Teen Counseling

Common factors: What makes psychotherapy work?

Common Factors in Psychotherapy

There are many reasons why therapy is helpful. A fresh perspective, particular skills, expertise in the various things that ail people…all of these change agents make sense. But research suggests that these skills are not in and of themselves the true mechanisms of change in psychotherapy.

In fact, there is an overarching set of factors that create the benefit in psychotherapy, pathways that are common to all established psychotherapeutic models. They work precisely because humans are social, and psychotherapy heals through social contact.

According to researcher Bruce Wampold (2015) the common factors of psychotherapy can be understood as the development of a relationship, the creation of expectations of change and the establishment of health promoting behaviors.

Relationship: Wampold reminds us that the first order of business in psychotherapy is the establishment of relationship and the exploration of the therapeutic alliance. This bond is critical, and takes time, but some of it happens very quickly and to some extent outside of our conscious awareness. How? The same way it does in any other arena of life—we rapidly and implicitly take in style of dress, mannerisms, voice quality, even office décor and use these things to make judgments and the critical assessment of goodness of fit.

In my professional judgment, the relationship between therapist and client is perhaps the most critical feature of treatment. It is a human connection, and just as we don’t connect with everyone we meet, we cannot expect to connect with every psychologist. For this reason, I always encourage new potential clients to interview several people when choosing a psychologist.

Expectations: Wampold tells us that a person’s expectations for treatment have a huge impact on treatment outcome. Sometimes people arrive with a ‘last ditch’ attitude, the sense they’ve tried everything else and, having reached the bottom of their personal barrel are now subjecting themselves to the scrutiny of a stranger. Other times, people arrive with an expectation that together with their psychotherapist they’ll explore what has and has not worked in their lives, and come up with new solutions to old challenges. Perhaps these people are arriving with similar challenges—they are likely to have very different notions about what psychotherapy is about.

I firmly believe that we as a species are growth oriented, even when demoralization has led us to forget that fact. I also believe that people’s symptoms are not just signs of problems, they are representative of best efforts at coping and change. I think goal setting is critical to progress in treatment, and a collaborative effort that clearly places the locus of change where it belongs—in the middle of the treatment alliance, surrounded by the tasks and rituals of psychotherapy.

Tasks and Rituals: And what are the tasks and rituals of psychotherapy? That very much depends on the nature of the problem, the individual’s goals, and the background of the clinician. Regardless of the details, each task of therapy is focused in one way or another on what Wampold calls “salubrious actions.” The treatment alliance allows trust, and gives a person room to think about his or her world in new ways, to consider thoughts and feelings from a different point of view, to experiment with new ways of being in the world and to collaborate with the trusted other on the mechanisms of change.

But the heart of the entire endeavor is the treatment relationship. So when you are looking for a psychologist, consider goodness of fit as carefully as you do any other quality.

Wampold, B.E. (2015). How important are the common factors in psychotherapy? An update. World
       Psychiatry, 14(3).
270-277.

 

Goal Setting

Dateline, Portland, Oregon--Amelia J. Wilcox, Ph.D.: Goal setting can feel like keeping a list of chores, but done right, it can help us feel successful, and assure we have time to relax.

Whatever you can do, or dream you can, begin it.
Boldness has genius, power and magic in it.

                                                Goethe

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When I was an undergraduate, I had this beautiful quote posted on the wall above my dorm room desk. And there is no doubt it inspired me—in fact It remains one of my favorite quotes to this day.

But where will boldness get you without a plan? Some potentially interesting places, to be sure…but maybe not the ones you’re intending!

I’ve just wrapped up my spring teaching semester—grades are in, my office is (somewhat) organized for fall, and I am looking forward to summer. How will I spend my time? I have patients to see and projects to tend to for the College and my family, but it would be pretty easy to drift along and get little else done. And yet, I have some bold plans…some specific goals for the months ahead.

This year for Christmas my daughter gave me the most beautiful planner I have ever seen. It is richly textured, the paper is fine, and it is laid out in precisely the way I like—week-by-week with a special column for notes. This planner has helped me indulge in my goal setting habit in style.

Once a week I sit down with my schedules—family, practice, college and personal. I begin by thinking about the main things I want to finish by the end of the week, and these things go on a list. Then I put obligations on my calendar—places where, if I didn’t show up people would notice. Next I build in time for myself—a lunch with a friend, a family event. After that, I take my week’s goals and think about what days might be best for what projects or parts of projects. On the calendar they go!

Setting goals is an important part of feeling successful and moving forward in life. For many of us, it is a difficult challenge. Some worry that it will be too time consuming, or make them feel trapped in obligation, or they fear they won’t accomplish what they hoped they would, and that would make them feel bad. For the last concern, I always tell people there is the next week, and the ability to break projects down into smaller component parts.

And a few reminders for us all

·         Setting goals helps us articulate what matters to us (and what matters to those to whom we are
       accountable).

·         Every time we check something off our lists, we get a little dopamine rush to the reward
       centers of our brains, and that feels good, and reinforces goal setting behavior!

·         Most important, setting goals down on paper helps us boldly stay on track—you wouldn’t drive
       somewhere new without Waze or Google Maps, think of your goal setting exercise as Waze for
       your life!

So this summer I have a number of personal and professional goals. I want to finish redoing the seat covers on our outdoor furniture. I am working on funding projects for Lewis and Clark’s Center for Entrepreneurship—that will be time consuming and a new area of endeavor, so I have blocked out a chunk of time each week to learn about institutional advancement. I have patients to see, some projects to oversee at my summer house, and the usual array of fun activities with friends and family. Armed with my lists, I know I’ve lots of free time, and a bunch of little dopamine rushes ahead!

I teach my students and patients to use a goal setting tool designed to help them break larger projects down to size and give them the big picture and the daily view. For many, this starts out as a chore, but for most it becomes unexpectedly freeing. I’d be glad to send you a copy of the worksheet I’ve designed for this purpose, just email me at ajwilcox@lclark.edu if you are interested.

 

 

 

Your creative brain

Dateline Portland, Oregon, Amelia J. Wilcox, Ph.D.: That flash of creative insight comes from somewhere. There are many ways you can cultivate your creativity.

Have you ever had the experience of working really hard to solve a problem—any problem—only to give up to take a walk to blow out a few cobwebs and some frustration? If so, you have also very likely had the experience of a solution to your problem popping to mind when you least expect it. Or perhaps you’ve fallen asleep mulling over a problem, only to wake with the solution in the morning.

These incidents are no accident, in fact the nap is a creativity strategy known since the time of philosopher Rene Descartes, who claimed that the basis of the scientific method came to him in his sleep in 1619. Other scientific advancements have arrived the same way—August Kekule’s benzene ring in 1865, and Dmitri Mendeleev’s design of the Periodic Table in 1869, were said to both arrive in dreams. Famously, Albert Einstein was known to take very short naps in his Princeton office (a habit that apparently did not get in the way of ten hours of nightly sleep), claiming that the liminal state between waking and sleep was critical to ‘loosening the ego’ and tapping into his creativity.

These days, the notion of downregulating the frontal lobes in the service of creativity is becoming well known. And neuroscientists have begun to explore it in earnest. We know that there are many routes to get there. Sleep is one—though Einstein’s micro-naps might be tricky for those who might prefer to curl up and nap for a while. I often encourage my students to take a walk when they are working on a thorny problem—and when they can allow themselves the luxury, they realize it is not luxury at all, but rather a necessary part of flowing into the creative process.

Why does this work? When you are trying to solve a problem, you tend to throw your intellect at it—what do you know that will help, how can you approach it from what you know, and what don’t you know that you might need to know in order to solve it. This is generally a good approach, but sometimes bringing what we know to a problem just isn’t enough.

Sometimes we need to get more creative, and this is where downregulating the frontal lobes can help. Why the frontal lobes specifically? Our frontal lobes do a great job of keeping us in line—they help us order tasks, they help us follow the steps involved in complex endeavors, they help keep our more elemental emotions in check so that we can adhere to rules and norms. That is terrific for following complex steps, for staying out of trouble and for getting places on time (without speeding tickets in hand). It is less good for the sort of loosening of associations and decrease of linear thought that aids creative problem solving. Quieting our frontal lobes promotes this loose, non-linear creativity.

So the next time you have a creative endeavor or a thorny problem you just can’t solve, take a walk, take a bath, go to the gym or zone out to your favorite music. See what comes to mind as a result.

When a friend is depressed

Dateline Portland, Oregon, Amelia J. Wilcox, Ph.D.: It is difficult enough as adults to know how to approach a depressed friend. Teenagers are often on the front lines with their peers, aware of a friend's depressed mood and wanting skills to help them through a difficult time, but unsure how to have such a challenging conversation. What do you do when you are a teen and your friend is depressed?

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A young friend of mine had tea with me a few months ago, and the conversation turned to an important question—how could she help her best friend, whom she thought was depressed. More and more teens struggle with depression these days. This reality means their close friends often end up on the front lines—the first to recognize that something might be wrong.

The first thing I did was ask some clarifying questions. Did my young friend, for example, understand the difference between a blue mood, depression that occurs in reaction to a stressor, and a major depression? Blue moods come and go for us all. They are, I explained, part of the human condition, and if we listen to them when they arrive they can tell us important and useful things about our stress and how we are managing life. An adjustment disorder, on the other hand, is a moderate depression that occurs in reaction to a stressor and may continue for a few months. Finally, a major depression is a more severe condition that can last for weeks to months and includes symptoms like sleep disruption, and sometimes suicidal thoughts. She explained that her friend had become increasingly sad in recent weeks, and that it didn’t seem to be getting better.

I asked her if there had been an unusual event or stress in her friend’s life. Were things okay at home? Had she experienced a disappointment in a relationship or problems with her applications to college?  I explained an adjustment disorder occurs in reaction to something that happens in life. For most people, even without treatment adjustment disorders will resolve within months of the stress going away. But just because something is likely to go away by itself eventually doesn’t mean you shouldn’t get some support. Support can help you learn what led to the stress and give you tools to better manage stress now, and in the future.  I also explained that for some vulnerable people an untreated adjustment disorder may not resolve, but instead evolves into a major depression, which can be very serious.

My young friend told me she wasn’t sure if there had been anything really recent, but explained a very specific stressor that had occurred a few months back, one that her friend’s family was still working to manage. That could, I mused, be a clue about what was going on. I asked my young friend what she was noticing that worried her.

She told me that at first she thought her friend was mad at her because she seemed angry all the time, and really touchy about everything. She asked if she’d done something wrong, and her friend promised she hadn’t, but acknowledged she’d been stressed and just didn’t feel like herself. Now, my young friend told me, her best friend just seems sad all the time. She’s not much fun to be around and she doesn’t go to games or other after school activities any more.

I told my young friend that it was a really good idea to talk to her own mom and maybe to the school counselor about her worries, and said that I had some difficult questions to ask, the answers to which would suggest whether those conversations should happen immediately or not. I explained why I was asking them, and assured her that it was okay if she didn’t know the answers. First, I asked if her friend had thought about harming herself. I also asked what she knew about her friend’s drugs or alcohol use, explaining that sometimes people use these things because they are depressed, but that it is also true that these things can cause or exacerbate depression.

My young friend and I finished our tea and she went home to talk to her mom. Her mom phoned me that evening to get some referrals to pass along. When my young friend and I met for tea recently, she told me her best friend had started going to psychotherapy and had also joined their group of girlfriends for a sleepover that weekend. I told her how impressed I was by her courage. It is a good friend who knows when to reach out for help, and does it even though it is hard.



The Importance of a Growth Mindset

Dateline Portland, Oregon--Amelia J. Wilcox, Ph.D.: We all strive to raise resilient children who understand the importance of hard work and have grit in the face of challenges that come their way. The growth mindset can promote resilience, grit and motivation.

Do you think accomplishments reflect innate talent, or hard work?
Do you bounce back from a failure and try to find a new approach to the problem?
Does your teen understand that it is effort, not native intellect that leads to success?

Creating Resilient Kids:
Researcher Carol Dweck has dialed in on some critically important information about how we learn to manage challenges in life. And according to Dweck and her colleagues, changing just one thing many of us say to our kids without thinking could make a huge difference in how they come to think about themselves and their skills, and whether they respond well to the inevitable setbacks that happen to us all. What is that thing? How we respond to them when they do something well and how we support them through setbacks.

Imagine for a moment your second grader bringing home a math worksheet with a big smiley face on it, mirrored exactly by the one she is wearing on her own, dear face. What is your first instinct when she jumps up and down, waving the paper happily in your direction? If you are like most of us, you’re likely to grab her in a celebratory hug and say something like, “Wow, sweetie, look how smart you are!” Well, according to Dweck, this natural instinct has the potential to backfire down the road.

Tame our instinct and encourage motivation in our children:
What should we do instead? The bear hug stays, of course! This is, after all, a cause for celebration. But instead of celebrating her smarts, Dweck suggests we turn our attention, instead, to her hard work and its role in her success. Imagine yourself saying, “Wow, sweetie. You worked so hard on this, you must be proud of yourself. I sure am proud of you!” According to Dweck, this shift in focus pays off in a big way now, and continues to do so down the road.

What difference does it make?
Dweck explains that praising intellect in our children risks causing them to develop a fixed mindset—the belief that skills and talents are fixed and finite. And when we think that way, we tend also to believe we have reached the outer edge of our finite ability when we have difficulty meeting the demands of a new challenge, or even if we run into problems in an area of life we’ve always found easy. If we believe this about ourselves, setbacks come to be seen as indication that we’ve reached our maximum ability.

It is easy to think that way, in fact, most of us grow up believing how “smart” we are about something is fixed from birth. Much like the color of our eyes or our height, this way of thinking suggests we are destined to have a finite helping in the brains department.  When a child is praised for her intellect she starts to believe things come easily to her because of that intellect. Praising her instead for her hard work may seem like a subtle difference, but it is an important change. Parents who make this subtle but important change help their children learn it is hard work (not luck or being extra good at something) that leads to success.

What’s the big deal—isn’t it good to know you are smart?
Dweck refers to this recognition as a growth mindset, and the research is pretty clear. Kids who have a growth mindset do respond better to challenges—both in and outside of school—than do their fixed mindset peers. And, interestingly, they are also more likely to seek those challenges out, because they are less afraid of hard work. They also seek out challenges because they know failing now and then is not proof that THEY are a failure, but an inevitable part of learning and trying new things. And when they fail at something they are less likely to give up and more likely to regroup and try a new approach, especially when parents respond with acknowledgement of how hard they are working, and encouragement about trying again. In other words, kids with growth mindsets are more comfortable meeting challenges, more resilient in the face of setbacks and well aware it is hard work that gets them where they want to go.

You mentioned this pays off down the road?
Dewck and her colleagues have looked at the many ways a growth mindset plays itself out across the lifespan. People with a growth mindset make better employees, because they are open to feedback about their progress. They understand it is their hard work that gets the job done—and they work hard as a result. They also become better bosses and coworkers, because they don’t fall for the faulty notion that people have a fixed amount of skill. And if you don’t see other peoples’ skills as fixed, you welcome their capacity to learn and recognize the learning curve is a natural and inevitable part of trying new things.

This theory of the fixed and growth mindset is one important way to think about helping people reach their potential and become resilient to the bumps along the road. If you would like a place to talk about helping yourself or your teen better manage the rocky roads that come along in everyone’s life, please call me at 503-490-5793.

If you want to learn more about this important topic:

Dweck, C. S. (2006). Mindset: The new psychology of success. New York: Random House.