“I must go forward where I have never been instead of backwards where I have.”

Winnie-the-Pooh

What I’ve realised over the last couple of weeks

I’m back from leave and ready to keep on blogging. I had some good time away and enjoyed switching off, but now it’s time to get back into the swing of things.

I have come across some awesome resources on deliberate practice since my previous post. A site called DPforTherapists (https://www.dpfortherapists.com) contains a good number of forms and materials to support DP. They also have their own DP certification pathway – many of their forms appear to be for supporting those undertaking DP coaching. One form in particular I noticed because it has been used in my DP coaching sessions, albeit indirectly.

I have since wondered if this reaction scale has ever been used with clients and whether it would be useful for them. I have noticed that my own ability to subjectively attune to whether a client is underwhelmed or overwhelmed by an activity in session can change often, due to various factors, such as my fatigue level. A series of questions have then passed through my mind; Could such a scale help me stay attuned to a client’s level of engagement throughout a session? Could a client use it for monitoring themselves through any sort of challenge? Would a client be able to generalise using it across situations?

There are a few different scenarios I’m thinking the scale could be useful with clients:

• Configuring and reconfiguring gradual repeated exposure steps in treating anxiety.
• Configuring and reconfiguring process goals for practicing behavioural activation.
• Monitoring a client’s arousal level and engagement while learning or practicing a skill in session (e.g. assertiveness role playing).
• Monitoring a client’s mental or physical energy expenditure while they engage in daily activities take up their cognitive load, such as work.
• Assessing goals or solutions and whether those are perceived by the client as realistic or overly challenging.
• Debriefing behavioural experiments.

I’m curious about the possibilities – I’m going to trial using the scale with client’s to see if it helps them with any of those challenges.

What I’ve managed to do since my last post

During my time away I focused on rest and “switching off”, taking deliberate effort to anchor in what I was doing at a given moment and preventing myself from multi-tasking, for example when watching tv I would avoid looking at my phone. What helps me do this is I imagine how my mental energy will deplete faster if I engage in multi-tasking, due to the increase in cognitive load and subsequent fatigue, limiting my output in the longer run. I also spent more time doing things I enjoy but tend to put off, like making pizza from scratch with my partner or putting together a Lego Boba Fett bust.

With that in mind I have honestly not taken any new steps in DP, as I haven’t had any new clients to practice what I spoke about in my previous post; which centred around new strategies ideas to discuss therapy structure and goal setting with clients. Though I have continued to practice the SRS debrief questions that I spoke about previously. So with all that said, any spare time I have had was spent thinking about the reflections found at the start of this post and below.

Doing Therapy just like Embroidery

Deliberate Practice and FIT (Feedback Informed Treatment) talks about the importance of integrating client feedback scales into therapy, to help maximise the chance that a therapist and client will see value in feedback, but how do we go beyond this to interweave what a client learns in therapy, in a way that helps them generalise what they learn in the therapy room into their daily lives? Clients taking skills beyond the therapy room has obviously been thought about by many of us and I have pondered this question a lot lately.

There are various things I have considered integrating into the therapy I do, such as providing client’s a quick assessment of personal values with the intake paperwork before a first session, creating an opportunity to explore these values in early sessions, if relevant, while providing a rationale as to why connection with values can help well-being. This may then connect to later therapy exercises where a client could be encouraged to call upon those values, so that they may feel more empowered to face a particular challenge. I know this is awfully presumptuous – it’s my attempt at an example where one concept of therapy can flow onto others, which I think at times my therapy lacks, due to my gaps in sustaining an intertwined treatment structure at times.

Similarly, I know I have a tendency to not always follow through on concepts that I cover with clients, for example I may run through using SUDS (subjective units of distress scale) one session but then fail to bring it up again in future sessions until we get to something like gradual exposure in treatment. I don’t think this one and done style helps a client consolidate their learning.

Thinking further – It’s all well and good to tie individual concepts and skills like values into therapy, but how can all these individual concepts and skills be meshed together to create a cohesive system?

So I had the following idea – could concepts and skills covered in a given session be recorded and tracked on a word document, like the image below, for example when a piece of psychoeducation (such as the anxiety vicious cycle) or skill is introduced, it is added to the document. My thinking behind this is that it may give a client a table of therapy contents for recall; to appreciate what they have learnt upon reflection and notice how the individual pieces of what they have learnt work together as a cohesive system.

These ideas strengthened after seeing my partner practice a new skill – embroidery. In embroidery you have to sew the string into the fabric, if she didn’t do that the string would just fall away, which obviously wouldn’t work. Once completed though, everything comes together to form a cohesive image, with all the individual colours combining to create that image, which cannot be easily broken because it’s literally sewn together. I have been thinking about therapy in this way and how such a strong cohesion can be achieved.

I’m keen to see how these ideas go; if they work I will keep them and if they don’t I can move on to try something different. Part of me thinks that this may be a waste of time or may not help at all because these are very complicated issues and while what I am hoping for is all well and good, I have no idea what will happen. With that said, I do not want worry and fear to kill my desire to find what works – where’s the fun in that?

There are three things I never want to lose in my career:

1. My curiosity with people and their stories.
2. My professional self-doubt.
3. My drive to try new things as a therapist, in the face of potential failure.

I hope these ideas act as an embodiment of my commitment to stand by these values for the rest of my career.

Till next time and as always – thanks for reading.

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