I have started to compile a list of common things that people present in their therapy and coaching sessions. I’ll add more to this list as I think of further things.

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What types of things can be addressed and resolved at Nottingham Therapy?

If you would like to read a little more about issues within those categories, click on the topics (currently just a few are click-able, and they are shown written in green, but more wil be written and hyperlinked over time).

see also

• Reasons to have therapy (word map)
• Which Therapy?

Anxieties

• General anxiety (GAD)
• Obsessions or Compulsions
• Anxieties about health, wellbeing or safety
• Post trauma
• Discomfort in social situations (or ruminations afterwards) - or Social phobia
• Panic attacks
• Specific phobia (e.g. fear of cats)
• Fear of flying
• Fear of public speaking

Symptoms

• Blushing or sweating
• Sleep problems
• Shaking or Palpitations
• Headaches
• Feeling dizzy, or ‘charged up’
• Mind constantly whirring, or constant chatter in head
• Weeping / tearfulness
• Lethargy/ fatigue
• Aches and Pains
• Gastro Intestinal disturbances, digestive problems

Depressions

• General
• Recurring
• Situational
• Life-stage
• Mood swings, or feeling up and down
• Background feeling of fed up or down
• Feeling numb, or ‘flat’

Behaviour

• Lack of motivation
• Bad or stuck habits
• Addictions (or being over-focussed on something)
• Doing risky or reckless things
• Having affairs or flirting inappropriately or compulsively
• Acting out anger
• Overeating
• Undereating
• Teeth Grinding or lip chomping or suckling
• Picking, scratching, or biting oneself (e.g. fingers)

Feelings

• Feeling lost, hurt, or betrayed
• Guilt
• Shame
• Anger
• Bereavement
• Frustration
• Deep sadness
• Feeling frightened, or scared

Relationships

• Infidelity
• Jealousy
• Abuse
• Miscommunication
• Lost spark
• Hostility
• Disrespectfulness
• Parenting issues
• Family problems
• Power dynamics
• Living arrangements

Self

• Understanding myself
• Being Defended
• Aggression
• Passivity or submissiveness
• Finding direction

Work

• Bullying
• Harassment
• Change management
• Stress
• Working relationships
• Understanding organisations
• Understanding others
• Good work ethic
• Time management
• Creating a compelling future
• Goal setting and achieving

Sometimes we all get a little illusionary in relationships.

In fact, in adolescence, its an absolute must-do. Not only because of the social norms, but also because it is a natural and healthy developmental phase to go through, usually throughout the teenage years.

If it happens when you are 35, 45, 0r 55, even, then clearly you aren’t passing through a phase of development, but rather have regressed back, for some reason or another.

Four examples of illusions in clients relationships

When Mr K  ’rediscovered’ the thrill of joining up with the football fans and going to all the away games and getting drunk for the whole day (something he had not done for 18 years)  he knew that it was related to the fact that his wife wanted a divorce (yet she would not go until the last of their children left home in 3 years time). Mr K was reasonably ok with what he was doing, considering it an ‘escape’ and harmless energy release (but discounting the sometimes dangerous atmosphere).

 

During couples therapy, Mrs J told me how she ’cheered up’ when she put on her Boyzone DVD’s every evening, while her husband was in their attic study on the Internet until midnight. Although, she said that she would much rather he come down and be with her. Yet when he did, they both felt uncomfortable and did not make any conversation.

 

D said that he just needed to sort out his depression. There was nothing wrong with his life, nothing wrong with his relationship, and certainly nothing wrong with his partner. She was the best thing that had ever happened to him. They were best friends, perfect lovers, and true soul-mates.  She was the perfect body shape, the perfect temperament for him, and was loved by ‘everyone’. All he wanted from therapy was to concentrate on getting his mood back up and ‘getting going’ again.

 

H wanted to cope with not seeing her partner very often. All the problems were due to his work, and the demands placed on him. H was super-reasonable about the circumstances of their living arrangement (i.e. he was just at home two days per week). She complained of her super-sensitivity, and disliked what she called ‘being weak’. Everything would be all right in her life and in her relationship if her partners workplace did not put so many obstacles in their way (i.e. it is the organisation that is the problem, not the relationship).

What do all of these stories have in common?

Positive Relationship Illusions.

There two types of illusions that I am referring to are

• I. Idolisation
• II. Idealisation

Idolisation

In the first one, Idolisation, we uncritically ‘love’ a figure or group from the world of music, entertainment or sport. Celebrities receive wide exposure in the mass media and are available to us via TV, events and concerts, films, etc.

Idolisation is based on two components

1. Worship
2. Modelling

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Worshipping is about intense admiration and involves behaviours such as repeatedly viewing or listening to them, collecting memorabilia, going to events.

Modelling refers to the desire to be like the idol, and involves attempts at trying to be like them, or taking on their values and beliefs.

The purpose of idolising is to shield us from hurt and fears (for example, isolation or lonliness). We withdraw from ‘real’ relationship and seek  to love and be loved by a completely dependable, constantly available object.

We create the idol and it provides both satisfaction and a sense of security.

Being a ‘fan’ offers a way to sublimate romantic and sexual yearnings.

Media stars are the obvious choice of idol because they are a ‘legitimate’ choice (its socially acceptable to be a fan) and because they media stars are always inaccessible (i.e. it is unlikely that a real romantic relationship will evolve and thereby spoil the fantasy of having a reciprocal relationship).

Idolisation is usually done with awareness.

Idealisation 

The process of idealisation, however, is usually not done in awareness. It is a subconscious process. Idealised qualities are projected onto the person or situation and even when we are confronted with faults or weaknesses we deny them. We are projecting what we most desire, and we are believing it is real.

Idealisation illusions can include:

1. Illusions of self-positivity
2. Optimism about the future
3. Exaggerated perceptions of control

 The purpose that idealising serves is to keep up our self-esteem in the face of threats. So, for example, we could believe someone (or our relationship with them) was perfect, i.e. avoid acknowledging flaws, and this would assist us in side-stepping the pain of disappointment. Or, in another example, we could be idealising a person or situation to avoiding becoming aware of disapproval from them, and denying the discomfort and unease.

They don’t call them defences for nothing

 Everyone is doing the best that they know how at any one time.

We sort things out when we are ready to.

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 If a situation or a stage of life is perceived as unsolvable, if  a person has to live with anxiety or stress for a fair amount of time, then it is understandable that defences will be used.

They can be quite handy at times.

Defences can enable us to: carry on, keep functioning, see things out.

 Using processes of idolisation and idealisation is normal in small degrees. For peace of mind and a relaxed psyche, though, we need to work through defences, and gradually take them down.

Solutions

 A possible therapeutic direction for using idealisation would be about acknowledging flaws and weaknesses gradually, at a pace that is the same as your ability to deal with them.

 For idolisation, look at what you are doing, and see the good in it. Use the idol as a model and, along with your therapist, integrate aspects of that person as appropriate.

Additionally, spin the projection around. Discover what the idol ‘gives back’ to you in your ‘relationship’ with them, or acknowledge what it is that you so selflessly give to them, and find an appropriate way to give that to yourself (or find a way to get it for yourself).

Sunday Western

Hill farmers in Wales on a project that really shows off their skills in a most amusing way

Take a look (approx 2 and a half minutes of video)

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The Registration Idea

The Health Professions council (HPC) is opening a register for psychotherapy and counselling, with a view for having it in place by about 2011.

Originally, the UKCP (United Kingdom Council for Psychotherapy) was keen on state registration. They believed that registration would distinguish practitioners with the right training and experience, from anyone who did not have it, and that distinction would help the public to select bonafide psychotherapists and give them reassurance that they were safe with an ethical and professional therapist.

Good idea!

Problems with the preparation of the register

But, in practice, as this program is evolving and various bodies have gotten involved, it seems that not only the UKCP, but also the organisations that train counsellors and psychotherapists, and the individual practitioners themselves, have a sense of disapointment and frustration, in place of the optimisim that was there before in respect of this register.

As is usual for a big project such as this one, huge complexity has to be dealt with. In practice, it has turned from a good idea of making a register of suitable professionals, into something that is defining, not only who is credible, but most importantly, who is effective. It is this last little word that is causing a lot of fuss.

In the process of creating this register, the problems are briefly as follows (and possibly not limited to this list)

1. Who should be on the register (depending on what model of therapy you use, which organisations you belong to, and other things)
2. What everyone on the register can be called (e.g. which titles count as valid and which do not).
3. What can be done about the Health Professions council having a code of practice that are not compatible with the values of a lot of psychotherapists
4. What is ‘good’ therapy? It has been decided to be defined by research. However, not all research is being counted as valid, therefore are all therapies being counted as valid therapies?

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Sticking Points

From what I have heard,  points 1 and 2 have now just about been resolved, or will be with discussions ongoing. For example, The term’psychotherapy’ is used to cover the full range of psychological interventions. Although there is much more detail of those debates here.

Point 3, it seems to me, has a chance of evolving into an adequate solution, provided that the stakeholders in this project continue to work together throughout the process of regulation, and long after regulation , in order to put forward information to shape the values that will underpin the code of practice criteria.

(The UKCP and a lot of other bodies are doing a lot of work and a lot of talking, and always have done since the idea began).

The big-one

Point 4 is the current hot topic (of contention). The fact that the validity of a therapeutic model, or approach, is defined by the type of research done.

It is the NICE guidelines that are defining acceptable research.  OK, after having a quick look at their website, you might think, “whats wrong with that? - It’s got the NHS logo in the top corner”. NICE, however, is an independent organisation and NICE guidance is developed by a number of independent advisory groups made up of health professionals, those working in the NHS, patients, their carers and the public. So, it isn’t the NHS and it isn’t the government.

The research that NICE (currently) says is the only one that can be counted is something called RCT, Randomised Controlled Trails. And the HPC (remember it is the HPC that is making this register) is taking the NICE guidelines about research as the ones to follow. Therefore, in effect, NICE guidelines restricts the validity of research into ‘measures of how and whether therapy works’ to one particular type of research, the RCT’s.

Apparently, there are a couple of things wrong with the idea that Randomised Control Trials can define the efficacy of therapy.

• Therapy is not a branch of medicine - it doesn’t focus exculsively on the relief of symptoms. The goal of therapy is an improvement in the quality of life, in particular areas that the client has presented to the therapist. This is achieved by creating and using the therapeutic relationship (possibly sprinkled with “how-to’s”, sometimes, if appropriate within the context of, and not contra to, the aims of the therapeutic experience).
• In an attempt to find the change-active ingredient of psychotherapy, using the drug trial model for testing is fraught with problems. If you are comparing people who have the benefit of psychotherapy against people who do not, then data is surely subjective and qualitative. Where does one start to gather this data, and how can it be measured accurately?
• The funding for RCTs (or a broader range of research methodologies) has never been in place for the full range of modalities so this is not a level playing field.

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And furthermore…

In addition to the RCT thing, there is another gripe coming from the psychotherapists - the way that the group of people put in charge of creating this register have been selected, and the way that they are doing things to allegedly service their own interests.

The groups are:

•  Increasing Access to Psychological Therapies (IAPT)
• Skills for Health
• Health Professions Council

These are all projects sponsored by the Department of Health and the complaints are around the ways that these bodies benefit from their interactions, and how transparent all of that is to stakeholders in the registration project.

 The UKCP (one of the stakeholders in the project) is concerned that NICE guidelines appear to negate all forms of psychological therapies other than CBT and interpersonal therapy. If you are intereted in this debate you can check out the document here.

 My Opinion

I agree with forging ahead to make the register, and I am one of the (probably) very few therapists that is still in favour of regulation.

Having trained as a trainer, a manager and team leader, myself, I am aware of how other individuals have to work within a set of national occupational standards and I don’t see why counselling and therapy should be an exception. Especially if, as I am, we are really concerned with protecting the public (and ultimately the intergrity of our profession and it’s standards).

I do believe that, both the scientific, and the artful nature of the service (counselling / psychotherapy) can be taken in to account when setting measurable standards - although of course this will take a lot of research and processing of data to come to such conclusions.

Things to consider when making an awareness of occupational standards would be at least these three points: 

1. We therapists do employ a series of actions that we call ‘therapeutic interventions’ and this is done within the context of a relationship (i.e. the relationship is analysed by the therapist, as well as the content and structure of the therapy sessions).
2. Each client does present unique issues and demands to the therapist, as indeed does each session.
3. The therapeutic field is a complex ecology built up of many different approaches.

And even though these points are in evidence I do still believe that standards can be set.

A helping hand for holding the discussions needed

The UKCP is setting up a new Psychotherapy Council (source: UKCP newsletter, April 2009).

And this will be a deliberative and advisory body to consider the contours/identity of the profession, the profession’s relationship with government, media, and other professions, and other external stakeholders.

Great!

My view is that we, in the UK, do need proper standards of process and outcome for the services of psychotherapy and counselling. 

• I believe that therapists may be very skilled and effective with some issues, and some types of clients, but not others.
• Additionally, I believe that some therapists are generally more skilled and effective than some other individual therapists, and I believe that this variation carries across, and includes therapists in all of the wide array of therapuetic models (Some therapists are trained in only one model).
• It is my belief that psychotherapists are responsible in terms of intending to offer an effective service that meets the needs of the individual client presented to them at any one time. However, this is judged by the therapist at that time. There is the added benefit of whether the therapist is being effective with this particular client, by client and supervisor looking at it in clinical supervision (if that therapist decides to present that particular case in supervision, that is).

Are clients really getting the best possible?

The therapuetic results that a prospective  individual client might expect is too hit-and-miss, for my liking.

• I do not think that consumers (the clients) of the psychological services (in prvate practice expecially) can possibly make an informed decision about which therapist to choose (i.e. they have no reliable way of measuring depth and quality and effectiveness of service offered, and so cannot make a proper informed choice about investing their money and time).
• I do not think that clients have an adequate way of measuring the effectiveness of their therapy (so that they can choose whether to stay in therapy, or stay with this particular therapist)

You know, in my private practice clients often say that they have selected me as their therapist because I “looked like I had a kind face” or they “liked my photo” or “I sounded like someone they could trust” - or they chose me because of location, or because they liked the website. 

All of these reasons are very flattering, and I am delighted to take on these clients, of course, but wouldn’t it be better if I were being selected because these people were able to analayse some data, and after doing so, realised I was a good therapist?

I also have many clients say that they chose me because of my qualifications, or through recomendation of a previous client of mine that they know was helped by me. That’s a start, but its not really good enough for clients, in my opinion. I would like them to be able to make a choice based on standards set that I have obviously met, and then have them tell me that they chose me because of that.

Easier reading on this topic…

If you would like to have a look at a couple of more readable articles on this topic, try this Times Newspaper article, and these guardian letters , and there is also this little piece from a medical news blog

Issues and problems that can be addressed and resolved with therapy at Nottingham Therapy

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