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.

 http://www.leeds.ac.uk/educol/documents/00001260.htm

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.

Learner therapist (34)……Not good enough therapist

 

 Learner therapist (34)……Not good enough therapist

Torrey Orton
April 21, 2013

Another of my therapeutic errors…

A year ago I wrote:

I am somewhat obsessively tuned to my mistakes, a commitment moderated by a fairly balanced level of professional self-regard. However, it seems that mistakes continue to occur in sufficient numbers and powers to guarantee the balance falls slightly towards the obsessive side. From my point of view, my reputation is always in danger from my next performance.

And a striking case has arisen, as they do, totally predictable as sessions went on, but avoided by me out of my self-imposed belief that I should always be able to work with anyone and that I am infinitely flexible. Yes, I see the universalising and that I am in the grip of moderate catastrophising, but that’s the price of standards in practice (another argument this, but not now). I pay this price a few times a year in the currency of disturbed sleep and therapeutic relationship crises (in my mind often). Here’s this one:

In brief, he’s a 33 year old in a growingly committed relationship with a woman he characterises as anxious like himself. They are on the verge of cohabiting. But he doesn’t share with her the vitality of his anxiety – that it is persistent, permanent, paralysing – which he deploys like a shield from his deep sense of being notgoodenough. This sense has been unavoidably present to him for 10 years post a major car accident recovery, which took a year of physio and some subsequent therapies through a parade of therapists and psychiatrists of which I am the last, so far, in line.

We’ve been one session a week for three months on an insurance funded therapeutic journey. It was limited to 5 in the first instance and then only after review which I did not do at the time. I had never clearly monitored the conditions of the insurance. So, I was working for free.

He knows his notgoodenough comes from somewhere further back in his past, and has recently acknowledged that father is the obvious source. Father has never been accessible to him nor outreaching for him, though always present… an active, unconscious (?) denial of the son’s existence. Mother appears as the good parent, though almost acknowledgeable as a collusive partner in father’s absent presence. She is also in late stages of thrice recurrent cancers, so seriously compromised as a pathway to the father, or even a discussant of son’s needs.

He can do anger at two things: his parents, but especially his father, and me if I suggest he “out” his admittedly socially phobic obsessions and compulsions to anyone, but especially his girlfriend. When angry he presents clearly as powerful – language strong (f bombing) and posture strike ready. Outing is part of a process of exposure which is a widely accepted ingredient of anxiety and addictive therapies, and one I’ve used in a wide variety of situations with workable effectiveness for patients of many sorts. I said as much to him in roughly the following words:

The principle reason for encouraging self-outing of any kind is to reduce the burden of the un-outed secret(s) which, for lack of psycho-spiritual-relational air, fester in the paranoid richness of the dark holding bay of the self. At this point it was a crucial move because we were going around in circles and the only talking place for this was therapy.

There exists alongside the phobic persona a competent, though self-doubting, one with a wide range of social and potentially professional skills, and with better than average verbal skills, both spoken and written. He is supposed (psychiatric report) to have done CBT for self-doubt, but shows little retention. He’s devoted to the latest manual driven self-improvement thingy about social phobia – very CBTish in style. He hasn’t been able to stick with any such processes or related tracking of moods over the three months, though getting started a couple of times. He’s swamped by the daily flux of his fears, and amplifies them at each session by arriving late and leaving early, starting to notice the approaching self-imposed departure time 30 minutes into the session.

Because of his intense resistance to raising his phobia with his girlfriend or selected workmates and his increasingly reported despair about the phobia (expressed in spontaneously written emails capturing the daily experience), I felt trapped and ineffective and looking to reduce it by stopping our work and handing him on to someone appropriate.

I had not confronted him with this thought, but he could have been aware of my doubt from my unwillingness to add another session to the present once a week. He has history for losing therapists because they cannot / will not fit into his workplace secrecy regime which requires him to do nothing in work time (even if lunch) which might invite a question from colleagues or management about what he’s doing.

I did not feel that I had the time or mood flexibility to respond usefully to his needs. At the same time, progressively over the preceding two weeks, I found myself under a rapidly increasing load of high need patients. It takes a while for me to notice I’m close to not coping, but I’m getting better at it. This is a significant straw in this story, and this camel’s back was bending. With this case I was feeling like death and actually surrounded by long term patients considering themselves as candidates for death. My decision to discontinue our work came off a base of having done similar things at very high pressure times of near overwhelm over the decades of my organisational development practice, both here and in China.

A few days ago we had our first session since my coming to the conclusions above about my needs and his. He walked in and started immediately with his doubts about how we were going, beating me to the task. Within 20 minutes we had agreed that I would find him an alternative therapist within the day and pass that option back to him, which I did. He was a bit angry that he had once again lost a start on therapy which happened partly because he did not demand at intake that the proposed therapist (in this case, me) work outside normal hours. Some of the other lost therapists had parted for similar reasons, he said.

I think from the backside of my failed effort that it is principally a result of insufficient checking with the patient about how things were going for him. Checking is about the only antidote to letting things amble along when they really aren’t ambling much at all. And it is not as if I don’t check regularly. But maybe it is that I check somewhat less regularly than I think and that rigorous attention to checking (putting it explicitly on every session’s agenda) would reveal a pattern that somewhat more diffident checking occurs with more diffident patient experiences – and it’s my diffidence I’m talking about here. My failure to check the insurance requirements for continued payment are party to my self-deception or avoidance.

As I said at the start: “my self-imposed belief that I should always be able to work with anyone and that I am infinitely flexible”  may facilitate my not taking seriously some recurrent but slight evidence that things are not getting very far or very well, though they continue! As so often in development matters, awareness is all except when it isn’t enough, as in this case. I know exactly what that self-monitoring awareness feels like from my commitment over the last 6 weeks to raising my performance in aikido weapons practice to both a higher intensity and greater regularity. The subject is always close to the front of mind, including when I choose to not make the required effort.

For the moment it is clear that my reputation to myself as an aikido practitioner is more important than my professional one!!