With apologies to The Supremes who sang “You can’t Hurry Love“, this version came to me during a session with a client last week. I don’t think it is quite as compelling as the original, but the sentiments are important.
We can often give a good estimation of recovery times for a range of physical health problems, but it is notoriously difficult to do this for psychological problems. Clients, perhaps influenced by friends and family, usually have unrealistic expectations about how long the process of recovery can be. When they see that they are not recovering within these timescales, they often become more anxious and depressed. The pressing need to recover becomes an additional stress which, unsurprisingly, becomes a mantle that weighs them down further and contributes to a sense of hopelessness.
My message is an attempt to help clients put this mantle aside. I have likened recovery to a seedling taking root or to a flower blossoming. These natural processes unfold in nature’s time, but they can sometimes be helped along a little by tender care from the gardener. In this sense, therapy can be seen as a kind of fertiliser to promote the growth of recovery.
Luckily for my clients, I have not yet attempted to sing nor turned up to a session in gardening gloves.
The past often casts a long shadow over the lives of people who have survived childhood trauma, like a tall tree blocking the rays of a slowly setting autumn sun. The world can seem dark and cold within this umbra, a long path stretching into the future.
Therapy can often help a little light and warmth get through, tickling the long shadow with penumbral greys before giving way to more vibrant colours. The work is not easy, often requiring the metaphorical use of safety helmets and harnesses as branches are cut back and the tree is reduced in size. Complete removal of the tree is not really an option, it is part of the landscape of the person’s life, and the roots reach deep into the earth.
It is not always necessary or desirable to tackle the tree directly. Sometimes, therapy can be most helpful when it shows the client that stepping sideways out of the shadow is often an option, a solution which also affords the opportunity of viewing the tree from a different perspective – to see it with an adult’s eyes.
I remember the fun I used to have sliding down the long corridor in my grandmother’s house when I was a child. As an adult, it was a short passage of two or three paces linking the kitchen and bathroom.
In my more lucid moments, I try to justify my membership of the multi-disciplinary mental health team by saying that I put the “psycho” into biopsychosocial. Sometimes this gets a laugh, more often an embarrassed silence. In my more grandiose moments, I liken the role of the psychologist in the team to that of the grit in an oyster shell, the irritant, without which there would be no pearl. My pearls of wisdom fall to the floor like a broken necklace, and in the end turn out to be just paste. More often than not, I put the “nit” into cognitive.
However, notwithstanding the above, I have been grappling of late with the challenges of reductionism. A bit like grappling with a crocodile. Biological psychiatry is the crocodile in the river – highly respected, a bit scary, and you wouldn’t want to get too close.
Without the physical reality of our brains we would of course not exist as conscious beings. But are we more than our brains? Am I more than the areas of my brain that light up in response to external stimuli? For my latest analogy, I have turned to the cinema. Think of some of your favourite movies, of some the great classics of the big screen. Think also of some of the not so great films you have seen. The films, in a reductionist sense, are reels of celluloid in metal tins. A great movie will look exactly like a poor movie. It is only through the wonders of technology that we experience the films and can make judgments about their artistic merits. The distinction is between the physical reality of the film and what it actually is at an experiential level. The film is what is on the screen, not what is in the tin. I think I know what I mean. Cut!
It is time to pack away our summer thoughts, the memories and wishes we shared in rain and sunshine, in the city and on the beach.
We carefully bring down the box of autumn cognitions from the loft, remove the dusty lid, unfold them carefully.
These are thoughts in a range of subtle colours. They are slower in their melancholia, and condense like dew on the windscreen of my car.
It was only a matter of time before I crumbled and jumped onto the current fad for subjugation – which is my understanding of the literary phenomenon that has spawned, in a manner of speaking, a whole industry. However, I am not sure how one can crumble and jump at the same time.
Subjugation is a recurrent theme in my work with clients as they struggle with issues around self-esteem and assertiveness. Many people learn from a young age that they can gain acceptance by others only by subjugating their own physical and emotional needs. It is not just a question of self-denial, it is a matter of denial of the self. Subjugation is a form of maladaptive schema in terms of cognitive behaviour therapy formulation.
I remember one client describing how she would not put brown sauce on her cooked breakfast because the smell of it disturbed her husband. Years of bacon and eggs without brown sauce. It seems like such a small thing, but we recognised it as a potent emblem of how in this and in many other ways she subjugated her needs within the marital relationship. It became a short-hand way to flag similar patterns of behaviour in the relationship.
My client was like a rose kept in a darkened room, unable to flourish because of both the constraints placed upon her and her acceptance of those constraints.
In line with the prevailing market forces underpinning the provision of health care in the UK, the specialist drug and alcohol service I have worked for over the past 16 years has been part of a competitive tendering process. The contract has been awarded to another organisation and the majority of staff are in the process of being transferred to the new employer as the service is excised from the current NHS Trust which has hosted it since its beginnings.
It has been a very stressful time for everyone because of the uncertainty, and this uncertainty remains for my colleagues who will be moving into what is effectively a black hole – there is no information about who will retain their jobs, whose will change, and who will be asked/forced to leave at the end of the consultation period.
I am fortunate not to be transferring to the new service, although this in itself raises very big questions about the relevance and future role of psychologists within the specialist field of substance misuse and addictions. This is not an isolated case. It has already happened in other areas of the country and will continue to happen elsewhere – an unstoppable wave of politically- and economically – driven policies seemingly dissociated from both a sense of humanity for the people affected (staff and service users) and a deeper understanding of the complexities of substance misuse.
My role within the NHS Trust will change and I will not be working with drug and alcohol clients. As the realities of this dawn on me, I feel a lot of sadness. I have devoted a huge portion of my working life to the field of addictions and I am left wondering – in an illogical way – why this is not seen as important any more.
There is a sense of loss. My identity was as an addictions psychologist and this has been taken away from me. It is as though I am in a state of forced abstinence. I need to expect withdrawal symptoms and cravings to work in this area. There is hardly a day that passes without mention in the media of a drug or alcohol-related story – plenty of triggers for my cravings. Maybe later I could work with one or two clients with substance misuse problems – maybe I will be able to be a “social addictions therapist”, not take it to extremes. Or run an addictions group for a few weeks – a kind of therapeutic binge. The echoes all this has of the struggles faced by our clients may be wryly observed, but the feelings are no less real.
This has been an unusually personal post, but I am sure you will understand why.
Clients come to the clinic with complicated psychological problems. This is particularly so when their use of drugs and/or alcohol impacts on other problems such as anxiety, depression and PTSD. It takes sensitive and skillful questioning to try to deternmine how their difficulties interact with each other, to find out which came first, to find possible causal links and thereby to develop a collaborative strategy to help the client make the necessary changes in their thinking and behaviour.
Psychological therapy can thus be seen as a form of tapestry – tracing how the individual threads combine to create a picture of distress, identifying the point at which it needs to be unpicked so the whole does not unravel, and knowing how to incorporate a new motif that will create harmony and longevity.
After the gold, silver and bronze comes the blues…
Even while the closing ceremony is in progress, I begin to feel a loss I had already anticipated last week. We have experienced something remarkable with the London 2012 Olympics, not only due to the success of UK athletes but in recognising the universality of the human spirit. I have admiration and profound respect for every participant from every nation. The dedication, self-sacrifice and determination of these extraordinary people should surely inspire us all to put more into our daily lives, to give more and to expect more from ourselves.
We have shared in the joy and ecstasy of those who met or exceeded their expectations, and we have felt the desperate sadness and despair of those who did not quite achieve their dreams. These are the opposite poles of a continuum of emotional experience common to us all. We identify because they are exemplars of our own lifetime experiences, as we remember our successes and failures in all areas of our life – relationships, work, the arts, sport, education, and our daily attempts to engage and understand the world.
We have reached the end of a wonderful holiday and now we have to return to the reality of daily life. But we are changed. All experience changes us. The trick now is maintain and build upon the positive changes – as individuals, as nations, as citizens of this planet.
Surviving the post-Olympic blues is a matter of making a commitment to change – to take up a new activity, resolve to do more selfless and good deeds, develop known and yet to be discovered talents in sport or the arts at a level that is just beyond our current reach and personal to us. Success is idiographic – it is about being better tomorrow than we are today.
We have recently witnessed a large increase in the number of people trained in cognitive behaviour therapy (CBT). This is a welcome development as it allows more people to benefit from this very effective form of psychotherapy.
However, there is a danger that consumers and commissioners of mental heatlh services lack the discriminant ability to recognise that there are differing levels of skills and training in CBT. Differences can be attributed both to variations in the quality and style of teaching, and to the knowledge and competencies of the individual CBT therapists. These distinctions are well-understood by people closely involved in training and service-delivery, but they may not be shared by the population as a whole. There are, for example, differences in training for the low-intensity and high-intensity CBT therapists currently working in primary care – mostly in “IAPT” (Improving Access to Psychological Therapies) services.
A further important consideration is the quality of clinical supervision that the practitioners receive on a regular basis. This helps to ensure that therapists recognise and work within their range of competence – many people with complex psychological problems will need input from a therapist with more training and experience, typically (but not exclusively) from a clinical or counselling psychologist.
To illustrate, I think we can find an analagous distinction between the many people who can use computer software packages and the few who actually understand the underlying programme languages. It is not necessary to know how the code is constructed in order to use the software, but it becomes important when the programme is not working as it should. In therapy terms, many CBT practitioners can apply the basic principles of treatment but encounter difficulties when confronted by the idiosyncracies of people with enduring and complex psychological problems. This is where the therapist with a deeper understanding of the psychological substrates – e.g., motivational processes, emotional regulation, information processing, learning and developmental aspects – is able to step outside the limitations of manualised approaches.
The list of reasons why my clients cancel or fail to attend their appointments with me grows longer and stranger. Earlier posts have mentioned dentists and breathing clinics. Others not formally recorded in this blog include preferences for supermarket shopping, hairdressing appointments and fishing.
Today, my client explained over the ‘phone that he had experienced an uncomfortable side-effect of a recent change in his medication. The constipation per se was not the problem, rather it was the remedy he turned to which prevented him from straying far from home. Thankfully, he spared me the graphic details, but maybe it was lax of me not to pursue this further.