Writing Results With Refs

Im learning the hard way at the moment about how to write results after a thrashing by a journal for a study titled   Exploring How Trainees Manage Their Own Distress In-Session: An Interpersonal Process Recall Study

The review was very constructive, pushing me to write better, particularly suggesting that I integrate theory from the literature in my results rather than saving it all for the discussion..I confess to finding this quite difficult but after about 8 hours of mental struggle Ive found my results have really come to life in a much better way that before.before they were descriptive...now they kick arse? well..they are better but it's still a work in progress...here they are, completely unproofed and informatted..they are obviously out of context without the intro and method but I thought some of you writing at the moment might find it useful..

Results

The Discrepancy Between Planned Content and In-Session Process

Watzlawick, Bavelas and Jackson (1967) differentiate between content and process in therapy. The former is seen as the digital or rational where messages are unequivocal and can be analysed easily. The latter is analogue or emotional and messages as more subtle and hard to interpret. In this study we saw the overwhelming majority of trainees become distressed when faced with unexpected processes in the therapy room.

They described feeling as “lost”, “confused”, “unsure”, “floundering”, having a “mental blank” or unsettled.

Trainees recalled preparing well for their sessions, including ‘reading books and notes’, ‘revisiting the formulation’ and ‘making a number of session plans’ but felt that this preparation did not necessarily equip them for what was occurring that moment in the room.

 In-Session Interpersonal Difficulties

Many of the unexpected processes involved interpersonal difficulties between trainee and client, including clients who are seen as resistant, disengageing, attempting to assert control or seeking direct advice.

Here a clients is seen as being resistant to cognitive restructuring.

What was I meant to say to that? In all the cognitive therapy books the person says, “Wow! Now that you put it like that, I completely agree.”

Here a trainee becomes confused when a client disengaged, despite a previously strong therapeutic relationship.

When I said something that wasn’t an answer to her mind, you could tell she  immediately disengaged. She stopped looking at me and started playing with tissues. Whereas every other time she was completely looking at me, very, very engaged.

One trainee described feeling “frozen” and “backing down” when a client was seen as overtly counteracting explicit guidelines for homework tasks. In this case a couple were asked to write on the same sheet, to facilitate a comparison of perceptions concerning events. The trainee recalls the husband disagreeing.

 “Can we have separate ones of these?” I went “Oh! Okay! Yep”, agreeing to it because I was just so thrown by something that I thought we’d really explicitly talked about.

Another trainee described feelings of powerlessness in the face of a client who frequently requested direct advice.

It’s an expectation of me to provide advice, it didn’t sit comfortably. I felt like I was being trapped in a corner. She was putting me on the spot – trying to nail me down kind of thing. I didn’t feel very comfortable [slight nervous laugh]. I notice that I wave my hands around a lot more when I’m feeling scared.

Each of these examples suggest that trainees had an expectation that client’s would follow therapy as described in text books or in their own pre-session planning, as if what Bennet-Levy & Thwaites (2007) calls declarative knowledge would be translated directly to procedural (skills-in-action) without reflection on the interpersonal dynamics at play in the room.

 Complex or incongruous presentation

While trainees found interpersonal interactions difficult they also had difficulty making sense of the complexity of the client’s story.

What I had sitting on that chair were three different session plans. What I did not expect was for her to have all three as a presenting issue. “Ahh! Which one?!” I got frazzled, there was a sense of urgency.

These stories were seen to  “lack of coherence and stability,” and trainess were unsure of how they related to the presenting problem or how to integrate these experiences into their formulations or treatment

Here a trainee is poised to intervene with a client who has a history of social anxiety, only to discover that he is telling the story of breaking up with his girlfriend.

I was lost. I thought he was going to go and have coffee with this girl and explore his feelings, so I thought we were testing predictions like, “It’ll be awkward” and “It won’t be fun.” It became apparent that actually he was going there to tell her he wasn’t interested. I was like like, “Riiiigggght. Now I’m going to leave.”

Here a trainee finds it difficult to make sense of seemingly incongruous reactions to a death in the clients life.

I’m thinking, “What’s going on with you? This guy had died and you’re . . . reacting with humour.’”He does impressions. He does impressions when asked emotional questions.

The emotional reactions described by students regarding both interpersonal processes and complex client presentations reflect discomfort with what family therapists Anderson, H. & Goolishian, H. (1992) call a ‘not-knowing’ position, an essential prerequisite to curiosity (Palazzoli et al. 1980) that leads one to ask open-ended reflexive questions of the client, rather than concern oneself with how to best intervene. It would seem in both of these types of situations trainees are momentarily “frozen’ or ‘baffled. Many also described feelings of inadequacy at not knowing what to do next. ’

I didn’t like that feeling. It felt like I was ineffective, like I’d lost purpose, um, and I don’t see how that’s useful to the client.

One trainee described how her supervisor helped her see that her negative judgments were related to her idea that therapy had to be formal and technical, rather than natural and conversational.

I was thinking “That part wasn’t special – it’s conversation” but my supervisor today was going, “That – that’s therapy. That bit where you casually dismiss that you re-framed that he lost his job? That’s therapy, What about the bits where I couldn’t fill in the sheets and do the ABC  and he’s like, “Yeaaahhh.”

In this example the trainee seem to have misconstrued the collaborative nature of therapy, where meaning is contracted through dialogue.  (Overholser, 2011)

Activation of Rudimentary Reflections

Bennett and Thwaites (xxxx) provide some conceptual confirmation for the findings in this study, asserting that the reflective system is activated when there is a mismatch between expectations and reality. In their approach trainees are taught to focuss attention on the problem at hand, develop a mental representation of it and engage in an active cognitive proves of problem solving. However this occurs in supervision, as a form retrospective of reflection on-action rather than in-session reflection in-action (Schon)

While they were initially ‘taken aback’   Trainees describe how, in “what seems like a fleeting moment”  or a ‘rush’ they are able to acknowledge the emotion they are feeling then struggle to engage in a process of reflection (in my head I was like “What the hell?”).

Three different strategies were then described, each of which has been described here as rudimentary.

Referencing the expert

A significant number spoke about mentally referencing a supervisor or perceived superior to help them decide how to proceed. For one the supervisor operated as a “voice in your head going, you should do that”. For another it served as a reminder of “what is the right thing to do in terms of an intervention point-of-view”?

In some cases this strategy was seen as helpful, particularly when their supervisor was trusted or open about their own mistakes. For others comparisons with an “expert” only exacerbated feelings of inadequacy.

He’d have something meaningful to say, with his level of insight. Whereas I don’t know what to do with her.

Attempts at transference

Despite the range of distressing emotions experienced by trainees the majority described an ability to acknowledge these emotions while they were happening in sessions. In some cases trainees discussed how their own emotional response communicated to them the emotional experience of their client.

“I was feeling lost, and I guess that’s how she was feeling as well.”

“He’s probably feeling really upset and really disappointed, too”

These reflections, while important, do not yet mirror the complexities of transference dynamics, in terms of recognising that interpersonal difficulties encountered with clients are actually a potential tool for exploring complex unconscious processes (Gabbard, 2001).

Check the therapeutic relationship

Trainees also engaged in momentary reviews of the therapeutic relationship, either checking whether the relationship was strong enough to handle the difficult moment, or reviewing it so as to make a choice between trying to re-establish rapport or continue with the skills-based intervention. Relationships reviewed as strong made it “easier to say a lot of things” and caused some easing of distress because “I don’t really mind making mistakes in front of her.”

Engage in Self-talk

Self-talk was also a common strategy used to try and get the session back on track after distressing events. Trainees described talking themselves through fleeting reviews of their formulation and treatment plans.

Just trying to quickly re-formulate in my head how I could quickly change th  direction of therapy to be still effective. 

I’m sort of not wanting to shut that possibility down but at the same time I do sort of have a therapy plan which I went back to. I’m trying to make sure that we take each session somewhere and that I use the time well.

This differs significantly from the kind of complex inner conversations described by Rober et al. (2008) in his analysis of work by more experienced therapists. Here the therapist can make mental room for a conversation between multiple positions, including the interaction in the room, client’s story and planning for action. This conversation is held internally but at a distance, a process of constructive hypothesising about how to respond in the moment (Rober, 2002).

Retreat to Safety of Non-Directive Counselling

For many trainees, especially those who lacked confidence in treatment techniques the next step after reflection was to retreat to the safety of non-directive counselling.

I’m supposed to be using some sort of technique and I don’t know what I’m doing. I  don’t have any strategy for her, CBT or DBT or schema stuff– I have nothing to structure her thinking.

Skills used included listening, affirming, summarising, reflecting or asking questions. For the majority of trainees these basic counselling skills came more  “naturally” than skills that were seen as more interventive.

I feel like being warm and being empathic towards a client are not things I have to fake, and not things I have to remind myself to do. I suppose things that I’m still less comfortable with, and still getting used to, are you know, particular questioning techniques, or, you know, more sophisticated cognitive challenging and things like that.

Using basic counselling skills in the moment also served as a “coping mechanism”, “buying time,” supporting a “facade of control” and the maintenance of a “professional stance.” For many therapists “surviving” the distressing moment was the goal.

Risk Taking

Other trainees, however, decided to push themselves ‘outside of their comfort zones’and focus on intervention. Some were motivated to “take these risks” by “professional growth.’ Intervention did not necessarily flow from a reconceptualization of the case or the formulation based on the distressing experience but was instead described as an attempt to ‘push ahead’, be more ‘directed’

See! It works!  You’ve just got to talk. Now you can get back to what you’re doing.” I’m pleased I did something. That it actually went okay – that when I interrupted they both seemed to settle fairly quickly – was a good reminder to me that when I do this it doesn’t actually damage the relationship too much.

Arguably, despite the limitations, this type of risk taking is critical to learning (Spellman & Harper, 1996). Trainees who took risks, however, were careful to review the therapeutic relationship first to see if it was secure. . Those trainees who felt it was less seemed more tentative in their decisions and less likely to respond in a way that might “challenge” the client.