Safety

Safety. This is a term we hear often within clinical psychology – safety of our clients and our own safety. How safe is clinical psychology training? We have many sources of potential support – placement supervisors, clinical tutors, mentors, 'Buddys', personal and professional development groups, group processes – other courses probably have more that I haven't heard of. But what if none of these actually feel safe? These are, after all, provided within the context of a training programme – one which peoples opinions of you matter, all these people are potential employers or colleagues, now or in the future. How safe it it then really? Yes, there's therapy. But sometimes therapy can feel like the least safe place of all, always in flux, sometimes a haven, sometimes anything but. Of course, it depends on the sort of therapy you're 'in' – I've had experience of CBT and counselling which felt supportive but somehow limited (see my last post for more on this) and now see a psychoanalytic psychotherapist. I don't know you're opinions on this approach. I know it's one that can divide and polarise. I was very cynical of it before this year of training and now I'm imersed in it I hate that I'm dependent on my therapist, get anxious over breaks and all those other stereotypical stories about therapy that deep down convince me that it's working. After all, its about connecting with the emotional aspects of your way of relating and therefore forces you to face that which is painful. It breaks down defences you didn't know you had and can leave you exposed, vulnerable, raw. And then you're alone to deal with the fallout of those short 50 minutes as you continue to try and contain your clients' distress as you barely contain your own. Melodramatic? Probably. Uncertain? Definitely. Worth the emotion? I hope so.

Trust?

Trust. This may be an odd thing for me to say but I hadn't really considered trust in the context of my clinical work until this week. Confidentiality, yes. Privacy, yes. Clients' rights to see their clinical notes, of course. But trust – no. For me, trust is associated with a relationship I would have with a partner, family member or friend. I wouldn't use the term 'confidential' in relation to the sharing of the hopes, dreams and heartbreaks of someone close to me. Yet I would when a client does. What does it matter? It's the language of the professionals, the subtleties of language, right? Well, maybe. Or maybe it's part of what some psychodynamic therapists have identified as a way of distancing ourselves from our clients and keeping them as distinct and separate from us. A way of protecting ourselves from the pain and suffering that our clients may bring.

By aligning ourselves with this language of professionals, are we missing out on the human connection that is integral to the therapist-client relationship in a way that isn't demanded of our relationship with our solicitor or bank manager?

This week I've been approaching my sessions with clients as one based on 'trust' rather than confidentiality and this experience has subtley shifted something. I've been more attuned to the humanity in what has been brought to the session. Rather than a head full of formulation and worry about what question to ask next, I've made space for the need to 'be there' for the client and be present. Formulations and asking appropriate questions are certainly integral to our work. But I have become aware as a trainee that I have been so focussed on getting these things right that I may have been avoiding something. The human pain of their experience.

Of course, our clients want us to help them to understand how their problem has developed and ways of intervening (ie. a formulation). But my sense is that this need not be at the expense of something which may be more fundamental – a human connection based on trust.

CBT

I'm trying to make up my mind about what I really think of CBT (Cognitive Behaviour Therapy). CBT is a bit of a hot topic at the moment - it's the therapy recommended in many of the NICE (National Institute for Clinical Excellence) Guidelines - the treatment of choice for anything from depression to schizophrenia. I've got views of CBT from both a personal and professional point of view. On a personal level, I engaged in 12 sessions of CBT over about 6 months with a private therapist. At the time I also read lots of CBT informed self-help books such as Mind Over Mood: Change How You Feel By Changing the Way You Think and those from the 'Overcoming' series.

The tools of CBT were pragmatic and portable and they made sense to me. I quickly began to spot my own 'cognitive errors' - catastrophising, discounting the positive, labelling, should and must statements etc..... What strikes me about my own CBT was it's utility while I was seeing my therapist ..... However, once my sessions were over and I went back time and again to the books and the thought records, I had this dawning sense that despite knowing it in my head, I wasn't experiencing it in my heart, an observation that has been identified by Deborah Lee in her chapter in Compassion by Paul Gilbert.

I had this sense that there must be something wrong with me. I was 'working the programme' and superficially things were improving but deep down I still wasn't feeling 'right' -whatever that is.

And so with this in mind, how do I experience CBT from the other perspective - that of being the CBT therapist? I have worked with a number of clients using a CBT framework throughout my clinical training to date. Despite CBT theory emphasising the need to be collaborative (coupled with the desperate desire on my part to avoid positioning myself as the expert), it has been my experience that clients want me to be the expert - I am after all offering NHS funded services to the client (referred by their GP or some other similarly identified expert) as someone who can help them. And, implicit in the theoretical basis of CBT is the message, "Your thoughts are not the most helpful, let me help you change them". And I have seen people change their thoughts, schemas and core beliefs and been inspired and privileged to be a witness to this change. But I have also seen people for whom the thoughts that they were having may not have been the most helpful but were the most rational given their individual social environment. Someone living on the poverty line. Or the victim of racism, sexism or homophobia. In which case working with someone's thinking patterns feels like one small part of the jigsaw for whom those 8 NHS funded CBT sessions only succeeded in scratching the surface.

So...why the blog? Well, that's a complicated one. I’ve been wondering about what’s led me on this particular career path for a while now and I read recently (in Psychologies magazine I think) that it can be a good idea to think back to what you were interested in as a child. This can help you clarify what you enjoyed doing before being subjected to outside influences in the form of peers, media sterotypes, parental expectations and the like! The theory is that this can provide clues as to what your 'signature strengths' are. You might know that psychologists in the field of positive psychology (e.g. Martin Seligman, http://www.authentichappiness.sas.upenn.edu/Default.aspx) have found that identifying our signature strengths can lead to a sense of 'flow' (http://en.wikipedia.org/wiki/Mihaly_Csikszentmihalyi#Flow) - the state of being so immersed and absorbed in the enjoyment of one's activities that other concerns become immaterial. This led me to think about what I enjoyed as a kid and whether this bears any resemblance at all to what I’m now doing as a trainee clinical psychologist ;)

Well I have definitely always been more of a listener than a talker which I guess could be a valued quality of a CP. But what I remember most is happily spending hours reading - fiction, non-fiction - whatever I could lay my hands on really. I don't readily admit this but I was actually quite into ‘how-to’ guides (things like the Girl Guides Handbook springs to mind!) - it was the 'improve yourself' aspect that I loved and I guess some might argue this bears some similarities to what a CP is all about, (although my psychoanalyst would of course be making links with other reasons why self-improvement and wanting to be different captured my interest...but that's a story for a different day). And the other thing I loved was writing – putting thoughts into words and making experiences come alive.

So in a round about way I guess I'm wondering about how to get back in touch with those early interests. But why so publicly, on a blog? I think I'm a funny mixture of show off and wallflower. I like the idea of putting my ideas ‘out there’ in some way but at the same time am hugely aware that the world of clinical psychology is an incredibly small one. So this blog will stay as anonymous as it can be. Plus if you’re reading this as a graduate psychologist and thinking of applying for training I think there may be space for some real life experiences of clinical psychology. If so I hope it may be a source of insight for you.

Another reason for wanting to do some writing is that I recently discovered that it can be very therapeutic. A study conducted with people with experiences of chronic pain demonstrated that self-expression in the form of writing helped with their ability to manage their pain, whether or not they chose to write about their pain or another topic entirely (this isn’t the study but a link to the general topic: http://chronicpaincontrol.net/expressing-yourself/writing.php) I don’t suffer with chronic pain but I do have a different health problem to manage so I began to wonder if putting some of what I’ve been experiencing in training down in black and white may help me to make sense of it. It all feels very unknown. Risky even. But I’m aware of the many times I’ve said to my clients when faced with embarking on a behavioural experiment of some kind in CBT, “What have you got to lose? It’s an experiment – whatever the outcome we can learn something”. So it feels like it might be time to take my own advice. Here goes.

Training to be a clinical psychologist is hard. Emotional, raw, vulnerable, challenging, exposing, uncertain, exhausting, demanding, anxiety provoking.... Don't get me wrong, there are also moments of enthusiasm, confidence, achievement, passion, gratitude, contentedness, privilege.... But I don't think I fully appreciated what a roller coaster the journey would be until I actually embarked on the journey that is 3 long years of clinical, academic and research commitments that make up the DClinPsy. I write this fully aware that people warned me. I read it on clinical psychology forums. I heard the remarks by supervisors and current trainees I knew through work. I imagined myself juggling the demands and remember feeling overwhelmed just thinking about it. So I did what any cognitive therapist would have told me to - I reframed it. "I'll be ok, it'll be different for me, I'll cope. Challenging is good, I like a challenge". I looked for evidence that I'd be able to cope - I thought back over other difficult challenges in my life and the skills I'd developed to deal with them. So I stopped entertaining these ideas and soldiered on, knowing that to successfully gain a training place I would need 100% commitment and nothing less. Perhaps I was naive not to heed the warning signs. But here I am, mid way through this journey and I say it again...training to be a clinical psychologist is hard.

So would I have applied knowing what I know now? That's a difficult one. Of course hindsight is a wonderful thing and how can any of us accurately predict how we may feel once fully immersed in the results of any decision we may have had to make in life. It's all about stepping out and trusting. Anyway, it's not like I have any idea what else I'd be doing...although how much of that is the result of having invested the last 7ish years of my life to this career path and I therefore can't face entertaining the possibility of not following it through....