Tuesday, October 6, 2015

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.

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