With each plane crash, future flights become safer.

With each therapy failure, we feel less safe with ourselves. We are cast into a sea of self-doubt. Our confidences plummet; our competence is called into question.

Photo by Suhyeon Choi

We struggle to speak about failings to a trusted colleague, let alone find the time to analyse the mistakes. Worse, you are afraid to speak to our supervisors about them in fear of being judged as incompetent, especially if your supervisor is a senior at your agency.

We need to learn from aviation and how they got better. As a result of an open loop system of learning, commercial aviation has dramatically improved their safety records. [1]

The trouble is, for us psychotherapists, we have a “closed loop” approach to learning from our mistakes. As a result, we do not improve our outcomes.

Build Your Own Blackbox

If you are invested in getting better, I highly encourage you to build their own Blackbox.

Here are 5 specific ways to adopt an open loop of learning:

1. Have a Simple Recording System in Place

Record all of your sessions. Instead of trying to pre-determine who you should record your sessions with, make it as part of your practice to record the majority of all your clinical work. But doing the front work on this in the first sessions, you’ve taken the cognitive load off your mind for the future sessions.

Provide a clear rationale to your clients for recording the sessions:
e.g., “I record the sessions so that if we are not on-track with our progress, I will review the recordings and figuring out if I’ve missed something, and if I need to take a different approach in helping you.”

There is an unspoken resistance to recording our sessions. The truth is, clients are more likely to be ok with the recordings than us.[2] When we are clear what the recordings are for, our clients are more likely to feel the confidence in us.

Have a consent form in place [3]. Make sure your explicate the reasons for recording your sessions.

When I coach/supervise someone, along with their outcome data, it’s a requirement that they send me their therapy recordings. And I often get asked, “Must it be video, or would audio suffice?”

I much prefer video, as this allows me to look at the non-verbals. But interestingly, I recently came across an article that demonstrates that we are no more accurate with reading emotions with both audio and video, then with audio alone. When we listen to the voice only, though handicapped by the lack of visual input, we seem to be able to pick up the emotional cues from the vocal quality alone.[4] Even if you are using audio-visual (AV) recording, the audio quality is more important than the visual (It’s an irony that our technology has made leaps with its consumer level of high definition video quality, while our audio consumption typically suffers through compression of files i.e., mp3s, and poor speaker outputs out of our mobile devices)

For my setup in my clinical practice, I use a basic Logitech webcam that is hooked up to my laptop. I found that the mic audio quality on my laptop was a little too “roomy,” given the distance of the people in the room and my MacBook. As a result, I now use a Zoom H2 audio recording device placed on the coffee table next to my client(s) and I, with a long umbilical USB cord linking the Zoom H2 to my laptop. That way, I don’t have to do any post-production work to combine the video with the audio.

How should you angle your video? I recommend having the client in the foreground, and the therapist at least visible in the frame. The intention is to be able to see the impact on your client, based on what you said.

As for software to capture the recording, I simply use Quicktime or even just Photo Booth (smaller file size than Quicktime). As a default, it is good practice to have at least two levels of password security for your clients’ recordings. First is your personal computer password. Second, I recommend using some form of encryption software. I use Mac Hider 2 for mac.

2. Don’t Watch Your Entire Therapy Video

Start by watching segments of the recordings. For instance, if at the end of a session, you noted that the way you started the therapy led you and your client to a wrong footing, review the first 10mins of that session recording. If a client rates you lower on the goals and topics sub-scale of the Session Rating Scale (SRS; a measure of working alliance), review the segment when you were trying—or should have—begin to develop an effective focus.
If there is a full blown therapeutic rupture, make sure you review watch the preceding 10-15mins leading up to the moment of conflict.

3. Capture Your Weekly Learnings

In less than a 140 words, at the end of a work week, note down what you did well that you want your future self to remember. Note the date, and session number and with whom.

Learning happens when we develop the ability to retrieve from our memory. Creating your own weekly learnings is like writing your own Yalom’s The Gift of Therapy book. Priceless.

For more details, see this post on Therapy Learnings: A Memorable Practice

4. Capture Your Weekly Mistakes

Some therapists balk at the idea of noting down your mistakes. “I have too many mistakes… where do I begin?” Others struggle to spot any.
The important thing is to be situation and client specific. On a Friday, set aside 5mins, look at your schedule and focus on the clients you’ve seen that week. Extract one key thing that you could have done better or something you’ve slipped in.

Better yet, capture the decisions, assumptions and train of thought that led you to do what you did. World-renowned investor Ray Dalio encourages us to create an “Error Log,” detailing the steps that led to a mistake.[4]
He says, “Observe the patterns of mistakes to see if they are products of weaknesses.” (p.352). Dalio emphasises, “One of the worst mistakes anyone can make is not facing your mistakes.” (p. 354)

Mistakes are when we fail to engage a person.

The only way to be a good psychotherapist is to know when you are a bad psychotherapist. When you are faced with a difficult situation, instead of consulting the stars, consult your file of mistakes.

An important caveat: I do not classify not following a particular treatment protocol as a “mistake” or a “failure.” Too often, therapists think they’ve made a mistake by not following a sequence of a method or realised they weren’t adhering to a model. Granted, certain steps are necessary to produce a therapeutic climate, but rigid adherence to a model is counter-productive. We become invested in our pet solutions instead of tuning ourselves to appreciating our client’s problems.

5. Get A Coach to Watch Your Recordings

Watching our own recordings can be like starring in the mirror, we see the same things. We need fresh eyes. I highly recommend for you to enlist a supervisor/coach who is willing to review your therapy recordings. Without the objective feedback of therapy recordings, we lapse into theory talk and vague case consultation. How is it that we would never allow the absence of some form of reviewing the tapes in the realm of sports, but it’s common practice in psychotherapy?

I recommend supervisors to watch at least 3-4 session recordings of your supervisees before making comments about how to improve their clinical practice. Armed alongside with outcome data, aim to help your supervisees become better versions of themselves, not a copy of you or the inventor of their pet therapy model.

For more on the clinical supervision, see
a. The Scandal of Clinical Supervision: Here’s the Shocker (Part 1 of 2)

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

c. Why We Need This One Person For Us To Get Better

d. Everyone Needs a Coach

e. Do Not Seek Out a Supervisor

See  part two of Blackbox Thinking for Psychotherapists, where we’d explore the psychological framework needed to fully utilise blackbox thinking.

~

Footnotes:

[1] Black Box Thinking by Matthew Syed.
[2] Here’s a great article addressing the issue of client’s comfort in recording the therapy sessions:
Briggie, A. M., Hilsenroth, M. J., Conway, F., Muran, J. C., & M., J. J. (2016). Patient comfort with audio or video recording of their psychotherapy sessions: Relation to symptomatology, treatment refusal, duration, and outcome. Professional Psychology: Research and Practice, 47(1), 66-76. doi:http://dx.doi.org/10.1037/a0040063

[3] Email me (daryl@darylchow.com) if you’d like to see my sample of a Consent Form for Therapy Recordings. Briggie et al.’s (2016) article provide a useful appendix containing a sample consent form as well.
[4] This is a fascinating study by Michael Kraus: Kraus, M. W. (2017). Voice-only communication enhances empathic accuracy. American Psychologist, 72(7), 644-654. doi:http://dx.doi.org/10.1037/amp0000147

[5] Principles: In Life and Work, by Ray Dalio