unfinished! (You’ve been warned – so now you have some time to prepare for that one…)

Loss is one of the great themes of everyone’s life – you do well not to turn away from it. Some people, when the time comes, simply run from therapy. It’s the only way they can handle it, but it’s not a good response. Losing your therapist is but one of many losses you will have in your life. USE the experience to address the issue of loss and what it means to you and how you handle it. It’s an excellent chance to add to the benefit you get from your therapy.

Your therapy is about you and what’s good for you. This may seem obvious, yet concern for others and a desire to take care of others, sometimes in inappropriate ways, is common, especially in psychotherapy clients. Your therapist, if she/he has a lick of sense, has done psychotherapy work themselves, and has taken up the issue of loss in the course of that work. He/she comes to their work prepared to handle the eventual loss of clients. You don’t need to be worried or concerned about them. Your attention belongs on you.

You can come back. Surprise! This doesn’t occur to many people. You can think of leaving as an experiment. Do it and see how it goes for you. You can return, if you find that you’re not ready. I’ve had a number of clients return, virtually always for only a short period of additional work. Some have come back 2-3 times. One came back four, and the fourth time was the one where she really got down to work. I was thrilled, and I think she was as well. You can simply take things as they come, just like you have to do with the rest of your life.

SOME GOOD WAYS TO TALK ABOUT LEAVING THERAPY

I want to offer here some little “mini-scripts” which may help you deal with leaving.

(To your therapist) – “I’ve been thinking that I’m about finished with therapy. What do you think about that?”

(To anyone at all) – “I’m feeling about ready to leave therapy. It’s been a challenge/good experience/disappointment/real puzzle to me/a life changing experience (pick one or more). I’m ready for a rest.”

(To yourself) – “I feel about ready to stop. I want to respect that. I can come back if I want to, or go elsewhere, later. I will always have many options.”

(To your spouse) – “I’m graduating soon from therapy. I hope you’ve been keeping up, because your life is about to get really interesting!”

(To your therapist) – “Thanks for the challenges, for the patience, for information, for the compassions and caring. I’m not who I was when I came here. I know I’ll keep growing after I leave, and what’s happened here will help to make that good growth. I’m grateful. I hope you think of me from time to time. I know I’ll think of you. Maybe I’ll send you a postcard.” (I always like to hear these sorts of statements. Expressing gratitude is something I very much value. I will often express a lot of it back – I do admire the courage and humanity of my clients. I always am inspired by it. Rarely, I think, do they realize how much they enrich my life. I want them to have some small sense of that. And I always respond positively to the idea of that “postcard”.)

CONCLUSION

I wrote this originally in one sitting, while thinking particularly of one client of mine (who reported finding it useful), but always had in mind a more general problem, involving many more individuals. What I have written seems incomplete, and unfinished, and I hope to revisit the topic and revise it further, but for now it’s time to go. This, too, is a work in progress.

(revised 2008.06.03)

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(continued, from previous post | part 1 | part 2 | part 3 )

WHY I (AND YOU AS WELL) SHOULD CARE

We’re part of a critical historical time – and science is at the center of it. I can easily predict that 2000 years from now our times will be noteworthy by virtue of three things, the first being the most important, because it’s the cause of the other two:

  • the emergence and cultural dominance of scientific method, as a way of validating and creating knowledge;
  • our managing not (yet) to blow ourselves up with weapons which were capable, for the first time ever, of removing most life from the planet; and…
  • whatever it is we do about the approaching global climate change and resource exhaustion crises.

So, I urge that the first thing we need to do is have respect for our place in history – all of us living at this time in human history, as educated, thoughtful people.

Psychotherapy is a part of the culture of science. That’s why we study it only at the graduate level, after getting a general education which includes non-trivial introductions to mathematics, physical science, biological science, and social science. Without science, we are reduced to the nonsense of prior ages – to things like ether, and phlogiston, and to the notion of evil spirits as a cause of plagues. With science, we have fought back magnificently against these erroneous idea and perplexing problems, and others as well such as Ptolemeic astronomy, infectious disease, and instability in large scale economic systems. We are even beginning to fight successfully against genetic disease, a truly astounding achievement.

We have erected a vast and well-oiled machinery for validating critical propositions, such as:

  • Does every cancerous breast really have to be surgically excised? (It was thought necessary, before the matter was empirically investigated.)
  • Is an extract of cocaine a good ingredient for a popular soft drink (Coco-Cola)? (Once science understood a little about cocaine and the brain, this seemed like a not-so-good idea; the practice was discontinued, but not the name.)
  • Is schizophrenia best treated with restraints and cold water baths? (Well, not any more. We actually can do some helpful things now, and science brought them about.)
  • Does vitamin C in large doses prevent the common cold? (Science found that it didn’t, sadly, but large doses ARE a dandy way to mess up certain parts of your body and biochemistry.)

You get the idea, I hope. Taking psychotherapy away from the science of psychology is unthinkable, howsoever much the science at its core must be tempered by, and enlivened with, the art of human relationship and the intermittent irrationality of existential optimism.

Professional psychotherapy is part of the democratization of knowing. Psychology, and its rowdy child, psychotherapy, is a part of a much larger historical movement. For many reasons, in western European culture there slowly developed a concern for the kind of knowing which allows for reliable prediction. This turns out to be best developed when what is “known” can be experienced by more than one person. Prediction came to be based on process accessible to all, rather than on the dogma of person or tradition. If this change of value hadn’t gotten real results, it would merely have been another dogma, and thus not very important at all.

That didn’t happen. Instead, what slowly emerged was the notion that the basis for our best knowing had to be accessible to our senses. Not MY senses, or YOUR senses, but OUR senses. Knowledge and the making of knowledge took on a decidedly democratic flavor. It could no longer be private, dispensed by the knowing to the unknowing. This criterion rules out what cannot be seen, heard, touched, etc. Use of instrumentation, as sense extenders, is allowed, of course. Astronomers and microbiologists, among others, do it daily.

Our own profession, psychology/counseling/psychotherapy, clearly developed under this umbrella. The critical distinction that sets all domains in this group is that between dogma and science. Dogma is validated by the authority of person or tradition. Science is validated by anyone who is informed enough to set up the conditions of observation. If you know how to operate the Hubble telescope – or access its photographs, you too can observe the Cat’s Eye nebula (and I hope you get to – it’s extraordinary). But, I have no way of observing a past life, or the archangel Michael – at least not in a way that can be reliably replicated by other people. The culture of science insists that we draw a firm line, placing that which can be known reliably by all on one side, and all else on the other. So: general principles of psychotherapy go on one side, angels and space aliens on the other.

Ersatz reality – it does nothing for us. When we take something that is a concept and act as if it is a validated reality, we commit the logical fallacy of reification. I have seen too much of that in my profession. I don’t mind creative thinking and unusual concepts – far from it. I do mind blurring the distinction between (a) a mere idea and (b) reality as it may be known by any adult of sound mind.

There is a large class of concepts which may be used to account for observable phenomenon in psychotherapy: among the ones I don’t think we can use are evil (or good, or ancestral, or whatever) spirits, space aliens, past life re-experiencing, the archangel Michael, and so on (see note 1, below). Some of my clients freely use such ideas (as do some of my Texas relatives!). Therapists I know have had clients who speak of alien abductions. I even had one once (such a client – not an abduction!). I see no need to contest such concepts with our clients. But, we must not, in our own thinking, glibly take them at face value, either, for several reasons:

  1. We usually don’t have enough information to validate much beyond what we can observe in our consulting room. We tend to forget this, and at that point we commit the sin of reification. Bad dog! Heel!
  2. Our job is to validate a client’s feelings, not their thinking. People have a need to explain, and particularly so when they are experiencing painful feelings. People are also inherently creative – we are all natural storytellers. Just because I can concoct some colorful or compelling explanation for something does NOT mean that I understand it, or that my explanation is valid. We must not forget that people make explanations (or borrow them from others) for many reasons. In trying to make sense of what’s happening to them, psychotherapy clients sometimes get it right, and sometimes it’s just a desperate grab. Any port in a storm. This is not a problem as long as we ourselves stay on track concerning what our job is and is not.
  3. Our OWN thinking does need to be as valid as we can possibly make it. Someone may think that their heart pain is due to messages from their dead mother, but their cardiologist had better not pursue this line of thinking. Better that she/he consider that anxiety or fear or some other stress may be related to the pain, as that sort of linkage does have an empirical basis and may thus lead to a useful intervention. In fact, what a competent cardiologist will likely do is look first for organic explanations. As psychotherapists, we have exactly the same objectives and priorities. Again, let me urge: when science is available, don’t use art. Culture (including religious beliefs and their many relatives) supplies art. Hard thought and work supplies science. (Ever wonder why they call it “hard” science?)
  4. Effective therapy is focused on client feeling. A client’s thinking is of primary interest only when it fairly directly connects to this. This principle is the basis of cognitive therapy, and of good case management. We can leave our clients free to do their own cognitive investigations, as long as their affect (feeling) dynamics please them (in which case we have no work to do). We need to focus on the causes of their affective distress, using the best information available to locate those causes. To look to spirits (or whatever) when relevant personal history is at hand, or evidence of mal-formed thought about self, or any other ordinary psychological explanation, is simply irresponsible. It is incompetent. I regret to say that I see my peers do this far too often. (see note 2, below)
  5. Strong feelings never validate; data validates. When client thinking matters, and it often doesn’t, it gets validated by reference to other thinking, and ultimately by reference to data – the stuff we can see, hear, touch, etc. Feelings are great – they give life meaning. They do not, however, validate anything. If you’re up on your neuropsychology, you’ll know that the function of feelings in the brain is to cause a temporary unity of otherwise relatively dissociated brain parts, in order to bring about some act or additional thought (see note 4, below). For that reason, feelings are utterly essential to life itself…but not to scientific method – at least not a means to validation of any hypothesis.

We should care because history demands it. Rarely do we return to a former mode of thought in order to improve our effectiveness. I see no reason to retreat from that which may be verified (even if it hasn’t yet been, as is the case with much in psychotherapy) and embrace that which we have for good reason abandoned: thought which merely is coherent, or which merely appeals to us for some reason, or which “feels” right. All those things may well lead us to a good place, and are often our starting point in the search for new knowledge, but we must not go there if we have better places to go.

The thrust of our history is that science is what we are about, whenever possible. In science, we strive mightily to stay on the ground, to get our fingers dirty. It’s often not glorious work, and it’s not for the lazy, the ill-trained, or those lacking in long range vision. It is, however, for those who have some grasp of human history. It’s clear which direction history is headed, and it certainly isn’t toward the use of astrology or past lives in psychotherapy!

An age is called Dark not because the light fails to shine, but because people refuse to see it. ~ James Michener

I am unable to account for how it is that, in a time when we are literally peering into the brain as human personality expresses itself in real time, some of us are retreating to Chinese folk medicine and the like (see note 3, below). For that you need a graduate degree, and years of supervised internship? Someone, at some point, has taken leave of their senses.

THE FIX FOR PRESUMPTUOUSNESS

Honesty, and a degree of humility, will do the trick. The last thing in the world I want to do is discourage innovative thinking in the best field of work I’ve ever known. That is not to say, however, that anything goes. We do have standards, and they have been both hard won (remember Galileo’s run-in with the Roman Catholic dogmatists?) and well tested (it wasn’t Chinese folk medicine, or astrology, which produced a vaccine for polio, or a treatment for HIV AIDS).

In professional psychotherapy, we are obliged to do our best. We are obliged to learn about both belief and knowledge, and respect both in their proper place. We are obliged to be transparent, and not to appear to have knowledge when we have something less than that. We are obliged to be honest – with ourselves, between ourselves, and with our clients. There is much that we do not know, and some that we do. Let’s be clear about which is which, and not seek to fly where we can only crawl. Let’s simply get it right, because this is not a game for children, or for the mind of a child.

WHAT PSYCHOTHERAPY IS NOT – AND IS – ABOUT

Aside from issue- and context-appropriate psycho-education, as part of our case management of a client, psychotherapy is not about validating a client’s thinking. It is not about uncritical acceptance of a client’s way of thinking about themselves, or anything else – or uncritical rejection, either. It is not about being distracted by the inherent creativity of human cultures and human minds.

It IS about compassionate relationship – after all, we’re all trying to solve the same problem, albeit with differing tools, and different skills. It IS about embracing the core of meaning: our feelings about what has been and is happening to us, and about doing what we can to change the essential nature of that core for the better.

So – they report being abducted by aliens? You know what to do: Screen for the many flavors of psychosis, then get on with helping your client make their peace with their universe, howsoever they see it. Don’t get distracted by the exotica. Stay focused on the dance, and the music driving it. The costume may or may not interest you, but unless attending to it helps you to make a happier dancer, don’t go there.

Lion and tigers and bears…oh my! And angels and aliens and reincarnation…oh my, for sure! But…we really do need some kind of “parental block” device for errant concepts in psychotherapy models. Until that device arrives, it’ll be up to us to keep things in order. We must not let our clients, ourselves, or our historical destiny down.

Little children, when asked to run, sprint full out, then collapse. We must run as adults, knowing our capability and conserving our resources. This approach has taken us far, and the journey is not over.

NOTES

1. I can just hear the howls from certain quarters, so allow me throw a little cold water: I fully realize that all human thought rides on wheels of pure assumption, including physics. Especially physics – witness the miasma of modern pre-empirical (theoretical) physics – things are orderly enough until one looks beneath the hood, as it were, then out come the strings and the quarks and the quacks and the klinks (OK, I made up those last two, but who really noticed – come on , be honest…)

However, the realization that all certainty is built on a foundation of uncertainty does not give one license blythly to be presumptive. One legitimately presumes only when these is no other option. Filling that pot for supper is always a priority. Elegant theology is a lovely thing, but doing something about birth defects is a whole different order of concern. They simply cannot be put on the same level by sane people. At some point, the ability to actually DO science really matters. Wait until you get cancer, then you’ll understand, if you don’t already. Until then, you have the luxury of denial, if that’s the best you can do.

2. I’m sick of hearing about “energy” in psychotherapy discussions when what is clearly being talked about is “feeling”. We can observe the latter in brain scans (indirectly, of course, but rather convincingly). But what in blazes is “energy” – as in “energy psychology”? I can make no sense of this, nor I suspect can anyone else, yet there are a number of books about it. I do have some comprehension of energy – physics was my favorite hard science, in high school and college. But “energy psychology”? Well, my best guess is that someone’s battery was a bit drained one night, and they continued to think past the point of reason, and out came “energy psychology”. I recommend a conceptual recharge.

Seriously, though, while there do exist coherent expositions of energy psychology, there also exist coherent expositions of the politics of heaven, as conceived of by Scholastic Catholic philosophers. The problem should be obvious: these ideas aren’t falsifiable. They don’t belong in science OR psychotherapy, for that reason.

3. Chinese folk medicine, I will remind you, has been busy for years supporting a trade in bear gall bladders, tiger penises, rhino horn, and other assorted animal parts, for their purported healing properties. I can predict that these aspects of Chinese folk medicine will soon be no more, as various animal populations it preys upon depart our planet forever due to breeding stock decimation. What does that do for your chi? If only we could sneak a little real science in the back door here we might save a few of our precious animals.

4. Siegel, D. J. (2004). The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York: Guilford.

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