In Part III of the working alliance series, I’d addressing some ideas, practical tips and research findings that might seem obvious at first blush. However, do not confuse obviousness for triviality.
I hope you find some of these recommendations, include this week’s Therapy Tip of the Week, useful. In case you missed them, here are the previous recommendations on the topic of Alliance:
I love to hear from you about your reactions to these ideas in the comments section below. And if you end up experimenting with them, the all of us in this community on Frontiers would benefit to hear about your learnings.
🎥 New Video from Frontiers, Therapy Tip of The Week: Seek to be Disconfirmed Dissonance can be a powerful ingredient for learning. How do we challenge our intuition in order to listen to our client's unspokens in order to foster a deeper connection with them?
In this video, I recommend an exercise that I use called the "Rate and Predict," to help me open up the conversation in therapy.
👓 From the Frontiers Archives: To Understand? Easy. To Help Someone Feel Understood? Difficult. The tough part is to help someone feel understood. This is why I strongly believe we need more direct training in the conversational nature of therapy, much more than the emphasis that we place in theoretical understanding especially at the early stages of our career.
📜 Research: The Alliance-Outcome Association in Couples Therapy I mentioned this in issue FF41. This study was conducted in Singapore. We found that from a shared influence model was a significant predictor of therapy outcomes. Even though each partner were rating their alliance experience with the therapist, there was a shared experience. I know, this isn’t earth shattering news. This is something systemic thinkers have previously conceived the couple-hood as an entity, and understood that both parties have an influence on the other. This is also makes couples therapy more challenging (and rewarding).
📜 Research: Socioeconomic Status and the Therapeutic Alliance I suspect that we don’t fully appreciate how much SES affects a wide variety of life factors, such as physical health, mental health, cognitive ability. When I read this paper, I was still somewhat taken aback that SES also affects the engagement levels in the therapy room. These researchers from Sweden found that clients of lower SES, on average, felt less understood and inferior to their therapist, "as well as possible perceptions that such client(s) are less suitable for psychotherapy." This was more pronounced in a psychodynamic context than CBT treatment approach. This study has prompted me to include SES (and maybe even perceived SES if I might add that in my pre-therapy questions) as a factor to consider in my future outcomes analysis.
⏸ Words Worth Contemplating: "It takes two to know one."~ Gregory Bateson
Part I: Who makes you feel understood? Picture this person in front of you. What does that feel like? How does this person relate with you that makes you feel warmth?
Part II: Are they people whom you see who are economically disadvantaged or are on the margins of society? Picture them in front of you. How do you think they experience you? How do you equalise the ground so that they might feel less inferior to you?
BIG HUGS TO NEW PEOPLE WHO ARE AT THEIR FRONTIER!
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Thank you for your considered reply. Really excited to hear about an implementation of the DCT study. I look forward to it.
I hear what you're saying about group feedback type situations, and I agree that "the quality of the feedback determines the quality of the learning". I was thinking that the type of feedback provided in the DCT study was absolute gold and that, whilst the feedback clearly needs to be individualised and specific, I'm sure I could also benefit from watching others receiving this kind of feedback, though it might not be directly relevant to me.
Thank you for the piece about Native Skills and Wisdom. What a lovely way of phrasing it. It resonated with me because it describes some of my reflections up to now. I often wonder: what is my theory of change? What do I believe will be helpful? what do I believe leads to growth and healing? It's been a long process, but I feel like I'm getting closer to an answer that feels authentic given my knowledge and experience up until now. Perhaps I've undervalued this formative process in the impatience I feel towards all I would like to learn and improve on, considering the time I have available. Thanks for the reminder.
Your comment also made me think of the importance of the right type of guidance, at the right time. Thank you for your work in this space.
"we need more direct training in the conversational nature of therapy". This really resonates with me as an early career clinician. There's certainly no lack of avenues to deepen content knowledge, but I personally struggle to find guidance on the process, the how to, the implementation of the skills I read that seem to be important. Supervision might be an appropriate place for that but it often isn't the kind of methodical skill building enterprise I'm referring to here.
I imagine we're talking about deliberate practice. However, if I've understood "Better Results" correctly, I need to have worked with at least 60 clients to make sense of what my strengths and weaknesses might be as a therapist. That strikes me as somewhat inefficient. By then I will have reinforced some less than helpful habits, I imagine. I know there are some general deliberate practice exercises available but perhaps what we need is a widespread implementation of the model used in the difficult conversations study where participants received individual feedback. I really think that would be a sort of holy grail of therapist training. Is anything like that available anywhere at this point? I guess that might be the realm of individualised coaching... But if there was some kind of formal group training like that, where therapists can learn together and from each other, I'd certainly sign up for that.
Hi Ester, I really appreciate your line of thinking... Pls pardon the length of my response.
Two Key Points:
1. How We Learn
2. Tapping into Our Native Wisdom Early On
1. How We Learn
- Re: The Difficult Conversations in Therapy (DCT) study and implementation: That's something we are planning to implement as a pedagogical approach to enhance deep learning. Stay tuned!
More about DCT:
- The video of challenging situations are not the meat, but just a stimulus. I've seen groups who were given videos to work with, and some were told to provide feedback to each other.
The issue with this is that
i. Most of us don't know how to giving learning feedback. Most of us give evaluative feedback. The latter is about performance and judgement ("You did great"), which is not optimal for deep learning.
ii. When we do give feedback, it's too specific to the example and not generalisable e.g., "Say this..." or "Say that..."
- I'm bringing up this point because one of the most important things that I've learned from running the DCT project is this: The quality of the feedback determines the quality of learning.
- Although it's not such a surprise to discover that people improve when given feedback compared to those who learned on their own without feedback, what was surprising was participants in the feedback group were able to generalise their learnings onto other clinical scenerios! Our suspect was that we did provide specific or performative feedback, but we provided principle-based learning feedback that has the affordance for transferring the learning (sidenote: turns out that "Transfer of learning" is the holy grail in education. Too many evidence suggests that what we learn in the classroom doesn't translate to the world outside. I bet many who read this wouldn't be surprise).
---
2. Tapping into Our Native Wisdom Early On
I don't think it's a "do-nothing" "or wait and see" while you build up your 60 cases. I work with people who are still developing their baseline.
Especially at the early days of the profession, instead of colonising the learning endeavor, because of the relational nature of therapy (unlike more technical jobs), one would really benefit to receive guidance that taps into each person's Native Wisdom.
Below is a half-baked piece I've yet to complete for Frontiers of Psychotherapist Development... it's related to the points you've raised, so here is my incomplete thought about Native Wisdom.
"Everyone has native skills.
Native skills are located in our prior knowledge, live encounters that consists of edifying and adverse histories.
Instead of indoctrinating people about theories of other people’s view about human development as the first port of call, why not start with unearthing our theories about how growth and healing, based on our personal experiences of growth and healing?
No matter how well-intentioned, when we begin by teaching other people's views and approaches, we inadvertently end up mimicking their beliefs, and we become somewhat "lazy" in trying to think for ourselves, or further shape and mold our own thoughts, informed by our prior knowledge.
Native skills can be fermented into native wisdom. Our education, training and development activities can do well to recognise that unlike specialised fields like being a surgeon or a rocket scientist, the craft of psychotherapy does not belong to a “specialised” field of knowledge—the art of conversation is inherent as to our humanity. But to become a *great* conversationalist, that needs to be honed in.
Tapping into each therapist’s native wisdom, is perhaps a pertinent alchemy that is required in our field. I say we begin with that, and join the dots to various theoretical frameworks, after the fact."
Thank you for your considered reply. Really excited to hear about an implementation of the DCT study. I look forward to it.
I hear what you're saying about group feedback type situations, and I agree that "the quality of the feedback determines the quality of the learning". I was thinking that the type of feedback provided in the DCT study was absolute gold and that, whilst the feedback clearly needs to be individualised and specific, I'm sure I could also benefit from watching others receiving this kind of feedback, though it might not be directly relevant to me.
Thank you for the piece about Native Skills and Wisdom. What a lovely way of phrasing it. It resonated with me because it describes some of my reflections up to now. I often wonder: what is my theory of change? What do I believe will be helpful? what do I believe leads to growth and healing? It's been a long process, but I feel like I'm getting closer to an answer that feels authentic given my knowledge and experience up until now. Perhaps I've undervalued this formative process in the impatience I feel towards all I would like to learn and improve on, considering the time I have available. Thanks for the reminder.
Your comment also made me think of the importance of the right type of guidance, at the right time. Thank you for your work in this space.
Ester, the questions that you have will put you on a quest. I hope you do write them down
"we need more direct training in the conversational nature of therapy". This really resonates with me as an early career clinician. There's certainly no lack of avenues to deepen content knowledge, but I personally struggle to find guidance on the process, the how to, the implementation of the skills I read that seem to be important. Supervision might be an appropriate place for that but it often isn't the kind of methodical skill building enterprise I'm referring to here.
I imagine we're talking about deliberate practice. However, if I've understood "Better Results" correctly, I need to have worked with at least 60 clients to make sense of what my strengths and weaknesses might be as a therapist. That strikes me as somewhat inefficient. By then I will have reinforced some less than helpful habits, I imagine. I know there are some general deliberate practice exercises available but perhaps what we need is a widespread implementation of the model used in the difficult conversations study where participants received individual feedback. I really think that would be a sort of holy grail of therapist training. Is anything like that available anywhere at this point? I guess that might be the realm of individualised coaching... But if there was some kind of formal group training like that, where therapists can learn together and from each other, I'd certainly sign up for that.
Any suggestions?
Hi Ester, I really appreciate your line of thinking... Pls pardon the length of my response.
Two Key Points:
1. How We Learn
2. Tapping into Our Native Wisdom Early On
1. How We Learn
- Re: The Difficult Conversations in Therapy (DCT) study and implementation: That's something we are planning to implement as a pedagogical approach to enhance deep learning. Stay tuned!
More about DCT:
- The video of challenging situations are not the meat, but just a stimulus. I've seen groups who were given videos to work with, and some were told to provide feedback to each other.
The issue with this is that
i. Most of us don't know how to giving learning feedback. Most of us give evaluative feedback. The latter is about performance and judgement ("You did great"), which is not optimal for deep learning.
ii. When we do give feedback, it's too specific to the example and not generalisable e.g., "Say this..." or "Say that..."
- I'm bringing up this point because one of the most important things that I've learned from running the DCT project is this: The quality of the feedback determines the quality of learning.
- Although it's not such a surprise to discover that people improve when given feedback compared to those who learned on their own without feedback, what was surprising was participants in the feedback group were able to generalise their learnings onto other clinical scenerios! Our suspect was that we did provide specific or performative feedback, but we provided principle-based learning feedback that has the affordance for transferring the learning (sidenote: turns out that "Transfer of learning" is the holy grail in education. Too many evidence suggests that what we learn in the classroom doesn't translate to the world outside. I bet many who read this wouldn't be surprise).
---
2. Tapping into Our Native Wisdom Early On
I don't think it's a "do-nothing" "or wait and see" while you build up your 60 cases. I work with people who are still developing their baseline.
Especially at the early days of the profession, instead of colonising the learning endeavor, because of the relational nature of therapy (unlike more technical jobs), one would really benefit to receive guidance that taps into each person's Native Wisdom.
Below is a half-baked piece I've yet to complete for Frontiers of Psychotherapist Development... it's related to the points you've raised, so here is my incomplete thought about Native Wisdom.
"Everyone has native skills.
Native skills are located in our prior knowledge, live encounters that consists of edifying and adverse histories.
Instead of indoctrinating people about theories of other people’s view about human development as the first port of call, why not start with unearthing our theories about how growth and healing, based on our personal experiences of growth and healing?
No matter how well-intentioned, when we begin by teaching other people's views and approaches, we inadvertently end up mimicking their beliefs, and we become somewhat "lazy" in trying to think for ourselves, or further shape and mold our own thoughts, informed by our prior knowledge.
Native skills can be fermented into native wisdom. Our education, training and development activities can do well to recognise that unlike specialised fields like being a surgeon or a rocket scientist, the craft of psychotherapy does not belong to a “specialised” field of knowledge—the art of conversation is inherent as to our humanity. But to become a *great* conversationalist, that needs to be honed in.
Tapping into each therapist’s native wisdom, is perhaps a pertinent alchemy that is required in our field. I say we begin with that, and join the dots to various theoretical frameworks, after the fact."
---
Thanks for bearing with a long response.
Love to hear your thoughts about this.
Note: More broadly speaking, Here's a visual of the iterative pathway I've done previously relating to our professional development journey : https://darylchow.com/frontiers/the-iterative-pathway-of-a-psychotherapists-professional-development/