Frontiers of Psychotherapist Development

At the Bleeding Edge of Development, Reaping Benefit for Our Clients.

Author: darylchow (page 3 of 4)

Three Types of Knowledge, and Why This Matters in Psychotherapy

Card trick (smaller)

Information does not equal to transformation.

When I was in secondary school, I had a good friend who seem to morph every time we return from our month-long school holidays. For the rest of us, we came back with grandiose updates about girlfriends – factitious or not – the latest music we’ve heard, and other raving topics. Every cycle of return to school in January and July, most of us were pimple-ridden with awkwardness. Herman had the acne, but was focused and hard-pressed for an audience.

Herman was different. He wasn’t the coolest kid. In fact, he was scrawny, somewhat of an oddball, and didn’t quite fit in. Every holiday that he came back from, he would use us as guinea pigs to test out his latest magic trick. And it was usually a flop. Cards fall of his hands, coins did not reappear as it should. And of course, this was met with testosterone mockery. At least for the start.

But after a few more vacations, we were floored. He almost seemed like he came from an apprenticeship with Houdini. His close-up card tricks became seemingly flawless. He even had our teachers pop in between classes, gasped in amazement.

As it seems, in every class, they would always be at least one smart Alec. This person repeatedly tried to call our Herman’s bluff. “Ah ha!! I saw that. You are cheating!”

What do you expect, smart Alec? Real Magic?

Here’s the thing: as noted by Seth Godin in his book Tribe, citing the great magician Jamy Ian Swiss, it’s easy to figure out how a trick is done, but the real difficult part is to develop the art of doing it. Knowing how a magic trick is done does not make you a magician. (For a good example on this, check out the magic competition TV program, Penn & Teller: Fool Us show).

Continue reading

The Pursuit of Excellence is Not the Pursuit of Perfection

the pursuit of perfection vs the pursuit of excellence

“An expert is a person who has made all the mistakes that can be made in a very narrow field.”

-Niels Bohr, Danish physicist and Nobel Prize winner.

The pursuit of getting better at our craft in therapy requires us to make fine distinctions. One of them is to make the distinction between  the pursuit of excellence vs. the pursuit of perfection.

The pursuit of perfection has no room for mistakes. Failing = Failure. The pursuit of excellence treats errors and blunders as grist for the mill. It is where the ordinary magic of growth happens. Failing ≠ Failure.

The pursuit of perfection is rigid, exacting, clinical and cold. The pursuit of excellence is flexible, warm and humanistic in the emotionally charged interpersonal encounter of two persons coming together to co-create a better life for one party. In turn, the giver is moved to be a better person in return as well.

The pursuit of perfection is self-centered. The pursuit of excellance is others-centered. It uses the self in service of the other. It doesn’t use the other to enlarge the self.

The pursuit of perfection sees therapy as a performance. As if held within the judging gaze of another, it’s ego is at stake, thus it confines to it’s comfort zone. The pursuit of excellance seeks to re-form the status quo, seeking to reach beyond our comfort zone.

The pursuit of perfection suffers chronic anxiety. The pursuit of excellence embraces uncertainty, and accepts the uncontrollable force of life circumstances. It treats the turn of each event as teachable moments for the inner life. Its antidote to worry is to believe that the most perfect thing to do is to embrace imperfection.

The pursuit of perfection wears a fixed mindset hat. The pursuit of excellence wears a  growth mindset hat, which promotes receptivity in learning, and learning to take feedback seriously and not personally.

Finally, and perhaps most importantly, the pursuit of perfection thinks it is pursuing excellence.

May we make room for the pursuit of excellence in the new year ahead!

– Daryl Chow, Ph.D.

*imperfect image above hand drawn with Paper & Pencil  on iOS device

8. Productivity for Therapists: The Top 5 What-Not-To-Dos (Part 2 of 2)

Runner

 

 

In the previous post, I talked about the pit-falls of engaging in the “Blame-Game” and getting mixed up with being busy and being productive.

We continue the final count-down of “What-Not-To-Do” if we want to increase our productivity in a busy schedule.

Continue reading

7. Productivity for Therapists: The Top 5 What-Not-To-Dos (Part 1 of 2)

 

Busy man

“Thus we are busy people just like all other busy people,

rewarded for the rewards which are rewarded to busy people.”

– Henri Nouwen, from The Way Of The Heart, p.22.

 

 

Just do a google search, and you’d soon be inundated with many blogs and self-help books that specifically addresses the issue of raising productivity. Many of them provide useful to-do suggestions.

While trying to straddle conducting research, providing training and supervision, writing commitments, myriad of meetings, making time to create music, and maintaining a clinical practice, I found out that I had to take a deep look into the issue of productivity, especially since the birth of our beautiful one and a half year old daughter. I love being with her. It was also a crucial time that I work out my schedule, so that I can afford the capacity do the stuff that matters to me. This also means that I would have have to cull activities that are unnecessary time killers. Like useless and mindless meetings.

 Necessity is the mother of important learnings.

I realised this issue of time scarcity isn’t unique to me. Many of my colleagues are overwhelmingly busy, sometimes to the point of skipping lunches just to squeeze in a therapy hour for an ad-hoc client, or going home late so as to finish up a report.

I’ve decided to write this post for the busy therapist, but from a less common angle. I reckon that this is more crucial than telling you “what-to-do”, which you would probably already know.

Continue reading

What Psychotherapists Want

children, kids, hair, horizontal, sky, tower viewer, binoculars

If we were to pool together about a 1000 clinicians and ask them what were the topics relating to professional development that were of most interest to them, wanna make a guess what they would say?

(Hint: it’s not about treatment manuals)

Check out my mentor and collaborator, Scott Miller Ph.D.  blogpost  describing the answers from a recent study published in an APA journal Psychotherapy about this.

Come August 2015 in Chicago, Scott and I will be conducting a first ever 2-day workshop on Professional Development. We will be laying out concrete steps that clinicians can take, we will review the evidence as we map out a highly individualised professional development plan.

If you are interested in pushing beyond your growth edge, come join us! Seated are limited to 20 participants.

Registration details can be found here.

6. The Scandal of Clinical Supervision: How to Resolve It (Part 2 of 2)

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In the previous post, I described the 3 common pitfalls of clinical supervision, which are “theory-talk”, “pad-on-the-back”, and the lack of monitoring progress.

Here, three key methods are suggested on how to enhance the use of clinical supervision.

Here’s How:

Keep in mind the use of the “3-Dimensional Perspective” I proposed in an older post Why Our Self-Assessments Might be a Delusion of Reality. I suggested this to guard against the fallacy of the illusion of expertise.

Quick recap: The three approaches are

1. The use of formal client feedback measures;

2. Video recordings of sessions; and

3. Clinical supervision.

In order to fully benefit from clinical supervision, I’d suggest the following three features:

1. Stay Close to Client Engagement:

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We often assume that we have consensus to pursue a particular track with our clients.

First, make sure we have consensus on the goals. Then explicitly check on client’s willingness to engage in a particular area.

We make the mistake that once the client explicates a goal, that we have her will on-board, which may not be the case. For example, a  client might have a goal on making friends as she is experiencing loneliness that’s making her depressed. Through therapy, it’s established that she sees herself as unlovable, based on her past abusive relationship with her father and recent divorce. The self-attacks keeps her isolated and depressed.  The therapist cannot simply assume that since there is consensus on the goal (i.e., to develop friendships), that she is willing to work on her self-deprecation, which has been keeping her away from the social world. The therapist needs to ask – by knocking on the doors of her inner life – and to request for permission to be invited in as a guest.

“Is this something you want to work on?”

 

Second, the therapist needs to systematically monitor if client is engaged in the process and rationale of the particular method of treatment. For example, where working with her core emotions through a two-chair dialogue, does she see the rationale for doing so? Does she see the causality of how her self-attack is keeping her depressed?

Third, all of the above can only take place when there is an emotional bond and a sense of emotional safety working with you. Take the time to check in on their perspective on this. (Also see Matthew Bambling and colleagues excellent supervision study1).

2. Listen to the Music First:

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Imagine a friend comes to you and tries to describe to you a beautiful and inspiring song that he recently heard. Would you rather him continue his description with his best of intentions, or would you rather him let you have a listen to the piece of music instead?

Without a skip of a beat, I’d pick the latter.

This is where the value of recording your sessions reaps its rewards. Bring in the audio/video recordings of the session to supervision. Hearing the start of a session is often useful; how we start a session has a ripple effect on how the rest of the hour unfolds. Thereafter, pick a 10 min segment to let your supervisor listen/watch. This clip could be one of the following:

a. thin slice of the representation of the quality of the engagement;

b. a difficult interaction/alliance rupture moment; or

c. If you do not have either of the above, randomly pick some where in the middle of session. You would be surprised at would might be useful from this!

This is not only helpful in clinical supervision, but also useful in self-supervision. (More on this in a later post).

When a sound rationale is given to clients on the purposes of recording (e.g., “I record my sessions so that I get to ensure the highest service delivery and experience in therapy… I would review them, and sometimes with the help of a supervisor, when necessary.”), clients are more likely to agree. Clearly, when the client is not comfortable of the idea, do not process with the recording. Let them know that you respect their choice. Nonetheless, the rate of compliance to be audio/video recorded is dependent more on the therapist than the client.

3. Use Routine Outcome Measurement + Revisit The Case: 

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For supervisors: Try out this little experiment. Once you’ve got your supervisees routinely monitoring their client outcomes using measures, get your supervisees to pick 3 cases that show no improvement and advise them to bring them up in supervision.

Pick another 3 cases that show no improvement, and put them on your “wait-list,” that is, hold off providing case consultation on these cases. The verdict: see if there’s a difference in outcomes for the 2 groups (Supervision vs. No Supervision) of 6 cases. This definitely lacks the rigor of a randomised clinical trial (RCT), but it is definitely worth testing it out. Whatever the verdict is, reflect on it. What factors in your supervisory encounter impacted the supervisee/therapist to act similarly or differently, that led to client improvement, or the lack of?

For supervisees: Do likewise, and note down what pointers you applied into your 3 cases in the supervision group. How did it go? Did it help, or was it off-the-ball? Did it have an impact on the outcomes and alliance ratings? Either way, reflect this back to you supervisor.

This lets your supervisor know how on-target their guidance has been, and allows continuity or re-calibration when needed.

Stick-It: 

Pasted Graphic 2Pasted Graphic 3Pasted Graphic 4

Reference:

1. Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research, 16(3), 317 – 331. doi: 10.1080/10503300500268524

5. The Scandal of Clinical Supervision: Here’s the Shocker (Part 1 of 2)

Screen Shot 2015-02-22 at 8.15.09 AM

 

 

Like most psychotherapists, you are likely to regard clinical supervision as highly integral to your professional development.1I cannot imagine not having someone to turn to for case consultations and guidance, especially when I’m stuck in the rut and not making progress with a case.

Clinical supervision has be hailed as the “signature pedagogy” of choice in the field of  psychotherapy.2 In an important review done by Edward Watkins3 (I highly recommend reading it), he examines the past 30 years of research, churning out in total 18 empirical studies that specifically examined the impact of supervision and client outcomes. Dr. Watkin’s points out that out of the 18 studies, only 11 were related to the impact of supervision on outcome. Critically, he says,  “…the collective data appeared to shed little new light on the matter: We do not seem to be any more able to say now (as opposed to 30 years ago) that psychotherapy supervision contributes to patient outcome.”

In case you are wondering, 3 decades worth of stalemate is quite a long time, given the prevalence of clinical supervision as the learning method of choice by psychotherapists.

More recently, fellow ICCE associates, Tony Rousmaniere and Robbie Babins-Wagner and others conducted a large five-year dataset consisting of 23 supervisors involved in a naturalistic setting 4, supervision was found to be not a significant contributor on client outcome. Rubbing salt to the wound, the supervisors’ experience level, profession (social work vs. psychology), and qualifications did not predict differences between supervisors in client outcomes as well.

Now, if we piece all of this together, it sounds like this. Even though most of us wholeheartedly swear by it that our experience of clinical supervision helped us to grow and develop as practitioners, it rarely makes a den on our client improvement.

The Danger 

Why isn’t clinical supervision translating to benefit for our clients? Here are three speculations:

1. Theory-Talk:

Often, the encounter in clinical supervision revolves around case discussion, theoretical formulation, case formulation, and even gossip (isn’t that when we talk about someone without him or her present?). This mostly fits under the umbrella of conceptual knowledge, and does not delve further in the actual moment-by-moment interactional pattern. (See future post on 3 Different Types of Knowledge.)

2. Pad-on-the-back:

What feels good doesn’t necessarily equate to what helps us grow. While it is important to take care of the supervisee’s ego, at times we fail to focus on their “growth edge”, that is, taking care of the supervisee’s sense of self as a helper, and helping them going ever so slightly beyond that comfort zone.

3. The lack of a monitoring progress:

We therapists are an optimistic bunch. In the absence of real-time monitoring of outcomes and engagement, session-by-session, we fail to detect deterioration, or at least the lack of progress.

Even when we do use routine outcome monitoring devices, like the Outcome Rating Scale (ORS) & Session Rating Scale (SRS), Outcome Questionnaire (OQ-45), or Clinical Outcome Routine Evaluation-Outcome Measure (CORE-OM), we fail to integrate this in the supervisory process in a meaningful fashion.

I once had a supervisee who insisted on his shortfall in helping a particular client. He didn’t have her ORS/SRS graph at that moment. I insisted that he brought it in the following meeting. Here’s what the client is saying from the graph’s information: outcomes where gradually improving, and alliance had a dip at the 2nd session, but continued to pick up thereafter. And here’s what the supervisee was essentially saying: Things aren’t improving.

We then spent time to work through the supervisee’s uncertainty, while holding in mind that the client is likely to be reporting benefit from the engagement. We then need to take our eyes and ears from the perspective of the client to lead us further. It turns out that the therapist was concern about answering to the referral concern posed by the referring psychiatrist, which wasn’t the client’s main issue at hand. Then we proceeded to work out how to attend to the primary client, which is the patient seeking help, and how to address the secondary client, which is the referring psychiatrist.

The marriage of data and clinical knowledge emerged a type of dialogue that is richer, and aids clinical decision making.

Summary:

Beware of the 3 common pitfalls in clinical supervision. They are “theory-talk”, “pad-on-the-back”, and the lack of monitoring progress.

For some ways to improve the situation in clinical supervision, see the next post on The Scandal of Clinical Supervision: How to Resolve It (Part 2 of 2).

 

References:

 

1. Orlinsky, D. E., Botermans, J.-F., & Ronnestad, M. (2001). Towards an empirically grounded model of psychotherapy training: Four thousand therapists rate influences on their development. Australian Psychologist, 36(2), 139-148. doi: http://dx.doi.org/10.1080/00050060108259646

2. Watkins, C. E. (2010). Psychotherapy Supervision Since 1909: Some Friendly Observations About its First Century. Journal of Contemporary Psychotherapy, 1-11. doi: 10.1007/s10879-010-9152-2

3. Watkins, C. E. (2011). Does Psychotherapy Supervision Contribute to Patient Outcomes? Considering Thirty Years of Research. The Clinical Supervisor, 30(2), 235-256. doi: 10.1080/07325223.2011.619417

4. Tony G. Rousmaniere, Joshua K. Swift, Robbie Babins-Wagner, Jason L. Whipple & Sandy Berzins (2014): Supervisor variance in psychotherapy outcome in routine practice, Psychotherapy Research, DOI: 10.1080/10503307.2014.963730

#4. Why Our Self-Assessment Might be a Delusion of Reality

 

Homer

It seems that we share more in common with Homer Simpson than we like to admit. Did you know that social psychologists found that in general, people rate themselves as more attractive that they really are?(1)

In my doctoral study of highly effective psychotherapists(2), the results of an area investigated about therapists self-ratings of their Healing Involvement (HI) in therapy left us initially scratching our heads. Orlinsky and Ronnstead(3) describes someone with high HI as someone who views themselves as personally invested, efficacious in relating with the client, affirming, and highly skilling, experiencing flow states in therapy, and employ constructive coping strategies. What we found was a negative relationship between their outcomes performance and HI rating. In other words, therapists who rated high on their HI scores were more likely to be less effective than their peers! How is this possible? Going further, the same group of therapists we studied, half of them rated their current effectiveness as above average. None rated below average. What’s more, these self-assessment of effectiveness ratings did not predictor their actual client outcomes. Continue reading

#3. Clinical Practice vs. Deliberate Practice: Why Your Years of Experience Doesn’t Get You Better

 

In times of change, learners inherit the Earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists. 

– American moral and social philosopher, Eric Hoffer (1973, p. 22)

 basketball-hoop

Question: Would you hire this guy? Imagine an NBA basketball player decides that he doesn’t need training outside of competitions, because he has gotten so good at his game, and all he needs to do is continue play more game. If you own an NBA team and it’s drafting day, would you invest in this guy? Probably not. You won’t bet your money on the “Learned”, but you would do so for the “Learners”.

Many mental health professionals, counsellors, psychologists, psychiatrists, nurses, social workers, and marriage and family therapists alike, spend hundreds of hours clocking in our practicum years in order to be accredited and/or licensed to practice. Not to be confused, the word “practice” here means, well, work. It is not practice per say. It is the real deal. We end up falsely believing that since we have spend all that time in practice during our educational years, we are well equipped for the real work, that is, clinical practice. Thank goodness not everyone falls into this “Learned” group. Others whole heartedly believe that learning is lifelong. These are the “Learners”. But both “Learned” and “Learners” group have to deal with the same professional development issue: What keeps me at sharp at my skills in helping people?

It is crucial to make a distinction between work, and work that targets at getting us better at what we do. Therapists often confused that they worked hard to improve at their craft when they find themselves experiencing “flow” states during sessions. Clearly, when we are engaged in the therapeutic encounter, we strive to be fully present, attuning and relating to the emerging emotions and unfolding lived experience of this person who is in front of me seeking help and counsel. We get taken by this process, sharing a specific aim to ameliorate the person’s suffering. Continue reading

#2. The Most Important Weekly Appointment: The “MMI” Meetings

“Thus we are busy people just like all other busy people, rewarded for the rewards which are rewarded to busy people.” 

– Henri Nouwen, from The Way Of The Heart, p.22.

Top Secret

I struggle with this all the time. Yet It is crucial to schedule time for ourselves. We know how important this is, but often more pressing issues get the better of our attention. It’s so easy to be drawn to busy-ness. But if our development is prized, we must devote a portion of our time to it. If we left it to, “I’d catch up on it when I get the time,” or “I’d squeeze so time in-between my work,” chances are, you won’t have the time. (See Cal Newport’s take on deep and intense work.)

If left to my own device, without any structured automation or scheduling, I probably spend more than 90 percent of the time trying to catch up on demands from other people, leaving little time – and energy – to work on what really matters.


Here’s How:

In you weekly planner, schedule at least one hour of the week called “MMI” Meeting (Me-Myself-&-I). You don’t have to explain to others what this stand for. If you can, get away your usual office space (“where are you going,” asks the inqusitive colleague. You reply, “I got a meeting to attend.”). If you are in private practice, book yourself in at the least scheduled hour by your clients. This is your protected time towards self-development. It is what Moore-Edd calls your “time cocoon.”

In this weekly hour of “MMI”, you’d devote towards one of the following things:

– Read;

– Watch therapy videos of others;

– Review your recordings of your session;

– Reflect on your recent sessions;

– listen to a piece of music, with your full singular attention through to the end of the piece;

– Take a walk; and/or

– Take a nap (seriously).

What Not to do:

– Check your emails (in fact, do not leave your email application on);

– Play with your smartphone;

– think about how great having MMI meetings might be;

– have a guilt trip while you have a MMI meeting;

– See more clients.

I can’t have said it better than Wayne Muller, the author of a book, Sabbath:

“The busier we are, the more important we seem to ourselves, and, we imagine, to others. To be unavailable to our friends and family, to be unable to find time for the sunset (or even to know the sun at all), to whiz through our obligations without time for a mindful breath, this has become the model of a successful life.”


 

Stick-It:
Add into  your weekly calendar a one hour “MMI” Meeting.

Once you have established your “MMI” Meeting in your schedule, resist the urge to over-ride this MMI hour. Busy-ness bedevils deep work and stunts growth. As Henri Nouwen alluded, busy people, reap the rewards of more busy-ness.
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