A couple of months ago I delivered a workshop to a group of fresh CBT therapists, during which I did some role plays. After the event one of the participants commented on how unprofessional my demonstration was, because – as he pointed out – “during the role play I did not talk about the topic brought up by the client, only focused on what I personally thought was relevant”.
Well, that’s an interesting feedback given by a clinician to a clinician. It sounds like during his own training, my colleague learned the rule saying that “being professional” means “talking about what clients wants to talk about”. I wonder how many of you have learned the same principle. And did you verify how the rule serves the real outcomes of your work, if you follow it?
But before jumping into discussion, let’s take a step back and have a look at therapeutic competencies from a broader perspective.
HOW versus WHAT
While behavior of all other species is shaped by consequences of their actions, human behavior is largely governed by principles. It is so because – besides having ideas about what they want to achieve – human beings make also rules on HOW to behave in various circumstances. And once such a rule is adopted by an individual, the real outcomes of her/his actions tend to lose impact on behavior. Simply behaving in a “right” way becomes reinforcing in itself, no matter what consequences are.
Throughout centuries rule-governed behavior has been a major source of human suffering, pushing individuals and whole societies to rigid and fanatic actions. As philosopher George Santayana pointed out “fanaticism means redoubling your effort when you have forgotten your aim”. The quote is right on money. Being guided by behavioral principles we easily lose our purpose from sight and no longer match outcomes of our actions with their aims. We are “right” by the way we behave, not by what the behavior brings.
Behavior-governing rules concern all aspects of human life, including psychotherapy. During therapeutic training clinicians learn certain sets of principles, some of them more general and some limited to specific approaches. No, I’m not saying that those “HOW” rules are problematic in themselves. Problems arise from detaching rules from their aims and from becoming blind to actual outcomes of our actions.
So, how about the rule of “always following the clients in what they want to talk about”? How does it work in practice – not for you, but for your clients?
Following the rule of following
My own experience tells me that not all depressed clients would for instance choose their excessive alcohol consumption as the desired topic for the conversation, if I didn’t bring it up. Some of them because of shame and a desire to protect self-esteem; some simply believing that lowered mood is like a wrong channel in a car radio – it has nothing to do with the style the car is being driven.
And as a mental health professional I can’t expect my clients to have the same level of expertise as me and to always be able to sort “unpleasant” facts from “irrelevant”. It’s me who is paid for understanding how certain things are connected and for knowing that sometimes mood can’t be fixed without fixing the life.
So, yeah, I must admit that I can take a lead in a therapeutic conversation and choose its directions. I’m not a therapist who follows the principle of always following the client, that’s for sure.
As it has already passed a few months since the mentioned workshop, I’ve almost forgotten my interaction with the trainee. However, in the last week the memory has been revived by the newest blog by Scott Miller. His post drew my attention to another therapeutic principle (which I do not always follow, either) and by that to the topic of “therapeutic competencies” more generally.
In his recent writing, Scott focuses on the principle: “do not give direct advice to your clients”. Some approaches, like ACT, have even included this rule into the set of “core therapeutic competencies”. The ACT core competency number 4, for example, discourages therapists from “arguing with, lecturing, or attempting to convince the client” and from “providing own personal opinions”. And ACT is certainly not a unique approach on that.
As I wrote earlier, our ideas about “How to behave” may sometimes get detached from the ideas “What is the purpose” and then they may limit our flexibility and efficiency. So, in his blog, Scott takes a look at how the rule of not giving advice works for clients.
In a study discussed by Scott (link to the original paper is here), a group of researchers surveyed therapists and clients about their preferences in giving/getting advice. What they found was a large and robust difference between the two groups. While the therapists preferred less directiveness in therapy (not giving advice), their clients would choose the opposite: getting clear directions from therapists. The results of the study led researchers to the conclusion: “Stop projecting your own desires onto the people you treat.”
Is the new rule: “stop following the rules”?
Nope. The results of the study do not automatically mean that you should start giving more advice in therapy. Remember, that the study concerns a “HOW” principle, so the answer depends on (1) your purpose and (2) the outcome.
It would be difficult for me to count all the times I was asked for advice on whether the client should or shouldn’t leave the partner or quit the job. And I never gave it. Why? Because growing up we learn that being an adult does not only mean getting freedom to drive a car, but also making own choices and taking responsibility for decisions. So, my advice might remove the burden of responsibility from my clients in a short run, but it wouldn’t be really empowering for the client in a long run. Empowerment is all about standing on your own feet not on the feet of your therapist.
Thus, I never give advice about WHAT to choose or decide. But you can easily hear me talking about HOW to get to where the clients themselves want to be. I have, for example, no problems with advising a depressed client to get out of bed and to pull the curtains open.
My best advice: be aware
Have you ever wondered what might be the overarching competency that helps therapists choose whether or not to follow certain rules under given circumstances? Well, if you look at the picture above, you’ll find the model of personal growth that underlies Emotional Safeness Therapy (EST). One of its pillars is awareness and it applies to the clients as well as to therapists.
So, for an EST therapist (and I would argue that for any therapist in general) awareness is the number one core competency. And it’s not only about being aware of your own emotions and of how you attach meaning to events. It’s not only about being aware of what’s going on between you and your client and of the quality of your relationship. It’s first of all about being continuously aware of own actions and matching their purpose against outcomes.
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