Becoming a Better Therapist:
--Eight Essential Skills--
Are you a lucid therapist?
What does howtherapyworks.com stand for?” I’d like to think of myself and my (professional) readers as “Lucid Therapists," meaning that we seek to base our clinical decisions and actions on the clearest possible understanding of what is going on and how best to support positive change in our clients. To do that, we are constantly seeking to improve our knowledge and skill. Importantly, we don’t measure ourselves by the standards of any one brand of therapy or protocol, but by universal notions of the human mind and change processes.
To make this more specific, here are eight things a Lucid Therapist should be able to do well. You are encouraged to rate yourself on each, using whatever scale works for you. This exercise should not be discouraging because we all have a lot of room to grow and Lucid Therapists value what they don’t know as highly as what they do know!
- Connect: This means build an alliance with the client, but it means much more. It also means we need to engender trust, actually be trustworthy, and align our goals and actions with those of the client. Being trustworthy is especially important because we are responsible for safety, that is, seeing that harm is not done and that informed consent is in place when risk is inevitable. And it helps to remember that this standard applies not only to our words, but to our nonverbal communication and the implied promises and meaning embodied in our actions.
- Diagnose: We need to be able to start from the client’s expressed concerns and troubles, clarify the maladaptive pattern(s) behind them, and formulate the work that needs to be done to help the client achieve enduring change. Doing this with skill means continually seeking greater depth of knowledge through observation and learning from others regarding psychological, social, developmental, biological, cultural, and other dimensions and constructs. See #3 below for different kinds of work needed to bring about change.
- Plan: How, then, will we help our client overcome barriers and do the necessary work of change. This can include emotional work, such as grieving or acceptance, but it can also mean learning new ideas and adopting new behaviors, including movement and posture.
- Motivate: Serious therapy is often hard. Every therapy, even those that profess neutrality, has ways of supporting and encouraging the client when the going gets tough. The trick is to provide enough support without taking over ownership of the project.
- Activate: The central healing process in psychotherapy can be described as the Corrective Emotional Experience (in its broadest sense), mindfulness, or as a “Healing Moment.” For this to happen, the first of two requirements is that the old, maladaptive pattern must be in an active state in the limbic system. We know this when we are in the presence of affect, meaning conscious feeling accompanied by spontaneous bodily signs of emotion such as tears, breathing, movement, facial expression. Activation can happen spontaneously, through triggering, as in transference, where the therapeutic relationship itself activates an old pattern, or through words or other stimuli that evoke or trigger the old pattern. An important, but often neglected way of activating old protective patterns is to encourage adoption of healthier behavior. For example, acting more assertive or holding others accountable can activate intense affect and set the stage for a healing moment.
- Illuminate: This skill is quite broad. Opening the client’s eyes with new and important information starts as counseling, which means giving helpful new information where the client is ready and able to make use of it. This can be cognitive, but may also involve experience and practice to consolidate learning. Strictly speaking, counseling ends and psychotherapy begins when the client has trouble making use of the new information. Therapy is primarily about making changes where the client has already tried and had difficulty. However, in practice, therapists often incorporate counseling as part of the work.
But that’s only the first part of illumination. The next part completes the requirements for the healing moment, the part I refer to as the “antidote.” The client needs to be exposed to new and surprising information that generates "prediction error." That is what triggers volatility in the synapses that encode memory and allows the new information to overwrite the old, maladaptive pattern. via memory reconsolidation. (In an alternative mechanism, extinction, the cortex learns temporarily to suppress the maladaptive response.) Here is the tricky part: As in mindfulness, illumination can be communicated by tone of voice and other non-verbal channels as well as words and ideas. The information can exist already in the client, but be re-awakened by the therapist. It may also require the client to take in information in the form of experience. Performing an action or adopting a new posture may be the only way to illuminate with experiential information. Illuminating means helping the client be exposed to new and surprising information in any form, leading to replacement (or inhibition) of an existing but maladaptive pattern. - Regulate: We know that when clients are overwhelmed or dysregulated, no therapeutic work can be done until the state of alarm is reduced. The relationship is a good starting point, but more recent work has shown how breathing, posture and other autonomic inputs can help at times of dysregulation.
- Repair: Finally, we all make mistakes and get things wrong on a regular basis. Repair starts with making sure we create open channels for feedback. Next comes self examination. Are we missing some blockage in ourselves that needs to be addressed? Then repair involves working through a break in the therapeutic alliance. Defensiveness and failure to consider our own responsibility will obviously prevent success, but beyond that, repair is a joint operation between people who want to make the relationship work.
Thank you for your thoughtful attention. If you would like to learn more, be sure to visit howtherapyworks.com https://www.howtherapyworks.com/. I recommend starting with a deeper look at the Healing Moment, the final common pathway to enduring change.
Jeffery Smith MD
