In the Room

Making Metaphors

No matter what your therapeutic orientation a good metaphor can be therapeutically very powerful. A good metaphor allows the client to put some distance on their problem but also capturing not only the essence of the problem but the solution as well.

The Ben-Porath paper discussed in the previous post has a nice example:

Therapist: Do you think marriage is always fun or raising children easy?

Client: No, of course not. I realise it can be difficult, especially when you are raising children.

Therapist: Okay, so suppose you are a mountain climber and you have to climb, one of the tallest most difficult mountains yet. When you look in your closet would you choose the hiking boots or the stilettos? (This client had a particularly large collection of shoes that she had spoken of previously)

Client: The hiking boots, of course.

Therapist: Exactly, because wearing the stilettos, you would never get over the mountain. In fact, you would probably break your ankle one-fourth of the way up.

Client: So you think I have been selecting stilettos?

Therapist: You certainly  haven’t been selecting hiking boots.

I like the conciseness of a therapeutic metaphor.  Making your own collection of  metaphors is a good way to develop as a therapist. If you have a favourite therapeutic metaphor feel free to post it in the comments below.

Helping Difficult Clients to Stick to Therapy

Here is a nice little paper by Denise Ben Porath (full text available) on securing commitment to treatment with more complex and difficult clients such as those suffering borderline personality disorder. This is a great article in that it provides lots of examples of therapist-client dialogue.

She outlines a number of commitment strategies designed to enhance the client’s engagement in therapy. These techniques are not for use when a client is clearly engaging but more when a client is motivated both to change but is maybe frightened of what this will mean for them. This client often presents as stuck and conflicted, for example the client who turns up for therapy but is resistant or will not work once they get there.

The Devil’s Advocate is a technique to engage the client in arguing for change. The therapist takes up the no change position and argues the benefits of not engaging and not changing. Using this technique requires some forethought as positive reframes for the status quo and not engaging need to be thought of. Ben-Porath provides a nice vignette of this.

Therapist: It must be hard for you to have hope in a system that hasn’t been able to help you for the past 13 years.

Client: Yeah, I mean I am like. what’s the point.

Therapist: Yes, what is the point? You have seen therapist after therapist for 13 years. Why bother with treatment at this point?”

Client: I don’t know

Therapist: I mean really therapy can be expensive, it takes time why not just be at home watching television or doing something else.

Client: Because I can’t keep living like this!

Therapist: Living like what?

Client: Being miserable. My options are to be miserable or try to figure out how not to be so miserable which would you choose? Maybe this time therapy will help me be less miserable.

When done well it enables the side of the client that wants change to be strengthened. To some degree it is a variation on a cost-benefit analysis of engaging in therapy with the therapist providing the costs.

Another technique she writes about is the door in the face technique. The therapist starts by making a large and probably unreasonable request of the client given their current situation. When this is refused they then ask for a smaller and more reasonable request.

What is your Favourite Personality Test

I spent part of the weekend running a course on utilising personality testing and how it can enhance the psychotherapuetic process.  As a result a short poll for a bit of light diversion.

Web Polls by Vizu

Do you Suffer from Premature Termination Syndrome?

Premature termination is when your client terminates before the agreed time or against the therapist’s current recommendation. This is a common problem for many beginning psychologists and one which many find frustrating and disturbing.

There is a great review article in this in one of last year’s Harvard Review of Psychiatry. Unfortunately full text is not available free online.

The review summarises a number of studies looking into why clients terminate early or do not complete recommended number of sessions. The primary factors identified in the review include:

• Pre-therapy preparation
• Time limited
• Treatment negotiation including goal setting
• Appointment reminders
• Motivation enhancement
• Facilitation of therapeutic alliance
• Facilitation of affective expression

This type of termination impacts on the therapist

Surprisingly, very little has been written about the effects of patient-initiated premature termination on therapists. Most commonly, it is acknowledged that patient-initiated premature termination can be demoralizing to therapists, particularly for beginning therapists.5 Therapists may believe that they have failed, or were rejected by, the patient. Such a belief may, in turn, impair therapists’ confidence and effectiveness. There may be a sense among therapists that they have wasted their time and effort when they experience a premature termination. Narcissistic injury is also common among therapists. That is, for therapists whose own self-esteem is closely tied to their ability to help others, the loss of a patient through premature termination threatens their sense of self-worth. Painful reactions to losing a patient through premature termination, such as hurt, rejection, or anger, may interfere with other aspects of the therapist’s professional or personal life.

It also impacts on the client:

From a clinical perspective, the patient may not receive full benefit from treatment, including the benefit of a worked through termination. The patient often experiences a sense of dissatisfaction or failure, which can result in a worsening of problems. Indeed, patients who terminate prematurely report less therapeutic progress and more psychological distress. Premature terminators are more likely to be characterized as chronic patients, with a tendency to over utilize services, in some cases contacting mental health services at twice the rate of patients classified as appropriate terminators. In the context of group therapy, patient-initiated premature termination can be even more disruptive. Discontinuation disrupts group solidarity and can precipitate other premature terminations. Patient-initiated premature termination may destroy or delay meaningful work for the rest of the group, often leaving other group members feeling insecure, worried, or angry. 

The next few postings will focus on a number of these issues one by one and expand on what therapists can do to minimize this.

Difficult Situations with Children and Families: Mark's FAQ

Some useful ideas on what to do and say in those difficult situations with children and families. More from our guest blogger Mark Donovan.

Children misbehave in session

Ideally you want the parent or carer to respond and set limits for their children, as this provides useful information about how they manage misbehaviour and set boundaries. It can be helpful at this point to say.

Please feel free to do what you do at home.

Please feel free to do what you normally do when they ….

You may, however, need to intervene if the child is doing something potentially dangerous. I will often use this as an opportunity to explain:

I can’t let you climb on the table/chair in case you hurt yourself, please get down

Then maybe redirect towards toys etc. Your directions to the child need to be firm but fair.

A child gets too physically close (sits on your lap etc.)

Again this is useful information about the child’s knowledge of social boundaries and/or ability to inhibit impulses. I usually remind the child: You don’t know me well enough to sit on my lap/hug me. Then redirect so it isn’t received as a punitive comment. Everyone in the family starts arguing or talking at once More useful information! Try to move from the particular content level to the general process level.

Is what is happening right now a good example of what happens at home?

I noticed that everyone wanted to get their point across – did you feel listened to when you did this?

What do you think might be happening?

What happens at home when…