Therapy for non-reflective clients

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Therapy for non-reflective clients

Postby frankdim » Tue Dec 27, 2016 5:30 pm

Case:
There's this older woman.

She suffers significantly, she's willing to talk to a psychologist, she's cooperative, she's moderate intelligent, she doesn't have problems that impact her thinking/reasoning/expressing. Yet it's almost impossible for her to reflect on herself. She has simply never done it ever in her life. She finds a therapist, but the therapist refuses to treat her as she lacks reflective skills.

My question is: does anyone know if there's a psychotherapeutical school or specific techniques for this lady?
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Re: Therapy for non-reflective clients

Postby Ruthie » Wed Dec 28, 2016 1:37 pm

I've edited your post to remove potential client identifying info.

First thing I would want to do is to establish if the client understands what therapy is and if they are willing to actively engage. Many people who seek therapy don't realise how much it requires of the client and that there is potential for therapy to feel uncomfortable and challenging at times.

If the client was willing then I would want to formulate what is causing their difficulties in self reflection. Cultural and generational differences? Emotionally avoidant interpersonal style? Lack of emotional vocabulary? Shame? Some combination of those factors and/or something else?

In cbt framework I would want to understand the client's past experiences, beliefs and feelings about self reflection and emotional disclosure.

In terms of strategies, the formulation should point the way but useful resources that spring to mind are Dan siegel's mindsight and Robert Leahy's work on emotional schemas. That said, I think even the most basic start to cbt encourages and teaches self reflection on thoughts, feelings and behaviours so unless it is really clear that these aren't a good place to start for this client, I wouldn't change course too quickly.

Another factor to consider is the remit of the therapist - if they are strictly limited to a small number of sessions then starting to foster self reflection and potentially open up painful emotional experiences may be unwise and unfair to the client.

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Re: Therapy for non-reflective clients

Postby Pink » Mon Jan 09, 2017 12:50 am

frankdim wrote:Case:
There's this older woman.

She suffers significantly, she's willing to talk to a psychologist, she's cooperative, she's moderate intelligent, she doesn't have problems that impact her thinking/reasoning/expressing. Yet it's almost impossible for her to reflect on herself. She has simply never done it ever in her life. She finds a therapist, but the therapist refuses to treat her as she lacks reflective skills.

My question is: does anyone know if there's a psychotherapeutical school or specific techniques for this lady?



I'm writing cautiously, as I see you are a first-time poster, and a part of me is wondering if you are the client who received this message, rather than a would-be clinical psychologist. I've written some thoughts based on what is written here, but the major caveat I would have is that I am conscious the client may have received a different message from what the clinician meant to communicate, as we often do when under stress, or in states of distress. However, my comments are based on the information given here.

I'm really uncomfortable with this message being given to a client, if it is what was intended to be communicated, and I don't think it is a fair or good rationale for not offering therapy. As Ruthie says, sometimes clients may not wish to do the work, but that's a different thing, and I'm really uncomfortable with a client being left feeling that they did not merit care because of a lack of reflective functioning. The 'not psychologically-minded' trope went out 40+ years ago. I would argue that many-most clients who come to therapy 'lack the ability to reflect on themselves' or have 'simply never done it'. That's normal-we can understand reflective functioning (the capacity to reflect on oneself) as having been developed from childhood through a secure attachment relationship-being 'held in the mind' of another. Dan Siegal calls it 'mind-sight'. Most of our clients will not have had this experience, and I would argue that the role of the therapist (whatever model they use) is to act as that secure reflective person, who offers enough safety and containment to begin to allow the client to develop these skills. Susie Orbach talks about 'pause and reflect', Tara Brach says 'attend and befriend'. That's pretty much therapy in a nut shell really, whatever the presenting difficulty. Figure out what's going on for you, learn how to regulate it, and offer yourself some compassion in the face of your distress. Have choices in the way you respond instead of just reacting. Make choices and set boundaries for the relationships you are in, instead of just re-enacting a past dynamic. Some types of therapy (such as EMDR) don't even require talking!

The only way I can see a therapist saying that from a solid place is if we are speaking about a client who has severe affect regulation difficulties, and copes by very risky behaviours. That's not to say that therapy couldn't still be helpful for someone with these difficulties (large part of the work of most CMHTs, and actually the evidence base for intervention with this group is very strong) but just that the person might benefit from stabilisation work first, perhaps a group intervention such as STEPPS or DBT. It's definitely true that for some people, the risk of individual therapy is that it will bring up more pain than is actually helpful or manageable within the time available. There are some really interesting critiques of therapy written from the client's perspective (Falling for Therapy by Anna Sands, Folie a Deux by Rosie Alexander, When Boundaries Betray Us by Carter Hayward) and the message to therapists is clear-sometimes it is more harmful than helpful to intervene, and this process can cause life-changing pain and harm without any gain.

I'm also uncomfortable with this woman being described as 'moderate intelligent'. This seems so loaded with layers of ableism and meaning, and is actually irrelevant, as well as possibly inaccurate if a WAIS has not been done. If you are a would-be psychologist I would be cautious about this kind of language. I've done complex therapy work with clients who have had learning disabilities, early stage dementia, acquired brain injury-I believe good therapy work can still happen in these contexts.

In summary, based on what has been written here I don't think this is a good piece of work, even as a one session assessment. The client should have been left with a clearer understanding of her difficulties, a sense that she had been understood and heard, and potentially helpful ways forward, not a message that she is inadequate in some way-that could really compound previous traumatic relational experiences. However, it may be that the clinician tried to feedback something helpful, but that this could not be heard because of the level of distress occasioned by the perceived rejection. That said, you don't say what kind of therapist, and there are some really dodgy people practicing out there under that title-it's not regulated. It might be that she saw someone really inadequate and poor at their job, without proper training, who re-enacted something or blames clients for their own inadequacies. If she is willing to take the risk of looking again I'd advise her to see a clinical psychologist where possible-it may be more expensive but it's properly regulated, and we can draw on more than one model to understand the client's difficulties and adapt our approach accordingly. She can meet with a few practitioners until she finds one that feels like a good fit-it's perfectly ok to go along for an initial session to see whether you like the therapist without committing yourself. With my current therapist I insisted on 3 sessions before I decided whether I wanted to keep working with him or not, and he was fine with that-any good therapist would be. Might be worth looking for someone who specialises in treating older adults.

Without knowing or assessing the client it would be dodgy for any of us to recommend a therapy, but if she enjoys reading then a compassion-focussed therapy self-help book may be helpful (Paul Gilbert, Deborah Lee). You say that she is suffering, and compassionate practice looks at being kind to ourselves during our suffering-it might give her something to hold on to until she finds someone good.

I hope she's ok.

warm wishes,
Pink
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Re: Therapy for non-reflective clients

Postby TaraS » Sat Jan 21, 2017 5:10 am

You could look up the concept of pre-therapy.

Also, you could simply have said that the client appears to have no disabilities or difficulties which might impair what we class as normal cognitive/psychological functioning.

But honestly, depending on how this "cant reflect" is coming up, it seems much more likely to be a defence mechanism to guard against emotional content.
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