Learner Therapist (64) … Test myself, test my patients
Torrey Orton
Oct. 06, 2015
Feedback Informed Therapy
(FIT)
It is claimed, with
reason, that the most effective therapists are those who seek constant and
consistent feedback on patient experience of their therapy provision. The
International Centre for Clinical Excellence offers research backing for this
claim and tools for feedback informed practice. I find them sensible but
unremarkable, being an obsessive self-doubter about my therapeutic effectiveness,
which springs a little from my tendency to self-denigration and a lot from my
constitutional scepticism.
My skill at feedback
seeking and giving has been fashioned and refined during years spent in various
educational roles ranging from teacher to instructor, coach and, drawing up
last, therapist. I became accustomed to checking if things were working well
enough from both my and the other’s viewpoint. During my first two years’ high school
teaching in 1966 to ‘68 I kept a teaching diary daily for five classes a day assessing
the appropriateness of my teaching plan and implementation over year levels 9
through 12 in English and year 12 in philosophy. For the latter course, I
invented a student reflection process which has flowed on into later life teaching/learning
settings. Both have a life today when patients take up diary keeping as a path
to self-clarification.
As a result of these
sources, I am inclined to see my therapy skills as applicable in a wide range
of learning settings and roles, though most obviously in therapy, coaching and
teaching. The process of testing patient / participant purposes or needs morphs
naturally into testing learning processes and outcomes, and shifts emphasis
from testing me to testing them – testing their confidence in their grip on
themselves in whatever ways they are seeking in our work. One could say
competent confidence in one’s ability to self-correct is the signal attribute
of a professional or high performing amateur of any kind.
8 critical feedback opportunities
There are at least eight
critical junctures for testing what patients / participants are working on,
whether in therapy or training group:
1.
Preferably first, some kind of pre-session
needs assessment before the moment of first entry, which may be a proforma
tick-a-box, open-ended questions or a quick inquiry by phone at the initial
contact for an appointment like “what’s your concern?” or similar.
2.
On arrival for the first session, the
opening test is reconfirmed in this hello: ‘What are you here for?’ or its
slightly more pointed sib ‘What can I do for you?’ In a group this is usually
formalised in a group needs chart cobbled out of individual contributions.
3.
A little way into the first session (and
many sessions thereafter), I propose this: ‘So, what concerns you is…? Am I right?’
This is a test of me, not the patient / participant, though they often hear it
as a test of them.
4.
One step beyond mirroring is framing a
chunk of patient / participant input into slightly different language and at a
slightly higher (or lower!) level of generalisation, which does double duty of
checking my grasp of their material and testing their capacity to generalise or
concretise it.
5.
I pretty consistently check progress in
session by inviting patient / participant assessment of the clarity and
relevance of almost anything I offer beyond mirroring their contributions: “Is
that clear?” “Does that make sense?”
6.
Towards the end of a session I seek a
general assessment from the patient / participant like: ‘Are we on the right track
for you here?’
7.
Over multiple sessions I check how the work
is fitting their original and emerging objectives’ prediction of its direction
and process, sometimes pointing out a new candidate for objective of the day,
or week, for which I have evidence in their behaviour. Such “pointings” are
raised as queries with explicit room for patient disagreement. Almost no
patient / participant arrives at the end of therapy without discovering some
learning objectives they did not start with.
8.
And, at the end of the learning process (in
therapy there seldom is a complete closure, just as there is no closure to
learning in life except the closure of life itself) we may look back by looking
forward to see what new pathways have been unveiled by the work and what
vulnerabilities have now been raised to the level of self-correcting
consciousness.
5
in-session reflection ‘tests’
1.
Phrase completion test – there are a
number of ways to signal I am paying attention to a patient / participant: This
is a normal conversational move not just a therapeutic one and has the same
effect – the person feels attended to, recognised, understood and shows this by
continuing their conversational flow. For example,
a) Add
the word which comes next in a run of expression when the person pauses
b) Punctuate
chunks of expression with ‘Uh huh’, etc.
c) Ask
the patient to repeat what they’ve just said in other words, or give an example
d) Encourage
them to stay on a track they’re on with a rolling hand signal, not words.
e) Stay
silent when they reach a natural pause in their talk to make space for them to
continue
2.
Feeling awareness tests, often repeated
especially early in the work to authorise using feelings and help discover
them.
a) Mirror
back a non-verbal, usually embodied, or say back a particularly striking
expression
b) Invite
reflection on where in body they are feeling something: ‘’what body feeling is
happening with this experience you are describing?’
c) Invite
an example / trigger of a particular feeling.
3.
Conflict engagement test
a) Suggest
an alternative perspective for a situation they are exploring – ‘I imagine you
could look at this matter in other ways. For instance…’
b) Propose
an alternative interpretation for a situation – e.g. ‘Another way you could interpret
at this is…’
c) Assert
they are wrong about a perspective or interpretation of theirs, with an
appropriate degree of certainty in the truth claim involved. Use ‘perhaps’,
‘probably’, ‘possibly’, ‘certainly’ (as appropriate) to show your level of
confidence in your assertion.
4.
Emerging theme identification test
a) Repeat
back a word in their conversation which suggests the patient / participant is
evaluating something, especially them self – words like ‘value’, ‘care’,
‘like’, ‘avoid’, ‘worth’, etc.
b) Invite
an example of a particular evaluation, especially those where ‘could’ can
easily replace ’should’ or ‘must’ in their speech.
5.
Objective description test – have they
covered the what, who, when, where, how and why of their concern concretely?
NB
– all of these ‘tests’ are feedback opportunities for both patient/participant
and therapist/coach.
Learning to learn is the
primary objective of therapy (and training and coaching!!)
A useful model for
thinking and acting about adult learning is experiential action learning which
comes out of workplace development needs arising from unexpected circumstances
which out-date existing business operating constructs and competences.
I roughly work with this
kind of framework in all learning settings where local design is necessary to
fit specific conditions - a typical therapeutic requirement. The above ‘tests’
of both patient / participant and facilitator / therapist can be applied
(should be applied) in any such setting for optimum effectiveness.
