Any correlation between expertise and length of experience ?

On 24 March, our discussion was based fairly loosely on ‘Expertise in Psychotherapy An Elusive Goal?’ by Tracy, Wampold, Lichtenberg and Goodyear. The paper largely supports the view that experience as a psychotherapist leads to increased confidence but does not lead to expertise.

The group found it problematic to define expertise or to accept the definition in the paper which discussed it in terms of reputation, performance or client outcomes. The paper seemed more concerned with measurements and techniques used in psychology than psychotherapy.We were particularly unhappy with the authors’ promotion of  a ‘ disconfirming stance’ which for some of us suggested experimenting  with a different approach to the one we believe to be efficacious in order to make a comparison.  Others of us felt that it might be understood to mean having a questioning attitude to our practice and a lack of assumption that we are already working in the optimal way.

We felt that if we have a body of knowledge to bring to our work, a recognition of our limitations, ever developing self awareness, good use of supervision, we were likely,over time, to develop something that might be called expertise. The discussion progressed to the more attractive goal of becoming a peer-reviewed  Master Practitioner  rather than an expert.

A frank conversation followed in which we admitted how difficult it is to tolerate the low status we are given in the eyes of other health professionals and some lay people. We noticed how hard it is for the quality of our work to be rated or for meaningful comparisons to be made between therapists . Consequently, much of our competence goes unrecognised. The depth and quality of the therapeutic relationships we make are impossible to measure. The private nature of therapy means that any skill we may possess is not seen. This invisibility can lead to attacks in the form of contempt or envy. Contempt from those who feel threatened by or ignorant of therapy and envy from those who resent us the privilege of holding  secrets .  We tend therefore to be generally under estimated ,given low status and only feel valued  by peers in the therapy world.

We bolstered ourselves by each focusing on what we perceive to be our strengths. Some members found it easier than others. We noted that the personal qualities which correlate positively  with a good outcome for clients  included a degree of self doubt, deliberate practice, an ability to form working alliances across a range of clients, a high level of facilitative skills, keenness and curiosity. Qualities all members of this group possess.

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Any correlation between expertise and length of experience ?

The ‘Fells & Dales’ group of counsellors in Cumbria/North Lancs met for our monthly meeting today, 9th December, and a new member was welcomed to the group.  We discussed two chapters in Sheldon Kopp’s book ‘If you meet the Buddha on the road, kill him!’

Sheldon Kopp wrote, ‘A grown-up can be no man’s disciple’, and ‘The most important things that each man must learn no one can teach him.’  Our discussions began with considering the extent to which we, as counsellors, have an ‘expertise’ to offer our clients.  We may claim to be non-directive, to have no agenda, to seek to empower the client rather than exerting any power of our own, and yet what is it that clients come to us for?  Are they not needing help and expecting a service, which we have been trained, qualified and experienced in providing?  How to we steer a middle course between counsellor over- and under-involvement? 

We agreed that there is a valid place for psycho-education, and that we are more than merely observers or witnesses of the client’s process, but in fact play an instrumental part in that process ourselves.  On the other hand, we want to disabuse clients of the myth that there’s an answer/solution ‘out there’ somewhere, waiting to be grasped  –  a fixed end-point, and that all will be well if only we can reach it.  Perhaps the best that we can offer is to accompany the client as closely as possible on their journey,  tolerating the ‘stuckness’ and the not-knowing, despite being made to feel useless and inadequate in the process, rather than trying to (mis)lead them to a non-existent destination.

Clinical Practice

We met in October to listen to and discuss two pieces of recorded client work.

The first piece prompted discussion about the effects of apparent knowingness or certainty in the therapist. While therapist confidence might reassure some clients, we saw how it could also block the client’s process. We were particularly interested in the extent to which mis-communications between client and therapist were exacerbated when the therapist is insufficiently tentative . This style in the therapist  seems  to intrude in the development of a mutually understandable language and increases the risk that each person attributes his own meanings. In the extreme , the client is lost and confused.

The second recording provoked a lively discussion about possible ways of responding to the erotic transference, in particular when a client falls in love with the therapist. The main question to emerge was ‘at what point should it be made  known that there can be no romantic future.’ One opinion is that this information should be held back to allow the client to express as much about the loving feelings as he would wish. This approach risks inflating the client’s unrealistic fantasy but allows full expression of the client’s experience. An alternative view was that it is kinder and clearer to make an early intervention to explain that there can be no romantic attachment but the therapist is respectfully interested in hearing more. This might stiffle the clients ability to say fully what he wanted to say, but has the merit of clarity. It seemed to hinge on the extent to which the therapist can convey a quiet steady openness to the subject and the extent to which client is able to continue to explore his feelings in the face of a felt rejection. We were acutely aware of the effort required by the therapist to manage her own powerful feelings in response to a declaration like this from the client.

Clinical Practice

Dare Psychotherapists Reinterpret a Mental Illness Diagnosis?

This month the group came having read a chapter from Isabel Clarke’s Psychosis and Spirituality, published by Wiley-Blackwell in 2010.

The chapter was entitled ‘Transformative Crisis ‘ written by Caroline Brett.

 

This theme came about from the recognition that clients who present with a diagnosis given by a psychiatrist, for example, can bring also the fear that they are  ill, and a reluctance to engage in ameliorative therapy for fear of the return of former symptoms.

We recognised that therapists are more familiar than some other mental health practitioners with comparisons of spiritual crisis or transforming experiences with those attributed to mental illnesses, and we wondered about the similarities with those who do not make a meaning of their experience in this way. The latter however, can be helped to think of their previous distress in different paradigms. We shared evidence from our own practices.

Familiarity with the ‘window of tolerance’ could invite awareness that hyper-arousal of the autonomic nervous system can be alarming but is in truth the human mind-body protecting that individual from intolerable stress.  Managing stress differently means that that arousal will not re-occur and medication may not be appropriate. Awareness of different ego-states and dissociative identity disorders, and the way in which dissociated ego states come into existence often, albeit mistakenly, to protect another part of that person, can become the insight that brings about the integration of those separate parts which have led to extravagant and diagnosable behaviours.

Some therapists in private practice, and this was true our group, can be a little nervous  because they are aware of the presence in the consulting room of ‘white coated’ mental health practitioners who have given their client a DSM category and treated them according to current NICE guidelines. Having the courage to explore alternative paradigms to make meaning of the client’s experience is what we do in therapy and such an approach anticipates what therapeutic experience has shown, namely that clients do reinterpret their experience given the constructs they need in order to do so and no longer think of themselves as mentally ill.

One of our number was fortunate enough to be offered supervision from members of a mental health team in a frontline psychiatric hospital. Encouragement was gratefully received when it was noted that the team concerned was asking the same questions about the meaning of mental illnesses. That team is using EMDR therapy with those formerly labelled psychotic and schizophrenic patients and indeed looking at the role of anti-psychotic drugs. The changes in perception encouraged by emerging neuro-biological research is evident. The challenge to all therapists must be therefore to try to keep up to date with that research. A significant challenge.

A useful reference work is that by Paul William Miller, EMDR Therapy for Schizophrenia and other psychoses, published in 2016 by Springer Publishing Company.

The value of supervisory processes taking place across the divide between private and institutional practice is recognised therefore within the group and should be promoted.

Dare Psychotherapists Reinterpret a Mental Illness Diagnosis?

Pluralistic Counselling

Pluralistic Counselling

Narcissism

The most recent meeting of Fells and Dales Counsellors explored Grandiose Narcissism as an adaptation in response to an early lack of empathy. Kohut’s Self Psychology Model was used as an initial stimulus to the debate.

It was noteworthy that people with narcissistic traits present for therapy relatively rarely. However, a good proportion of clients in therapy are the children of narcissists.

We used professional and personal experience to think and talk about the particular challenges of working with people who relate in this way. We recognised that we are best serving these clients when we can meet the vulnerable parts of the individual. These parts might have low self esteem or  feel shame and inadequacy , or be interpersonally isolated. The therapeutic challenge is to access this suffering through the thicket of a complex defence mechanism. When defences include a sense of entitlement, grandiosity or bravado, and an extreme sensitivity to criticism, the work is delicate.

Narcissism

ADULT TWIN RELATIONSHIPS

For our May meeting of Fells and Dales counsellors, we explored the relationship between twins, and in particular to what extent the twin bond is “special”. We read a research article by Tancredy and Fraley on ” The nature of Adult Twin relationships: an attachment-theoretical perspective” from  the Journal of Personality and Social Psychology,2006, vol.90,no1,78-93.

 The article defined the main characteristic of attachment relationships as comprising proximity seeking, separation distress, and the use of one another as a secure haven and safe base. Twins were then measured against non-twins to assess whether twins used each other as attachment figures rather than mother in the first instance and then siblings or other key figures.

 An interesting finding was that twins do not fully acknowledge the presence of their co-twin until the end of the separation-individuation process at around 36 months so until then are more focused on the mother to meet their needs. However, for identical twins who share the womb space, there can be ” an embodied sense of the other” which creates a lasting attachment greater than that between fraternal twins or non-twins.

 We then discussed the relevance of these findings for the therapeutic relationship and the extent of sibling rivalry between twins.

ADULT TWIN RELATIONSHIPS