Ya Think (bloody damned morons)

I needed a little break from my final paper, so I thought I would take the moment to share this little nugget of wisdom I found in The Cognitive Therapy of Substance Abuse. Keeping in mind that this is in the context of the first session with a new client:

For example, the cognitive therapist would be ill-advised to speak in the following manner:

"We're going to be examining your thinking processes, to understand the kinds of cognitive distortions that lead you to engage in maladaptive behaviors such as drug abuse and antisocial behaviors."

I'm sorry, but if you are honestly stupid enough that it would ever cross your mind that saying anything at all like this to any patient would be reasonable, you really need to find a career that doesn't involve cognitive therapy of any kind. And if you are stupid enough that you would consider saying that to an addict you would actually like to see get help, you really need to consider a career that doesn't put you in a position to be a risk to others - like pressing buttons that go bing.

What irritates me about this example, is not simply that it's so completely absurd, it's that there are a host of more subtle mistakes that a therapist could make that aren't shown. For example, I could see a therapist saying the following, especially if said therapist was new to this and rather nervous:

"So John, what I'd like to do is explain a little bit about how cognitive therapy. I'd like you to feel free to ask me any questions you might have about this type of treatment, so don't be shy. We're going to try to understand how you see things, how you feel about your life, who you are - about using drugs. This is important, because it can give me a good idea of where your coming from and where things went wrong. This will also start to help you understand yourself a little better and help you turn your life around in a direction you would be more satisfied with."

Do you see the problem ? It's subtle and could actually turn out to be language use that the client will be comfortable with. But there is no way that the therapist can know that in the very first conversation with a client - especially a client who is a substance abuser. Even when they were the one to initiate contact, drug abusers are notoriously reticent about help seeking. Quite often the first session is going to be the only session - even if the therapist does everything right. So this first session is walking in eggshells - you will not get a second chance to fix any mistakes you make.

"...where things went wrong." is the problem statement. Yes, they are there because something is very wrong and presumably things went wrong somewhere. Odds are pretty damned good that if they're in your office, they even know that things went wrong somewhere and assume that you know this too. The problem is that verbalizing this smacks of judgment. The client may well decide you believe that they are wrong as a person. Even if they don't go to that extreme, it is likely to both anger them and flare up their shame response. One simple word like that can easily cut the chances that the client will return in half.

I don't want to give the impression that this book is horrible. Actually I think it does a fairly admirable job, though I disagree rather strongly with some of the base assumptions of the authors. It is a book intended to be supplemental material for the practicing cognitive therapist who is getting involved in treating substance abusers and addicts. Ultimately, this is really my problem with the aforementioned scenario - while the example they give should be absolutely obvious to anyone who was able to become an accredited cognitive therapist, the example I provide might not be as obvious. And while making a "wrong" statement to any patient should be avoided in initial sessions (with most clients, at all), it is especially critical when dealing with addicts. If an example of what not to say under the circumstances were necessary, it would make far more sense to use one that is more subtle - a reminder to reinforce what the cognitive therapist has already learned, probably repeatedly, over the years they've spent in school.

As a complete aside, I will note that under pressure and feeling rather crappy, I have managed to smoke only three cigarettes thus far today. Although my Joni Mitchell station on Pandora is helping an awful lot. That and my e-cig...