Deploying Therapeutic Airbags to Enhance Clinical Outcome

• Jessica
• Clinical Creeds
• Mistakes are Mentors
• Using Therapeutic Airbags

“Angels can fly because they take themselves lightly.” -C.K. Chesterton
 

Jessica

Jessica (an amalgam) was 30 years old when she came to our clinical team. Her health was complicated and so I attended a consultation to discuss the details. This meant another meeting sitting around a round blonde table that looked like it was donated by a local elementary school. If you’ve ever worked in an institution, you know the table I’m talking about. I was told that Jessica had a brain tumor that would periodically swell with blood, and it was hypothesized that this tumor was the reason she would become aggressive. The theory was that when the tumor would expand, it placed pressure on the parts of her brain that stimulated survival reactions, and this is what led to her violent outbursts. This caught my attention. I was astounded, really. These were the early years in my practice, and this case formulation was bringing all the pieces together. It made sense of what I learned in graduate school about the fight-or-flight response, and it demonstrated the mistake of thinking that aggressive behavior was simply a result of poor character. It opened the door for compassion, and it humanized Jessica. I left the meeting with a bit of a brain buzz. It’s that feeling you get when you come across a new idea that you can chew on for a couple of days. It’s like a runner’s high, but for therapists.

Eager to meet Jessica, I walked down the hallway enjoying my high. I eventually found the right room, stepped in, and we made small talk for a bit. The discussion was off to a smooth start, and with my compelling conceptualization in hand, I decided to jump in.

“If you’re comfortable, tell me about the brain tumor. I’ve heard it plays a role in the aggressive times.”

With the appearance of deep reflection, Jessica looked down, paused, and then looked back at me. Then she gave me something to think about.  

“I’m 30 years old, and somehow, I’ve got a brain tumor. Has it occurred to you over-educated and stubbornly inept shrinks that this is the reason that I’m angry?”

I felt the capillaries in my cheeks begin to swell, and I knew my skin was glowing red. It seemed there was nothing left to do, and so I just sat there, draped in embarrassment’s ridiculous costume.

Clinical Creeds

When we’re in graduate school, we learn about the maxim, “First, do no harm.” The adage comes from the ancient Greek physician Hippocrates, but we talk about what this motto might mean for a therapist. No dual relationships. No receiving large gifts. Keep your clothes on.

We learn that therapy can be dangerous in its most negligent manifestations. What makes it powerful is also what makes it dangerous. Therapy is like a flame; it can warm you or it can burn you.

While the cardinal sins seem easy enough to avoid, once we move deeper into our work, we discover how difficult it really is to do no harm. No harm? Really? Zero? Well, what about the time I was caught checking the clock only five minutes after I started the session? Or the time I made theatrical eye contact and then confidently called my client the wrong name? Masterstroke! And what about the time I immediately damaged my rapport with Jessica because it was more important that I be entertained by an interesting idea than to discover who she really was? Some amount of harm was done in each of those instances, and for the record, I’ve made much bigger mistakes.

I understand the intent behind the axiom, but I think, “First, do no harm,” is a puritanical expression. I don’t like that third word. No mistakes allowed. Be perfect. You’re only one fumble away from doing serious damage. That’s a lot of pressure, and so I’m going to try to convince you to gently set this motto aside.   

Like many creeds, “do no harm” is a noble abstraction, and when we try to pull abstractions down from the ethereal world of ideas and place them into the corporeal world in which we live, we discover their limitations. We find out that what makes sense in our head doesn’t always translate into our hands. It’s like when an inspirational speaker tells you to “Carpe Diem” or “Do what you love, and the money will come.” These diet Deepak Chopra-isms seem to know more about lofty slogans than implementable methods; more about the sky than the soil.

Why does this matter? It matters because something happens when our eventual mistakes collide with this puritanical mandate to do no harm. It creates fear, and it’s a fear that lives in the heart of every therapist I’ve ever met.

Mistakes are Mentors

Fear runs deep in the heart of this profession. We fear being sued, we fear being interrogated by the regulatory board like we’re testifying before congress, and ultimately, we fear losing our careers.

But maybe this climate of fear shouldn’t surprise us. While in school, we watch video clips of awe-inspiring clinical moments. We read transcriptions of perfectly executed interventions. How many of these moments are helped along by editors? We can’t be sure. My hunch is these videos clips are often highlight reels, and the perfect dialogue transcriptions are like glossy grocery store magazines — air brushed to remove blemishes. It’s tabloid therapy.   

Tabloid therapy is any presentation of the therapeutic process that’s absent of imperfection, and unfortunately, it saturates the university and post graduate training environments. But where are the blooper reels, the blunders, the awkward moments, and the misunderstandings? Where is the throat clearing, the sneezing, the spilled coffee on the shirt? I never saw myself in any of those videos or books. The unpolished learning process wasn’t role modeled, and because we’re only introduced to perfect therapy, it makes sense why we treat our blemishes like pathologies.

Problems begin to emerge when we’re too afraid of our mistakes, because this makes it difficult to learn from the valuable information held within them. When making mistakes becomes forbidden, our mistakes create fear, and then the adjustment signals are more difficult to discern. But when we relate to mistakes effectively, they signal to us where to adjust. They mentor us. This means that to grow as a therapist, the great majority of our mistakes must be taken lightly. We must sit safely with our mentors and listen for their guidance.

While I wish that all harm could be entirely avoided, I don’t see a way around it. This isn’t an invitation into clinical recklessness, but the reality is that some of our clients will experience our growing pains, while others will benefit from what we’ve learned. So go ahead, stumble over your words, double-book an appointment, botch a reflection, catch yourself zoning out, violate HIPAA, and commit insurance fraud. Okay, don’t do the last two things, but because “do no harm” interferes with the learning process, we should sweep it into the dustpan with the other noble abstractions. Carpe Diem could use the company.   

First, Reduce Harm

Instead of developing an adversarial relationship with our mistakes, what if we thought about learning therapy in the same way we think about learning to drive? I didn’t want to make mistakes when I first got in a car, but despite wanting to drive perfectly, it wasn’t meant to be. The speeding tickets and fender benders were part of the learning process.

As I learned to drive, the car had safety features to reduce the risks. I did my best to drive safely, but just in case, I could rely on the airbags. What if we approached therapy this way? We don’t want to make mistakes when we’re practicing therapy, but mistakes will invariably occur. Therapy carries inherent risk, and eventually we’ll get into accidents, but what if we built strategies into therapy for damage-reduction? “First, do no harm” is unrealistic, but “First, reduce harm” might work. We could create therapeutic airbags.

The types of mistakes that can occur within therapy are limitless, and so it’s natural to wonder where we should begin with trying to reduce the risk of harm. Which mistakes should we build these airbags around? Let’s start by exploring where the accidents are the most dangerous.

Over many decades, a slow consensus began to emerge about why therapy works. Instead of believing that the correct therapeutic method was necessary for the client’s improvement, researchers noticed that there were common factors across different types of therapies that ultimately made the difference.

There were many people involved in this emerging consensus, but it was Michael Lambert who suggested that the single variable that influenced client improvement more than any other had little to do with the therapist. Instead, the client improved because of their personal qualities and environmental resources. When the client improved, about 55% of the reason had nothing to do with the therapist (1).   

Up until this point, therapists were taking credit for improvements they had no part in influencing. As the saying goes, we were roosters taking credit for the sunrise. This didn’t mean that therapy wasn’t effective, but it did mean that the single most influential part of what made a person feel better was not within the therapist’s control. In hindsight, it was hubris to think we could take most of the credit for a client’s improvement.

The area where the therapist had the most influence was the quality of the therapeutic relationship. Lambert concluded that the relationship between the therapist and the client accounted for 30% of why the client improved. It mattered if empathy and warmth were characteristic of the relationship. It mattered if there was a sense of personal closeness. So, there it is. If the relationship with the client is where we can make the biggest difference, then damage to the relationship with the client is where our accidents are the most dangerous. This is where we should install the therapeutic airbags.

What does damage to the therapeutic relationship really mean? It seems to depend on who you ask. If you talk with a client-centered therapist, they’ll warn you about directing the client too much. They'll remind you about the problems with giving advice. Directive therapy can create an aura of expertise that makes it harder for our clients to disagree with us. If it’s difficult for the client to disagree with us, they will express agreement even when they privately disagree. Then the client can’t be themselves, even with their therapist. Giving advice can lead to client hiddenness. That’s one way we can do damage to the relationship.

If you talk to a therapist that’s directive in their style, they’ll tell you about how nondirective therapy becomes aimless, and for that reason, frustrating for the client. They’ll tell you about how cognitive behavioral therapy, dialectical behavioral therapy, and acceptance and commitment therapy are each directive treatments protocols, and they work just fine. They’ll tell you about how expecting people to come up with their own answers is a form of withholding help. Clients will think you’re too removed, they’ll say. That’s another way to damage the relationship. I think they both have a point.

I once had a well-meaning directive therapist say to me, “You know when you have to tell your client that it’s time to leave their marriage?”

Nope, I really don’t. Point for non-directive therapy.  

I’ve also heard something like this said multiple times, “My problem with therapy is that eventually, I need someone to tell me what they think. Some therapists just want to listen. I start to wonder if they don’t know what to do with me.”

I get that, too. Point for directive therapy.

Both directive and non-directive therapies have important critiques about each other. They’re a divorced couple that has a refined sense of the other’s shortcomings. Fortunately, the truth is that our choice is not between directive or non-directive therapy. We don’t have to pick a parent. Instead, there’s a long green field between these two positions, and how much we engage with the client should be a matter of degree. When we decide to engage with our clients more directly, we can incorporate strategies that address the concerns of the non-directive therapists, but we can proceed with our work, nonetheless.   

Using Therapeutic Airbags

If we decide that we’re going to be directive to some degree with a client, then we should use a strategy that helps reduce the risk of potential harm to the therapeutic relationship. As Lambert demonstrated, the relationship that we have with our client is the single greatest factor where we have influence, and so it’s where we should be the most careful. This is where we should use the therapeutic airbags. The nondirective therapists are correct that our clients might be uncomfortable disagreeing with us, and so the purpose of a therapeutic airbag is to incentivize client disagreement. This way we can be confident that our clients aren’t overtly agreeing with us even when they privately don’t. We can work to prevent hiding, and here’s how we can do it.

Step 1: “This simply crossed my mind...”

Before we’re directive to any degree, it’s important to signal to the client how seriously we’re taking our own thoughts. If we present our impressions as authoritative theories, then the client will feel more pressure to agree with us. For many clients, it will be difficult to disagree with the theory of a professional. But if we use the opening, “This simply crossed my mind,” then we can signal something quite different. This phrase seems uninteresting on its face, but when we look closer, the words “simply” and “crossed” are doing some heavy lifting.

The word “simply” suggests that we aren’t taking ourselves too seriously. It diminishes the authority of what we think. It’s casual. There’s no grand theory about the client’s life that’s about to be introduced, because the thought just simply came to mind.

The word “crossed” also communicates our own lack of commitment to what we’re about to share. The thought passed through our mind. It came, and it went. We haven’t spent excessive amounts of time thinking about what we’re about to say. We’re signaling that we’re not personally committed to the ideas that they’re about to hear. We’re keeping things relaxed.

Step 2: “…and so tell me if this doesn’t fit.”

This is an invitation for disagreement, but it’s also more than that. Notice what word isn’t being said. We aren’t saying, “…and so tell me if this is wrong.” If we were to use the word “wrong” it would make the disagreement overt. This would make it harder for the client to disagree with us. For some people it will be hard to explicitly say to a therapist, “No, that’s wrong.”

Instead, we can use language that invites more subtle disagreement. “Tell me if this doesn’t fit,” sounds more like we’re in the changing room of a department store. Yes, there would be ethical issues with that, but you know what I mean.

Step 3: “but I found myself wondering.”

This is where we share our impressions about the client or their situation. It’s where we’re the most directive. In this step we aren’t conveying conviction, but it’s opposite — we communicate wonder.   

Wonder is an essential quality in a therapist. Wonder is the combination of imagination, openness, and awe. It helps us to travel into the experience of another, and for this reason, wonder is a relative of empathy. Expressing wonder might sound like this:

“This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering…”

Notice the difference between, “I found myself,” and “I find myself.” The first one is past tense and the second one is present tense. When we say, “I found myself” then we are sharing a memory. When we say, “I find myself,” then we’re talking about right now. The present tense creates immediacy, and immediacy can create intensity in the conversation. There’s a place for immediacy in therapy, but this isn’t one of them. Instead, if we express what we found ourselves wondering about in a previous moment, then we can continue to keep the pressure on the client low.

Step 4: “But tell me where this misses the mark.”

This is the closing phrase. It’s useful because, “tell me where” assumes that we made a mistake. If we were to finish the skill with, “Did I miss the mark?” then for many agreeable clients, this would elicit a reassurance reaction, “No, you got it right.”

Instead, the client must correct us if they want to express agreement. Here’s how this might look:  

Therapist: “But tell me where this misses that mark.”

Client: “Well, I’m not sure it does miss the mark.”   

If the client wants to agree with us, then they must be disagreeable. They must jump a hurdle to correct our assumption that we made a mistake. When we set things up this way, we can have more confidence that the client is being sincere in their agreement because we’ve made the agreement harder. We’ve also made disagreement easier, because conveying the assumption that we’ve made a mistake makes it easier for the client to follow our lead.

Here’s a fictional example of the skill in its entirety. This is how things often transpire when we successfully get our client to correct us:  

Therapist: “This simply crossed my mind (step 1), and so tell me if it doesn’t fit (step 2), but I found myself wondering (step 3) if part of the difficulty is that you’ve thought that setting boundaries is selfish. Setting boundaries seems to chafe against your values. But tell me where this misses the mark (step 4).”

Client: “Well, I don’t really believe that having boundaries is selfish, so I’m not sure.”

Therapist: “Okay, I gotcha. You don’t take issue with boundaries. Can you help me understand what I’m missing?”

Client: “Well, I think it’s okay to have boundaries, but I just don’t do it for some reason.”

Therapist: “I think I’m getting it now. You don’t have anything against having boundaries, but putting them into action doesn’t happen, and you’re not sure why. Tell where this missed the mark.”   

In the last exchange, the therapist can return to the assumption that a mistake was made by repeating step 4 (“tell me where this missed the mark”). This way the therapist can gain confirmation from the client, or elicit a second correction.

***

This strategy is built to constantly elicit feedback from the client. It’s a feedback machine. If we use the strategy effectively, then we’ll be corrected more often. When I first started using therapeutic airbags, I thought I was getting worse at my job. The truth is that I was previously unaware of how many mistakes I was making, and this strategy was bringing my mistakes forward.

Let’s learn to view our mistakes differently. Rather than be afraid of them, we should actively work to hear about them, and then we can protect our relationship with each client. Mistakes don’t have to be blemishes, and they don’t have to be threatening. A client who talks about our mistakes is a client who feels safe enough to share them. This is not a sign of damage to the therapeutic rapport, but a sign of investment in the relationship — the client has decided not to hide. When we use these therapeutic airbags, our mistakes will come forward, and when they do, so will our clients.

Editor’s Note: This is the first in a series of five articles by David Prucha. While initially intended for beginning therapist based on his own clinical evolution, you will see that there is certainly something in each of these essays for clinicians at all levels. In the next installment of this five-part series, the author will address the challenges and benefits of working effectively with client dependence.

Reference
(1) Lambert, M.J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J.C. Norcross & M.R. Goldfried (eds.), Handbook of psychotherapy integration (pp.94-129). Basic Books.  

©2023, Psychotherapy.net