March 07, 2011

What Should I Call You?

When you see your doctor, you’re a patient. When you see your accountant, you’re a client. But what about when you see your psychologist? Are you a patient or a client?

Merriam-Webster says that a patient is an individual who is awaiting or under medical care and treatment or who is the recipient of personal services. A client, M-W says, is a person who engages the professional advice or services of another or a person served by or utilizing the services of a social agency.

‘Recipient’ and ‘engages’ are the key words here. The term patient invokes the medical model, implying that you’re sick or broken and that you’re seeing an expert in order to get fixed (i.e., receive care). I consider myself a patient when I visit the sports doctor, the dermatologist, or the surgeon, and I patiently wait over an hour in waiting rooms for these professionals. In contrast, client implies that I’m paying someone to do a service for me, that I shopped around and selected the lawyer, accountant, or psychologist I want to see, and that they have to listen to my needs and preferences (and not keep me waiting).  I have more power as a client than as a patient.

The choice of term by mental health professionals provides information about the professional’s view of the power differential in the relationship, and about whether or not the professional sees him or herself as working with or for or even on the client/patient. This distinction and the paying/non-paying distinction definitely apply in psychology, where you are more likely to hear the term patient in a hospital and the term client in a private setting. My default term is client, a choice that reflects a general trend in mental health away from the medical model.

Tu versus Vous

If you live and practice in Quebec, there’s a second question to consider regarding what to call your clients. French employs second-person pronouns that connote varying degrees of politeness, social distance, courtesy, and familiarity. Vous is the formal term, used in interactions with people you don’t know (e.g., the maitre d’ at a restaurant), people older than you (e.g., your partner’s grandparents), and people with whom you have a formal relationship (e.g., the VP of your company). Tu is the familiar term used with friends, peers, children, and people who asked you to please, call them tu (e.g., your boss, your friends’ parents).

What should you call your clients?

As an intern doing therapy in French, I was taught to a) always start by calling the client vous, b) if I feel comfortable and think the other person will be more comfortable, propose the switch to tu but c) don't switch without asking, d) and don’t switch back and forth. Of my seven internship clients, I maintained vous with four of them without broaching the topic, and switched fairly quickly to tu with the three others. The three I used tu with were my age or younger and I felt quite comfortable with them. Of the other four, one was someone I saw only briefly, one was someone I was uncomfortable with, and two were clearly older than me (NB: without any discussion, one of the latter four called me tu from the very beginning, something that irked me).

Which is appropriate? 

It depends. Vous maintains formality and distance. This can be a good: for example, if a client becomes overly familiar and starts asking personal questions or for special privileges, the use of vous is one method for maintaining a bit of distance in the therapeutic relationship. However, to a socially isolated client, the therapist’s use of vous could feel standoffish, whereas the use of tu could indicate warmth. Finally, depending on your age and on the client’s age and background, some clients may be just plain uncomfortable with one or the other term.

The choice to use patient or client implies a general attitude, whereas the choice of tu or vous is more of a case by case decision involving age, experience, and comfort level. Both can impact how psychologists think about their role, and how both parties see the relationship.

As the person receiving mental health services, what would you prefer? What does it depend on?

March 02, 2011

Just Don't Think About It

Last time, I described exposure therapy and how it can be used to successfully treat most common fears and phobias. But what if what you fear and avoid isn’t dogs, flying, or heights? What if you’re scared of and avoid your thoughts?

Some people get overwhelmed by worries—What if I can’t pay my rent next month? What if this lump is breast cancer? What if I marry the wrong person and one day get divorced?—and cope by pushing them out of their heads. Cognitive avoidance is the equivalent of putting your hands over your ears and singing “LA LA LALALA!” in order to not hear your scary thoughts. It’s things like distracting yourself with another activity, thinking about something pleasant instead, and avoiding places, people and situations that remind you of your worries.

The problem with cognitive avoidance is that it doesn’t work. Distracting yourself from worries provides short-term relief, but a) the relief you feel when you successfully avoid your thought reinforces the idea that the thought is scary and that you can’t deal with it, and b) thought suppression doesn’t work and your worry will come back. In the same way that crossing the street every time a dog approaches maintains and reinforces a dog phobia, avoidance of worries prolongs and reinforces worry.

The cure for cognitive avoidance is cognitive exposure. Cognitive exposure rests on the principle of habituation, that is, that with enough exposure to a feared stimulus, anxiety always fades naturally. In this case, the feared stimulus is your worry. Cognitive exposure requires you to choose one of your worries and compose a short text describing the worst-case scenario. You have to include all the thoughts and images that you associate with the worry, especially the most disturbing ones; you have to describe the situation in the present, as if it were happening right now, leaving out any reassurances or distractions. In other words, write out your worst nightmare in the simplest, scariest way. 

The exposure part is to interact with the scenario by listening to a recording of yourself reading it out loud. You have to close your eyes, vividly imagine yourself in the situation, and allow your anxiety to mount. Prolonged and repeated exposure (e.g., 45 minutes every day for a week) to your scenario will decrease your anxiety to the point that you’ll eventually be able to hold the worry in your mind without becoming overwhelmed or having to distract yourself.

NB: Cognitive exposure is primarily indicated to help with hypothetical worries (e.g., What if I get divorced one day?) whereas real and current worries (e.g., What if this lump is cancerous?) are managed through problem solving. However, I think that cognitive exposure can be used for both types of concerns. It’s true that if you have a lump (real and current problem), you need to see a doctor; however, if you’re too anxious to even think about the lump, let alone make an appointment, cognitive exposure can help you calm your fear enough to be able to begin the problem solving process.