Sunday, February 27, 2011


I've been transitioning into a new role at work, one that is as yet not clearly defined.  I'm still doing a lot of the same things I've been doing -- namely therapy -- but the idea is that I will also have some time to do other things (like training, program development, research, etc.).  I'm taking part in a new division that is still in the development stage.  Since we aren't completely up and running I haven't been exactly sure how I'm supposed to fill my free time.  The other day I sat down with my supervisor, who encouraged me to take some initiative in defining my role and identifying tasks or projects to take on.

I was caught a little off guard by my supervisor's instructions.  Take initiative.  Hmm.  I remember a time when I didn't need to be told to take initiative.  I used to be full of ideas and eager to take action.  I used to relish the opportunity to use my imagination and to come up with new ways to do things.  Yet, here I've been for the last couple of weeks with a significant amount of free time on my hands and what have I done with it?  Absolutely nothing of value.  What happened to me?

I think I've become either disillusioned, complacent, or both.  As I explore this a little further I realize that the two states of being -- disillusioned and complacent - are quite different from one another.  To be disillusioned suggests disappointment upon discovering that something is not as good as you believed it to be.  Complacency suggests almost the opposite -- satisfaction with the status quo.  Disappointment and satisfaction are not things that tend to go together.

For me, the disillusionment definitely came first, early in my career.  My first job was in an environment where my ideas were routinely ignored and the welfare of my patients was always less important than the company's profits.  I initially made an effort to do some things differently but I received absolutely no support and the changes I had in mind were not things I could do by myself.  After a while I became discouraged and quit trying.  I had started out wanting to make a difference.  Eventually I concluded that it really wasn't possible, at least not where I was at the time.

Things improved significantly when I switched jobs a few years later.  I was relieved to be in a place that allowed me to interact with my patients in whatever way I thought was best.  I focused on improving my skills and on growing as a professional.  When people asked for input about the department (or the "system") however, I stayed away.  I didn't want anything to do with the "politics."  I just wanted to do my job.

Is that complacency?  I didn't think so before, but maybe it is.  Maybe it's not enough to focus all of my energy on change at the individual level.  I hesitate to make the effort to go beyond that though.  If I invest my time and energy and it all comes to naught will I become disillusioned all over again?  I remember the depression that ensued the last time I realized that the status quo wasn't budging.  Do I want to open myself up to that again?

So now I am being asked to take initiative.  I wonder if I still have it in me...

Friday, February 18, 2011


A couple of weeks ago one of my blog readers suggested that I check out the website  I got a message stating that the website is no longer being maintained but there were links to other websites being managed by the same people.  I followed the links and read some of the articles on the sites.  Their emphasis was on how measuring outcomes and asking for patient feedback about sessions facilitate therapists' professional development.  All this talk about outcomes got me thinking: what are the factors that influence whether or not therapy is helpful?

I did some investigation.  A lot of research has been done in an effort to identify what distinguishes helpful psychotherapy from unhelpful psychotherapy.  Here are some things that have relatively little impact on effectiveness: level of therapist training (Master's vs. PhD vs. MD), years of therapist experience, the discipline of the therapist (psychologist, clinical social worker, licensed professional counselor, psychiatrist, etc.), and therapeutic modality used.  I was a little surprised by this but I also felt relieved.  If none of these things have much influence on whether or not I'm a good therapist then I can stop worrying so much about needing to know more. 

In talking with some of my peers I've discovered that I'm not the only one who, a week or two into her first "real" job, came to the realization that, "I have no idea what I'm doing!"  What a scary feeling!  I'd fooled myself into thinking my education had prepared me well for the real world.  When reality hit, my first instinct was to run the other way.  (I mentioned before that I started thinking about going back to school to learn to do something else).  I've come a long way since then but I still have fears that I don't know enough and that my patients will suffer because of my lack of knowledge.  (This is particularly true when I encounter a patient with severe difficulties).  So  what a relief to learn that how much I know doesn't make very much difference.  (It does, however, make some difference; maybe about 15% of therapeutic outcome is accounted for by therapeutic techniques used). 

So what does make a difference?  The two most important factors that determine whether or not psychotherapy is effective are patient factors (e.g., motivation, social support, etc.) and therapeutic relationship factors (e.g., empathy, acceptance, genuineness, etc.).  The relationship between the patient and therapist accounts for about 30% of outcome variance.  That's DOUBLE the effect of therapeutic technique/skills.

What do I make of this?  Well, I guess it is who I am more than what I know that has the biggest impact on therapy.  (That doesn't mean I'm going to stop learning.  Actually, I love to learn and I often pursue knowledge just because I'm curious).  I actually feel pretty good about this conclusion.  I am much more confident with who I am than I am about my ability to apply theory and techniques to helping someone get better.  It also gives me a good reason to keep working on myself; the better I understand me the more helpful I am to other people.

Sunday, February 13, 2011

Core Beliefs

I know I've talked a lot over time about how our subconscious beliefs influence our thoughts, our feelings, and our perception of reality.  Most people aren't aware those beliefs even exist - remember, they are subconscious.  Most of the time there's no real need to uncover them; they serve a valuable purpose (helping our brain to attend to important information and to filter out insignificant information).  However, sometimes these beliefs cause problems, such as low self esteem, anxiety, depression, chronic anger, interpersonal difficulties, etc.  When problems like these emerge in your life it is time for you to take a look at the underlying core beliefs that are driving them.

So how do you know when a problematic core belief is at work?  Look for strong emotional reactions.  Notice times when, for example, you become extremely distressed when a friend forgets that you'd agreed to get together and makes other plans or when you erupt with anger over something trivial.  When your emotional response seems to be more extreme than what the situation would warrant you know that a negative core belief has been triggered.

Here's an example from my own life.  I used to belief I was unlovable.  Now if you met me on the street of course I wouldn't say, "Hi, nice to meet you.  I'm unlovable."  Perhaps it is more accurate to say that I feared that I was unlovable.  A string of bad relationships caused me to worry that maybe something was wrong with me.  Maybe there was something about me that caused the men in my life to treat me badly or to completely disregard my feelings.  Maybe there was something inside me that made me inherently unlovable...

Anyway, this belief (or fear) led to a lot of suffering.  If a romantic interest didn't call me the day after a date I became first extremely anxious and then despondent.  I'd lay in bed sulking, unable to think of anything else.

It's obvious to me now that this was a rather extreme response.  A "natural" response would probably be to feel a little disappointed for a day or two before moving on.  The fact that I reacted so excessively was a sure sign that a negative core belief had been triggered.

When a potential love interest didn't call it triggered my belief that "I'm unlovable."  Subconsciously, I perceived the love interest not calling as evidence that he didn't like me.  This quickly led me to recall other relationships that ended with me feeling rejected.  This brought up fears about whether or not I would EVER find the "right" person.  What if there was no right person for me?  What if no one could ever love me because I was simply unlovable?

I share this example because I strongly believe in practicing what I preach.  I spend a lot of time with my patients identifying their negative core beliefs and talking about how to change them.  The first step in changing negative core beliefs is to recognize when they are at work.  If you can't recognize them then you can't change them.

I know it is possible to change negative core beliefs because I've done it myself.  First I started noticing when my belief had been triggered.  Then I identified and acknowledged how the belief made me feel.  I countered the negative belief with more balanced ones -- "Everyone deserves love, including me," or "You are a lovable person."  I also tried to make a more realistic appraisal of the situation that triggered the negative belief.  Sometimes that meant having to accept that the person was not interested in pursuing a relationship with me.  Sometimes it meant he was at work and just hadn't had a chance to call.  Either way, I realized, his actions said nothing about whether or not I was lovable.

Saturday, February 5, 2011


I am a person who thrives on structure and routine.  I prefer for things to be straightforward and unambiguous.  I like for things to make sense.  I am task-oriented and I can't relax if I know there is work that needs to be done. 

When I started doing therapy I quickly concluded that I'd gone into the wrong profession.  Therapy is often about the process; I felt like I was doing a lot of talking but not really accomplishing anything.  It didn't seem like my patients were getting any "better;" I didn't even know what "better" would look like.  Therapy seemed like a never ending endeavor.  I had no idea how or when to terminate.  How was I supposed to know when a patient was "finished" with therapy?  Shouldn't the patient be the one to decide?  Because I was unsure about when to initiate termination I simply didn't do it.  Most of my patients just eventually stopped coming after a while.  (Maybe when they felt like they didn't need it anymore or maybe for any of a thousand other reasons).

Therapy, I decided, wasn't really a science; primarily it was an art.  This made sense to me; I'd never been good at art so why would I be good at therapy?

Oh how I struggled with this!  I considered going back to school to do research - real science.  I got accepted into a PhD program at Virginia Tech but I had a house and a mortgage; I couldn't afford to quit working to go to school full time.  I felt trapped.  I had no choice but to keep working in a profession I despised.

Two things happened that changed things.  First, I was introduced to "protocol" therapies.  Protocol therapies are very structured.  For each session there are certain topics that must be discussed and tasks that must be completed.  Patients are typically given "homework" assignments that they have to complete in between sessions.  These therapies are time limited; the number of sessions is built into the protocol.  Patients know from the very beginning how long the therapy is going to last.  Finally, the best thing about protocol therapies is that they are research based.  Each of these therapies have been the focus of well designed research studies and have been shown to be effective. 

In order to determine whether or not a treatment is effective a person has to measure outcomes of the treatment.  Protocol therapies lend themselves to research by design.  Each protocol therapy incorporates some means for measuring changes in patients' symptoms throughout the treatment process.

Protocol therapies appealed to me for all the reasons "other" therapy did not.  They were task-oriented.  If I covered everything that was on the agenda for a given session I felt like I'd accomplished something.  There was not a lot of ambiguity.  I knew what needed to be done during each session and I didn't deviate from it without a compelling reason.  The therapies were research based, so I felt confident that if I simply stuck with the protocol the patient would make progress.  Best of all, these treatments provided a means for measuring progress.  Each session, the patient completed an empirically validated scale designed to assess the presence and severity of their symptoms.  Oh the joy I felt as I watched my patients' scores fall each week!  This was the first time I'd ever felt certain that my efforts had helped someone heal.  This was why I'd wanted to become a therapist; I wanted to help people!  The reason, I realized, that I'd been so unhappy doing therapy was because I really didn't feel like I was helping anyone.  Now I knew that I was.   

So the first thing to convince me that maybe I hadn't made a mistake by becoming a therapist had to do with measuring outcomes.  This provided concrete evidence - both for me and the patient - that the patient was getting better.  The second thing that happened took me in the opposite direction. 

The second thing that happened involved a change in perspective.  I became interested in how the Buddhist practice of mindfulness -- paying attention in a particular way: on purpose, in the present moment, and non-judgmentally (Jon Kabat-Zinn) -- might be used in therapy to help patients learn to accept and tolerate their emotions.  The idea that it is not always possible or desirable to get rid of negative emotions was completely new to me.  Wasn't that my job -- to help people get rid of their negative emotions?  Not according to the principles of mindfulness.  In fact, Buddhist teachings suggest that refusing to acknowledge and accept negative emotions only creates more suffering.  Refusing to accept what is at any given moment creates anxiety.  We feel compelled to do something to change the way things are as quickly as possible.  If this doesn't happen we become increasingly anxious and upset. 

I was intrigued.  I bought books about mindfulness, went online to read articles and visit websites, and started trying to apply what I was learning in my own life.  I read a book about being a mindful therapist and learned that the best thing I could offer my patients in a therapy session was my own mindful presence.  This meant learning how to be with a patient without allowing myself to get distracted by concerns about whether he or she was getting better.  Mindful presence meant devoting my entire self -- and my undivided attention -- on that patient in that moment.  To worry about outcomes would take me out of the present moment.  I had to learn to just be with what is.

Over time I learned to stop putting so much pressure on myself to make people better.  That's not to say I completely stopped thinking about outcomes.  I just stopped obsessing about them.  Without the pressure, I actually started to enjoy the process of therapy.  I started thinking that maybe therapy wasn't such a bad choice for me after all.

The moral of my story is that, as with all things, there must be a balance.  Measuring outcomes is absolutely necessary for research and research helps us to identify treatments that are most helpful to patients.  Measuring outcomes helps to build confidence for both the patient and the therapist.  The patient sees concrete evidence that he or she is improving and is motivated to continue treatment.  The therapist sees that the patient is making progress and feels good about the work he or she is doing.

Focusing too much on outcomes, however, can be distracting.  Therapy is both a science and an art.  Above all things, though, it is a relationship.  If a therapist becomes too focused on where he/she and the patient are trying to go (the outcome of treatment) then he/she misses out on being with the patient where he/she is.  This takes away from the therapeutic relationship.  Without that, it is very unlikely that the patient will get any better.

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