You Can’t Hurry Recovery

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.

 

Fifty Shades of Brown Sauce

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.

 

Therapy as Tapestry

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.

Therapist as Programmer

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.