Looking back on my 1-1 coaching with Alex Vaz
Over the past few weeks I've been documenting what I've learned from working with Alex Vaz, the world's greatest therapy coach.
Well, our time is done now. Alex is busy building a graduate program and managing multiple therapy clinics so he doesn't have time for 1-1 consultations.
I'm happy for him, and a little sad for myself.
As I reflect on our work together, I can identify four significant areas he consistently emphasized.
Now, there were many smaller areas he focused on, such as providing structure, but even these were nested in one of these four bigger areas.
I've come to believe that these are the four areas that are the four reasons therapy fails. My hope is that by sharing them with you we can help more people.
Therapy Mistake #1: We rupture the alliance.
The therapeutic alliance has three parts. Envision it as the three legs of a stool. It includes:
the client-therapist bond,
mutual agreement on therapy goals,
and alignment on the steps towards reaching those goals.
A common therapy mistake is assuming that the alliance is solely about the bond, which they boil down to how much the client likes them. I think this leads some therapists to think that if they are just empathic with their clients change happens.
I don't think that's true.
Now to be clear for some clients they do just want or need support. And I think this support can be beneficial. I just also happen to think it's different than changework.
I regularly ask new clients, "I can see you had a previous therapist. Why didn't you go back to them?"
Client's often say, "well, I really liked her, but I feel like we were better friends than client-therapist."
These clients are saying, "Our client-therapist bond was good, but we weren't making progress towards my goals."
So we also have to make sure that we have clear goals and clear tasks/means/methods of reaching those goals. If we don't have these, we basically have a rupture in the therapeutic alliance.
How do we fix this?
Oftentimes it's pretty clear what the problem is. That gives us a clear goal. If a client comes in for anxiety it's pretty obvious the goal is anxiety reduction. If a couple is fighting it doesn't take a rocket scientist to realize they need communication skills.
Where I often messed up was helping clients understand the ways we were going to reach their goal. Clients didn't understand the intervention I was offering.
The big fix was for me to ask the client if they want to do the intervention, and give them a rationale for why the intervention would be helpful.
I might say something like:
"You know many people benefit from EMDR (intervention). It's a way to take the emotional charge out of painful memories (rationale). Would you be open to trying it out?"
Or with couples, when I wanted them to discuss emotions topics with each other I might say:
"You've done a beautiful job telling me how you feel. And we're here to help you communicate better with your partner. One way to practice is to tell her directly (rationale). Can you tell her what you just told me (intervention)?"
Therapy Mistake #2: We ignore client motivation.
I think of motivation as clients consciously agreeing with the goals of therapy and the task required to meet those goals.
You'd be surprised how often you're working on something and isn't the thing the client wants to work on, or it's not the way the client wants to work on the problem.
Early on Alex identified that I was trying to resolve problems before the client had stated a problem. A wife might say something like:
"I'm so angry with my husband."
And I'd jump in with, "Oh wow, where do you feel that in your body?"
The client would respond, "I don't know; it's just that he's so frustrating. You know he never does the dishes."
I'm not offering a solution ("maybe you should talk with him about it."), but I am offering an intervention (" where do you feel that in our body"). I used to think this was better than offering a solution because I was focusing on the emotion.
It's not.
The client hasn't stated how being angry with her husband is a problem. She's just venting.
Maybe she's just telling me about it because she trusted me and it just happened.
Maybe she's angry, rightfully so because he doesn't follow through with what he said he would do.
Maybe she's angry and ashamed of her anger because in the house she grew up in, anger was prohibited.
It could be any of those, or something else entirely. Regardless, I was skipping a step. I first had to see if she was motivated to change some part of this.
How do we fix this?
One way to fix this therapy mistake is to ask the client, "is this something you'd like to work on today?"
Of course you need to do it tactfully.
I often give clients a way out.
So I might say something like:
"I can tell this is so painful for you. So I want to make sure I'm really attending to you here. I have a few ideas of things we could do that would be helpful, but I want to make sure we're not moving too fast. Are you wanting to work on this? Or are you just needing to process? Either is fine with me."
I'm surprised how many times clients say "I just want to process through this," but I'm totally fine with it because now I have clarity. I know what I'm supposed to be doing, so I don't have to worry about pushing for change. The client isn't asking for change in this area.
Therapy Mistake #3: We try to push through resistance.
Every once in a while I'd have an individual client who's having some problematic reaction. Let's say he kept having panic attacks when he got to work, but he didn't know why. So I'd offer, "hey, many people find EMDR helpful here. It's a way to process traumatic memories. It might be helpful for you."
He'd say, "okay,"
I'd start doing the bilateral reps and he'd stop me. "I'm confused. Why are we doing this again?"
So I'd explain, "well you're saying you are panicking and you don't know why it's happening. EMDR helps people to follow feelings across memoires in their past. I think it could help you understand yourself better. "
"Okay" he says and I'd start on the reps again and then he'd stop me, "I just don't think this is going to work. Like what's supposed to happen."
It wasn't until coaching with Alex that I realized the client wasn't misunderstanding therapy, he was resisting therapy and he probably didn't realize he was resisting.
If motivation is the client consciously agreeing to work on the goals of therapy, then resistance is the client unconsciously working against the goals of therapy.
As soon as you say "unconsciously" some people immediately get thrown off. It's really not that complicated.
The big idea is oftentimes clients say "yes I want X," and then immediately work against the goal.
I see a lot of couples. It's pretty common for a client to be in a softer emotion, maybe they're feeling sad. So I ask them to share their sadness with their partner, and they turn and just blast their partner with criticism and blame.
They are in my office talking about how much they want a closer relationship with their partner, but as soon as we go to help them be closer, they become angry, destroying any shot at being close with their partner.
Resistance.
How do we fix this?
The big fix for this therapy mistake is to bring this resistance to conscious awareness so they can work on the resistance directly, instead of allowing it to derail their growth.
One way I do this is by labeling their resistance as a "part" of them, identify the way this part resists, and attempt to find the pain this part is protecting from.
So you might say something like:
So right now a part of you is keeping you from doing the EMDR (label part). And this part keeps asking questions (identify how the part resists). Maybe it's really scary to go into this right now (attempt to find pain)?
Or for couples:
"Okay. So right now there's a part that makes it hard to share with your wife (label part). And this part makes you so frustrated so you don't share your pain with your wife (identify how this part resists). I'm guessing this part is protecting you from feeling a deep pain (attempt to find pain)
Of course this is just one move out of many. It's not a magic bullet and can often talk whole sessions to help identify the pain this part is protecting from.
So think of this as more principles, not specific techniques. Label the resistance as a part, identify how this part resists, find the pain this part is protecting them from. And all of these
Therapy Mistake #4: We try to fix problems we can't fix.
What if you hired a personal trainer, took the time out of your day to go to the gym, and once you got there told her, "Hey, just give me some tips or tricks so I can do this at home."
She'd probably say, "Well, you're here at the gym. We should do the training here."
"Yeah, but can't you just give me some mindset shifts so I can do more training later? Or better yet, how about I tell you all about how I tried to run a mile yesterday, but my feet started to hurt and I think it's because of these stupid shoes I got. You know the shoe company really tricked me out of my money. They should really be more honest in their advertising -"
At this point, I'd hope your trainer would level with you.
"Let me slow you down. You hired a personal trainer probably because you can't do this on your own. In fact, I think what's happening right now is a big part of the problem. You're talking about working out but haven't started working out. Until you start working out, you're never going to get into shape. Can we start the workout now?"
We have the same problem in therapy.
I've talked about this before. Clients come in talking about all sorts of things that happened in the past outside of therapy that we can't change. The only thing we can change is the client's experience in the present. If we don't, if we try to help clients change things that are external, vague or in the past we're doomed to failure.
How do we fix this?
The way to address this therapy mistake is to nudge the client to talk about things which are present, specific and internal.
So for a client who's being external you might nudge them to talk about their internal world:
"Oh, I can see how this is so painful. And when he yells at you, how do you feel?"
For a client who's talking about the past, you can nudge them to being present:
"Yes, you felt so much anxiety yesterday. Can you feel that anxiety right now? Take a second and check in with your heart. What are you feeling now?"
And for a client who's vague, you just make overt that they are being vague and you can't help them unless they are more specific.
"I'm a little confused. And I think it's because we're talking about this in a vague way. It would help me to help you if we could be more specific."
Hope for the future of therapy...
There you go. Regardless of model there are four areas that trip therapists up the most and lead to most therapy failures.
Focusing on the bond and ignoring the client's goals and the task required to meet those goals.
Not working on what the client is motivated to work on.
Leaving resistance unconscious instead of working on it directly.
Trying to change things outside of the therapy room which we can't change.
There's a big part of me which thinks therapy is easy, if we learn to manage these four therapy mistakes.
It makes me much more hopeful about our field and our ability to help people. It may be idealistic, but a part of me feels like if we could master these four therapy mistakes, then we'd have a world were therapy rarely fails.
Which means a lot more people are overcoming mental illness and living rich, full lives.
Which is the point of therapy anyway.
Best,
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 about the biggest business mistake therapists make.
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.