Have you ever wondered what might be the overarching competency that helps therapists choose whether or not to follow certain rules in therapy?
A couple of months ago I delivered a workshop to a group of CBT learners, during which I did a role play as a “therapist”. After the event one of the participants pointed out, that 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. And that wasn’t the way of talking to clients that they’ve learned during the CBT course.
Well, that’s an interesting feedback given by a clinician to a clinician. During his own training, my colleague has apparently learned the “golden rule” that “being professional” means “talking about what clients want to talk about”. So, he became quite confused when I did the opposite – I talked about what I thought was relevant.
How many “golden rules” have you learned during your own training? And did you verify whether the rules serve the real outcomes of your work, when you follow them?
HOW? versus WHAT?
While behavior of all other species is shaped by consequences (punished or reinforced), human behavior is largely governed by principles. It is so because – besides having ideas about our goals (the WHAT-question) – we humans make also rules on HOW to behave while pursuing those goals.
Once we adopt a rule, the real outcomes of our behavior tend to lose impact on what we do. Simply behaving in a “right” way becomes reinforcing in itself, no matter what the consequences actually are. This “blinding effect” of rule-governance has been already spotted by Skinner.
Rule-governed behavior has always been a major source of trouble, driving 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”. When guided by rules we simply tend to lose our purpose from sight and then we no longer match outcomes of our actions with their aims. We are “right” by the way we behave, not by what the behavior brings.
We make rules in all aspects of our life, including psychotherapy. During therapeutic training clinicians learn certain sets of principles, some of them more general and some limited to specific approaches. Rules make us more effective but problems may arise when a rule becomes detached from its aims.
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 us, but for our clients?
Following the rule of following the client
Every rule works great until it doesn’t. Some depressed clients, for example, consume excessive amounts of alkohol. And when asked about preferred topic for the session, they seldom mention drinking – unless I choose to bring the topic up. Some of heavy drinkers avoid the topic because of shame and a desire to protect self-esteem; some simply believe that lowered mood has nothing to do with life-style. But how to engage drunk people into rewarding social and physical activities?
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.
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 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 of our behavior” and then they may limit our flexibility and efficiency. So, in his blog, Scott takes a critical 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 direct advice), their clients would choose exactly the opposite: getting clear directions from therapists. The results of the study led researchers to giving an advice: “Stop projecting your own desires onto the people you treat.”
SO, should the new rule be: “stop following the rules”?
Nope. The old “golden rules” are good. But there’s one meta-rule above them all: any “HOW-to-behave” rule must be measured against (1) your purpose and (2) the real 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 being an adult does not only mean getting freedom to decide but also taking responsibility for own decisions. A direct advice might remove the unpleasant 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 our own feet not on the feet of the 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 get. I have, for example, no problems with advising a depressed client to drink less, get out of bed and pull the curtains open on a sunny day.
My best advice: be aware
So, what is the overarching therapeutic 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 that underlies Emotional Safeness Therapy (EST). One of its pillars is awareness and it applies to the clients as well as to therapists.
For an EST therapist (and I would argue that for any therapist in general) awareness is the number one core competency. It’s bout being aware of our own emotions and of how we attach meaning to events. It’s about being aware of what’s going on between us and our clients. But first of all, it’s about being continuously aware of our own actions and matching their purpose against outcomes.
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