Author: Psychotherapy.net Team

The Truth About Facebook and Your Practice

Posted on by Psychotherapy.net Team

Many marketing professionals point to the 900 million worldwide users on Facebook and say you must have a strong presence there to have a successful practice. They discuss the myriad ways you can use Facebook: your profile; a business page; advertising and frequent posts. They tell you how to get more “Likes” and “Fans” and the referrals will come. As a psychologist who has experimented with everything Facebook has to offer a private practitioner, I totally disagree with this common advice. You can waste a great deal of time and money on Facebook and have very little to show for it if you go into it naively. In this post I’ll discuss why this is so, and review one area I have found that does work well to generate referrals from Facebook.

Yes, Facebook has millions of users, and it also has the longest time per visit of any website (about 20 minutes). But monetizing those eyeballs is not easy, since few people go on Facebook with a primary purpose of seeking information. People go to search engines to find information, and go to Facebook to socialize, play games, look at pictures and videos their friends have posted, and comment on those posts. This means the only way you can successfully promote your practice on Facebook is to return to the 20th century model of “interruption Marketing,” where you do what the major TV networks, newspapers and magazines of that era did: you interrupt people's attention from what they are focusing on to check out your product or service. But we're in the 21st century, where the prevailing advertising model is “permission marketing” (see Seth Godin's brilliant 1999 book by the same name). As consumers we now get to choose what we want to see and hear. We give people, businesses and networks permission to tell us about their wares—and get annoyed or angry when this permission is violated. And on a rapidly-updating newsfeed such as Facebook, a post about your practice will usually elicit far less interest and attention than the photos from a friend’s vacation or the video of a sibling’s new puppy.

While every practitioner should have a free business page on Facebook (see https://www.facebook.com/pages/create.php), gathering “fans” for your page or getting people to “like” your posts is almost always a complete waste of time. Becoming a “fan” of a psychotherapist page or liking one of their posts is a quick, superficial action that implies a very low level of engagement with your work (aside: what does imply more engagement is when someone gives you their email address; building an email list is a very wise practice-building activity).

The one unique advantage that Facebook has over the search engines involves pay-per-click advertising. Unlike Google, who is forced by their business model to let everyone play the search game, Facebook has an exact way to segment who sees your ads. Thanks to the remarkable amount of personal data Facebook users put on their profiles, Facebook can offer the most highly targeted advertising in the history of business. Pick your target market very precisely—by age, gender, education level, city of residence, marital status, age of children or personal interests—and Facebook has a way for you to get your message out only to that specific niche of people. Specialize in working with children between the ages of 12-15? Want more referrals from women between the ages of 35-55 with a college degree who live only in two very affluent zip codes? Have a new workshop for Baby Boomer retirees? No problem; no one else but those people will ever see your ad. Combine that with an emotionally engaging photo and a problem-oriented headline (i.e. "Panic Attacks?" or "Still Arguing?" or "Defiant Teenager?") and you have a great chance of interrupting focus from the social activities to your service.

One important note: when people click on your ad, Facebook gives you the option of having the person visit your Facebook business page or leave Facebook and go to a specific page on your website. Get them off of Facebook to your website! There are far too many distractions on Facebook that greatly reduce the chances of someone focusing on your services for more than a few moments.

In summary, approach Facebook with caution and experiment with pay-per-click ads—but only if you have a very specific, targeted niche. For all others, create a business page, update it when necessary, and enjoy the social aspects of Facebook. Just don’t expect it to fill up your practice.
 

Mental Illness in Politics

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In a recent debate about mental health services in Britain’s House of Commons, a Member of Parliament paused and laid aside his prepared notes, departing from the abstractions of rhetoric, the lingua franca of all legislative bodies since antiquity, and spoke at length in concrete terms of his own past experience with debilitating depression. The very next speaker, possibly prompted by his colleague’s candor, decided to see and raise the ante on a past history of mental health challenges, revealing that he presently deals daily with the symptoms of obsessive-compulsive disorder and has done so, sometimes more successfully than others, since childhood. In the course of this rather remarkable Thursday afternoon an additional two members chipped in, relating personal stories of dealing with mood disorders.

The use of gambling terms to portray the day’s events may strike the reader as being somewhat flippant, but considering the stakes, also apropos. These four individuals each took a sizable risk in revealing information that could quite possibly effect their future electability in a negative way. Those in the political class rarely reveal weaknesses to the electorate if it can at all be avoided; and, of course, the stigma endemic in a mental health diagnosis, past or present, need not be elaborated upon. Yet, at least initially, the wager has paid off for those involved, as press accounts speak of their courage and statesmanship in dealing with such an issue so honestly. Reportedly, comments emanating from their various constituencies have been overwhelmingly favorable as well. At least one mental health advocacy group has praised the day’s events as a shining moment for the parliamentary government system.

Just now in the United States, public discourse is much noisier but less substantive. We are, of course, in the final months of one of our multi-years long Presidential campaigns and have just completed the nominating convention phase. Party conventions have largely outlived their usefulness in an age when the nominee of each party is almost always known months before they convene. Today they serve primarily as a sort of infomercial designed to sell or re-sell a particular candidate to the populace. Due to the lack of any real suspense and a general disillusionment with government at present, the vast majority of Americans may simply be glad there are so many more viewing options than there used to be when the conventions first began to be televised in 1948. Still, despite the largely ceremonial and theatrical nature of the political conventions, at the end of the process one of the two men celebrated will be the next President of the United States.

It used to be a common practice to accord the nominee’s home state delegation the honor of putting the candidate over the top in the delegate count. Typically, the state in question would abstain from awarding its delegates until the appropriate moment, passing in the roll call so that they can be returned to at the appropriate juncture. This tradition was set aside at both conventions this year. Had it not been, President Obama’s home state of Illinois would have had the honors at the Democratic Convention. Absent from that state’s delegation was a man much in the news of late, Representative Jesse Jackson, Jr. Mr. Jackson is now reportedly back at home with family but had been in treatment in a number of facilities, most recently, the Mayo Clinic since June of this year for physical and emotional issues the latter eventually identified by medical personnel as being Bipolar II.

During the time of Rep. Jackson’s inpatient hospitalization, his opponents in the fall election have somewhat predictably attempted to call into question his ability to adequately represent his district due to his supposed mental status. (Jackson’s emotional collapse reportedly occurred following his primary victory and he has remained on the ballot as the Democratic Party’s nominee.) The usefulness of this tactic seems limited, as Jackson is widely expected by observers of the local political scene to retain his seat in Congress in November. The opinions from more relevant quarters—state and local Democratic Party VIPs and prominent elected officials have generally been guardedly supportive of Mr. Jackson during his hospitalization. Similar courtesy was extended to one of Mr. Jackson’s high-profile visitors to the hospital, former Rhode Island Congressman Patrick Kennedy, when he also acknowledged and sought treatment for mental health issues several years ago. Kennedy continued to serve in Congress following his diagnose until choosing to retire in 2010 to devote his time to a brain health research initiative.

Knowing what we know as trained professionals about the efficacy of modern treatment for Bipolar illness, this optimism and slowness to judgment seems perfectly sensible. It is quite reasonable, after all, to assume that Mr. Jackson, his physicians and family have all collaborated in the best manner possible to ensure his recovery and, considering his continued status as a candidate, his ability to successfully withstand the continued rigors of public service at minimal or no detriment to his wellbeing.

The importance of this relatively new attitude of acceptance in regard to political clay feet cannot be overstated, I believe. A single generation ago the current Republican Presidential nominee Mitt Romney’s father, George, a candidate for the same office in the 1968 election effectively crippled his campaign when an offhand remark he had made to a reporter the previous year came to light in which he had explained that his prior but since renounced support for the Vietnam War had come about as a result of a “brainwashing” by Pentagon officials. In the 1972 Presidential campaign, the Democratic Vice Presidential nominee, Senator Thomas Eagleton of Missouri, was summarily dropped from the ticket after damaging press scrutiny of his history of hospitalization for depression and treatment with electro-convulsive therapy.

The turning point, when a mental health diagnosis ceased to be politically fatal, may perhaps be traced to Lawton Chiles’ 1990 campaign for governor in Florida. Rather than attempting to conceal his treatment for depression (as Eagleton allegedly had after being invited on to the ticket by nominee George McGovern), Chiles spoke openly about it and extolled the virtues of the then-revolutionary Prozac, which he felt benefitted him greatly. He went on to win his party’s nomination and won the governorship with nearly 57% of the vote in the fall election, going on to serve two terms.
Odds are that there are more than 4 members of 650-member British House of Commons and more than 1 member of the 435-member United States House of Representatives dealing with mental health issues.

Perhaps others in these august legislative bodies will now be comfortable in sharing their trials and success stories, further normalizing the experience of living with a mental illness. Those of us concerned with advocacy can possibly take heart that as the elected class comes to understand that mental illness is not an automatic disqualification for service and that it can strike anyone, and that those able to successfully avail themselves of treatment dealing with it are quite capable of carrying out tasks as important as governing large Western democracies, policy makers may begin to be more receptive to arguments on the importance of adequate funding for mental health and expansion of preventive services. Time and helpful affirmation from the ballot box will tell.

Who Cares About Creativity?

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“Who cares about creativity? I have real problems to deal with!” This is a common reply that I get from clients (and sometimes from colleagues!) when I bring up the topic of creativity. However, the more I have a chance to write and reflect on the subject of creativity, the more convinced I become that creativity is an essential part of the healing process.

I recently had an opportunity to interview Dennis Palumbo, a therapist and writer in private practice in Los Angeles, CA. Dennis brings a unique perspective to therapy, as a former Hollywood screenwriter (he was a staff writer for “Welcome Back Kotter” and wrote the film “My Favorite Year”) and now therapist to up-and-coming and established writers, artists and Hollywood executives. The topic that came up was the connection between creativity and anxiety. Dennis mentioned that his clients will often say the following: “If only I could get rid of my anxiety and self-doubt and depression, then I could finally write!” To which Dennis invariably replies:” Write about what?”

The clients I work with often don’t see themselves as creative, but they certainly also express the wish to get rid of all the things that they see as “bad”—their anxieties, sadness and losses—and sometimes express the hope that I can “fix” them. And certainly, an important part of the work that we do is helping clients achieve symptom reduction. However, there are some things in life that can’t be “fixed” or “reduced,” such as the loss of a loved one, or a chronic illness, or the anxiety that we all face knowing that we are finite beings. And sometimes, the only thing there is left to do, beyond accepting the situation, is to “use it.”

“Using it” is a term I’ve heard many times in theatre, as a direction to actors who are facing various feelings that may be coming up in their lives. So, if an actor has an angry breakup with his girlfriend prior to getting onstage to play Hamlet, he can use his anger or sadness and allow it to inform his performance. However, in my experience, clients don’t need to be actors or writers to creatively transform their painful emotions. For example, a client who loses a child to a drunk driver, and then reaches out to other parents to form a support group is using the power of creativity to transform their feelings of grief into empathy and social action. It is my experience that people aren’t satisfied with symptom reduction. Their depression or anxiety may get them into the room but the question remains: What am I going to do with myself, with this person that I am, with all of my strengths and weaknesses?

In this way, anxiety and depression become more than symptoms to be reduced. Instead, they become an invitation into the creative process, an opportunity for a client to create a new and more satisfying life. I am always interested in questions that stimulate the client’s imagination, asking them to imagine who they would be without their problem, or what message they think their problem might be sending them. And I firmly believe that if we, as therapists, care about creativity, our clients will come to value it as well.
 

Emotional Healing Through Creativity (Or: How Creativity Got a Bad Name and What We Can Do About It)

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As a therapist and theatre instructor, I hear many stories about creativity. It usually goes something like this: Creativity is something you either have or don’t have, and if you have it, you’re probably manic, anxious and neurotic. Certainly, very few clients come to me complaining that they don’t have enough creativity in their lives. However, I’ve come to experience that healthy creativity (and yes, I believe that this exists!) can help in the process of emotional healing.

For the past several years, I’ve hosted an internet radio show about creativity and healing, and this has deeply informed my therapy practice. The stories that my guests have shared go against the narrative that creativity is associated with madness and neuroticism. One guest who continues to inspire me is Ray Johnston, and I’ll share his story to illustrate the power of creativity.

Ray Johnston grew up with one dream: to play professional basketball. However, he went to a small college, was not drafted or even scouted by an NBA team, and eventually graduated from college and found himself working in real estate. However, Ray was living in the Dallas area, and would get tickets to see the Dallas Mavericks. As he began attending games as a fan, he started connecting with former NBA athletes, who encouraged Ray to try out for the Dallas Mavericks summer league. Ray did try out and was eventually chosen to be on the summer league.

If that were the end of the story, it would be remarkable enough, but that’s not where the story ends. Soon after being chosen to play on the summer league, Ray was playing a pickup game of basketball with some friends and banged his shin. The next morning, Ray woke up and his shin was swollen to twice its normal size. Ray went to the hospital and as he recalls, “It was July 2004, and I passed out in the emergency room. When I woke up, I was in a hospital bed and George Bush had just beaten John Kerry for the Presidency of the United States.”

Ray was horrified when he learned that he had been in a coma due to leukemia. He was even more horrified to learn that seven of his toes had been amputated and that he would never play basketball ever again. Ray fell into a deep depression, and wondered what he would do now that his only dream had been taking away from him. Ray could have stayed in that depression, but as he lay in his hospital bed, he decided that he was going to create a new life for himself, given his new circumstances and conditions. Ray decided that he was going to pursue his only other passion—music—and decided to start a band. His doctors and friends told Ray that the stress of creating a band and touring would be too much for his body, and they urged him to stay home and rest.

But Ray did not stay home. He went out and started a band, created music and began touring. As he did this, his depression began to lift. Ray felt like he had a new purpose and mission in his life. He began donating a portion of his proceeds towards leukemia research. And much to the dismay of his doctors, he is still very much alive and touring with his band, the Ray Johnston Band, and working towards his dream of playing in the Dallas American Airlines Center. He has been able to overcome his depression and lives a life of joy, meaning and purpose.

To me, Ray’s story illustrates the power of creativity to overcome emotional pain. Ray made a choice to create, rather than to stay stuck in his depression. Whether or not he becomes a famous singer, he is already successful. Likewise, in my work with clients, I want to know more not only about their symptoms, but also about their hobbies, their dreams and their creative interests. And for all the people who have told me they are “not creative,” I’ve yet to meet a human being who does not possess the ability to be creative in some way.

As therapists, we can be advocates for creativity, and pay attention to the ways in which our clients are already creative. We can hold the possibility of creativity as an asset that helps our clients thrive, instead of as a burden that they need to live with. Finally, we can see the therapeutic process itself as a creative practice, something which I’ll write further about in future posts!

Don’t Ask, Don’t Tell

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Last Sunday night I dropped a pot of boiling water on my hand. My quick thinking teen aged son who was standing near by promptly grabbed me, led me to the sink and held my burned wrist under perfectly tepid running water. Shortly there after we took a quick trip to the ER where they wrapped me up and sent me back home.

I’m healing nicely. But the white bandage around my left hand has been good fodder all week in my office. There’s been an interesting hodgepodge of reactions from my clients, from not noticing at all to “Wow! What happened to you?”

It’s brought me back to the several pregnancies I’ve had while in private practice when my body was inflating in front of me, and in front of my clients. Some noticed early on, and others were shocked when – toward the end of the pregnancy – I said I would be out of the office for a bit. Some wanted to know why, others just wanted to know when I’d be back. It was indeed an interesting study in narcissistic transferences, object relations, relationships and character.

So here I am with white gauze wrapped around my literal wound debating about which figurative hat to wear in session. My own analyst, if wounded, (would I want her wounded? If so, why?) would most likely nod slightly and say something like “What do you think happened?” And then we might spend the session in some sort of fantasy exploration of my ideas, associations or feelings about what may have happened, about knowing or not knowing, and what that would or would not mean to me. Depending on my mood I would find this either interesting and helpful or downright annoying and useless. Probably some of both. But I would tell her that too.

That’s part of the freedom of being able to say everything and anything in therapy. It includes saying whatever you feel about the therapy and the therapist, which does often lead to better feeling states and more insight. So what’s better for my clients? To know? To guess? To talk and see what comes up? Or to satisfy the question if asked? Feed the desire, gratify the need? Or perhaps just to engage in the righteous social norm of polite dialogue? After all if I tell too soon, are we missing out on a memory of a mother being hauled off in an ambulance, or the time they cut their own finger? Maybe if I don’t answer too quickly I will find out that they feel concerned about me, that I mean a lot to them, or the opposite. Some folks just want to know that I am able to do my job or continue to take care of them or both. With some, the exchange has been sweetly and simplistically human, a currency of concern and connection that flows naturally through both the therapeutic and real relationship that exists between us.

Perhaps too, my injury offers an opportunity to explore empathy and to learn more about how aware we are of each other, of others, of ourselves. And for some, my injury means that I must know now, for sure, what it feels like to be hurt.

Mostly, my clients have been satisfied to know that my attention to them has not been affected by whatever has happened to my wrist, even though it does bring home, on some conscious or unconscious level the registration that I exist outside of the office and am susceptible to the perils of life just as they are. And that I too might benefit from an analysis of why I hurt myself, unconscious though it was.

Not mistreating the treatment seems to be the most important thing. That and taking very good care of the relationship. So, to satisfy or to analyze? It’s hard to know exactly all the time, but it seems to me that a little bit of both usually goes a long way toward healing and avoiding burns.

Who Else Wants To Know Why Americans Spell Counseling With A Single “L”?

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A while back, when I opened my afternoon snail mail I received a card from Dr. Thomas W. Clawson, CEO of the National Board for Certified Counselors (NBCC). Dr. Clawson asked in his correspondence if I knew why the words counseling and counselor are spelled with a single "L" in the U.S., while in England and Canada the words are correctly spelled with two "L's” (i.e., counselling or counsellor).

He then went on to answer his own question. The mystery, he noted, could be traced back to Frank Parsons, the so-called father of guidance and vocational counseling. It seems that the multi-talented Parsons was also trained as an attorney. To avoid confusion he would spell counseling or counselor with two "L's" when working in the legal profession (e.g., counsellor- at-law), but he used a single "L" spelling (i.e., counselor) to distinguish his work as a helper.

Clawson shared with me that his source for this information was none other than Dr. Joseph W. Hollis, a prominent figure in the counseling arena. Joe had been the Chairman of the Department of Psychology and Guidance Services at Ball State University in Muncie, Indiana. After thirty years of dedication to the university, he retired in 1984. But retirement for Dr. Hollis turned out to be the beginning of a new venture. He founded a publishing company, Accelerated Development (later purchased by Brunner Routledge, a division of Taylor & Francis), that he initially ran out of his garage. But the company blossomed and Joe brought a lot of the seminal titles to our field in the 80's and 90's. In addition, he was known for undertaking the first major study of counselor preparation programs. He also helped found and served as president of C-AHEAD, the Counselors Association for Humanistic Education and Development. I had the pleasure of coauthoring a book with Joe in 1994.

I emailed Dr. Clawson back to report that I had not only been privy to the story about Parsons, but my source was precisely the same as his: Joe Hollis.

At that point in time I became very curious and wanted to verify our hypothesis in a scholarly source. I searched near and far and was assisted by several talented college research librarians. I perused ancient tomes that had accumulated over nearly a century of dust (now I know why some books have dust jackets!) to no avail.

Since I came up empty handed, I thus contacted the one individual who I knew had publicly broached this subject, Dr. Samuel T. Gladding. Gladding is a noted counseling textbook author and a former president of the American Counseling Association (ACA) and the Association for Specialists in Group Work (ASGW). Indeed Dr. Gladding was espousing the identical explanation concerning Parsons. His source: None other than—you guessed it—Dr. Joseph W. Hollis.

For now, I'm sticking with the story because Joe never told me anything that wasn't the truth, the whole truth, and nothing but the truth! Sadly, Joe passed away at the age of 80 on November 23, 2002, so we can't ask him where he acquired his information.

But hey, if you uncover something in the literature that proves we are wrong, just give me a holler. I'm all ears.

Albert Ellis and the Traveling Road Show

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As a master's level graduate student at the University of Missouri, St. Louis, I was very fortunate to have Dr. Patricia Jakubowski as my advisor. Pat was not only a recognized behaviorist, but she was also a pioneer in the assertiveness training movement. Best of all, she had befriended a psychotherapist who was very close to Dr. Albert Ellis. That's right the Dr. Albert Ellis.

At the time, it was virtually impossible for a student such as myself who didn't own a master's degree sheepskin to attend an ongoing training session with Dr. Ellis, but Pat worked her magic (can you say used her connection?) and there I was at the Institute for Rational Emotive Therapy in New York City. Although Ellis came across as dynamic in his writings, he was ten times as colorful and entertaining in person. During the training Ellis cast many gems of wisdom related to his baby, RET, which stood for rational emotive therapy. In his mind it was the ultimate form of counseling and psychotherapy. Later, with a little coaxing from psychologist extraordinaire Raymond Corsini, Ellis renamed the modality rational emotive behavior therapy or REBT in 1993. Thus REBT is the name which lives on in the pages today's textbooks and counseling classes.

But the one thing that stands out in my mind after all these years was a remarkable story he shared that transcended the boundaries of his own theory. Ellis mentioned that during the early 1970s he was conducting a presentation at a major national conference. After his speech another presenter demonstrated a new form of therapy. Suffice it to say that this other treatment modality was everything RET wasn't. This novel approach stressed intense catharsis, abreaction, and focused heavily on one's childhood experiences. Convinced of the superiority of RET over any other form of helping Ellis was ready to dismiss the whole idea until he watched a demonstration of the new system in which an acutely disturbed client was cured of what ailed her in less than sixty minutes.

Even the great Dr. Albert Ellis was amazed and could not believe his eyes. Could this innovative form of therapy be that effective? But make no mistake about it—Ellis had an open mind and decided he would investigate the new paradigm. His investigation came to a surprising and screeching halt in less than 30 days. You see, not long after the first conference, Dr. Ellis was scheduled to present at still another national conference. At the second conference he spied the same psychotherapy expert, curing the same client, of exactly the same problem, in precisely the same period of time.

So the moral of the story is that if some new, improved form of psychotherapy makes a giant splash onto the helping scene that just seems too good to be true . . . just use a little creative visualization and think of Albert Ellis and the dreadful deception of the traveling road show.
 

The Joy of Small Miracles in Psychotherapy

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I confess that sometimes in the course of my work sadness overwhelms me. I am not talking about compassion fatigue, burnout or a concoction of transferences and inductions. I’ve been listening to folks talk for almost two decades now, but sad narratives still affect me, as well they should.

Sometimes the healer in me dips under the radar and I feel only like I am standing at the station watching a train wreck happen, or so I think. Faith and that good old fashioned “patience for the process” that I learned back in social work school get eclipsed by the urgency and impulsiveness that often walks through my office door. Even though I know that we do not control outcomes (and as my career ages into its mid life, I am finding this truism to be a relief), I do sometimes wish for miraculous epiphanies and prescient strides forward.

Not too long ago, I got my miracle.

A couple I’ve been seeing was in therapy to discern whether or not they were going to stay together. He wanted to stay married and she was, she said, not sure. She did not feel loved. He did not feel supported. When she felt angry or hurt, she threatened divorce, or told him what she hated about him. When she did this, he became more frustrated, backed away further, and so went the dance.

We’d been unpacking things for a while—the dialogue between them, her history, his. But still she maintained that he was a louse. (He had never impressed me as such.) There’s more to their story, but over the course of the therapy, I began to feel utter sadness. I found myself wondering why I was such an advocate for their marriage. Was I thinking of their four kids? Was I feeling his sadness? Or hers? Was I feeling my own sadness? How do I know what’s best for them? Or their kids? Was I lapsing into judgment? And if so, why?

My sadness in this case was this too: This guy really did step up. And this woman kept knocking him down at every turn. She seemed to be deeply, wholly cathected to killing him, the marriage and love itself.

As a defense against my sadness, I began to diagnosis her in my head. “She is borderline,” I’d tell myself. Or, “She is a typical ACOA.” And then, “She suffered too much trauma to be able to sustain a mature relationship.” Silently I found myself begging her not to destroy her home. She did love this man, she claimed. And she fessed up to his good fathering. But for session after session she wept about how her husband was not her hero, and how out there somewhere her real love awaited.

And then one day, out of the blue, she came into session and said that she had prayed. And that she had made a decision. She said that she had been behaving terribly and it was going to stop. She said that her husband was a good man and deserved her respect and support. She said that she sees that he is not her father who disappointed her, that she is loved and loveable and that her relationship with her husband and her self fair much better when she acts reasonably and kindly, and handles her feelings better. She told me that she understands that when she feels vulnerable and afraid she threatens instead of saying a feeling or expressing a need. She understands that words can build or break, and that she wants to build. That she is now fully aware of this and can and will do it differently.

Her husband was right on board, appreciating her openness and her effort, restating his love for her and his willingness to keep working on himself and on their emotional connection.

Perhaps all those elements of EFT, IFS, CBT, DBT, Imago, Attachment and good old psychoanalysis that I’d been pulling from did their job. Or maybe it was my attentiveness or occasional loving looks, or as of late, my restraint from saying very much at all. In my mind, as I listened to her I would visualize writer Ann Lamott’s acronym for WAIT – Why Am I Talking? Perhaps in my silence she felt understood, and that her profound longing and sadness could breathe.

I admit that I really do like to see breakthroughs now and again. I suppose they help me hang in better when all those feelings come through my door, whipping up my own like a wind gust on dry leaves. With all my ideas about what really happened swirling about, I’m settling on the miracle. I’m giving myself the gift of joy, of seeing the train wreck derailed and not the train. I know that in this business some miracles are temporary—sometimes it seems like character, relationship and repetition difficulties are more resilient than their resolutions—so I’ll take the miracles when they come.

The Miraculous (or not) Efficacy of Solution-Focused Therapy

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For years solution-focused therapy approaches have been all the rage; the popularity of this distinctively brief therapy method is unarguable. Beginning in the 1980s, solution-focused therapy hit the mainstream and many mental health providers (and third-party payers) continue to sing the praises of its brevity and effectiveness. For example, in a 2009 book chapter Sara Smock claimed, “. . . there are numerous studies, several reviews of the research, and a few meta-analyses completed that showcase [solution-focused therapy’s] effectiveness.”

Solution-focused counseling and psychotherapy has deep roots in post-modern constructive theory. As Michael Hoyt once famously articulated, this perspective is based on “the construction that we are constructive.” In other words, solution-focused therapists believe clients and therapists build their own realities.

Ever since 2003, my personal construction of reality has been laced with skepticism. If you recall, that was the year President George W. Bush included 63 references to “weapons of mass destruction” in his State of the Union address (I’m estimating here, using my own particular spin, but that’s the nature of a constructive perspective). As it turned out, there were no weapons of mass destruction, but President Bush’s “If I say it enough, it will become reality” message had a powerful effect on public perception.

From the constructive or solution-focused perspective, perception IS reality. Nevertheless, as much as I’d like to ignore all evidence contrary to my own beliefs, I also find myself attracted to old-fashioned modernist reality—especially that scientific research sort of reality. Consequently, over the years I’ve often wondered: “What the heck does the scientific research say about the efficacy of solution-focused therapy anyway?”

Well, here’s a quick historical tour of scientific reality.

• In 1996, Scott Miller and colleagues noted: “In spite of having been around for ten years, no well-controlled, scientifically sound outcome studies on solution-focused therapy have ever been conducted or published in any peer-reviewed professional journal.”

• In 2000, Gingerich & Eisengart identified 15 studies and considered only five of these as relatively well-controlled. After analyzing the research, they stated: “. . . we cannot conclude that [solution-focused brief therapy] has been shown to be efficacious.”

• In 2008, Johnny Kim reported on 22 solution-focused outcomes studies. He noted that the only studies to show statistical significance were 12 studies focusing on internalizing disorders. Kim reported an effect size of d = .26 for these 12 studies–a fairly small effect size.

• In 2009, Jacqueline Corcoran and Vijayan Pillai concluded: “. . . practitioners should understand there is not a strong evidence basis for solution-focused therapy at this point in time.”

Now don’t get me wrong. As a mental health professional and professor, I believe solution-focused techniques and approaches can be very helpful . . . sometimes. However, my scientific training stops me from claiming that solution-focused approaches are highly effective. Although solution-focused techniques can be useful, psychotherapy often requires long term work that focuses not only on strengths, but problems as well.

So what’s the bottom line?

While in a heated argument with an umpire, Yogi Berra once said: “I wouldn’t have seen it if I hadn’t believed it!” This is, of course, an apt description of the powerful confirmation bias that affects everyone. We can’t help but look for evidence to support our pre-existing beliefs . . . which is one of the reasons why even modernist scientific research can’t always be trusted. But this is why we bother doing the research. We need to step back from our constructed and enthusiastic realities and try to see things as objectively as possible, recognizing that absolute objectivity is impossible.

Despite strong beliefs to the contrary, there were no weapons of mass destruction. And currently, the evidence indicates that solution-focused therapy is only modestly effective.
 

Psychotherapy: Terminal or Interminable

Posted on by Psychotherapy.net Team

“I was okay until I met you!” she said and slammed the door of my office as she left. I have never forgotten that moment. I was shocked, not just by the vehemence, her incandescent anger, but by my complete failure to anticipate her reaction. I thought I was a good judge of character and I had got this woman badly wrong. I had invited her husband to attend the previous session and, instead of supporting her jibes and scarcely veiled attacks on him, I had taken a neutral stance. In her eyes, I had let her down. The one certainty was that the therapy had ended. Abruptly, unilaterally, angrily, admittedly, but it had the virtue of being unambiguous. I never saw my client again. 

During my long career as a psychotherapist I rarely experienced such a definitive ending. Fortunately, one might think, but was it? Looking back, I wonder whether I missed a trick, that, basking in my role as the Good Therapist, I colluded with my clients’ fantasies that therapy might go on forever. I would always be there, willing to see them again if they wished, for a few more sessions or a resumption of therapy. There were many clients who returned to me after an apparent ending. Smugly, I thought of myself as good at this job. I was not taken in by the idea that CBT or any other set of techniques was what determined outcome. It was the therapeutic relationship that mattered most and, for many clients, that relationship was the gossamer thread that linked us together. It might be scarcely visible but it was always there in the background even after therapy had ended. Now I wonder if something else was going on and the reason I was prepared to let people return, encouraged it even, was a fantasy of my own. Was it that I thought I was truly important to my clients, indispensable even, and that each time I received a phone call or a letter asking for more help, I felt the warm glow of satisfaction at the confirmation of my self-worth? 

This is not a comfortable thought. It would be easy to dispel it. I could tell myself that therapy rarely works in a straightforward way at first, people need more than one bite at the cherry, and those who returned to me did so because they trusted me and valued what they had received. And they benefited. All that may be true. But perhaps it is not the whole truth. Sometimes, therapist and client are dazzled by the therapy. It becomes a unique, special relationship. They have fallen in love. I do not mean that romantically or sexually but that something of the same specialness delusion operates. Good sense goes by the board and the relationship seems timeless. Until at some point it has to end.

“I have something to tell you,” I say. I am apprehensive, hesitant.

Patricia gives me a hard look. “That’s what people say when they want to end a relationship.”

“Well, that’s partly what I mean.”

Suddenly, her eyes fill with tears.

“In a year’s time I am stopping being a psychotherapist. I thought I should give you a year’s notice.”

She looks down. Tears are falling freely now. “Do you think that makes it any easier?”

I had thought exactly that but I don’t say it. I had wound down most of my clients. And earlier, I had thought that I might just keep Patricia on, to keep my hand in so to speak. When I mentioned this possibility to my supervisor, she looked me straight in the eye and said: “Why would you do that, John?” And I knew immediately that it would be wrong. 

“I’m sorry,” I say, inadequately, deflatedly, although what I am apologising for is only clear to me much later. 
All therapies have to end. When a therapist loses sight of the ending, it is no longer therapy but something very different.