Persuasion and Behaviour Change

All behaviour is considered to have been innate or learned.  Having a dog is a real lesson in ‘innate’ behaviour, seeing how the lessons of breeding herding and hunting behaviours pass on ‘genetically’ so to speak.
In addition behaviour is learned.  You can influence all behaviour. This was the work of Skinner with conditioning and work with lab rats and mazes.   Complex human behaviours changed and are understood in a variety of ways.  Social sciences in general focus on understanding behaviour with a view to changing behaviour.
Naturally there are judgement calls.  A behaviour is described as positive or negative, healthy or unhealthy, useful or unuseful.  Each of these words is ‘packed’ with meaning.  It’s a window to understanding the ‘meaning’ of a behaviour for an individual.  It’s a way of finding a handle into ‘changing’ the behaviour as well.
Freud said there was a life and death wish.  It’s paraphrased today as ‘You’re on the up elevator or down elevator’.  “You’re going forward or backwards’.  Barack Obama said you are on the right side or the wrong side of history.
My friend who was in a concentration camp said the most potent behaviour change device was hunger and food.  My patient who was tortured described pain and stopping of pain as the most significant behaviour change he had known. Quantanamo was a study in ‘behaviour change’.
Administrators, employers,  police,  jailers have  a whole slew of options others don’t.  Working with adolescents one sees the power of money.  Kids will do a whole lot of things for money but once the money stops they stop the behaviour. They are not stupid.  The relationship are conceptualized in regards to ‘power’ and at the most basic derive developmentally from childhood with the ‘parent/child’ construct.
But as every parent knows one can ‘teach’ a child to do a behaviour but to have the child maintain that behaviour against distraction is a different matter.  In the ‘good old days’ a medieval parent ‘owned’ a child, like a master might own a slave.  There was the full range of choices for how to go about changing a behaviour. It was frowned upon if you killed the child, or slave or horse for that matter.  Doystoyevsky has a marvellous story about killing a horse and the whole discussion that follows is elucidating.
Behaviour change is also tied to the concept of ‘internalization’.  Can a learned behaviour change persist without the presence of the rewarding agent or the torturer.
To understand a behaviour such as ‘tidiness’ there is a need to grasp that each behaviour is not obviously superior in and of itself.  The nature of ‘culture’ is that there have been thousands of different ways found by humans over the length of our time here finding ways of doing things and after tens of thousands of years there remains preferred and not preferred ways by culture to achieving the same end.  Human behaviour is complex.
Changing behaviour in therapy begins with the idea of the least harm and least invasion.
In therapy with a psychiatrist in the community there is no ‘master/slave’ relationship and there is no ‘parent/child’ relationship.  The power politics of the relationship can be conceptualized in many ways and commonly a truth for a ‘group comparison’ is extrapolated to the individual context.  For instance aboriginals in a certain area of Canada are poorer relative to others so their power is diminished but in another area they are commonly richer and more powerful than most so that the power dynamics change.  This is lost in modern political correctness politics with their fixed debates.  The fact remains a female empress is more powerful individually than a male sharecropper just as a black president is more powerful than a white janitor.  It’s hard for people to see these distinctions because of their own inherent biases.
When a person comes for therapy they may see that the therapists is there ‘servant’, a kind of glorified ‘cabana boy’ who does their bidding.  A princess has many servants and the doctor and therapists are just another one. Her relationship with them all is ‘master/slave’ , ‘parent/child’, ‘employer/employee’.
The professional is in an interesting position because he is a ‘servant’ but he has obligations to the ‘profession’ and this is seen specifically in the complex arrangements for ships doctors relative to ships captains.  The whole dynamics of physical health are exploded to a whole other level when it comes to mental health. I do a whole lot of competency assessments for mental health and dearly miss the simplicity of the assessment from a physical health perspective.
Where you have real power everything is relatively easier. The rich can buy good behaviour. The physically threatening can bully good behaviour.
In therapy there is a ‘schtick’ a relatively naive and frankly ignorant notion that the therapist has ‘power’ as if the world is 1950 and ‘authority’ is respected and police are never questioned and children do as they are told.  I am daily aware that the world is mad and individually I hear of teachers who are only able to spout dribble because they are never in the field.  I talk with my military friends and we laugh at ‘academics’ because it’s all so easy when you are not in the thick of it.  It’s so obvious to anyone who is a Monday morning quarterback and our society is brimming over with everyone wanting to be a ‘consultant’ or an ‘analyst’ or a ‘judge’. No one wants to be in the ‘fog of war’ or actually do the hands on face to face work. It’s the least paid. The soldier in the line is the least paid. The most paid is the ‘oversight committee member’ who ‘reviews’ the behaviour.
Therapy can be about change or ‘collusion’.
The rich paid for psychologists to agree with them.  Today a fortune is made by divorcing people who hire counsellors who agree with them that their ex is a toad.
There is a fortune to be made in ‘agreement’ with tyranny.  There are countless tales of the deaths of advisors to kings who told the truth but didn’t live to see their genius.  The emperor has no clothes is the most eloquent of all the tales.
As long as a person is doing something having another discuss and talk about that behaviour indefinitely is not unpleasant.  The problem arises when there is an expectation of ‘stopping’ one behaviour and starting another.
One conceptualization of behaviour change that has served me well is to see a person on a mountain clinging to a couple of crevices and to move forward having to let go of their temporary safety and risk reaching for another hand hold. I love watching goats traverse such perpendicular surfaces.
I treated a hundred cutters. These are people who have learned that ‘cutting’ themselves with razor blades is rewarding experience.  It’s been likened to masturbation in the literature.  A slow crescendo to the ultimate release of blood flow.  It’s controlling and rewarding and attention seeking or secretive. It’s just one of thousand ‘behaviours’ I’ve treated over the years.  The words “I’ve treated’ don’t do justice to the experience.  Encounter is better.
Right now I more often have recurrent encounters with people who stick needles in their arms with unknown powders in the hope that the substance is heroin and not fentanyl. They know people who have died. Their motivation to change despite the risk of imminent death is little.
The cutter is a whole lot easier to treat.  Acutely suicidal people and violent people , perverts and such were more challenging.
The first step is always , in medicine, ‘observe’. To this end I ask a whole lot of questions about the behaviour.  When did it begin. What’s it like. What are the pros and cons.  What would it be like without the behaviour.  Generally we talk about the behaviour more than anyone ever before has.  I remember days of sitting in the stink of rooms smeared with faces asking an endless number of questions about the shit smearing behaviour.
Adolescents, borderline personality disorders, psychopaths, sociopaths, schizophrenics and rich and powerful people and people in jails and prisons will commonly stonewall you.
The term ‘therapeutic alliance’ is critical to therapy.  The patient and the doctor agree not just overtly but at the deepest level to work together to change the behaviour.
However if the person is in the office because of the police, or employer or insurance agent or because the wife or husband wants them there, the therapeutic alliance might well never occur. Duplicitous behaviour is common. Malingering is common. Factitious behaviour is common. In general a whole lot of people are happy to ‘go through the motions’.  They will do anything ‘but change’.  Alcoholics were happy to spend an hour a day with a therapist as long as they could have their drink after the session.  Workers sit daily or weekly in a therapists office to remain off work or collect their pay.
It’s naive to assume everyone wants to change.  Most people don’t want to change.
Whatever they are doing worked for them at some time and would work now if you just got out their face.
A whole lot of people have given up hope that they can change.  A whole lot more don’t see what the problem is.
The question is therapy is always ‘whose problem is this’.  It’s like who wants the bed made in the whole and who benefits from a made bed and even if both people benefit who can win the war and get the other person to be the one to make the bed. Commonly the only person who has a problem is the therapist.
Increasingly therapy is parallel behaviour in which the therapist is doing an academic procedure and the patient is going through the motions.  The two collude to get paid or rewarded for this unusual dance interaction.  If the therapist doesn’t ‘test’ if there is change then with endless resources this dance can go on indefinitely.
I will never forget a psychiatry resident in our psychotherapy training treating a psychopath thief who they saw for 3 years weekly all the while the theif continued to steal and amass a fortune all the while the therapy ‘interpreted’ their behaviour and discussed their ‘behaviour’. I thought of the psychiatrist seeing the mob member and considered that was okay since the mob member was paying for her ‘services’. He continued to ‘whack’ people but his marriage improved.  MAD comics once put out a funny issue describing the therapy of therapist and Hitler, and therapist and Stalin. But therapy is medicine and a ISIS jihadi executionist beheading people might get a head ache doing his job. No one would fault the pharmaceutical industry or pharmacist or the local doctor for giving him as aspirin so he could continue his work with less of a headache. So Tony whacked people and the psychiatrist paid by Tony helped him with his relationship with his wife and the other mob leaders. He gained ‘insight’ into what he was doing and his sleep improved.
When I work in the jails I’m working first for the jailer.
When I work in the government health care services, since the person I’m seeing pays taxes, I’m working for them but the Minister of Health and Medical Service Plan is paying.  When I’m working for a person seeing them for that but they have ‘private’ or insurance from another source I am working for them plus the government and always for my profession and responsibly for the community.  Commonly someone else wants my patient to do something they don’t want to do so they use therapy appearances to procrastinate.
A lovely lady didn’t want to get women to have sex with her husband . She didn’t mind threesomes per se but she drew the line at going out to bars to find willing women to bring home.  He was rich and powerful and she felt a whole lot of humiliation with this position.  After a bout six months of him paying me cash with the hope of treating her ‘depression’ she told him she didn’t want to do that. He stopped paying me and kicked her out and got a woman who apparently was more willing to provide this service. “My” patient got over her depression and may or may not in future get women for the next man.
In the US I was paid directly for services.  It was a lot clearer who I was working for.
When I was on salary to an organization it was a lot clearer who I was working for.
Increasingly as a therapist I’m being paid by several different people with competing designs and I’m already managed by a half dozen beaurocrats and others with competing plans. The government is always confused.
The patients are confused.  Do I really want to change. Is it worth it.  Should I give up picking my skin.
I use morbidity and mortality statistics to judge myself whether I’m doing anything. Increasingly I’m going through the motions like so many others. I used to really work at change but l was taught always to question who was doing more work you or the patient. Increasingly the third party is doing the least work. They don’t care. They fume and have temper tantrums and cut off funding or services but there’s just a whole lot of bullshit in the system these days that no one seems to want to change. Everyone wants to talk the talk but no one wants to walk the walk.
Harm reduction is the craze.
Divorce facilitation is marriage therapy.
I don’t want to go on and on about this but it’s the reality.
I rarely see a person who really really really really wants to change.  Those people change when they discuss the matter with there family, friends, or gp. By the time a person gets to me they have ‘failed’ in ‘changing’ for years and for dozens of therapists. Commonly the come to me and they are already seeing at least two or three other healers who are hoping that they can all blame me for their collectively not having changed anything in anywhere for five to twenty years.  I see really chronic negative behaviours.
And all I can do is ‘persuade’.
In contrast the administrator or employer can ‘punish’ by taking away their job.  I can’t even ‘fire’ a person without getting in trouble with some authority.  Look at the difficulty landlords have with eviction.  It’s no different than a ‘seat’ in an office. Once that person is allowed to ‘sit down’ hell can freeze over before you can move them or you can move them but at risk to your life and livelihood.
I used to be able to do things like talk about things, but today “I don’t want to talk about that’ is quickly followed by ‘If you insist upon talking about that I’m going to make your life miserable for years and cost you millions.”
Really.
People pull out guns and show me where they want the discussion to go. Others pull out knives. More and more people tell me the name of their lawyer.
Change my behaviour at peril.
Truly there are more who are truly perplexed by their inability to change a behaviour. “I thought I could stop cutting myself but I can’t. I used to be able to hide it, cutting under my clothing but now I’m cutting my hands”.
Education doesn’t work. But we all do it.  “Have you tried…."
Insight - this is ‘why'
What is the benefit , when and where,

Drugs are marvellous. Prozac in combination with therapy is twice as effective as therapy alone.  When prozac didn’t work and a dozen other as like drugs didn’t work one could punish the patient with ECT which would at least cause the patient to forget whatever it was that they were thinking about when they are cutting or it might well have not punished them but simply increased the serotonin which seems low in people who cut themselves.  But what happens when all the pharmacopeia has been used and they’ve had ECT and they’re still cutting.
That’s what’s happening today.

I see people who have tried ‘everything’ to stop their drinking, their cutting, their wife beating, their child fucking, their refusal to leave their homes, their inability to get on planes, their inability to work, to have sex, to eat, whatever.
All of what used to be seen in the hospital where the doctor had power and status and a ‘team’ is now seen in the community by an isolated practitioner who lives in fear about what the next angry person is going to do when you suggest, ask, hope they will change their bullying behaviour.
Patients take pleasure in ‘proving’ they can’t change. “See I told you no one could change me."
People said I should see you but I know you’re not going to help me."

No one listens to me.
No one helps me.
You’re just another stuck up asshole who thinks you know so much , well you don’t know me and no one is going to change me.

The world is full of toddlers and everyone with a connection to the internet is having a temper tantrum on the floor of the supermarket and getting a gang of other people who like doing whatever they do, including not going to work, including getting everyone else to pay for the, including being physically incapable of getting out of bed, including wanting their arms cut off, including having sex with animals and really thinking everyone else has a problem because all they need is more money and to be left alone and not judged and if you judge them you are just like everyone else.
The world is having a pout.
We’re on the verge of war.
War is a failure of diplomacy. No one seems diplomatic these days. Increasingly they bully and lie. Deceit in my experience is at an all time high. People say one thing then do another and I’m always wondering do they know that. We need cameras and recordings and I have done that, I’ve recorded every session and played back what people said and did but it’s just upset them and made them angry.  You’re bullying me they say when I record what they say and play it back.
Borderlines are the norm.
Everywhere I look I see the fear in peoples eyes.
Somedays I miss sitting in locked rooms with people who smear shit on the walls.
I’ve always understood that behaviour.

William Hay, Psychiatrist

I am thankful for my name. Wiliam has served me well.  I use the formal, long version, though have been nicknamed Bill or Will throughout my life. The name Hay is a name I acquired from my parents.  My grandfather was a Reeve and my father a man admired as a leader.  The problem for me was ‘psychiatrist’.
I had no problem being, William Hay, Physician.  Today I still commonly introduce myself as such.  The stigma against the mental ill which is so prevalent in this country also applies to their caregivers.
I’m proud to tell people that I was accepted into surgery and did a year of the three or four required to be a surgeon.  Mine was a surgical internship and my electives had been in plastic and orthopaedic surgery as a student.  I had concluded in my training that I wanted to be a missionary doctor and that best equipped missionaries were surgeons.  I was reading a lot of turn of century history at the time.  The problem was my wife, another doctor, by the time I was an intern, didn’t want to be a missionary. She wasn’t even a Christian per se.  She wanted to work in the university and stay in the city.  She wasn't adventurous and certainly didn't like camping when I introduced her to the wilderness.  Our marriage never did work out.
In those days, and the tendency remains, I thought if something was ‘good’ , like obviously being a missionary to me was, others would see it as such.  Today I know a whole group of people think missionaries are idiots.  My wife hated the idea of my becoming a psychiatrist.  She loved the idea of being married to a surgical resident.  She didn't like psychiatrists, possibly because she'd grown up surrounded by severe mental illness and wanted a life as far away from that as possible.
When I announced I wasn’t going to return to surgery and wasn’t going to stay a family practitioner, but rather I was going into psychiatry, my wife was ashamed.  My medical colleagues collectively expressed their astonishment.  The jist of their concerns were summed up in these repeated exclamations,
“You’re such a good doctor, you don’t have to be a psychiatrist’.  When I entered psychiatry it was thought to be a place where only the lowest level of doctors worked.  Often immigrants entered the country by agreeing to work in asylums because even psychiatrists didn't want to work in asylums in those years.
“You can be a surgeon, you don’t have to be a psychiatrist”.  The hierarchy in medicine was from the ‘seen’ (surgery is so obvious) to the ‘unseen’ - the work of psychiatry is by far the ‘subtlest”.
“You’re a real physician, you’re not going to get along in that quackery’.   As a ‘real physician’ this meant, that I was a scientist.  I’d come into medicine with a mixed arts and science background.  My arts background made me ‘suspect’ to those students whose only interest had been science or technology.  I felt I had to ‘prove’ myself as a ‘scientist’ and that having done theatre and arts and english, liking music and writing, well, I was suspect.  I ‘proved’ myself with outstanding performance and knowledge in biochemistry and a gift for surgery.  So having ‘proved’ myself, here I was’ forfeiting’ my ‘membership’ in the ‘elite’ medical group of the ‘scientist doctors’ or ‘surgeon doctor’ to become somehow ‘less than.'  This 'elite' group has made an ironic comeback with in recent years as the respect for medicine declines and everyone is turning to superstition versus science in the true quackery of so many 'alternative medicines' and 'health food stores'.  People don't want 'scientists' or 'technicians' as much as they want 'physicians' but I never could explain my decision to be a psychiatrist because that was what was most "needed" back then and I can't explain this to them now.
The real ‘money’ in medicine was in surgery and internal medicine.  The psychiatric patients were predominantly poor in comparison.  The richest doctors were surgeons and internists and the poorest were often psychiatrists. The billing schedules from the start were always against the psychiatrist.
We were often mixed up with ‘psychologists’ and psychologists were considered collectively as ‘flakes’.  Mostly the psychologists were girls and the counsellors were usually people who couldn’t do the heavy lifting, like radiology technicians so ‘just talked to people’.  They were likened to ‘high school teachers’.  Doctors were university men.
As a family physician and a flyin doctor in the north I’d seen that the ‘greatest need’ was in psychiatry and addiction. I’d become interested in ‘non compliance and ‘non adherence to medical regimen.  This was only addressed at my university by psychiatrists.  It was called ‘resistance’.
Alternatively I considered ‘immunology’, a fledgling speciality pre HIV, because it too discussed the idea of the organisms' ‘rejection’ of transplants, and ‘immunological vulnerability’ to disease.  
In surgery and infectious disease, the emphasis was on the terrible external environment.  Bad things like bulletts entered good bodies and good surgeons took out the bullets and returned people to wellness.  Bad bugs entered good bodies and good doctors made good drugs to kill bad bugs and restore people to healthiness.  I consider 'regular' medicine like playing chess (I played chess at university) whereas psychiatry was like three dimensional chess. In psychiatry I was juggling a lot of ideas whereas in medicine I was usually just following protocols.
My first patient who died that upset me so much had been given excellent care. His doctors had all given him good drugs and he had good education and all should have been well but he and his family rejected the ‘education’ and he didn’t take his medication and therefore died.  Nothing all the kings soldiers could do would put humpty together again.  I felt a personal failure despite having done above and beyond the call of duty.  I 'd pulled out all stops to save this man and in the end it changed my interest from surgery to understanding 'noncompliance' and 'resistance' and a renewed interest in 'spirituality'.
That’s when in research  I learned first that 30% of all patients are ‘non compliant’ and another ’30% of patients spontaneous remit.  I'd always been interested in 'placebo' effect and became even more interested in 'psychosomatic medicine' when it was a fledgling idea. Further in a lot of populations 50% of patients didn’t follow their treatment and in psychiatric patients the number was as high as 80% of patients. 80% of patients didn’t take their medications.
My  colleague, rich, and loved by drug companies always saw a patients lack of progress directly a consequence of the medication so he prescribed a newer more expensive medication. I went to the patients homes and found that their drug cabinets were full of unused medications.  I asked why they didn’t take their medications and learned a wonder of information about how humans behave which was wholly overlooked in the pharmacy training at the university.   I remained poor and eventually didn't even teach whereas my colleague because the richest and most admired and favoured physician and psychiatrist because he was the principal representative of the pharmaceutical industry. Their greatest promoter and richest retainer.  I continue to look in drug cabinets and do home visits and believe thats where the real money of medicine is.
I also saw that the most difficult patients to treat in my family practice were the ones with mental illness. They were the challenge and the businessmen doctors didn’t like these patients because they didn’t get better like ‘good’ patients did.
There was a fine line between ‘bad’ and ‘mad’ and everyone, despite their expressed ‘liberal’ and ‘politically correct sentiments’ about the ‘mad’ ultimately treated them as ‘bad’.  They were ‘non compliant’ and ‘resistant’ and ‘difficult’ and as doctors became family men and businessmen and pharmacists vied to prescribe, all people wanted to make money and have a good job and go home to their families with patients who came sick, got better quick and went home themselves. No one wanted psychiatric patients. And no one wanted addicts. These groups were complainers and angry and didn't get better.  This was the time before 'lifestyle disease' became a fashionable word.
Most mental illness is life long.  The ‘chronic’ diseases are a waxing and waning sort. They have relapses and recurrences and there is a ‘vulnerability’ that causes patients with psychiatric illness to often slowly deteriorate overtime or not quite get back to where they were. Or, even if they do succeed very well, whose to say they won’t have an episode a decade or so down the road.
Whereas we never looked at people who had recurrent respiratory infections as having ‘weak’ lungs because of the ‘bad bug’ idea of infectious disease, we tended to look at people who had recurrent depression as ‘weak’ because psychiatry focused on the ‘vulnerable’.  Indeed psychiatrists who focused on 'trauma' or 'stress' or 'toxic workplaces' were no more welcome than were jail doctors who faced with treating bones broken by guards questioned the breaking rather than just setting the fractures. There's 'preventative' medicine and 'preventative medicine'.
Psychiatric patients were therefore called them ‘weak’ and especially those  with addiction, a part of psychiatry.  They were told  ‘buck up’, “man up’, ‘quit your crying’, ‘toughen up’.  Don’t be silly.
It’s 25 years later and I’m still calling myself, William Hay, Physician, without any concern but when I say, I’m William Hay, Psychiatrist, I’m hesitant.  When I am an ‘advocate’ for a patient who has heart disease or is in a wheelchair or has infection, I’m seen as ‘doing my job’.  A physician is supposed to be an advocate for his patient.  It’s part of the code of ethics for physicians.
I am an advocate for my patients.  As a Christian I am a healer and know that Jesus was a healer and he was also a teacher and advocate.  Part of my becoming a physician, when I could as easily have been anything else, I was a straight A student in Arts and Science at the university, the golden boy, a very large part was that I was a Christian. The finest doctors I’d known were Christian to that time in my life.  When I studied the history of medicine I saw that the truly religious, not just of Christianity but of every religion were the ones who made the greatest contribution to the healing sciences.  Religions in general took care of the sick.   My hero was Albert Schwietzer.
But to be an advocate of a psychiatric patients, worse, an advocate of an addict, or even a former addict, was to be akin to the "despicable."  Even St. Peter denied his association with Jesus when Jesus was condemned by the courts.  I saw that psychiatric patients and especially the addicted were condemned by society at large.  I was condemned by ‘association’ from the time I said I wanted to be a psychiatrist.  25 years later I am still condemned by association. I’m the modern equivalent of the ‘leper’ doctor.
Advocating for the addicted and mentally ill makes one ‘bad’ and as everyone knows psychiatrists are ‘mad’ already.
So William Hay, Psychiatrist is still a thing I hesitate saying despite years of experience, years of healing, years of amazing restoration of health of thousands of individuals and the overwhelming evidence that what I’ve done as a psychiatrist is deeply ‘good’, I’m still afraid to be associated with the ‘fallen’ .  Just like Peter, I fear ‘association’ with Jesus. I fear association with the mentally ill and especially those in recovery because they, and we are punished.  
This is today, when all surgeons and all internists know that they are working in the area of 'chronic illness' and that their patients all suffer mostly from 'psychosomatic' illness. As psychiatry has learned it's somatic aspects with MRI and beneficial somatic treatments like surgery and medicine, the rest of medicine and surgery has had to come to grips with it's psychiatric aspects and especially address the issues of non compliance and non adherence to medical regimen.  
William Hay, Psychiatrist.
William Hay, Advocate of the Mentally Ill and Addicted.
It still doesn't sit as well as William Hay, Physician.
Some days William Hay, Psychiatrist is a truly frightening thing to call myself.   It's like putting a target on.  It's like wearing general’s stripes on a helmut in a war zone. It's  like painting a red cross on an ambulance in a war with people who see illness as weakness and weakness as something to be exploited. That’s like saying to the rich, I’m poor, and waiting for the condemnation and laughter.  That’s not something one says openly in a world of ‘survival of the fittest’.
William Hay, Physician. That’s something societies at large have grown to accept and live with. Physical illness isn’t viewed superstitiously or as ‘malingering’.  But mental illness is.
Mental illness and those who treat mental illness and the advocates of the mentally ill are actually ‘threatening’ to those who are the most mentally ill themselves but conceal this as people who have secrets and lies do.
People who are hiding mental illness, especially those with alcoholism or doing cocaine,  for instance, or pedophilia, or sex addiction, or sadism, like to ‘punish’ the mentally ill to distance themselves from themselves.  But that’s something psychiatrists know.
William Hay, Physician. I can live with that.  William Hay, Psychiatrist, most days I’m too cowardly to say that.  Just like William Hay, Christian, is hard for me to say.  Christians are the most persecuted group in the world.  So what’s worse in a secular insane society, William Hay, Psychiatrist and William Hay, Psychiatrist and Christian.  Might as well, lock oneself up in the asylum.  When I worked there and lived there I knew as we all did that the bars on the wall were to protect us from the outside.  We didn't want patients to escape, not because they were so much a risk to society but because society was so harsh on them.  Jails were where people were locked up to keep them from escaping by comparison.  Jails protected society from criminals.  It's a subtle difference but then psychiatry is 'subtle'.  
Anyone who ‘advocates’ for the mentally ill and the addicted has painted a bull’s eye cross on their forehead for enemies to take aim at.
Much easier to be William Hay, Physician.
William Hay, Psychiatrist.  I don't know.  It takes a better man to wear that title.  I think I'll wait for the cock to crow a few more times.

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.