Dibs In Search Of Self

A detailed, session-by-session account of a therapeutic intervention. Written by the therapist and detailing all the detours & blind alleys that never make it into textbook accounts of the therapeutic process.

Many clients, some famous and some not so famous, have written of their experiences in therapy. Therapists’ accounts of therapy tend to be confined to heavily anonymised snippets of conversation illustrating a particular point in therapy textbooks, or case studies in peer-reviewed journals which focus more upon the diagnosis & outcome than upon the process of intervention.

Dibs In Search Of Self is that rarest of books, an account by a therapist of every session (and the related consultations with teachers and family) of her contact with a small boy, the titular “Dibs”.

Virginia Axline is the author of Play Therapy, which outlines the application of a Rogerian, client-centred therapy approach to the psychological treatment of children. Play Therapy is heavily illustrated with the usual one paragraph snippets of conversations with clients (including Dibs), but this book describes, one chapter per session, the actions & discussions comprising each session and the therapist’s reflections on her client’s disclosures & her own actions (including her errors).

Dibs In Search Of Self is accessible to any reader and is a fascinating, moving book in its own right. It is, of course, required reading for anyone working with children. Moreover, as an insight into the mind of a therapist as a case progresses, it serves as an illustration not just of Play Therapy, but of sensitive & reflective practice with lessons for any therapist, regardless of their profession or client group. Oh, and it has a happy ending.

Reference

Axline, V (1964) Dibs: Personality Development in Play Therapy. Penguin Books Ltd

Have stuck clients keep a prospective diary

Ask clients stuck awaiting change to keep a prospective diary. An explicit account of life after the hoped-for change can help clients unstick themselves and start changing now.

Some clients (and some therapists) get stuck awaiting a single change which will solve all their problems at a stroke. “Once I’m rehoused…”, “Once I get my compensation…”, “Once you start taking your medication consistently…”.

A key feature of these hoped-for changes is that they are usually external to the person holding out for them: the client holds out for change at the Housing department or law court, the therapist holds out for change in the client. The implicit message is “it’s not my fault nothing is happening yet”.

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Compensation cases and miraculous recoveries

Experience suggests that receiving compensation for physical or mental injury or distress is often followed by a significant improvement in the client’s symptoms. Many therapists decline to take on clients with ongoing compensation cases and some question the honesty of clients who make such recoveries.

Therapists who decline such cases may simply be unwilling to become embroiled in a legal battle (or fearful that a litigious client may turn on them) but those who doubt the client may be failing an empathy test. A client claiming compensation has a great deal to fear from their therapist.

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Setting homework has negative implications

Setting “homework” for clients implies that no relevant work would otherwise occur between sessions. When clients fail to do their homework but achieve positive change anyway, the focus may fall on the former rather than the latter.

Physical therapies often entail a certain amount of work on the part of the client inbetween sessions with the therapist: daily exercises may be set, weekly diet sheets may be provided, medications may be prescribed.

Psychological therapies may also require work inbetween sessions. The notion that therapeutic change occurs only within sessions, in the presence of the therapist, is disproved by the evidence: the greatest portion of therapeutic change is attributable to factors entirely outwith therapy.

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Practicing Therapy

A collection of exercises for developing therapists. The insights to be derived from this book should improve the practice of any therapist.

Somewhere there’s a book that all the experienced therapists know about and it’s not about how to do therapy, it’s about how to do therapy better. It’s got all the secret little extra tricks they know about that aren’t in any of the models and that they forget to tell you about in class. And they won’t ever tell you where that book is – you just have to figure it out.

As Margaret Rambo admits in the introduction, Practicing Therapy doesn’t contain many secret tricks, but it is a book about how to do any therapy better.

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The Road to Recovery is not smooth

Continual improvement in therapy is the exception, not the rule. Stalls and deterioration may indicate a problem with the client, therapist or both, but may also be a sign of progress onto dealing with greater difficulties masked by the initial problem.

The impression given by many textbooks is that improvement is gradual and continous. Clients progress smoothly from one treatment goal to the next until all issues have been resolved and they can be discharged from your caseload.

Many therapists experience a sinking feeling when a client who had been making progress reports no change (or worse, a deterioration) in mood or function (or both).

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Change occurs outwith therapy

Therapeutic change is due more to factors outwith therapy than any one aspect of therapy. Factors outwith the session are at least as important as our rapport with our clients…and much more important than our years of experience or the technique we’re using.

The myth of therapy is that it is done by therapists to patients and that the outcome is a measure of the therapist or of the technique employed, not of the client (unless, of course, the client is “resistant” or “non-compliant”, in which case the outcome is very definitely attributed to them!).

The myth of therapy is perpetuated by research focusing upon the outcome of a given intervention on a given condition, where the therapist is merely a vessel for delivery of the treatment and the client is an interchangeable recipent of said treatment.

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How will you know you’re a better therapist?

Solution-Oriented therapists ask clients how they will know when they are better. Therapists often wish to be better in their role, but few ask the Miracle Question of themselves.

Solution-Oriented therapists often ask clients the Miracle Question:

Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different? (de Shazer, 1988)

Stressed therapists might be asked a similar question:

Suppose that tonight, while you are asleep, there is a miracle and you become a better therapist. How will you know that this has happened? What will you notice has changed about the way you’re working?

I’ve asked this question many times, of my self and of others. The answers tend to be much the same.

  • Every intervention I make in therapy will work
  • My clients will never try to manipulate me
  • I will always be available for my clients whenever they want me
  • Nothing I say will ever upset my clients
  • All my clients will get better all the time
  • My clients will be grateful for the help I’ve given them
  • My clients will co-operate with my therapeutic strategies
  • If I see a problem, I will be able to address it and solve it
  • I will always know what to do in any situation arising in therapy
  • I will not feel frustrated, angry or anxious during therapy sessions

If our clients gave such unrealistic answers, we would renegotiate more practical, achievable goals. How will you know when you’re a better therapist?

Relaxed Therapists make better therapists

Relaxation improves our performance, benefitting us and our clients. We promote relaxation in our clients but we rarely apply our approaches and techniques to ourselves.

Both physical and psychological therapists promote relaxation as a way of decreasing disease and distress. Relaxation improves balance, coordination, digestion & sleep. Relaxation also improves concentration, memory, decision making & self control.

Sports coaches and life coaches recommend relaxation as a way of improving performance. A colleague once said that he knew his clients were getting better when their golf game improved. I know my clients are recovering when they don’t need me to repeat the date of their next appointment.

Physiotherapists are usually fit and speech therapists enunciate clearly, but relaxed therapists are rare. Therapists are typically pressured by excessive demand, inadequate resources, wide responsibilities and the need to balance personal & professional life. Not only do we need to practice what we preach, any gains will be experienced both by us and by our clients.

The pressures on novice therapists are primarily related to competence: the fear that this client will be the one who uncovers your inadequacies.

The pressures on experienced therapists are related more to the burden of success: the demands that follow from from having demonstrated your competence and being sought for it.

The pressures on senior therapists are usually related to being pulled away from therapy by the responsibilities of seniority: consultation, supervision, management & service development.

At each stage of our career, we evolve strategies to support us, sometimes effective and sometimes not. These strategies are mostly personal and rarely passed on to anyone other than our trainees and closest associates. This site is an attempt to promote sharing of such strategies across disciplines, across professions and across the world.

We know how to help others relax. By making our own relaxation an explicit goal, we can improve our performance and our services.