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Working with sensitive or traumatic material with a person who speaks a foreign language is never easy. A good interpreter makes all the difference
Here is a good set of suggestions on working with intrepreters.
Hat tip: The Relaxed Therapist
At the end of the day all the talking and insight in the world is worth nothing if it does lead to a change in behaviour and a resulting change in outcomes for a client. At some point in time what is learnt, understood or acted out in the therapy room has to generalise to the client’s everyday world.
This translation from therapy room to real life is often done using homework exercises in cognitive behavioural therapy. A frequent complaint I hear in supervision is that the client turns up but hasn’t done their homework. This often generates a sense of frustration in the therapist leading to a label of being resistant used more pejoratively that psychologically.
If a client is not doing their homework but is turning up regularly for therapy it is not in my view useful or accurate to say the client is resistant to change. It is more useful to say the client has conflicting motivations about change. Clients may avoid working in therapy because they fear it will not work and this will reinforce their hopelessness. At the same time client may avoid working in therapy because it will work and then they will have to take responsibility for themselves and get on and have a life which can be scary stuff.
The very fact that they continue to come to therapy suggests that some aspect of them believes in or wants to change. Highlighting this as a conflict and exploring the mixed motivations using a cost benefit analysis technique frequently uncovers a way forward.
Calling it homework often casts in the frame of teacher and pupil with accompany memories of school, sometimes for the worse. It also puts it into a frame that this something the client is doing for somebody else i.e. the therapist rather than for themselves. At the same time I have never been totally comfortable with other descriptions such as activity scheduling or behavioural experiments.At the end of the day I usually come back to calling it homework.
There area number of good books and articles on using homework in a cognitive behavioural framework. Leahy’s great book; Overcoming Resistance in Cognitive Therapy covers homework problems in his chapter on process resistance. There has been a recent book published devoted entirely to homework in CBT whose authors include our own Professor Frank Deane. The book is called Using Homework Assignments in Cognitive Behavior Therapy. Judith Beck has some brief suggestion in her book: Cognitive Therapy: Basics and Beyond
Before exploring client resistance to homework it is useful to check that therapist or delivery issues are not interfering with homework completion. In my view it is always best to start with something small and simple and build on success. Far easier to be able to be positive about a success than it is to re-engage a client who feels like they have fialed you or themselves. Beginning therapists often carry beliefs about homework such as more is better. While compliant and compulsive clients may go off and complete all the homework given there will also be a feeling of resentment that may impact on the therapeutic alliance at a later stage.
While there are 50 millions blogs out in the Internet few of them deal with the subject of being a psychologist or a therapist, particularly the day to day issues we face in our work. One of the few I have found is the Relaxed Therapist. This site is full of useful and controversial points to consider and worth a weekly look if you are practicing clinician. This lack of hands on blogging from clinicians is surprising to me. So many of my colleagues are practitioners in solo practice and blogging and the net seem natural ways to stay in touch with the profession.
There are also a number of blogs covering clinical and therapeutic research. Staff Psychologist has an almost daily posting on interesting psychology research. The British Psychological Society has a similar blog updating the latest research. One of the oldest and well known sites/blogs is PsychCentral with a wealth of psychological and psychiatric information. PsychSplash is blog planning to provide links and highlights to psychology writing and blogging on the net.
I’ve had a few moments in therapy when personal boundaries have felt challenged – more earlier on and I’m not sure whether this is a function of loss of physical attractiveness due to ageing and/or clearer therapeutic boundaries due to experience. I think I may have taken the ‘pretend it didn’t happen and hope it goes away’ approach early in my career – often my non-verbal responses may have alerted clients to the inappropriateness of their comments. Women are probably less likely to make such comments from my experience, and I think at least half of the comments I’ve dealt with have been from males.
For the vignette you’ve posted, my thoughts would be along the lines of:
I haven’t used the word ‘sexual’ in the above, and have used ‘personal comments’ & ‘attraction’ instead. I prefer to use the client’s words/meanings. I would probably wait for the client to make clearer that the comments were of a sexual nature before constructing their communications as ‘sexual’. If their comments were very explicit, I would then of course be much readier to call them ‘sexual’.
A plug for a new book, Clinical Psychology for Trainees: Foundations of Science-Informed Practice,
This book describes the practice of clinical psychology with special emphasis on providing trainee therapists with the skills and strategies to achieve the core competencies required for a science-informed clinical practice. 
It will support the reader in making the transition from the lecture theatre to the consulting room. The approach incorporates a contemporary perspective on the multiple roles of clinical psychologists within a competitive health care market, where professional psychologists not only need to be accountable for their outcomes and efficient in achieving them, but also need to be conscious of the social and political context in which psychology is practised. Chapters are organised around the acquisition of key competencies and linked within an evidence-based, science-informed framework. Case studies, handouts, graphics and worksheets are employed to encourage the implementation of the skills described. This book should be read by all those enrolled in, or contemplating, postgraduate studies in clinical psychology.
Time to breakout the champagne? A recent paper (no free access) in the Archives of General Psychiatry provides clear evidence of the effectiveness of long term treatment, both cognitive and dynamically based, for Borderline Personality Disorder.
As a clinician actively involved in a borderline treatment program using an integration of both these models this research is incredibly exciting news.
It is a significant piece of research conducted over three years showing clear efficacy for both treatment modalities but with Schema Focused Therapy
To me it is not the evidence that one therapy is better than the other that is most important but the publication of long term research showing that borderline personality disorder is eminently treatable and that people with abusive histories and seriously dysfunctional behaviour can find ways to live normal and fulfilling lives. The clinical evidence that the interns report in the day to day work with borderline personality disorder is now supported by high quality research.
Hopefully this is the first in a series of evidence based research showing that intensive long term therapy using both cognitive and dynamic techniques.
Three years of SFT or TFP proved to bring about a significant change in patients’ personality, shown by reductions in all BPD symptoms and general psychopathologic dysfunction, increases in quality of life, and changes in associated personality features. Using intention-to-treat analysis with adjustments for baseline assessments, SFT and TFP effectiveness became apparent at 12 months of treatment and was further extended at 3 years of treatment. Schema-focused therapy was superior to TFP with respect to reduction in BPD manifestations, general psychopathologic dysfunction, and change in SFT/TFP personality concepts. All in all, it seems that changes in manifest (BPD) psychopathologic dysfunction go hand in hand with changes in pathologic personality features. An explanation may be that both treatments address the level of personality, not merely the “surface” symptom level. Schema-focused therapy was not consistently dominant over TFP with respect to patients’ improved quality of life, as trend and end point analyses yielded different results.
I favour a mix of socratic-type and forced-choice questions
Therapist: I notice that every time I meet or phone you, you …. I’m wondering what you wish to communicate by these comments.
Client: Denies any sexual tone. …..
Therapist: Well that’s good. [Validate appropriate positive feelings such as gratitude that therapy is going well] AND ..I thought it was important to clarify this. Because these comments are personal in nature and may be interpreted as having sexual tones, I’d like you to avoid personal comments in future. What’s your take on this?
Therapist: So, shall we agree that personal comments will be avoided in all future interactions? … Thanks… I appreciate your compliance with this. Possible follow up questions and responses Would it surprise you if you discovered that most therapists found these comments inappropriate because they are of a personal nature and may have implicit sexual overtones
Possible follow up questions and responses
Would it surprise you if you discovered that most therapists found these comments inappropriate because they are of a personal nature and may have implicit sexual overtones?
Would it surprise you if these comments were interpreted as your ‘hitting’ on a woman or making a pass at them?
Therapist-client interactions should remain professional for therapy to be effective. Our interactions will be no different. That’s non-negotiable. How do you feel about that?
I’m pleased that our interactions have been positive. They can continue to be positive. However, our interactions will remain professional. So, shall we agree that you will avoid personal comments or gestures in future?
Here is a table that our Clinic uses to differentiate personal from professional relationships (table should list appropriate and inappropriate comments and behaviours for personal vs. professional relationships). Would you like to go through them now or would you like to read them at home and discuss them when we next meet?
Messages may have to be repeated several times if the client doesn’t get it or is not keen to negotiate the outcome
I have assumed that these feelings and expression of sexual attraction have arisen at the very beginning of therapy. If these behaviours started expressing later in the course of longer term therapy then the approach would be different.
I keep the following mantra in mind for any behaviour that begins to transgress boundaries.
In this particular instance I would suggest the following possible set of responses.
Highlight
I am aware that each time we meet you give me a complement about my appearance or my dress.
Is that something you are aware of?
What do you make of that?
Reflect
Do you make these comments to everyone you see men and women?
So what makes you decide when you might make these comments?
Some people may interpret these comments as suggesting sexual attraction. What would you make of that?
Would you make these comments when you are sexually attracted to someone?
Even though it might be difficult to acknowledge do you have some sexual attraction to me.
Normalise
It is not uncommon for clients to have these feelings, it fact it is quite normal.
Refocus
I wonder how we can put aside these feelings of sexual attraction so that we can focus on the task you came here for which is to get better and change some things in your life.
Repeat (if needed)
What do you do when a client starts to be flirtatious or ask questions that appear to be sexual in nature. These comments can often be ambiguous and tend to nudge our boundaries rather than overtly step over them. The ambiguous nature of the comments means the clinician may have a tendency to dismiss their intuition that they are sexual in nature and try and just ignore it. However the more often it is repeated the less the clinician can ignore it and at some time has to make a decision to confront of highlight what is going on. Failure to address the issue often leaves the clinician with 
feelings of anger and powerlessness which may impact on their therapeutic interaction with the client as well as impacting on the therapist’s confidence and self esteem.
As a changing in blogging approach I have put this question out to all the clinical staff in our psychology department and will post their responses as they come to hand. What I have asked them is to provide the exact words they would use to confront this behaviour.
Dealing with this issue can feel difficult even for experienced clinicians. As an older man it is not an issue I face with any regularity but in supervising interns many of whom are young and female they regularly run into this issue.
See the following for responses to this:
It has been an interesting process blogging on psychotherapy. There is clearly a certain amount of anxiety as well as narcissistic pleasure in putting one's views out for public viewing and comment. The response from colleagues, students and other psychologists has been extremely positive, supportive and encouraging. One starts a blog with a certain enthusiasm with initially what appear to be numerous ideas on what you will post about. However even a commitment to post, once a week, you soon find your original stock of ideas begins to dwindle rapidly.
This brings me to the point of this more personal posted. Posting to the blog has forced me 
to go searching for ideas and these have come from a variety of sources. Firstly, it has made me identify all those journals that had papers about technique and the practical aspects of psychotherapy. I now have an alerting system for all these journals that puts an e-mail into my inbox whenever a new issue of the journal is released. Secondly it has forced me to reflect in some detail about my own application of therapeutic technique not only now but in the past. The actual fact of writing rather than just thinking about therapy or talking about therapy means that your ideas are out in front of you in black-and-white, and gives you some reflective distance on what you're thinking about. This idea of some reflective distance or reflective processing is an important part of psychotherapy development that has recently been highlighted in a paper by James Bennett Levy in Behavioural and Cognitive Psychotherapy. This complex and somewhat dense paper looks at a cognitive model of how therapists acquire their skills. One of the ideas he proposes is that once basic skills are gained, the ongoing development and progress of the therapist is mainly around self reflection and enhancing of the reflective process in supervision by a supervisor. I am forced to organise my ideas into some sort of coherence and this makes for further reflection on the technique or idea I am talking about.
A similar process has happened for me in reflecting on ideas and themes that interns bring to their supervision with me. A good example of this is a recent supervision with a young female intern. She raised the issue for her of one particular client, a young male client, who every time he saw her gave her a complement about her appearance, clothes or the sound of her voice. The comments clearly had a sexual tone, and the intern felt her boundaries being nudged to the extent that she felt uncomfortable. As an older male therapist this is an issue I have rarely faced. However looking wider than the individual intern, at least 80 or 90% of psychology interns are young and female. I’ve realised that this is likely to be a very common issue that most new psychologists face.
I have found this forced reflective process the greatest value for me in the whole blogging process and it has contributed greatly to my ongoing development as a supervisor.
