Tuesday, October 20, 2009

Small talk therapy

OLJ in the last post mentioned that at times she seems to engage in small talk in therapy that can last up to 20 minutes. This I found interesting as I, as a therapist, can also spend the first period of time in a session in apparent small talk. It got me thinking about why I do that, or what am I doing in the small talk that is going to end up being of benefit to the client.

Whilst I am engaging in small talk with a client, there is a lot of ‘other’ talk going on inside my head. In this way it is quite different when I do small talk in a normal social situation where there is not the same cognitive calculations going on inside my head.

Upon reflection, I think I use small talk therapy in a variety of ways. As OLJ says sometimes the small talk can lead to ‘hard’ talk. I would say that at times I am doing the same in small talk. It buys me time where I can assess the client’s current mood and allows me time to plan a strategy to follow for that session. As they talk I am constantly looking for a therapeutic angle where I can make a small switch of direction or make a connection they may not be aware of to their life script. Once done then the small talk becomes hard talk and sometimes clients will say things like, “How did we end up here”, or “I didn’t expect to be doing this today”.

It is also a good opportunity to give positive strokes to the client which builds the relational and then that can always lead into work on the client’s stroke filter. It is also a time where I might slip in some self disclosure which again helps build the relational with the client.

As I think about it, it is also a good way to take a psychological history from the client and do cross checking at the same time. I have always said that there are certain similarities between a therapist interview of a client and the police interview of a suspect. They seek some of the same goals but for different motives.

Positive strokes? These three women seem to have

a distinct dislike for each other

I worry myself at times how I never believe anything anyone tells me anymore, at least with client’s that is. Now don’t take that the wrong way. I am not saying that client’s are a group of pathological liars, but having been in the therapy business for 30 years I know how well people lie to themselves regularly. If they are lying to self about some thing and I ask a question then they are going to lie to me about it. In addition, at times I am asking people very personal questions and they may choose not to be fully candid in their answer with me at that juncture. There is nothing wrong with that and if I was in their shoes I would probably do the same.

In police interviews they can ask suspects the same question three times in three different ways. When doing small talk at times I am doing the same. Not to catch them out but to be able to identify incongruencies and bring them to the client’s attention.

Therapist: Did you go out on the weekend?

Client: Yes we went to a restaurant called ‘x’.

T: I know that one, they have great fish there

C: Oh do they, for my meal I had.....

I am now going to get all sorts of information about this persons eating. In my initial history taking with the client I may have asked about their diet and eating. I am just about to find out how consistent or inconsistent that information was. The client may be quite skinny and report eating a high fat meal or they may be over weight and report ordering just a salad. This is the other kind of information I may pick up.

Therapist: Were you there with family?

Client: Yes, my mother and sister......

I am now going to get all sorts of information about the client’s family dynamics and will be able to compare it with previous information the client has given me. I am also going to get lots of information about their social life which is important in any mental status examination.

I definitely use small talk for such psychological history taking and to cross check information.

Sometimes I just forget stuff about the client and small talk allows me to remember it without the client realising I had forgotten. I am sitting looking at a client and I can’t remember if her mother is dead or alive, if she has a father or brothers and sisters so I might say, “Have you caught up with any family lately?”. As I get a little bit of information a whole heap of information can comes rushing back as I recall it. Its like I just need that little prompt and then I remember lots of stuff about the client. So in this sense small talk therapy is like me reading my notes on the client that I should have done more diligently before they arrived

Well there you have it! I just discovered that I know all this stuff that I never knew I knew. Thanks OLJ.


Monday, October 19, 2009

Elective mutism and the non-talker

Been working with a guy for the past 6 weeks. He is a non-talker. I never know which is worse, the client who has verbal diarrhoea where you can’t get a word in, to the other client who says hardly nothing.

I like this guy. He has virtually no sense of self worth. I mean unusually so and self deprecating to the same degree as well. Presentation is depression and some history of suicidal ideation.

His natural temperament response to stress is flight - as in fight, flight or freeze. He has a GAF response to a degree that I have not seen before. GAF comes from the life positions and stands for “Get away from”. It means that he will have a tendency to get away from others in his life script and thus he is likely to end up alone or with very few social contacts.

In this instance there is actually no problem with this. He enjoys his own company and can spend long periods of time by himself in the country, which he does. That is not the problem. The problem is that he does not tell anyone anything about what he is thinking and feeling. He never has for as long as he can remember. When ever he has a distressing thought or feeling he withdraws and says nothing to anyone. The technical diagnosis for this is elective mutism.

This worked fine at first except that humans cannot keep doing that for too long and eventually they collapse in on self. They will start to either hit the alcohol, drugs, prescription medication, get depressed, develop anxiety and so forth. The Child ego state simply needs the human contact and communication when it is distressed about something. If it does not get it over an extended period of time it has a ‘nervous breakdown’ as they used to call it.

Human communication. Some try to live without

it for long periods but it never works in the long run

The problem for him (and thus me) is that it is completely and absolutely antithetical for him to talk to anyone about his inner thoughts and feelings. But he comes to see me for precisely that goal, to talk about his inner world and hence he ends up as a non-talker (sort of).

The first sessions were difficult because he said so little and there were often prolonged silences. I thought that he would simply decide that it was all too much and I would not see him again. However at the end of each appointment he has initiated the request for another appointment and there has been another change in the last few sessions.

For the first 45 minutes he is his usual muted self. Then as I am thinking of winding things up (a little early) he starts to talk and even initiate conversation. In the last few sessions he has even gone over time (and I have allowed it). I don’t think it is a game about getting more time but he is starting to not want the conversation to stop. And indeed that is what we are doing. We have done very little therapy in the usual sense of the word. We basically just have a conversation. Mostly about him and his life but we are by no means doing the usual therapy things like setting contracts and so forth.

Some seem to feel like they just don’t fit

in with the rest of the human race


Thursday, October 15, 2009

Is suicide an angry act? (editted)

Some time ago I would answered yes, this was the case but I have tended to change my views over time or perhaps refine them over time.

There is a view that the more a person has difficulty expressing aggression or anger then the likelihood of suicide increases as the anger gets turned in on self. In support of this such research is quoted

Horesh et al (1997)

“Anger correlated significantly with suicide risk. Higher anger contributed synergistically to the suicide risk.”

DiGiuseppe et al(2007)

“Increasing evidence indicates that aggressive behaviour may be related to suicidal ideation and attempts. Many adolescents report intense anger immediately prior to their suicidal gestures. In one study, a third of adolescents who completed suicide displayed anger as their predominant mood just prior to their deaths.”

“Prior to suicide attempts adolescents may engage in intense verbal attacks or display physical aggression towards objects or people”

DiGiuseppe et al(2007) also conclude that anger inward turned has a higher correlation to hopelessness in suicidal adolescents than anger outward turned. However the outward turned is also correlated as well.

One firstly needs to identify the possibilities with anger

It seems reasonable to concur with the research. If a person has made the suicidal decision (“Don’t exist”) and they have high levels anger then they could be assessed as being at a higher risk of making some suicide action.

This would seem to be particularly so if the anger tends to be inward turned rather than expressed outwards as is shown in the diagram but I would also concur with the last conclusion of the research that there is also a correlation with outward turned anger as well.

When one sees a client who has inward turned anger one of the treatment directions is to get them to identify a thing or person to whom they could also direct some of the anger. The anger starts to be directed at something outside the person and thus one would assume that less of it is directed at the individual them self. This is a typical scenario in the treatment of depressed people.

However whilst the correlation was higher with inward directed anger there still was a correlation with outward directed anger. Getting the anger outward directed is better but still not the full solution. Why would this be so?

I have said before that psychologically there is some similarity between the murderer and the suicidal as well as some psychological similarity between the self harming person and the person who harms others. Some seem to find this hard to understand and take it as me saying that self harmers are in some way bad people for this. I am not saying such a thing and I have sought to find a metaphor that may make it clearer. I am not too sure if I have achieved this but I will give it a go anyway.

If I capable of speaking german then I can insult and verbally abuse others in that language. Or I can choose to insult and verbally abuse myself in german. If I have no mastery of the german language I do not have the choice. I cannot verbally abuse others in german and I can not insult myself in german. The self harmer and the “others” harmer both have mastery of the same language. They have both decided that physical assault is a viable solution to a problem. The person who does not harm self or others does not speak the language so they are far less likely to do either.

Thus we get back to the diagram and the research. Anger directed at self could obviously be correlated to suicidal behaviour. However anger directed out at others could also be correlated (but less so) because they are still speaking the same language than the person who does not have such anger in the first place.

In the treatment of such a kind of depression, one would first want the inward turned anger to start being directed at an outward thing or person. Once done then one would be wanting the person to drop the anger and thus they start to loose mastery of that language entirely.

Whilst on the topic of anger and suicide one can make further assessment of suicide risk by enquiring about how a person would plan to kill self. The method chosen could be reflective of the degree of anger involved. The more destructive the method may indicate a higher degree of anger involved.

The less violent methods would be things like poisoning self, gassing self or perhaps drowning and even cutting self in a effective manner (ie not hacking away at self). The more violent methods would include shooting self in the head, throwing self under a train or jumping from a high building. However it seems that the penultimate expression of violence in the act of suicide would be self immolation. Without a doubt a very violent means of suicide and reflective of substantial angry feelings.

Thus it seems productive for a therapist to enquire about the method of suicide considered and if violent then one knows to further look into the level of anger felt by the client and how they deal with such feelings.

One also needs to consider temper tantrum type of anger. If one sees a young child have a temper tantrum one would notice how they lash out in an indiscriminate way. Temper tantrum anger is completely directionless anger. The child is enraged and expresses that rage by lashing out at anyone including itself.

What is meant to happen in normal child development is slowly the child learns about its anger and learns to recognise the stimuli for the anger and then its anger expression is focussed at the identified cause. Some however never master this psychological task of child development and thus you get some adults who have the temper tantrum type expression of anger where its expression is indiscriminate. Hence you can have some suicidal type of behaviours when the tantrum anger gets directed at self.

In my view this can explain the situation where a 19 year old man goes into a school, starts shooting at people indiscriminately and eventually suicides at the end of it all. A temper tantrum type expression of anger.

If a client presents as having made a suicide attempt that seems to be anger related it would be instructive to question as to the context of that attempt. Namely, around the time of the attempt did the client display other indiscriminate anger expression. If he did then one may be dealing with an individual who has a temper tantrum type of anger expression and the suicidal behaviour is a consequence of that.

I am reminded of one person who almost completed a suicide in these circumstances. When I was working in a prison there was one inmate who had a phone call with his girlfriend where she dumped him and told him the relationship was finished. His response to this in the space of about 30 seconds was to smash the phone, slit his throat with a razor blade which he obviously had on him at the time and throw himself head first off a 4 meter high landing onto a concrete floor. The medical reports showed that he very nearly died, but he did survive. Indeed after that the other inmates referred to him as “Black magic” because he was black and it was magic that he did not die.

One could say that this suicide attempt was an angry act, but technically this is not correct. I got to know this man very well as that was my job in the prison, to identify and manage suicidal and self harming inmates. This man had not made the suicidal decision in childhood, he did not have a Don’t exist injunction.

What had happened was he was abandoned by his girlfriend to which he responded with rage. He then displayed that rage in a temper tantrum type of way. He damaged property (the phone) and then attacked himself (fortunately there was no one standing nearby or they may have been attacked as well).

His goal was not to kill himself, so technically it was not a suicide attempt, he was simply enraged and he expressed that anger in a temper tantrum where at one point he attacked him self. In such instances one gets the unplanned and spontaneous type of suicide attempts and thus many of them are not completed. In this case his anger was very reactive anger.

One can have other temper tantrum type of anger that is not reactive anger but is based on character anger. Thus an event does not happen that sparks the tantrum like anger but the person has character anger deep inside that pervades over time. In these circumstances one can get well planned suicidal and murderous acts. An example of this could be Martin Bryant.

He was an Australian in his early 20s. At one point he took a number of guns and considerable ammunition to a home where he shot dead two people he knew. After that he left and went to a popular tourist resort and randomly shot dead another 33 people. Any person, man woman or child who got in his sights he shot dead. At the sentencing the judge stated in part:

“The prisoner, having had a murderous plan in contemplation and active

preparation for some time, deliberately killed two persons against whom he held a

grudge, and then embarked on a trail of devastation which took the lives of a

further 33 other human beings who were total strangers to him and which caused

serious injury, distress and grief to literally thousands more. The repercussions

of these crimes have been world-wide. His selection of victims was

indiscriminate. He killed and injured men, women and even children”. (end quote)

After he killed the people at the tourist resort he left and went to a house where he set him self on fire in an attempt to kill himself. He survived the attempt and remains alive today.

Thus we have temper tantrum type behaviour. The indiscriminate killing of others and eventually the attempt to kill self. We have an instance of firstly controlled and thought out anger directed at a distinct target and then indiscriminate directionless anger expression.

Even in murder children will display a child like quality.

As another example

The Boomtown Rats were at a US radio station for an interview when the story

of Brenda Spencer came over the news wire. A 16 year old California high

school student made headlines when she grabbed her father's gun and opened fire

on her school from a house across the street, injuring eight students and killing

the school's principal and custodian. When later asked why she'd gone on the

shooting spree, she responded "I don't like Mondays."

I Don't Like Mondays

by the Boomtown Rats

“The silicon chip inside her head

Gets switched to overload.

And nobody's gonna go to school today,

She's going to make them stay at home.

And daddy doesn't understand it,

He always said she was as good as gold.

And he can see no reason

'Cause there are no reasons

What reason do you need to be shown?

Tell me why?

I don't like Mondays”.

Hence we have apparently unexplainable behaviour which mystifies many. The temper tantrum explanation may give some insight into why such things do occur.


Saturday, October 3, 2009

Working with the indecisive client.

At times clients present with the difficulty of not being able to make a decision about something. Life has offered them a fork in the road and they cannot decide which path to take. It may be to leave a job or stay, to move to another state or not, what course of study to take and so forth.

Of course the problem is not the actual decision but the psychological forces at work in the decision making process. In a decision about whether to do A or B there are actually three solutions.

1. Decide to do A

2. Decide to do B

3. Stay undecided or as it is called in psychotherapy - to stay stuck.

This child has made a decision why can’t some adults

Sometimes people can’t take solution 3 for very long because the circumstances mean a decision has to be made. For instance a new job is offered to you and you are given a month to decide. In this case one can make a decision by not making a decision. If the person remains undecided then they don’t take the new job. The decision is forced upon them and they don’t actually make any decision. Sometimes people can take solution 3 for many years such as in deciding to leave a marriage, or deciding to look for a new job or not.

So why would a person choose solution three? There could be a number of reasons.

They may have what is called a “stuck racket”. The person remains stuck or undecided and then agonises over and over about it. Here they are getting plenty of psychological strokes which we all need and it will also be proving to them some life script decision they made as a child. That early decision could have been something like, “Life is never easy”. They then set about establishing a life that is hard work and one way to do that is by agonising over decisions. This client needs to change the early decision and get their strokes in other ways.

Some people have what is called an “Always’ life script. This person was told by their parents - “Now you have made your bed you have to lie in it”. Once you have made a decision you have to live with it forever. As you can imagine this person will be very cautious about making big decisions because they have the view that they can’t change their mind later on. Which of course is a nonsense. This client needs the permission that it is OK to change their mind later on which of course one usually can.

There are times however when the decision is a one off and one cannot change their mind later, such as with a one time job offer. This raises another possible feature of the indecisive person. They think - “What if I make the wrong decision and regret it for the rest of my days”. I have always found this an odd sort of thought. This person needs to live in the Here & Now as the diagram shows. This person lives too much in the past rather than the Here & Now.

If I look back at my life in hindsight I can see that I made some bad decisions along the way but isn’t that the tapestry of life? What would my life be like if I had always made the right decision? However this is still missing the point. If I made the decision to go path A and in hindsight it probably would have been better to go path B what does that matter. I am now on path A and that means there will be whole set of life events and circumstances that are going to come my way. I have never been one to see the glass half empty, or to see if the neighbour’s grass is greener. It is a change in focus from regretting the past to looking at what one has now and what the future holds.

Some are indecisive because they have lost touch with their Free Child ego state. The Free Child knows what is the right decision to make. Those who are so shut off from that aspect of their personality can end up indecisive because they don’t get a feeling of what is the right decision. With such clients I sometimes flip a coin.

They have worked out all the pros and cons for decision A and decision B and they weigh up fairly equal. So the person remains undecided. I set the scene. I get out a coin and say heads is decision A and tails is decision B. By this time the client is wide eyed and feeling “Holy s**t my life is based on the flip of a coin!”.

The coin is flipped and it comes up heads so decision A it is. At that point sometimes the client will respond in one of two ways.

1. “Damn I wanted it to be tails!”

2. “Phew that’s a relief”

We have found out what decision the Free Child wanted.

Finally we have the indecisive client who is a dependent personality and basically wants me to make the decision for them. Do I make it for them? Watch this space.