What Do Therapists Do?

I have been really pleased recently lots of people are having conversations regarding mental health, I mean, we talk about health in general all the time. We talk about obesity, cancer, sports injuries, bird flu, food poisoning etc, so while we are at it why not have a conversation about ‘mental’ health? There seems to be an acceptance that it is good to talk, that we should address the stigma and in doing so more people will have useful conversations about mental health which can only be positive, right?

I think it is probably more useful than not, but I am an evidence-based practitioner so only time will tell whether more conversations about mental health will lead to actual better mental health. What I am really interested in is how conversations about mental health lead to action, I find this aspect of the new dynamic endlessly fascinating.

When I first started practising as a student CBT therapist I had to constantly explain to people what CBT is, and what therapists do. I find that I am having that conversation less and less, because more people seem to have their own ideas about CBT and/or how therapy works/what therapists do. I have to say; a lot of what people think regarding therapy seems pretty bizarre to me. More worryingly is that they seem to have these ideas because they have either a) had one or two sessions of therapy or b) know someone who has had therapy. This is a topic which could probably be better explored in another post, what I want to concentrate on today is what I do as a therapist and how I hope the things I do will help someone who is seeking therapy.

I read a post recently on the excellent Respite Room website in which the writer was explaining that despite the fact they have gained an awareness of their mental health, despite the fact they now have resources, have developed coping strategies, despite the fact they can acknowledge the action they are taking and the knowledge they have gained, there are days in which they are physically and mentally challenged.“ I am doing all the right things and it’s still not enough, not always.” This description is something I am frequently aware of with clients, and the frustration this brings can become debilitating, adding to the existing pressures and challenges they are already facing.

As a therapist one of my jobs is to look at the process when clients are affected n this way. Each client is a unique individual, and a unique set of circumstances has brought them to therapy. When we are working towards the recovery phase of treatment and looking at relapse prevention, or if we are finding the initial stages of therapy challenging because progress isn’t being made at the pace the client desires, I am mindful of the process the client is engaging with. I am looking at several details, but I definitely want to know, “what expectations does the client have in relation to their capabilities?”

I will illustrate this with an example. *I haven’t used any specific details from a client I have worked with in the past, but I have drawn inspiration from different people I have worked with to come up with a plausible, illustrative scenario.

Michael (no reference to any real person) has been attending therapy for weeks. Michael is a year-old male who is affected by depression, anxiety, anger management and appears to have PTSD due to a sexual assault he survived when he was years old. The main reason Michal is attending therapy is his use of street diazepam which he has used for years to self-medicate. Michael has experienced sustained periods of abstinence but is frequently relapsing and would like help to enter sustained recovery. He has now been abstinent for 10 weeks but almost used yesterday.

When Michael attends the session, he explains that he is feeling very low, he struggled to get out of bed for the past two days, he is avoiding answering his phone, even to text people and has struggled to find the motivation to attend mutual aid meetings which had been providing support, “I don’t think I am ever going to get better!”. He reports he only came to the session today because his sister popped by to check on him and insisted on driving him to his session.

Where to begin? Although Michael may seem like a fairly extreme example, let’s look in general at his history. Michael experienced a traumatic event during his childhood. Traumatic events take many forms and are subjective, it may be that Michael has PTSD which has not yet been diagnosed, he may not, but it’s safe to assume that what Michael experiences as a child has affected his beliefs about himself, other people, and the world in which he exists. Michael has used diazepam to cope with his day to day experience, this may also seem extreme to people, but in general we all find diverse ways to cope with our existence. Some people work lots, some people never work. Some people paint, some people have lots of cats, come people have lots of children. We all find ways to exist, sometimes these coping mechanisms are healthy or helpful, sometimes they are not. Michael has recently been thinking that he is not experiencing the change he desires and has doubts that therapy will help. Who among us doesn’t have doubts sometimes? Michael also is no longer engaging with the things that seemed to be helping, which some may find confusing, but ask yourself then next time you are feeling tired or anxious, what are the things you do which give you joy, are you doing them?

On the surface Michael appears like an extreme example, but dig a little deeper and we find a person who:

  1. Has experiences from his past which were difficult to live through and reminders of which cause distress
  2. Has developed coping mechanisms which may be problematic
  3. Has thought patterns which appear to be unhelpful and irrational
  4. Is behaving in ways that at times are counter intuitive and appear designed to perpetuate his problems rather than provide solutions

Does this describe anyone you know?

I know this describes my experience, and certainly most of my clients or service users have tended to present along these lines. Therapy, in all it’s modalities, is designed to help tackle these very human traits. For example, if Michael was attending a psychodynamic therapist as opposed to a CBT practitioner, their goals for therapy would probably be designed to tackle this presentation, but they would probably be stated in different language. I would hope the goal of all therapy would be not only to help clients make whatever changes clients have identified, but to allow through the therapeutic process the client to come to the realisation that it’s okay for the client to be who they are. To be able to accept ourselves as human beings with frailties and nuances, to accept that some days we function better than others, and more importantly not only to have awareness that this happens, but to embrace this is part of our very human condition. In other words, to find what being ‘good enough’ is like. To embrace it, to accept what it means to be good enough, to differentiate between doing wonderful things for ourselves and others and true self care which lies in the development of a compassionate voice that tells me ‘you are good enough, even when you feel like utter shit!”

What do therapists do? I hope by using the various tools and techniques at our disposal we facilitate a process whereby clients achieve their goals for therapy, while at the same time learning to accept that it is okay to feel how we feel, even if that isn’t a very nice feeling, because it will pass, especially if we learn how to challenge and intervene while feeling comfort in our discomfort, peace in our conflict.

If you are interested in reading more about mental health, I highly recommend The Respite Room https://www.therespiteroom.com/blog/ where you will find diverse voices talking about mental health in a natural way, and they aren’t trying to sell you anything! They also organise a weekly walk in Glasgow and are starting an orchestra!

For the same reasons, I would recommend listening to the Mood Swings podcast http://moodswings365abz.libsyn.com/

And finally, if you want to geek out a  bit regarding mental health/psychology/psychiatry then you could do a lot worse than by listening to the BBC ‘All In The Mind’ radio show, or work through the archived episodes here https://www.bbc.co.uk/programmes/b006qxx9/episodes/player

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