Creating Ethical and Effective Directives

I received a question the other day about the use of directives in psychotherapy due to my having written other posts about applying absurdity and paradox as effective therapeutic directives. The question I received is “How do you do directives in an ethical manner”? This question caused me to pause as I usually do not think about how I do directives as being unethical at all. Upon further reflection I think the question came about because of the power distribution within the session in which directives arise. In order to give directives, the therapist has to become the “director” of the session and cannot be merely a passive onlooker. This can create concern for those who are uncomfortable with having a larger amount of power and control in their therapy sessions. I completely understand this concern.

 

Ethics

 

To address this concern, first, I must state that if you are a therapist it is crucial that you adhere to the ethical guidelines set forth by the organizations who are involved in your licensing (APA, ACA, NASW, etc.). Thoroughly knowing what is appropriate and what is not in the ethical codes is an important part of being a professional therapist. If there is uncertainty on one’s part about a course of action, I recommend consulting with a colleague or supervisor to bounce ideas off of so that one can have a better perspective on a directive. The allure of power can be seductive so it is imperative that we in the healing profession proceed with caution. At the same time, we need to not be so uptight and worried about what we are doing that we lose our spontaneity and creativity.

Secondly, I think the best way to use directives is to simply ask yourself, “Would I be willing to do what I am asking my clients to do?” If the answer is “yes”, then implement the directives. If the answer is “no”, then do not implement the directive. If we are unwilling to do what we are asking of our clients, then not only are we not congruent with the therapeutic offering, but we are also putting unnecessary burdens and expectations on the people we are trying to help. By approaching directives with this mindset, it creates an opportunity for us to expand our own comfort zones. If we ask our client to do an odd action to change his or her patterns of interaction, then why not implement that same pattern in our own lives? It may help us become less regimented and more creative in how we approach our own problems. I have a rule that I never ask any of my clients to do anything that I would not be willing to do. This helps keep me mindful of the issue of power in the therapeutic relationship and also reminds me that there are areas that I need to work on and expand in myself.

A recent example of this occurred when I had a client who was very anxious about having things in order. She specifically was bothered by the idea of germs in her home. I was able to get her to agree to not wash one of the pans she used in cooking for two days (it was no small feat to get that agreement!). This allowed her mind to observe that not having everything perfectly clean would not automatically lead to excessive germs and sickness. As I gave this directive, I noted that I can be a bit of a neat freak in my own home. I make my bed and wash my dishes daily and do not like things out of order. As a result of giving her the directive to not wash a pan for two days, I decided to implement a similar directive for myself. I did not wash a pan for two days nor make my bed. This may seem like it is not a big deal to some of my readers, but for me it was an annoyance to alter my usual routine. It did pay off as I reminded myself that routines are sometimes made to be broken and it also gave me a level of congruence with my client.

If you direct your client to stand up more for himself in situations where he would previously back down, then make sure you are willing to stand up for yourself in a situation where you usually back down. If you want your client to expand her comfort zone by try something new, then make sure you are willing to try something new outside your comfort zone.  By being willing to do what we ask of people we can defend against potential ethical issues.

 

Episode 13: Clifton Mitchell Interview

Clift_Mitchell

In this information packed episode, Dr. Clifton Mitchell is interviewed about how to effectively and creatively deal with difficult and resistant clients. Clift is a licensed psychologist and an international clinical trainer and keynote speaker. He is currently a professor of counseling at East Tennessee State University in Johnson City, Tennessee, where he received the Teacher of the Year award in 2002. He has taught hundreds of mental health organizations, businesses, leadership and civic organizations effective techniques for improving communications and for creating change through the precise use of language. He is the author of the book, Effective Techniques for Dealing with Highly Resistant Clients, in which he presents cutting-edge approaches for managing psychological resistance in creative ways. He has published in numerous professional journals and his ideas and writings have also been published in “Men’s Health Today” and “Barron’s Financial Weekly.” His website is http://www.cliftonmitchell.com/

Episode 12: Lisa Dion Interview

Lisa Dion

In this episode, the dynamic and engaging Lisa Dion is interviewed. Lisa is an therapist, international teacher, clinical supervisor, author, and entrepreneur.  She is at the cutting edge of her field creating new and innovative models of therapy with children and adults. She is the creator of Synergetic Play Therapy, the first research-informed play therapy model to blend together neuroscience, attachment/attunement, physics, emotional congruence, nervous system regulation, and mindfulness. Lisa is also the founder and Executive Director of the Play Therapy Institute of Colorado.

In this interview Lisa discusses important concepts that apply to any area of therapy, including the need for therapist authenticity,  the therapist being the most important “toy” in the playroom,  the amazing story of what lead to her to create her form of play therapy, the importance of the therapist accepting aspects of him/herself in order to create change, and being open to possibilities that can occur in surprising ways.

In addition to her clinical work, Lisa has also launched multiple for-profit and non-profit businesses and is a business consultant to various organizations worldwide. For more information about Lisa Dion, check out her websites: www.synergeticplaytherapy.com and lisa-dion.com

That’s Absurd!: Using Absurdity to Create Change

Performing odd, unexpected and absurd actions in psychotherapy is not something one usually learns in graduate school. In fact, in my many years in training, giving absurd directives was never covered. There were examples of various leaders in the field doing strange things to create change but this was never followed up with explanations or encouragement on how to perform such actions. In really examining the use of absurdity and paradox in therapy we find that it is the unexpected that creates a sense of confusion in clients which opens the space for new possibilities to emerge.

Even though great therapists such as Whitaker, Haley, Erickson, Palazzoli, etc. have used absurdity and paradox in their work, as of late there does not appear to be much information in the literature about how or why to perform such maneuvers. I personally believe that being open to absurdity not only makes you a better therapist, but also allows you to have a happier life. The nature of life itself is absurd, so why not embrace this fact? Absurdity can be utilized for shaking up interactions in a way that forces clients to find a different way of relating to the situation which originally brought them to therapy.

 

absurd

In order to create absurdity in the therapy room, clinicians must be one hundred percent willing to abandon any rigid ways of interacting with clients. They should be prepared to act in a spontaneous and creative manner. To be absurd we need to not make any sense. This statement will clash with the prevailing paradigm of logical, left brained therapy which appears to engulf much of the evidence based research. We are often taught that we need to teach our clients to think and act rationally in order for them to change. Certainly these are good objectives, but I will raise the point that it is in learning to deal with the absurdity of life where we really learn to be happy. When we become confused by things we naturally search for understanding. While we are trying to make sense of certain absurd actions, we automatically are being stretched out of our habitual ways of relating to our world. With this stretching process we become open to new resources in how to respond to the absurdity of the moment and of life in general.

 

Some examples of using absurdity to create change:

1. I once saw a couple who were having issues due to the wife’s unwillingness to let her husband have any power in the relationship. She was very controlling but at the same time wanted her husband to “step up” and take some control in the household. The husband wanted to do this but every time he attempted to “step up” she would create a fight because it triggered her control issues and he would back down. He was stuck in a “double bind” situation (which was absurd to begin with). Even though both the husband and the wife logically knew what the situation was, nothing was changing. When they came to their first session, I got their approval for them to do anything I asked them to do as long as it did not violate any safety, security or ethical boundaries. I then told them to go home and on the next day that they were home alone with nowhere to go (which was the upcoming Saturday), they were to wear each others’ clothing for the whole day. The husband was to wear one of his wife’s dresses and she was to wear one of his suits. They were instructed to do whatever they wanted to do that day but they were not allowed to talk about how they felt about the change of clothing. They reluctantly agreed. On the next session, three weeks later, it was revealed that the wife had begun to allow the husband to take on more responsibility in the home.

2. A man in his late 50s came to therapy stating that he was emotionally wounded from the constant “destructive” criticism he received growing up. He stated that he was in a wonderful marriage and his wife rarely ever criticized him. He said the problem was anytime she would offer anything that was “constructive” criticism; he would emotionally withdraw because it would activate his old fears and emotional pain from his past history of “destructive” criticism. He was open to trying anything to get past this problem. His wife was called during the session and put on speaker phone. I directed her to constantly criticize her husband for the next three days about everything. I told her to let him know that he was breathing incorrectly eating incorrectly, sleeping incorrectly or anything else he naturally did. Clearly confused, both parties agreed to do it. When the husband returned in a week he told me not only had he not been upset at any criticism, but both his wife and daughter began to open up more to him to let him know how they felt about certain private things. The dialogue in the home was more emotional in a positive way and he felt closer to his family. He was clearly confused how getting criticism from loved ones for three days created the ability for a family to become closer and more loving toward each other.

 

In order to be effective at performing absurd actions in therapy we need to be sure that we have our clients’ best interests at heart and that we are asking them to do things which we would be willing to do ourselves. We are creating an alive” Zen Koan” in our therapy room when we allow absurdity in. By being open to absurdity and paradox we also free ourselves to become more creative in our interventions. There is not fixed pattern when we utilize absurdity. To do this we are jumping off into the unknown. This may be frightening to some practitioners who cling to standardized regimentation. To me, that is absurd!

 

For a case study of the absurd I offer the following clip from the Marx Brothers. Get out your notebooks and watch how literally everything within this clip is absurd, yet it creates a wider perspective of what could happen.

Episode 9: Courtney Armstrong Interview

Armstrong

Courtney Armstrong is a licensed professional counselor and the best selling author of The Therapeutic “Aha!” and Transforming Traumatic Grief. In her twenty years of practice as a grief and trauma specialist, she has helped thousands of clients recover from trauma and experience deep personal transformation. In this interview we discuss Courtney’s background, how to access client resources, and the importance of creating an experiential session for clients.  She is also kind enough to give out some crucial pieces of the puzzle in helping those who have been through trauma make rapid changes.

Courtney offers training to mental health professionals, showing them how to use creativity, care, and humor to elicit transformation for their clients and make trauma recovery less painful. She is a regular contributor to magazines like the Psychotherapy Networker and The Neuropsychotherapist and has appeared on CBS Radio News, NPR affiliates, and networks in Europe, Asia and Australia. Her website is www.courtneyarmstronglpc.com/

 

How to Become an Irreverent Therapist

I recently came across an old article while doing some research that really got me thinking in a different direction. The article was written by Cecchin, Lane and Ray and published in the Journal of Marital and Family Therapy in 1993. It is entitled “From Strategizing to Nonintervention: Toward Irreverence in Systemic Practice”. The article discusses the shifting of focus in systemic therapy away from cybernetics and directive interventions and towards nonintervention and a focus on narrative (this shift was a huge mistake in my opinion). In the article, the authors suggest that in order to avoid the trap of being constricted in any way, therapists may want to embrace irreverence in their clinical work. This will enable them to avoid any potential limitations. It is a fantastic article that still has applications today. I was so inspired by the authors’ ideas that I wanted to share them, along with my own thoughts about how to become an “irreverent therapist.”

How to become an Irreverent Therapist

To be able to act without any restrictions on effectiveness, irreverent therapists need to take 100 percent responsibility for the actions they take and the directives they give. They must be willing to do anything within ethical guidelines to create the conditions for change to occur. If a therapist needs to be silent for the whole session in order to create change, she will. If a therapist needs to be confrontational in order to create change, she will. If a therapist needs to jump up and down on the couch singing songs from the 1960s to create change, she will. An irreverent therapist has an incredible amount of flexibility because her client is the focus of the session, not her theory.

 

Jester-_Joker_Card001

 

This will mean that the therapist will have to abandon any concepts, ideas, theories, or beliefs which could hamper the successful outcome of treatment. To quote Cecchin, Lane, and Ray, “therapists should maintain a healthy disrespect for any idea which restricts therapeutic maneuverability and creativity.” If you want to be an irreverent therapist, it is crucial that you successfully overcome any desire to stick to predetermined theory or technique that is regarded as the gospel truth. Any allegiance to a dogma is to quickly be rejected in order to flow with the moment as you and your client interact.  Practice laughing maniacally when you hear that a specific theory or technique is labeled “the best”.

An irreverent therapist will go out of his way to undermine and create havoc in the rigid beliefs and patterns of his clients. The order of the day is to embrace playfulness and see what happens when an inspired, uninhibited shrink gets to have fun. The irreverent therapist is also expected to poke holes in his own beliefs and patterns as he weaves a web of possibilities in his interactions with his clients. Uncertainty is not only embraced but encouraged in the therapy room. Any viewpoint the therapist or client takes as an absolute certainty in the session must be disregarded and discarded in favor of pure spontaneity and aliveness. Any certainty that the problem the client brings is unsolvable needs to be immediately dismantled in the therapy session. Spend time observing mastery of the absurd by watching a Marx Brothers movie or a Samuel Beckett play (these are much more enjoyable and teachable than most therapy textbooks).

An irreverent therapist pays little attention to how problems got started. He or she will be mostly focused on how things can shift and change. Investigation into past history and narrative explanations are kept to a minimum as the therapist redirects focus away from problem investigation and towards an exploration of client strengths and resources. Diagnostic labels are regarded with much suspicion and even disdain (maniacal laughter can be used here as well).

Try on the mantle of “Irreverent Therapist” for a week. Put it on your business cards. For this title there are no expensive, long term trainings to attend in order to obtain some silly certification. All that is needed is an openness to absurdity, an embracing of compassion, and a sense of humor.

principles

Episode 8: Lisa Mitchell Interview

Lisa Mitchell

In this wonderful interview, we get to talk with Lisa Mitchell. Lisa is a therapist, speaker, workshop facilitator, and the director of “The Art Therapy Studio” in Fair Oaks Village, California. She is the author of the acclaimed book, “Creativity as Co-Therapist: The Practitioner’s Guide to the Art of Therapy“. In this interview Lisa discusses the importance of embracing creativity when performing therapy and how to get the most out of one’s clients using creative resources. She also discusses how many therapists can often be apprehensive to opening up to creative expression and how it is crucial to overcome such resistance. In her consultation work, Lisa trains therapists how to come alive and flourish while becoming better therapists when they embrace their creative spirits. To find out more about Lisa’s fantastic approach and workshops, visit her website: www.innercanvas.com