A Case Example of How I Work
Walk with me as I walk you through some of the “choice points” that exist as I professionally partner with someone to solve their problem with anxiety. This is not a real case, and it is vastly over simplified. There are many more choice points then what I disclose here. However, by sharing some choice points I face I hope you come to appreciate how complex and powerful behavioral science can be when practiced well.
My hope is you will get a sense of some of the challenges for a doctor who emphasizes not just the importance of being empathetic, but scientific. I think the best doctors are great at being both.
There is a widely accepted myth in mental health/behavioral science that if the therapist/counselor cares enough, people magically get better, regardless of the level of training of the doctor. Even when people have simpler problems, this is rarely the case. Part of the problem is people think of medical science as the “hard science” and behavioral science as the “soft science” because in the latter we are more often dealing with factors that cannot be touched. In reality, behavioral science/psychology is even harder in some ways because there is no one dominant model of human functioning upon which all clinical work, theory, and ongoing research is based. We will have a unified model one day, but for now we must use our scientific skills to use the best available research as we work compassionately to find a sustainable solution. In stark contrast, all physicians practice by referring to a unified theory of physiological functioning (i.e., the cellular model).
So one way a doctor shows they truly care about the patient/client in my field is by working hard to integrate the most advanced (but sometimes competing) models of psychological functioning and apply the most scientifically compelling ones into their daily work. You may now be getting a feel for why the scientific training a psychologist undergoes is so vital…so much is unknown about the mind and the brain. The less we know, the more careful we must be with the little bit of knowledge we have. Practicing behavioral science is like working with a map that is only readable in some areas. And with so many competing theories and treatments out there, you need a sharp analytical sword to cut through this jungle of knowledge to find the path you should take. It is the thrill of being able to break down this complexity and work with it to help others that drew me to this field.
Let’s say Mr. Gibra (not a real person) comes in and reports “I am having problems with Anxiety”. Beware! Even seemingly simple problems (like Anxiety) cannot be only superficially evaluated. In reality, anxiety (and depression, ADHD, and most other emotional/behavioral/learning issues) and its many forms (OCD, GAD, PTSD, Phobias, Panic, etc.) are quite complex. Think about it this way: anxiety is like a “common cold” for psychologists like myself, very common in people, but just because it is common does not mean it is simple. Ask any MD you know how often a cold is misdiagnosed as just a cold, when it is actually something else. You may be surprised by their answer!
Anxiety can be the result of a complex combination of factors falling into many categories including the following: genetic, medical, neurological, cognitive (i.e., mental), emotional, and environmental (e.g., trauma). And this is just to name a few common types of factors – there are others. Each type of factor must be assessed, or treatment is doomed to fail. One of my favorite sayings is “You cannot replace a good history”. No matter how kind, charismatic, or confident a doctor or therapist is, if they are not highly trained, then they can miss critical puzzle pieces. And no matter how much empathy a therapist shows, a caring heart is not enough, though it is an essential part of being a good doctor.
My style is to conduct a thorough but concise assessment so we do not miss any factors. One of my chief criticisms of the field of mental health practitioners is the lack of truly thorough assessment, which leads to mis-diagnosis, overdiagnosis, and lack of helpful recommendations . For example, ADHD is over diagnosed (and people are often over medicated) because so often professionals forget that focusing problems can be caused by factors including the following: trauma, anxiety, depression, sexual or physical abuse, medication, poor sleep, and anger.
Back to Mr. Gibra. Let’s say that through our careful history we find that generalized anxiety runs in Mr. Gibra’s family, but he was also recently in a car accident. So, we have a genetic factor suggesting that in his daily life he is more likely to feel anxious. But, just because he is more likely to feel anxious does not mean he is doomed to a life of anxiety. He can learn skills to prevent and/or manage his anxiety effectively. As a doctor who practices from a wellness model, I do not “pathologize” anxiety, or anger, or many other basic emotions or behaviors. Rather, I teach people to regulate how they experience and express these core emotions so they can channel their power into productive and purposeful behavior that helps them reach their potential. That is what psychological insight does when it is at its best, helps people reach their true potential. So any skills I teach Mr. Gibra are based on the reality that if he is motivated enough to learn certain cognitive, emotional or learning skills, he can reach his potential.
After we learn that Mr. Gibra tends to have a higher level of anxiety in his daily life, we must then identify whether any patterns exist to the ebb and flow of that daily anxiety. If certain situations make that anxiety worse or better, this tells us more about the nature of that anxiety, and helps us design a treatment approach targeted to Mr. Gibra’s form of anxiety. All along the way, we must account for the unique way he is experiencing and expressing his anxiety, given he has a unique personality through which the anxiety is “filtered” . Some people experience anxiety more cognitively, as it makes them “worriers”. Some people may act out their anxiety more, and more impulsively do things like eat food to feel less worried. Some people do a variety of things to cope with their anxiety.
Now, we must remember that Mr. Gibra was also in a car accident. So, we must also make sure he did not sustain any head trauma, as head trauma can also contribute to anxiety if he is now cognitively impaired in any way. Not being able to think as clearly as usual is an example of how someone might be cognitively impaired. But, any interruptions in their thought flow could be due to the physical impact their head made against their window, or it could be due to an increased worry they have about getting in another car accident, or it could be due to both. Again, you can get a feel for how nuanced and complex the work of a psychologist is if they are practicing carefully.
We must also determine if he is having any bad memories from that car accident which is a common occurrence after traumatic experiences. If these memories are occurring, or if any anxiety signs/symptoms began after the accident, we must examine whether he has Post Traumatic Stress Disorder (PTSD). If he does, then this adds yet another layer of complexity to working with Mr. Gibra. Again, a careful history would include asking Mr. Gibra about what kinds of feelings/thoughts/behavior have changed since his car accident, and maybe asking someone who knows him, so objective collateral information is obtained as well.
Let’s assume we have determined that he has generalized anxiety, does not have PTSD (but is a bit shaken up by the accident), and is very worried that he will get into another car accident. After the assessment stage is completed, the next choice point is to decide how to help Mr. Gibra find a sustainable solution to his problems: chronic generalized anxiety, and an added “layer” of ongoing worry specifically about getting into another accident.
I will then find treatments that will provide the most sustainable solution to his anxiety. I will think of the components of the treatment plan as all part of the “Treatment Success Formula” (TSF). I call it a formula intentionally, because the best way for people to get better is often by giving them more than one skill set so they develop a spacious toolbox of skill sets, instead of just over relying on one tool.
So, Mr. Gibra’s TSF will look like an addition “formula”, composed of such skill building elements as the following: “cognitive-behavioral skills + education about how anxiety functions + relaxation skills (so he can calm himself down as necessary) + exposure response prevention skills (to teach him how to avoid worrying even when he is in a car)”. These elements are examples of evidence based methods psychologists have determined to be effective for treating anxiety. Many of these treatments are based on research with thousands of participants over many years where findings have been published in peer-reviewed journals. The clinical scientist for the most part uses treatments that are based in well grounded research, whereas many other types of healers use treatments with no understanding of their relative credibility.
However, no matter how technically competent a psychologist is, the TSF can fail if it is not delivered in a way that accounts for Mr. Gibra’s unique motivations, needs, goals, temperament, etc. In one word, his “personality”. This is where being a good or even great psychologist is about having a feel for how best that person will learn these new skills. How well a psychologist can draw from a person’s set of strengths is critical as well as their ability to make the work compelling and viewed as a meaningful part of that person’s journey toward health and healing.
Again, psychologists at their best teach people skills that their clients find relevant, understandable, comforting, and even at times fun. This is an example of where behavioral science work is highly nuanced and demands sensitivity. Look at it this way: we are asking something more demanding of Mr. Gibra than having him swallow a pill. We are asking him to learn a new set of skills, ones he must practice daily if he is to truly get better.
When people ask me what I do, I have continued to refine my answer over years of practice. Currently, what I say is I am helping them accelerate their strengths and minimize the impact of any gaps in skills sets by teaching them skill sets they internalize and can use to find their potential. Most people I have worked with improved because I used my knowledge of their core personality traits to help them learn and internalize new skill sets so they can reach their potential and find more joy and meaning in everyday life.
Teaching people skills is what psychologists like myself specialize in doing, and what I most enjoy is helping people unleash their potential. Learning new skills is the most common way millions of people around the world on a daily basis overcome new challenges in their lives. But as any coach knows, you must take the personality of the person you are “coaching” into account as you educate and motivate them.
While many people take medication, and this is understandable, they often forget that medication does not teach them the new skills. Research indicates that the learning of new skills is often as powerful (or more powerful) as medication for many conditions. This is not to say that medication does not have a place in treatment. But, my philosophy is medication should be used as a last resort after other methods have been exhausted, since with medication can come side effects and new problems.
I once heard someone jokingly refer to psychologists as “shrinks”. My response was I do not shrink, I expand. I expand a person’s sense of what they can do and the problems they can overcome. In other words, I expand a person’s sense of their own potential. My best day’s are when I am approached by a parent or client and they tell me about all of their accomplishments since ending our work. To witness the incredible growth people can undergo is truly inspiring for me.
Thank you for taking a walk with me as I went through a small portion of the many decisions I must make as I join a client/patient on what is often a very meaningful and life changing journey.