Sunday, January 1, 2012

Eclectic Therapy - 1) Counselling

I am an "Eclectic Therapist".  I have been formally trained in a variety of therapies so now use them all either when indicated specifically or as an amalgamated therapy drawing on the parts I've found most effective over the years.
My first therapy was 'counselling'.  Counselling is fundamental to training in general medicine.  Even surgeons, not noted for their interest in verbal communication are trained in counselling.  Counselling is a process of one person listening to another and then providing feedback.  The family physician commonly hears a person's complaints which can be physical but as commonly are biopsychosocial.  Counselling in family medicine involves listening carefully and discriminately and asking questions specifically to elucidate the nature of the problem in it's entirety.  Friends often 'counsel' one another but rarely explore the situation with the experience and training of a medical doctor.  Common questions are 'how do you feel?, how do you feel about this?  When did this begin.? What started it?  What makes it worse? What makes it better?
Indeed when I worked as a country family physician I was the town de factor secular  psychiatrist. My good friend the Lutheran Minister and I would discuss how similar our roles were in this regard. He did 'pastoral counselling' and I did medical or secular 'counselling'.  Later I'd study pastoral counselling in my ministerial training at St. Mark's, Vancouver Theological School, Regent College and Almeda.  Frankly, as physicians we often had more to offer than the ministers who often had better 'bedside manners'. The art of medicine is really to a large degree 'counselling'.
My research interest in psychiatry was 'non adherenece to medical regimen' and 'non compliance'. I was fascinated that 80% of schizophrenics in many studies didn't take their medications yet there was this almost cult like following of the 'neurochemistry' effect of medicine without consideration of the 'relational' aspects of the process of prescribing.  Psychologists given the right to prescribe as well as pharmacists or even family physicians rarely had the success with prescribing to the mentally ill as psychiatrists.  In my early practices my personal results with medication or any therapy in fact were commonly lightyears ahead of those reported in general because of a wide variety of research bias factors.  My patients in those halcyon days were 'selected' and highly motivated as compared to some of the post licensing multi centre trials where the rubber hits the road and commonly patients don't respond despite the 'halo' effect of the research.
Not surprisingly an anciety physician said that medicines must be novel and changed frequently to maintain sucessess. He was referring to the 'placebo response'.  Placebo is the tendency of the person to be self healing. Neuts will re grow tails and our evolutionary heritage is this self healing propensity. Much of therapy is removing whatever obstructs a person from healing especially in what are often self limitting illnesses.  As a country gp I remember putting three casts in three weeks on a teen age hockey player with a minor fracture who refused to stop playing hockey. Were it not for me, his minor fracture would have ended up a gross disability not because of his lack of healing capacity but because he was a teen age boy and stupid as a mule.
It may be that all medicine works to enhance this 'placebo effect'.  Nocebo is the opposite.  I had a doctor (see quack - despite the letters after his name) tell me I'd never heal from a condition.  If I had kept him as a physician that would have been a 'self fulfilling prophecy.'.  Lucky for me I saw his shifty eyes and smelt the sulfur in the room. My second opinion was decidedly more favourable and that doctor indeed 'cured' me of the aliment I'd sought treatment for.  His bedside manner was decidedly superior. Unlike his predecessor ,  he didn't slither like a snake.
Counselling was first studied in depth using scientific rigour by Rogers. Rogerian Counselling was easily reproducible and easily taught and proved decidedly effective for mild and moderate conditions. It's still a mainstay of treatment in student mental health.  Here the therapist listens agreeably and validates the person's emotional response and generally is very 'supportive'.
The word 'supportive' is key in Counselling.  Indeed counselling is often called "Supportive Psychotherapy".  This refers to the tendency to 'take the side of the patient."  The patient for instance says, "My boss treated me like shit today."  A supportive therapist or counsellor would say, "that's awful".  As the person went on ad infinitum about the terrible boss the therapist would 'validate' their emotions and sympathize and empathize with their feelings of being abused.
Today more often than not a 'legal advocate' will be a 'supportive therapist'.  Neither will go to any great lengths to ask 'why do you think the boss said you were a danger to society'.  Tyrants love counsellors, supportive therapists and advocates. Mad Magazines wrote a very funny piece on the therapists of Hitler and Stalin.  Very sympathetic indeed.
In contrast those trained in insight therapies or other forms of psychotherapy might dwell on helping the patient see a connection between their behaviour and the boss firing them.  In 12 step facilitation therapy the person is asked to 'clean up their side of the street' for instance.  In this case, the patient might for instance have been a gas station attendant who insisted on smoking while filling school buses.  A counsellor or supportive therapist and certainly a Rogerian might never learn this important detail.
Supportive therapy indeed and counselling go beyond the 'empathic listening'.  They involve exploring the whole context.  The early feminist therapists were notoriously inept at this and only last year  I had a patient who mistakenly went to a so called 'professional' and was told to leave her marriage of 30 years in the first half hour of therapy. The husband was never physically violent and his so called verbal abuse was a product of a head injury which had resulted in a tourette's like phenomena. A dozen of the cities finest specialists were involved but this stupid and arrogant self serving feminist counsellor in 30 minutes destructively advised this beautiful, vulnerable  and intelligent woman to give up on her marriage, her kids, her future all because of the counsellor's grotesque political agenda own political agenda.  Indeed in one community I worked,  the mental health counsellor "marriage therapist'  was a man hating radical feminist divorcee who had a formal complaint lodged against them and it was found that of the hundred couples who had gone to her for marriage therapy all had divorced.  Unfortunately counselling is not scutinized like Obstetrices were a hundred baby deaths would be noticed, the marriage itself being called the couples first 'baby' in formal marriage therapy training. Indeed often counsellors just assume that individual training in counselling makes them capable of working with couples or with groups when in fact I've had to take formal training in both modalities and know well that my individual therapy training used out of that context could be seriously damaging, something I see counsellors doing not uncommonly.
I confess I've seen the best of counselling and worst of counselling and must work to forget the radical feminists or the religious nutcase who had my patient flailing himself naked alongside the minister counsellor.  Despite years of training and experience and heavy punishment  I know psychiatrists who have had sex with students and patients.  Now that psychiatrists, priests, and teachers have been vetted we're slowly moving through society and putting an end to these extreme abuses.  Right now the Boy Scouts are addressing their cover up of homosexual pedophiles in their midst.   The Girl Guides have yet to explore the lesbian sexual abuse that went on in their community.  A northern BC equivalent of the attourney general's 30 year sexual abuse of countless teen age girls has finally been halted. The Divorce Lawyers association has finally accepted only because of public outrage that they can no longer accept sex in lieu of payment for their extortionist bills.  Residential school hearings netted the highest levels of administrators, principals and politicians as well as the janitors and orderlies.  We can be truly thankful for Chief Justice of Canada Beverly McLachlan's demands for increased transparency in the courts because historically abuse was never so bad in the initial round as it was when society subsequently abused the victims as was the norm  in courts in days gone by.  Indeed the concern today is that as only the truly rich can afford 'justice' we're going back to those medieval era times when money and power meant everything.
Back to counselling, advice giving is acceptable.  Often psychaitrists are said to 'lend their ego'.  We can spell out for patients what their options seem to be and even suggest what we might do. Supportive psycotherapy and counselling can be that directive.  When I worked with brain damaged patients I had no difficulty telling them to brush their teeth for instance or get a lawyer or take the medication.  I didn't ask them the meaning of tooth paste and I didn't discuss their cognitive attitudes and distortions. Some of them didn't remember what I told them the week before so my work was literally finding the most important issues and focusing on that.
This indeed was counselling but ironically I learned the 'techniques' from 'Focal" Psychoanalytic Therapy which I'd learned from Sifneos and Malan. Only I actually applied it to developping strategies for team approaches to working with brain damaged individuals. Rather than having them being told a dozen things we would reduce our counselling efforts to gaining success in a few areas because success begets success.
I consider my work in Addiction Psychiatry to have been highly benefited by my learning in "Focal" therapy.  If a person can do such a simply discrete task as stopping taking a needle with heroin in it and instead take their opiate by mouth as methadone maintenance therapy it's not surprising to see these same individuals learning all manner of complex self care matters and societal normals later.  Too often the 'focus' of therapy is really off and horrendous effort and resources are squandered.  I'm cynical enough to think that the people getting paid for the problem aren't obligated to find a solution so are very happy to continue appearing to do good while 'enabling'.   These' do gooders are painful to say the least.  Freud followed by Kernberg and Kohut said that alcoholics were untreatable with insight psychotherapy.  Motivationa therapy and 12 step facilitation therapy both cornerstones of addiction psychiatry, unlike general psychiatry, take a very clear position on whether the addiction is good or bad.
Like Forensic Psychiatry Adddiction Psychiatry in contrast to traditional Psychoanalysis takes a position on abuse of heroin and cocaine. They are not good to the Addiction Psychiatrist as murder and theft are not good to a Forensic Psychiatrist. In contrast I remember in residency training discussing with a psychoanalyst  in group analytic training  a patient seeing a colleague, the patient being a cocaine abuser, thief and enforcer,  and the trainee continuing to ask them the 'meaning' of their theft and violence all the while the community the patient lived in was ripped off and violently assaulted. I was not terribly impressed by the popular psychiatrist playing psychiatrist to the Sopranos.
As an aside I have been the psychiatrist to many people who had committed  criminal acts such as murders who weren't caught or even in war did horrible things which they later saw me about. I was trained that I could not continue to see these people and thereby implicitly 'validate' their behaviour if it were to be ongoing.  In the classic Tarasoff case the psychiatrists confidential responsibility to the patient and the responsibility to the patient alone is overriden by obligation to the community and need to protect specifc targets. Further I always discussed such cases with senior colleagues so that i was not manipulated by psychopaths and sociopaths as the Soprano psychiatrist was. In fairness to this actress , she too sought colleagues for advise and in many ways her performance deserved the award she was given by the American Psychiatry Association as it exemplified the true complexity of modern psychotherapy.
Every day there are advances in our understanding of mental illness and how best to apply therapies and which therapies are most likely to work. For example Cocaine and sex addiction commonly go hand in hand. All efforts to treat the sex addiction without treating the cocaine addiction are likely to fail. This has been demonstrated ad infinitum. Interesting 75% of the those who had sex addiction and cocaine addiction, if only they stop their cocaine addiction will hot have evidence of sex addiction a year later.
Counselling and supportive psychotherapy and indeed 12 step facilitation involved 'self disclosure'.  I enjoyed working with obstetricians who'd tell their patients 'when I had my baby I found breast feeding helped stop the colic."  Pediatricians commonly tell parents what they used with their kids and counsellors often recommend products they've found beneficial.  Self disclosure is not used in psychoanalysis.  It's foundational though in 12 step facilitation therapy. Indeed a psychoanalytic psychotherapist who moved into addiction psychotherapy was only able to get success when he learned to "share' with  his addicts and alcoholics that he himself had been an addict to cigarettes and had had great difficulty overcoming his own addiction.  Something about the field of addiction with it's underlying anti authoritarianism and long history of hearing 'advice' from 'do gooders' and those who are 'superior humans' causes patients to shut off anything from anyone who doesn't meet them half way.
Indeed Christian psychotherapy as well and pastoral counselling are distinctly different from the 'Psycho educational" counselling model used as a mainstay of psychopharmacological therapy.  In traditional psychoanalytic psychotherapy of the Freudian model the therapist was actually fairly paternalistic but having to go through therapy themselves was 'non judgemental' and usually humbler.  One of my favourite Jewish Psychoanalysts was famous for saying 'we all must find the 'eichman' within because he was trained in the non paranoid model of humanity in which we're half good and half bad and there but for the grace of god go I.  The Christian and Pastoral Counselling models see patients as 'sinners" ie those who have 'fallen from the Way' but we are all 'sinners' and we all 'fall' at different times .This is the nature of humanity.  In the psycho educational model and the pharmacological model, I am okay and you are not okay. I am the doctor and your brain, mind, being are broken and I will 'fix' you wilth a "pill' with "shock" therapy or even 'neurosurgery'.
The Transactional Analysis folk summarized these various therapies as I'm Okay, You're Not or I'm Not Okay, You're Not Okay but together We Can Be Okay.  In the Jungian psychoanayltic model we are all on a journey and the therapist is just a little further ahead and acts like a guide.  This notion of a guide is common in the counselling models that stem from First Nations roots.
Lawyers are decidely counsellors and commonly called such.  Advocates too.
Family physicians have long been trained in these more conscious therapies as well as the standard psycho educational model which every surgeon must learn if only to explain to patient's why he plans to cut off their legs.
As a family physician in the country, the city and the far north, working within my own culture and cross culturally and with individuals, families and communities I had extensive experience and formal and informal training in counselling and Supportive Psychotherapy.  Indeed supportive psychotherapy seemed to be the mainstay of hospital care in psychiatry whenever I worked in hospital settings.  One must establish rapport, build therapeutic alliance, learn a common language and common symbols and share information and help change behaviour or thinking and facilitate progress or at very least acceptance.
I trained for a week workshop with Elizabeth Kubla Ross, author of Death and Dying. Her whole work as a psychiatrist was a very elegant and refined form of supportive psychotherapy.  To see her working with a dying patient was to watch a ballerina doing swan lake.  She was a truly  brilliant and loving psychotherapist but she didn't tolerate foolish colleagues well. Probably that had to do with her efficient Swiss background.  I am very thankful that I have had the teachers I've had.
I still do Grief Counselling occasionally, last year having at least a dozen such cases, and this is not a place or time for Psychoanalytic Therapy perse or Cognitive Behavioural Therapy, Supportive therapy is, to my mind, the best form of therapy for grief work.  It's also well documented in assisting people with straightforward psychosomatic difficulties that cause time off work. Commonly 'stress therapists' and 'personal coaches' etc use alot of the techniques of Supportive Therapy.
They include things like journalling, and tracking an illness, monitoring, using score sheets, and all manner of pen and paper techniques.  I've even used gold stars on calendars which I learned in child psychotherapy with great success working with adults.  All manner of Reinforrcement scheduling is part of the repetoire of counselling.
And generally where there is a 'positive transference" , ie very good rapport and the patient is highly motivated, young, educated, attractive and affluent these techniques work well. They are severely limitted where there are 'negative transferences' and where there are unconscious resistances to getting well. Where there is incongurence, ie patient says they want one thing but do the other the problem is usually beyond the level at which counselling is by itself sufficient.  In the more major psychiatric illnesses other and more specific psychotherapies have been developped to deal with the more resistant conditions.  That said, 'supportive therapy and counselling is usually a part of even the greatest 'purists' repetoire.


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Nduese Peter said...

Mr William, i am impressed by your efforts. You are focus and your approach is encouraging. Keep it up as am also trying in my own country as a guidance counsellor in training. Cheers!