1000 sessions in…

I’ve been working in private practice for the last two years as I complete the research component of my PhD in Clinical Psychology (a dual program that includes the components of both a master of clinical psychology and a research PhD – my research is focused on health psychology). During that time I’ve typically worked 2 – 3 days a week, typically working with 5 – 8 clients a day.

A few months ago I realised that I had delivered my 1000th session as a registered psychologist! I couldn’t believe it. That I, Daniel Brown, after all this time and training, had conducted over 1000 sessions as a psychologist.

Given this, I thought I would write some reflections on the things that have become much clearer to me. Most of them I would have probably said I always intellectually knew but now have a deeper appreciation for.

1. Supervision

I cannot stress how vital good supervision is for professional development as a psychologist. I believe a significant portion of my learning and growth as a therapist has been because of my clinical supervision. A good supervisor, like a good psychologist, nurtures, challenges, confirms, corrects, and supports.

On the clinical psychology registrar program, I engage in fortnightly supervision, which means that at times I don’t feel I need to discuss a specific client or problem I’ve encountered. Given I’ve paid good money to be there, it forced me to think about topics or themes that we could discuss. At times, this has turned into exploring my beliefs about my clients and therapy. For example, I realised I had an underlying belief that most people would not want to prioritise spending money on seeing a psychologist after their medicare/WorkCover/insurance ran out for the year. We explored what this may mean: Do I go too fast with some clients? Do I focus on short-term problems? What is my relationship with money and how has my background affected this? Do I also believe that clients do not prioritise therapy, in general? etc…. Never in my training did we have an opportunity to think about such (obscure?) beliefs, that may have an impact on the way I conduct therapy.

This is but one silly example of hundreds of moments I’ve experienced with my supervisor. I love that I so often get to say to her, “oh my god, there is so much still to learn”, or “yes, of course, I had never thought about it like that”. This is the wonder of supervision and psychology!

2. Process vs Content

A significant focus on all training is content knowledge: theoretical orientations, diagnosis, measurement, treatment, conceptualisation and the like. All of this knowledge must be learnt and reading books or listening to lectures is often appropriate. I believe the only way to learn about the therapeutic process is by doing therapy. Naturally, now I have more experience, I have a deeper appreciation for how vital process is in therapy.

For those unfamiliar with the term process, I am referring to the nature of the relationship between the client and therapist. This includes how things are said, what is left unsaid, the defences, distortions, and beliefs the client and the psychologist both bring to therapy and how they interact together.

There is a shit tonne of things to say about process and I would recommend reading up on specific types of process-oriented therapies to understand it (a great book to start is “Interpersonal process in therapy: An integrative model” by Teyber & Teyber).

3. Honesty

I find this an interesting one and is still something I continue to reflect on. What does it really mean to be honest as a therapist?

One part of what I mean is being open about what I’m doing and why. Not that I ever try to deceive clients, but I have recognised that at times I will be engaging in a specific but naturalistic technique (i.e., something that is embedded within a conversation, as opposed to a discrete/explicit technique that you do together, like making a SMART goal or identifying cognitive distortions from a worksheet) but won’t explicitly tell clients why I am doing that. For example, often I want to engage in “within-session emotional exposure” (i.e., I want the client to experience a specific emotion, such as sadness, in the therapy room, to reduce avoidance and build self-efficacy regarding their ability to tolerate uncomfortable emotions). The client may be describing an event where they happen to experience sadness. I will then encourage them to slow down and re-live that experience, asking them questions to evoke the beliefs, thoughts, and emotions that occurred at the time. This is, naturally, uncomfortable for the client and it can be easy to forget that they do not necessarily understand why I would be getting them to relive a painful experience (surely I’m here to make them feel good, right??). When we then reflect on the session or that particular part of the session, I try to ensure I am explicit with regards to why I “honed in on” that experience and how it fits within their treatment. I understand this seems so obvious, but I can’t help reiterate that I, at least, can so easily forget that most clients really have no idea how therapy works and it is an integral part of my job to let them know!

The other part of honesty is my frank evaluation of what my clients are doing. I still grapple with whether my evaluation is just an opinion or something that has more value. When I’ve raised this in supervision I’m reminded that 1. it is a good thing I continue to question what I am saying and how I am saying things to my clients and 2. my evaluation is an opinion, but all opinions are not created equally. My “opinion” is something that has been honed over the last decade of experience and training. I can misinterpret the ease of my “opinion” being generated to believing my “opinion” is whimsical or thoughtless, but of course, this is not true.

4. Ambiguity

I definitely, at times, have the feeling that I have no idea what the fuck I’m doing; I am much more comfortable with this now though. The nature of much of what we explore, as a treating psychologist, is grey and ambiguous with a bucket load of “perhaps”, “maybe”, and “it depends”. I vividly remember fearing not knowing the right thing to say to a client, or worse, not know what to say at all, while undergoing my clinical training. Similarly, I remember believing that I was meant to be comfortable with silence and how beneficial silence can be, but, deep-down, interpreting silence as my failure to once again come up with that life-changing, awe-inspiring phrase where everything just clicks together for the client. I’m still waiting to find that phrase, but in the meantime, I have learnt to take my own advice; accept and embrace the mild discomfort that ambiguity provokes and recognise that it has very little to do with my competence!

5. This is such a weird job

This is something I’ve reflected on with a number of my clients; what a weird fucking job this is?!?! I’m paid to sit there while strangers come in and tell me really personal stuff about themself. Things that, perhaps, they’ve never told anyone. And then I have to explore that stuff and work with them to make that stuff not happen again.

It is both utterly bizarre yet wonderful too. What a privilege I have, to bear witness to the courage and bravery that my clients go through each time they take the seat in my office. Despite this being such a weird job, I’m so glad I do it!

I would love, love, love to hear your comments, experiences, and reflections too.

In kindness,

Daniel J. Brown

7 thoughts on “1000 sessions in…

    1. Broadly, a “cognitive distortion” is a way of thinking that is inaccurate or unhelpful. For example, a common distortion is “mind reading”, whereby an individual believes they already know what another thinks (often negatively) and therefore doesn’t say or do something (often to their detriment). Another is “personalisation” whereby a person inappropriately attributes fault or responsibility to themselves for something (that has often gone wrong). Does this make sense? Cheers, Daniel

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    1. It is typically a collaborative and iterative process. For example, the client may describe a scenario and belief that evokes a sense of helplessness or guilt. The psychologist may reflect on that observation and ask if there are other, equally likely, interpretations of the scenario. These other interpretations may instead lead to feeling motivated or simply neutral. We can then explore whether that initial interpretation was perhaps an unhelpful distortion of the scenario.

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      1. Is it a premise of the process that the client is necessarily operating under a ‘distortion’, could it be something else? What is the psychologist ‘reflecting’ on exactly?

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  1. So ‘cognitive distortion’ doesn’t actually refer to anything per se (even if we have examples they are more categories than anything productive), because it’s an exploratory process that ‘they understand’. They as in you understand, or the client understands what you understand, what you are trying to get them to see about this ever elusive exists/doesn’t exist ‘distortion’.

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