January 29, 2012

Public versus Private

Last September, I started a clinical internship at a chronic pain centre in one of Montreal's hospitals. A few weeks ago, I started a concurrent training program at a private psychology clinic. The differences between these two experiences are striking:

Physical environment and space. The pain centre is housed in a small wing of a large hospital, and there is a distinct lack of space. The clinic director and associate directors have their own offices, but the part-time doctors, visiting fellows, residents, and psychology interns shift around as needed, sharing offices and computers. The rooms in which we see patients are relatively barren, with fluorescent lighting and hospital beds; on busy days when no rooms are free, psychology staff have been known to see patients in the conference room and the kitchen.

In contrast, the office at the private clinic is lovely--exposed brick, plants, and tasteful, comfortable furniture. The handful of therapists all take turns using the office, but when I book it, it's mine and there's no risk of having to conduct psychotherapy in the kitchen.

Multidisciplinary collaboration. At the pain centre, we have biweekly meetings to discuss patients as a team; rheumatologists solicit advice from anesthesiologists, internists seek advice from psychologists, and I learn a lot. If during a session with me, a patient has a question about medication or another component of his medical treatment, I can usually snag a doctor in the hall and get him or her to join us for a few minutes. Sometimes pain centre doctors come into the psych office to see if one of the psychologists or interns is free to sit in on an appointment with a patient and provide an on-the-spot psych evaluation.

Private practice is much less multidisciplinary. At the private clinic, I'm by myself or with my supervisor, who is a psychologist. If I need to, I can (with the client's consent) contact his or her GP or psychiatrist, but it's not usually necessary.

Social support and interaction. At the pain centre, after my patient leaves, I usually go across the hall to discuss the session with my supervisor. I might get stopped on the way by the patient's doctor, wanting to know the result of my psych evaluation; by a anesthesiology resident who wants to know more about CBT; or by a fellow psych intern who wants me to read over a report she's written.

At the private clinic, when the client leaves, I'm by myself. I can call my supervisor at any time, but I'm physically alone and it's easy to see why some therapists find private practice lonely.

Patients versus clients. At the pain centre, we use the term patient rather than client. To me, this term fits because the pain centre is part of the public healthcare system (i.e., it's not for profit, services are free, and everyone has access) and because it's primarily a medical clinic. The advantage: many patients have been waiting months for an appointment and are therefore grateful to be seen and unfazed by an extra hour in the waiting room or by psychotherapy in the kitchen. The disadvantage: some patients aren't keen on seeing a psychologist, agreed to it only because their pain centre doctor insisted, and have no qualms about missing appointments without calling.

In private practice, I see clients--people who have researched and chosen the clinic where I work from among many options, and who are paying to see me. This creates a different dynamic, wherein the client is more of a consumer. A therapy hour is always fifty minutes, both client and therapist are expected to be on time, and clients are unlikely to miss sessions without calling. Unlike in the public system, all of my clients are people with the time, money, and motivation to seek psychotherapy.

Although I'm new to both positions, I suspect that the differences I've observed reflect global differences between working in a hospital or other public clinic and working in private practice. There are clear advantages and disadvantages to both milieux, and it's not hard to see why nearly every psychologist I know works in both.

January 22, 2012

Threat Perception Bias

Threat perception bias refers to the tendency to interpret ambiguous stimuli as threatening. This bias has been demonstrated to be stronger in people who are generally anxious. For example, in one study, a researcher read aloud a list of homophones to two groups--anxious people and a non-anxious control group--and participants in both groups were asked to write down the words. Participants in the anxiety group were more likely than were control participants to interpret the words in a threatening sense, writing down die, slay, and pain, rather than dye, sleigh, and pane.

How does threat perception bias manifest in the real world? Example: A man who suffers from social anxiety speaks to a friend on the phone, and notices that his friend seems aloof. He might automatically imagine that his friend is mad at him for some social gaffe, rather than assuming that his friend is upset or distracted by something unrelated to the friendship. The friend's coolness is the ambiguous stimulus and the anxious man shows a bias by making a personally threatening interpretation.

Threat perception bias is usually related to long-standing or trait anxiety, but two personal experiences have convinced me that it can be induced in the span of hours:

Last week, I was watching an extremely disturbing movie--a psychological thriller that involved, among other things, cabins in the woods and creepy cult members flashing lights through the trees at night. Partway through the movie, I got up to check my phone. When I reached into my purse, my hand felt something unfamiliar and came out holding a palm-sized piece of hardware that resembled a mini-canister. My immediate thought: Someone put a grenade or some kind of explosive in my bag! I felt a stab of true fear in my belly. One second later, I identified the foreign object as the light bulb holder for the paper lantern I had received as a gift earlier that evening.

Similarly: When I was 15, I flew on an airplane alone for the first time. It was a 50-minute flight on a 14-passenger plane, and there was severe turbulence. Air pockets caused the tiny plane to plunge dramatically over and over; food and books flew off tray tables and everyone screamed and clutched their companions. I was paralyzed in my seat, terrified; it was the only time in my life I've ever really thought I was going to die. Safe at home that night, I was reading on the sofa when I heard explosions in the sky. My immediate thought: We're being bombed. One second later, I realized it was a holiday and that the noise I was hearing was fireworks.

Both situations involved instant interpretations of an ambiguous stimulus as life-threatening. I don't usually go around making such wildly inaccurate and catastrophic interpretations, and I'm convinced that my threat interpretation was induced by the respective priming effects of the movie and the turbulent plane ride.

Has this ever happened to anyone else?

January 14, 2012

I'm Watching You

One of the best things I've learned in my clinical training is that everything is information. Everything a client does provides data, and I can use it to generate hypotheses, even before the first session. For example, it's telling when a client asks the receptionist four times how much longer he'll have to wait, even though I'm only ten minutes behind schedule. It's interesting and useful to notice that a middle-aged client is dressed like a teenager, or that a client keeps his coat and hat on when he sits down across from me. 

What can I hypothesize about these clients? The client who repeatedly checks with the receptionist might be anxious, entitled, or both. The middle-aged client dressed like an adolescent might be emotionally immature or fear aging. The client who keeps his coat and hat on might be emotionally guarded and unsure about seeing a psychologist. These are only possibilities, but they allow me to start generating a conceptualization of the client--one that will be reinforced or corrected during the interview.

Naturally, the habit of observation extends outside the therapy office. I notice if an acquaintance is usually on her phone when she enters a party, and I wonder if it's important to her to look busy or if she's socially anxious about greeting people. I notice if a colleague starts every sentence with an apology and try to guess if it's just a verbal tic or if he believes that his contributions to conversation have no value or that others aren't interested in his opinion.

You don't have to be a psychologist to notice behaviour and make hypotheses, and there are benefits to this kind of observation. Say a friend tells you that she's thrilled about her new job, but you notice that she's biting her nails and doesn't smile once during the conversation. You can gently point out that she seem more stressed out than thrilled, and give her a chance to reflect and to discuss her true feelings. If you notice that a friend often busies himself with drinks and hors d'oeuvres and spends most of his time in the kitchen during weekly games night, you can hypothesize that he's unsure of his place in the social group, and--without necessarily saying anything--make a particular effort to include him.

Next time a friend or stranger does something interesting or unusual, or you notice a pattern in a colleague's behaviour, make a hypothesis. You might learn something interesting!