When I went back to see my counsellor (therapist) after a nine month break, she gave me some assessment forms to fill in, including one which asked what issues I wanted counselling for, and what I wanted to achieve. I had difficulty with this form because I wanted to write, ‘I don’t know yet’ and ‘to deal with things better than I would if I weren’t seeing you’. In the past I’ve always had counselling around a specific issue, one which has got me to a point where I’m about to stop functioning altogether. This time is different, I want to stay well and deal with things as they come up, rather than waiting until they get on top of me. Hence I didn’t know what the issues would be, as they often change week to week.
As I was filling out another form, which asked me questions about how I had been feeling in the last week, I found myself worrying that my (distress) score was not going to be high enough and she might say she couldn’t help me. Then I started wondering where that came from. I worked for several years for the NHS (UK healthcare system… for now) in a community mental health team, so I’m very aware of these forms, how they are scored and what they mean. There’s a ‘clinical cutoff’, and you have to score above that in order to access help, and successful treatment is measured by a drop in these scores to below the cutoff. Whilst this is clearly, in part, a way for resource-stretched clinicians to prioritise ‘service users’, and ensure that the service’s limited time and money is allocated to those most in need, I can’t help feeling that it has become absorbed into the (publicly funded at least) mental health professional mindset. It has morphed from what is essentially a matter of finance and efficiency, to being considered the reality of a person’s situation. The only legitimate mental health problems are those that can be treated quickly and effectively, and anything beyond this is untreatable (rather than uneconomical to treat, which is clearly very different).
I remember one colleague telling me that it was important not to pathologise the normal unhappiness that is part of everybody’s lives – if something bad happens, then it is normal to feel sad about it, and that therapy is not indicated unless that happiness lasts longer than it is supposed to. The government’s focus on an extremely short-term, one-size fits all, CBT program called IAPT (Improved Access to Psychological Therapies) locates responsibility for therapeutic success or failure jointly on the patient and the practitioner, rather than on any short-comings of the program itself. The unrelenting quotas can mean that people are cherry picked from the waiting list if their problems look like they will respond sufficiently on paper to the two telephone calls or the eight face-to-face sessions that will be offered. Individuals with complex presentations may go through a more traditional route and end up receiving up to 6 months’ counselling or individualised treatment, but only if they haven’t had too much before. Accessing lots and lots of therapy is seen as being unable to use it properly, not being able to learn from it and apply it in new situations, and this can count against you.
I am one of those people. Not because I have complex problems, or because I’ve had horrible things happen to me (no more than average anyway), and definitely not because I am unable to use it or learn from it. It is precisely the fact that I find it so incredibly beneficial that I ask for more. Sure, I’ve had some courses of therapy that have been of little or no help, but on reflection that has been because the counsellor was trying to work with my impoverished and difficult to articulate emotional self, rather than engaging with my surprisingly self-aware verbal self. I have been criticised in the past for ‘pushing down’ my feelings, and rationalising or ‘over-thinking’ everything, with no recognition of the fact that words are the only thing I know, the only way I can work (due to Alexithymia).
Now that I have found the right counsellor, I come away from every session with so much more understanding of myself and my life, and a clearer idea of what I need to do next. Even though I do find it difficult to transfer learning to new situations, I don’t feel like I am rehashing the same problems over and over. I am very confident in applying coping strategies to recurrences of the same problem. But sometimes I need help to reapply skills I already have to the new situation, because it is similar but I am unable to see that. Therefore part of what she does is to help me work out whether this is like a previous problem, or if it is different and I need to develop a new approach. Another thing she does, which I am unable to do on my own, is help me identify my feelings, sometimes by telling me what expression I have on my face so that I can test out whether that feels congruent. She may also ask me questions, the answers to which make me cry, acting as a signal that this is something which is upsetting me currently. She acts as a translator, explaining situations that I don’t understand, suggesting possible motivations, and pointing out where I might have misinterpreted something or been misinterpreted myself. Most importantly, she validates, rather than challenges, my experiences – something I don’t get from anyone else, even my nearest and dearest.
Asperger’s is a life-long condition, and difficulties like not knowing how I feel, and not transferring my learning, are not going to go away. It is estimated that a majority of people with Asperger’s also have mental health difficulties such as anxiety and depression, which may manifest differently, be harder to spot and treat, and be longer lasting (see this interesting article by the NAS). Given the daily struggles with independent living, communication, social interaction and myriad other things that others do with ease and take for granted, is it any wonder that our mental health suffers? These difficulties don’t go away, so why would our mental health issues be expected to improve after a superficial, short intervention focussed on one situation or one issue?
With the help of the right person I am able to build a tool-kit of strategies to use to try and compensate for the things I can’t do. For example, asking others to identify my emotions for me, or making a checklist of previous problems and solutions, and seeing if any match my current situation. This is not something that can be achieved in eight sessions of CBT, or even in six months’, but needs to be done over the course of my life as the new situations arise, and as and when I am able to fund it. Being able to do this in a safe, non-judgemental space, where I can focus on myself for once, rather than endlessly acting out social scripts, translating social cues and worrying about getting it wrong, is invaluable. I’m not a failure at therapy, I just have such a chasm of skill and understanding (often hidden by my ability with words), that a tiny CBT sticking plaster won’t even touch the sides.
© Catastraspie, 2012.