Monthly Archives: October 2012

Therapy Gems: Leave Yourself Out

Often we hear therapists begin a reflection, clarification, or suggestion with one of these stems:

I hear you saying…

My opinion is…

What I am getting is…

It seems to me…

I guess that…

I’m impressed that…

Sometimes clinicians end a statement with these questions:

Do I have it right?

What do you think?

These introductions or add-ons to an intervention seem superfluous and even counter-productive. These statements shift the focus onto the therapist and away from the client’s internal world.   Consider these two formulations of the same intervention.

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Research over about 30 years demonstrates a strong relationship between Expressed Emotion [EE] and relapse in many disorders, such as schizophrenia, anxiety disorders, substance use disorders, childhood psychiatric disorders, and depression.

EE seems to be a major factor in relapse and recurrence.  While EE affects the onset of these disorders and is high in families of children at risk of depression, it is not as robust a factor in the initial onset of these disorders as it is in relapse after remission.

High EE corresponds to a poorer prognosis.  The relapse rate for those living in a high EE environment is about 56%, 1.5 to 5x the rate for those in a low EE environment.

Professionals are high EE people.  Finally, professionals show a surprising degree of high EE.  We are sometimes a cause of relapse!  But with experience professionals learn to show lower EE and to be more successful with clients.

Three factors in high EE.   High EE does not mean all emotion, certainly not positive, supportive, encouraging, hopeful emotions.  But rather, high EE refers to three factors, Criticism, Hostility, and Over-involvement.

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Therapy Gems: Buzz Words Versus Meaningful Words


One of my supervisors once told me, “Never ASSUME you know what the client means.  Ask and analyze.”

As I was presenting the details of a case to another supervisor, he often would ask me to stop my presentation and to talk about the meaning to me of a client’s comment.  He asked me to freely associate to the comment.  From those intense, lengthy explorations, I learned about the riches contained in every comment… if we teach ourselves to think deeply about each one.  Every comment represents a depth of understanding of our client and our own reactions, all of which can help us to help the client.

I once attended a staffing led by Karl Menninger.  He stopped the presenter after each fact or sentence and invited the group of us therapists to bring out all the meanings we could think of for each fact or detail.

Another influence upon me was the writings of the famous analyst Theodore Reik, who wrote long involved treatises exploring his thoughts, which had been stimulated by a client’s single gesture or comment.

The Solution Focused therapist, Insoo Berg, developed detailed future scenarios with her clients.  Carl Rogers reflected specific emotions, working to be accurate and empathic.

All of these supervisors and masters had a common message to understand the client, to achieve specific, detailed knowledge of the meaning of the client’s words and ideas, and to communicate with the client in specific language.

So, we see that everything the client does communicates all of herself or himself.  Psychotherapy works best when the client experiences the therapist’s empathy and understanding, which in turn requires a depth of understanding.  We need a specificity of knowledge about the client and clear thinking about what each client uniquely presents.  Therefore, to repeat, never assume you know what the client means: ask, ask, and ask.

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Clinical News You Can Use: Anti-Depressants Less Effective in Mild and Moderate Depression


A 2010 meta-anlysis* by Jay Fournier and Robert DeRubeis et al (JAMA, 303, January 6, 2010) showed that for mild-to-moderate depression, medication has little effect compared to placebo.  Most drug studies showing an impact for medications involve patients with more severe depressions.  Therefore, past studies have been more likely to show a strong effect.  This analysis shows that for the larger  mass of people with less severe depression, medication has little impact.  This finding has major implications for psychotherapists.

That psychotherapy alone can be highly effective with Reactive Depression, Adjustment Disorder with Depressed Mood, and mild-to-moderate Major Depressive Disorder is not surprising to seasoned therapists.  But the finding the medication alone is not effective in those cases is a new finding.

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Introducing the Shorehaven Blog: Therapy Gems and Clinical News You Can Use

Welcome to our new Shorehaven blog.

We will post articles, announcements, and news.

Some of the posts will be intended for the public. We will post news and ideas of use and interest to our clients, to families, and to anyone with an interest in metal health, family health, and substance abuse care.

Much of the material will be for mental health professionals.  Amongst other articles, the Shorehaven blog will include short articles about psychotherapy.  Collectively, we will call these copyrighted articles Therapy Gems.  We will also have some short articles called Clinical News You Can Use.  In many cases, we will write a public and a professional article on the same topic so the ideas can be enjoyed by both of our audiences.

We also invite clinical staff and readers to contribute suggestions for topics.

Therapy Gems will be articles about topics which come up frequently in psychotherapy and clinical supervision, such as the use of language, the delivery of an intervention, how to think about the therapist’s words and their impact, and numerous other topics of interest to therapists.

Clinical News You Can Use will be short articles drawn from recent research findings and which therapists should integrate into practice.

The four-person clinical supervision staff at Shorehaven has over 100 years of clinical experience.

We have asked the supervisors to contribute short articles for professionals which meet these criteria:

  • Suggestions for improving skills for newer therapists
  • General clinical suggestions
  • Summaries of important clinical phenomena
  • Recent news in the field

Most of the Therapy Gems will be didactic articles with important pointers and ideas for therapists in the early years of training.  However, any therapist will benefit from re-thinking some key points or reading reminders about the more rigorous thinking discussed in these Gems.

We hope you enjoy our blog and find the articles to be helpful.