Depression: Youth, Counseling and Antidepressants

The advent of modern antidepressant medication has been a lifesaver to many. Recent research demonstrates that a combination of counselling and medication can provide the most effective treatment for youth suffering from depression.

However, there is evidence to suggest that in the early stages of medication treatment, there is an elevated risk of suicidal thought, which for some persons may lead to suicidal behaviour. This is causing a great many people to reconsider their use of medication, even when indicated.

This issue is determining which youth will benefit from one or the other or both treatments. To this end a good assessment will look for exogenous factors and endogenous factors.

Exogenous factors are those things outside of the individual that may contribute to depression. These include; family dysfunction, abuse or neglect, parental separation, school related problems and relationship problems. If it can be determined that one or more of these kinds of factors are at play, then counselling alone may be sufficient to treat depression.

Such counselling includes family therapy, or in the case of separated and fighting parents, mediation to help them resolve their conflict, so that the youth is no longer subject to their turmoil. If the youth is in a difficult interpersonal relationship, then counselling for the youth to address the difficulty may be in order. If the youth is abused or neglected, these issues must be addressed and the youth’s safety must be attained.

Endogenous factors generally relate to biological or neurobiochemical factors. If there is a history of depression in the family and there are no known exogenous factors, then medication alone may be the treatment of choice. Often though, with endogenous depression, the sufferer has difficulty controlling depressive thoughts and as such, in this situation a very specific form of counselling, CBT or Cognitive Behavioural Therapy, is also indicated.

There are times of course when both endogenous and exogenous factors are at play. In these circumstances a combination of counselling and medication could be in order and should seriously be considered.

Parents and youth are cautioned against making their decision solely on the basis of newspaper articles proclaiming the good or the bad about any treatment. Depression is a serious disorder, which left untreated can lead to suicidal thoughts, action, injury and death.

If you or your child is depressed, obtain a good assessment by qualified professionals that will look at both endogenous and exogenous factors and devise a treatment plan accordingly. Further, the counsellor and the prescribing physician should be working hand-in-glove following the individual to manage safety issues and communicating regularly about progress.

It is important to know that with antidepressant medication, it can take a good thirty days before the therapeutic effect is achieved. During this time, counselling may be of benefit to resolve other issues as listed above or to simply provide support until the medication reaches effectiveness.

If you or your child is depressed, get help. It is often advisable to start with your family doctor or community clinic. A physician can make the diagnosis and direct you to treatment.

Four Social Work Practice Models

To best assist clients as they work to overcome whatever challenges they are facing, a social worker must employ proven techniques. Different clients have different needs, and each of the following techniques approaches social work from a slightly different perspective. Social workers can choose the technique that best resonates with them, and their clients, to offer the most effective assistance possible.

Task-Centered Practice (TCP)

Sometimes referred to as one of social work’s original “evidence-based” practice models, TCP has been around for nearly 40 years. At its core, TCP asks social workers and their clients to come up with specific, achievable goals in order to treat target problems.

Task-Centered Practice uses a four-step process to do this.

  • Define the problem
  • Establish goals
  • Work on goals
  • Review goals

Once the problem has been defined, the process guides the social worker and client to establish goals to deal with the problem, creating a contract between them. They then engage in several sessions over some short period of time during which the clients and social workers share the outcomes of their work toward these goals, and how well those outcomes have succeeded at overcoming the initial problem.

Narrative Approach

The narrative approach to social work involves helping clients to talk about their problems as if they were a story. This has several effects. First, it helps clients view the problem as external to themselves, rather than some intrinsic part of them. Second, it helps them see how the problem affects their lives both in negative and positive ways, and it can assist them in developing compassion for themselves and their own situations. Finally, it presents the opportunity for the social worker and client to come up with alternate stories as a way for the client to envision what his or her life might be like without the problem in question.

The primary benefit of the narrative approach is in helping the client gain distance and objectivity in regards to the problem. The narrative approach can also be used to guide clients into discerning the causality that led to the problem, which in turn can help inform their future behavior.

Solution-Focused Brief Therapy (SFBT)

SFBT assumes that clients are the experts on their problems and that they are the makers, to some extent, of their own reality. The corollary to these assumptions is that clients already have the solutions to their problems and just need help recognizing them. SFBT then focuses on helping clients come up with their own solutions.

Much of this is done through hedging language, such as “I wonder what would happen if…”, and coping questions, such as asking clients how they manage to fulfill their daily obligations, even with the problem in question in the way. The “miracle question” is also a common technique, wherein the social worker asks a question like, “Suppose some miracle happened tomorrow and you no longer had this problem. What’s the first thing you’d notice?” By asking these questions in this way, the social worker and client work together to come up with achievable solutions and goals to help overcome or deal with problems.

Cognitive Behavioral Therapy (CBT)

The basic principle of CBT is that our thoughts and feelings shape our reality and by changing how we perceive the world, we can change how we experience it. For example, a person with anxiety might believe that everything is going to go wrong during a given day. This preconception then leads this person to pay disproportionate attention to things that go wrong, which confirms the belief and strengthens it. CBT challenges the client to confront that belief, to try to see things in a different way and be more aware of how things are, rather than perceptions.

CBT techniques often incorporate meditation, mindfulness, relaxation and out-of-session homework, in addition to traditional talk therapy. Through these techniques, CBT teaches clients to take control of their own therapy and their own world, to be more present in the moment and to be more aware of the reality around them.

Becoming a Social Worker

At Campbellsville University, the online Master of Social Work provides students with the knowledge and field practice for careers assisting people in need. Campbellsville also offers an online Bachelor of Social Work where students gain foundational skills for the profession. Learn in a dynamic and engaging online environment that allows you to advance your career on your schedule.

What is Superhero Therapy?

Superman-couch

Did you ever want to be a Superhero? Did you ever wish that you could possess magical powers, like Harry Potter, or travel around the world in a time machine, called the T.A.R.D.I.S. with an alien who calls himself The Doctor? What if you could, in a way?

Many of us wish we had some kind of magical or extraordinary abilities, and many of us strongly identify with fictional characters, like Batman, Superman, Buffy the Vampire Slayer, characters from Harry Potter, Firefly, and many others. Recent research findings suggest that identifying with fictional characters can actually be extremely beneficial as it can teach us empathy, remind us that we are not alone in our painful experience, inspire us to eat healthier, and allow us to better cope with difficult life transitions.

The goal of Superhero Therapy, therefore, is to help patients who identify with a particular fictional character to use that relationship with that character in order to identify and process their own experiences and feelings, as well as to encourage them to make meaningful changes in their lives. Thus, the goal of Superhero Therapy is to teach us how to become the very magical Superhero-Jedi that we need in order to become the very best versions of ourselves. Superhero Therapy refers to using examples of Superheroes, as well as characters from fantasy and science fiction in research supported therapy, such as cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT).

Why Superhero Therapy?

Many people have a hard time identifying their own thoughts and emotions, either because it’s too painful, or they’ve never thought about it. I see many patients with posttraumatic stress disorder (PTSD), including active duty service members, Veterans, and non-military civilians. I find that a lot of the time when I ask my patients how they felt at the time of the traumatic event, or even about which emotions they are experiencing in the present moment, many state that they aren’t sure or do not wish to answer.

However, discussing how a specific character felt at a given moment can be helpful in understanding our own emotions. For example, in the Defense Department’s recent efforts to assist Veterans with PTSD, they’ve contracted an independent company, Theater of War, to put on theatre plays for Veterans with combat-related themes, based on Ancient Greek plays. One of these plays, Ajax, for example, tells a story about a character struggling with his symptoms after the war and eventually committing suicide. Veterans and their spouses who saw the play reported that the play helped them understand their own emotions by relating to the characters. One Veteran in particular was moved by the play, stating: “I’ve been Ajax. I’ve spoken to Ajax.”

Talking about fictional characters’ emotional experiences might seem safer than talking about our own, so with my patients, that is where we often start, later drawing parallels to their own feelings and subsequently switching over to focusing on those. For instance, many service members and Veterans I’ve worked with strongly identify with Superheroes, in particular, Batman, Superman, and The Hulk. Let’s take a look at Superman.

Superman (real name Kal-El) is a comic book character who is an alien from another planet, Krypton, who was sent to Earth as a child. His Earth name is Clark Kent, and while in the Solar System, including Planet Earth, he appears to have superhuman abilities: he possesses super strength, super speed, he can fly, he can fight, he has X-ray vision, and many other cool powers. It is no surprise that Superman is a role model to many service members and Veterans, who believe him to be invincible. The phrase or a variation of the phrase I often hear in this population is “I wanted to be Superman… I failed.” This is a common response many people have, harshly judging their own experiences of having PTSD. This is a common dialogue I’ve engaged in with many of my patients:

Patient: “I just feel like such a failure.”

Therapist: “What makes you say that?”

Patient: “I wanted to be like Superman, you know? Strong.”

Therapist: “And now you don’t feel that way?”

Patient: “No, I have PTSD.”

Therapist: “And what does that mean about you?”

Patient: “It means that I’m weak.”

Therapist: “Wow, that’s harsh. Let me ask you this, did Superman have any vulnerabilities?”

Patient: “No.”

Therapist: “No?”

Patient: “Well, there’s Kryptonite…”

Therapist: “Right. What is it and what does it do?”

Patient: “Kryptonite is this radioactive material from Krypton, where Superman was born. It takes away his powers and can kill him.”

Therapist: “So Kryptonite makes him vulnerable?”

Patient: “Yes.”

Therapist: “And does this make him any less of a Superhero?”

Patient: “No, of course not… Oh, I see what you mean, that having PTSD doesn’t mean I’m not Superman.”

This is an example of how cognitive behavioral therapy (CBT) could look when using Superhero examples in session. CBT is a type of therapy that looks at the relationship between thoughts, feelings, and behaviors, which are bidirectional, meaning that they affect one another. In the example above, the patient’s thought: “because I have PTSD, that means I’m weak, and I failed in being Superman” is affecting his feelings (making him feel more depressed) and is affecting his behavior (for example, not wanting to socialize with others).

Some of the thoughts we have might not be 100% accurate, often leading to some painful emotions, and maladaptive behaviors. By challenging the validity of the thoughts (testing to see whether or not the thought is accurate), we can get out of the maladaptive loop. A CBT therapist’s job is to teach a patient how to implement the skill of challenging their own thoughts, to change the maladaptive behaviors in order to help the patient recover, as well as become their own therapist, to be able to help themselves in the future.

The other type of therapy that lends itself nicely to Superhero Therapy is acceptance and commitment therapy (ACT). I often describe it as Superhero Training, as ACT teaches us to become the very Superhero (or witch/wizard, vampire slayer, Jedi, or any other title that seems most helpful) that we wish to be by following our values, (the most important things to us, like family, friends, creativity, altruism, spirituality, and others), and by facing whatever dragons show up along the way (thoughts, feelings, personal stories we tell ourselves, such as “I’m a failure” or “I’m not good enough”) and practicing the Jedi-like skill of mindfulness.

Let’s take a look at how Harry Potter can be used in therapy to teach us some of these skills. Briefly, Harry Potter is a young wizard in training, whose parents were killed by Lord Voldemort, an evil wizard. Harry and his friends, Ron and Hermione, are studying magic at Hogwarts School of Witchcraft and Wizardry. When Lord Voldemort and his followers, the Death Eaters, start to come back to power, aiming to exterminate all non-magical humans (called Muggles), as well as all Muggle-born witches and wizards, it is up to Harry and his friends to stop them.

In the first book of the Harry Potter series, Harry, Ron, and Hermione find out that Lord Voldemort is attempting to come to power by trying to steal the Philosopher’s Stone, which grants immortality to its owner. In trying to stop him, Harry and his friends have to undergo a series of dangerous tests. One of them, the Devil’s Snare, is a magical plant that uses its tentacle-like branches to suffocate the person that touches it.

The Devil’s Snare presents a great ACT metaphor of acceptance and experiential avoidance: the plant seems to respond to tension levels, the more one struggles with it, the tighter its grip and the more likely it is to choke them. This is experiential avoidance, trying to escape the present experience, and just like the Devil’s Snare, in most cases, the more we try to escape, the deeper our struggle becomes. However, if we stop struggling and are willing to experience this discomfort (acceptance), then we are more likely to survive – when Hermione lets go of the struggle with the plant, for example, the Devil’s Snare releases her.

Here is how Superhero Therapy using ACT can look in a clinical setting. One of my clients was struggling with panic disorder and was too scared to go to places where a panic attack might take place and where escape might be difficult (this is called agoraphobia). The patient (let’s call her “Lucy”) stated that as a result of her fears of getting additional panic attacks she had to drop out of college, move back in with her parents, was unable to spend time with her friends, was unable to volunteer in a community theatre, which was something she really enjoyed, and essentially put her life on hold. While she did not have many panic attacks when staying at home, Lucy’s life became constricted, based solely around her anxiety disorder. Lucy stated that she would not be willing to go to unfamiliar places until her panic attacks went away completely and she was absolutely sure that they would not happen again. Her thoughts, such as “if I go out, I will have a panic attack” and “I’m weak” prevented her from living the kind of life she wanted.

In our sessions together we talked about the Harry Potter series; her favorite character was Harry’s friend, Ron Weasley. She said that she identified with Ron because of his fear of spiders. While Lucy herself did not have a fear of spiders, she stated that she could relate to Ron because “he knows what it’s like to be really scared, he gets so overwhelmed by spiders that he can’t even move. That’s exactly how I feel.”

In discussing Ron in therapy, Lucy was able to identify that as scared as Ron was of the spiders, when it was really important, specifically, when Hermione was Petrified (turned to stone) by an unknown monster in Harry Potter and the Chamber of Secrets, Ron (as well as Harry) followed the spiders into the Forbidden Forest in order to get the information needed to save Hermione and other Petrified students. This is a great example of the ACT concept of values. No one who read the books can deny that Ron was terrified when he followed and interacted with the spiders. He was probably also doubting his own abilities and might have had many insecure thoughts, such as “I will fail,” or “I’m not good enough,” or maybe even “I’m a coward.” And yet, despite his fear he was able to follow through, he was willing to experience whatever terrifying emotions and thoughts showed up in order to save his friend, showing true courage and heroism.

I will never forget the first time that Lucy and I drove around her block as a part of her facing her fears. She was trembling and was saying that she did not think that she could do it. However, she got behind the wheel, tightened her Gryffindor scarf, and turned on the engine. It took less than 5 minutes to go around the block and when we were finished Lucy was ecstatic. She was in tears, she was laughing, and saying, “I can’t believe I just did that!”

Lucy and I continued working on taking “superhero steps” in her valued direction and practiced driving to a movie theatre and other locations. Lucy still gets anxious sometimes but just like a true Superhero that she is, she courageously goes out with her friends, she’s back in school, and has even traveled abroad with her family.

I always say that the bravest people I know are my patients. It takes a lot of courage to experience overwhelming, and at times, incapacitating, anxiety, to come to treatment, and to face our fears. Many people believe that fear is bad, something that needs to go away for us to live a normal life. However, fear can actually be quite advantageous. In a recent Doctor Who episode, Listen, we learn that fear can be a Superpower. Doctor Who is a British science fiction TV show about an alien, who calls himself The Doctor. The Doctor travels around the universe in a time machine, called the T.A.R.D.I.S. (which stands for Time and Relative Dimension in Space) and saves those in need.

The Doctor is over 2,000 years old, and seems to know a thing or two about fear. His take is this: Fear is a Superpower. Fear causes the release of adrenaline, which makes us think faster and fight harder, suggesting that we don’t need to run away from fear, fear might actually be helpful.

The bottom line is that running away from fear and not living our lives according to our values isn’t helpful, whereas learning how to face our fears in the service of what’s most important to us, that’s what being a Superhero is all about.

Microaggressions and Trigger Warnings Are Being Deemed Liberal Views Limiting College Students

PreCollegeProgramLL

After reading the article Coddling of the American Mind in the Atlantic, I felt compelled to pen a response. The article suggests that ‘liberal’ views about use of language, ‘trigger warnings’, microaggressions, and avoiding offensive language are damaging to university students’ academic progression and their emotional wellbeing. The discussion here will be in several parts, the first part considers the article’s origins and underlying assumptions.

The article is a worthwhile read after taking into consideration the initial response it elicits. There are references to evidenced based therapies such as Cognitive Behaviour Therapy (CBT), and many examples were given to support their points. Here is an excerpt:

Two terms have risen quickly from obscurity into common campus parlance. Microaggressions are small actions or word choices that seem on their face to have no malicious intent but that are thought of as a kind of violence nonetheless. For example, by some campus guidelines, it is a microaggression to ask an Asian American or Latino American “Where were you born?,” because this implies that he or she is not a real American. Trigger warnings are alerts that professors are expected to issue if something in a course might cause a strong emotional response. For example, some students have called for warnings that Chinua Achebe’s Things Fall Apart describes racial violence and that F. Scott Fitzgerald’sThe Great Gatsby portrays misogyny and physical abuse, so that students who have been previously victimized by racism or domestic violence can choose to avoid these works, which they believe might “trigger” a recurrence of past trauma.

The people who wrote this article are rich, white-skinned and well-established men, who work at the moment in business-type jobs. Jonathan Haidt has an incredible list of credentials, including top American universities, a Fulbright scholarship, and a long string of psychological research initiatives – ending in an evolutionary-based model of morality, which suggests that political conservatives have a wider moral base than political liberals. One foundation of Haidt’s theory of morality includes ‘respect for traditions’ and ‘deference to legitimate authority’. A simple reading doesn’t make clear whose authority should be counted as legitimate.

Greg Lukianoff is a “First Amendment lawyer” who spends his time purporting the right to free speech. He describes himself as politically liberal and has written books about unlearning liberty and how to have free speech on university campuses. In 2008, he received the Playboy Freedom of Expression Award ($25,000 for advocates of the First Amendment) and has written for a whole host of well-known media outlets.

The text itself begins with an anecdote about anecdotes. In other words, Haidt and Lukianoff reference an article about teaching rape law, which provides examples of college students being ‘oversensitive’. This includes students who ‘complained’ there should have been a warning before showing a video of a sex abuse investigation in class, and a student who asked, for personal reasons, that rape not be included on exam material. Following this, they provide a list of names of people who apparently agree with them. This includes an article by a ‘liberal professor’ who states he is scared of oversensitive students, which was actually later contested by a ‘liberal professor’ via the same media source, and even later contested by second professor, again via the same media source.

This tactic arguably places the authors in an apparently popular and reasonable position as stated by this professor. It’s presenting them as people who say what needs to be said in a dark era of closing down reasonable discussion due to ‘offence’. They include teachers, liberals, a woman, a black comedian and a white comedian. It fits well with current Western political rhetoric, especially in Britain and America. After all, ‘political correctness’ is no longer considered a synonym for ‘respect’ but for unnecessary censorship. And they use broad anecdotes to support this.

Another broad brush the authors use is the term ‘microaggressions’.  Dr. Derald Wing Sue in his book, Microaggressions in Everyday Life, gives a great overview of what they are, and how they affect different demographics. In essence, microaggressions reveal our unconscious biases and assumptions – if you’re interested, you can find out about some of your unconscious prejudices here. Because Western society frowns upon, and legislates against, actively hateful discrimination and incentives to violence, people tend to avoid overt demonstrations of prejudice. Prejudice is expressed more subtly, i.e. with microaggressions.

There is plenty of literature about how microaggressions are insidious and inherently damaging to wellbeing – the idea was conceived by Chester Pierce in the 1970’s and it was further developed in the 1990’s. This is not a term that has suddenly started to be bandied about on college campuses. It’s been present in literature for a while, and finally this literature is filtering to the public. One of the implicit messages present in Haidt and Lukianoff’s argument is that microaggressions are a newfangled pop-culture concept with little inherent value – “risen quickly from obscurity into common campus parlance (read: where it does not belong)”.

Coupled with this, they obscure the meaning of ‘microaggression’. The crux of Haidt and Lukianoff’s argument is that they appear to consider each microaggression as an individual event. And, of course, when you take something so small as an individual event, and totally out of context, it looks silly. But empirically, that is not how microaggressions are meant to be considered – it’s the aggregate of thousands of microaggressions throughout a person’s lifetime that makes them damaging. Actions deemed as microaggressions have no power by themselves. Think about a bee. A single bee sting does just that – it stings, it hurts. But overall there’s not much damage. The entire hive going after you at once, however, can kill. There’s a special word for this – synecdoche, where a small part of something symbolises the whole.

So, Haidt and Lukianoff ignore the context of why microaggressions are so dangerous: 1) Because they are present everywhere, all the time, and they steadily wear people down, 2) Each individual instance is so small it can be dismissed, which 3) Makes the less privileged person seem over-reactive to small misdemeanours, and therefore 4) Means nobody has to do anything about it.

Crucially, they pretend ‘microaggression’ is a monolithic term. They ignore the range of different ways microaggressions can present themselves – including using an identity as an insult (“don’t act like a girl”, “that’s so gay”), and assuming white male straightness is default (after all, gay marriage is just marriage, women’s football is just football). They ignore a huge power of microaggressions – that of erasure.

There is literally ‘nothing’ to complain about when mixed gender groups are called ‘guys’ not ‘girls’, when bisexuals are absent from discussions on the ‘gay agenda’, people are surprised when the boss is black, and when Asian women basically don’t speak in modern Western media. Indeed, it’s considered rude to reject well-meaning attempts to assimilate a person into the norm (“You don’t act gay” as a compliment, “I’m colourblind”, or “We’re all the same, gender doesn’t matter to me”).

Ironically, Haidt and Lukianoff don’t mention erasure as a microaggression at all in their discussion. They instead appear to condense all possible infractions against a minority/oppressed group as ‘offence’ at something. Even though they explicitly mention the phrase ‘I’m colourblind’ as part of an anecdote they don’t seem to pick up on what it means. And it’s on this reductionist basis they build much of the rest of the article. Whilst every point they make will not be looked at, it is worth thinking of an example they provide: “It is a microaggression to ask an Asian American or Latino American “Where were you born?”.

Of course asking an Asian-American where they were born isn’t an inherent microaggression. Haidt and Lukianoff don’t provide a reference to ‘some campus guidelines’ which have stated this. If people are talking about having been born in a different place to where they now live, then it’s not unheard of to ask about birthplace. That said, usually one would ask where people are from, not where they were ‘born’.

Either way, it’s not always microaggressive – it’s about context. If a person has only just met someone, or doesn’t know them too well, birthplace is generally not top of conversation topics. Haidt and Lukianoff’s assumption is that it’s not the university’s blanket and over-simplified definition of microaggression that’s the problem; they assume that the acknowledgement of microaggressions is in of itself is problematic.

They follow up with some additional isolated examples of microaggressions-gone-wild, coupled with the term “some recent campus actions”. Then they state: “This new climate is slowly being institutionalized, and is affecting what can be said in the classroom, even as a basis for discussion”. Perhaps this assumes that students aren’t already institutionalised and that the system as it was should be preserved. From this, it seems one of their  assumptions is that the system was better before students started speaking out about these issues i.e. the authors want to “restor[e] universities to their historic mission”.

There also seems to be an undercurrent of “we are rational and logical” versus “the oppressed (read: offended by microaggressions) are emotional” – the nuances of this will be addressed later as part of a discussion about ‘psychological harm’, ‘emotional wellbeing’ and ‘safe spaces’. It seems interesting that whilst the authors place themselves in this rational and non-emotional position, they deliberately coin the strongly-worded term vindictive protectiveness, which means ‘punishing people’ who interfere with the (admittedly atrocious) aim of ‘protecting students from psychological harm’. This is possibly a touch.. catastrophising, as CBT therapists might say.

Additional catastrophising themes include punishment and charges towards innocent victims (people who get called up on microaggressions). This is in spite of their earlier assertion that students should get themselves used to “words and ideas that they will inevitably encounter”, such as, for example, the idea that microaggressions exist and are damaging. Linguistically, microaggressions have now been reduced to words and ideas rather than oppressive actions, and also put on a par with common intellectual debate and discussion, which allows Haidt and Lukianoff to treat them as though they are the same thing.

This is something to bear in mind, as future posts will consider the content of their article, beyond some of its basic assumptions. To finish this particular analysis, readers will be left with one very telling quote about what the problem with microaggressions appears to be: “It is creating a culture in which everyone must think twice before speaking up, lest they face charges of insensitivity, aggression, or worse.”

So, to be clear, they are concerned about having to think before they speak.

As in, having to consider other people’s reaction to their words.

Otherwise one might get.. criticised.

But Haidt and Lukianoff aren’t being oversensitive, of course.

Acceptance and Commitment Therapy: A Different Approach to Anxiety Disorders

Most coping techniques that teach people how to handle their abnormal anxieties focus on skills that reduce, replace, and avoid discomfort. These techniques are many that I have tried for my own anxiety including deep breathing, relaxing music, muscle relaxation, and more.

Cognitive behavioral therapy teaches people to control and change their upsetting feelings and thoughts. On the other hand, Acceptance and Commitment therapy teaches people not to change their thoughts or feelings but to change the way they react to them. The three steps of Acceptance and Commitment Therapy are; accept, choose, and take action.

According to Psychology Today,

Acceptance and Commitment Therapy (ACT) is a type of psychotherapy that helps you accept the difficulties that come with life. ACT has been around for a long time, but seems to be gaining media attention lately. Categorically speaking, ACT is a form of mindfulness-based therapy, theorizing that greater well-being can be attained by overcoming negative thoughts and feelings. Essentially, ACT looks at your character traits and behaviors to assist you in reducing avoidant coping styles. ACT also addresses your commitment to making changes, and what to do about it when you can’t stick to your goals. Read More

  1. Acceptance: Acceptance of anxious feelings means learning how to observe and sense them without judgment. Instead, you are able to use compassion and gentleness when confronted with anxiety, fear, worry, panic, and other sensations that may cause discomfort.
  2. Choose: This step is where you decide how you want your life to go. You can ask yourself do I want to remain a prisoner to this anxiety or do I want to live a fulfilling meaningful life?
  3. Take Action: This is by far the hardest step. This involves accepting that in order for things to change you much change your behavior. Taking action means facing your fears and anxieties and making them a small part of your life instead of something that consumes you.

To learn more about Acceptance and Commitment Therapy check out the book:  The Mindfulness & Acceptance Workbook for Anxiety by John P. Forsyth and Georg H. Eifert.

10 Ways Therapists Go Wrong

It’s not uncommon for a client to enter my office with previous experiences in therapy elsewhere. When meeting a new client, I always make sure that I ask: “Tell me what you liked or did not like about therapy before. What worked? What didn’t work?”

I don’t want to offend a client in the same way another therapist may have and I really don’t want to waste time trying interventions that just don’t fit.

Here are some of the ways therapists have gone wrong, according to clients I have asked:

1. “They made me talk about _____ when I really needed to work on ______. ” 

Missing the mark.  Sometimes it is hard to not push our own agenda as therapists, especially when our knowledge and experience is telling us what clients really need to work on. Having buy-in from the client is crucial.  I think we explain why it may be important to discuss a certain topic, then clients are more receptive. Another common complaint here is digging up the past when unnecessary.

2. “They were late all the time.”

I have trouble understanding this one. Barring crisis situations, therapists need to respect and model time boundaries. I think 15 minutes is reasonable, but I’ve heard stories of clients consistently waiting over an hour. Frequent cancellations are another common complaint.

3. “I left their office feeling worse than when I came in.”

I think this could relate to unnecessarily digging up the past, but it also has to do with hope.  Of course there will be sessions where problems aren’t solved in 50 minutes, but homework and talking about future improvement is important. Effective therapy can bring up uncomfortable feelings, but hopefully with informed consent and some discussion, clients can learn to accept temporary discomfort as part of getting better.

4. “They wanted to pray during sessions.”

I hear pretty frequently about situations where the therapist tries to bring religion into therapy unsuccessfully. Many clients find religious practices to be a helpful adjunct to their treatment. However, we need to take care to be culturally competent and respectful of others’ religious beliefs. Remember that freedom of religion also means freedom to have no religion for many people.

5. “They relapsed.” or “They invited me to use with them”.

Self-care is so important for therapists, especially when they are in recovery from substance abuse or mental illness themselves. It can be really damaging to a client’s confidence that they will get better if even their expert therapist has failed. It is okay for therapists to have problems, but we are also responsible for demonstrating how to cope with these issues.  If you are having an acute substance abuse or mental health problem you need to get help, even if that means leaving your job until you are well enough to return.

6. “They fell asleep”

This one is hard for me to believe, but I’ve heard it several times. We all have clients who are depressed, flat, monotone or dull, but there is no excuse for falling asleep during a session. If you are so exhausted that you risk falling asleep during a session, then you need to get a strong coffee or cancel appointments for the day and rest up!

7. “It was too expensive.”

This is one that most therapists can’t avoid.  Truth is that overall, therapy is a luxury for most people. Offering sliding scale or case management to get appropriate healthcare resources can help.

8. “They didn’t seem accepting of _____.”

Just fill in the blank with anything remotely controversial. I’ve heard of clients who felt their therapist didn’t respect their sexual orientation, mixed race relationships, spiritual beliefs, culture, politics, you name it.  I think most therapists view themselves as being open minded, but everyone has their own bias and it can really show to sensitive clients. Refer to another provider if you need to.

9. “It seemed like they wanted to talk about their own problems.”

Sounds like a pretty classic self-care issue. It can be really helpful to disclose to clients your own experience, but this needs to be done very carefully and ideally after consult with a supervisor or colleague. If a client gets the feeling that you need them to listen to your problems, they probably will end up feeling like you can’t handle their issues. Not to mention feeling neglected themselves.

10.” They abandoned me.”

This is a by-product of our mental health system that has left too many therapists with the experience of showing up to work only to find a note on a locked door saying the company has closed. It is unfortunate that this happens because it can be so damaging for clients.  My first two jobs as a therapist ended abruptly and despite my attempts, I was forced to say goodbye to my clients with very short or no notice. I felt so guilty and awful that I wasn’t able to even make referrals for some clients to get set up with a different therapist elsewhere.

Ideally terminating the therapeutic relationship should involve wrapping up unresolved therapy issues, transferring to a new therapist, referral for community resources and a session to reflect back on the experience and say goodbye.  It is so rare in life that we get appropriate goodbyes in our relationships, so what a great experience to have if you can provide it.

I think what is most important is that we ask clients about their experiences and approach therapy as a collaborative process.  Checking in with clients periodically throughout treatment provides an opportunity for feedback.  If we are unaware of where we are going wrong, we can’t fix it.  What have your experiences been with helping clients who have dealt with some of these wrongdoings?

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