Feeling unprepared for therapy

[therow]

We've recently begun seeing clients in our in-house therapy clinic and I feel like I have no idea how to approach therapy. While I enjoy my supervision sessions and find them helpful I feel a huge fault of my program is a lack of skils/intervention training. I am learning a lot of theory but still have no idea how to "implement" therapy. I am mostly just offering reflective comments, asking questions to learn more details and determine their emotions/thoughts on a situation. I'm curious to know if this is a common sentiment or just a huge fault of my program and if so, how do I improve on therapy? I have spoken to previous students who have received their masters from other programs and they all agree that they felt the same when they were first starting off therapy.

---

Members don't see this ad.

 

[AbnormalPsych]

How far along in your program are you?

 

[psych.meout]

What is your expectation of what therapy should look like from your end at this point in your training?

 

[Ollie123]

You will never-ever-ever feel "fully prepared" to start doing therapy. I think what you are describing is normative. Things I'd suggest:
- Find and watch videos through whatever resources are available (e.g., Beck Institute, etc.). But also recognize that most psychotherapy training videos are of highly-idealized sessions that are not remotely representative of what therapy typically looks like
- While we can debate the merits of excessively structured therapy protocols, I do think a rigid structure is very helpful for early clinicians. Get a copy of the Unified Protocol, CPT manual or whatever else makes sense for your situation and work off that.

Most importantly, recognize that therapy is generally slower-moving than we'd all like it to be, even using evidence-based practices. The 30 minutes-in "Eureka! You fixed all my problems" moments aren't reflective of reality - if it happens at all, its only after months of what feels like aimless meandering discussion and constant redirecting the patient back towards what they are supposed to be doing that day. There are exceptions - things like gradual exposure, ERP, etc. inherently feel a bit more "active" but your bread & butter depression/GAD cases are inevitably going to involve some wandering discussion even in a structured cognitive-behavioral protocol.

I wouldn't stress. Like most things it comes with practice. Also expectations will lower over time🙂

 

[PsyDr]

 

[MCParent]

We've recently begun seeing clients in our in-house therapy clinic and I feel like I have no idea how to approach therapy. While I enjoy my supervision sessions and find them helpful I feel a huge fault of my program is a lack of skils/intervention training. I am learning a lot of theory but still have no idea how to "implement" therapy. I am mostly just offering reflective comments, asking questions to learn more details and determine their emotions/thoughts on a situation. I'm curious to know if this is a common sentiment or just a huge fault of my program and if so, how do I improve on therapy? I have spoken to previous students who have received their masters from other programs and they all agree that they felt the same when they were first starting off therapy.

Good.

People who think they are great at something complex that they’ve never done before are often resistant to training on top of being unaware of being fairly bad at it.

Thinking you’ll be good at it off the bat is like thinking you can pick up a guitar and start playing stairway to heaven in three minutes.

Read the foundations of theoretical approaches. Get more books if your training is insufficient. Conceptualize your clients by the approaches. See what info you miss to be able to do that so you know what to think about / ask about more in sessions.

I watched my own videos all the time and coded things I said (closed question, open question, paraphrase, etc.). Watching your tape is the only way to know what you’re doing; your recall is insufficient because you have too many units of cognitive energy devoted to performing the task to also monitor it.

One specific tip—I feel like trainees think what they say has to be something like “so, it sounds like maybe you kind of feel a bit like you might be depressed, did I get that right?” Short things are fine; something like “mmhmm, really sad” usually works fine to keep them going on something important.

 

[oliversacks4thewin]

Agree with all of the above statements a thousand percent. If you are really stressing though, I can always suggest reviewing motivational interviewing skills. 1) It's a relatively expedient therapeutic approach to learn and can therefore increase some of your confidence in feeling like you developed a "skill", 2) it has a wide net of utility, 3) you can find handouts with a quick google search and 4) it serves as a great foundational footing for most therapeutic modalities.

 

[borne_before]

I still feel this way... I've recently done my third licensure two year renewal.

 

[Sanman]

Check out the Treatments that Work series of workbooks or similar if you are struggling with session structure. That said, I find younger therapists often feel the need to do more in therapy and often struggle to put the responsibility of making change on the client. You can show them processes, you can't be their motivation as well.

 

[therow]

How far along in your program are you?

im in my second year of my program, in my first year we really just focused on theories.

 

[quickpsych]

im in my second year of my program, in my first year we really just focused on theories.

Your feeling and experience is pretty typical in most programs and most of our experiences during our training and education. There's obviously some variation between programs but typically you'll derive more and more of the skills and nuances through practicums under guidance of your supervisors and your practicum courses that go alongside them (some programs have Y1 practicums and some start in Y2).

Good supervisors when reviewing recorded sessions (which some programs do), role-played in class "sessions," and just through supervision groups and 1:1 will highlight and constructively challenge spots, statements, or moments where there's room for improvement and skill building. And some take a "baptism by fire" approach especially when first in a clinical setting, which has it's supporters and detractors.

Don't feel you're doing anything wrong at this point in the program, I had the advantage of having a Masters degree first (and many masters programs focus a lot more on drilling down interventions, techniques, and how to engage with patients because there's less time and opportunity to learn from real patient experiences in supervised settings). When I was admitted into my doctoral program with advanced standing (skipped Y1) it was clear many of my cohort classmates were super green and even with the program having them do some basic Y1 light face to face work with patients, they benefited from additional guidance, modeling, and feedback.

It's good you feel the way you're describing because it means you're open to hearing constructive , and sometimes critical, feedback, as well as fostering opportunities to ask how to connect the interventions (and how you interact with patients) to the theories and techniques.

 

[Therapist4Chnge]

It takes time, but you’ll get more comfortable being uncomfortable. Many early trainees feel the need to fill the silence, but As suggested earlier, manualized treatments can be helpful bc they provide a bit more structure. Video/Direct Obs & Audio recording are key. It can be cringe in the beginning, but those tools are incredibly helpful to better understand how you interact, especially non-verbals.

 

[AcronymAllergy]

You will never-ever-ever feel "fully prepared" to start doing therapy. I think what you are describing is normative. Things I'd suggest:
- Find and watch videos through whatever resources are available (e.g., Beck Institute, etc.). But also recognize that most psychotherapy training videos are of highly-idealized sessions that are not remotely representative of what therapy typically looks like
- While we can debate the merits of excessively structured therapy protocols, I do think a rigid structure is very helpful for early clinicians. Get a copy of the Unified Protocol, CPT manual or whatever else makes sense for your situation and work off that.

Most importantly, recognize that therapy is generally slower-moving than we'd all like it to be, even using evidence-based practices. The 30 minutes-in "Eureka! You fixed all my problems" moments aren't reflective of reality - if it happens at all, its only after months of what feels like aimless meandering discussion and constant redirecting the patient back towards what they are supposed to be doing that day. There are exceptions - things like gradual exposure, ERP, etc. inherently feel a bit more "active" but your bread & butter depression/GAD cases are inevitably going to involve some wandering discussion even in a structured cognitive-behavioral protocol.

I wouldn't stress. Like most things it comes with practice. Also expectations will lower over time🙂

Agreed with this and all the other great recommendations in this thread.

The vast majority of trainees feel the same as you the first time they see a patient: borderline-terrified. The idea of moving from studying theories and concepts to actually applying them to real people is scary. The same goes for testing--you can mock administer a test to a fellow student or friend until you can recite the instructions in your sleep, but I can guarantee you'll be anxious and feel unprepared the first time you test an actual patient (I definitely did). This is why, as a former advisor used to say, your supervisor is there to push you in and then make sure you don't drown. The only way you'll learn how to perform psychotherapy with patients is to see actual patients. Trust that your program (through your efforts) has prepared you sufficiently to get started, and then take every opportunity you can to monitor, adjust, and improve your technique and understanding of the process of therapy.

The recommendations to review recordings of your sessions can be particularly helpful. And yes, watching/listening to yourself is super awkward at first, but you'll acclimate quickly.

And yes, as MCParent said, one of the great skills in therapy is learning how to be direct. It's right up there with learning to be comfortable sitting in silence.

 

[Ollie123]

One other important thing I forgot is not to worry TOO much about "saying the wrong thing". I don't want to speak to others here, but as a beginning clinician I tended to treat patients as overly fragile. The result was very stilted therapy sessions where I was often too scared of saying the wrong thing and would be far too indirect. This might be a "me" thing, but my impression is that it is quite common.

If you possess basic social skills, you are very unlikely to shatter a therapy patient just by saying the wrong thing. You may mildly upset them. Sometimes this is even a good thing. Sometimes you'll even get fired by a client who decides you aren't a good fit. That happens to all of us and it's OK, even if it feels like a failure in the moment. I think most people are far better served by being more genuine and having patients move on quickly if its not a good fit, then a therapist who vastly overdoes the whole "blank slate" thing and doesn't get anywhere.

 

[MCParent]

And yes, as MCParent said, one of the great skills in therapy is learning how to be direct. It's right up there with learning to be comfortable sitting in silence.

When I taught intervention classes my students developed conditioned aversion to starting a sentence with “soooo…” bc I’d make them resay it without that every time they did it. Eventually if they said it they’d just cringe and resay the line themselves 😂

 

[Fan_of_Meehl]

Agree with all of the above statements a thousand percent. If you are really stressing though, I can always suggest reviewing motivational interviewing skills. 1) It's a relatively expedient therapeutic approach to learn and can therefore increase some of your confidence in feeling like you developed a "skill", 2) it has a wide net of utility, 3) you can find handouts with a quick google search and 4) it serves as a great foundational footing for most therapeutic modalities.

This is good advice. One can always default to Socratic questioning or the O.A.R.S. acronym/playbook:

Open-ended questions

Affirmations (where appropriate)

Reflections

Summaries

The most crucial thing, in my opinion, is to be an open, nonjudgmental, accepting fellow entity who is listening very carefully to what is being said and trying to empathize with the person whilst sincerely trying to help but not giving directive advice.

Too much focus on technique (or manuals, or pre-scripted session recipes/agendas) can get in the way of this core process.

Think of a good and effective psychotherapy session as being a fine balance between CHAOS and ORDER rather than simply a process that is supposed to be orderly (by design or checklist) and just play out according to what you, as therapist, would want to happen as some sort of ideal scenario.

The 'CHAOS' comes from the messy, multidimensional, fascinating reality that the client is bringing into the session and this is never going to align perfectly with the 'ORDER' that you think you want to impose by following the manual or some idealized version of how you wanted the session to play out that you imagined prior to the actual session occurring. I think it is important to collaborate with the client in order to keep the session 'on the rails,' so to speak, in terms of implementing evidence-based principles of behavior change (e.g., trying to implement self-monitoring, teaching people to properly identify/label emotions and their physiological, cognitive, motivational, and behavioral correlates, teaching the client to construct and apply his/her own cognitive-behavioral case formulation, behavioral activation, arousal reduction (relaxation), etc.---the list is endless. However if you 'grip the steering wheel too tightly' (to use a car driving metaphor), you're going to spoil the process. Similarly, if you try to exert too much 'control' over exactly how the session goes (without the crucial collaboration aspect with the client), then that's not really going to work out very well (this is where supervision is helpful). If you just 'give up' (take your hands off the steering wheel entirely out of frustration) which is what most VA 'psychotherapists' do if they are not 'implementing a protocol session,' then I'm not sure you could even say that you're 'doing therapy' of any sort. It's a balancing act between structure and flexibility, chaos and order, change vs. acceptance.

 

[smalltownpsych]

We've recently begun seeing clients in our in-house therapy clinic and I feel like I have no idea how to approach therapy. While I enjoy my supervision sessions and find them helpful I feel a huge fault of my program is a lack of skils/intervention training. I am learning a lot of theory but still have no idea how to "implement" therapy. I am mostly just offering reflective comments, asking questions to learn more details and determine their emotions/thoughts on a situation. I'm curious to know if this is a common sentiment or just a huge fault of my program and if so, how do I improve on therapy? I have spoken to previous students who have received their masters from other programs and they all agree that they felt the same when they were first starting off therapy.

Everyone else said pretty much what I would say. Develop rapport, begin exploring the dynamics of the patients problems, work on empathic listening skills and how to phrase questions in a good nonjudgmental explorative way as opposed to an interrogative way. Being open with supervisors about how you are asking things and open to their feedback about alternative ways of saying the same thing will be helpful. We all have individual styles, but learning how to ask questions and get patients to open up is key. In my second year of therapy training, my supervisor and I had a little bit of a contest to see who could get the most info from mutual patients. That was at an inpatient setting with reluctant adolescents so it really honed those skills. Don’t worry, it only takes about five years of experience to develop a base level of competence.

 

[cara susanna]

I didn't really start to feel comfortable with therapy until I became trained in specialized interventions like CPT and PE.

 

[ResidentForensicGirlie]

I DEFINITELY felt like this during my master's program and now in doctoral training. I'm at the internship phase, working full-time as a mental health therapist, and I still feel like I'm doing therapy for the first time with every client.

I don't know if you ever really feel prepared because you never really know who you're going to get, you know? There's no workbook or script to follow. You might walk in ready to conduct some psychoeducation on the cognitive triangle to lay foundation for emotional processing, and then boom, it turns into a 10-13/EP situation.

I agree with all of the great advice provided by others here! Especially never underestimate the power of silence and directness in sessions with clients. But at the end of the day, you will need to develop your own "flow", which won't work for anyone else but you and your clients. You'll find it naturally.

Where you're at is developmentally appropriate both clinically and professionally. Your confidence in your competence, which you absolutely have, will develop over time because you're still in training.