In any other domain of performance (e.g., sports, music) it would be unheard of for the performer not to analyze her performance. Yet, in the field of psychotherapy, we do less of examining the moment-by- moment dynamics of the therapy hour and more theorizing (see Three Types of Knowledge Clinical Supervisors Need to Know).
Much like other professional fields, it’s important to record sessions to receive feedback about actual performance rather than feedback about a perceived or reported performance. Feedback is useful when it’s based on well-defined objectives that are observable and specific.
After a workshop where I related this idea of making it a routine practice to record sessions as part of deliberate practice and service improvement for our clients, an experienced therapist said to me, “Yes, it is a brilliant idea. I used to do that as a post-grad student. It’s helpful for students…Not so much for me now.” Another therapist said to me, “I cannot stand hearing my own voice in the recordings.”
Now imagine this: You are a coach of a tennis player. He comes to you and says that he doesn’t want to analyze his videos of the games because he gets uncomfortable looking at himself on-screen. Would you accept that?
Who has a problem with recording the sessions? Mostly, it isn’t our clients. It’s us. A recent study by a team of researchers found that a majority of clients have no objections to audio/video recording of the sessions, and close to three-quarters of them are willing to consider it. Less than a third of them express discomfort about it¹.
It is critical that you do not no use recordings in isolation. Make sure your supervisees couple the recordings with client outcome and engagement measures (see Marrying Data With Intuition).
When ROM (routine outcome monitoring) is employed without the use of recordings, you will lack the specificity of what to work on in your learning endeavor. When recordings are used without the context of ROM, you risk walking blind. You wouldn’t know if what you’ve identified as issues are indeed concerns from your client’s perspective (i.e., working alliance measures), and you wouldn’t know if what you chose to work on has any impact on benefiting clients.
Real Feedback
Some years ago, Bill Gates gave an important TED talk called “Teachers Need Real Feedback.” Many teachers got only one word of feedback once a year and that was "satisfactory." With no feedback or coaching, there was just no way to improve. Gates suggested that every great teacher can get better with smart feedback, and he laid out a program for his foundation to bring it to every classroom, based on a project called “Measures of Effective Teaching (MET).” The tool that was used was simply a video recording device.
Listen to what Sarah Brown Wessling, a high school English teacher at Johnston High School in Iowa, has to say about the use of video recording in her teaching:
Curing “Explainaholism’
As therapists, when we talk about a session instead of listening to how it actually went, we try to recreate the experience in our heads. In the absence of the subject at hand, especially when we're talking about that in clinical supervision, it’s possible that we fill in some parts of reality with our imagination. We create interpretations. We become “explainaholics.”
Once you have the client’s formal consent to record for the sake of improving the service delivery, I would suggest recording all of your therapy sessions as a default. Instead of trying to predetermine who you should record your sessions with, make it part of your practice to record the majority of your clinical work. Make recording your sessions a default practice rather than an exception. This in turn reduces the cognitive load on your mind, given that it’s on most of the time, thus fading into the background. The value of recording your sessions is priceless.
By doing this front work in the sessions, you've taken the cognitive load off your mind for future sessions. I would suggest you provide a clear rationale to your clients of why you are doing this. So, for example, provide a social norm of your practice (e.g., “I do this with 90% of my sessions”), and provide a sound rationale for the purpose of recording (e.g., “I record my sessions so that I get to ensure the highest service delivery and experience in therapy...I would review them, when needed, and if we are off-track, I might get the help of a supervisor to offer a different perspective”). Clients are more likely to agree when you provide sound reasons.
The rate of compliance to be audio/video recorded is dependent more on the therapist than the client. Clearly, when your client is not comfortable with this idea, do not proceed with the recording. Let them know that their preferences are the priority. Must the recordings be videotaped or would audio suffice? I much prefer video as this allows me to look at the nonverbals. But interestingly, a recent study demonstrates that we are no more accurate reading emotions with audio with video, as compared to just audio alone. When we listen to the voice only, though handicapped by the lack of visual input, we seem to be able to pick up the emotional cues from the vocal quality alone². Note: If you're using audio-visual recording, the audio quality is more important than the visual.
Final Notes to Supervisors:
What to Watch
I recommend supervisors watch a handful of your supervisees at work, to get a sense of their presence, style and voicing within the context of facilitating therapy.
Pair Video and Client Feedback
Make sure that you pair video feedback with client feedback i.e., session by session outcomes and engagement levels (see Marrying Data With Intuition).
Figure Out the Growth Edge
After getting a (real) sense of how a therapist conducts therapy through the sessions recordings paired with client feedback, help your supervisees figure out their growth edge (see: Circle of Development). Thereafter, watch only thin slices of their recordings that are in relation to their identified growth edge. For instance, if you are working on helping a therapist deliberately practicing improving the way they solicit feedback, zoom in and watch only the last 10-15mins segment.
Focus less on content knowledge, and more on process and conditional knowledge (see Three Types of Clinical Knowledge). When we figure out the what to work on, therapists are more likely to be ignited with their own why.
Finally, go one step further. Once your supervisee’s growth edge is identified, help the therapist design a deliberate practice plan around this area (Watch this keynote to get ideas). Put both of your efforts on this sweet spot. This zone of proximal development is likely to evolve through time. (More about this in a future post on helping supervisees identify learning objectives that are predictive of improving client outcomes).
References
[1] Briggie, A. M., Hilsenroth, M. J., Conway, F., Muran, J. C., & M., J. J. (2016). Patient comfort with audio or video recording of their psychotherapy sessions: Relation to symptomatology, treatment refusal, duration, and outcome. Professional Psychology: Research and Practice, 47(1), 66-76. doi: http://dx.doi.org/10.1037/a0040063
[2] Kraus, M. W. (2017). Voice-only communication enhances empathic accuracy. American Psychologist, 72(7), 644-654. doi: http://dx.doi.org/10.1037/amp0000147
File under: The Art of Psychotherapy, Therapy Training
Much like other professional fields, it’s important to record sessions to receive feedback about actual performance rather than feedback about a perceived or reported performance. Feedback is useful when it’s based on well-defined objectives that are observable and specific.
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After a workshop where I related this idea of making it a routine practice to record sessions as part of deliberate practice and service improvement for our clients, an experienced therapist said to me, “Yes, it is a brilliant idea. I used to do that as a post-grad student. It’s helpful for students…Not so much for me now.” Another therapist said to me, “I cannot stand hearing my own voice in the recordings.”
Now imagine this: You are a coach of a tennis player. He comes to you and says that he doesn’t want to analyze his videos of the games because he gets uncomfortable looking at himself on-screen. Would you accept that?
Who has a problem with recording the sessions? Mostly, it isn’t our clients. It’s us. A recent study by a team of researchers found that a majority of clients have no objections to audio/video recording of the sessions, and close to three-quarters of them are willing to consider it. Less than a third of them express discomfort about it¹.
It is critical that you do not no use recordings in isolation. Make sure your supervisees couple the recordings with client outcome and engagement measures (see Marrying Data With Intuition).
Marrying Macro and Micro with ROM Session Recordings
When ROM (routine outcome monitoring) is employed without the use of recordings, you will lack the specificity of what to work on in your learning endeavor. When recordings are used without the context of ROM, you risk walking blind. You wouldn’t know if what you’ve identified as issues are indeed concerns from your client’s perspective (i.e., working alliance measures), and you wouldn’t know if what you chose to work on has any impact on benefiting clients.
Real Feedback
Some years ago, Bill Gates gave an important TED talk called “Teachers Need Real Feedback.” Many teachers got only one word of feedback once a year and that was "satisfactory." With no feedback or coaching, there was just no way to improve. Gates suggested that every great teacher can get better with smart feedback, and he laid out a program for his foundation to bring it to every classroom, based on a project called “Measures of Effective Teaching (MET).” The tool that was used was simply a video recording device.
Listen to what Sarah Brown Wessling, a high school English teacher at Johnston High School in Iowa, has to say about the use of video recording in her teaching:
"There is a difference for teachers between the abstract of how we see our practice and then the concrete reality of it...I think what video offers for us is a certain degree of reality. You can't really dispute what you see on the video. And there is a lot to be learned from that and there are a lot of ways that we can grow as a profession when we actually get to see this. I just have a flip camera and a little tripod and invested in a tiny little wide-angle lens. At the beginning of class I just put it in the back of the classroom. It's not a perfect shot. It doesn't catch every little thing that's going on, but I can hear the sound and I can see a lot and I'm able to learn a lot from it...it really has been a simple but powerful tool in my own reflection. Having the notes is part of my thinking process and I discover I'm seeing as I'm writing. I really have used it for my own personal growth and my own personal reflection on teaching strategy and methodology and classroom management, and just all of those different facets of the classroom.”
Curing “Explainaholism’
As therapists, when we talk about a session instead of listening to how it actually went, we try to recreate the experience in our heads. In the absence of the subject at hand, especially when we're talking about that in clinical supervision, it’s possible that we fill in some parts of reality with our imagination. We create interpretations. We become “explainaholics.”
Once you have the client’s formal consent to record for the sake of improving the service delivery, I would suggest recording all of your therapy sessions as a default. Instead of trying to predetermine who you should record your sessions with, make it part of your practice to record the majority of your clinical work. Make recording your sessions a default practice rather than an exception. This in turn reduces the cognitive load on your mind, given that it’s on most of the time, thus fading into the background. The value of recording your sessions is priceless.
By doing this front work in the sessions, you've taken the cognitive load off your mind for future sessions. I would suggest you provide a clear rationale to your clients of why you are doing this. So, for example, provide a social norm of your practice (e.g., “I do this with 90% of my sessions”), and provide a sound rationale for the purpose of recording (e.g., “I record my sessions so that I get to ensure the highest service delivery and experience in therapy...I would review them, when needed, and if we are off-track, I might get the help of a supervisor to offer a different perspective”). Clients are more likely to agree when you provide sound reasons.
The rate of compliance to be audio/video recorded is dependent more on the therapist than the client. Clearly, when your client is not comfortable with this idea, do not proceed with the recording. Let them know that their preferences are the priority. Must the recordings be videotaped or would audio suffice? I much prefer video as this allows me to look at the nonverbals. But interestingly, a recent study demonstrates that we are no more accurate reading emotions with audio with video, as compared to just audio alone. When we listen to the voice only, though handicapped by the lack of visual input, we seem to be able to pick up the emotional cues from the vocal quality alone². Note: If you're using audio-visual recording, the audio quality is more important than the visual.
Final Notes to Supervisors:
What to Watch
I recommend supervisors watch a handful of your supervisees at work, to get a sense of their presence, style and voicing within the context of facilitating therapy.
Pair Video and Client Feedback
Make sure that you pair video feedback with client feedback i.e., session by session outcomes and engagement levels (see Marrying Data With Intuition).
Figure Out the Growth Edge
After getting a (real) sense of how a therapist conducts therapy through the sessions recordings paired with client feedback, help your supervisees figure out their growth edge (see: Circle of Development). Thereafter, watch only thin slices of their recordings that are in relation to their identified growth edge. For instance, if you are working on helping a therapist deliberately practicing improving the way they solicit feedback, zoom in and watch only the last 10-15mins segment.
Focus less on content knowledge, and more on process and conditional knowledge (see Three Types of Clinical Knowledge). When we figure out the what to work on, therapists are more likely to be ignited with their own why.
Finally, go one step further. Once your supervisee’s growth edge is identified, help the therapist design a deliberate practice plan around this area (Watch this keynote to get ideas). Put both of your efforts on this sweet spot. This zone of proximal development is likely to evolve through time. (More about this in a future post on helping supervisees identify learning objectives that are predictive of improving client outcomes).
References
[1] Briggie, A. M., Hilsenroth, M. J., Conway, F., Muran, J. C., & M., J. J. (2016). Patient comfort with audio or video recording of their psychotherapy sessions: Relation to symptomatology, treatment refusal, duration, and outcome. Professional Psychology: Research and Practice, 47(1), 66-76. doi: http://dx.doi.org/10.1037/a0040063
[2] Kraus, M. W. (2017). Voice-only communication enhances empathic accuracy. American Psychologist, 72(7), 644-654. doi: http://dx.doi.org/10.1037/amp0000147
File under: The Art of Psychotherapy, Therapy Training