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How to structure your counseling sessions - According to the world's greatest therapy consultant (Alex Vaz)

Updated: Jan 10

1/5 I get weekly coaching with Alex Vaz. Here's what I learned on 11/17/23.

Every Friday for the past 8 months, I've received coaching from Alex Vaz.


For those who don't know, Alex Vaz is the greatest therapy coach alive. His specialty is helping therapists become more effective (regardless of the model).


It's wild to me that he's not more widely known. If I go to any grand program and mention Aaron Beck or Sue Johnson, everyone knows their names. If I mention Alex Vaz, I'd get nothing but blank stares, even though he's written dozens of books and papers on becoming a better therapist.


We initially connected years ago because I interviewed him for my podcast. Since then, we've kept in touch. And then, about a year ago, he asked if I wanted individual consultation.


I jumped at the chance.


You see, over the past few years, I've felt beaten up by therapy. It wasn't sitting with other people's pain that wore me out; it was a chronic feeling of being ineffective that was burning me out.


Many of us feel ineffective. We deal with this feeling in different ways. Some of us go to another weekend training, others move into teaching therapy instead of doing therapy, and I jumped at the opportunity to get coaching from Alex.


My hope was working with him would rehab my practice. So here's what I learned from him on 11/17/23.


 

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2/5 Structuring counseling sessions begins with case conceptualization.

There are a few things Alex continually pushes me on. One of them is structuring counseling sessions.


He's pushed me to structure counseling session by presenting my understanding of what the client's problem is and why they are stuck.


For instance, I might begin a session saying, "So last week we saw that you, Ginny, often pursue George, which triggers a sense of fear for you George. And George when you become afraid, you withdraw, and that leaves you, Ginny, feeling afraid and alone. So, of course, then you, Ginny, pursue, and it becomes a vicious cycle. As you check in with yourself right now, what feels most alive about this cycle today?"


Having this level of clarity on the problem is important because it tells the client where we should focus our energy if we want to make progress. Otherwise it's easy to lose focus in therapy.


For instance, I currently have several clients who struggle being vulnerable. They have a deep fear that if they talk about their feelings, they'll be criticized by their partners like they were by their parents.


Instead of talking about their feelings in session, they make jokes, or distract or change the subject or get lost in endless storytelling. These are all psychological defenses against feeling their feelings and talking through them. And, they're really good at defending; they're all funny interesting people which makes it hard to stay focused in therapy.


So if I don't have a clear case conceptualization of not only their pain but how they keep from talking about their pain, it's easy to get distracted and just talk about the latest tiktok trend.


Which is why I need a really good case conceptualization. A good case conceptualization:

  1. Clearly states the problem,

  2. what we need to do to fix it, and

  3. what usually blocks us from addressing the problem.


Once you have a good case conceptualization you know where the therapy needs to go, how to get there, and how to course-correct when you get derailed.


And the evidence seems to show that structure, even outside of a model, has a huge impact on therapy.


3/5 Structuring counseling sessions is even more important than your therapy model (sometimes).



When Alex says structure is a "common factor" he means that above and beyond the model having a structure is an important ingredient for change.


How can structure be an important ingredient for change outside of model? Think of common factors as universal principles which make the models work.


Let's use weight loss as an example. If you want to lose weight, there are two universal principles.

  1. Move more.

  2. Eat less.

But just saying that is not enough. People also need a way to do the principles. So if you go to a personal trainer she might start you on a kettlebell workout and ask you to sign up with Weight Watchers. Or she might advise you do intermittent fasting and high-intensity training. Or she might ask you talk to your doctor about an appetite suppressant but start you on nightly walks with your family in the mean time.


It almost doesn't matter what the model is, as long as you have one it helps you do the principles you'll make progress. To make initial progress, especially if your goal is quite small, isn't that complicated.


Of course, if the goal is bigger, you might need more nuanced help.


4/5 Structuring counseling sessions also changes with more intense clients.

So even outside of a model, certain common principles make therapy work. Structure is one of these principles. But, at the same time, the more intense the client the more structure is needed, and sometimes the more specific models work.


What gives? How can structure be an overall ingredient outside of a model, and yet certain models provide better structures for clients?


Isn't that a contradiction.


How is this true?


Well, if we go back to our weight loss example, I think it's quite clear. Yes, there are only two ways to loose weight: Move more or eat less. But the more intense the goal, the more specific and nuanced the structure might will need to be.


For instance, say you're 600 pounds; well, you probably can't just start working out for an hour. Getting up and going for a walk might be really hard. So any model we develop would need to rely much more heavily on eating less. We might put you on a fasting diet, where you eat no food but only take supplements. Well, if we do that, we know you're also going to need medical supervision and we're also going to need to teach you coping skills for dealing with intense cravings.


Now compare this to a rock climber trying to lose weight so they are lighter and therefore more nimble while on a rock face. The rock climber might start counting calories while also using strength training to strengthen their forearms and glutes.



What a competitive rock climber and a morbidly obese person might need in terms of a weight loss program might be drastically different, even though they use the same basic principles. And both would need a more structured and specific approach than someone wanting to lose a few pounds after the Christmas holidays.


So you can see how the more complex a case, the more a structure might matter.


5/5 This isn't really about structuring counseling sessions. It's about how we train.

We've covered a lot.

  • We've talked about how structuring counseling sessions is important even outside of a model.

  • How more intense cases require more structure.

  • How a simple way to structure counseling sessions is to start each session offering the client a case conceptualization.


But that's not really what this is article is about.


I'm writing this information because working with Alex has been a large part of what's rehabbed my practice. I know I'm not the only therapist who's struggled with burning out and feeling ineffective. I'm passing along what I've learned so that if you're in the same spot you can have some of the same care and mentorship I've received.


Which, I think, is what therapy is all about. All of us helping and healing each other.


Jordan (the counselor)


-Fin-

Notes


[1] Alex Vaz is the co-author of literally dozens of books on deliberate practice, has written academic papers on therapeutic change, has trained with the best trainers in half a dozen different models, is now the Director of Training at Sentio, ran a popular YouTube series interviewing therapy experts, and at one point had some of the highest clinical outcomes of any therapist on record.

 

If you liked this post, consider reading this next. I think you'll like it ;) It's what Alex Vaz taught me about listening.

 

Jordan Harris, Ph.D., LMFT-S, LPC-S, received his Doctor of Philosophy in Marriage and Family Therapy from the University of Louisiana Monroe. He is a licensed professional counselor and a licensed marriage and family therapist in the state of Arkansas, USA. In his clinical work, he enjoys working with couples. He also runs a blog on deliberate practice for therapists and counselors at Jordanthecounselor.com.

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