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Wednesday, 26 December 2007
The contradiction of the treatment contract
Over a number of posts now I have written about some inherent flaws or contradictions in counseling. I once again find myself on the same theme and probably would have not know that if I had not been blogging. Its only because I can see what I have written over the past 6 months that I can see a pattern evolving here. I find myself in one of those situations where I know I am going somewhere but at the moment don’t know where that happens to be. Its like I am seeing small bits of a larger picture, but am yet to see the larger picture. However these smaller pictures do seem contrary to mainstream thinking on counseling that it certainly merits further consideration.
For example I have discussed the fact that as soon as one opens for business as a counselor automatically the client is hindered in making therapeutic gain or moving towards psychological health. There is a contradiction. As soon as I become a counselor I am saying to the client that there is hope for relief from your distress. I am selling the client hope which undoubtably is a most positive thing and at the very same time I am saying to the client, I agree that there is something wrong with you. Indeed there is something wrong with you to such an extent that it is necessary to go outside of yourself and get help from another person. By the very act of me being a counselor I am saying that. The only way I cannot say it is by not being a counselor in the first place. So in this way the clients pathology is supported even before they have entered the therapy room for the first time.
I have discussed the contradiction of pain in counseling. It seems safe to say that all therapies to some degree subject the client to pain. Sometimes that is physical pain but most often it is emotional pain. However as each and everyone of us knows emotional pain can really hurt. Therapeutic techniques are sometimes painful weather that be from getting on and then the pain of getting off methadone to remembering painful things from one’s past. Again we have a contradiction. The therapeutic technique has the goal of assisting the person out of their emotional problems and at the very same time it is physically or emotionally hurting the person. So again the client’s pathology is promoted by the counseling. If a parent hits a child because it ran across the road without looking what does that hit say to the child. First and foremost it erodes the self esteem.
I have discussed at some length the contradiction of the relational and the client being viewed as ill. Another contradiction. As soon as a client enters the counseling room it is highly likely that they view them self as being ‘ill’. That happens even before they get there for the first time and the counselor can do nothing to halt it. It is also likely if not very likely that the counselor will view the client as ‘ill’ to some extent as well. They have been trained to think like that for years, even before they qualified as a counselor. As we know as soon as the client and therapist define the client as ill then the relational is curtailed if not severely eroded. And it is the relational or the therapeutic relationship between the client and therapist that has repeatedly shown since Freud first started in the 1800s, to be most powerful force in assisting the client to change. So the most curative factor in psychotherapy is curtailed and eroded even before the client has entered the first session. A contradiction indeed.
Hence we arrive at the case against contracting. As soon as a counselor suggests or accepts a contract from the client they have made it more difficult for the client to achieve their goals. A contract is the stated goal of the counseling. Every counselor in some way gets the client to identify what is their problem and how they would like to be different. What they want to stop doing and what they want to start doing instead. In some form every counselor gets the client to do this. For example a client may state that they want to stop putting self down and start being assertive. Or the client may say that they want to stop hiding their feelings from mother to protect her and start showing their anger and displeasure to her.
Powerful imagery
The contradiction of contracting with a client? On the one hand one gains a sense of direction in the counseling and has a focus of where to head. It also creates a battlefield or a war zone in the client’s mind. The two combatants are clearly identified and this is deleterious to the client. As a counselor one thing you do not want to happen is for a war zone mentality to arise in the counseling sessions. As an example take the client who presents in counseling and states they have panic attacks. The two combatants are first the state of panic and second the state of relaxation or calmness.
Why is a war zone mentality counter productive in counseling? The war becomes an entity in itself. In people’s minds the winning of the war becomes more important than what the war was about in the first place. So in the client and counselor’s mind the therapeutic goal becomes that the state of calmness ’triumphing’ over the state of panic . The triumph tends to become the goal more than the reduction of the panic and there are some main stream approaches to panic attacks that actively promote such a thing. In fact I would suggest that the vast majority of treatments for panic attacks get lost in the war zone mentality to varying degrees. Indeed a very common approach in treating phobias is systematic desensitization. Such a therapeutic approach very much proposes a war like mentality in the clients mind. It clearly and openly establishes the two combatants - a state of relaxation and a state of phobic anxiety - and then actively sets about providing the battleground between them. That is the whole nature of the therapeutic approach in this instance and there is no idea at all of loving the phobia to thus reduce the war like or adverserial nature of the systematic desensitzation treatment approach.
The other problem with wars is that they take up so much time and energy. If there is a conflict it quickly becomes the central focus of attention and get lots of strokes. The more attention and strokes the combatants get for fighting the more likely the fighting will continue. I mentioned this in a recent post on eating disorders. A crucial component in working with a client with an eating disorder is to focus on other things than food. The food and eating is the battlefield, so the counselor needs to avoid it for at least 50 percent of the contact with the client so the counseling does not get lost in the war.
Unhappy girl
Should she love the enemies in her mind?
The old christians had a very interesting saying, which was, “Love thy enemy”. The interesting part about this is that if you love your enemy then you don’t have an enemy in the first place. If you love the enemy you can’t have a war in the first place at least in one’s own psyche. So the goal in counseling is to love you panic attack. If the client can learn how to love her panic then the war zone will not develop. How the counselor assists the client to achieve that is the hard part that can take some fancy foot work to do. It is not just a matter of getting the client to say that they love their panic, it is assisting the client to establish an attitude of the same kind and establishing an attitude of love thy enemy in the sub-structure of the client therapist relationship. However if achieved then the war zone mentality in the counseling can be avoided and that is a great advantage to the client.
Unfortunately as soon as a counselor asks a client for a treatment contract he is encouraging a war zone mentality in the clients mind and the counseling in general. If one does not get a contract in the first place then that cannot happen.
So what is the bigger picture?
I am still not sure.
Graffiti
00:35 Permalink | Comments (20) | Email this
Comments
I like your analogy of the "battle" Graffiti. Mostly the client has come to counselling in the first place because of some "war zone" in their head or environment don't you think?
In some ways the same very survival/attack methods the client uses to survive their current problem or pathology can be enlisted between client and therapist. At least this is helpful for the skilled psychotherapist for diagnoses and treatment plan in whatever modality the therapist may have in his or ger toolbox.
I remember and olf story by Carl Jung called the "Rainman".
The Rainman came to a land that was in disharmony, the village had no rain for months. The Rainman said, to make rain for the village (bring healing), firstly he had to come to terms with the disharmony within himself. Once he had completed that inward process (was ok with the war zone) it rained on the village and the disharmony was dispelled.
Perhaps in a bigger picture of your workings Graffiti you are indeed working out the disharmony amongst the contradictions of the thrapeutic process. I for one appreciate your efforts.
Anyway, thats my philosphical input as the year draws to a close.
kenoath
Posted by: kenoath | Wednesday, 26 December 2007
Graffiti,
Yes an interesting journey.
I cant offer any idea's but what really fascinates me is where it is leading you.
I could be well off the mark, but what strikes me alot in reading this post is that this journey could change your life course. And I wonder if in 2008 you will make some big changes to your life as a result?
Guess I will just have to watch this space to find out!
I really get what you are saying about the battlefield. I guess its about embracing the change rather than fighting it. I cant help but think that some things are incurable, just part of our make-up. Why fight them, just manage around them and not torment ourselves with a struggle.
My partner always says to me if I am nervous about doing something "embrace your nerves and use them to your advantage" I like that saying.
So when you have a client with say an impulse control disorder, its about not focusing on it? But then again you could argue why are they bothering to see a counsellor if it is incurable?
Oh well I am rattling on. Its boxing day and I should go play with my pressies!
Posted by: kahless | Wednesday, 26 December 2007
Hello Kenoath,
I liked your rainman story. You surprise me sometimes Kenoath. Its like you have the huge mass of knowledge about thing such as the rainman and I only ever get to see it ocassionally when you let a bit out. Such metaphors (stories) have much potential in the psychotherapeutic process I think.
Your comments on the war zone in clients heads is leading me into a another post later today Kenoath! Ah yes the bigger picture, The only problem is there is always a bigger picture. So when one has at last found their big picture they only discover there is an even bigger one, but surely there must be at last - one big picture.
Thanks for dropping by Kenoath
Graffiti
Posted by: Graffiti | Friday, 28 December 2007
Hello Kahless,
Thanks for your thoughts. I like your comment,
"I guess its about embracing the change rather than fighting it".
It is an interesting idea and a potential 'answer' to the problem at hand assuming the notion of change is a valid one. The next question is how do we do that.
I will think more on it today and present some more thoughts later on.
I suspect that as this war zone approach to human psychopathology is just so much in the 'bones' of our thinking it will be a process of finding an 'answer' rather than just suddenly coming up with an answer.
I went to a workshop a long time ago and there was an exercise on brain storming. There was a problem presented and each group had to come up with various solutions. No one in the group was allowed to say no, or yes but, or that wont work because. Everyone had to agree with each idea and work with it. I have never forgotten that and it would be probably 15 years ago. It just showed to me how ready we are to find reasons why not.
It also showed me if you accept every solution and work with it, it can lead you to places that you could have never gotten to without accepting an 'wrong answer' in the first place. This is the part that I most took from it. I suppose it is like a method to do group lateral thinking. I learnt how to accept an illogical premise as valid and then work with that and once done then you can up at some very new and innovative places.
hope you got some good christmas presents
Cheers
Tony
Posted by: Tony | Friday, 28 December 2007
I like that Tony; what you did in the brainstorm.
Really interesting.
I guess only the wise see all ends and human beings aren't generally wise.
So by going down a path, which may be easily 'dismissed' as 'useless' can in fact lead you to insights that you never thought possible in the first instance. A path is seldom without other routes flowing from it.
Yes, I do like that!
And as for the notion of change, if someone seeks help then you could premise that they are seeking change. But maybe not, maybe something else like validation of a script?
As for christmas pressies; I did have some nice ones thank-you. I like doing puzzles so I got a new Sudoku book and also a new puzzle book called Hashi. I am not very good at it...yet!
:-)
Cheers
Kahless.
Posted by: kahless | Friday, 28 December 2007
Well that does sound like some good presents Kahless, I am sure you will enjoy.
Your views on humans being wise or the lack of maybe quite accurate.
Yes it seems reasonable is someone seeks help they are wanting some kind of change. So this is pie in the sky stuff at the moment. A person seeking help and not seeking change.
Perhaps some times it is necessary to go to the pie in the sky to end up with something that is down to earth and a bit different. Not that I am suggesting that this may happen in this instance but it is certainly well worth having a look.
Cheers
Tony
Posted by: Tony | Friday, 28 December 2007
I guess a person could seek help and not want personal change...
rather seeking the other person to change, such as couples counselling lol!
Or actually come to think about it, I remember an old post of yours where you talked of a client who came to see you because he wanted a friend. I guess he wasnt seeking change.
And the desire for change may evolve over the term I guess too. Someone may initially seek change and then feel comfortable fact that they have a trust and someone to confide in which they dont have in their daily lives?
And then there is the whole idea that some changes can be dead hard. So you seek change but when you see what that change involves you run a mile and dont change. Or battle it.
Cheers
Kahless.
Posted by: kahless | Friday, 28 December 2007
I have some couples clients who keep stating to me that they are only coming to counselling to talk about things they cannot discuss at home together. In my view that is a couples therapy issue, however when I start to sound like a couples therapist one of them reinstates their "contract" that they have only come to talk through subjects they cannot seem to discuss at home.
Now really, how creative is that; for a client to find a way to go to counselling when they don't have a counselling issue?
By the way even though they prefer to seem stuck in their relationship they are doing remarkably well in a couples therapy way. Some clients just hate to be "cornered" as the client/patient and fight for that ok-ok spot with therapy.
kenoath thats ok isn't it
kenoath
Posted by: kenoath | Friday, 28 December 2007
My humble opinion: You are seeing that there is more to, or something different to, the usual path of therapy. I agree and I think it is this --
You wrote, "I agree that there is something wrong with you."
Tony, the problem with the entire mental health industry boils down to this one thing. THE WRONG QUESTION IS BEING ASKED. If mental health professionals would stop asking, "What is wrong with this person?" and start asking, "What has happened to this person?" it would literally change the world.
Posted by: Lynn | Friday, 28 December 2007
Hi Kahless,
Nice summary on the different aspects of why a client might seek help to change.
They all rest on the assumption that there is something to change so perhaps one can have a psychotherapy where there is not that assumption.
I looked at the premier league table today and see that West Ham is half way up the tree. Is it only the bottom two that are relegated?
Cheers
Tony
Posted by: Tony | Friday, 28 December 2007
Sounds creative to me Kenoath,
To get a counselling whilst pretending not to.
It also sounds like you are being creative in providing the counselling in a non-counselling way Kenoath
Graffiti
Posted by: Graffiti | Friday, 28 December 2007
Hello Lynn,
Humble or not I think you make a most pertinent point.
Maybe it is a nonsense to ask, What is wrong with this person?
And that there is nothing wrong with them and that it is only the fact that things have happened to them. that this is the true perspective?
All the best for 2008 Lynn.
Tony
Posted by: Tony | Friday, 28 December 2007
Hi Tony,
Bottom 3 are relegated.
My team (Man Utd) play your team next, at the weekend. You won both games last season, so I think we will 'do' you this time.
:-)
I'll let you know the result.
But yes West Ham are doing well and should be safe this season.
Cheers.
Posted by: kahless | Friday, 28 December 2007
Hi Tony
I am enjoying thinking about your post and the idea of therapy as healing.
One of the most humbling things for me has been seeing a play therapist with my six year old son. Together, we observe the mother-son dyad and witness firsthand the potential injunctions, modelling and permissions. It is a heart rending process, but hopefully helpful for both of us in the future.
Posted by: hullaballoo | Saturday, 29 December 2007
Oh and Lynn; I like what you said too.
It makes sense.
Posted by: kahless | Saturday, 29 December 2007
West Ham 2: 1 Man Utd
:-(
Posted by: kahless | Sunday, 30 December 2007
Hello Hullaballoo,
That is a good blog name.
I wish you all the best with your son and the play therapy. You may be interested in visiting the blog of Kenoath as he does a lot of work with children and has some good ideas on the topic.
thanks for commenting
Tony
Posted by: Tony | Sunday, 30 December 2007
Hello Kahless,
I would like to say that is really good about West Ham, but I know you are for Man U so I wont.
I hope we get some of the replays here in Aust
Almost the end of 2007!
Tony
Posted by: Tony | Sunday, 30 December 2007
Hi Tony
I avoid contracting with my clients at all costs. Make up most of my contracts - I agree with you. It defines pathology and in my opinion it is only there to make sure the therapist can reassure themselves they are doing the right job.
Of course while on course to CTA I have to nod worthily when it comes to contracts and do my best.
Therapy is done through relationship. What couple ever sit down and draw up a contract together. Prenuptial agreements simply highlight the possibility of failure!
I go for a very rudimentary expression of wants on first session and then we both walk together and see where the path takes us.
Ps Dont tell the ITA
Posted by: Queen Vixen | Sunday, 30 December 2007
Hello Queen Vixen,
I promise not to tell the ITA if you want!!
Interesting comment about getting a rudimentary expression of want.
I do or at least have done contracting with clients. But not doing that makes for some interesting ideas
Tony
Posted by: Tony | Sunday, 30 December 2007