Here we are – it’s the first submission to ‘Ask Jimmy’!

Please welcome Mr X! (yes I chose a Simpsons reference). Please also thank them for having the courage to do this and to be the first one. They were actually part of the inspiration of these post series.

It just goes to show that you never know how impactful your vulnerability might be.

Click here if you would like to submit your own question to Jimmy.

Please note: I have shortened the responses for somewhat to help anonymity and for conciseness, so some of the niceties have been removed as well.

The submission (via email)

I am heavily invested in FIT and I follow the insights from literature about common factors and the importance of the alliance in therapy. My preferred modality is CBT, which I apply in a transdiagnostic manner, incorporating various CBT techniques and schools (MCT, ACT, MB-CBT, unified protocol, etc.). I try to tailor my use of CBT to the individual client, so I am far from doing a “manualised” version of it, which I find hard to combine with working from a FIT-perspective.

Anyway, over to what I am strugling with:

My struggle lies in balancing immediate usefulness with patience. I’ve noticed that I sometimes rush into psycho-education or suggesting techniques before fully understanding the client or establishing their engagement in therapy. This has become apparent after analyzing cases that does not end on track. I’ve considered investing more time in “case-formulation” (or just getting a better understanding of the client and their problems) to build a stronger alliance, before focusing on how to “solve” their issues.

However, FIT emphasizes early usefulness, expecting an increase in the ORS from the first to the second session. Daryl Chow’s “The First Kiss” also advocates for usefulness from the first session and avoiding intake. This leaves me in a quandary: I need to be patient, yet I should be useful from the outset.

I believe the key lies in redefining what “useful” means in this context. I would greatly appreciate any insights you might have from your practice. I guess the idead from Chow of “giving a gift” might be close. It seems to me this “gift” can be realtively small, and does not have to be a worksheet with exercises or a bunch of psycho-education.

I am looking forward to hearing your thoughts on this. Thank you for your time and consideration!

Jimmy’s response

Thank you for the initial context around how you do therapy and for taking the courage to reach out about this, vulnerability is hard!

FIT is a great place to start, in trying to individualise your approach to each client.

Good on you for picking up this pattern in your work.

Yep it’s so easy to quickly lean on psychoeducation or techniques in the hopes we can move the client forward this way – I think it’s also a bit of ‘path of least resistance’ playing out.

The issue here is that jumping in with these, in the genuine hope of helping as quickly as possible, can lead to missing the mark for the client. In essence, we are trying to help before understanding the client deeply enough, so it’s like offering them tailored clothing that is only measured half right.

This is understandable, as you feel the pressure to help as quickly as possible, like many of us – I’m a perfect example. It’s important to understand that this pressure is likely coming from within, not from the client (at least not most of them).

Unintentionally this pressure can escalate when you read ideas like the initial session “should be a therapy session” and to offer the client a “gift” from the first session.

It’s easy to feel more overwhelmed, not less!

Help is at hand – The thing is, once you learn to break things down, by gradually attending to some key principles, gifting clients becomes much easier. The thing is, when you listen to a client well, you don’t have to offer much. Because you listen well you “hit the mark” – and that’s enough.

You were already heading in the right direction in this line in your email! – “(or just getting a better understanding of the client and their problems)”

In order to listen better to clients, we need to slowly/gradually replace the undesired behaviour of leading them with desired behaviours of being led by them. I do this by following the key principles below, as best as I can. The principles flow somewhat in order, like a line of dominos:

1. Trim the fat – I have removed everything from my initial sessions with clients that encouraged me to lead them or made these parts as small as possible if I couldn’t remove them completely. E.g. I removed a 5 minute introduction to goal setting and replaced it with 30 seconds of ‘finding a direction to start’ (more on that below).
2. Sit back and listen – Give the client the reigns to share their story of why they have come to see you, what they need your help with, what they want to work on and how they want to work on it.
3. When in doubt; clarify, clarify, clarify – While I’m learning how the client is picturing things (which is always), I always make sure to ask a clarifying questions if I sense I’m starting to think from my own perspective too heavily or I’m not understanding them. Sometimes this is to confirm/disconfirm my understanding of what they are sharing.
4. Context questions – For framing and some structure – otherwise you can end up in ‘true but useless’ information territories e.g. client going into heaps of detail about what they had for lunch. An example framing question I ask might be “when did these challenges start?”
5. Outrospection – A word I learnt from Daryl’s blog. My understanding of the meaning of it is to gather the picture from the client, don’t try form an ‘imitation’ of their picture from your own.
6. No goal setting – All you need from the client is their desired initial direction. I don’t challenge what they choose unless it risks harm to them or others. Even if they say “I want to stop my anxiety”.
7. The formulation iceberg – I show clients a blank drawing of an iceberg. This is to help me very loosely frame their chosen direction. I explain that the tip of the iceberg refers to distress management and below the surface refers to working on the “underlying factors” that create the surface level distress (e.g. perfectionism). We can work on both eventually, but not at the same time. Some clients choose the tip first, others choose below the surface. I introduce this at the 40 minute mark at the latest, but no earlier than 20 minutes in most cases (my initial sessions are 60 minutes long).
8. Finish with a small gift that lines up with the clients chosen initial direction – e.g. if a client chooses that they want to start by addressing assertiveness, then I might offer a tip sheet on assertiveness. Don’t pressure yourself to explain the gift for anything more than a few seconds. If you think it will need more exploration, tell the client this can be explored more deeply at the next session.

Common gifts can be:

• A tip sheet (e.g. tips on assertiveness)
• A list of coping skills
• A questionnaire
• A self reflection exercise – e.g. I might give a list of common traits to reflect on values
• A mantra to trial on a sticky note
• Suggesting the client think about something or observe something more
• Reflecting on a key lesson/realisation from the session
• Emphasising the message of hope – that with our plan things can get better
• A suggested direction

To wrap up

I know this may be a lot, I try to be simple but thorough when explaining first connecting with a client, because it’s so vital to the process. You may feel a pressure to master all these principles tomorrow, but give yourself permission to work at them as gradually as you need – preferably one at a time. The principles are intended to inform/guide your behaviours. If you need help identifying specific behaviours to try, then I’d suggest finding a coach or simply allowing yourself to try some trial and error.

In the meantime, you’re welcome to keep contacting me or you can post in the Deliberate Practice Café Facebook group, if needed. Let me know if I can clarify anything and best of luck 😊

---

Click here if you would you like to submit your own question to Ask Jimmy!

• Instagram
• Facebook

If you want to stay in the loop for future posts, then please feel free to sign up for our mailing list: