To recap, over the past couple of days I’ve written about how therapists can contribute to ineffective treatment. These factors include our bias toward thinking that our therapy is working and we’re doing it well, while attributing failure to patient motivation or recognising small changes as much more important than they are. In addition, we can be fearful of ‘pushing’ our clients into behaviours that increase their distress in the short-term (even when this helps them develop long-term changes), we can get fatigued because of workload so we don’t plan or can’t be flexible during sessions, and we can avoid the ‘hard’ parts of therapy especially behaviour change.
I’ve referred to Waller’s (2009) paper ‘Evidence-based treatment and therapist drift’ because it nicely summarises the factors and gives some illustrations from clinical practice. I thought it might be useful to look at some from my own experience in pain management. Remember that I change certain details to protect client and clinician confidentiality in any clinical examples!
Waller identifies what he calls ‘therapeutic rocks’ that we drift onto – how we can make patients worse. The last thing patients need is for therapists to exacerbate their problem while trying to help them make progress! Now I’m not clear from his paper whether these errors have been found from research, or his experience – but they’ve cropped up for me, so I’m sure they’ll have cropped up for someone else!
The errors he identifies are:
- failure to work Socratically
- being driven by our own unhelpful thinking patterns and emotions
- failing to stick with eliciting behaviour change
Socratic questioning aims to help the person move towards his or her own realisation about ‘truth’. The overall purpose is to challenge accuracy and completeness of thinking in a way that helps people evaluate the helpfulness or truth of their own assumptions and beliefs.
The tendency is to move from this approach to doing an ‘info-dump’, or ‘teaching’ – that is, giving information and expecting or hoping that hearing or seeing it will be enough for it to change beliefs. Deeper learning and real change to beliefs only happens when the person considers the meaning of new knowledge as it relates to existing knowledge.
Being driven by our own unhelpful thinking patterns and emotions
All of us have typical patterns of thinking, intermediate beliefs and core beliefs that influence our lives. One common belief among people who are motivated to work in the helping professions could be ‘I must relieve distress’, or ‘I must not increase distress’. Another is ‘I must know what to do all the time’ or ‘I must not admit that I don’t know what to do’. Beliefs like this can be activated when working with people who need to approach rather than avoid activities that increase their pain (and therefore distress), or when we are uncomfortable with experimenting to test an hypothesis. This can make it difficult for us to allow the patient to try something – and for it not to ‘work’ the way we want it to.
The tendency can be to avoid addressing the ‘hard’ part of therapy – the ‘action’ part – or to control every part of therapy so the patient doesn’t learn to become his or her own therapist. Sometimes it means we don’t follow up on home-based activities, or we ignore or avoid allowing the patient to experience ‘failure’.
Failing to stick with behaviour change
It’s easy to sit in an office or clinic and make plans, or talk about information in comparison with getting out into the ‘real’ world where so many factors are uncontrolled. It’s also really hard to develop a ‘real life’ activity in which behaviour is elicited rather than simply talking about it. And finally, it’s really hard to work with a person to get them ready to take the challenge and act on it themselves – no matter how hard we try to persuade, in the end the person is the only one to DO something.
Phyllis – a case example
Phyllis was referred for pain management because she had been having trouble getting out and about, especially going to the supermarket and doing her usual household tasks. She had intermittent abdominal pain secondary to bowel resection, and she described her pain as like having a fist clutch her ‘innards’ and squeeze, leaving her breathless and perspiring and wanting to go straight to bed. Her main coping strategy was long-acting morphine, with a short-acting morphine when she experienced the intermittent exacerbation.
The case formulation suggested that she might be having trouble (1) regulating her physiological arousal related to her (2) thoughts that she couldn’t cope with a pain flare-up in public which lead to her (3) using short-acting morphine to provide immediate pain relief and distress reduction.
Phyllis agree that she had trouble reducing her physiological arousal, and that she found it difficult to think about what happens when her pain increases. She could understand how her morphine use might be unhelpful in the long-term, but thought she couldn’t hope to cope with her pain without it.
The therapist worked with Phyllis to help her develop better self regulation skills to reduce her physiological arousal. She became effective at using relaxation, diaphragmatic breathing, and distraction. She worked on her thoughts and could identify and challenge her unhelpful thoughts. But she repeatedly failed to use her coping strategies to delay using her short-acting morphine for 10 minutes, which was part of her home learning.
The therapist initially challenged her about this, but Phyllis said she was having a lot of trouble with her mood, and didn’t feel up to the home learning task. She started to talk about what was troubling her in relation to her mood, and the therapist started to work with her mood and energy. The clinician thought that Phyllis had ‘enough on her plate’ and reduced the home learning challenge to simply practicing the relaxation training.
The next session, Phyllis had practiced her home learning but continued to say her mood was too low and that she didn’t feel she could cope with delaying the use of her prn morphine. The therapist again thought that Phyllis was ‘too vulnerable’ to cope with the challenge and continued with relaxation training and exploring the depression.
During supervision, the therapist discussed the situation, and argued that Phyllis simply couldn’t move on with the behavioural components while her mood was so fragile.
Clinician contribution to the problem: Two problems are evident with the clinicians behaviour. One is that by protecting the patient from experiencing the distress involved in persisting with delaying her prn morphine, the therapist is taking on the responsibility for the client’s ‘happiness’ – and for change. The other is that by failing to explore and challenge the belief the patient has that she ‘cannot cope’ with the home learning, the therapist is failing to help the patient learn that her predictions about her own abilities are not true.
Solutions: One thing to start with is to decide whether the person was really involved in the process of developing the formulation. It would be helpful to review the formulation with the person and check, using Socratic questioning, whether she can acknowledge that her anxiety is increased by experiencing changes in pain, and that by developing effective arousal reduction, that she can have a measure of control in an anxiety-provoking situation. At the same time, it would be important to revisit the link between her thoughts (which suggest she is catastrophising when she thinks about experiencing increased pain) and her ability to maintain control of her physiology. By doing this, the therapist can help the patient develop confidence in her ability to use coping skills during the period before she uses her morphine.
The therapist may not be aware of his own reluctance to elicit short term distress, in order to achieve durable long-term effects. This can happen because of his own thoughts that he ‘should not make people feel bad’, or that his therapy may not be accepted by his client, or the client may be unhappy with him. This thought should be worked through in supervision, and the therapist helped to review his own safety behaviour (ie to try to protect himself from negative appraisal by his patient during periods of increased but short term distress).
The responsibility for change lies with the patient. It’s the therapist’s job to review the good and not-so-good aspects of carrying out the home-based activity, and to help the person determine the goals and priorities of therapy. This usually means working through the formulation with the person, identifying the ‘next best step’ to directly address the areas that need to change. The long-term goals need to be kept in focus so that short-term distress can be tolerated.
Sorry about the long post – shorter one tomorrow! I hope this is helpful, and I’ll provide another example tomorrow to look at some of the other errors that we can make.
Glenn Waller (2009). Evidence-based treatment and therapist drift Behaviour Research and Therapy, 47 (2), 119-127 DOI: 10.1016/j.brat.2008.10.018