Don't be afraid to give clients the steering wheel
Hello Future Nation,
I'm excited to announce we have a guest post from a fellow DP blogger from Australia! I'll let him introduce himself.
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Thank you, Jordan, for asking me to create a guest post for your blog.
Your posts following your DP journey are fantastic, your write up on ‘what actually makes therapy work?’ is one of my favourite all time blog entries. So I’m absolutely chuffed that you have invited me to join the party. More about me though for your readers – My name is Jimeoin Murphy, I’m a Psychologist based in Sydney Australia. I’ve been writing a blog following my own DP journey since June 2021. If you like this post you’re welcome to head on over, to check out my other posts and even subscribe for future posts if you like.
Enjoy!
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In this post I'm going to talk about some reflections I've had on giving client's more control of their therapy. I'll also share 3 scenarios on how I have changed my therapy approach to better align with my client's needs and wants.
Lately I've been compelled by a realisation that giving clients control of their therapy may be the most powerful thing I can do for them. In my experience, giving clients control leads them to a sense of freedom, freedom leads to hope and hope leads to change.
Giving up control is hard to do, I've wrestled with a fear that if I give client's control, they will sink deeper into their problems without realising it; because I didn't take control they will see me as an ineffective and unhelpful therapist - a burden. That fear can be a powerful motivator for me to stay in control of sessions.
As an example, previously if a new client came in saying they just want to learn coping strategies to tackle their anxiety; I would do my best to validate this desire, but I would also try too hard to convince them this was not a good idea and strongly imply that starting somewhere else was needed. I would give very convincing spiels about why learning coping strategies alone tends to be a band-aid fix and that you don’t want band-aid fixes.
I was trying to steer them away from the desire to avoid the emotions or thoughts they didn’t want. I didn’t want to validate their avoidance and wanted to set that tone early.
The problem with scenarios like this is that I would inadvertently invalidate the client in what they wanted.
They would try their best to understand where I was coming from and would seem convinced to take up my suggested approach, but on reflection it looks like they would also be left feeling disappointed, confused, or stupid. So, you can bet I wouldn't see those clients for much longer... despite feedback that was positive on the surface, these clients would stop coming after a couple of sessions.
Fast forward to me reading Jordan's fantastic blog post on goal-setting and it hit me... For client's that came to therapy feeling concrete in what they wanted, I wasn't giving them enough power to control their therapy direction. I instead would try take back control, out of a fear they would see me or my therapy as ineffective.
The point that I love Jordan has reinforced, is that while client's may not be right in how to fix their problems, my priority shouldn't be getting them to see why what they want is wrong, the priority should be protecting the therapeutic alliance from ruptures as much as possible, especially while the alliance is still fragile in its infancy.
Eureka!
Flow with the client, not against them and they will build trust and be more likely to respond to you positively when you do start to take a more directive approach.
As has been raised to me, you may be thinking: “wait, hold up – aren’t you just encouraging experiential avoidance? Client’s may be disappointed if we’re waiting just sitting back and not providing much input for the first few sessions”.
It’s again understandable to see in the scenario that I’m painting that I would be acting passively to the client. Fortunately, in reality I am still being assertive, while respecting the client’s wants and needs.
How?
Because in the first couple of sessions, almost all my energy goes into identifying with the client what they want to work on in therapy and helping them identify what they think the action plan should look like. If they are stuck, I will offer my thoughts as an idea but nothing more. If the client is concrete in using their own strategy I will let them, but I will also subtly ask them along the way if their strategy is working and what the benefits/costs may be (exploring workability) to their approach.
There is also the added bonus that with all this focus on client goals, I am able to far more easily identify if they are looking to address a goal that I cannot help them with. I can them help them explore alternative services.
I think as therapists we tend to focus so much on getting clients to see what they can't control, unintentionally taking power away from them in pointing this out. I think our focus instead should be on where we can let control go as therapists, to help the client's see what they can control. Take these wise words from BJ Fogg who wrote the book ‘Tiny Habits’: "people change best by feeling good, not by feeling bad".
So early on in sessions, even if I get a really anxious client that says they want to get rid of their anxiety but never leave their comfort zone. I will hold my tongue (my head screaming that their plan won't work) and will do the best I can to build the therapeutic alliance and the client's confidence by flowing with what they want.
When the alliance is strong and I know they have their buy in, I will gently start encouraging them to observe how our anxiety doesn't shift while staying in our comfort zone. The client gets to try the approach they want and I still feel like I'm being an effective therapist. I don't know about you, but I feel hella empowered right now!
The idea to me is that giving client’s all this control will build up trust. They will feel that I trust them to make their own decisions and if I can respect that, then when the time comes, they will feel ready to trust me in return. I’m leaning on the idea that as a species we are hard-wired to reciprocate.
I'm so fixated on this because I'm confident that it will help my client's increase their buy in into our therapy process, subsequently strengthening the therapeutic alliance as much as possible.
So what have I been doing lately to give clients more control?
Scenario 1 - Improved how I goal-set with client's who already have concrete goals
For the last few months, I would goal-set with almost all of my clients in the same way.
I’d explain the purpose of the first couple of sessions, that to find our therapy goals, we would explore what has brought them to therapy, like a puzzle. The first two sessions would focus on tipping all the puzzle pieces out of the box - to get a feel for all the factors that contribute to the client's presenting problem. Once we have an appreciation of the client's therapy puzzle, we would then figure out which part of the puzzle to prioritise in our action plan - Client's who come in not knowing their therapy goals tend to like this approach.
However, in the blog post of Jordan's I mentioned above, he talks about client's who are concrete in their therapy goals - these clients already know what they want from therapy. Reading his post made me realise that my concrete clients are fair less likely to feel open to exploring their therapy puzzle; to see it as a waste of time because they already know what they want - right or wrong.
Then the light-bulb moment!
Now I’ve made a change, whenever I am goal setting with a client who has concrete goals, I switched up my puzzle analogy. I would still introduce the puzzle analogy same as before but instead of encouraging exploration I would say something like "ok I can see that you're feeling clear on what you want out of therapy and how you want to go about it, so how about this... instead of us taking up time exploring your puzzle how about we take the one piece of the puzzle you want to start on, go from there and then bring in other pieces one at a time as we need to - how does that sound?" (we’re starting with one puzzle piece instead of all of them).
I have found that approach to be far more effective at increasing the buy in of my concrete clients, this new approach helps them feel more in control of the therapy, that I'm listening to them and I think it gives them a greater sense that I am putting in the effort to tailor the therapy to them as an individual.
Viola!
Scenario 2 - Client 'venting' from the start of session
Some of my clients are understandably really stressed, so they'll start the sessions like a greyhound bolting out of the gate, unpacking their week before I can sit down. I would find this overwhelming sometimes. I'd feel like a kid at school, just watching the skipping rope going around and around and around - I wouldn't know when to jump in.
In these scenarios I’d want to feel like I’m still doing my job, so I would formulate an action plan while the client was venting, but this would sometimes end up with me feeling completely tangled in the skipping rope – my brain would cease to work effectively.
Not anymore.
I honestly don't know how this came to me, but recently as client's started out venting, I would let them go for a few minutes and then gently raise my hand. The client would stop. I'd then say something like: "I can see there's a lot to get off your chest, I just want to take a moment to be sure I'm in line with what you want from the session today, do you want this to be a venting session, where I'm just listening, which there's nothing wrong with, or do you want me to jump in at some point?". The clients will typically look a bit surprised at first, then they will smile or laugh. Some will say they want to have a vent, others will say they just want to vent "for a bit" and the rest will give me permission to jump in. Everybody wins - another Kodak Eureka moment!
Scenario 3 - using my new 'buy in' scale
As you may know, for some time I've been using the Session Rating Scale (SRS) to debrief with client's and better calibrate to client needs as each session goes on. Lately I've had the feeling that something has been missing, that despite using the SRS I still may be missing what a client needs, at least sometimes, especially if I don't ask the right questions during the end of session debrief. While I allow myself more time these days to start the SRS debrief, more time won't help if I'm missing the point altogether.
So I started to think “what is the core purpose of the SRS?” and I figured at its core the SRS is there to help us infer how much a client is buying into their therapy. If they buy in, they stay, if they don't buy in they stop coming back - it's that simple.
I started to think - what if I could keep using the SRS (as it is extremely useful), but infer the client's buy-in, in a more concise way?
So I started using what I’m calling the ‘buy in’ scale, which is essentially a zero to ten scale on paper that asks client’s to rate how much they are buying into the therapy approach.
I have a copy of it ready for the client on my digital notepad. I explain my reasoning for introducing this new scale as above. I hand them the scale at the start of the session and ask them to rate their buy in right now. I have been doing this for all clients; those at first sessions, those that are still new and my longstanding one's. After they rate, I use a ruler to score their rating.
For now, most of the time I don't unpack their rating at the start of the session, I just say we will come back to it at the end of the session to re-rate their buy in and compare it to the start of the session.
Clients have responded really well to the buy in scale, some have said they feel it's more 'to the point' than the SRS. I still give client's the SRS at the end of the session, but instead of starting the session debrief on the SRS, I now start it with the buy in scale and then we go to the SRS if our debrief needs a more detailed analysis.
I think the true magic with this change though is that because it's mine, I've been more confident with the buy in scale than with the SRS. I've found myself in a jovial way saying to some clients after they mark the buy in scale: "you know what, I was expecting this to be lower", these clients seem to better describe what they are getting out of the sessions.
The remaining clients seem to like it when they see their buy in score being higher at the end of the session, like they are relieved. I haven't had a client yet where their buy in score has been lower at the end of the session, but I know when it happens, I'll feel more confident in exploring with them why :).
That's a wrap
It's funny I used to say proudly, as so many of us would, that I was the kind of Psychologist that puts effort into creating a different approach for each client, to match their wants and needs - I'd wear that effort like a badge of honour.
I realise now with this post that in a few ways I wasn't matching the client on their needs and wants as well as I thought I was. I was talking the talk. Now I feel thanks to the changes I've made in the last few weeks; I'm getting better at walking the walk.
I’m aware of the irony that in writing today, I am trying quite hard to convince you to let client’s lead the way. I would therefore say that if I haven’t convinced you, then I strongly encourage you to follow what you think works - but remember it’s important to stop every now and then to ask yourself: “is my approach working? Or do I need to try something different?”.
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