Monday, April 30, 2018

Your 1st Therapy Session and Soon Thereafter - Part 3

A wooden model of the human figure in CologneFor the past few blogs we have discussed the article 7 Things You Should Know Before Your First Therapy Appointment. I am still reflecting on the article and spending a good deal of time writing about its content because I see the article’s value and the time it can save if it were read before going to therapy.  

This article’s third guideline focuses on progress and check in’s. During my internships and soon after becoming licensed I worked for Los Angeles County agencies who had Department of Mental Health contracts.  Due to Los Angeles County’s licensing requirements we were often mandated to have some time requirement on treatment that was measurable; such as, quarterly or monthly written treatment plans with measurable goals.  Such rigid and often well intended items of the treatment plan would look something like this: Elizabeth is to reduce risky behaviors of excessive alcohol drinking, casual sex...
and drug usage (limited list) from 5 x a week to 2 x a week by increasing healthy positive activities such as book clubs, volunteering at SPCA, yoga classes, and daily hikes throughout the week.  This would be measured for three months or six months. If achieved then it would be addressed accordingly.

Most agencies in LA County are evidenced based and CBT (cognitive behavioral therapy) in modalities. And they are short term meaning clients do not have 2 years to work on their self growth. So, with the complexities of these mental health agencies and LA County, my experience was that often the root of the problem was never addressed and a client can have the problems return later in life because the treatment is often “short termed” or Solution Focused. To add to the complexities my experience of having approximately 9 managers in 3 years at one agency (which is not uncommon) did  not support consistent monitoring of treatment goals as each manager had a style and expectation (or perhaps agenda) of reaching goals. Moreover, the concept of treatment using CBT and a Solution Focused type modality have been consistently proven valid and they work. However, evidence supports a combination of CBT or solution focus combined with psychodynamic or psychoanalytic work. Furthermore, my experience is that I have seen more success with my clients who have been with me long term. So, If the client can accept spending GOOD money for GOOD treatment then they might be talking weekly sessions for 18 months. This is a hard pill to swallow if you only think of money and are resistant to therapy (or if therapy has historically been distasteful in your history).

I was at the Southern California Counseling Center’s 2018 Gala Saturday evening.  I bring this up not because of the great things the agency does or because of the memorable event itself; but, because of success in treatment.  While at the event one of the powerful speakers mentioned a successful client who was initially mandated to attend treatment through the courts. For this writing the magic was the 52nd week where the client was able to validate the positive experience of treatment.

He had been in treatment long enough to acclimate into the process. So, if you invest in therapy, how do you know you are “doing better.” This is the hard part of counseling. Evidence based treatments try to measure improvement. I am not fully on board with this “better,” or “improvement” thinking.  The article encourages you to “ask your therapist what progress might look like, and how often you should check in to gauge that progress.” This is a completely appropriate question. The danger is having high measurable expectations. One session you might actually get or feel something significant. A click that makes everything appear clear or a trick to help you no longer go for the pizza at midnight.  But often therapy is a process. My role often is to have a client have consistency. This consistency means attending therapy during a two month period without having any significant epiphany. The beauty in this two month period is six months later seeing and hearing from the client that their life is altered and that a movement has occurred (sometimes as a result of that seemingly boring 2 month period).

As stated before, working with new clients is a delicate relationship.  And wanting expectations and results should be expected. This is why the connection and relationship is so important.  I think this idea of progress is a client by client issue. A weekly check-in about goals for one person might be exhasperating for one client but needed for another and therapeutically unhelpful for another.

As previously stated, results and "fixing a problem" will not take three sessions.  Therapy is a commitment that takes work and part of that commitment is checking-in and measuring movement.  I refrain from labeling self-growth with success.

Therefore, the question about progress is highly legitimate.  The unconscious mind sometimes plants distractors and sabotages the work of analysis/counseling.  If one feels there is no $200 payoff each week; or worse, if there is “no progress for 2 months” leaving therapy and feeling disheartened and that the therapeutic process was unhelpful is a realistic feeling.  In short, instant gratification might not always work in healing psychic and long term wounds. So, this is the conversation that could benefit the analyst and client. Not just check-in’s or progress but if the connection is met how do we know when therapy is to be terminated?  And with a culture surrounded with instant gratification, how do we build a relationship that changes the narrative of gratification or progress to Self-growth and movement?
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