The Performance Trap

We’ve all been there! You assigned your client some homework to do over the week, and they didn’t do it. You might be like me in that upon learning they didn’t do it, your mind starts racing with thoughts like “There must have been a problem with the homework I gave them” or “The assignment wasn’t a good fit for them; maybe they just need another idea.” At this point, I feel a tremendous pressure to not shame the client by dwelling on what they didn’t do, and to come up with another brilliant homework assignment. I’ll then start generating a new idea that I think will work perfectly for their presenting problem. I’ll put a lot of effort and enthusiasm into describing the idea, how it could help them, and how they can practically apply the concept over the next week. The client agrees to practice the idea, record some reflections, and report the following week how it went. I breathe a sigh of relief that I quickly put that fire out and have full confidence that the client is motivated and will come back next week with a glowing report about how great the homework was… I do this only to be disappointed again.

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So what is the right move at this point? Do I abandon all hope that the client will ever complete a homework assignment and therefore never give out assignments again? Do I make a paradigmatic shift and drop homework altogether from my clinical work? Or do I put my nose to the grindstone and continue generating ideas and homework assignments for the client?

Sadly, I’ve found myself stuck in the performance trap, which is the pressure to wow the client every week with a new idea. However, this option comes with many pitfalls. First, the pressure to wow the client is completely misguided. Rather than wowing the client, I should be holding them accountable. They made an agreement to do the homework, and I need to hold them to that. If the situation were reversed, I would have to be accountable to them. And, in fact, this does often happen in the clinical contexts. The client may want me to fill out some paperwork, forward their notes to another provider, provide them billing information, or email them a resource discussed in session. I agree or not, and then I am accountable to fulfilling my end of the bargain. This makes sense. That seems reasonable.

So why, then, do I drop this standard when it comes to the client? Secondly, moving on to another idea doesn’t provide any information as to why they didn’t do the homework. Maybe there is a clinically relevant reason why they didn’t do it. And, quite possibly, understanding why they didn’t do it could be the secret to unlocking the reason why they are seeing me in the first place. Thirdly, the pressure I felt to come up with great idea after great idea was removing the work from the client and placing it on myself. In essence, I was creating a context where my client was dependent on me, resulting in a situation where they didn’t value the work I was doing. Why should they have to act on an idea I suggested this week, when next week I may have something even better?

I can remember a couple with whom I had been working for a few weeks and found myself stuck in the performance trap. We had spent enough time building trust, gaining an understanding of the problem, exploring their story and relationship history that I thought they were ready to test out a few of the ideas we discussed. So I gave them a homework assignment, taking care to explain how it related to their presenting problems, how it would help them reach their treatment goals, and what the homework would look like using practical examples. The couple wholeheartedly agreed to do the homework, and the session ended with a buzz of excitement. When I asked how the homework went during our next session, they put their palms to their foreheads and said, “Whoops! We forgot.” I said, “That’s okay. No problem. Maybe the homework assignment wasn’t a good idea.” And then I proceeded to explore another idea from my therapist bag that could address the problem and get them closer to their treatment goals. Little did I know that this was the start of a trend that would last session after session. After months of getting nowhere, the couple terminated therapy. They said they liked me and appreciated my efforts, but they just weren’t getting anywhere. I now realize why.

As you can see from this scenario, I was fully engrossed in the performance trap. Sure, I felt like I was working hard for the clients, and they even appreciated my efforts, but that had no effect on their making real, tangible movement towards their goals. And that is the whole point. If my efforts are not getting the client closer to their goals, then that is cause for reflection and re-evaluation. So don’t make the same mistakes I did. Rather, follow these recommendations when giving your client homework: don’t abandon giving your client homework, keep your client accountable, understand the “why” when they don’t do homework, resist the urge to generate idea after idea, and (yes, it’s cliché but true) don’t work harder than your client. 

Barry Duncan on The Heart and Soul of Change

Routine Outcome Monitoring

Lawrence Rubin: You’ve dedicated your professional career to improving clinical outcomes and effectiveness at the individual and organization level with the Partners for Change Outcome Management System (PCOMS). Can you tell us what this is and why you think it’s so important for optimizing clinical outcome?
Barry Duncan: It’s really a very simple idea that fortunately has had a great return on investment. The idea is simply that you monitor outcome with clients and you identify those consumers who are benefiting from whatever treatment or service that you’re providing to them. You then put your heads together with those clients that aren’t benefiting, collaboratively deciding what to do next and based on the information of their lack of benefit, create a new treatment plan. Try a different venue of service.
Try everything at your disposal that meets the client’s resources and needs and your own areas of expertise and limitations
Try everything at your disposal that meets the client’s resources and needs and your own areas of expertise and limitations. And ultimately, maybe give them to a different provider if you’re not able to get things back on track. So, it is a process of monitoring clients’ response to treatment, and then using that feedback to determine the way the treatment is delivered. So, if it’s working, you rock and roll, keep doing what you’re doing. If it’s not, then you figure out what else to do. That prevents dropouts, and by recapturing those clients who would otherwise not have benefited, you can improve your outcomes quite substantially.
LR: In the truest sense of the word, and perhaps invoking Carl Rogers, it is truly client centered, for together with them we become partners for change.
BD: That’s exactly it. And that’s the part that the field is a little slower to come around on. The idea of routine outcome monitoring is generally thought of as a therapist-driven process. You know, we monitor outcome and then we get our expert information, we figure out what else to do with people. PCOMS is client directed. We get the information collaboratively from clients and then together, we figure out what to do next based on their reaction to the treatment being administered, their reaction to the services, their experience of the alliance. From there, we can formulate a better path for them if they’re not benefiting from our therapeutic business as usual.
LR: So, your approach to working with clients is really trans-theoretical and trans-methodological. A clinician can bring in their own pet therapy as long as they listen to the client as to how that therapy is working.
BD: That’s exactly it. So, do what you do that works best for you and your clients until you have direct evidence from the client that they’re not responding to that, your business as usual, and then, with that, you can move on and try other things. This also happens to be a great way to grow as a therapist in that you don’t always do what you’ve always done, you step outside your comfort zone and do things you’ve never done with people before, and therefore grow and expand your own repertoire of interpersonal relationship and technical therapy skills.
LR: Didn’t Einstein have something to say about doing the same thing over and over again and expecting different results?
BD: It doesn’t make sense to continue doing the same thing in the absence of response from the client. And we only know if our treatment is working if the client says so, if they are monitoring their benefit and reporting that on outcome measures. We haven’t been very good in our field at changing tracks. When treatment fails, therapists are quick to attribute it to client pathology or resistance. Only later do they consider perhaps that “I’m not competent enough to deal with this person.” So, first, we shoot the client, and then the therapist, right? But we don’t want to shoot anybody actually; we just want to alter the treatment to better fit what the client will respond to.

For the Love of Model

LR: Why are therapists so entrenched or in love with their models and techniques? What makes it so difficult for them to say, “This isn’t working. I need to change?”
BD: Our field has had a long love affair with models and techniques. I mean, we’re really enamored of them.
We begin to believe that our models represent truths about human beings, rather than being metaphorical representations of how people can change
We begin to believe that our models represent truths about human beings, rather than being metaphorical representations of how people can change. We just over-attributed the truth value to all these different ways of thinking about things, and some fit our own view of how people really are, our own view of ourselves, and we hold those close and dear.

That makes it very difficult to say that it’s not the client, it’s actually the method that I’m using, and can we find another thing that’s a better fit? It is very hard to let that sense of certainty go, leaving us with the existential angst. It’s like, “Well, if I don’t have these certainties to hold onto, I’m in the abyss of uncertainty when I’m with clients and I won’t know what to do next.” So, the models give structure and focus to the work, and help us manage our own anxiety when we’re in the room with somebody in a lot of distress.

We also have to acknowledge that there’s no conceivable way that every client will respond to a model and technique that we’re using. If that were the case, we’d all use the same one with everybody that walked in the door. In reality, it’s a far more interactive and changing process that we engage in with clients as we try to figure out what will work best with them. 

The Rating Scales (ORS/SRS)

LR: Ironic isn’t it, that on top of this inflexibility, your research strongly suggests that therapeutic technique accounts for only a very minor portion of treatment outcome. Yet still we cleave! May we shift here to a discussion of your remedy for this dilemma which is routine outcome monitoring and use of rating scales like the ORS and SRS?
BD: I’ll start with the Outcome Rating Scale (ORS). It is a four-item analog scale that asks the client how they’re doing in the major areas or domains of their life: individually, their personal wellbeing; interpersonally, how things are going in their close family relationships; socially, how things are going with them outside of the family in the social world at work, school and with friendships; and finally how they are doing overall in their life. The client puts a mark on each of the four 10-centimeter scales. This results in four individual scores and a total score between zero and 40. It takes about 20 seconds to do.

What clients do, amazingly, is that they imbue their life and their life experience on those four little lines of the scale
What clients do, amazingly, is that they imbue their life and their life experience on those four little lines of the scale, and whatever presenting concern they have, they represent that by the scale they mark the lowest. So, if they’re struggling with anxiety or depression, they’ll usually reflect that on the individual scale. If they’re having a relational problem with a kid or a partner, they’ll reflect that, and so on. And so, it goes from this general view of how life is going to a specific representation of what they’re doing in therapy. And at that point, then, it becomes a valid measure of therapy’s progress.

The Session Rating Scale (SRS) is a classic alliance scale built on the major ways of looking at the therapeutic alliance. In fact, it’s built on Borden’s classic view of the alliance, which is the relational bond, the Rogerian triad variables, the degree of agreement with the client about the goals of therapy and then how you’re going to accomplish the goals of therapy. So, it’s a quick check with that. We do the ORS at the beginning of the session. We do the SRS with about five minutes to go in the session to check with them. In essence, we are asking the client, “how is this for you here today?” This way, we can alter our approach if it didn’t go well or there’s something else they want to make sure that we do.

My own style is to do a wrap-up of the session and a take-home message. I ask the client if they have a take home message from the session, and then I give the SRS to check in with them about their experience of the session, with the idea being that
I’m building the alliance, not just giving lip service to it. I am very interested in their experience
I’m building the alliance, not just giving lip service to it. I am very interested in their experience. 
LR: Are these measures a hard sell to clients?
BD: It is not a hard sell at all. First of all, they only take about 20 seconds to fill out, and so it’s not a big investment of time or energy. And it’s all in how you present it to clients. If you’re flicking forms and not using the information, clients are going to get tired of it in a hurry, but if it’s integrated into the therapy that you’re doing, and it makes some sense and they see the benefit of it, then it’s not a hard sell at all. I simply say, “Look, I like to work and use these two very brief forms. The first one is the ORS, and this is a way to ensure that your voice remains central to everything that we do here, that your view of whether your benefiting is going to actually direct what we do in our sessions. And second, it’s going to be the way that you and I can collaboratively look at whether you’re benefiting, and if you’re not, you and I will put our heads together and figure out what else to do.”
LR: I would imagine most good therapists implicitly incorporate some sort of client feedback into therapy. Is there a real difference between those who implicitly check in with their client and those who use standardized measures such as these?
BD: The other advantage is that you have this incredible data that lets you know your effectiveness, so you can then strive to get better and do things to improve yourself over time. You can actually monitor your career development as a therapist and know whether the strategies that you are implementing, the new things you’re learning, are actually improving outcomes. Also, when you have data, then you have your client list, you can look at your client list, and of course, that’s what software does for you. You know, you have a client list and you can look at a glance and see who the clients are who aren’t benefiting so that you can reflect more about them, talk to a colleague, talk to a supervisor before you see them again. And we found just that process alone, to be more reflective about what you’re doing, improves outcomes, improves effectiveness.

PCOMS-The Heart and Soul of Change

LR: And that’s really where psychology is attempting to go; in the direction of a science-based and empirical-based foundation for what some have otherwise called soft science or an art. I’d be remiss if I didn’t ask you to tell us what PCOMS is. We’ve been talking around it?
BD: PCOMS is the Partners for Change Outcome Management System, the title for which came from the book, Heroic Clients, Heroic Agencies: Partners for Change that Jacqueline Sparks and I wrote. We conceptualized the whole therapy process as working together with clients as partners for change. PCOMS brings this partnership process to routine outcome monitoring using the SRS and ORS to solicit the client’s response to therapy and their experience of therapy through the alliance measure. I co-developed the measures with Scott Miller and then developed the process of using them clinically in what would become the EBP of PCOMS. Jackie and I wrote the first PCOMS manual.

I thought it was a great idea to check in with clients more formally, and I wanted to get therapists to talk to clients about outcome and the alliance. Then, we started doing the research to validate the measures and not only were these short, feasible and easy to do, but they were also reliable and valid when compared against much longer measures like the OQ45, Michael Lambert’s gold standard outcome questionnaire. And then, finally, I was able to say, “Well, gosh, I think this really works. Let’s do the language of science. Let’s do a randomized clinical trial.” And
with my colleagues, Morten Anker and Jacqueline Sparks, we did the first RCT of PCOMS. And since then, we’ve done seven more that have shown the increase in benefit
with my colleagues, Morten Anker and Jacqueline Sparks, we did the first RCT of PCOMS. And since then, we’ve done seven more that have shown the increase in benefit.

We next expanded our research populations and implemented the PCOMS in many large organizations. My own main work has been in public behavioral health, so I really wanted to apply it to clients who are often get the short end of the stick. We’ve shown that use of the system improves outcomes in real-world settings where we can achieve outcomes comparable to those achieved in randomized clinical trials. The final step in the evolution of these ideas is performing RCT’s in integrative care, and then making it even easier through technology. We launched a web version of PCOMS called Better Outcomes Now, which allows the whole process to be automated, easy and very visually appealing to clients. 
LR: Because I’m a child clinician, I wonder what challenges you’ve had using your system with kids, considering their developmental differences.
BD: Great question. There are, obviously, developmental differences, and we have implemented with kids since the very beginning. You know, I did family therapy and seeing children has been a part of my own development as a clinician, and so I wanted to develop measures right away that would apply to kids. Soon after the ORS and SRS were developed, Jacqueline Sparks and I applied these measures to children ages six to twelve. In fact,
the child outcome rating scale is the first self-rated outcome measure for children six to twelve in the world
the child outcome rating scale is the first self-rated outcome measure for children six to twelve in the world, because previously, only parents were rating children that young. When you have a child in therapy, it’s always a good idea to get a parent view or an adult view of how the child is doing, as well, just for the reasons that you speak to. While we validated the measure for six-year-olds, that doesn’t necessarily mean they all get it. They have difficulty connecting the dots between what is talked about and what happens in therapy, and what’s going on in their life from session to session.

By the time a child is nine, they pretty much can make that connection, so you have to use your own judgment. That’s why we always also want to have the parents’ view of how the child is doing. On the research side, we just published an RCT that we did in the UK with Mick Cooper with children under 11 years of age, which demonstrated a very similar feedback effect using the Strength and Difficulties Questionnaire, which is a mandatory measure in the UK.
LR: Am I correct in assuming that with kids, you would use pictures on the SRS rather than words, per se?
BD: First of all, the child versions of these measures are in eight-year-old language, and there are faces. There are happy faces and frowns that give an orientation to the child. It’s basically, “How did it go for you today? Did you like what we did? How are things in your family? How are things at school?” So, it really puts it in a way that children can understand. I think it’s been very nice to do with kids, because kids can be very lost in the shuffle and not have a voice.
I think a good therapist will make sure that children have a voice in therapy, but this systematizes the process
I think a good therapist will make sure that children have a voice in therapy, but this systematizes the process. And whether the measures are valid, I’m still going to use it to check in with the kid.
LR: For the connection.
BD: Yes.
LR: I’m wondering if the PCOMS has been effectively used with families? Are you actually going to give out the SRS and the ORS to six family members in the room, or is that sort of an insurmountable challenge?
BD: It’s not an insurmountable challenge. Actually, it works quite well with families. The more people you get in the room, the greater the logistical challenge, so you’ve got to use it wisely. For example, if I have five people in the room, and the kid is presented as a problem, I’m going to do only the key people. I’ll have everybody do it, but the only data I’ll record will probably be the kid or the main parent that’s there, or both parents, if they’re there. If I also have grandma and a pastor, I’m certainly going to include them in the conversation and get their viewpoints, but the data points will be the parent(s) and the kid.

And you know, in this day and age you can have two iPads in the room for filling out the scales. Twenty seconds each and I’m rocking and rolling. I can put all their scores on the same graph and talk about it in that way. It quickly cuts to the chase with families. I really like that about it, so I’ve used it with families since the very beginning. I know who is seeing the problem the most, who is seeing it the least, what the differences are, and I have them explain those differences to me right at the top of the hour.
LR: I can see therapists believing that they can easily use the PCOMS measures without training. What do you say to them?
BD: I would encourage them by saying, “I’m glad you’re really interested in this and you’re seeing the benefit this could bring to your practice. So, I would just ask you to invest a very small amount of time. For example, you know, on our website, betteroutcomesnow.com, there are 250 free resources. There are 20-minute webinars about every aspect of doing PCOM, so with very little time investment you can access a whole curriculum of reading and watching free videos about how you might do this.” So, I think it’s quite possible for a thoughtful therapist to implement this just with the available resources.
LR: You’ve mentioned, and I’ve read in your work, that you’ve applied the PCOMS at the institutional level in community mental health centers and hospital settings. And I know documentation is critically important on that end of it. What challenges and benefits have you seen in this facet of your work?
BD: There’s almost always, at the very least, institutional apathy, if not resistance. Because the way therapists are in institutions tends to be “Oh, now, gosh, here’s the new paradigm shift. The next one will be five days from now. Let me just hunker down, the storm will pass, and we’ll go back to business as usual here.” One thing that’s helped is that the three main accrediting bodies now require client generated outcome data.
LR: Yours or just in general?
BD: In general. We’re one of the approved ones, but nevertheless, it’s required now, and people are coming to grips. If they’re going to be re-accredited or accredited by COA (Council on Accreditation) or JCAHO (Joint Commission on Accreditation of Healthcare Organizations), they’re going to have to face this. So, that’s the wakeup call to a lot of places which is making them move. However,
if an organization’s mission is to put consumers first, outcome monitoring allows for an operationalization of that mission in a very real way
if an organization’s mission is to put consumers first, outcome monitoring allows for an operationalization of that mission in a very real way. That’s an institutional benefit. As a quality improvement or quality assurance initiative, this allows the organization to know whether any of their initiatives are actually working—the beauty of data. You can know at the individual provider level, you can know at the program level, you can know at the location level.

Let’s say you implemented another evidence-based practice like functional family therapy for your kids who have been adjudicated. So, you spend the money, you get the training, you implement it. You’ll know whether that was or wasn’t money well spent because you’re collecting data on every client that comes in the system. So, besides the benefit of looking at your supervisory practice, identifying at-risk clients and looking at programs to address the needs of people who aren’t benefiting, you can track each program to see which ones are really doing the job for you and which ones are not. And again, not to be punitive about that, but to learn from that data what else you can do to improve your outcomes. The largest public behavioral health venue in Arizona, Southwest Behavioral Health, was an early adapter of PCOMS. By collecting and analyzing data, they have been able to raise the bar of their performance in all their programs, including their inpatient units. So, there are institutional benefits, but it’s not for the faint of heart to implement this. You’ve got to be in it for the long haul. You’ve got to think this whole process through.

The Heroic Client

LR: We began by discussing the PCOMS, its use in the individual consulting room and then its use at the institutional level. I’d like to drop back to the level of the client/therapist relationship and ask about the so-called “heroic client” you discussed in your book of the same title.
BD: I coined the name of that book, like I did The Heart and Soul of Change. Titles are important and in guiding readers. For too long, we’ve thought of the client as this helpless victim of their own psychopathology. But what if we think about clients in terms of what they’ve endured, what they’ve accomplished, what they’ve overcome.
The metaphor of the heroic client was a way of shifting our thinking about therapists riding in on this white horse of theoretical purity and brandishing the sword of evidence-based treatment to slay those psychic dragons that terrorize them
The metaphor of the heroic client was a way of shifting our thinking about therapists riding in on this white horse of theoretical purity and brandishing the sword of evidence-based treatment to slay those psychic dragons that terrorize them. It’s their story of transformation, not ours.

We’re a useful component of change in that story, but it’s not us making those changes, so I just wanted to shift that. The notion of the heroic client is really borne out by the literature which says that the client and their life factors account for the majority of the variance of change in psychotherapy. If look at how change happens—at meta-analytic views of psychotherapy change, about 86% of it is due to the client. If we discard them in the process, or only see the more negative sides of who they are, we are really starting out with two strikes against us in terms of how change happens. In fact, we are embarking on a new, edited book process about the common factors, and one of the themes of the book is that you should spend your time in therapy commensurate to the amount of variance that the different factors account for.

Since client variables account for 86% of outcome, you probably ought to be spending most of your time harvesting, recruiting, activating clients’ resources, strengths and resiliencies. You’ve got to spend a fair amount of time doing that because clients walk in with a lot already to contribute to the process of change.
I call it soliciting these heroic stories, because where there’s pain, there’s endurance; where there’s suffering, there’s coping and where there’s destitution, there’s desire for something different
I call it soliciting these heroic stories, because where there’s pain, there’s endurance; where there’s suffering, there’s coping and where there’s destitution, there’s desire for something different. Those are the sides of the story I want to come out in my interview with a client, these more heroic aspects of who they are. Doing this doesn’t invalidate the struggles that they’re having, but it also puts it next to the other things about them that could be utilized to deal with the struggles they’re having, if that makes sense.
LR: It reminds me very much of some of the basic tenets of narrative therapy and solution focused brief therapy in that it’s really the therapist’s obligation to dig into the life of their clients to find evidence of strength and resilience. You know, it’s interesting. Patch Adams said that if you treat a disease, you win or you lose, but if you treat a patient, you win, regardless of outcome.
BD: It is a real shift, and as you mentioned, there are approaches that line themselves up with that shift, like narrative and solution focused views, and positive psychology as well. The Heart and Soul of Change books have been best sellers because people like the idea. I wrote an article in 1994, published in Psychotherapy and with Dorothy Monaghan, who was a student of mine at the time, about the clients’ frame of reference guiding psychotherapy.

I had been publishing for almost 10 years at that time, but I got more requests for reprints from that article than all the other articles I’d written. I got almost 1,400 of them for that article. So, the idea of the common factors and actually operationalizing them, what that actually means in therapy, really resonated with a lot of people. So, of course, then that led into “The Heart and Soul” and all that business, so I think there are a lot of people out there that these ideas resonate with, and that speaks to this shift and the way that psychotherapy is thought of as a far more collaborative, client-directed process.
LR: In therapy, we try to teach clients, if i may evoke John Bradshaw, how to move from the perspective of human doings to human beings. In your model, we’re asking therapists to do the same, “Don’t be a therapist, don’t be someone doing therapy. Be someone in a caring, monitored relationship with a client, with whom you’re not central, but influential.” It’s almost liberating for the therapist.
BD: I think that is liberating, for sure, and I think that in the course of training, younger clinicians really get that. They like the liberation that flows from the idea that “we’re in this thing together. It’s not solely my responsibility. I don’t want to have to figure everything out, we can come to some terms about what change means.” The measure then provides some structure to that process about how you know whether the client is benefiting and how is the client experiencing their time with me so that I can alter that. So, in that way it does free you from having to know the right way to be a therapist, as if there is some golden right way to be or right method to use. We’ve been in search of that holy grail throughout our history as a field, but it’s not been very fruitful considering all the different models and techniques.
At last “count”, I think it was up around 400 different models and techniques, and still no holy grail yet
At last “count”, I think it was up around 400 different models and techniques, and still no holy grail yet.

In Search of the Grail

LR: Why do you think the field is so hell-bent on finding the holy grail? Is that taking us away from the true holy grail, which is the relationship with the client?
BD: People are so dismissive of the relationship, it drives me crazy. It’s my biggest irk with the field, that people think that, “Oh, you form a relationship and then you do the real treatment.” It’s like it’s anesthesia before surgery, right? We dumb the client down with our Rogerian reflections until they’re asleep, and then we kind of on the sly stick it to them, right? It’s crazy, because you could make a much stronger empirical case that the relationship alliance is the therapy, right? That’s the continuum for everything to happen, all the exploration, and it’s not easy to experience with everybody that you see. You have to work at it. I used to love it when someone would come in and we’d hit it off great, we got down to what we needed to be doing really quickly, but then there’s everybody else. It’s the same with those people who are not so sure about therapy or they don’t want to invest, or they’re mandated, or they haven’t ever been in a good relationship, or they’ve been screwed over so many times. My job is still the same. I’ve got to form a relationship with that person, and it’s not easy. It’s a daunting task. It’s not something I do just because I’m a nice guy. So, it’s those things that are real misconceptions about the change process and the skill it takes to form strong alliances with the varied amount of people that we see.
LR: I can’t tell you how many times I hear from interns, “Okay, I built rapport. Now what do I do?” It’s just amazing.
BD: It’s such a simple idea of just asking the client, what do you think, do you have any ideas? A lot of people have ideas about how things started with their struggles, and perhaps even ideas about what would make it any better? You know, I call it the client’s theory of change, and it’s a great alliance building tool, and a way to dig into their own viewpoint. And you know, what I find is clients have very good ideas. Not all the time, but most of the time. These are worthwhile questions to ask. And you know, what do I do next? Well, what does the client think about that? That’s my broken record in the situation. What does the client say? Then you talk to them about them not benefiting. What are their ideas about that? That’s what you’ve got to do, have a dialogue about this.
LR: What would you offer to the readers who are not really tuned into this whole evidence-based relationship gig yet, or who are not even aware of the value of client-driven informed therapy. What would you offer as closing words?
BD: My closing words to them would be, take a step back and think about the way that they are a therapist, and what their identity is as a therapist, and who they aspire to be as a therapist. And that it is a relational process more so than any other way that you can describe it.
Therapy is not a biomedical process, it’s not diagnosis plus prescription equals cure
Therapy is not a biomedical process, it’s not diagnosis plus prescription equals cure. That’s not what we do. It’s a relational process. The main things that account for outcome in psychotherapy are the people involved, the client, the therapist and their relationship. These account for the overwhelming majority of outcome variance, so they should focus on those aspects, harvesting the client, you know, monitoring their own outcomes and improving themselves in that way, and then putting their efforts into getting better at their relational repertoire.

That would be the way they can improve. In fact, my recipe for improvement is to focus on harvesting client resources, abilities, and the therapist’s alliance and relational abilities. And the way that you can get at both of those things is to monitor outcomes in the alliance with clients. It’s long-winded advice, but nevertheless, that’s how people can get going. And there’s lots of free stuff to help them do that. Very brief videos to help getting their thinking process going about all those things on the website I mentioned.
LR: As you make these concluding comments, I think of medical practice, and it seems that doctors have this built in magic by virtue of their tools, medicines, techniques and machines. I wonder if medicine could be better oriented if it moved in the direction of outcome monitoring, patient collaboration and relationship building.
BD: I think this would be a very nice fit into the primary care world, and in fact, a colleague and I, Bob Bohanske, developed and validated primary care measures analogous to the PCOMS. The next step will be an RCT, and so they’re patient-guided quality of life measures. We believe that if patients improve the quality of their life with treatment, then that will translate to biomedical markers. The physician checking in to ensure that their intervention is what the patient is looking for—the part of their life they’re most distressed about, and then checking in with them that it was indeed a collaborative process, we think will have an impact on chronic illness outcomes.
LR: This seems to be a necessary next step; taking all that you’ve learned from psychotherapeutic relationships to medical relationships and treatment.
BD: Absolutely.
LR: I want to thank you Barry, for the voluminous amount of time and research you put into developing PCOMS, the contributions you have made to the field and for sharing your time today.
BD: Great, great. No, Larry, thanks very much. I enjoyed it. My pleasure, totally.

Daryl Chow on Reigniting Clinical Supervision

Supervision at the Crossroads

Lawrence Rubin: Good morning Daryl. Thanks for sharing your time with our readers. Your research and writing suggest that supervision as it has traditionally been practiced is in crisis. What is the crisis in the field of supervision that you are responding to in your work?
Daryl Chow: I think there are weaknesses in the status quo practice of supervision, and that is something that we should pay attention to and do something about. I think change needs to start to grow from what we know from the research, as well as from clinical practice in supervision. We need to do something that's closer towards two domains: helping therapists improve their performance and, while they're doing that, also emphasize what they are learning. So,
it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time
it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time.
LR: What does it mean to help supervisees or therapists grow and develop, as opposed to just performing in supervision?
DC: In my online course, Reigniting Clinical Supervision, we make an important distinction from the get-go between coaching for performance and coaching for development and learning. Coaching for performance is one way of doing clinical supervision where we help each therapist improve in the stuck cases they are presenting in supervision. This is indeed important in helping them work through the clinical issues that may be blocking progress or preventing them from making inroads in their work with clients.

But I also think what supervisors need to support is an undulating process of helping clinicians with their stuck cases, while also trying to glean general principles with which they can help clinicians then create or identify patterns that are showing up through these stuck cases. It is a matter of looking closely at the cases in which the clinician is not making progress in order to help them in their own personal and professional development. This transcends a case-by-case supervisory discussion in order to focus on the therapist’s growth edge; those skills and characteristics that are generalizable, or what Wendell Berry talks about in terms of agriculture, which is solving for patterns. So, these two worlds of coaching, or supervising for performance and development, need to come together in the supervisory relationship.

If you look at the literature right now from Edward Watkins and others who have done great work in the study of clinical supervision, we have not made any progress. If the outcome of effective supervision is reflected or measured in client improvement, we have not actually moved the needle.

Tony Rousmaniere and his colleagues wrote a paper in which they concluded that
the variance in client outcome accounted for by clinical supervision is less than 1%
the variance in client outcome accounted for by clinical supervision is less than 1%, which means not much, right? That's concerning, because we put so much time, effort, and money into supervision. So, while I don't think I would use such a strong word as crisis to describe the field of clinical supervision, there is definitely a need for change. I really think that we are seeing things slowly changing on the ground level and there are people who are trying to change what we have come to accept as standard practice in supervision. 

Supervising for Development

LR: Okay, so what is the supervisor actually working on when she is focused on the supervisee's development?
DC: Well, the short answer is specific stuff such as the supervisee’s learning objectives. And their learning objectives are based on their performance. I will give you an example. If a clinician was to seek help from a clinical supervisor, that clinician (the supervisee) would first need to have a baseline of their performance, not just at the client-by-client level, but based on a composite of cases that they're seeing that provides them with enough reliable client outcome data.

And then, from those results, they would try to figure out where they're at before deciding where they need to go and what issues they need to address in supervision. I think that's a critical first step, because better results in in clinical supervision as measured by client outcome are obtained sequentially, not simultaneously. By that I mean we need to figure out where the supervisee is at. If their clinical outcomes are average, that really doesn’t say much about what they need to do in order to improve their performance. It is a matter of taking the second step, which is zooming in or focusing on those areas of clinical practice and therapeutic relationship where that clinician needs to improve. Simply focusing on the fact that the clinician is “average regarding their clinical outcomes,” doesn’t tell the supervisor where she needs to focus her lens regarding the supervisee’s skills and development.

So, as an example, if a clinician’s performance was average compared to international benchmarks, the supervisor would then focus in on those cases in which the clinician was stuck. They might listen to some recordings of the clinician’s work to discover that the clinician and the client did not develop therapeutic goal consensus. And it is often the case that
goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions
goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions. You and I both know that the goalpost changes as we go, right?

Sometimes the goal is to figure out the goal, to figure out what is or should be the focus of the session. Then the therapist and supervisor work on that one specific area. And then—and this is the critical piece—if the clinician and client are indeed working on goal consensus, it's important for both the therapist and the client, as well as the therapist and the supervisor, to follow through with the work towards that goal and then determine if doing so actually had an impact on therapeutic outcome.  
LR: And just to define the outcomes variables you're talking about—are you talking about outcomes in the client progress, or in the supervisee’s behavior?
DC: I think you hit on an important note, because the feeling of benefit for the therapist does not mean actual benefit for the client that they work with. Remember, we're dealing with two steps removed from the office, so we need to make sure that the work we are doing with the supervisee translates into positive outcome for the client. It's almost like a paradox if you see two overlapping circles. Yes, it's about the supervisee’s performance, but if you focus purely on their performance, you're not going to go anywhere with the client. You're going to be riddled with anxiety. "Am I doing well? Am I doing badly?" And there's so much judgment involved.

We need to see the impact on our clients and see if our learning leads to impacting the people that we're working with. If the learning was focused on goal consensus, we want to see that it actually translates to an actual impact on the clients that you're working with on that level, on one client at a time. But we also want to see if that helps you to move up your effectiveness above your baseline. 
LR: It seems you're saying that, if a supervisor is good at his or her job and guiding the supervisee effectively in the deliberate practice of therapy, then the client will by definition improve.
DC: Wouldn't you expect that?
LR: I would, but isn't it possible that—and I'm not trying to be provocative—but that a supervisor may be very effective in guiding the supervisee or the clinician in deliberately practicing their craft, but the client doesn't improve? Does that mean that the supervision failed? Or might it just be that something was missed? In other words, can you have good supervision and still poor therapeutic outcomes? Or do poor outcomes in therapy mean that the supervision was not effective?
DC: That's a really good point that world-champion poker player, Annie Duke, talks about in her book, Thinking in Bets. She makes a very important distinction which I think we need to think about slowly and carefully. And the point that she was making is:
we tend to conflate outcomes with process
we tend to conflate outcomes with process.

She says that when we get a poor outcome, let's say in the game of poker, we think that our process is responsible for that outcome. She says we tend to conflate the two. If you take some time to think carefully about how you're making decisions, how you're building the process and making a good plan, then if the outcome is bad, don't make that conflation too quickly.

Because in the game of poker, just like in the game of life, there's a lot of random noise, a lot of things that are beyond your and my control. But if you understand with the help of a supervisor that you are working on something critical—in our case, goal consensus because we know the effect size for goal consensus is huge, then it becomes a matter of focusing more directly on building that particular skill in supervision, not other skills unrelated to goal consensus.

And if goal consensus is indeed important—even if one client doesn't work out well, you don't want to go and throw the baby out with the bathwater. You want to just go back and refine goal consensus building skills again. Close the loop. And this is one thing supervisors and therapists can do, is to make sure that, after a discussion, they close the loop.

It sounds so plain and simple, but I think it's really something that's lacking in supervision as well as clinical practice, that people don't really close the loop by figuring out ways to refine the important skills in supervision that actually impact client outcome. If you continue doing this with other clients, will this have an impact as well? 

Deliberate Practice

LR: Along these lines, you have an upcoming book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, with Scott Miller and Mark Hubble. How can supervisors use deliberate practice to improve not only their supervisee's performance but their own performance as supervisors?
DC:
When we are working in supervision… we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client.
It's a brilliant question, and I know, Lawrence, we've talked about this. My belief at this point is I think that it is critical. We are really in the early days of this type of investigation, but I think it's an important area to work on, and here's why.

My belief is that knowledge is multilevel. When we are working in supervision, we are doing just that because we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client. And let me just use an analogy from the world of music. I'm always impressed by not just what the musician does in a music studio or how they work. I'm always interested in who else is in the room. And one of the things that comes up very often for me is the role of the producer. Sometimes it's the group of artists itself, and sometimes it's someone else.

And a couple of people that stick out to me are Brian Eno, who has worked with Talking Heads, Madonna, U2, and Rick Rubin who has worked with death-metal bands like Slayer. He's worked with many Hip Hop artists. He's also worked with the late Johnny Cash. There’s something about being in the presence of these types of producers that brings out the best in the musicians.

My question is twofold. One, what the hell are these producers doing that brings out the best in the musician? But I also am interested in how I can help others and myself be able to become more like a coach or mentor the likes of college basketball’s John Wooden. And the one thing that I think is becoming a little bit clearer as I go is that we really need a system of practice, a way to systematically organize ourselves around how we think about supervision. So, when I say system, it just means as simple as: how do we track outcomes?

My mentor and collaborator, Scott Miller, talks a lot about feedback-informed treatment. To me, measuring what we value is key, because measurement precedes professional development, so it is critical to help people, supervisees in this case, to systematically track their outcomes and to have a system of coaching already in place by the time they come into supervision.

And then we develop a taxonomy of deliberate practice activities so we know where they're at in the baseline, how to help them figure out a way to deconstruct the therapy hour and then pick up little things that they can work on. So, I guess my short answer, or rather my long answer is really, to figure out a system that can function as a platform from which we can begin to work on the more nuanced stuff in the role of supervisor. Am I making sense about this? 

A Portfolio of Mentors

LR: You are indeed, Daryl, and related to this notion of the producer and artist working in collaboration, you recommended that clinicians build a portfolio of mentors. Does that mean that, even though supervision is, as you call it, a signature pedagogy, that clinicians should build a production studio of sorts with other professionals? 
DC: As much as supervision is a signature pedagogy for our field, what's interesting for me of late is how people reaching out for consults or coaching often follows having given up on working with a supervisor for various reasons, unless they are in an agency setting where that is provided. But, yes, I think the idea of a portfolio of mentors is to say that
if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you
if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you.

And what you want to do is to create a community of people that you can turn to, that you can talk with, and then maybe a certain person you turn to more routinely. For instance, I've known a supervisor for more than a decade, and I always return to her. But if there was something else that was missing, or I wanted to stretch out and pick another mind to think of it from a different perspective, I would reach out to other people, even people who are so-called experts, and send them an email. I would ask them, "What's the fee? Can I come talk with you?" And most people are friendly. 
LR: In a way, isn’t that what you are trying to provide through your online supervision training, Reigniting Clinical Supervision?
DC: My focus for Reigniting Clinical Supervision is to help clinical supervisors design better learning environments that sustain real development for therapists, so as to achieve better client outcomes. The choice of an online learning platform is not a mere substitute for live teaching. Instead, gleaning from the best of what we know of optimizing learning, adopting a “one idea at a time” drip-based method of delivery of content and maintaining learner engagement, helps the busy practitioner weave what they learn into practice, and return to renew and reconsolidate new knowledge as a result of being in the course with me and other clinicians/supervisors.

Here’s how I think about the difference between a live training and how Reigniting Clinical Supervision is designed: A real-time training/workshop is like a river. It is a constantly flowing torrent of ideas. If the learner steps out of the river for a few minutes, or needs some time to think, he is now behind. The learner may be able to ask questions but needs to constantly try and catch up and not fall behind. A chance for a revisit of the content after some time of reflection is not possible, with only the notes or slides that you've captured.
Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time
Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time, and pace herself as she moves along; the water remains the same. This stillness allows for pausing, revisiting the material, reflecting, and connecting with past knowledge. Online learning at its best allows for the learner to ask questions, revisit the materials, and for the person to master a difficult segment before moving on.
LR: Within this community of mentors model, there are different factors that predict therapeutic outcome. They include goal consensus, alliance and repairing therapeutic ruptures. Can the same principles be applied to improve supervisor performance and development?
DC: Hopefully, that's paralleled or modeled within the supervisory work. I would encourage supervisors to also elicit feedback within the supervision. And most of us do that, but it is also important to do it in a way that's a little bit more about a ritual. This would mean using some quick check-ins that give the supervisee some space to think about it, and then to explore the nuances of the supervisor/supervisee relationship. It's much harder when you really know somebody well, like the supervisor knowing the supervisee, to give feedback.
LR: Have you experienced working with expert clinicians who are lousy supervisors?
DC: I'm thinking of the converse. So, let me look back in my mind. I don't mean this in any disrespectful way because I really respect this person's work. Jay Haley of the strategic school of family therapy talked about this and said that he was really good as a supervisor, but not as good as a therapist [laughs].
LR: I think of myself as being a better supervisor and teacher than therapist. In your language, perhaps that’s because I have not deliberately practiced therapy.
DC: Yes, right.
LR: I've performed therapy, but in the words of Scott Miller, I've not deliberately practiced it. So, it's interesting that just because someone may be a very competent clinician, it doesn't mean that they have the patience or skill to guide a fellow clinician as a supervisee, and vice versa.
DC: This harkens back to your question about the role of training supervisors in how they do deliberate practice, because, to me, there are overlaps, of course, but there are also distinct skills required in their roles as supervisors and therapists.
The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction
The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction.

Cardinal Supervision Mistakes

LR: Talking about getting lost in the weeds, you wrote an article for us about seven mistakes in clinical supervision. If you were to pick the top two cardinal mistakes from that list of seven that supervisors make, which ones flash red to you, and what can supervisors to do about them? 
DC: This is tough because the language around mistakes is all negative. I think, for me, the one that I've seen in my own experience and through my own mistakes is that of too much theory talk.
I think we talk too much. On the ladder of abstraction, talk is quite high up there
I think we talk too much. On the ladder of abstraction, talk is quite high up there. Bear in mind, when we're in supervision and in the absence of the actual client, we spend all our time talking in abstractions, at the level of theories about the client rather than about the therapeutic relationship.

When we're doing that, we've got to bear that in mind, that we don't have that person there, and we're talking at the level of theoretical abstraction, so many steps removed from what is occurring between the supervisee and the client. It's very easy to speak of it from whatever orientation or whatever philosophy you hold, without joining the dots of what's going to ripple down into the actual therapeutic relationship where the real work is happening.

Another big mistake in supervision is that when the clinical work is stuck and the supervisee and client are not making progress, the supervisor may say something in an attempt at being supportive to the supervisee like, "Well, at least they keep coming back, right?" In this instance, the supervisor is doing little more than what I call, patting them on the back–encouraging the supervisee without giving her any clear direction out of the stuck situation.

I'm really conflicted about that statement that I hear very often. Is that good enough for you, that they still come back? Or what else? What else can we be thinking of? How do we escape this domain of just talking on their level and to be able to make some real impact?  
LR:
Another big mistake in supervision is…encouraging the supervisee without giving her any clear direction out of the stuck situation
I know that being able to effectively conceptualize a clinical case, to think about it from different theoretical perspectives, is important. But you're saying, Daryl, that sometimes we err on the side of overthinking the theory at the expense of guiding the supervisee in building the relationship with their client, and then we congratulate the therapist for minimal progress? Seems like damning by faint praise.
DC: Yes and no. I think all prudent supervisors know that therapeutic relationship really matters. And by therapeutic relationship, let's be clear, it's not just about the emotional bond, even though that is one critical part. But the other part is the focus, which is about the goals, the directionality, where it's going. The next is also about whether there is a cogent method for both the therapist and the client. Are we in agreement? Is there a fit in where we're going? All those things relate to the therapeutic alliance.

I think most people are focused about that. But as you will see in the upcoming blog that I am writing for Psychotherapy.net, I will be talking about the three types of supervisory knowledge. One type of knowledge is about the content knowledge, about the clinical case, about the psychopathology. Those things are necessary but not sufficient. The second type of knowledge is the process knowledge about how you engage with somebody who's, say, depressed? How do you engage with somebody who's anxious? That's a process or type of relating kind of knowledge. How do you have that kind of conversation? As David Whyte, the poet and philosopher, would say, "the conversational nature of reality." How do you engage in that? How do you come into being with another person into that field? But the third one is conditional knowledge, which is; if you're working with somebody who's depressed due to bereavement, it's going to be very different than when you're working with somebody who is depressed as well but due to, say, domestic violence. The context is very different, and you need to figure out a way of relating with them given the different situation. So, by considering all three of these in supervision; playing into the content knowledge, process knowledge and conditional knowledge, I think the supervisor can synergize them for the benefit of both the therapeutic work and the development of the supervisee. The supervisor and supervisee having this multi-level conversation will benefit both the client and the supervisee. 

The Humble Teacher

LR: What do you see as some of the important personal qualities of an effective supervisor or a clinician who might become an effective supervisor?
DC: For me, of course,
a good teacher is somebody who is willing to be a good student
a good teacher is somebody who is willing to be a good student. If I'm picking a supervisor for myself, I'm always looking for somebody who implicitly—and it's not something that people would say explicitly, is willing to be wrong, willing to seek the counterfactuals, and then to have by default a stance of humility not just because they're trying to act humbly or bragging about their humility.

This humble teacher will say, “Hmm. Oh, hang on a second. I've really never thought of that.” And they're rethinking. That, to me, is interesting. And it's not because they don't have a wealth of knowledge. It's because this is dis-confirming what they know. And that's so exciting. That's like fresh air, you know, when you're working with somebody that way.

Additionally, somebody who has mental models or mental representations and concepts in their head about different ways to think about clinical situations and suggestions for the supervisee. They know that when they're facing this kind of situation, they have what Gerd Gigerenzer calls fast and frugal heuristics. They have little maps of how they will approach stuff. You know, they've thought it through before. They have ideas in their memory bank that they will pull into their working memory.

And you know that because when they're just giving off-the-fly statements, you know that it's off the fly. But if you know that they've thought about it, you realize their mental networks are vast. They know that it's an “if-then” situation, and they're thinking about it and all kinds of communications. That excites me because that shows to you this person has done some thinking before meeting with you. 
LR: Is this what you refer to when you say that true experts think like novices, or beginning therapists, while true novices think they're experts? Is it related?
DC: I think so. [chuckles] I think so.
LR: I like that idea that the expert supervisor, who may or may not be an expert clinician, has these—what did you call them—fast and frugal heuristics? Was that the term that you used?
DC: That's right, and I mean that's the term from Gerd Gigerenzer, who studies cognitive science. He talks of the importance of having these sorts of heuristics. You know, the way we've been terming it is mental representation. Things that happen might not just be easily explained using therapeutic models but by different ways of thinking. Like, what do you do if you meet somebody who is angry or depressed in the session? These heuristics or maps are not like stock answers but are based on clear principles that flow from these mental representations. What do you do with somebody who doesn't have a goal? How do you work with them? They have a rough and ready guide.

At the Cutting Edge

LR: So, the supervisor should aspire to flexible thinking, drawing on different belief systems, different ways of looking at the human condition, different interpretations of the same clinical presentation? It sounds like the advanced supervisor is out at this cutting edge of creativity, untethered to any one way of thinking.
DC: Yes.

This domain of creativity is something I'm really interested in. I think one thing we need to remember about creativity is that it's about something novel and something useful coming together? Wouldn't it be great if supervisors were not restricted to thinking solely in terms of the field of psychotherapy in the course of doing their supervision, and could bring in greater creativity?

Just thinking about architecture, music, art—thinking about other aesthetic forms and how all of these can inform ways of thinking. Coming back again to the example about goal consensus, why do we need to only think about this within the domain of psychotherapy? Why don't we learn about how other fields and business organizations think about creating focus? 
LR: So, we should consider using a flexible system of metaphors that transcend psychology and psychotherapy. When we first contacted each other, I mentioned that there seemed to be almost a spiritual undertone to the way that you described your personal philosophy of living and helping. Am I seeing it correctly, that there's a certain spirituality or spiritual dimension to your work as a clinician and a supervisor, and perhaps we should embrace that as well?
DC: Well, I'm grateful that you picked that up. To me, the answer is yes. And I think that's personally a deep embedment in my life. I was raised a freethinker from my Singaporean days. You know, this means I'm free to think or whatever that means. But I converted to become a Catholic when I was 21. When everybody else was running out of the Church, I was going back in. So, to me, that was my start.

But I think, fundamentally beyond religion, what's really driving me on a first principle level is human dignity. And the way I think about this is that
if a person comes to seek help and opens up to another person, that's a sacred moment
if a person comes to seek help and opens up to another person, that's a sacred moment. We need to honor that. We need to figure out a way that we can help each other come alive, because it's not just about creating purpose and meaning, but it's really to help each other come alive. And the therapist needs to come alive. The therapist needs to be alive and kicking and playful and to be able to ignite that. And the therapist also needs help and guidance from a supervisor. And for the supervisor to do that, the supervisor also needs to come alive. 
LR: I remember Bill Moyer’s interview with Joseph Campbell at George Lucas’ Skywalker Ranch. He said to Joseph Campbell, “So, you're saying that people are searching for the meaning of life?” And Campbell said, “No. People are searching for the experience of being alive.” How does that find its way into the world of supervision, that tripartite relationship between supervisor, supervisee, and client? Where does that element of being alive get infused in that three-level process? And whose responsibility is it?
DC: Sounds like a family.
LR: Yeah, doesn't it?
DC: Yeah. I think everybody is going to come into play. I think it is the interaction. It's this ecology of a systemic perspective that's going to be important. How does it come alive? You know, I think we need some kind of platform for this to work, which we have talked about. But I think it critical is to keep this conversation going. Once we see that therapists are working hard to improve in what they are doing—once they figure out the baseline, once they figure out what to work on based on the baseline, then they develop a system to help them do their practice on an ongoing basis. And that they see the payoff of what they're doing.

It's like your child who's worked hard for the math test and starts seeing see the result. There's the real payoff. I mean the whole temperature of the room changes. Their focus becomes more intrinsic. And at that point, the role of the guidance is going to evolve as well. There's always going to be state of change. You’re right when you pointed out that quote from Joseph Campbell as well. That's something I'm very familiar with, and I think it's important that we continue to keep the conversation alive within clinical supervision as well as at the level of the therapist and client. 

Fanning the Flames

LR: So, just as we encourage clinicians to take care of themselves and to grow and to rest and to seek meaning and a reason for being alive, so too must supervisors continually replenish and rest and grow and seek internal expansion, because if they wither, then the supervisee withers and the client withers. Who are the roots, and who are the leaves in this tree? It's a quite interconnected system.
DC: [chuckles] It is. It's just like our world now, isn't it? I mean I'm suddenly reminded about this teenager from Sweden that's really been striking me about what she's doing. I don't know if you follow the news about Greta Thunberg and how she's doing this protest about climate change and rallying a million teens around the world to protest about how the adults in this world had better take this seriously. And she's been going on global forums just speaking about this.

And I heard one of her speeches which she starts by saying, “Our house is on fire. What would you do if your house was on fire?” And she expands on that. And I think that's so important, that somebody her age is speaking about this. 
LR: So, supervisees must find ways to, in your words, reignite supervision. I have one last question. You were born in Singapore, you live and practice in Australia, and you've traveled the world doing training in therapy and supervision. What have you noticed about teaching and supervising cross-culturally?
DC:
I think the first thing that comes to my mind is how similar across culture we are in terms of helping people
I think the first thing that comes to my mind is how similar across culture we are in terms of helping people, trainings and our roles as therapists and supervisors. But, of course, each culture has its own subcultures that you're dealing with. But to me, really what's striking is how much similarity there is. We're all in the same boat.
LR: What do you mean, the same boat, Daryl?
DC: We're all struggling to get better. We all want to. I mean all therapists and all supervisors want to do a better job. And that propels us. That makes us stay hopeful. It makes us invest time, money and effort to go and do CPE [continuing professional development] activities. You know, we're all trying to get better. But what's implicitly underneath that wish to get better is worry. We do worry about, “Am I getting any better? Is what I'm doing really helping to translate?”

And people are asking this question as they are looking deep, long, and hard. And I think the onus is on us as a collective, as a field, to start to come together, to start to build this brick-by-brick, to help out from the therapist's level and the supervisor's level, and to help us build this house, build it up again, and to help us to get just that 1-2% better each step of the way. Because the payoff and the morale that comes with that is going to move us even further. 
LR: So, if everyone in that multilevel relationship strives to be a little bit better, then the whole system becomes better.
DC: That's right.
LR: If client outcome improves, then that goodwill is shared beyond the therapeutic space. If the supervisor is dedicated to practicing their craft, then they are in a better position to teach clinicians. And if clinicians practice deliberately, they are in a better position to help their client. And that is consistent across cultures.
DC: That's right. And, you know, I'm not the only one who is doing this, but I think I've started doing this whole thing about clinical supervision because I think we are a critical piece to the puzzle. And I think this one little story might help to illuminate this. You know, this gentleman, he knocks on his son's door, and he says, “Jamie, wake up, please. Wake up. You've got to get to school.”

Jamie then says, “I'm not going.” And the father says, “Why not?” He says, “Well, Dad, there are three reasons. First, school is so dull. And second, the kids tease me. And third, I hate school anyway.” And the father says, “Well, I'm going to give you three reasons why you must go to school. First, because it's your duty. And second, because you're 41 years old. And third, because you are the headmaster.”
LR: [laughs]
DC: I think we play that critical role. We do need to show up. And when we show up, we then need to think about what's our status quo and what's the one thing we need to start in order to refine our work to bring us alive again.
LR: To play that instrument a little better, to hit that tennis ball a little straighter, to run a little bit more efficiently. The supervisor must have a commitment to continued growth and development if the supervisee and the client are to improve.
DC: Yes, and I will say one last thing, if I may, Lawrence.
LR: Of course.
DC: If we use the musician analogy, I don't think it's to play the instrument a bit better.
LR: No?
DC: I think it's to play the instrument well enough but to be able to become better songwriters. I think that's a tougher job, because you can get technically better as a musician, but to write the next Hard Day's Night or Yesterday or Bohemian Rhapsody, I think that's a different skill. And I think we need to find a way to become better songwriters in our field.
LR: So, we can make better music together and because the audience is indeed listening.
DC: That's it.
LR: I think on that note, Daryl, I'm going to say goodbye, and on behalf of our readers, thank you so very much.
DC: Thank you.

Dual Aspect Monism: Centering Psychotherapy on Mind

“My brain needs to be fixed.” My prospective client looked down, then up, to search my eyes.

The statement is deceptive in its simplicity. I feel an involuntary retreat from almost all the multiple layers of meaning I can fathom for the utterance. I don’t think my client’s neuro-chemical functioning is the cause of his pain. I think I can help him more effectively if we explore his mind.

Back in the day, there was body, and there was mind. Medical practitioners treated bodies. Therapists and analysts treated minds. Every binary hides a hierarchy: the people who treated bodies were highly respected. Those who treated minds were considered, well, a little off.

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Then people started realizing how much mental and physical functioning affected each other. They can’t be completely separate. The obvious solution (that preserved the hierarchy) was that mind must be an epiphenomenon of brain. Somehow, matter (brain) behaves in a way that creates a non-material phenomenon (mind). The battle cry became “mental illness is disease of the brain.” If you believe that mental illness is a disease of the brain, the way to fix it is to alter the brain. Chemically, surgically, magnetically, whatever. Talk therapy in this scenario is a poor substitute for direct neuro-chemical intervention, and one glorious day we will remember psychotherapy as a treatment analogous to applying leeches.

Except…logic dictates that the effect cannot impact the cause. The effect cannot precede the cause. So, if mind is caused by body, then mind cannot, logically, affect the body; a change in mind cannot precede a change in the body. And yet we know that it does. So maybe mind exists separately from the body after all? But if they’re separate, we’re still left with the problem of how two completely separate things can interact with and affect each other, as we know mind and body do.

As an ontological position (a statement concerning the nature of reality) offered by some philosophers of mind, Dual Aspect Monism offers a simple solution. The position is that there is a single reality that has two equal and irreducible aspects: mind and matter. Prior to the development of Dual Aspect Monism, there were basically three competing views concerning what is real. The dominant view today is Material Monism. From this perspective, reality is believed to be that which has physical properties. If you can’t measure it, it isn’t real. From this perspective, mind is the product of physical (neuro-chemical) activity. Idealistic Monism is the view that what is real is mind, and that matter is an illusion generated by mind. The third ontology is Dualism, which posits that mind and matter are both real, but they are completely separate realities. If they are completely separate realities, it’s hard to imagine why changes in one covaries with changes in the other.

According to Dual Aspect Monists, there is a single reality that is both physical and mental. Neither of these aspects is derived from or reducible to the other. These aspects are like two sides of a coin: you can’t make the head side of the coin square without altering the structure of the tail of the coin. But this does not mean that the change in the head caused the change in the tail. It is the change in the coin that changes both the head and the tail. When we use this analogy to understand humans, we see that some changes are more easily accomplished if we focus on body (I would not suggest that we focus primarily on mind to treat cancer), others may be more malleable by focusing on mind (I would not want to give a client a drug to help them develop a more fulfilling sense of self).

The implications are profound for psychotherapy: if mind is real and irreducible, we can legitimately aim our interventions directly at mind. We can use our minds to help clients change their minds. That means that our minds are the mutative factor in therapy. More precisely, the connection between our mind and the client’s is the mutative factor in therapy.

This means that some of the most profound changes our clients experience are changes in qualia (purely subjective experiences), and hence difficult to put into words, let alone observe from some outside objective position. It means that we know when our clients are improving because our minds are working together, and when their minds change, ours does too, a little bit. It means that what I do/say next is completely dependent on what my client and I are experiencing in the connection, not on some pre-determined protocol. That, in turn, means that my mind must remain attuned to the connection between our minds, not busy trying to problem solve, predict, or control the direction of the process.

We are psychotherapists. Many of us entered this field because the human mind is fascinating to us. Some of us have felt that the understanding of what we do has been slowly eroded as mind has become more and more devalued as an epiphenomenon of body. We always knew the two were connected (Freud was, after all, a neurologist). But many of us also know that what we do is not best captured by purely physical descriptions, or best understood using methods designed to understand the physical world. For us, dual aspect monism offers a way of understanding the world that explains what we do.

“Can you tell me what it feels like for your brain to be the way it is?” I try to join my client’s quale. By seeking to do so my mind reaches out, searching for, inviting a connection that can lead to change.  

It’s Time for Supervisors to Help Clinicians Marry Data with Intuition

“It’s easy to lie with statistics, but it’s hard to tell the truth without them.”
—Andrejs Dunkels

Nearly every therapist I ask says that they regularly monitor the progress of their clients. Besides, why wouldn’t therapists check in and ask for verbal feedback?

Yet, given our clinical expertise, how is it that the assessment of our client’s progress is often inaccurate? In addition, why is it that therapists’ view of the process of clinical engagement is less predictive of outcome than that of their clients?

I believe this is because of our over-reliance on clinical intuition. We are trained to listen and take heed of our gut sense. Don’t get me wrong; intuition is critical, as scores of studies on this topic will attest (see Gary Klein’s body of work). Yet, relying solely upon clinical intuition is like asking a physician to treat a patient without the use of a stethoscope, a thermometer and the results from a bloodwork.

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From Assessment Thinking to Conversational Thinking

It’s time that practitioners learn to use outcome measures and engagement tools as part of regular clinical practice. And not merely as assessment tools, but as conversational ones. And to make this happen, clinical supervisors need to be on-board, trying it for themselves (especially if they are also practitioners), learning as much as they can about how to integrate measures as part of treatment and then teaching them to supervisees.

I once had a supervisee who wanted help getting “unstuck” with a client. We talked at length about the presenting concern, clinical background and what she had previously tried. The supervisee and client had just completed their 4th session when the therapist described that “things aren’t moving.” In other words, there was no discernable clinical progress.

Therapist View of Progress in the First Four Sessions.

I asked if she used any form of measures in her work. I learned that this therapist had been using outcome and alliance measures in her practice, but had not reviewed the graphic description of those measures. She was using the measures only because the management team insisted that she do so. I suggested that she bring the graphs to our next supervision meeting.

Here’s what the graph looked like:

Therapist View of Progress Alongside Client’s View of Session-by-Session Progress and Engagement

Even though there was a dip in the alliance at the 2nd session— a rupture from which the clinician was able to bounce back—contrary to her perception, this client’s experience suggested that outcomes were gradually improving. Not only was the therapist’s appraisal off the mark, but the plans we had devised with which to repair the perceived rupture were not right for the context. It was like wearing winter clothes in anticipation of being in the frigid Alaskan north, but instead finding ourselves baking on a beach in Bali.

We went back to the drawing board. We spent time working through the supervisee’s uncertainty and anxiety about her perceived lack of progress, while keeping in mind that the client was clearly perceiving and experiencing benefit from the engagement. As it turned out, the therapist was torn between addressing the psychiatrist’s referral concern of OCD, versus the client’s implicit desire to improve his relationship with his father. Thankfully, the therapist maintained fidelity to the client’s rather than the psychiatrist’s concerns.

In supervision, we re-focused our attention around attending not only to this particular client rather than the referral source, but how to do so with future clients so we could also address the perceived need of their referring sources. More importantly, the therapist needed to unpack and clarify some inferences about what she was doing and thinking that might have contributed to this gradual improvement, despite thinking that none was being made, so that she could continue doing so.

In this instance, thankfully, the client was improving. However, the opposite can just as easily happen, i.e., when we think that improvement is being made, but the client reports that “things aren’t moving.” When intuition and real-time data are either out of synch with each other or not taken together into consideration, clinicians (supervisees in this case) are prone to self-assessment bias. While we are re-playing mantras in our heads that say, “The clients will get worse before they get better,” we quickly realize that our client has dropped out of treatment.

Quick tip: In clinical supervision, make sure that supervisees bring in graphs of the client’s outcome and engagement. This is one critical way to privilege the client’s view of progress and engagement across time, while incorporating it into supervision. In turn, we can also monitor the impact of the “backstage” conversation of supervision on client outcomes.

But Why?

Here are two primary purposes for weaving ongoing measures into therapy and using them in clinical supervision:

1. At the Client Level

a. Guide the treatment process: “Are we on-track, or are we off-track?”

b. Use the feedback to feed-forward: Real-time feedback allows you to tweak the service delivery to fit each client, each step of the way.

2. At the Therapist-Level

a. Effectiveness: If used systematically, session-by-session with every client, the
therapist can figure out the nagging question at the back of all our minds: “How
effective am I?”

b. Individualized Development: Once you figure out where you are with the help of a
supervisor who is attuned to this type of process, you can start the journey of figuring out
“where you need to go” in your individualized professional development. (More on this in an upcoming blog post).


There may be many reasons not to use routine outcome measures in therapy, and only a few good reasons to do so. Personally, I am not a fan of numbers. The irony is not lost on me being Chinese and failing math (and Mandarin) in my early years. Besides, it is not as if therapists around the world need another thing to pile onto their existing and ever-growing paperwork! Yet, the benefits far outweigh the costs of not integrating some form of measures—tracking what is of value to the client.* A groundswell of studies now show that the use of measures such as a real-time feedback tool not only reduce deterioration in client well-being by a third, but doing so cuts drop-out rates by half, and as much as doubles the overall effectiveness of therapy.

The use of intuition without high-value data** is like trying to drive in a foreign country without a GPS or an old-school map. It’s possible to still get to your pinpointed destination—especially if your sense of North is better than mine—but the journey is likely to be mired in and derailed by unwanted detours. On the other hand, the use of data in the absence of intuition is like blindly following your GPS into a ditch, when the new road, which is just to your left, has simply not yet been updated into the system.

The knowledge gained from the marriage of data and clinical intuition contributes to a type of dialogue that is richer and aids clinical decision-making. Sometimes, client-reported data confirms what we intuit. Other times, the data contradicts our gut sense. The point of monitoring progress and weaving it into clinical supervision is not to defer all judgement to cold and unintelligent data. The point is to wrestle with this tension in order to see and think more clearly.

To learn more about becoming a better supervisor, check out the in-depth online course, Reigniting Clinical Supervision.

Notes:

*It is highly possible to be measuring something systematically that is not relevant to your client. For instance, capturing data without integrating the measures to inform the treatment process. Second, dogmatically using a symptom-specific measure that may not make sense for all your clients. This is why it makes more sense to be capturing information about a person’s global wellbeing.

** Data is only valuable when you are not valuing whatever you measure but measuring what is of value. 

Premature Endings: When Clients Leave Therapists

Premature Endings in Therapy

In this blog post, I consider the impact of premature endings of therapy on psychotherapists in general, and on myself in particular. I am focusing here on situations where a client leaves and breaks off therapy without giving the psychotherapist any preparation for the ending.

In my clinical experience, few scenarios have been as challenging as premature client termination, especially when I have not been prepared for that ending, and/or it was not foreseeable at the time. Certainly, many clients do not return after the first or a few visits, but others break off the relationship after considerable work has been done.

This may be years-long, ongoing treatment which involves complicated work around critical and aggressive transferences, and client concerns around trust. In such a case, a client may use attacking defenses to provoke reactions from the therapist, reactions that will serve to prove that the therapist cannot be trusted.

If we think of Freud’s 1912 Remembering, Repeating and Working Through, we have to work with our clients knowing that the therapeutic relationship may be part of a broken repetition of a previous relationship, rather than a more complete and healing experience that culminates in successfully working through the client’s issues.

When there is a premature ending, the therapist is often left with the sense that the client has used the work and the premature ending to remain fixed within their problems, rather than be able to work towards a better solution.

Because the premature ending of treatment is always an ongoing occupational risk, it is helpful for the psychotherapist to have come to terms with the way in which his or her own early environmental and attachment failures and problems exist as real and deeply felt experiences that may not have been healed but had to be painfully and quietly endured. There may be cases where we have become deeply invested in long-term therapy, where we may have worked, alert as possible, to projections and different transferences.

When the work breaks off suddenly, it can wound us deeply and leave us with grief and loss, along with a profound sense of failure, disappointment and rejection. Sometimes this occurs with a client who may have been overly critical and anxious about trusting the therapist throughout the work. This can be particularly so in treatment which has gone on for several years and in which the clinician worked hard on the client’s behalf.

The Pain of Premature Client Termination

Such a difficult client-initiated termination happened to me last year and I found the suddenness of the ending extremely hard to deal with. I felt myself overtaken by painful grief. I went over and over the final sessions questioning myself as to what I might have done differently.

What strikes me about these kinds of situations is the way in which, after the ending, the client remains in one’s mind, the way the transference remains alive. For example, on coming into my consulting room after a break, I tidied the place up a bit, and could vividly recall the way my client would often criticize my room.

In the end, and upon reflection, I don’t think there was anything I could have done. In one way, it could be said that my client broke off with me the way her father had broken off with her. This was a client who had particularly strong and unresolved attachment issues in her very early years, had gone through the breakup of her parents’ marriage at age four, and had then lived with her mother and brother. Her mother then remarried a very abusive man and the client witnessed as well as personally experienced violent abuse.

During our work, her capacity to trust me was the paramount cause of her recurring anxiety. Progress might have been made, but the question of trust would always hang over us, and in the end, the breaking off of the work, I think, had very much to do with the question of her not being able to trust me.

It is a difficult burden for us to carry when we are left suddenly in situations like these, when we are very invested in the work. In fact, we may not realize how much we are invested until the work has suddenly broken off and we are left dealing with the ending alone and/or in our supervision.

I am aware of my enduring sense of attachment to my client, and that for a long time I still thought of the 6 p.m. Monday time slot as “her” session. When I gave it to somebody new, I had the sense that they only had it on loan from her. The pain of the difficult ending remained in my mind, thoughts, and psyche. I wondered if it remained in hers, or if by ending with me, she found the freedom to be creative in another area of her life.

Therapist Growth Through Client Transference

I say this because I was recently teaching a seminar on Freud’s 1905 case of Dora. One of the key events of that case was that Dora broke off her treatment. It may be that the energy Freud was left with in the abrupt termination was part of what fueled him to write the case up. This in turn makes me think of the acrimonious split between Freud and Jung, and the creative energy that was released in each of them following the breakup of their work together.

One interesting thing about the ending of Dora’s case is what she did after leaving Freud. Because she returned to see Freud, we know that she confronted Herr K about his advances towards her and received an apology from him. For Dora, breaking off the work with Freud can be read as part of her way of escaping the abusive paternal transference. For Dora, the right to break off the treatment was crucial.

Could something similar have been provoked in my client? Could it be that in ending with me she was starting something that would lead to healthy creative expression? I like to think so. This abrupt ending may have felt premature from my side of the couch, but it might have been right for her. Nonetheless, I am still left working on the painful sense of loss, and perhaps abandonment, that her premature separation evoked in me.

Questions for Thought and Discussion

How did the author’s reflections on his case resonate with you?

How have you dealt with clients who have terminated without explanation or warning?

How would you like to use the information in this essay in your own clinical work?

When the Clinician Becomes a Client

After my husband and I moved to our new home state, I found myself coping poorly, to put it mildly. Hundreds of miles from our friends and family, unable to find work and struggling to start a family, I found myself spending entire afternoons lying on the floor of our would-be nursery. I had no appetite, snapped at my husband over every minor annoyance, and was consumed by utter hopelessness.

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But when my husband gently suggested that I seek professional help, my defensive glare could have sliced him in half. Me go to counseling? Had he forgotten that I was the therapist here? I knew what to do; I didn’t need anyone’s help.

But after another month of being impossible to live with, I conceded. I found a clinician who shared my therapeutic approach, swallowed my pride, and stepped into her office feeling completely powerless.

I quickly discovered that my therapist had no idea what to do with me. She also believed that I already knew everything I needed to know to cure my own symptoms, and spent most sessions starting psychoeducational sentences, then cutting herself off.

“Here is a sheet with some common types of cognitive distortions—although I’m sure you already know them…Let’s try keeping a thought record. In the first column—well, you don’t need me to explain that.”

To make matters worse, I was a horrible client. I had intentionally chosen a clinician with more education and experience than me, but the result was that every session felt like supervision with one of my old bosses. I felt the need to impress her, and struggled to discuss my symptoms honestly. When I didn’t offer her anything to work with, my therapist ended up talking shop with me, making me feel more than ever that I was in a work setting where my symptoms would be unacceptable signs of weakness.

After a few months, I stopped booking appointments. The feeling of discomfort must have been mutual, because my therapist never reached out to ask why I had stopped coming. I wondered to myself if this was a common experience, if those of us who are the most steadfast proponents of therapy and bear the emotional burdens of 20 to 30 people at a time, end up having the most difficulty accessing (or contributing to) quality treatment.

A Washington, D.C. area clinician I asked about this noted that she had long avoided counseling for the same reasons I had. “I am certain that working in this field has prevented me from seeking out treatment in times where I could have greatly used it,” she said. “I believe I didn’t seek treatment because of my own belief that I could ‘treat’ myself because ‘I know what I should do and not do.’” Another clinician, based in Massachusetts, confided that when she did seek out mental health treatment, differences in therapeutic approach between her and her therapist made her experience unsatisfying.

“[My therapist] was very approachable, patient and validating,” she recalled. “[But] what I found disappointing was that, in my work with my clients, I generally had items prepared as tools we could use to address challenges or present new perspectives and techniques, and that was not my experience in my own sessions. It had more of your stereotypical air about it where you sit on a couch and talk about your feelings, no preparation, just whatever the client brings. And my work being different, I had a harder time appreciating that and eventually discontinued my work with her.”

I only found one person who felt that being a clinician had improved her experience as a client. Mia DeCristofaro, a Florida-based LMHC, recalled seeking counseling early in her career, when concern for her clients escalated into unmanageable anxiety. “My fear of not doing a good enough job or someone getting hurt on my watch was really hard for me to manage at first,” she recounted. “But being in the field also made it easier to be a client, I think, because I knew what I expected for my own treatment, what I believed about treatment, and I knew how motivated I had to be for it to be effective.”

Perhaps if more therapists who have received mental health treatment were open about their experiences, other clinicians would not feel like professional failures for seeking counseling. Although it may be awkward to discuss, who knows how many clinicians—and their clients—could benefit from this transparency. “We take on a lot of pain in this field and, diagnosable or not, I think we need somewhere to safely manage our own feelings,” DeCristofaro said. “Even if a problem we’re going through isn’t related to our work, we should manage it so that it doesn’t impact our work.”

Maybe this shift in focus from reducing our own symptoms to better serving our clients is the cognitive key to getting more mental health professionals through a therapist’s door. But whatever your reason for going, be the brave one at work and start the conversation about your experiences; you may be surprised to find you’re in good company.

The 7 Ways Psychotherapists Undermine Psychotherapy

We evaluate. That’s what we do. We ask question after question after question, and when we’re not asking questions, we’re noting answers to questions we haven’t asked. We’re so curious, professionally curious. It’s a trained curiosity, and if we’re not careful, a habitual curiosity, a distractive curiosity, a harmful curiosity.

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Psychologist James Hillman (1967) warned: “Curiosity awakens curiosity in the other. He then begins to look at himself as an object, to judge himself good or bad, to find faults and place blame for these faults, to develop more superego and ego at the expense of simple awareness, to see himself as a case with a label from the textbook, to consider himself as a problem rather than to feel himself as a soul.”

There is often a contradiction between my image of a person in therapy through their self-assessment of their issue and my actual experience of the person. There is also a vast gulf between the diagnosable issues as seen through the lens of psychological expertise and the essence, identity, strengths, and hopes of the person before me.

Therefore, I must cultivate space to come to know the whole person. This begs the question of what “knowing the whole person” entails. But let’s be clear: trained curiosity and assessment are not the soul of psychological change. Therapists mean well, but at times we all stray outside of the bounds of helpfulness.

Here are seven ways psychotherapists get in the way of psychotherapy—

Interrogating

When people come into session in the midst of an emotional storm, the last thing they need is to be inundated with endless questions on the basis of an agenda that is likely intended more to fulfill organizational protocols than to promote a foundation of therapeutic empathy and rapport.
Questioning always runs the risk of interrogation. The details learned about people’s lives ever tempt helping professionals toward distraction. There is a distinct difference between a personality and a person, a diagnosis and a destiny. It is our responsibility to stir hope and catalyze strengths rather than to stew history and analyze at length.

Pathologizing

The concept of “mental disorder” is rigid and misleading. In short, diagnosis is description, and by and large, mental health diagnosis provides description of “software” issues rather than “hardware,” so to speak. It’s a language of understanding what type of struggle a person is experiencing. When therapists refer to people by these diagnostic labels, we overgeneralize a person’s experience and distance ourselves from a critical resource: the powerful, complex, and fluid process of therapeutic understanding, the power center of effective therapy.

One of my professors, Bill Collins, taught me “pathology” is a dangerous categorization of a person’s experience. He contrasted “providing treatment to people” with “puzzling through a process with someone.” He told of one friend whose father, growing up, would never let him finish anything without taking over. His friend would, as his father asked, begin to screw in a nail with a screwdriver, and before he could finish, his father would grab it from him and say, “Oh, just give me that.” Those kinds of experiences, he noted, leave long-lasting impressions on a person regarding self-worth and competencies. Bill said we are to “help others to unpack their conclusions about who they are.”

Shaming

We ever risk a false sense of expertise about people’s lives against the backdrop of anxiety about our own. If we’re not careful, we may find ourselves reinforcing the tyranny of the perceived should. Should is shame's accomplice, and therapists must take care not to aid and abet them.

Sympathizing

Researcher Brené Brown (2010) rightfully proclaimed, "Empathy fuels connection, while sympathy drives disconnection.” Saying you understand is unhelpful and probably not true. And let’s be honest—it’s usually a ploy to rush people out of their emotionalism, which sends the message, “I really don’t care enough to walk with you through your suffering.”

Lecturing

Psychologist and psychotherapy researcher Les Greenberg (2002) wrote, “Darwin, on jumping back from the strike of a glassed-in snake, having approached it with determination not to start back, noted that his will and reason were powerless against even the imagination of a danger that he had never even experienced. Reason is seldom sufficient to change automatic emergency-based emotional responses.”

With a surge in cognitive therapies, there has been a surge in their wrongful implementation, with many therapists engaging in power struggles to convince people of faulty beliefs in order for new, more positive truths to simply work some magic ripple effect into their lives.

As an emotion-focused therapist, I have been prone to, for instance, encourage couples to engage in safer, softer, and more emotionally responsive interactions, yet when I have stood on my own soapbox, encouraging them to do so out of pace with their own readiness, I have violated my own guidance. Miller (1986) observed that people will “persist in an action when they perceive that they have personally chosen to do so.”

Babbling

Silence can provoke anxiety, even for therapists, who think they should surely be redirecting, conjecturing, advising. I find myself observing people in therapy watch me watch them watching me watch them. And I have found a power in it. Like a Rorschach ink blot, presence has power in and of itself to nudge a person’s anxiety, so it presents and speaks up for itself.

My former colleague, Blanche Douglas (2015), wrote: “There was a method in Freud's madness when he prescribed the analyst be as undefined as possible, not disclosing details about his life and sitting behind the patient out of sight, saying little. This forced the patient to make meaning out of an ambiguous situation, and the only way he could do this was by recourse to his own experiences.”

Methodologizing

If a psychotherapist is lifeless or their technique too technical, their efforts to help may be worthless. Therapy, in this case, is not a relationship but a poor excuse for scientific experimentation. The mechanisms of some psychotherapies undermine their therapeutic value. When we fixate on therapeutic modality, we run great risk of missing prime opportunities to interject the most valuable therapeutic tool we have to offer—ourselves.

Conclusion

As a new therapist, I remember trying hard to demonstrate my own capacity for psychological insight—even though, I must confess for my wise professors’ sake, I was certainly not trained to be an egotistical show-off. Fortunately, somewhere along the way, I started to better understand and experience the disparity between knowing and being. All these years, I am still learning each day how to lean into the latter. There is something powerful in it, not just in the experience of the therapist but in the experience of the therapy.

The family therapy pioneer Lynn Hoffman, who sadly died in 2017, gave a language of values for sitting with clients—the non-expert position, relational responsibility, generous listening, one perspective is never enough.

If a therapist is not fully present as a warm, accepting, genuine, caring, and appropriately vulnerable person, the power center of therapy remains turned off. Whatever insight may come along the way, meaningful, sustainable change requires transformative experiencing. Analysis without encounter is nihilistic, all the apparatus of thought busily working in a vacuum. Far from data to be interpreted or even a patient to be treated, we are heart and soul, of the same essence, both facing existential predicament.

Only in the context of authentic relationship and therapeutic alliance can I grasp and catalyze the breadth and depth of formidable resources already existing within my clients. 

———
 

References

Brown, B. (Speaker). (2010). Brené Brown: The power of vulnerability [Video file]. Retrieved from https://www.ted.com/talks/brene_brown_on_vulnerability?language=en

Douglas, B.D. (2015). Therapeutic space and the creation of meaning. Context. Warrington, England, United Kingdom: Association for Family Therapy and Systemic Practice. [Edited by Edwards, B.G.]

Greenberg, L.S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. Washington, DC: American Psychological Association.

Hillman, J. (1967). Insearch: Psychology and religion. New York, NY: Charles Scribner’s Sons.

Miller, W.R. (1986). Increasing motivation for change. In W.R. Miller & N.H. Heather (Eds.), Addictive behaviors: Processes of change. New York, NY: Plenum.

That Certain Feeling: “How Ya Gonna Keep ’em Down on the Farm (After They’ve Seen Paree?)”

I used to drink bad coffee. Growing up with canned Maxwell House, how would I have known any better? Coffee shops at college served percolated coffee, which wasn’t any better. The paper filter and easy access to whole roasted beans changed things. I didn’t really want to taste the difference, because I thought the procedure of grinding and pour-overs was snooty, and because in fact the flavor (which I now recognize as “coffee”) set a new standard of expectations. It wasn’t only that I knew that from then on that there was something I had been missing; it was also that I knew not to be satisfied with less. I suppose I might move to an even higher standard someday, if exposed to something even more delicious and not too expensive.

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One thing all kinds of therapy have in common is that they produce and consolidate certain feelings and psychological states that clients are not used to experiencing. For example, a depressed client might have a moment of joy, or an anxious client may feel serene. Technique aside, if the therapy dyad or the couple or the family can appreciate the moment, a number of positive consequences may follow. The client might have proof that she is capable of serenity, for example, or a couple may recognize that they are capable of making each other laugh, or a family may see that a disruptive child is capable of cooperation. The focus then turns from whether the client is capable of positive behavior to when, under what circumstances, this occurs, and how to reproduce it.

Once a desirable feeling or psychological state occurs, clients can see what they are missing and begin to insist on it. The depressed person becomes motivated to change not by a promise of paradise but by a taste of honey. Parents relinquish the self-protection of “nothing works,” and they try to reproduce the cooperation they experienced firsthand. Just as I never knew what good coffee tasted like, some people go on dates and don’t know what curious attention feels like. They don’t then insist on it (by not continuing to date someone who doesn’t provide it). They also drive away people who do provide it, since their prospective partner’s curious attention falls on deaf ears, and the partner feels the way talented baristas feel when they prepare a delicious cup and the customer gulps it down without tasting it.

Virtually every client can be construed as wrestling with aspects of themselves that don’t fit the narrative they are promoting, internally and externally, about who they are. In whatever manner those ignored aspects of the self eventually get integrated into the total self, it goes more smoothly if they are seen as natural and welcome facets of the human condition. Thus, the feeling of being understood is central to therapeutic growth. Once the marginalized aspects of the self learn what this feels like, they can insist on it. (I’m talking about feeling understood, which is different from being catered to). Clients are then likely to stop doing things that defensively drive away other people, because the feeling of being understood undermines a sense of being repulsive or unacceptable. Clients who feel understood are likely to seek opportunities to feel it again, and collaborative, mutual relationships follow.

Therapists are people, too. No therapist can provide a collaborative mutual relationship if they don’t know what it feels like, and no therapist can provide it in therapy if they know only how to provide it in romance or friendship. You don’t necessarily need to have felt truly understood in your own therapy to become a good therapist, but it helps, just as drinking great coffee is a good foundation for becoming a master roaster. Therapists can also feel understood in supervision or peer consultation groups, where showing mistakes plays a role similar to revealing marginalized aspects of the self in therapy.

Depth

Elizabeth was a first-year college student who was finishing up a short period in psychotherapy subsequent to the breakup of a relationship with her boyfriend. In our final session, she expressed feeling good and looking forward to the future—but she also made a comment that caught me off guard. She said that she wished she knew how to be a “deep” person. Not knowing how to respond in the moment, I said something reassuring about being who she was, and that depth would take care of itself.

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Since that time, I have often thought about the concern she expressed and wondered if my response did her justice. What, exactly, had she meant by wanting to be a “deep” person, and had I, in effect, brushed it off?

Several years after working with Elizabeth, another situation emerged that appeared to be related. One of the students in my counseling lab was expressing confusion about a practice session with another student who had brought up an issue to talk about but had seemed unable to elaborate it in any meaningful way. “What do you do,” the student-counselor asked, “when the client can’t say anything more about their problem—when there’s just nothing more there?”

My response was immediate: “Oh, believe me, there’s always more there!” As an afterthought, I added, “You may never get to it, but there’s always more there!”

I was a little surprised by the emphatic certainty with which I uttered this comment, and I have thought about this, too, on several subsequent occasions. What made me so sure that there is “always more there”? It seemed that in the years since I had worked with Elizabeth, I had learned more about what “depth” is, and that I had learned it in a deeper way.

I’d worked with hundreds of patients since Elizabeth. I had seen case after case in which patients who had presented in a defensive or superficial manner in therapy had subsequently opened up to reveal poignant, sometimes moving, emotions underlying their problems. And on other occasions, I had seen patients who had persistently avoided opening up, but in ways that made clear why they could not afford to do so.

Ironically, as I have come to appreciate the meaning of depth, the field of psychotherapy has moved in the opposite direction. In some ways, the field has been a victim of its own success, as increasing demands for therapy and concerns about costs have led to the development of faster, more cost-effective, and more problem-focused approaches to treatment. These more structured approaches are often favored by third party payers and others concerned with the efficient use of resources. Unquestionably, these approaches can be more practical, more down-to-earth, and more immediately helpful to many patients with discrete and clearly defined problems; it might even be argued that they are more democratic and empowering, as they have removed much of the mystique that previously allowed some therapists to elevate themselves as shamanistic elites.

But I fear that the move we have witnessed in the clinical field toward more symptom-focused therapies also represents a retreat from the very real insights underlying the discoveries that are possible in psychotherapy. These insights include an appreciation of the complexity of the dynamics that underlie many forms of human suffering and the degree to which these dynamics sometimes involve co-optation of individuals by familial, social and institutional forces.

A few years ago, I discovered an example of the latter when I wrote a detailed critique of a videotaped therapy session conducted by Aaron Beck¹. Beck’s patient Mark was suffering from anxiety about his performance as a manager on his job. In the session, Beck used guided discovery to help Mark see that he suffers from “social anxiety,” that such anxiety is perfectly normal, and that it can be reduced by learning some simple techniques of self-acceptance and reassurance. A close review of the video, however, suggested that Beck’s focus on a pre-categorized symptom blinded him to some important underlying dynamics. The job in which Mark was experiencing so much anxiety was one in the clothing industry where he was caught in an inescapable conflict between his superiors, who were forcing him to set progressively lower piece-rates, and the workers, who were blaming him for the cuts in their pay. It seemed never to have occurred to Beck to ask Mark how he felt about the job itself. Instead, Beck repeatedly directed Mark’s attention away from the job and labeled his problem “social anxiety.” In doing so, Beck unwittingly aligned himself with Mark’s superiors and failed to explore his feelings about his role at work, the meaning and significance of these feelings, and what he might do about them.

Thus, while symptom-focused therapies can be genuinely empowering in some situations, cases like this suggest that they can also be disempowering if they fail to consider the personal histories and social forces that shape the symptoms that clients bring to the therapy. And more than this, they may leave the client alienated from his or her own internal experiences, values, and feelings—that is, from the underlying issues that led the client to seek psychotherapy in the first place.

The student-client who was unable to elaborate her problem in the counseling lab had not yet discovered some of the depth of her own internal life. Interestingly, I came to know this student quite well over the next few years as she learned more about herself. She worked in several stressful jobs, including doing manual labor and, later, human service work in a poorly governed agency that created more problems than it solved. The stress from these experiences led her to a time in therapy and a period of soul searching about her values and goals. Eventually, she decided to pursue a career in a health-related field with an emphasis on doing in-depth interview research. She had come to be a different person, and a deeper one, than the student I had originally known.

Returning now to my session with Elizabeth, I doubt that her wish to be “deep” indicated a need to reopen her treatment. But if I had it to do over again, I would ask her more about what she had meant: Who were some of the “deep” people she was thinking about? What kinds of traits suggested depth to her? Had she ever experienced any of these traits in herself? Perhaps these questions would have led nowhere. But then again, they might have touched her in some way and given her something to think about in the future.

After all, there’s always more there.  

Resources

1 https://psycheandsense.com/empiricism-and-psychotherapy/