Frontiers of Psychotherapist Development

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

Tag: routine outcome monitoring

Signs That Therapists are Barking Up the Wrong Tree in Our Professional Development 


Signs That Therapists are Barking Up the Wrong Tree in Our Professional Development

Sometimes you climb the ladder to the top,
only to discover that you’ve placed it against the wrong wall.

~ Joseph Campbell


I’m going to re-look at some deeply held truths  we were taught to believe about professional development in the field of psychotherapy.

Actually, if these truths are closely examined, they are perpetuated lies.


What’s worse than falsehood is a distorted truth.


This is not an attempt to put up a straw man about our field. Rather, I hope we can

a) Stop digging ourselves into a deeper hole, and

b) Get ourselves out of the entrenchment.

Before you read on, answer the following question:

Do you consider yourself a person who is open to challenging your own assumptions

If you are, read on. If not, the following list is going to cause you some discomfort.

Here it goes:

In no particular order, here are signs that we are barking up the wrong tree in our professional development:

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How Do You Get Better At Eliciting Feedback?



…But what questions should we ask?

In the previous post, we addressed the issue of how to receive feedback.

In this post, we take a step back and address how we can elicit feedback.

But before we dive right in, ask yourself:

Do you really want to know? I used to find myself hesitant to ask for feedback when I know someone was amiss in the session. I’ve learned from my colleagues that this is common. What I learned is to point it out anyway, “You know Tim, I noticed that I might have missed something essential to you today. Am I mistaken? Can you help me figure out what that is, or what we could have explored further on?”

How we convey a sense of openness to the other person’s point of view will determine the type of feedback we get.

When we ask, ”Is everything ok today?” will skew towards a vocal-tic response, “Yeah. All good.”

Where we point the lens, it becomes the foreground. Discuss in advance what you are looking out for. While it may sound counterintuitive at first, take some time to process the following:

High session ratings of engagement by your client is not predictive of good outcomes (e.g., Owen, Miller, Seidel, Chow, 2016). In contrast, highly effective therapists seem to be able to elicit low engagement scores in early sessions. High alliance scores in the first session tells us nothing. The client could be truly happy with the session, or she might not feel safe to tell you how badly you missed her point today.


















Do you know the average alliance formation trajectory among your clients? Which of the above fits your pattern?

We’ve also found in our initial Supershrinks study (Chow, 2014; Chow et al 2015. Stay tuned. We are on to some replication studies. More on that next time) that as compared to the average cohort, highly effective therapists are more likely to report being surprised by client feedback. That is, the top performers are more likely to report being surprised by client’s feedback that their counterparts. It does seem to suggest that the highly effective therapists are more willing to be corrected. They have a sense of openness to receive and consider client’s viewpoints, even if it may be contradictory to the therapist existing expectations.

Janet Metcalfe and colleagues suggest that individuals are more likely to correct errors made with initial high confidence than those made with low-confidence, so long as the corrective feedback is given (Barbie & Metcalfe, 2012; Butterfield & Metcalfe, 2001; Butterfield & Metcalfe, 2006; Metcalfe & Finn, 2011). Although it may seem intuitive that deeply held beliefs are more entrenched and are the hardest to change, experimental studies have indicated that individuals are more likely to overwrite their responses and correct their beliefs (Butterfield & Metcalfe, 2001; Butterfield & Metcalfe, 2006), and are more likely to retain the correct answer compared to knowing the correct answer at the outset (Barbie & Metcalfe, 2012).

What? That’s a mouthful. Put it this way. Stand tall, and stand corrected.

Here’s some key points to remember when trying to elicit feedback from your clients at the end of a session:

1. Prime the Recall:

Give a good rationale WHY your client’s feedback about the session is crucial to you;

2. State What This is Not:

For example, “This is not an evaluation tool…You know how we are asked to do feedback surveys at restaurants? This is exactly what it’s not! Simply because those types of feedback, do not effect a change that will impact you. Your meal isn’t going to change because of your feedback. Here in the session, your feedback is important to me as it can help me tailor to fit you specifically…”

3. Juxtapose Open and Close Ended Questions:

Conventional wisdom argue to use open ended question. “What was the session for you?” Most of the time, this is too vague for clients. Instead, ask the specifics. “As you recall out what we talked about, and the exercise we did before we wrapped up, What was helpful to you?” After they share with you a response, follow it up with, “What was not helpful to you?” “…I know it’s tough to give feedback… we don’t normally tell others what we think, but your point of view is very important to me. I won’t take it personally, but I will take it very seriously…. cos’ sometimes, I just can’t see what I can’t see.”

4. Be Specific:

If you want specific feedback, be specific with your questions. “You know Kelvin, I got a feeling that I’ve pushed you too far today, especially when we were attending the issue about your fears. Am i mistaken?”

“What should I do more of?”


“What should I do less of?”

5.  The Small of Things:

Say this, “You know as it’s hard to give someone feedback, I just want you to know that even if you think it’s a small or minor issue, please, I would love to hear about it.”

Cite examples: “You know, I once had a client who told me that I was too careful with her, and she wanted me to just be blatant with her. Do you feel that way too?”

As a form of closure, you can ask, “If there’s just one thing, what stands out for you today that you’d like to remember from our session?” Write that down, and begin to form ideas to bridge this into the next session.

Don’t forget to take a gamble on your own to make a prediction of how your client rates the session, before you see their ratings on the alliance measure. (see an older post that I talked about this practice, called Rate & Predict exercise)

All systems balances itself with a feedback loop. It’s up to us to elicit the specifics, and then follow through be an open and warm receiver. It’s abit like receiving presents during this Christmas. Be thankful.

At the time of this writing, I wish each of you a happy new year.


Daryl Chow, PhD

30th of Dec 2016


Three Surprising Facts About Psychotherapy You and Your Doctors Need to Know

boy hearing for the first time (w hearing aid)

With the help of a hearing aid, boy hears for the first time.

This is for those who are thinking about seeking help. Maybe you are wondering, unsure of who to go to and what to look out for. Or maybe you just need a reason to give a shot at therapy/counselling before you take a psychotropic drug for your emotional problems.

Click here to find out more: Three Surprising Facts About Psychotherapy You and Your Doctors Need to Know

boy with new pair of shoes_overjoyed

Boy overjoyed with a new pair of shoes

Like the images of the two boys, I hope you get the help you deserve, and experience a renewed sense of joy in your life.

Daryl Chow, PhD

You might also be keen to read from related posts:

Why Our Self-Assessment Might be a Delusion of Reality

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

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.


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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