Frontiers of Psychotherapist Development

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

Tag: clinical practice (page 2 of 2)

The Tension of Opposites: Clinical Intuition vs. Clinical Data (Part 2 of 2, The Rate & Predict Exercise)

 

In the previous post, I advocated the marriage of our clinical intuition and the use of outcome informed data.

Do not let me convince you. Let your experience convince. Put it to the test. Try them on for size.

fashion-men-vintage-colorful

Here’s how:

I call this the Rate & Predict exercise. There are two parts:

A. Using an Outcome Measure (Outcome Rating Scale, ORS; Clinical Outcome Routine Evaluation, CORE),

1. Rate: After the first session, ask your client to RATE the outcome measure in subsequent sessions;

2. Predict: Before you see your client’s score, PREDICT what they would score. It is important that you write down scores for each of the sub-scales, if any. (for ORS, Individual wellbeing, close relationships, Social, General). This prevents us from falling into the “I knew it all along” hindsight bias effect.

3. Evaluate: Compare and contrast the scores. See what stands out. Talk about the with your client.

B. Using an alliance measure (e.g., Session Rating Scale, SRS),

1. Rate: At the end of the first session, ask your client to RATE how they feel about the level of engagement in the session;

2. Predict: Before you see your client’s score, PREDICT what they would score. It is important that you write down scores for each of the sub-scales (for SRS, level of emotional connection, goals, approach/method, overall).

3. Evaluate: Compare and contrast the scores. See what surprised you. Form your feedback questions from there.

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The Tension of Opposites: Clinical Intuition vs. Clinical Data (part 1 of 2)

Data & intuition = better decisions

 

There are those who embrace routine outcome monitoring (ROM), and those who shy away from it like the plague.

On one side of the fence, skeptical practitioners point their crucifix against the use of any client-focused outcome measures, while others who embrace ROM think that outcome measures are like the second coming, thinking that it can supersede decision making about the treatment process.

The adamant Non-ROMer would say, “How can a simple outcome measure tell me about whether my client is benefiting from treatment and how effective I am? Besides, change takes a long time to happen, and it’s gonna get worst before it gets better.”

While the rookie ROMer would say, “The outcome measure is sufficient to inform me about whether my client is benefiting from therapy and how effective I am. Change happens early all the time, and it won’t get worse before it gets better.”

Like all fundamentalism, such rigidity snaps easily under pressure. The words of Gregory Bateson reminds as that the test our stability is how flexible we are.

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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

#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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