In the 90’s, Scott Miller and Barry Duncan developed the Client-Directed, Outcome-Informed approach to psychotherapy (CDOI). More recently, Miller along with other clinicians and researchers, developed Feedback-Informed Treatment (FIT), while Duncan developed the Partners for Change Outcome Management System (PCOMS). These innovations in the field center on the idea of understanding and honoring the client’s voice; to understand how they are experiencing the therapeutic process and relationship and to give them agency over the course of treatment. This body of research demonstrates that client feedback increases retention rates and improves therapeutic outcomes. The implication of this new research, for those of us who want to provide best practice to our clients, is to leave the beaten path of rigid model adherence to be client-directed and feedback-informed. Understandably, this may not be as easy as it sounds.
For some clinicians, leaving the useful guardrails of model adherence may feel like following a rabbit trail. After all, we are practitioners of evidence-based models, models shown to be effective in producing positive outcomes for clients. Many of us were taught in graduate school that best practice is synonymous with model adherence. It is the model and how well it is delivered by a clinician that heals people, right? Hubble, Duncan, and Miller discussed the eye-opening common factors of their research in their book Heart and Soul of Change. They showed that the psychotherapy model only has a minimal impact on client change, as opposed to the therapeutic alliance and extra-therapeutic factors, which have the biggest impact. By way of implication, we must consider that clinging too tightly to a model may not ultimately serve the client. That putting all our eggs in the model basket may not constitute best practice. That we need to follow a client when they stray from the path — to follow a rabbit trail — in order to discover the true nature of their issue. And that we need to embrace rather than shy away from the paradigmatic tensions between rabbit trailing and model adherence. How can a therapist hold the reins of these two stallions running in opposite directions and not be torn asunder?
Advantages
What are the advantages of rabbit trailing? A client may need to rabbit trail so as to feel in control of the therapeutic process. We want our clients thinking, “This is MY therapy.” We certainly do not want clients thinking, “This is HER therapy.” Treatment is enhanced when clients feel a sense of ownership over the therapeutic process.
It has been my experience that a segment of clients seeking therapy do not know the nature of the problem that is holding them back. Therefore, a journey of rabbit trailing and discovery is necessary in order to identify the true nature of their problem. Additionally, clients’ initial presenting problem may indeed be a genuine problem, but not the true or core problem. Again, rabbit trailing may be necessary to explore the depths and discover what is holding them back.
Rabbit trailing also feels very organic. Think for a moment how odd our profession is. We sit in a room waiting for people to come and tell us their problems for a concentrated period of time. The relational dynamics active in counseling are unlike anything our clients experience in their daily lives. So, if the counseling process could feel more natural and organic, and less artificial and cold, all the better. The relationship between client and therapist can develop; you and the client are in the dark, together, searching for the answer that is right for the client. Rather than a regimented process where you are doing something to the client, rabbit trailing is an exploration, collaboratively done by client and clinician.
Rabbit trailing allows for issues of the “here and now” to be addressed. If strictly following model protocol, a client’s true issue may not be addressed till session 5, or 6, or 7. Clients may not have that kind of time. Or, rather, they may not stick around for you to get there. And, to be honest, a single model may not be enough. Rabbit trailing allows for other models to be integrated into the course of the treatment as it seems useful and appropriate for what the client needs in the moment.
Cons
What are the disadvantages of rabbit trailing? Some clients may need the regimented approach and may not do well with rabbit trailing. We’ve probably all had those clients who show up for session and look at us, waiting for us to “do” therapy. And hey, I get it. Between patient and physician, that’s kind of how it works. The patient shows up, and the physician does something to them to make them better. There’s a logic to the approach that’s carried over from the healthcare system, and I’ve done it too. So, if that’s what the client wants and needs, then let’s give it to them and walk them through the model.
Rabbit trailing could certainly devolve into weekly check-ins, versus working on something substantive. There is a place for a systematic, step-by-step approach, otherwise, therapy could deteriorate into putting out fires and never truly working on the issue causing the fires. In other words, rabbit trailing could fall prey to chatting and socializing rather than doing serious clinical work.
Rabbit trailing may lack consistency and accountability. For example, with the model adherence approach, there is assessment, intervention, homework and exercises, and then follow up. If a client didn’t do their homework, rather than getting distracted or moving on to a new topic, the reasons why they didn’t do the homework need to be addressed. Addressing those reasons could enhance treatment and client outcomes. With rabbit trailing, you may be ping-ponging issue to issue, week to week, and not keeping clients accountable.
Sam
A father brought his 15-year-old son, I’ll call him Sam, regarding concerns of depression and anxiety due to his divorce with his wife. Sam, he didn’t have much to say about his parent’s divorce. He felt like it happened a long time ago and it didn’t really bother him. He felt like no one believed him and he didn’t have much else to say. Sam seemed uncomfortable and was slow to open up. As sessions progressed, I felt the urgency to connect with Sam and make it comfortable for him to share. I remembered Sam mentioning he wanted to buy and fix up a car. I asked him if he had bought a car yet, and he said he had and was planning on fixing it up, but it would cost a lot of money to do so. He went on to say he felt conflicted; he wanted to get a job to earn money for the car, but that would mean he couldn’t play sports, which he felt okay about because, even though he loved sports, playing in front of other people overwhelmed him with performance anxiety. We weighed the pros and cons of both options and concluded that Sam really wanted to play sports but was paralyzed by performance anxiety. I mentioned to Sam that I had a number of ideas and strategies that could help with his anxiety, at which he became very excited. From that point on, Sam was open and engaged in therapy. Following Sam’s rabbit trail led to the discovery of his performance anxiety and his hidden motivation to resolve it. I was then able to utilize CBT and standard methods to effectively treat his anxiety.
Holding the Reins
Hopefully, weighing the pros and cons of rabbit trailing has answered the question, is it possible to hold the reins of BOTH model adherence and a client-directed/feedback-informed approach? I believe an awareness of the upsides and downsides of both model adherence and a client-directed/feedback-informed approach will allow us to synthesize the best of both worlds. We can operate from a model, loosely, and allow for clients to stray from the beaten path when they need, bearing in mind clients’ need for accountability.
File under: The Art of Psychotherapy
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
For some clinicians, leaving the useful guardrails of model adherence may feel like following a rabbit trail. After all, we are practitioners of evidence-based models, models shown to be effective in producing positive outcomes for clients. Many of us were taught in graduate school that best practice is synonymous with model adherence. It is the model and how well it is delivered by a clinician that heals people, right? Hubble, Duncan, and Miller discussed the eye-opening common factors of their research in their book Heart and Soul of Change. They showed that the psychotherapy model only has a minimal impact on client change, as opposed to the therapeutic alliance and extra-therapeutic factors, which have the biggest impact. By way of implication, we must consider that clinging too tightly to a model may not ultimately serve the client. That putting all our eggs in the model basket may not constitute best practice. That we need to follow a client when they stray from the path — to follow a rabbit trail — in order to discover the true nature of their issue. And that we need to embrace rather than shy away from the paradigmatic tensions between rabbit trailing and model adherence. How can a therapist hold the reins of these two stallions running in opposite directions and not be torn asunder?
Advantages
What are the advantages of rabbit trailing? A client may need to rabbit trail so as to feel in control of the therapeutic process. We want our clients thinking, “This is MY therapy.” We certainly do not want clients thinking, “This is HER therapy.” Treatment is enhanced when clients feel a sense of ownership over the therapeutic process.
It has been my experience that a segment of clients seeking therapy do not know the nature of the problem that is holding them back. Therefore, a journey of rabbit trailing and discovery is necessary in order to identify the true nature of their problem. Additionally, clients’ initial presenting problem may indeed be a genuine problem, but not the true or core problem. Again, rabbit trailing may be necessary to explore the depths and discover what is holding them back.
Rabbit trailing also feels very organic. Think for a moment how odd our profession is. We sit in a room waiting for people to come and tell us their problems for a concentrated period of time. The relational dynamics active in counseling are unlike anything our clients experience in their daily lives. So, if the counseling process could feel more natural and organic, and less artificial and cold, all the better. The relationship between client and therapist can develop; you and the client are in the dark, together, searching for the answer that is right for the client. Rather than a regimented process where you are doing something to the client, rabbit trailing is an exploration, collaboratively done by client and clinician.
Rabbit trailing allows for issues of the “here and now” to be addressed. If strictly following model protocol, a client’s true issue may not be addressed till session 5, or 6, or 7. Clients may not have that kind of time. Or, rather, they may not stick around for you to get there. And, to be honest, a single model may not be enough. Rabbit trailing allows for other models to be integrated into the course of the treatment as it seems useful and appropriate for what the client needs in the moment.
Cons
What are the disadvantages of rabbit trailing? Some clients may need the regimented approach and may not do well with rabbit trailing. We’ve probably all had those clients who show up for session and look at us, waiting for us to “do” therapy. And hey, I get it. Between patient and physician, that’s kind of how it works. The patient shows up, and the physician does something to them to make them better. There’s a logic to the approach that’s carried over from the healthcare system, and I’ve done it too. So, if that’s what the client wants and needs, then let’s give it to them and walk them through the model.
Rabbit trailing could certainly devolve into weekly check-ins, versus working on something substantive. There is a place for a systematic, step-by-step approach, otherwise, therapy could deteriorate into putting out fires and never truly working on the issue causing the fires. In other words, rabbit trailing could fall prey to chatting and socializing rather than doing serious clinical work.
Rabbit trailing may lack consistency and accountability. For example, with the model adherence approach, there is assessment, intervention, homework and exercises, and then follow up. If a client didn’t do their homework, rather than getting distracted or moving on to a new topic, the reasons why they didn’t do the homework need to be addressed. Addressing those reasons could enhance treatment and client outcomes. With rabbit trailing, you may be ping-ponging issue to issue, week to week, and not keeping clients accountable.
Sam
A father brought his 15-year-old son, I’ll call him Sam, regarding concerns of depression and anxiety due to his divorce with his wife. Sam, he didn’t have much to say about his parent’s divorce. He felt like it happened a long time ago and it didn’t really bother him. He felt like no one believed him and he didn’t have much else to say. Sam seemed uncomfortable and was slow to open up. As sessions progressed, I felt the urgency to connect with Sam and make it comfortable for him to share. I remembered Sam mentioning he wanted to buy and fix up a car. I asked him if he had bought a car yet, and he said he had and was planning on fixing it up, but it would cost a lot of money to do so. He went on to say he felt conflicted; he wanted to get a job to earn money for the car, but that would mean he couldn’t play sports, which he felt okay about because, even though he loved sports, playing in front of other people overwhelmed him with performance anxiety. We weighed the pros and cons of both options and concluded that Sam really wanted to play sports but was paralyzed by performance anxiety. I mentioned to Sam that I had a number of ideas and strategies that could help with his anxiety, at which he became very excited. From that point on, Sam was open and engaged in therapy. Following Sam’s rabbit trail led to the discovery of his performance anxiety and his hidden motivation to resolve it. I was then able to utilize CBT and standard methods to effectively treat his anxiety.
Holding the Reins
Hopefully, weighing the pros and cons of rabbit trailing has answered the question, is it possible to hold the reins of BOTH model adherence and a client-directed/feedback-informed approach? I believe an awareness of the upsides and downsides of both model adherence and a client-directed/feedback-informed approach will allow us to synthesize the best of both worlds. We can operate from a model, loosely, and allow for clients to stray from the beaten path when they need, bearing in mind clients’ need for accountability.
File under: The Art of Psychotherapy