Other techniques used with the client included positive “culture of healing” (Fisher 2006) and socratic questioning (Blackburn and Tavaddle 1996). This process of socratic questioning is efficient in that it allows precipitation of feelings, thoughts and behaviours to come together for both E and I and hence lead us both individually in projecting ways forward (Calvert and Palmer 2003). The sessions were structured (Wells 1997) and it allowed a more clear critical formulation of problem with anxiety with E, and hence aid and facilitate recovery.
In my supervision sessions with my line manager, I asked what was my short term goal and what were my long term goals (Johns 1994). I tried to alleviate E’s perceived suffering by using aspects of CBT, specific to the triggers causing onset of OCD symptoms. I was careful not to enforce my own views rather, it was a collaborative process whereby E was able to “see” for himself, the way ahead in terms of coping with his own signs and symptoms. In my position, I was able to reflect on the skills and the efficiency of these, in practice with E and how I could better them.
(Stuart 2001) believes that to verbalise communication with the clients it helps to build a good therapeutic relationship and hence I was trying to communicate to E, the parameters with which we were both working and the limitations with which success could be measured. This helped E to see for himself his own progress over the weeks. Confidentiality and issues around this, like legal and ethical issues need to be conveyed and agreed so that the client feels comfortable (Nelson Jones 2003). I feel E was anxious about the information that he was sharing with me, which in turn, slowed down progress in the sessions. He was reticent and hence not able to speak from the heart and be open (Keats 2000).
I engaged with E in a sensitive way by getting his permission and agreeing what information I was able to share with my line manager (supervisor). My line manager in turn, was happy for me to continue with the initial formulation as it was a necessary step in socialising the client to do CBT in the long term. My line manager asked me why had I done this with E and what was my thinking behind this. It was clear that I needed to understand my motives and strategy as an aid to reflection (John 1994) to which my reply was that though I was able to engage with E initially I had not set the boundaries in terms of confidentially in a manner that E was comfortable with and which needed exploring. When done, this enabled both of us (and hence the formulation and intervention) to work better.
I wondered if E’s levels of self esteem were hindering his progress but I was not able to gauge this initially, in hindsight I should have used, Fennell’s model of development and maintenance to gauge and formulate his problem earlier but I was not aware of it until I was made aware in my supervision session. My own anxiety was an issue as I feel that perhaps I was letting E down but I was made aware that it is ‘normal’ to feel this way. One issue that I raised with my supervisor was that E had negative feelings about Muslims (and I am one). I did not want to create a bias in my intervention work with him and having discussed this with my supervisor, I was able to make a conscious effort not to discriminate according to his beliefs. My re-assessment of myself and subsequent reflection allowed me to work in a more positive way that was professional and empathic.
I feel these processes are best expressed by Proctors Interactive Model (1986) who labels
my introspectivity and emotional response as “restorative-supportive”. Another view supported by Proctors model is the method of gaining knowledge through sessions/discussions with the line manager (supervisor) and applying the new knowledge with the client, hence improving the formulation. Proctor calls this the “formative educational” function.
What factors influenced intervention
Many factors influence the type of collaboration and hence positive intervention experience that can take place, but one of the most important is the way that the relationship between myself-supervisor and myself-E progressed over the period of the sessions. This also happens to be the best way to do formulations. They need to be organic, that is they need to improve and change with the changing needs of the client but at the same time, my own learning experience which is enhanced by my supervision
Of course other factors are; the time limitations of the therapeutic process, the rate of uptake of the homework exercises with E and the relative success with which the process can change from purely medication indicated to CBT attenuated symptoms, enhanced by critical management of the case.
What have I learnt
I have learnt from my practice that reflecting, and in particular continuous reflection is indicated for positive interventions. Driscoll (2000) argues this point by saying that though Proctor’s model is effective, it can only be viewed as tentative guide and that the best outcomes can only be shaped by the practitioners who continuously reflect on their intervention skills and knowledge. I found that E was able to respond better to a formulation that he had a hand in producing than merely a paternalistic standpoint whereby I was dictating. The anxiety that he felt at the beginning were as a result of the inhibitions he had.
Bishop (1994) suggests that all practitioners should have clinical supervision as a means of reflection on their practice. He says that this would improve the quality of the client care overall and hence would ensure quality assurance through quality of service. I also feel that my personal attitude has changed. I am more aware of the differences of approach to formulations and also the differences between care and therapeutic practice, in that I am able to challenge my own age old views on aspects of mental illness. I was also able to work through my feelings when E insinuated that Muslims should leave the UK and when he said he did not want to live in an area where there was any significant concentration of them.
I have learnt that I need to improve my attending skills, I need to organise my therapeutic sessions with my client in a sequential way such that it allows more contact with my supervisor and also more time for introspection. I feel that I have learnt to keep a sessional reflective diary which has helped me to build on my practice learning. I also understand that though E’s OCD had elements of faith focussed obsession, I was able to steer away from what could be termed as “ethically dubious” (Salkovskis 1998).
Instead, Salkovskis advises, that its better to “find the basis of the clients worries, and then try to deal with them in the clients own religious framework”. (Salkovskis 1998; p76).
Conclusion
Through my practice what has precipitated out from the sessional intervention is that clients need and should be empowered with respect to making choices regarding care. In this way they are able to take some control of their own recovery.
Personally my skills have generally developed to incorporate verbal and non-verbal communication, and personal attitudes towards formulising techniques which are more inclusive. I feel that I am developing greater awareness of OCD with faith focus and this will in future, help me to become a better practitioner.
I feel that though reflection is a valuable tool in practice and produces positive effects on the practitioners practice, it does have drawbacks. One of the drawbacks is the assumption that it should allow more influential input from the client and when that does not happen, it can be seen to be paternalistic which can be harmful to the overall intervention and hence recovery.
However both positive and negative aspects are important to understand as they are both valid for us to continue on the path of developing positive interventionary toolkits which are empirical yet organic to reflect the development of CBT.
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