Wednesday, April 09, 2008

The Blog as Therapy

This post was inspired by a comment made by Dr Shock on my recent post titled: "Letting People In" .

I found his comment very thought provoking. He said: "...what is interesting is how can a blog help besides "getting it of your chest", what are the therapeutic factors. Another important topic is how can a therapist use the blog for the therapy. Especially when doing a more psychodynamic psychotherapy. For cognitive therapy [CBT] with housework it is relatively easy, you can monitor the progress but with more psychodynamic therapy based on psychoanalytic principles such as transference and counter transference and defense mechanisms it is difficult to use the blog together with the therapeutic sessions."

I was intrigued for a few reasons. I agree that a blog, shared with a therapist, for CBT, would be fairly straight forward. In a CBT situation the blog could be used as a documentation and reference for the activities, goals the patient is accomplishing.

I am not 100% sure I understand what Dr. Shock was referring to when he said " but with more psychodynamic therapy based on psychoanalytic principles such as transference and counter transference and defense mechanisms it is difficult to use the blog together with the therapeutic sessions", but if I understand his comment correctly, I think I believe the opposite . I believe a blog is an incredible way for the patient to clearly layout their defense mechanisms and for the Psychiatrist to have a much more in depth and detailed view of his/her patient's transference. If the blog is two way; one written by both the patient and the pdoc, I could see tremendous value for the therapist to also recognize their countertransference more clearly.

I am very interested, and in fact believe I have been utilizing my blog, more and more to enhance my therapy experience. Second to that my hope is that those who read my blog will see how I struggle and work through different difficulties in therapy; how I depend upon a safe therapeutic experience, a consistent and trustworthy psychiatrist, to both ensure, and allow me to be completely open and honest in therapy. I believe that is the cornerstone of good therapy. If I am not safe to say anything and everything, then I cannot work through the things I have the most difficulty with.

Here are some of my ideas/experiences/hopes for using my blog as therapy:

My experience thus far:
My blog has always been a means by which I both prepare for my therapy sessions and debrief myself AFTER my therapy sessions. This debrief allows me to absorb what I have learned in therapy; to retain the lesson.


My thoughts about my therapy sessions are often much more intense after I leave the session. In the 50 minute session I am so focused on interacting that I find it difficult to clearly reflect on the dynamics happening between Dr. X. and I, or around a specific subject. I often feel so emotional I cannot think straight. While in a highly emotional state I become reactive instead of reflective. To me, what happens between Dr. X. and I; the feelings while we discuss something, my reactions to him etc. are like a microcosm of my feelings and reactions to people in the outside world. Our interactions replicate difficulties in my life. This is super important for me to recognize and work through. My blog assists me with this.

Ideas to enhance my experience and my therapy via a blog:

I have some ideas about how to use a blog to enhance my therapy sessions even further, with each idea I have pros an cons I need to consider:

Idea #1: Keep my current blog and use it IN therapy sessions.

I was thinking of asking Dr. X. if we could together spend the first 10 minutes of my sessions reviewing my weekly blog postings. The next 40 minutes could be spent reviewing what was read/discussed:

Pros:

  • I wouldn't forget to tell Dr. X things like I do now
  • He would have a really clear record of what I'm thinking/feeling
  • I often find it easier to write about a topic, rather than bring it up in therapy. I often use my blog as practice to get brave enough to open up and tell the truth, or explain how I really feel.
  • My feelings, thoughts, experiences etc. are clearly laid out,
  • I could list any medications side effects (I always forget to tell him things),
  • I could clearly list any interpersonal difficulties, successes etc.
  • I could make a simple list of discussion topics,
  • If he wanted, he would have access to the information later( he takes notes, but if he missed something he thinks might be important, the information is there).
  • I could express in clear details what I wanted to achieve in my session (I often get side tracked)
  • I believe he would see transference, projection issues etc. even more clearly than he may already...because sometimes I am more shy or embarrassed to say things in person.

Cons:

  • Privacy (from my employer, my insurance company etc.)
  • Ethics on his part in terms of what he keeps in his files about me
  • Boundaries would have to be really clear with me. I.e. I would not expect him to read my blog on his own time. It would be part of our therapy sessions

Idea # 2: Start a new Co-blog

This idea was inspired by an Irvin Yalom story about how, after each therapy session, he and a patient wrote a brief synopsis about each of their experiences, learnings, understandings etc. in that session. They then shared what they wrote at the beginning of the next session. It was intriguing how each picked different components of the session as meaningful. It seemed like a really interesting way for a patient to learn to fully understand their behaviours and experiences from a third part perspective.

I thought maybe Dr. X. and I could set-up a private blog; with the two of us as co-bloggers. Maybe we could shorten our sessions to 30 minutes and then each of us would be responsible for utilizing 20 minutes sometime during the week for each of us to blog about the experience. At the beginning of each session we would debrief what was blogged by each of us.

Pros:

  • I often leave my sessions and think, what was Dr. X. trying to tell me,
  • What did I miss?,
  • I'm not quite sure I understood what we talked about.
  • Maybe Dr. X. experiences that too.
  • It would be a great way to remember and/or clarify lessons, ideas, sharings, understanding, misunderstanding etc. etc.

Cons:

  • Privacy...I checked out to see if you can set these blogs to a private setting. It appears you can, but I need to find out if private blogs are "googleable", if they are really safe to be 100% open about EVERYTHING, like in therapy.
  • Unsure how the Canadian medical system would view and reimburse Dr. X. for this type of therapy. I would not do this if he couldn't be reimbursed the same as he is now. (I have heard of a new system being introduce in Canada whereby Drs can communicate online with patients on a patient pay per contact basis)
  • A co-blog would be really cool and groundbreaking for others to view therapy sessions in progress...I can imagine it as a really interesting teaching tool for psychiatrists and therapists in training, and for patients in therapy themselves, but privacy in therapy is really a huge part of why I (and I assume many others) are able to discuss certain things.

Idea # 3: Co- Blog as a means of identifying transference/countertransference/defense mechanisms etc.

I think the co-blog would provide the perfect opportunity to address some of these psychodynamic issues.

Pros:

  • You would have to really trust your therapist/pdoc, as there would be no deniability about what was said...it is written down for each of you to see.
  • I see tons of defense mechanisms on my part when I both write and read my blog. My current blog has been a wealth of information for myself, and, if I remember to bring it up, for my pdoc while we discuss these in therapy.
  • Conscious and unconscious thoughts, of both patients and Drs/therapist may become more evident when they are seen on the page.
  • Dreams are there to review and analyze more clearly (I am a great believer in my dreams telling me things, so this is important to me).
  • Feelings could be clearly written about, there for posterity and further discussion and clearer understanding
  • What you write would open doors to both the therapists and the patient's perspectives. What Irvin Yalom discovered was that what he thought was intensely important to his patient was often not the case at all. Often what mattered to the patient, what inspired the patient was some aspect of Dr/patient the relationship that came out in therapy; a gesture of kindness, or respect; a moment where the patient felt really understood.
  • Identifying these could really have the potential to add value to therapy and really move the patient's therapy forward.
  • Alternately, it could also really help therapists identify what really makes a difference to their patients.

Cons:

  • Privacy...again...for this type of therapy to help it has to be very clear that what is said remains between Dr. and patient.
  • If there was not an intense sense of trust between the patient and therapist difficulties might arise in what was written (although with the trust I have with Dr. X., even though I am afraid sometimes, I think I would feel safe and secure in this type of therapy)

13 comments:

Polar Bear said...

Wow, you have certainly given this a LOT of thought.

I think a co-blog would be a great idea, if your pdoc is open to the suggestion and agrees to do it.

I can't wait to hear more about how this will go for you.

I do agree, that a blog is a great place for preparation of a therapy session as well as a place for reflection after a session. This is probably what Imostly do with my blog.

Dr. Shock said...

I think this what you wrote is the essence of psychodynamic psychotherapy: To me, what happens between Dr. X. and I; the feelings while we discuss something, my reactions to him etc. are like a microcosm of my feelings and reactions to people in the outside world. Our interactions replicate difficulties in my life. This is super important for me to recognize and work through. My blog assists me with this.

The question is does that also happen or does it get enhanced by a blog therapy.
Practically I think you need a private blog for co-blogging.

I am a great fan of Yalom, were did you find this information about using the blog in therapy by Yalom?

I think you just wrote a magnificent post on the topic of blog therapy, a classic, take care Dr Shock

Aqua said...

Polar Bear: Thanks for the comment. I did give it a lot of thought. I use my blog now to reflect upon, prepare and enhance my therapy sessions. I'd really like to take it to the next level.

Dr. Shock: Thank you also fror the comments (and the referral on your recent post). I am flattered.

My therapy definately gets enhanced in many ways by using my blog.

From the mundane...e.g. Sometimes I cannot actually say (speak) about what is going on for feeling guilty, or ashamed...but I can hand Dr X. a printout of what I wrote about that topic on my blog...this opens the door to communicating about things I might never speak up about.

It allows me to reflect deeper on what happened in my sessions. Again I often use my posts as a jumping point for what I discuss in my next session.

I agree that for a blog to really be utilized in therapy Privacy needs to be guaranteed, so a co-blog would have to be completely private between therapist and patient (although I would so love to read co-blogs written by other people and there therqpists). I find therapy fascinating.

Re: Irvin Yalom. I absolutely love how he thinks. I believe his style is very similar to Dr. X's. Existential Psychotherapy is really the cornerstone of how I try to use my sessions. The philosophy behind this type of therapy really reaches my soul.

It was not co-blogging between patient and therapist that Yalom spoke of, it was old fashioned writing with each of them writing in journals. I first read about it in his textbook "Existential Psychotherapy" (I love that book and have read it numerous times), but he and the patient turned the journals into a book called "Everyday Gets a Little Closer"...heres a link to the summary http://www.yalom.com/edgcsummary.html

Take care,
...aqua

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Linda Gali said...

Hello, I am starting out MFT and really appreciate your in depth thoughts, candidness, and clear writing. I have often wondered about therapy blogs and their true purpose or rationale as we would call it. Are they for leasure or as a supplemental tool for clients... or just the benefit of all who read? How much is too personal or too professional? after all we do want to connect... and how do they influence the actual therapeutic relationship and perceptions from the public or potential clients? Anyway thanks for the thought provoking post as they stimulate my growth as a new clinician and blogger.

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