In the Room

Do We Unconsciously Invite Gifts?

With Christmas upon us, gifts from our clients can become an issue. I have posted on this earlier but was just revisiting a great paper on this by Helen Spandler and others. This paper is now free online.

The Spandler et al paper is a great one and covers the issue of gift giving in psychotherapy extensively. In rereading this, of particular interest to me, was the section on whether we as therapists unconsciously elicit gifts from our clients. Money quote:

It would appear that therapists generate their own specific gift patterns. While one respondent reported being offered what were the two ‘biggest’ gifts in the study, most respondents reported receiving gifts rarely. There were a number of examples of therapists reporting no gifts. One retired female therapist claimed she received no gifts after thirty-five years of therapeutic work, and another only twice in twenty years’ practice. Yet, on the other hand, some therapists reported a number of examples of gifts. We could speculate: are therapists who receive many gifts ‘better therapists’? Alternatively are therapists who rarely receive gifts those who are able to ‘contain’ the therapy so that the therapy itself is ‘enough’? As one therapist asked: ‘Do we unconsciously invite gifts?’ Clearly, such matters depend on the particular ‘take’ or interpretation of therapeutic approach, which in turn may relate to the personality/background of the therapist. However, responses highlighted other factors involved in evaluating the gift, including the mobilization of gender dynamics.

This can lead to complex unconscious patterns when groups of therapists work together. The person receiving the most gifts in the group practice can feel guilty, the rest can feel envious.

While we are on the topic, one of my favourite Christmas gift stories. I can remember one year receiving a book of crossword puzzles from one of my client’s prior to leaving for a three week Christmas holiday. Although we had explored the issue of how she felt about me being away she denied being angry at me. It took me a number of minutes to understand the real meaning of her gift: cross words = angry words.

What's on the Blogs

Catching my eye on the psychology blogs this week.

For those of you working in the health service then you are often part of a multidisciplinary team. Ever wondered why some of them worked and some of them didn’t. Sadly mostly didn’t in my experience. BPS Research Digest reports on a study looking at what makes these teams work. Money quote:

Teams with more professions on board only introduced innovations of greater quality when effective group processes were in place – including all team members being committed to the same cause; everyone in the team being listened to; the team reflecting on its own effectiveness; and there being plenty of contact between team members.

Psyblog has a great roundup on emotion, models of emotions and even unconscious emotion. This is useful stuff for us clinicians, given that working with affect is so much part of our day to day work.

The best known modern theory conceptualising emotional states concentrates on two dimensions: valence and arousal. Valence refers to whether you feel positive or negative and arousal refers to physiological 'excitement'. This model has been extremely popular probably because it provides a relatively simple way of researching emotions that can at least provide some answers. Rage, for example, can be considered an emotion that is high on both negative affect as well as arousal.

Read the rest

Psychsplash continues to provide reviews of a range of psychology blogs. Thanks by the way for the very positive review of In the Room. Thanks also for the positive plug at A Clinician’s Journal.

Following the Fallacy: Enhancing your Logical Analysis

Cognitive therapy involves assisting people to change their cognitions and in the longer run so does psychodynamic therapy. Part of our role as a therapist doing cognitive therapy is to recognise and to challenge dysfunctional thinking patterns. To do this we need to understand what is dysfunctional and illogical about the client’s thinking patterns

Most courses teaching cognitive behavioural therapy spend a limited amount of time, often only two to three lectures, on this component of cognitive therapy. Rarely if ever do students come away with an overview of deductive and inductive logic and particularly of logical fallacies. Here is a simple test for yourself: Can you define the difference between inductive and deductive logic? If you got that right then: What is a straw man argument? Not able to answer either of these questions? Maybe it is time for some review.

I have already discussed Socratic questioning as an area that takes considerable practice. This is another area where it takes constant practice to develop one’s skills. Because it is hard work developing these two skills, therapists often give up on continued development and tend to run with a limited number of cognitive distortions they are familiar with. These are often the easier one’s to recognise such as black and white thinking or selective attention. I think it enhances our power as a therapist when we are able to also pick up on the more subtle distortions in client thinking and highlight these gently for the client.

It raises the question for me as to how as a therapist we can enhance a client’s critical thinking and application of deductive logic to their situation if we do not fully understand these concepts ourselves. It adds a further question (the topic of a further post) of what it means if we are not familiar with our own favourite logical fallacies. To develop our ability to recognise logical fallacies involves firstly understanding what each one is and then practice and practice at spotting these.

Here is an excellent site outlining all the major logical fallacies people use in debate or argument either with others or with themselves. Another more in depth site here. Again this is from the critical thinking literature which in my view provides a much better overview than does the cognitive behavioural literature. Robert Leahy has some good stuff in his Cognitive Therapy Techniques but does not go beyond providing a single example of each logical fallacy. The value of the site above is that it provides a clear outline of why each fallacy is not logical and then provides numerous examples to make sense of it.

One of the best places to practice spotting logical fallacies is to listen to politicians. Or you can play spot the fallacy on the famous Monty Python sketch. Once the ability is developed to label the fallacy then the therapist can use this understanding to develop a set of Socratic questioning to help the client understand the fallacy. Simply pointing out the fallacy is rarely helpful to the client. It is a therapist fallacy that by presenting logic and evidence to a client who has not been using this in the past that the client will be immediately convinced.

As important as all this is we need to recognise as cognitive therapists that logic and reason fails to provide good understandings about a lot of what it means to be human. Love, sex death and poetry are just a few that come to mind. Oh and God as well before someone reminds me. The limits of logic are not better put than by Albert Einstein.

Gravitation cannot be held responsible for people falling in love. How on earth can you explain in terms of chemistry and physics so important a biological phenomenon as first love? Put your hand on a stove for a minute and it seems like an hour. Sit with that special girl for an hour and it seems like a minute. That's relativity.

Avoiding the Hemlock: Socratic Dialogue III

Socratic questioning is something that takes a lot of practice to do well. For many beginning therapists there is not enough time spent developing this technique particularly in getting observed feedback on what they are doing and not doing well. This skill cannot be developed without this feedback. Ideally it should be video feedback.

The second overarching problem that arises is not understanding what Socratic questioning is. Given the confusing array of definitions outlined in an earlier post this is not surprising. Without a model of what you are doing in your head it is very difficult to know whether you are actually delivering the product in a useful manner. Before you start using this technique define what it is for you. Are you going to use Padesky’s model or someone else’s?

On a more specific basis there are a vast number of ways that Socratic questioning can get derailed. So where do therapists go wrong?

Moving too quickly in general.

Sometimes a client may take some time to give up a cherished and long held dysfunctional belief. Not going at the client’s pace or slower usually leads to resistance. This is commonly seen by the use of the word “but” in the client’s responses. For me that first “but” is a sign I am going to fast and need to go back a stage or two. I observe for many clinicians that the first “but” leads to an increase in what I call “presenting the evidence” behaviour with a resulting argument/counterargument pattern that leaves both client and therapist frustrated.

In general I see moving too quickly as a reflection of the therapist’s need to control the process. To me it is important to remember that not only are we helping a client challenge and find news way to think about an aspect of themselves we are also teaching or modelling a critical thinking process.

Moving to the evidence to quickly

This is the most common mistake I see.  It is often compounded by the therapist presenting the evidence to counter a current belief rather than eliciting this from the client themselves.  In a worst case scenario the client states a dysfunctional belief that is then immediately countered by therapist.

But what about the following evidence? Therapist then proceeds to outline all the evidence against the belief.

Client either resentfully acquiesces or a but/counter but exchange follows. Our job is not to convince the client but enable a process where the client convinces themselves.

Sometimes a Cigar is not a Cigar

Dr X has a thoughtful post on my own post about self-disclosure in therapists. In the post, he laments the move of clinical psychology towards a focus on the manifest and on the surface content of what a client presents. He makes a direct comparison between simplistic and manifest approaches to psychotherapy such as congitve behavioural approaches and fundamentalist approaches to religion and the dangers inherent in this. It is a lament I share however my position on it is a little different.

His post highlights the difficulty that listening on a deeper level to a client demands much more of us as a therapist, not the least of which is that the client's own struggles with the less salutary aspect of themselves, their hatred, their pettiness, their shame and their despair emphasises these very aspects in us as a therapist.  It is easier, less demanding and less threatening to stick with content.

Money quote:

When we work in this way, we will fail often. It is only then that we can honestly appreciate the client's struggle and the nature of the obstacles we and our clients face in taking up the honest pursuit of meaning that all of us face as finite, limited human beings in a vast dynamic creation. No one ever said this job would be easy.

Read the whole thing.

Questions with a Punch: Your Favourite Question

As a therapist we develop our own repertoire of high-impact questions. Such questions open up territory in clients’ lives in powerful ways.

Much of my work in a child and adolescent mental health context requires that I chart back into a child’s developmental history, gain a sense of the child’s underlying temperament or emerging personality, and become aware of significant events in the family’s history including mental health issues and family scripts (Byng-Hall, 1985). After completing a three generation family tree, I find the following question allows me to respectfully approach all three of these areas. Hat tip Evril Silver for this one.

Of all the people in your family (referring to the genogram), who does this child remind you of the most and why?

I have always found answers to this question informative. Sometimes I need to ask the question without the child in the room, as well as with the child present. Sadly many mothers tell me that their child reminds them of an abusive ex-partner. However even in this instance we are then able to move onto exploring ways in which the child is just a child, rather than the parent’s representation of the ex-partner (Fraiberg, 1975). The parent is then more able to take charge when necessary, rather than stepping around the issue of control to avoid feared conflict (Marvin et al, 2002).

The question also allows easy entry into discussion of family mental health issues – often the parent’s concerns for their child are linked back to difficulties experienced by other family members (e.g., schizophrenia). Again, once space is opened up for exploration of such issues, parents are often able to revise some of their perceptions and concerns (family scripts). On occasions when the question is asked with both parents present, marital conflicts may surface where it becomes apparent that one parent ‘blames’ the other for their child’s behaviour. Progress can be made here by addressing such implicitly-held beliefs openly. There are many other benefits, including of course discovering possible genetic influences.

So what is your tried and tested question? Please share it with the readership of this Blog…

Mark

Guest Blogger Returns

Guest blogger, Mark Donvoan returns posting the question: What is your favourite question?

The Short and the Long of it: What’s on my Bedside Table.

I have just picked up the recently published paperback version of R. Horacio Etchegoyen’s book: Fundamentals of Psychoanalytic Technique. This book was first published in 1991 and has been on my must read for some time. At some 800 pages it needs quite some time to be read and digested. However Etchegoyen has a delightfully easy to read style and makes many of the complex concepts of psychoanalysis readily understandable, at least to me who always struggled to some degree with Freud in the original. The focus of the book is on technique and not theory and it goes well beyond the last book of this type which in my view was Greenson’s book: The Technique and Practice of Psychoanalysis which sadly only every got to Part I.

For those of you who cook I liken this book to Madeleine Kamman’s book: The Making of a Cook. Everything is covered in fine detail but this is no dry technical tome, the personal character and passion of the author comes through on page after page. It is book you can read solidly or dip into repeatedly and always come up with something new. I have a soft spot for Argentineans. A favourite poet of mine is Gorges Luis Borges. His poem: Another Poem of Gifts hangs on my wall, a reminder to keep life in perspective. Racker’s book on countertransference I return to with some regularity.

If Etchegoyen’s book is a Kamman then Coren’s book Short Term Psychotherapy is a Jamie Oliver cookbook. Short, slightly frothy with a few great recipes. Coren whips through the shorter dynamic psychotherapies in fifty or sixty pages with a competent brief few pages on each. It is the middle of this book which is the more satisfying for me with a number of chapters devoted to technique in shorter term therapy integrating a number of ideas but particularly Malan’s. There is a nice discussion for example on the when, how and the need to make transference based interpretation in shorter term dynamic therapy. These chapters are extremely practical and easy to understand. I would recommend this as an introductory text for anyone thinking about taking up short term psychodynamic therapy.

 

 

What do you Know and how do you Know it: Socratic Dialogue II

One of the difficulties with Carey and Mullan’s paper discussed in the first post is that you come away from it thinking Socratic question is multi-defined with a number of different purposes and therefore is not a useful or functional technique. Nothing in my view could be further from the truth. I think a more useful way to look at this is that a lot of techniques have received the same label but this has nothing to do with their usefulness.

I want to look at a couple of these in more depth. I think with any technique it is useful to look at both the technique as well as the purpose or purposes for which it is to be used. It can also be useful to think about the outcomes that occur in therapy as a result of using this technique.

For myself I have found it far more useful to go outside of psychotherapy literature to find helpful stuff on Socratic questioning.A good example would be R Paul’s book: Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World.

Of all places I came across this useful summary of Paul on a site about teaching engineering. Here is another useful site with a summary of Socratic Techniques also citing Paul. Both these sites have a good range of questions you can also use as a therapist. I have included a range of them below.

Socratic questioning is a simple yet strong method for exploring ideas or statements in depth and breadth. In its simplest form, it involves:

• Selection of a question or issue of interest
• Clarification of the question or issue
• Listing and critical examination of Support, Reasons, Evidence, and Assumptions related to the central statement
• Exploration of the Origin or Source of the statement
• Developing and critically examining the Implications and Consequences of the statement
• Seeking and fairly examining Conflicting Views (alternative points of view).

Paul divides the questioning up into six types. I find understanding these different types of questioning really useful as it helps me to keep in my head where we are up to in the Socratic process. It is much more useful in my view to view Socratic questioning as a process with a set of steps than to see as a tool to get to some place. In my experience going through the process of one type of question after the other always yields something useful. As Padesky would put it, when you do it this way the client ends up owning the discovery or insight with no pressure to accept the therapist’s point of view on anything. This fits well with one of my little sayings in therapy along the lines of that it is the client’s job to do the work i.e. they have responsibility for the outcome. Usually in supervision it gets framed in the reverse when I say to a supervisee “if you are working then the client is not working”.

Paul's six questions include:

Clarifying questions

• What do you mean by ______?
• What is your main point?
• How does ____ relate to ____?
• Could you put that another way?
• Let me see if I understand you; do you mean _____ or _____?
• Could you give me an example?
• Could you explain that further?
• Could you expand upon that?

Assumption questions

• What are you assuming?
• What could we assume instead?
• You seem to be assuming ____.
• Do I understand you correctly? You seem to be assuming ____.
• How would you justify taking this for granted?
• Is it always the case?
• Why do you think the assumption holds here?
• Why would someone make this assumption?

Reason and evidence questions

• How do you know?
• Why do you think that is true?
• Do you have any evidence for that? What difference does that make?
• What are your reasons for saying that?
• Can you explain how you logically got from ____ to ____?
• Do you see any difficulties with your reasoning here?
• What would change your mind?
• What would you say to someone who said ____?
• Can someone else give evidence to support that response?
• By what reasoning did you come to that conclusion?
• How could we find out whether that is true?

Origin and sources questions

• Where did you get learn this?
• Do your friends or family feel the same way?
• Have you always felt this way?
• What caused you to feel this way?
• Did you originate this idea or get it from someone else?

Implication and consequences questions

• What are you implying by that?
• When you say ____, are you implying ____?
• But if that happened, what else would happen as a result? Why?
• What effect would that have?
• Would that necessarily happen or only probably happen?
• What is the probability of this result?
• What is an alternative?
• If this and this are the case, then what else must also be true?

Viewpoint and perspective questions

• You seem to be approaching this issue from ____ perspective.
• Why have you chosen this rather than that perspective?
• How would other groups/types of people respond? Why?
• What would influence them?
• How could you answer the objection that ____ would make?
• What might someone who believed ____ think?
• Can/did anyone see this another way?
• What would someone who disagrees say?
• What is an alternative?

Begging the Question: Socratic Dialogue Part I

Ask any Cognitive Behaviour therapist do they use Socratic Dialogue as one of their techniques and they will all say “yes”. Move to a clarifying question such as what do you understand Socratic Questioning to be and the waters become murky very fast. This technique appears to be one of the most difficult ideas to learn in CBT partly because everybody suggests using it but very people can clarify exactly what the technique is.  The technique has been promoted by therapists from Adler and Winnicott through to Padesky and Beck.

For many therapists any type of open questioning gets called Socratic Dialogue. Maybe it sounds better saying I engaged in Socratic dialogue with the client compared to I questioned them about themselves for an hour.

Finding an agreed upon definition of Socratic questioning in psychotherapy or even within Cognitive Behavioural Therapy is next to impossible and it is pretty clear that Socrates has been hijacked as a brand name for all sorts of questioning techniques. Tim Carey and Richard Mullan in their paper: What is Socratic Questioning (no free access)are clearly totally gobsmacked by the lack of definition and outright contradiction surround this concept in psychotherapy. The range of conflicting definitions is quite remarkable and as Carey and Mullan remark somewhat ironically, Socrates often used his dialogue as way of reaching a clear definition.

Despite the stated importance of the Socratic Method for psychotherapy (A. T. Beck et al., 1993; J. S. Beck, 1995), clarity regarding this procedure is chimeric. Someone wishing to learn Socratic questioning could not discern from the literature what the procedure was, when it should be used, how it should be used, or what it should be used for. Indeed, a question as seemingly banal as the title of this article—“What Is Socratic Questioning?”—cannot be answered from existing descriptions. It seems that the term “Socratic method” can refer to almost anything at all. The discrepancy in the section describing the purpose of Socratic questioning is instructive. If Socratic questioning is concerned with changing minds, then a technique designed not to change clients’ minds could not legitimately be called Socratic questioning. It would seem inherently underhand and deceptive to advocate a process of self-discovery if it was the case that predetermined “discovery” was on the agenda. Currently, however, Socratic terms are used to refer to both changing minds and not changing minds.

Should one have the end point of the inquiry process in one’s mind or should it be an open ended go anywhere inquiry. Padesky in her paper: Socratic Questioning: Changing Minds or Guiding Discovery, for example would argue that using guided discovery should be utilised not to change a client’s mind but to allow the client to explore and reflect on their thoughts and behaviours. However even a brief reading of the old man himself indicates that Socrates had a pretty good idea where he was going on when he started out on his dialogue and his job was to make others come around to his way of thinking. There appears to be considerable debate about the degree to which one should have an end position in mind when one is using this technique.