““If it’s not Here, that means it’s out There.””

Winnie-the-Pooh

What I’ve realised over the last couple of weeks

It feels like it has been 3 months since I was last writing a post here; not 2 weeks, maybe because Sydney only left lockdown last week after approximately 45 years of stay-at-home orders. Perhaps it’s also because it feels like such a different time now, being allowed outside, compared to a couple of weeks ago.

I did have an ‘aha’ moment of sorts, when reflecting on a couple of drop outs (clients that ceased therapy with me without an improvement) from my client caseload. I came to a decision that they may have decided to disengage because I had failed to connect with what they saw as their main presenting challenge; that I wasn’t being client-directed enough.

So after a very productive conversation with my partner I decided to make some small adjustments to my approach with clients, in the interest of increasing my odds of connecting with what they feel they need – not what I think they need. Normally, prior to a session, I would go through the previous session note to bring myself up to speed, pull out a sticky note and write on it what I wanted to bring up with the client for the session that day. It was essentially a reminder of the treatment plan. The other thing I would do is start a session by checking in with a client how they had been since our previous session and then present options or give suggestions on what we could “work on” in the current session. I would often list out these suggested topics before asking a client if they would rather cover anything else. I began to suspect some flaws with these approaches; in that I would very rarely look at the sticky note and that some clients may have felt lead on by my suggested topics for a session – feeling pulled to picking one of those instead of something they would prefer. So I decided to make some small changes. First, I now review the previous session’s case note with the client present, as a way of prompting what we discussed and helping me to connect. Second, I now ask client’s if they have had anything on their mind or something specific they would like to work on before raising my suggested topics, which I now only raise if the client says they don’t have anything specific in mind on what they want to cover.

I have hope that these changes have been working – as I have been more often getting feedback from clients that our session hit on exactly what they felt they needed to work on, for some of them even when they were not sure what they needed.

This struck me as an example of the role self-doubt can play in my work, in that I see it as a crucial tool for my improvement, without it I may have never decided to reflect on my recent drop outs or decided to try changing my approach. So does this mean self-doubt is a good thing? I’ll come back to this in the last section of the post.

What I’ve managed to do since my last post

It seems that this last fortnight was one of consolidation for me – in that I turned towards tweaking my existing tools to help me improve connecting with clients, instead of coming up with new ones. I altered the wording of my goal setting template, so that it uses less Jargon such as “means goals” instead to “The symptoms that get in the way of how I want life to be”.

I added to the list of personal qualities I see as important to me in my work:

“Values

• Patience
• Curiosity
• Helpfulness
• Drive
• Doubt
• Genuine
• Creative Thinking”

Finally, I added the following questions to the session reflection scale I previously created:

• Have any of my behaviors above or approach in therapy prevented me from connecting with the client and what they see as their core/priority issue?
• If I engaged in any of the above behaviors in a session, why did I make that decision?
• If I decided on a particular approach in a session. Why was that?
• If I am not connecting with the client and their core/priority issue (i.e. sensing their buy in) – what can you do differently to assist that connection?
  • Are you avoiding the core issue? If so – could they benefit from another therapist who may be a better fit for the core/priority issue?

I have started something else that I am very excited about. I have decided to write my first book. It will be for the regular person, not trained in mental health – centred around ‘normalising’ the brain. I have noticed that I am very passionate in helping client’s learn that their actions come down to natural workings of their brain, such as the preference for ‘path of least resistance’ or an ‘amygdala hijack’. I really enjoy helping people feel more human by learning about how their brain works; and so that’s exactly what I want to write about.

Self-Doubt

I will return to the topic of self-doubt by first thanking Ben Buchanan, the director of NovoPsych, who provided me with the opportunity to be part of a test run on two measures – the Professional Self-Doubt Questionnaire (PSD) and the Counselling Self Estimate Inventory (COSE). The PSD, according to the information sheet I was provided by NovoPsych “is a 9-item self-report questionnaire designed to assess the level of uncertainty a therapist has in their ability to help patients.” In this information, there is research that suggests higher scores on the PSD are associated with higher levels of therapeutic alliance and positive therapy outcomes. I scored in the 99th percentile for the PSD, which notes “notes above the 90th percentile are of particular note, and indicate that PSD significantly interacts with work satisfaction, performance and professional identity.”

The Counselling Self Estimate Inventory (COSE) “is a 37-item self-report questionnaire
designed to measure a clinician’s self-efficacy” as written in the information sheet provided by NovoPsych. The information also notes “Although the COSE is not a direct measure of counselling skills, it does measure self perception and confidence in the ability to provide counselling.” While the research presented does not suggest that professional self-efficacy is related to client outcomes, it does propose that higher levels of self-efficacy are more likely to help someone be more open to feedback, more likely to engage in professional development and helps skill development. My score for this one was in the 28th percentile – the interpretation provided notes that “Low scores may be indicative of someone who has struggled with their basic skill development or who has pervasive difficulties with confidence. People who score low may experience constructive feedback as demoralising”. However the information also suggested that more normative data is needed for the the COSE.

These tools have just launched on NovoPsych and could really useful to help people monitor their confidence and self-doubt.

I’m a bit torn as to what to make of these findings, as on one hand the suggested interpretation of the PSD posits that my high self-doubt may be a “good” thing, while the COSE suggests that my high self-doubt would be a “bad” thing. My thoughts are that the Jury is still out on the role self-doubt plays in our professional lives.

I do wonder if self-doubt acts in a similar way to the individual zones of optimal functioning when it comes to client therapy outcomes, as previously proposed by Yuri Hanin (image below), who was looking at the impact of emotional arousal on performance. Based on the interpretation suggested by the PSD, it may be that the ‘optimal zone of self-doubt’ is more towards the 90th percentile (as I attempted to mark in green). Though I would also guess that there is a point where self-doubt is ‘too high’, which may contribute to avoidance or over-compensatory reactions when I work. Conversely, there may be situations where self-doubt is ‘too low’ (so high confidence), which may contribute to me being ‘blind’ to my weaknesses in those situations where I am more confident. I hope this might act as food for thought, when it comes to your own relationship with self-doubt.

Till next time and as always – thanks for reading.

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