Note: This is originally from Frontier Friday, a weekly Substack published, originally released on 09 Feb. 2024
Part I
- đ§ Listen: Undoing the Intake Model.
In this podcast interview with Elizabeth Irias, I tell a personal story I did not include in the book, but was dedicated to this special person that has profoundly changed the trajectory of my life.
Key Grafs:- Focus on doing the right thing vs. doing things right.
- Focusing less on our in-take, and more on what we are giving.
- 20-30% stop therapy after the first visit.
- Clients are 2-3X more likely to discontinue treatment if the intake personnel was different from the treating therapist.
- Information is not transformation (e.g., horse-racing study).
- The distinction between an assessment tool vs. a conversational tool in using measurements.
- Donât let your furniture subdue you!
- Fred Rogers: The most important person is the one in front of me.
- Follow the pain AND follow the spark.
- 3 Layers of Empathy: Will Say, Wonât Say, Canât Say (with a clinical example).
- Timely vs Timeless casenotes, and tapping into client factors, which accounts for 80-87% of outcome.
- đ§ Listen: Very Bad Therapy Podcast: 11. The Intake Process (with Daryl Chow)
What hosts Ben Fineman and Carrie Witta did with this podcast was very special. They basically got people with bad therapy experiences to come to the show!
What a great way to learn.
We learn best from screwups. But we don’t have a lifetime to learn all of them from personal experience, so we might as well learn it from others.
Listening to this podcast helps you to learn fast, so that you make new mistakes.
In this episode, Bryan talks about his first therapy experience and his rather discomforting experience, with multiple red-flags, right from the get-go. - đ Read: The Backstory That Led to Writing The First Kiss
Taken from the introduction of the book. - âď¸ From the Archive: What Therapy Is (Or Isnât)The psychodynamic camp says, âYour past is the problem.âThe third wave mindfulness therapist says âMindlessness is the problem.âThe emotion-focused therapist says, âYour unresolved feelings are the problem.âThe Mental Research Institute (MRI) at Palo Alto says âthe attempted solution is the problem.âThe solution-oriented practitioner says âThere are exceptions to the problem.âMeanwhile, the problem-solving camp says âThere are solutions to the problems,â and the narrative therapist says, âThe person is not the problem, the problem is the problem.â
Hereâs our problem: The way we define what therapy is or isnât could be the source why some clients who do not engage with us. - â¸ď¸ Words Worth Contemplating:
âOur highest priority is to protect our ability to prioritise.â~ Greg Mckeown, Essentialism p. 101
Reflection
When was the last time you opened up to someone for the first time?
Part II
- đ Web-Read:
The Cobra EffectThe law of unintended consequences is one to really watch out forâand cobras. - đŠđźâđťExclusive Read: Follow the Pain, and Follow the Spark
In the twin pieces from Chapters 24 and 25 of The First Kiss, I talked about the need to juxtapose between following “what hurts,” and following what makes someone come aliveâplus an incident early in my career when I thought I was going to get punched in the face. - đž Web Read: The Domino Effect
The process starts out linear by becomes geometric
A video on the law of geometric progression⌠It all begins with the first piece. See this video. - đ§ Research: Predictors of dropout after the first session for traumatised youths
This Norway study asks the question, What are the factors that lead to dropout after the first session for youths who experienced trauma (e.g., domestic violence, physical and sexual abuse, or the sudden death or suicide attempt of a caregiver).
Key Grafs:- Dropout after the first session rates: 25%
- Predictors that influenced dropout: a lack of caregiver attendance, lower rates of youth-perceived parental treatment approval.
- Surprising Findings: Youth-rated alliance or caregiver alliance, did not predict dropout after 1st session. Only weaker therapist-rated youth alliance did.
- Three reasons speculated by the researchers:
a. Change in alliance is a much stronger predictor of dropout with large effect sizes, compared with alliance measured at a single time point where effect sizes are smaller
b. The first session may have been too early for parents and youths to truly know the degree to which they agreed with the therapeutic tasks and too early for them to rate their relational bond with therapists.
c. therapists are likely to have met a wide variety of youth, making it easier for them to more precisely determine their own abilities to form an alliance with a particular youth.
- Three reasons speculated by the researchers:
- Types of treatment (trauma-focused cognitive behavioral therapy or therapy as usual in a community) did not make a difference in dropout.
- Caregiversâ actual participation in the first session makes a difference.
- Youthsâ perception of their parentsâ approval of treatment seems to influence treatment attendance.
The researchers explained,
âSince the youthsâ reports of their alliance with the therapist were not a significant predictor of dropout, the results suggest that, at least in the first session, youth are more oriented toward their caregiversâ opinions than toward their own relationship with the therapist.
Since trauma treatments may be particularly emotionally demanding, youth may need active encouragement and support from their caregivers to endure the process.â - Implication: Therapists should “engage caregivers in therapy and address possible discordance in treatment goals and tasks.” Donât just keep parents in the waiting area.
- â¸ď¸ Worths Worth Contemplating:
âFind a place inside where thereâs joy, and the joy will burn out the pain.â
~Joseph Campbell, mythologist, writer.
Reflection
In the first sessions, how do you âfollow the painâ and âfollow the sparkâ?
Part III
- đ§ Research: Discontinuity⌠After Intake?
Sidenote: if you actually look at the list of contributors in this study, itâs astounding that 18 researchers were involved! Wow.
Question: If you pay attention to the models of service delivery around the world, do you notice it is getting more common for an intake therapist to conduct the first session, and then gets passed on to the âtreatingâ therapist?
Hereâs what the 18th researchers found about the unintended consequence of this approach:
– clients who saw a different therapist at intake were twice as likely to dropout from treatment and not attend the appointment after intake.
– In terms of outcome, clients seen by a different therapist at the get-go lagged in improvement by 2 sessions, compared to those who were seen by the same therapist, making it 19% more expensive when an intake therapist is used.
– Implication: Given the disruption and less cost-effective finding, the authors concluded the following:Abandon formal psychotherapy intake⌠begin psychotherapy at the first meeting.
- đ§ Research: First Impressions Matter: Patientsâ Experience of Initial Assessment and Outcome Expectations and Subsequent Attendance
This recent study was part of the previously known as Improving Access to Psychological Therapies (IAPT) programme in England, now known as NHS talking therapies services for anxiety and depression.
Key Grafs:
– 985 out of 6051 clients (16%) did not return after the initial assessment.- Even if you have a different therapist that conducts the intake, who conducts this first contact makes a difference.
– Clients with more optimal outcome expectations1 at the beginning predicted them continuing therapy (but not dropout for the subgroup who started treatment). 16% of the variability was explained by who the therapist was, after controlling for client-level variables.
– In short, the first contact matters.Patients assessed by the above-average therapists were between 10% to 20% more likely to start treatment by comparison to those assessed by below-average therapists (based on their patientsâ mean expectancy scores and associated odds of treatment initiation).
My thoughts:
Curiously, even if agencies decide to have a different personnel at intake, for triage or for whatever reason that they could justify doing so, given the above finding, would it be justifiable to employ less skilled therapist to do the so called âintakeâ?
For more about Outcome Expectation (OE), see our last book, The Field Guide to Better Results, Chapter 6, Hope and Expectancy Factors by Michael Constantino and colleagues. - đ§ Research: What Can We Learn from Those Who Do No Attend
Another study from the previously known as IAPT services in the UK. this qualitative study interview 14 people who were referred for treatment, but either never attended, or only attended one treatment contact.
Key Grafs:
– Non-Attendance Rates for IAPT: approx. 47%!
– Waiting Process:
Waiting for treatment, which varied between 2â3 weeks and 9 months and the lack of contact from services:ââIn the first 7 months there was nothing, absolutely nothing…not even recognition of being on a waiting list.ââ- Expectation of Assessment and Treatment:
Some respondents expected that assessment would be both more robust and more personalised.ââWhen you finally got in there and feel like you actually might be speaking to somebody then it was very much about âoh no we are not going to speak about anythingâ . . . she only wanted me to answer her questionsââ- Disappointed to find out that often the assessor was not a trained therapist:ââ[I] . . . had a good cry and she wrote some notes down but she was not a trained therapistââ- One respondent angrily reported that her desire to express her emotions contrasted with the practitionerâs expectation that she do homework:ââAnd Iâm trying to tell her how Iâm feeling and itâs just not good. âGo home and do this and weâll talk next timeâ, No, I donât think so.ââ- Rigidity of Service:
Inflexibility of the IAPT services including communication with the service, appointment making, choice of treatment or practitioner and their experience of a heavily protocolised system
– Practitioner Contribution to the Relationship:
A significant barrier to the development of a good working relationship was the experience of heavily protocolised treatment and not being listened to because of this. One client thought that her practitioner addressed her in a patronising manner and offered little opportunity for a two-way dialogue:â…itâs insulting and, you know if I was eight, maybe fine. No. I think if I was eight years old I would still be cross.â - đ Resource: Pocket Guide to The First Kiss
No, not a technical manual of how to be a good kisser, but a succinct summary of the nuggets to the book, The First Kiss: Undoing the Intake ModelâŚ
For more resources, check out the special link provided at the end of the book.
Download the Pocket Guide - â¸ď¸ Worths Worth Contemplating:
âThe most important thing is to figure out what is the most important thing.â~ Shunryu Suzuki, 1970.
Reflection
What can we subtract, in order to get more personal in our initial conduct with clients?
At the end of a first meeting, do we really know what is the most important thing in their lives, what they really care about, what makes them come alive?
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