In the Room

How to Talk to Adolescents

Here is a great article on interviewing adolescents in Contemporary Pediatrics.  Although it is written for doctors, its is full of good questions to ask.  It provides a structured psychosocial screen and includes examples of useful and not so useful ways to ask your questions.  Hat tip Mark Donovan.

Managing a ‘Family Session’

One of the most common questions I get as a supervisor is what do I do with children and families.  For a number of reasons interns get more anxious about this than just about anything else.

There is a lot to be learnt from seeing a whole family, rather than just meeting with a parent or a referred child, however sometimes chaos ensues!  The following ideas are based on my own experiences over a dozen years.  You need to develop your own style; however this might provide a starting point.

Should I meet with the adults first before meeting with the child?

I invite the immediate family members including children over 4-5 years to the initial assessment.  Some clinicians prefer to meet with the adults first.  In some cases you may want to arrange a professionals meeting before seeing any family members (e.g., abuse cases).  There are costs and benefits of each, so think about the issues, age of the referred child and what you are comfortable with as a clinician.  Most of what is written below relates to an initial ‘family session’.

Heading them off at the Pass : Create a ‘Child-Friendly’ culture from the outset.

Children are usually brought to therapy by their parent/carer(s).  They may be ambivalent about attending, and sometimes are not informed or are misinformed about the purposes of their attendance (e.g., “we’re going to see the doctor”).  In cases where they are told, it may well be in terms of ‘you are the problem’ and so unsurprisingly children need a little warming-up before they can become active customers of therapy.

I will always have at least some pencils or felt-tip pens and lots of paper, and depending on the age of the child may have other toys (e.g., tea-set, dolls, figures, plastic animals, construction toys like wooden blocks/lego, simple puzzles, few books).  Think about how the room is set up. Is it sufficiently child-friendly and safe?  When children enter the room I usually ask that they sit down for the first part of the assessment, and then can draw or play with the toys “after I’ve found out a little about you all”.  The overall guide here is: children need firm and reasonable boundaries and warmth and genuine interest in them.  Our job is to provide a structure that meets these two aspects.

Guest Blogger of the Week

This week's guest blogger is Mark Donovan.  Mark is our supervision co-ordinator here at Wollongong University and has many years experience working with familes and children.  His first posting is some basic tips on first meeetings with familes and children.

Podcasting on Cognitive Behavioural Therapy

This is a great introduction to Cognitive Behavioural Therapy.  The podcast is about 30 minutes long and is more an overview than an in-depth focus on technique. You can give it to a client to play on their MP3 player. Download it or play it at the site. 

Cognitive Behavioral Therapy: Core Concepts

Dr. Elizabeth Podniesinsky discusses Cognitive Behavior Therapy (CBT). She reviews fundamental concepts and practical applications of CBT and suggests a wealth of resources for both clinicians and patients.

Does anybody know of any other podcasts or online mp3s relating to psychotherapy.  I have had a good search of the net and they seem hard to find unless you want to pay for them.

What to Say to: I Don't Know

“I don’t know” is a client response that often throws beginning therapists. Some therapists feel at a loss when presented with this response to some question about how a client is feeling or thinking. If this response occurs repeatedly then there is often a sense of frustration and helplessness built up in the therapist. I need this information to understand my client but they won’t give it to me. This frustration can lead to us labelling our clients as resistant, defensive or stupid. These blanket or pejorative labels do not lead to a good psychological formulation of what is going on for the client and as a result limit our thinking and motivation to work with the client.

A place to start thinking about “I don’t know” with clients is to think about the task of the client in therapy. At a basic level there are three rules for a client coming to therapy. Firstly the client must arrive on time. Secondly the client must talk about themselves and thirdly the client must leave on time.

If the client says “I don’t know” they are in my view breaking rule number 2 i.e. they are not talking about themselves but avoiding this for some reason. Usually when a client says “I don’t know” it is response to a question about themselves, their lives or their internal states. I will accept a client saying they don’t know the capital of Italy or to some factually based question but not when it is a question about their internal state. 

People say “I don’t know” in therapy for a number of reasons.  It is possible the client genuinely does not know but this is a very interesting piece of information that requires much more exploring. If the client is not able to access cognitions or feeling states or is unable to observe their own behaviour then as a therapist we need to understand this. Failing to take time to understand this difficulty with self reflection about an aspect of the self may have a significant impact on the progress of therapy. 

JCP on the Treatment of Borderline Personality Disorder a Must Read

For those that are involved in psychotherapy with clients with borderline personality disorder the April 2006, Journal of Clinical Psychology is a must read. The whole journal is devoted to a series of articles by the best in the field including Marsha Linehan, Jeffrey Young,  Otto Kernberg, John Clarkin, Aaron Beck and Peter Fonagy to name but a few. They are a series of highly readable articles with an overall optimistic message. Borderline Personality Disorder is an eminently treatable disorder. While some of the articles are more theory focussed there are also some wonderful outlines and examples of specific technique particularly Levy et al’s article on “The Mechanisms of Change in the Treatment of Borderline Personality Disorder”.

   

One of the common themes that comes through virtually all of the articles is some type of variation on the need to help the client develop a reflective space where they can actually stop and think about themselves and their lives. While each of the different therapies arrives at this through different techniques all agree on the vital need to develop this in clients with borderline personality disorder.

We, the editors of this special issue, have been fortunate to enlist the participation of some of the leading researchers in the treatment of borderline patients. The various articles in this section stimulate the reader to compare the different approaches to the essential aspects of borderline pathology and the related specific therapeutic interventions. For example, affect dysregulation and related dysfunctional behaviors are conceptualized as the key deficit by Lynch and associates. Fonagy and Bateman place this affect disregulation within the attachment and interpersonal sphere. There seem to be similarities among the concepts of mindfulness (Lynch et al., this issue), mentalization (Fonagy & Bateman, this issue), and reflective functioning (Levy & Clarkin, this issue), all of which are seen as processes the individual can use to modulate affective stimulation.

Here at our own psychology clinic we have an ongoing program for the treatment of clients with Borderline Personality Disorder. Doctoral interns provide a 32 week individual treatment program based on Transference Focused Psychotherapy. As well clients engage in a six month dialectic behaviour based group program run by the Area Health Service. This program has been having remarkable success although we all agree that the 32 weeks of individual treatment is insufficient for many of the clients.

Just a Little Something I Made for You: Gifts in Psychotherapy

Thanks to my supervision group for exploring this issue so openly and frankly in discussing their responses and thoughts on gifts as part of our supervision session. This has led me to summarise some of these thoughts and add a few of my own that I thought might be useful for other students and supervisors to think about.

Gifts in psychological treatment are complicated. They inevitably arouse conflicts and emotions within the therapist including:

• Pleasure, feeding of self-esteem, specialness, feelings of approval

• Conflict and anxiety to accept or not to accept

• Guilt about accepting gift:  I want to but I am not allowed but maybe just this once

• Guilt about rejecting the gift: I will hurt the client, they will disapprove, become angry, punish me, I may not be able to cope with their rejection

• Anger how dare they intrude on my boundaries, how dare they put me in this conflict.

Why do clients give gifts?

Clients may have a genuine appreciation of the therapist. At times of significant change clients may what to genuinely acknowledge the contribution the therapist has made to their lives.

Clients may want to test the boundaries of the relationship with the therapist.Clients may attempt to bind the therapist to them. I have given you a gift now you owe me. Clients may want to see how far they can personalise the relationship with the therapist. Gifts may be given at times in attempt to make the therapist  “be nice” to avoid confronting certain issues or themes i.e. to buy the therapist off. They can be a defence or an attempt to ward off perceived therapist anger or criticism A need to feel special may underly some gift giving.A gift may be an attempt to become more special in the eyes of the therapist. Gifts made by the client may reflect “look at what a clever boy/girl I am”. Gifts may be an attempt to personalise the relationship with the therapist and balance the power in the relationship.

Online Audio Files to Help with Relaxation

This site at the University of North Carolina, Health and Wellness Centre has a number of downloadable audio files for helping with relaxation as part of an online introduction to anxiety management.

Deep Breathing

Progressive Muscle Relaxation

Body Scan

Cultivating Mindfulness

Clients or therapists can download these and clients can play them on their iPod/mp3 player and even on their mobiles.  To download the files; right click on the link and click Save Target As.