Introducing diagnosis 

 

I’ve been asked to write a book review of Lucy johnstone’s ‘introduction to clinical diagnosis’, so one the train on the way home from pink therapy’s annual conference, I read the book. This isn’t the review, but it will no doubt contain elements from the review (which I have yet to write…)

 

It’s a great book. A fast reader; it took me less than the two hour train journey home, and it’s accessible in that rather than make it one large tome that covers lots of angles, it is part of a series, which I am inclined to buy all of!

 

There were two things that struck me- one of which will be next week. I have never been a great lover of medication. I do absolutely recognise that for some people it is life-saving and they couldn’t function without it. But, and I speak as a person who has been through the mental health system (and therefore was heavily medicated at times), it can be a sticking plaster. As Lucy points out- we have no proof about how medication works and a quick read of a blog site such as mad in America will soon throw up discussions about big trials that falsify outcome data (which would otherwise have shown placebo to be as effective as the active drug). She also points out that a significant amount of people connected to writing the DSM are *also* connected to the big pharmaceutical companies.

 

So- I’m largely anti-drug. Perhaps that was inevitable; I’m a counsellor. But I think that to a large degree, people take pills (and sometimes more and more pills, often simply to chase the side effects of the original pill) and do not discover how to talk through things. I recognise that talking therapies (of whatever ilk) aren’t plausible for all people- there are exceptions everywhere. But for me there is a question about how to make that known to my clients. I would suspect that none of the clients for whom this would be a salient issue suspect that I am ‘anti-drug’, but I would like to be known as someone who believed in therapy rather than in drugs, but at the same time, would not like to be a person people felt they couldn’t come to if they WERE taking medication.

 

It is a delicate balance; how to hold true to my beliefs, give clients a space to talk about their own medication, and not scare off clients who DO want to take medication. If anyone has any solutions to managing this, I’d be happy to hear them!31

 

 

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Frames of reference, and forgetting yourself. 

It occurs to me recently that during sessions I am quite good at putting my own frame of reference aside and being with the client’s frame. But to some degree, because that frame isn’t ‘what I would feel in your position’ I forget that ‘what I would feel in your position’ is actually a valid point. I forget myself in the room. 

This leaves me, in session, trying very hard to ‘be with the client’, but it means I Struggle to recall afterwards. I think it was made much worse by the fact that my last supervisor* was often asking me things about what I thought my clients meant when they said or did X, and that never felt useful to me, because it had been through so many iterations (a client experienced a thing and communicated it – imperfectly – to me. I then experienced that imperfected communication and communicated it imperfectly to my supervisor. Who then experienced the imperfected communication about the experience of the imperfected communication of the original experience (lost yet?!) and on the basis of that, asked me a question about ‘why?’. And I didn’t know. I am not in the client’s head. And sometimes I might clarify about what something means but the imperfections remain. So for several months my supervision was less about encouraging me to stay with my client and more about encouraging me to dissect my client. Fred would never have done that, and I miss him a lot. Maybe next year if I get paid more, I might be able to go back. Let’s hope. 

That dissection, that ‘why’ I realise, means that often when a client occurs to me outside of a session, I’m looking at it from a critical frame of reference ‘well why DONT they do that?’ And it wasn’t until very recently when I was with a particular client that I caught myself stepping into that and stopped myself and thought to REALLY see it from their point of view, and considered the words they were saying and how those might map on to my experience, that I realised just why they might be doing a thing. Of course then, if I wish, I am able to gently check that out (go me with my ‘use of self’). Or not – it depends. 

*I did realise back in December that that supervisor was bad for me and stopped seeing her, but I have had tribulations finding a new one. I start seeing someone new Thursday- John. I have told him I need to be challenged to be a better therapist. I think he’s ok with that and I hope he can. 

when someone you love, loves someone who is dying

English: Moon

English: Moon (Photo credit: Wikipedia)

This is much more of a personal post for me, but it feels like an ok time to post it. You might have seen that my dad died recently. He died of cancer, a diagnosis he only knew not even five weeks before his death. I’ve had various interactions with people at all points that have made me think, and I wanted to share them, for anyone else out there. They’re not definitive- what hurt me might help someone else, and vice versa. If you have your own positive or negatives to add, please feel free to do so in the comments.

  • At diagnosis, don’t minimalise- don’t say ‘oh that’s the best kind of cancer (or other disease)’ or ‘that’s a really slow-growing cancer/disease- they should be fine’. Don’t assume that it is caught early. Cancer – even ‘types’ of cancer have such radical variation in them that a) unless you’re the oncologist involved in their care, you don’t *know* if it’s the best kind of cancer (the most virulent of breast cancers is an awful lot ‘worse’ than the ‘best’ kind of breast cancer) and b) your loved one may realise that it’s the ‘best kind’ of cancer, but right now they are assimilating the idea that someone they love HAS cancer. If they’ve just found out, they probably don’t know much more than ‘type’. Individual differences mean nothing right now- it’s ALL potentially bad.
  • If they find out it’s terminal, and tell you how long they have left (usually a ‘best-case scenario’), the textbook way NOT to respond is to say ‘but you always say that’ (yes- I’m still bitter). Also, don’t say ‘it might be much longer – you don’t know’. It might be, but in my case it was actually much shorter and when you are talking weeks when you thought you had years, I suspect that ‘a month’ longer isn’t much solace in the grand scheme of things
  • When someone tells you that they (or their loved one) has cancer, try and respond in a way that is relevant to them, rather than relevant to you- a lot of people said ‘I’m so sorry’ to me, and I was fine with that. But personally, the most helpful responses were ‘cancer is a b*stard’. It let me be angry momentarily, rather than forcing me to sadness. If the person tells you and you don’t know how to respond, DONT IGNORE IT, even if you think they want that- at the very least check out ‘would you rather not talk about this’- it is easy to misinterpret, especially if your loved one is in a state of grief.
  • On that note, don’t assume that the person telling you is sad. I was, but I also had a *really* complex relationship with my dad, and actually, I was grieving a lot more than just the incoming physical death of my dad. I was grieving my childhood, the inability to be able to repair some of the things (because when someone won’t acknowledge that they don’t have long, you may not want to risk alienating them)
  • If you want to help, offer specific help. Don’t be ‘there for you if you need it’, but BE THERE for them. Send a random text message every few days- don’t expect a response, but be mundane, make the connection. Remind people that you are there, because they probably feel quite alone. If you want to make them a meal say ‘I was thinking of making a lasagne tonight and wondered if you fancied a night off cooking- I make an amazing lasagne and would love to drop one round’. Offer a low-key visit; whatever feels appropriate.
  • It’s hard to know what to say. It is. I’ve been on the other side also. And say that, but don’t *just* say that- that lays the responsibility on the person dealing with this. ‘I don’t know what to say, but I wanted to let you know I was thinking of you’ or ‘I don’t know what to say, so I made you a cheesecake’ are probably appreciated (especially if they like cheesecake. No-one made me a cheesecake, sadly)
  • When death happens, or at any point in the process to be fair, if the person you love doesn’t have religion, DONT DO RELIGION ON THEM. If it is important to you to pray for them, or light a candle for them, do it. If it’s important for you that they *know* you’re doing this, ask who you’re trying to help. If they have never mentioned religion or are anti-religion, making statements about where you think their loved one might have gone (heaven, etc), it has the potential to be insulting and inappropriate, not to mention potentially alienating, and the last thing that person probably needs right now is to lose someone else from their lives.
  • The funeral may take some time. Don’t assume it will all be over fast. It just isn’t always. Your loved one may also feel in a state of stasis at least until the funeral happens. Grief is complex.

Being on this side of the fence has taught me a lot about how I respond to death (or cancer) in other people. It has shown me some of the things I did wrong when a friend was diagnosed with cancer (some of the points above are based on things I’ve said too) and it has also underlined some of the things I did right. Maybe they will help someone else. The relevance for us as trainees is to remember that death probably isn’t that simple, and even a seemingly simple statement about a diagnosis *probably* isn’t that simple. I will forever be grateful for my therapist’s reaction when i told her- immediate compassion and recognition that it just wasn’t that simple.

what makes a good supervisor?

There’s been some discussion recently on the facebook trainee group about what makes a good supervisor, andI realised that I’d never really posted about my supervisor experience.

 

I’ve had two supervisors and am on a hunt for my third. My first supervisor, Fred, was great. I’ve spoken about him here. I felt challenged by him, with regard to my practice; my way of working; my way of being. He was able to use person-centered theory to challenge me. Usually I would take a ‘thing’ I was concerned about, and we would discuss whether it was person-centered, what my motivation behind the ‘thing’ was, whether THAT was person-centered. I enjoyed working with Fred very much. We had a big problem back last summer where we seemed blocked over an issue (and I felt like I was being chastised for something I couldn’t help), but after 3 weeks I eventually spoke to him and it turned out that he had been doing his own thinking and realised that he needed to let me be on that front; that my way of working wasn’t ethically or theoretically wrong, it was just different.

 

Unfortunately, Fred was too expensive for me to maintain, and he is also based in an awkward location, so I had to stop seeing him. I began to see a new supervisor. I did not feel challenged. I never really heard the words ‘person-centered’ come up, but I DID learn a lot about that supervisor’s previous places of work and what they thought of those. The one time I asked for direct support on an issue my only response was ‘what do you think you should do?’ and when I tried to talk through it ‘You should do what feels best’. Well; yes. I’m aware of that. However, I’ve been doing this a year only and would appreciate some support. So I’m now looking for a new supervisor. So far I’ve had one disastrous interview with someone that felt actively dangerous, and another one coming up this week (fingers crossed).

 

A good supervisor:

 

  • Will set good boundaries, in advance, so you know when you can call, or text, and what (if anything) payment for that extra contact will be.
  • Will hear the problems you need to raise
  • Will challenge you – to a level that you are happy with, or will be open to discussion about being more, or less challenging. The challenging will be aimed at making a better therapist out of you, rather than browbeating you.
  • Will be able to engage with you on a theoretical basis – there is no point picking a modality-specific supervisor if your supervisor isn’t working within that modality, especially as a student, when we are learning how to work within our modalities.
  • Will be talking to you about how YOU feel in your sessions, not about how your client might feel (or worse, how your client’s (for example) non-present partner might feel) – there is little to be gained in asking you to infer what someone might be inferring about someone else, especially when there ISN’T follow up about you in that session.
  • Won’t spend much time talking about their other work. Both Fred and my second supervisor talked about other places they had experience. The difference for me was that Fred seemed to be using it to illustrate his point to support me, and my second supervisor was using it to illustrate her (mostly) frustrations about certain environments.
  • Will be open to challenge. It was hard for me to bring my issue up with Fred. It took weeks. That’s mostly about me, not him. But I did feel I could. I didn’t feel like I would gain anything from bringing it up with my second supervisor, so I just left.
  • Will be open to learning new things. It’s possible that your client group or relevant life experiences won’t immediately be familiar to your supervisor. That’s fine – we all have clients who have something outside of our own experience. But your supervisor shouldn’t be relying on your to teach them about those things. They should be prepared to learn for themselves, although they might also ask you for good recommendations – websites, books, etc.
  • Finally, hopefully your supervisor would be on the same kind of academic level that you are – I have seen form fellow students that it can be helpful to get a supervisor’s opinion on academic work (especially where it involves things that were talked about in supervision), so if your supervisor is able to work at the same level, that can be enlightening. It’s not always necessary; I’ve never asked a supervisor for that feedback (and Fred had previously taught on a university counselling degree), but if it’s important to you – ask.

What other things would people add?