Reflective essay on professional practice

¶ … Robert Frost poems, "Stopping by the Woods on a Snowy Evening." And after reading it, I had the cognition that yes, I too "Have promises to keep, / And miles to go before I sleep" (1923). I say this because the path I'm on, or really the journey I'm on, is far from over. I have so much to do and I am only in the nascent stages of my long-term career pursuits.

But sometimes it's nice to stop, as the speaker does in the poem, and "watch the woods fill up with snow" (Frost, 1923). That is to enjoy the moment one is in and, perhaps, to look back to see where one has been. To step away from the hustle and bustle of undergraduate school and do a little self-reflection. After all, it was the great Socrates who said, "The unexamined life is not worth living" -- Apologia line 38a (339 BCE). However, here one can draw a distinction between the fugue-like state and wistful self-meditation in the Frost poem and the constructive self-reflection intimated in Apologia. The former implies the emotional experiences one has in looking back while the latter implies a more constructive, goal-oriented process.

The point is that the two are connected, especially with regards to counseling and therapy. To explicate, one cannot engage in a process of self-reflection and critical thinking in an emotional vacuum. One's decisions carry with them emotional weight. The individuals one has worked with and interacted with have had an emotional imprint, whether that imprint is good, bad, or indifferent. So, thinking critically about self-reflection is admitting the limitations of its implied objectivity. It's realizing that emotions are involved in everything we do. Moreover, strictly emotional musing without a constructive element does the professional counselor or therapist little good. The end result of being mired in sentimentality is vanity. One could possibly argue, as Flaubert did, that vanity is the basis for everything we do, and that what one calls inner conscience is only inner vanity, but let one suspend that thought long enough to pretend that what separates the counselor and the therapist from everyone else is that they are cognizant of their own vanity, they can confront their vanity on a daily basis and, as a result, they can control it so that they may answer a higher calling -- to help others. This is what self-reflection means to the therapist and counselor, acknowledging that one is an emotionally-plagued, fallible, human-being, but at the same time realizing that one can hone one's craft and skills as a professional counselor via objective-based self-reflection to affect the lives of others in a positive and meaningful way.

I suppose this is a round about route to my central discussion point, my first placement working with Down Syndrome NSW. However, I think the introductory paragraphs serve as a more macro view of my thoughts and opinions about the process of self-reflection and about the plight of the therapist and counselor. But I suppose that some might find it to be tedious and irreverent. It is convention to graft in a "thesis statement" at some point to clarify things (admittedly, this is a rather discursive start to things). So, here is my thesis: It is the purpose of this paper to examine my intellectual, scholastic, and career-driven pursuits thus far, to evaluate (self-evaluate) how well I am doing on my journey thus far. One last word about the style and (post-modern) voice of this paper, there are times when treating a subject unconventionally is appropriate. I feel that this is one of those times.

The first thing one should recognize about people diagnosed with Down Syndrome (DS) is that the majority of them do not want to be treated as if they have DS. Except for severe cases, the majority of them loathe condescension and pandering and efforts to make things "easier" for them. For many of them, different means deficient. That is, when they receive assistance and guidance that other individuals do not receive, their differences become magnified. Many of them then conclude that this difference is not like a difference in phenotype -- "he has black hair, I have brown hair" -- but rather they see it as a personal deficiency -- "I receive assistance, he doesn't receive assistance, I am therefore deficient." This is compounded by the fact that many parents and guardians create insular and/or protective environments for their children with DS. In many cases, this undergirds their conflicted feelings about self-worth and self-image.

Some psychologists believe that the best way to treat this self-perpetuating problem (i.e. many benefit from therapy and counseling, but that therapy and counseling can also contribute to a deeper sense of co-dependency and, therefore, a lower self-esteem) is to allow people living with DS the "dignity of risk" and the "right to failure." According to Craig Parsons, author of "The Dignity of Risk: Challenges in Moving On," the dignity of risk and the right to failure "is a concept that was first described by people with a physical disability and has since been adapted for people with a mental illness. It is based on the observation that there is a double standard for people who are diagnosed with mental illness and those who are not. People who are not diagnoses have the 'right' to make risky and potentially self-defeating choices without intervention form authorities, clinicians or service providers wishing to protect them from the consequences of their choices" (2007). In this context the author uses "mental illness" not DS. The two are not synonymous terms, nevertheless the "dignity of risk" and the "right to failure" concept applies to both people with a mental illness and individuals with DS.

To be perfectly honest, I was naive to these concepts. And with respect to my placement, as a facilitator for a circle of support around 2 young ladies with DS I had to quickly disabuse myself of both my preconceptions and my naivety. I had to recognize the paradox set before me, the support and counseling my clients were receiving could simultaneously help them and harm them. That is to say, if it was too restrictive and too centered around steering them clear of the rocky shoals of life it would be a reductive endeavor, if on the other hand, it was too laissez-faire and too unstructured it would not deliver the assistance they needed. In many ways my first placement taught me that negotiating between doing too much not doing enough is an ongoing struggle. Furthermore that therapy and counseling is as much about hands-on intervention as it is about letting go.

One way to help find the right calibration between direct intervention and dignity of risk-type approaches is through learning and practicing the various types of therapeutic models out there. I have learned about and practiced several different therapeutic models, including cognitive-behavioral therapy (CBT), personal centered therapy (PCT) and narrative therapy. I've also integrated family systems theory into my repertoire. In enumerating these models its critical to remember that they are not rigid processes incapable of being molded and adapted. On the contrary, many therapeutic models yearn to be integrated with other theories and therapeutic models. Why is this? The answer I've found is that there is no empirically proven therapeutic model that works for all people all of the time. Instead a therapist or counselor needs to be sensitive and attuned to a client's needs and address them via the most optimal therapeutic model he/she knows. And in many cases, it's not just one particular model but a hybrid model that works best, i.e. CBT, which is already a hybrid model forged from behavioral therapy and cognitive therapy, integrated with occasional narrative therapy.

For my long-term goal, which is to eventually open up my own practice and to specialize in grief and loss I have been doing more and more research on CBT and it's ability to effectively treat people suffering from Post-traumatic stress disorder (PTSD). PTSD is essentially a type of anxiety disorder that occurs after one has experienced a traumatic event that involved the threat of death (Gelso & Fretz, 2001). This is certainly an area in which I need to learn more about. What I have found thus far in my research, and to continue with the theme of integrated treatment models, is that despite valiant efforts by psychologists and therapists there is no unified treatment model for PTSD. To explicate treatment for PTSD typically focuses on either the mental side of the disorder and the maladaptive behaviors that result (CBT) or (unorthodox) treatment such as acupuncture that exclusively focuses on the somatic side of the disorder, the physical pain people feel in their back and neck, etc. What I have yet to come across is an integrated therapeutic model that attacks PTSD in a coordinated effort on both fronts.

This is really interesting, at least to me. Studies I've read have shown there is a strong relationship between combat-related PTSD and physical health problems (Hoge, Terhakopian, Castro, Messer & Engel, 2007). One study published in the American Psychiatric Association found that "PTSD has been shown to predict poor health not only in veterans of the 1991 Gulf War but also in veterans of World War II and the Korean War. Our study extends these findings in a group of active duty soldiers returning from recent combat deployment to Iraq, confirming the strong association between PTSD and the indicators of physical health independent of physical injury" (Hoge, Terhakopian, Castro, Messer & Engel, 2007). From this study one can certainly glean that PTSD has a somatic component to it, or at least there is a prevalence in which persons afflicted with PTSD also suffer from physical health problems. One can also assume that the somatic component was downplayed or overlooked in prior studies, as most treatments for PTSD do not seem to address the physical aspect of the disorder.

To elaborate on this assumption one should consider CBT, as mentioned, one of the most researched and most studied treatments for PTSD. To provide a little more clarification on what CBT is, it's an integrated approach that blends cognitive therapy, therapy that address the thoughts that produce and lead to maladaptive behaviors with behavioral therapy, therapy that focuses on curbing behavior (Gelso & Fretz, 2001). In a study conducted to find out how effective multiple-session psychological interventions were at preventing and treating traumatic related stress symptoms shortly after the event had occurred (within 3 months), the researches found that "Trauma-focused CBT was the only early intervention with convincing evidence of efficacy in reducing and preventing traumatic stress symptoms, but only for symptomatic individuals and particularly for those who met the diagnostic criteria for acute stress disorder or acute PTSD" (Roberts, Kitchiner, Kenardy & Bisson, 2009). In other words, despite all the other intervention techniques that were tested and analyzed in this study, only CBT was effective at mitigating stress symptoms for individuals who had manifested symptoms of PTSD and those, in a particular subset, suffering from acute PTSD. Although this may sound like CBT is a formidable treatment against PTSD, it is really not maximally effective as an early-intervention treatment (especially for those who are asymptomatic and who fall outside that subset). But to be honest, there are no real known cures for PTSD or early interventions that will completely eradicate (latent) symptoms.

This study concludes by stating this, "Given the modest overall effects of trauma-focused CBT, the development and trialing of other psychological treatments are important" (Roberts, Kitchiner, Kenardy, & Bisson, 2009). Although the orthodox approach of CBT is modestly effective, more research is surely needed. Psychologists have miles to go before they sleep with regards to finding a super effective treatment for PTSD.

With that said and to address what I alluded to earlier, there are other unorthodox treatments that show signs of promise. One pilot study published by The Journal of Nervous and Mental Disease in 2007 found that acupuncture might help mitigate symptoms of PTSD. Of the 73 people diagnosed with PTSD and examined in the study, those who received acupuncture treatment and those in a separate group who were part of group-CBT treatment both achieved similar results that faired better than the control group (Hollifield, Sinclair-Lian, Warner, Hammerschlag, 2007).

What's interesting about this study is the fact that a treatment methodology was used (acupuncture) that addressed the patient's body. As mentioned above, most treatments (including trauma-focused CBT) neglect a tactile, literal "hands on" approach. Before one jumps to conclusions, I should acknowledge that the findings in the acupuncture study are tenuous. For starters it was a small sample size, it was a pilot study, and acupuncture -- as many practitoners of acupuncture hate to admit -- is not grounded in empirical science or biology. Nevertheless the proposition of combining and integrating trauma-focused CBT with acupuncture and other forms of physical treatment (exercise, running, etc.) is an enticing one. More research needs to be conducted to determine how this two-pronged treatment approach (CBT and physical techniques) can work to maximize PTSD treatment efficacy.