Hello everyone. I’m back again and ready to get my posts started for 2023. To begin the year, my posts will focus on my top 10 tips for engaging in Deliberate Practice (DP) as a therapist. The tips won’t be a prescription of DP; you will still need to do the work to individualise DP to yourself and the tips will not be the ‘be-all and end-all’ of effective DP. I do believe they could be considered core principles of effective DP and that without them DP can be a whole lot harder. It’s the perceived difficulty of DP that is probably the greatest roadblock to it being adopted more often. I therefore have the very stubborn belief that the simpler DP can be presented, the more adopters it will have.

I will do my best to be as concise and brief as I can to present these tips – the simpler, the better.

If any of the content does not make sense, please feel free to provide feedback and I’ll endeavour to rewrite to clear things up.

The first tip focuses on the importance of gaining actionable feedback from clients. Feedback that will help you improve the therapy approach with each individual client, but also to use that feedback to see patterns across your client caseload, so that you identify where to improve your skills as a therapist.

It’s becoming more popular to gain that client feedback by using an in-session scale or measure, such as the Session Rating Scale (SRS). These scales are useful, because it would be taxing to verbally ask for feedback about different elements of the therapy approach, such as therapeutic relationship and goal alignment at every session. The SRS helped me delegate some of that legwork.

An example SRS from Fit Outcomes, a web-based tool for administering the SRS.

I would recommend choosing a measure that focuses on the therapy approach, instead of client symptoms. It can be tricky to pull out any client feedback on the therapy approach if you’re debriefing with them using a DASS-21.

There are a few feedback tools out there, but I will focus on the SRS because it’s the only one I have used and am personally familiar with. If you use others, feel free to shout them out in the comments to help others become aware of them.

Using feedback to improve the therapy approach for an individual client

Once you pick a tool though, you will need to be able to introduce it to clients. I introduce the SRS to my clients at the first session; including a brief heads up at the session start and a full intro at session end.

Towards the start of the first session, I always explain to clients the purpose and structure of the first session. As a part of that I explain that the end of the session involves gaining feedback about the session itself and at that time I’ll provide a brief measure to help understand what is working in the therapy approach and if anything needs to change.

Fast-forward to the last few minutes of the session. I let client’s know that we are coming close to the end and ask if we could use that time to gauge the session and set ourselves up for next time. Here is my general spiel for introducing the SRS using a digital tablet:

“Here is the tool I use to gauge the session. It will gauge four things; how we’re connecting, the goals we’re working towards, how we’re getting there and overall the session together. Some people when they first do this they might be feeling pretty good about how we’re starting out. If so, you’re more than welcome to score on the higher end of the scales, though I never expect perfect 10’s. In saying that, other people may feel mindful of the fact we’re still getting to know each other, identifying what we’re working on and how we’re getting there. If you’re trying to encapsulate that with lower scores to start – I won’t be offended. At the end of the day the purpose of this scale is to help us identify what is working about the therapy approach and where it needs to be altered to suit you, therefore strengthening the therapy approach”.

In this spiel I am doing my best to give clients an idea of what to expect with the SRS, giving them permission to give the feedback that feels right to them, but most importantly I make it as clear as I can that the SRS is meant to help them, not just me. It helps clients to buy in when they understand how something is meant to benefit them.

Once the client completes the SRS I then ask them about their results by making an observation. I endeavour to use questions that are not person centred, so I don’t say I or you, and are specific to the task at hand. I also frame addressing lower SRS scores as an opportunity to improve the therapy approach. For example, if I notice the score for ‘goals and topics’ is lower than the other SRS scales I’ll say something like:

“We might have an opportunity already to strengthen the therapy approach, the score for ‘goals and topics’ is coming up as lower than the others, could the therapy approach change next session to take that score from a 6 to a 7?”.

If the client says nothing needs to change, I don’t push and simply thank the client for completing the measure.

If the client says they are not sure, I then ask if I could provide some of my own thoughts. I then comment on what I think could have changed and ask the client if my reflections are accurate.

If the client provides feedback, I treat it with curiosity, note it down to emphasise its importance and state how I plan to action the feedback next session, if possible. For example, if we missed a topic important topic, I’ll say that I’ll make sure to bring it up next time.

Using feedback to identify therapy skills to improve across your caseload

It’s not just with individual therapy approaches where feedback measures can be useful. You can go even further by reviewing your client feedback data across your entire caseload, to find patterns on where you could improve your skills.

Recently I had a first coaching session with the almighty Daryl Chow. He tasked me with reviewing my client outcome data for clients that ended therapy before they improved, to look for patterns on why they finished therapy early. A very quick pattern emerged when reviewing the SRS scores for these clients, their ‘goals and topics’ scale  was reliably the lowest score versus the other scales. In then reviewing the case notes for these clients, it was often the case that the ‘what’ and ‘how’ of therapy goals was never established or directly discussed at all. Reviewing my SRS data across clients helped me realise that in my previous DP attempts I had in fact improved how I goal set with clients, but I still could improve on ensuring that the goal setting occurs in the first place.

In short, my goal setting process with clients can be amazing, but it’s useless if I don’t bring up goal setting in the first place.

Without analysing this outcome data I felt completely lost in the wind, when it came to trying to figure out where to next improve my skills as a therapist. Without outcome data, it is almost impossible to know where we need to improve, unless you have a strong gut feelings, which can be flawed…

Now as a result of that finding, I’ll be pivoting my DP efforts to focus on ensuring that goal-setting has been raised with all of my clients.

I hope now you can see the usefulness of feedback measures in therapy, they don’t just improve therapy for an individual client, they can also help your entire caseload by picking up areas of improvement across all clients.

If you would like to take a more in-depth dive into how to use measures like the SRS to gain client feedback, I suggest grabbing this book:

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