"Thank You For Counseling!"

I was delighted when a counseling/coaching client told me his wife's Thanksgiving prayer: "Thank you for my husband, thank you for my children, thank you for counseling!"

:-)

A Mother Wonders

A colleague asks:

A therapist, writing on a listserve for therapists, asks for suggestions on behalf of a client whose concerns about her 3 year old son have to do with what she describes as social/behavioral issues. This mother wonders about some unusual behaviors in her son, including that he often doesn’t seem to perceive or respond to body language. He often doesn’t look at his mother in the eyes, sometimes walks with his head cocked and, when walking, often doesn’t look up and around to make sure that he won’t run into things. In addition, he often doesn’t smile at people who smile at him, holds his hands in unusual positions, and likes to walk in circles and spin. Her pediatrician seems inclined to disregard her concerns.

Dr. Einhorn replies:

Your client does well to notice her son’s behaviors. There aren’t really any tests to determine whether a 3 year old with these behavioral signs does or doesn’t have a diagnosable issue. A professional who is experienced in working with children, particularly those on the autistic spectrum, might be able to identify some signs or tendencies in that direction, if they are present. If issues were identified, the interventions would be social: helping the family encourage more socially responsive behavior in this child, helping them to communicate more effectively with him (if that’s an issue), helping him to self-regulate more effectively, finding a preschool program where these interventions could be implemented to some degree.

Pediatricians often disregard subtle behavioral signs in children which are of concern to parents, and they are usually right to do so; most of the time, parents are overly concerned and/or the kids grow out of whatever behaviors their parents are concerned about. However, in my work with children with learning disorders, it has often been the case that pediatricians dismissed signs that parents, usually mothers, identified early on that actually turned out to be of real concern as the child grew up and did not grow out of them.

A behavioral assessment of the child would involve meeting with his parents first, then observing him at home and perhaps elsewhere (playgrounds, preschool if he goes to one, etc.). A psychologist with experience in working with children on the autistic spectrum, and their families, could provide this. Occupational therapists who are experienced in working with children on developmental delays and on the autistic spectrum can also contribute to the evaluation and treatment as well.

Two Couples

("Two Couples" was printed in the fall, 2010 "Illinois Psychologist," the newsletter of the Illinois Psychological Association)

As the year anniversary of their marital therapy approached, the couple and I reviewed how far they’d come. At the beginning, it wasn’t at all certain that one spouse, acutely suicidal, would survive the year, or that their severely troubled marriage would. Neither the suicidal spouse nor the troubled marriage is safe for certain, but both are much better now.

During the year, I have at various times accepted, supported, and challenged the narrative of self and history presented by each or both spouses. I have used “bottom-up” emotion-focused therapy (learned from Sue Johnson), behavioral interventions, and “top-down” psychodynamic interpretations. One spouse had to go through what seemed like a volcano of rage and pain, sometimes abusing the other spouse, and I had to simultaneously endorse the feelings and experiences that led to that state while helping to stop the abuse and leading that spouse toward a higher level of self-integration. I have offered understanding and support for the other spouse’s distancing and disengagement while challenging that spouse to take steps of risk toward being more authentically available. I have, at various times, included in our talk therapy, or supplemented it, with mindfulness, hypnotherapy, spiritual counseling, humor and metaphor. I have consulted with each partner’s individual therapist.

This couple came to me after having seen a marital therapist on their insurance plan who thought she could fix them in twelve sessions, or something like that. The suicidal partner had been seen by an individual therapist working on the same lines. One of the first things I had to do was find an individual therapist for that partner who would allow that partner’s feelings and experience to actually enter the room.

This couple are not even bothering to submit their marital therapy bills to their insurance company. And if I had been asked, on a pre-authorization, to submit a treatment plan describing how I planned to work with them over a finite number of sessions, I don’t see how I could have done it.

Another couple is brand new to me and marital therapy. Brought to the brink of divorce by an infidelity, they are emotionally all over the place. The betrayed partner started a recent session by forcefully asserting that the marriage was over, and ended it by almost whispering that marital repair was the goal. The unfaithful partner, full of guilt and remorse, is challenged to make sense out of behavior that was more lived than reflected on when it was happening. Both partners, full of pain, have to understand their own contributions to what happened, even as they revise their individual and shared narratives of their marriage. Both yearn for stability which neither is able to commit to, right now, and I have to help them accept that uncertainty as they work through the issues that have suddenly become the most important in their lives.

This couple does intend to use their insurance, and I will be asked to complete a treatment plan. How about if I say: “I will empathize with each partner in such a way as to understand that partner’s experience of their relationship and the impact of the other partner’s behavior on them, and convey that in intensive conversation with both partners together in such a way as to help them integrate these perspectives into their conscious reconstruction of their relationship, supporting them in the meanwhile through a period of intensive uncertainty while encouraging each partner to discover and acknowledge what is authentically his or her truest wish for their relationship.”

What do you think the insurance company will make of that?

Coaching Versus Therapy

(posted on a listserve for psychotherapists, as a contribution to a discussion about the differences between coaching and therapy):

As I've read, with interest, the dialog about coaching vs. therapy, it seems to me that the distinction, at least in my practice, has to do with the coach-client and therapist-client contract. I don't mean a written contract, but the mutual understanding about what we're doing and why.

Some of my coaching clients are in therapy when they come for coaching, so I can say things like, "This is what you need to do to take a step toward achieving your goal. If you have feelings that interfere with your taking this step, you can talk with your therapist about them." Other coaching clients have come for help making a career change, or for doing what they're doing better--for example, improving employee selection and retention procedures, improving relationships with colleagues at work, or coping with a difficult supervisor. The coaching contract is action-oriented, goal-focused, and not about a mental health or emotional problem. Feelings are a part of it but not the main part, and if they begin to become the main part, that begins to look like therapy to me. The action agenda can certainly be modified to take emotional issues into account; for example, a very anxious client who wants help with job-seeking skills, including modifying her expressions of anxiety in job interviews, may need to move more slowly than an executive with a successful career history now ready for a job change. If I help her learn to relax, it's so she can pass a job interview; not primarily to help her be less anxious 24/7, although it may have that effect.

Now, I don't know about the overlap between the kind of coaching I'm describing and the "life coaching" I've seen advertised on the web--"You, too, can become a life coach, get rich, help everybody..."--which is much more like the old-fashioned mix of self-improvement and hucksterism that is so quintessentially American. I suppose that the people who are really better at life coaching will eventually develop referral networks based on their competence, like therapists--or any other professionals--tend to do; and "caveat emptor" will be the rule for clients. For that matter, to the extent that "life coaching" really is about improving one's life in general, I'm not sure that mental health professionals, as a group, have the advantage over any other professional group on being prepared to be good at that.

When Is Therapy Done?

(This article printed in the Fall, 2010, Cappstone, the newsletter of the Chicago Assn. for Psychoanalytic Psychology)

Susan C asks: “When is therapy done?”

One of the most important contributions of psychoanalytic psychology is the perspective that each person, and each client-therapist dyad, is unique. Susan has asked a general question, rather like one might ask a medical question: “When is antibiotic treatment done?,” or an educational question, “When is a course of study done?,” or even a plumbing question, “When will the furnace be installed?” If we are talking about people in therapy, we have to rephrase the question, to something like, “When is who’s therapy done, with whom?”

Generally speaking, people come into therapy with a acute problems which tend to improve after awhile, often within several months. Along with that improvement comes the perception that the client is vulnerable to react to certain stressors in certain ways; such vulnerability and reactions having contributed to the acute problem in the first place. Some people feel, once the acute problem has been relieved, that therapy has done its work, and that’s one way of looking at it. Others feel that it’s important to continue to work on the underlying vulnerabilities so that the problem is less likely to repeat itself. Here are a couple of cases that illustrate the situation of therapy that could be approaching completion, or could go on substantially longer.

An elementary school child who has developed some OCD type symptoms in response to various stresses is making good progress, and has become substantially freer of compulsive behaviors that used to complicate eating and bathing. He doesn’t especially like the idea of being in therapy, and he hopes that by checking off the list of ways in which he’s being compulsive, he’ll be able to stop. That’s alright by me; if the desire to be done with therapy provides the motivation to resolve his compulsive behaviors, then I can work with that. His mother, however, is concerned about his vulnerability to the stresses that he’ll encounter as he enters a new grade in school, and becomes a year older among his peers. She thinks he ought to use therapy to become socially more adept and personally more resilient. That makes sense to me, too, since his history demonstrates that he is vulnerable to developing OCD symptoms under stress. So he has a rationale for stopping soon, his mother has a rationale for continuing, and I can support both rationales.

Another client is a bright high school senior with a learning disability and family stress issues, both affecting his self-concept and self-esteem, which came to a head in a suicidal episode that brought him into therapy. In mainly individual therapy, with some family sessions, he’s worked on a number of difficult issues. He is doing much better, is no longer at substantial risk for suicidal behavior, and is on track to begin college this fall. However, his reactions to his learning issues and family stresses are still problematic, if no longer life-threatening, and significant gaps in his understand about himself and others make him vulnerable to getting into very stressful situations that he may have difficulty finding his way out of. These vulnerabilities put him at risk if some combination of stressors--such as he’s likely to encounter when he starts college--occur simultaneously and interact to become more intense. Again, there’s a rationale for stopping, and also for continuing.

When I’ve been on the receiving side of therapeutic conversation, it’s been pretty clear whether it’s helpful or not. If my therapist or consultant is trustworthy, listens carefully, and helps me to understand how I’ve been perceiving and reacting to various situations and how I could do better, that’s adding value to my life. When therapy or consultation is no longer making much difference in my quality of life, I can use my time and money in other ways.

Of course, therapy or consultation is an economic relationship, partly. Like any other service, it is selected and paid for because it is deemed to be of sufficient value, and ended when it’s value priority decreases relative to other priorities. This holds true whether the payor is the client, an insurance company, a not-for-profit agency, or the government.

Another client is an adult with a pervasive developmental disorder who came into therapy with a serious depression. On a scale of 1 to 10, where 1 is totally depressed and 10 totally happy, he rated himself a 2 or a 3. Several months later, he rates himself a 5 or 6. He’s dealt with some issues and his social life has improved. He still has issues, and could usefully work on them, but he’s also lost his job. His mother is supporting his therapy but anticipates a time when she may have to support his basic living expenses. Is therapy done or should it continue?

One thing that therapy should not do is cultivate dependency. The therapeutic dyad should be engaged around issues of importance in the client’s life, in ways that sustain and enrich her life, in a way that a careful observer, who can take the time to learn the details of the client’s life and needs, and to see how her therapy is working, ought to be able to recognize. There should always be that imaginary “third person” in the therapy room, someone who only has the client’s best interests at heart and in mind, who will know whether this particular therapeutic experience is adding value to the client. Maybe we can call her the Therapy Angel.

So, the response to Susan C’s question is, “What would the Therapy Angel say?” Clear-eyed and loving-hearted, she’d (or he’d, EOE) know when therapy’s done. And would know that “done” means different things for different people. For one person, “done” means the presenting acute symptoms have abated. For another, “done” means, beyond resolving acute symptoms, that the client has become a wiser and more resilient person. For another, “done” means that the client has benefitted more or less as much as possible from this particular therapeutic dyad. For another, “done” means that therapy, as an economic priority, has decreased compared with other economic priorities.

One last word about economics, though. I’ve found that therapy can often help people economically, either by helping them to maintain employment or earning power that otherwise might be compromised by psychological stress and dysfunction, or by helping them to recognize and take advantage of new opportunities in life--including business or professional life--and partnering. As one of my teachers used to say, “When therapy is working, it is very good value!”

Canned Training

An executive coaching client asked my opinion on a certain brand of management training seminars. I replied:

I'm not familiar with these particular seminars. My attitude about canned training is that, in general, most of it doesn't apply to specific needs, but if you take an idea or two away from a seminar that you can plug into your work back at the ranch, that's probably pretty good. There can be a problem with being told to work in ways that actually won't work in your particular organizational milieu, market niche, or for your personality. So there's a sorting out responsibility that one has to do for oneself. Looking at the seminar descriptions, I found myself put off by what seem to me to be hyperbole in the titles and short descriptions, but then I became more interested when I looked into the details. I'm generally wary of hyperbole, and wonder how much of that will get into the presentations themselves, as a kind of hypnotic suggestion or propaganda wavelength. It's possible to leave training seminars feeling like one has been handed a jewel, but then find, afterward, that one's hand is really empty after all!

So, the bottom line is, yes, do go, bringing both your notebook and your skepticism with you, and be prepared to have to work, after the seminar is over, at sorting out what was potentially valuable from what wasn't. I'll look forward to hearing about it, and maybe that's where I'll be able to provide some value for you, in the sorting out process.

Stenhouse on Curriculum

As the new school year begins, I picked up my old copy of "An Introduction to Curriculum Research and Development," by the Scottish educational thinker and teacher Lawrence Stenhouse (1975), and found some good old thoughts about curriculum.

Stenhouse saw curriculum as both what a school (or teacher) intends to do, and what it actually does.  He takes it as given that there will always be a gap between intent and delivery, so understanding a given curriculum requires awareness of both what we're setting out to do and what we're actually doing. He thought teachers should be studying this, both on their own and together. 

Stenhouse saw curriculum as composed of three broad domains:
-- content (information to be learned, which you can pre-specify and test with a multiple choice test),
--skills (recognizing letters and words, writing a three-paragraph essay, solving mathematical problems, which you can also pre-specify),
--knowledge (using what you've learned to solve problems or meet challenges in some unexpected way that can't be fully prespecified; an essay question at it's best, a scientific, artistic or community project).

He thought that educational thinking and theory often fell short by confusing content and skills, which can be prespecified, with knowledge, which cannot. He saw the teacher as being at the center of education, contrary to the trend to see teachers as deliverers of pre-packaged curricula.

35 years after his "Introduction to Curriculum Research and Development," Stenhouse's thinking holds up very well indeed. The only substantial addition that I'd suggest is about the way teaching methods relate to the more recent knowledge about learning and the brain; for example, strategies designed to engage the left and right hemisphere, frontal lobes and attention, and the domain of social-emotional learning (individual and group strategies, etc.).

In these times, when education is so often about making sure that children can simply read and define words, do math, or pass pre-specified tests at such and such a level, Stenhouse can help us to remember that there are domains of education that connect with potentialities of human nature that lie far beyond these meager models of what learning and knowledge are about.