Before I begin – some short updates

Update 1: In case you missed this, I have started a new set of posts called quick missives. They are intended to be quick tips or reflections on Deliberate Practice. I made the decision to create these because I have many blog post ideas and concepts that feel too small to create a big post on – but I thought would still be interesting enough to share – I’d love to hear what you think 🙂

Update 2: My apologies to those of you who have subscribed to the blog via Mail Chimp, I only recently realised that I have failed to sync Mail Chimp to my blog posts here, so no one would have been getting emails when these posts go live – which has made subscribing redundant!

Unfortunately it seems that I can’t easily make the sync happen without plug ins for WordPress and I can’t apply those without paying almost double the cost to upgrade my WordPress account…

I instead found a way to transfer all MailChimp subscribers to WordPress – if you have wish to have your subscription removed following the transfer – please let me know.

Update 3: We have created accounts for social media (Facebook and Instagram). Please feel free to follow us! You’ll find links throughout the website and at the end of this post. For now I’ll be posting the ‘quick missives’ posts there, but over time I hope to create more exciting and interesting content!

Now onto the show

You’ve heard me say it a lot before. That one of my biggest lessons here is how I have had a tendency to ‘try to hard’ in helping my clients. Interestingly enough, this was never a lesson that came from my clients. It came from supervisors. It also came from my brain – in the form of tension headaches.

My Deliberate Practice efforts were therefore heavily focused on how to not try so hard.

I’m glad to report that I have largely succeeded in that goal. My brain is no longer trying to do 10 things at once in a session. If it does I largely have systems in place to manage it (thanks to deliberate practice). It’s now much less likely I get a headache at the end of my shift.

This year I’ve been reflecting heavily on how I’ve evolved over the last three years. Which is partially due to the decision I’ve made to not make any major changes to my processes this year.

I’ve also been thinking about, well if I was trying too hard before, surely I have to try at least to some degree – so what does that look like?

I thought it would be a good time then to consolidate and strengthen what I have now by sharing with you the principles and pillars that act as the foundations in guiding me with my clients.

How I’m guided not by a particular therapy or set of techniques, but by how well I can nurture and strengthen the therapeutic alliance with my client. Reflecting on the efforts I go to early on, especially in the initial session. I’ve worked on how I conduct an initial session so thoroughly (where there is the highest chance of client drop out) – that it has possibly become my strongest session. My goal is to have the client as glued as possible to the therapy process by the end of the first session.

Again, it’s all about building and protecting the alliance with my client – 95% of my effort is always there.

So how do I do it?

I always start with a structure. Structure becomes my scaffold. Its the guard rails in my 10-pin bowling lane. I let new clients know what to expect in a session (initial admin, confidentiality spiel, outcome measures) including what to expect in the conversation. I tell them that I don’t expect them to talk about what they don’t want to or feel ready for and that if they ever feel unsure on what to talk about, I’ll have “a million questions” for them anyway to keep the conversation rolling. I use a puzzle analogy to let them know the initial therapeutic process – that first we’ll be getting our “pieces out of the box”, the picture of what they are going through will start to form. That chances are that picture will start to look “complicated” (because as human beings we are complex. This will mean it will be too “overwhelming” to tackle the whole puzzle at once, so we’ll figure out where in the puzzle to start, which will form our “action plan”.

After I provide the initial structure, I then introduce clients to the outcome rating scale. From there I ask clients to share with me what has brought them to therapy. This is now the part where I let them share and talk.

Anywhere from about 30 minutes to 40 minutes in I then seek to understand what a client wants to focus on in therapy, but especially to ascertain where they want to start – we start to form the action plan.

From there its all about goal alignment (process is prioritised over outcome) – I go with what the client wants even when I think I have a ‘better’ idea. A common example is where a client wants to pursue experiential avoidance or “stop my anxiety” as their initial goal. My instincts tell me that this will be an unhelpful goal, but I roll with it anyway.

Why? I know a lot of therapists may feel like this is a bad idea or even a scary idea, but I’ve found its crucial to client engagement early on.

In the early phases of therapy, most clients don’t trust me enough for me to start over-riding their goals – that I have ideas that will ‘work better’. Me trying to convince them to change their goal only creates friction (trust me I’ve been there). Friction can lead to drop out, even if its just a small amount of friction.

Early rapport building is too fragile to risk friction. So I go for as little friction as possible, until there is enough trust. It’s like I’m a baseball pitcher chucking up soft and easy lobs – I want to build up my clients confidence. I stay patient. I wait. Once there’s enough trust, that’s when I can start throwing my curve balls.

So how do I figure out where clients want to go in the first place? In an initial session I ask a client if they want to focus on “the tip of the iceberg” – which means distress management/coping skills or do they want to start by going “under the surface” – which means addressing underlying contributing factors (e.g. perfectionism). This generally takes about 30 seconds to a minute to address (though there are exceptions). There’s no ‘big talk’ about goals. I don’t talk about the difference between outcome vs process goal, avoidant goals, behavioural goals – definitely no SMART goals. I used to have much bigger spiels when it came to my goal setting approach.

It’s simple – just me give your goal(s) as they are. It doesn’t need to be much, it’s just to find an initial direction.

You want to start with coping skills to lower your distress? I got you. You want to start by tackling perfectionism? I got you. You want to start by me just listening? I got you.

If it turns out I don’t got you, then we’ll help you find someone who does.

The hope at this point is that the client is thinking something like “wow, this guy is really attending to what I want. He’s not trying to push me anywhere I don’t want to go. Not only that, we have a direction already. I’m now feeling more hopeful and motivated!”.

All that and I’ve only known the client for 40 minutes at this point. There’s already hopefully a strong foundation of a solid alliance forming – and we have barely even started.

I don’t step in unless I’m not understanding the clients goal (leaning on clarification) or if I’m worried the client will potentially hurt themselves or others with their goal.

If the clients genuinely have no idea what their goals are, I’ll either ask them what part of their experience is “impacting” them most. If they cant tackle that then I ask what part is most “doable” to tackle. Failing that I’ll give them a therapy goal reflection activity as homework to see if that gives them more space to think.

Once a direction is found this doesn’t get revisited until the client chooses another direction later, outcome scales/feedback shows the direction/approach isn’t helping or the client achieves their initial goal.

There’s no more elaborate or detailed talk about goals later, e.g. how I used to aim to do this in a 3rd session.

Finally, when it comes to the initial session. I do my absolute best to provide the client with “something to go away with” that aligns with their chosen therapy direction. I might give a client who wants to become more assertive a tip sheet on boundary setting. The first session with me is a therapy session, not an assessment session. The earlier the ball is rolling, the better, most clients don’t want to wait around for me to formulate or diagnose before I give them anything tangible.

When it comes to providing structure, I do the same for clients in their 2nd session. I start off by explaining the structure here as well, because the structure is different for subsequent sessions. I’m transparent on how the sessions will have a start, middle and end. I explain that I’ll start by getting admin cleared off first (including booking future appointments), I’ll then “check in” with how they have been since the previous session (including the ORS). As we unpack that verbally I’ll ask them how their homework landed and if that will inform our “focus” for today. If homework went well, I’ll then ask the client if they “have anything you would like to focus on today?”. If they don’t I’ll start making suggestions. Either way, I always do my best to ensure I’m aligned with a clients process goal before I start to offer anything. There’s no point offering them a train ticket when it turns out they want to take the ferry. The majority of the session is then on our chosen topic.

In subsequent sessions, I also check in with clients about how well the therapy process is fitting at the start of sessions – not the end. Why? I’ve found it too hard to consistently check in at the end of sessions, I just find it so challenging if a client has something important they want to talk about at that time, I don’t want to interrupt them to “check in”. Also often I just plain old forget, because I’m present in the conversation. Finally, because I only have 10 minute gaps between sessions (for the most part), so I’m pressed for time if the client does have feedback they need to dig into. That’s why, while I know it’s not perfect, I find it more effective to check in with clients at the start of a subsequent session. When a check in happens at the start, there’s plenty of time to address it, I’ve had some awesome sessions with clients where the whole time has focused on addressing their feedback – and thereby strengthening the alliance hugely and deepening my understanding.

I also do admin at the start- not the end. Why? I want the last moments of the session to resonate with a client as much as possible (a part of the the session they are more likely to remember). I don’t want that spoiled by talking about what on Tuesday in a fortnight suits them best…

I protect the ends of sessions too. I know a lot of therapists struggle in wrapping up on time, clock watching is really hard – we all need to finally admit it!

My smartwatch buzzes silently at ten minutes to end and five minutes to end. This time is focused towards reflection, clarification and/or next steps. I recently discovered that stopping myself from asking exploratory questions in the last 5 minutes (e.g. do you have high standards for yourself?) – has been massively helpful in ending on time.

More generally, I lean on clarification and feedback to make sure I’m aligned as consistently as possible.

Why? Despite my intentions to let the client lead their therapy direction – my brain can’t help itself and will try and generate interventions it thinks could work ‘better’. I’m also not perfect, nor am I a mind reader. So I might misinterpret where a client wants to go. These tools help me ensure I don’t drift too far away from where my client is going, or wanting to go.

Feedback is crucial to help me see what I don’t currently and realign with a client when I start to drift or miss something important. Lots of clarification helps clear up the picture from the clients point of view – like an optometrist swapping lenses until they find the clearest one. Feedback and clarification help me also ask about and understand a clients goal, especially when I wasnt understanding it fully.

I also give plenty of rationale when I’m offering an intervention to a client. I try my best to keep those rationales quick and simple. Rationales help clients understand what they can expect and decide if the intervention is something they want to take part in.

All these pillars then combine to build trust. I have put trust in my client, allowing myself to follow them where they need to go (often going against my instincts) – they will hopefully return the favour if the time comes that they need more input from me.

Trust builds client openness to my own interventions and insights.

These then combine to strengthen client engagement immensely. Clients build engagement over time because they feel heard and attended to. It helps the therapy process gradually adjust to their individual needs.

Engagement then leads to long term clients – which tends to lead to better outcomes. Because as research suggests, long term clients tend to experience better outcomes vs short term clients.

Safety nets

I also always have my safety nets. Again, because I’m not a mind reader, I do miss things and I can only keep my eye on so much at one time. These safety nets are a series of scales I give clients at the start of or prior to (same day) of each session.

These days I provide the scales using Google forms. Using a digital format allows me to email the scales to the client prior to the session. More importantly it allows to more easily compare client responses across sessions and provides a visual graph of their progress!

A very important note: While I’m happy to share the scales I use with my clients (as below – although I’m only sharing one in full), in the interest of transparency about my processes for the purpose of this blog. I can’t recommend that anyone else use these with their own clients. Simply because the scales have not been tested with research. It’s therefore unknown if they would have sound psychometric properties.

The first set of scales focus on understanding the effectiveness of therapy in a more detailed form. You might be thinking – don’t you use the ORS for this? Yes I do – but I provide these additional scales to ‘zoom in’ on different aspects of the clients well-being. I explain to clients that while the ORS is awesome, one challenge with it is that the ORS scales are very broad and general at first glance. Providing these additional scales allows me to check in with a clients experience in more detail. Note that I’m currently at version 6 of these scales, which have evolved based on client feedback. The following factors make up the ‘therapy effectiveness’ set of scales, they are presented using a 0-9 scale:

• – Suicidal ideation
• – Self-acceptance
• – Connection to values
• – Hope (that life can improve)
• – Distress (average distress level over last week)

The second check in is about understanding the process goal that a client has for their session. These were born after consistent feedback from clients. I’ve been giving clients feedback scales for quite a while, like the session rating scale (SRS). A lot of my them however had never had therapy before, so whenever I asked them for feedback, they would say something like “I’d love to provide feedback, but I’ve never done therapy before, so I have nothing to compare to. So how can I know what we’re doing here is ‘right’ or any good?”.

I thought for a long time about how to solve this – how could I give clients an idea of good therapy looks like?

I then came across a visual representation of the ‘contextual model’ of therapy and had my answer!

I didn’t provide an exact translation of the model to clients, but it helped me come up with the following:

This ‘pathways to recovery’ check in has been monumental for my own self-care. Before my brain would try give a client room for all 4 pathways at once in a session. I’d be trying to give them space to vent, while trying to formulate an ‘explanation’ of their pain and simultaneously coming up with strategies to resolve what was happening. I did this because I didn’t know for sure what a client wanted, so I tried to play it safe and cover every base at once. It was a perfect recipe for burnout (and those headaches I mentioned). But now I’m much better at honing in on one pathway a time, so if a client wants to focus on finding strategies, for example, that’s where my mental focus goes the most.

Last but not least, there’s the ‘therapy experience’ check in. These are a set of four scales I use with clients to gather their feedback, insights or advice on how the therapy process is going. These scales are currently at version 7. They have replaced the session rating scale. Why? I found I wasn’t able to explain the SRS scales to clients as well as I would like, which impacted my confidence in using it. Developing my own scales based on client feedback has helped me come across as more confident. I know these scales back to front because I made them. Like the first set of scales, these are also presented on a 0-9 scale and contain the following factors:

• – Therapy skills check in (how accessible the lessons or ‘tools’ from the session feel to the client)
• – Therapist trust (how much the client trusts me)
• – The ‘need’ scale (how much the current approach is targeting what the client needs to work on in order to grow)
• – The ‘same page’ check in (whether the client feels I’m on the same page with them, when it comes to the current approach)

Final thoughts

I know what I have shared today might be a lot to take in, so please feel free to ask any questions if I can clarify things further. I hope it comes across just how much time and effort I have put in to the foundations of my therapeutic approach and process – it’s been a lot of hard work. You’re welcome to provide any advice or feedback as well. I still have my goal to not change my processes this year – as 2024 is my year of consolidation – but any ideas I’m given will still help me reflect, for once I am ready to consider any changes from next year.

To be clear as well, I’m definitely not saying this is the right way of doing therapy. DP is all about finding your own path. One of my goals in being so open with my process is hopefully to inspire others to look deeply at their own foundations – at the core of how they do therapy.

Reflecting on my process has helped me realise that while before I was trying too hard, I now understand that doesn’t mean I was putting in too much effort. The effort was simply misplaced. Instead of listening, formulating and intervening; all at the same time – I can instead put all that effort into building and protecting the therapeutic alliance. Working very hard on my process over an extended period of time has actually helped me work smarter, not harder – but I’m still putting in the same amount of care and effort with my clients as I was when I started this journey. The difference now is that instead of stretching my energy across trying to cover multiple bases at once, like a shotgun, I can now better focus all that energy on one base at a time – like a laser. It helps me and my clients take one single step at a time; those single steps are far more efficient, productive and powerful than they ever were before.

Clients are paying us to put in effort. So if you’re going to put in the effort – focus it most on what matters, the therapeutic alliance and find a way to take one step at a time.

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