Harnessing Accountability in CBT: Expert Tips, Techniques, and Q&A

Harnessing Accountability in CBT: Expert Tips, Techniques, and Q&A

IN THIS VIDEO:

Jill Levitt: So, welcome everyone to our 2nd monthly Q&A with Feeling Good Institute, and today we'll be talking to you about harnessing accountability in CBT, and we'll be sharing some tips with you, and we'll be answering some questions that were sent to us ahead of time. And then we're also going to be welcoming your questions today, and I will tell you a little bit about Feeling Good Institute and introduce the presenters and then we'll move forward with the presentation. So, yeah, we'll be recording the presentation today so that we can share it with all of you. We'll add it to the workshop page in a day or two. And so if you don't want to be in any way recorded during our presentation today, then just black out your screen and then you won't be on screen. So let me just tell you briefly about Feeling Good Institute so you know kind of where we're coming from and what we're going to be sharing with you today. So our mission at Feeling Good Institute is to alleviate suffering by nurturing elite therapists.

So Feeling Good Institute was originally started back in 2013 by a group of therapists that were mentored by Dr. David Burns at Stanford University. And our goal is to train and certify therapists in the processes of therapy that are known to lead to the best therapeutic outcomes. So those are things like the use of measurement, empathy skills, helping our patients to be more motivated and reducing resistance, and then lots and lots of cognitive and behavioral therapy techniques. The Feeling Good Institute group are really highly skilled and vetted therapists and trainers, and we all engage in a weekly system of continuous improvement using deliberate practice, lots of teaching and training and practicing and role playing. We have video-based treatment that we offer across the United States and Canada, and then we also have in-person treatment centers in New York City and the Bay Area in Canada and in Israel. And we have outpatient counseling, and then we also offer intensive therapy, which is where patients come in from out of town to do more intensive work with us, still in that kind of one-on-one fashion, but we often times have people who engage in therapy for multiple hours a day, multiple days a week in order to kind of expedite treatment.

So let me introduce you to today's panelists. Let me pull up my notes. Sorry, I don't have all my intros memorized.

So first, let me introduce you to Mike Christensen. Mike is an MACP,RCC and he serves as the Director of Professional Development at the Feeling Good Institute. He's a registered clinical counsel with the British Columbia Association of Clinical Counselors, and he holds a Master of Arts in Counseling Psychology. His diverse background in business, community organizations, and family support roles has provided Mike with a wide array of experience in leadership, administration, parent training, and team building. And Mike is a certified Level 5 Master TEAM-CBT Therapist and Trainer. He's currently co-authoring a book with Dr. Maor Katz on deliberate practice of TEAM-CBT, and Mike really enjoys assisting others in their growth and development to become really phenomenal therapists at Feeling Good Institute.

And next, I'll introduce Zane to you. So with over 13 years of counseling experience, Zane Pierce, LMFT, specializes in therapy approaches that are humane, pragmatic, and empowering. He teaches his clients to hone their own problem-solving skills so that they can continue to reap the benefits of therapy long after therapy is over. He's a practicing TEAM CBT Therapist since 2017, and Zane studied under the mentorship of Dr. David Burns. And his experience includes providing community-based mental health, working in school settings with children and teenagers, and providing on-site therapy to Google employees. And Zane especially enjoys working with clients who struggle with relationship difficulties, depression, and coping with life transitions.

And finally, I'll introduce you to Brad. So Brad Dolin, AMFT, APCC, is an Associate Marriage and Family Therapist and Associate Professional Clinical Counselor at the Feeling Good Institute in Mountain View, California. Brad's previous career was in science and technology, where he did Fulbright research on evolution-inspired artificial intelligence, led software teams, and applied data science to improve health outcomes. As an Associate MFT at the Feeling Good Institute, Brad has lots of experience addressing common challenges that early career therapists encounter in harnessing patient accountability, especially as a therapist who's new to using measurement and assigning homework. So Brad is looking forward to sharing with you today his own awareness of what has helped him to overcome these common challenges. I'm going to turn it over to you, Mike.

Mike Christensen: Thanks, Jill. Well, I just wanted to stimulate our thinking a little bit and get a bit of a sense of where you're at, because we know where we've had struggles. But I'm just going to run a poll here, and it's a multiple choice. You can answer as many that come up for you. Have you had clients or patients who, any of the above or any of the below, show up late to sessions, don't do therapy homework, forget or neglect to do mood surveys, or are reluctant or hesitant to get to work during sessions? I'll just give you a minute to fill it in. I'm feeling very validated and affirmed that Zane and Brad and I and Jill are amongst colleagues and peers here that have also shared in some of these challenges. And just give another 10 seconds to fill it out. We have almost everybody done and share the results with you here. Well, it's also pretty clear that we all have patients or clients that, at times, will either show up late to sessions or even cancel sessions. The number one here is don't do therapy homework between sessions at 89%, forgetting or neglecting to fill out mood surveys, 61%, and reluctant or hesitant to get to work, 68%. So the vast majority of you have all experienced some of these challenges. And so we want to explore a little bit today what we can do about that and try to answer your questions and really maybe just give you a little bit of a taste of how we handle some of these situations. And so some of the challenges that we faced include the things that we've pulled here, patients that don't complete homework or forget or are reluctant to fill out surveys. Sometimes the challenges are in us, right? We don't want to come across as kind of demanding or scolding, and so we can be hesitant to keep them accountable for that. And other times, there may not be other options that are available to send clients or patients to. And so then what do we do in these situations, right? How do we keep them accountable if there isn't an option to send them to another therapist? Well, a few tips, things to keep in mind as we think about how to keep patients accountable. The first is we aim to start with setting the expectations early. I start doing that during the 15-minute consultation, giving them the real clear direction that I do require homework and I require filling out surveys. And so we want to be real clear upfront, and that really leads to number two is the more clear and specific you are with what you require and what you can deliver, the better chance you have of being able to keep them accountable. Thirdly, we want to provide a sense of hope when we're keeping them accountable. It's not so much a demand as an opportunity. And then the last tip is making sure that we're giving our patients or our clients the full agency to choose from the options that we're laying before them, that it really is their direction that they're setting, not necessarily ours, but we're being clear about what the options are so they can choose from them, not trying to persuade or push or, you know, motivate them in one direction. So there's a few skills that we use in TEAM CBT that help us to keep them accountable.

The first is what we call dangling the carrot. We instill hope by offering something tangible the patient will value if they engage in the work. Either it's a powerful resource, a method, a tool, or a desired outcome, some success in obtaining their goals, even the opportunity to work together, knowing they're not alone, that you're going to go through the process with them. It can be an opportunity to instill that hope for them. The second is what we call the gentle ultimatum. And this is where we're clarifying in a gentle and open way what's required to obtain that result. And this is that clarity that we're looking for. You want to be really, really clear on what the tasks will be. What are we going to ask them to do in order to reach their goals? Might be written homework. If there's anxiety for me, I almost always use exposure. Could be taking responsibility for relationship issues, maybe doing some additional reading, some reading homework, listening to podcasts and behavioral exercises. We need to be putting forth with our clients or patients what it is so they know what they're choosing from. And then delivering that in a gentle way, not a demanding way, but in a gentle way. The third component is bringing that with the spirit of open hands. It's not our job to convince them to change. If we're trying to persuade people to change, I don't know about you, but people that try to change me and say, oh, you need to do this or you need to do that. I tend to push back and say, I don't need to do anything that you're telling me to do. And so we want to be very open hands or if they give options and say, oh, you could do this or this. And here's the results. Here's what it's going to take. Are you interested in signing up? So we present the options and then allow them full agency. We do that in a respectful and genuine way, avoiding pressuring or leading or guiding. So that when they choose, we know it's their idea. It's their driving the bus is one of the ways I say it. And then lastly, knowing what our fallback position is, what will we offer our patient as an alternative if they choose not to do the work, if they choose not to adhere to our requirements? And so that might be a referral to somebody else who doesn't require the same things we do.

Maybe there's a therapist who doesn't use the testing before and after each session or doesn't require homework and we could refer to them. It might be supportive listening for a number of sessions and then getting to work or it could be working on a different problem that doesn't have the same requirements. And finally, one of the options is even taking a break from therapy until they're ready. I offered this to somebody the other day. They were really busy, had a lot of things going on in their life. And so I suggest I wouldn't want to pressure you or make you feel like you're being guilted into doing this work. And maybe it would make sense for us to take a little bit of a break. And then once this season of your life is through, then you'd have that time and energy to focus on the therapy, homework and doing that in a respectful, open way. And so we wanted to get to some of the questions that were posed to us earlier on. And maybe Jill, I'll draw you back in to lead and guide so we can bring Zane and Brad's brilliance to the floor.

Jill Levitt: Absolutely. So before I lead the questions, I'll just make a couple summary comments on what Mike said, which is, I think, the important piece. And for people who've done other trainings with us, this would be very familiar. But as Mike is stating that when someone seems reluctant or ambivalent or not quite doing what we think they need to do in order to get better, our goal is not to chase them or convince them that they have to. But our goal is to share with them, as Mike said, dangle a carrot and share with them what we have to offer and how great we think things would be if they did engage in the work. And then to be really clear about what it is that's required. That's that gentle ultimatum. In order to get better, you'd actually have to be doing daily homework or engaged in exposure therapy and then turning to them and saying, so what do you think? Right. Kind of we're saying, do you want to get better? Do you want to do this work and see this beautiful outcome? Or do you think this isn't quite the kind of therapy that you're looking for right now? And so we believe that people need to do certain things in order to get better. But we're leaving the choice up to them. Do they want to do this kind of work and see those results? Or do they feel like, no, now isn't the time. I really can't commit to this kind of therapy. And then we're kind of going to gently let them go. And as Mike said, how you let them go depends on the nature of kind of your work environment or what you have to offer. But essentially, we are making it clear that if patients do want to get better, they actually are going to have to do the work required. So kind of given that, and I think with the questions, Mike and others will also model some kind of answers and some things you might actually say, because I think it's very helpful to hear some of that modeled for you. But I'll start with some questions that were submitted to us ahead of time.

And then also, please send me your questions in the chat box, questions you have, difficulties you face in keeping your patients accountable. Again, whether that's that they show up late, or they try to see you once a month instead of weekly, or they don't do their homework, etc. So I'm going to pose the first question to Zane, although any of the presenters would be very welcome to jump in and piggyback. But the first question we got sent to us ahead of time was by Anne. And she said, the biggest barrier that I run up against of all the things is that I only do virtual. I work online, and a few of my patients can't figure out the electronic forms that I'm sending to them. And I don't know how to explain it to them, so they end up just getting frustrated, and so do I. And even further, some of them only have their phone, and that isn't the best medium for doing these forms. She mentions the DML, that's the Daily Mood Log, or the Brief Mood Survey. Do you have any tips or suggestions for how to get patients to engage in doing their forms online and doing their homework online?

Zane Pierce: Yeah, I think this is a great question. It's one that I've struggled with as well in working with clients. I do think that virtual therapy definitely comes with its own set of challenges, and using online forms is one of them. So I think from the outset, this is maybe a really good opportunity for you to get to know your client better, to find out at what point this person is getting stuck and where they're feeling confused. A therapist could use their screen sharing to kind of walk them through the steps of the Daily Mood Journal. It could also be that the therapist might be feeling stuck themselves and might have their own cognitions about using technology. This is an aside, but that might be another direction in which the therapist could kind of address this internally. But talking about workarounds, we might want to talk to our clients about, are there other options? Is there a possibility for them to meet you via their laptop or their desktop computer, so they could have multiple windows open, including being able to have face-to-face contact with you? Or could the client perhaps use some combination of a smartphone and a tablet or something? And of course, if that's not available, because it's not available to everybody, some people just work better off of pen and paper. I think there really is something to that. So one thing I've done would have clients to print up a copy of the Daily Mood Journal at home. If they own the book, feeling great, there's actually a link, a URL in there that the client can actually visit, so they get the Daily Mood Journal on their own device and they can print it up from there. Or if you really want to go kind of old school and add another layer of accountability, you could actually treat it like as if you're in office, but instead of handing the client the forms, you could send them to them via the postal service, and then they would be without excuse. They would have the documents in their hands. I've had one client who really preferred the Daily Mood Journal, the printed form. So he would just send me a photograph and upload that to the chart. And so I'd be able to follow along that way. So I found that to be a nice workaround. As for the Brief Mood Survey, if you're using simple practice, you could have the person do it beforehand and afterward. Although I know not everybody here uses that format. But with the Brief Mood Survey, yeah, they could do something similar, print it up at home. Filling it out, perhaps taking a picture, perhaps holding it to the screen so you can review those scores and go over that in the way that you usually would. If they're on their smartphone and they need to navigate away from the conferencing software, it might turn off the camera, but I don't think it would cause one to lose a connection. Now, another aspect of this is the length of the surveys. So we want to meet our clients where they're at with compassion. So it might be a matter of using maybe one of the more tailored or adjusted forms. Like perhaps there's a child version of the Brief Mood Survey that one could use. You could also, if you're working on a specific thing like anxiety, for example, you could have them just do the Brief Anxiety Survey. So those are some possible workarounds.

Jill Levitt: Great. Thank you, Zane. You brought up lots of important things. So I just want to highlight one thing you brought up, which I don't know if people really got it, but I think is an important point, is a lot of times these are therapist barriers and not just patient barriers. So if your therapist, sorry, if your patient is giving you the runaround on filling out forms or doing homework, you kind of have to ask yourself, am I committed to this, right? Have I talked this up in a way that I've made it really clear that it's super important? Or do I even feel comfortable with the technology? And you talked about sharing your screen. I think that's hugely valuable if a therapist shares their screen and they actually walk through how to complete a measure that will help the patient to do it as well. And you talked about many workarounds. And so the number one is making sure that you're motivated, making sure that your patient is bought in and motivated, willing to do it. And then number two is then addressing the nitty gritty about how to actually make it happen. Someone also entered an idea in the chat box as you were talking that was about like that there are some apps that sometimes have cognitive therapy forms built into them. I know that David Burns is working on the Feeling Good app and it's in its beta version. But you can definitely actually try that out for yourself as a therapist or for your patient. And I think it's on, I mean, it's on his website, which is feelinggood.com So great, that's great. We've got lots of other questions, so I'm going to move on to the next one. But thanks, Zane. So the next one I'm going to ask you, Mike. This one is, is there any way to make a patient who's receiving money from the country because of their mental disorder, so disability, that kind of thing, accountable? Like how do we make this kind of unique patient population accountable given that I assume embedded in this question is given that there's maybe some secondary gain or some benefit to being symptomatic?

Mike Christensen: Yeah, this is such a good question because this is a difficult and challenging situation to be in. And I know I'm sure David Burns has talked about this on podcasts, but he's got a pretty hard line for, I think, himself there. He wouldn't work with somebody who's getting other, you know, secondary gain benefits, the motivation. You've got competing motivational forces going on here. And so, you know, when I asked myself this question, is the motivation to get better more powerful than the motivation to maintain financial stability, right? And that can be a real, real difficult one. I had an example of somebody who came to see me. This is a number of years ago. And she had been in a vehicle accident. And then there was an insurance kind of claim where there was going to be a lot of money involved. And when she first came to me, she said, yeah, I want really help with my anxiety about, you know, driving that sort of thing. And I said, great, I'd love to work with you. I have a lot of great skills and tools that we can apply and help you overcome this anxiety. And then in the second session revealed that actually, you know, there's this kind of upcoming lawsuit and there's a lot of money on it. And so really wanted my assessment forms to prove that she had anxiety. And so the motivation to get better was actually not that high because the financial gain from continuing to get a, you know, assessment of anxiety was so high that the tools that I had available to her were not going to be powerful enough to help her overcome it. And so I had to make the difficult decision of actually releasing her from therapy and saying, you know, I'd love to work with you and it'd be a pleasure to show you how to overcome your anxiety. But I don't know that I have anything powerful enough to overcome the challenges that we're facing with the impending lawsuit that's on the horizon. But, you know, once it's done and that's all completed, then by all means, come back and see me and I'd be happy to work with you. And so that was sort of my fallback position, a little bit of the, you know, carrot dangling, but also the gentle ultimatum. There's always some motivational component, but you have to ask yourself the question, is it going to be powerful enough to overcome? And there are some situations I've had, you know, one person I worked with who was receiving disability, but they were incredibly motivated, right? And they said to me, you know what, I need to get out of this. I want to get off of this, you know, the support I'm getting and get back, get my life back so I can get back into my career. And they were very motivated. But I'll be honest, I was pretty aggressive and I'm going to use the word pushing hard to make sure now in a gentle way, but also really clear about what I could and couldn't deliver. So it becomes a judgment call, but I'm fairly hesitant to work with people who are getting no support if it's going to maintain their symptoms.

Jill Levitt: Absolutely. And, you know, another idea, even as we have a tool and not everyone would be familiar with it, but a decision-making form, which is kind of like a sophisticated cost-benefit analysis. And we might be asking them, you know, do the costs outweigh, what are the costs and benefits of essentially maintaining your disability and continuing to collect disability or the lawsuit, etc? And what are the costs and benefits of, you know, option B, which might be like overcoming your anxiety, you know, working hard in therapy with me and overcoming your anxiety and something like that would be a very respectful way of asking a patient to really look at what are the benefits of the status quo, right, versus the benefits of change. So, you know, we're not essentially saying it must be addressed, right? We can't ignore this because it's a really significant, you know, motivator for maintaining the symptoms, essentially, the financial piece of it. But it doesn't mean we couldn't work with someone if they really seem sufficiently motivated to overcome their symptoms.

So that's great. Let's move on to the next one. We've got, I think, six questions from the chat box and then I have a bunch more in front of me that you guys have been sending in. So please keep sending them in the chat box. So let's see. I'm going to ask you this one, Mike. Could we see a demo of how you would talk to a client who stopped filling out their measures? And I just want to tell people what we mean by that is we have all of our patients complete measures of their symptoms at the beginning and end of every session, you know, with every patient so that we can track progress over time. We feel like that's a super important part of doing effective therapy. And this is a question that speaks to the alliance and sort of how they feel about the therapy session. And so this person is saying, you know, what happens when you're working with someone, you've introduced measurement that patient knows it's super important. Maybe even they started out doing it, but then they stopped doing it. They kind of fall off the wagon. So, Mike, what might you say to someone in that situation?

Mike Christensen: Yeah, and this is a great one as well and I really appreciate when we’re discussing this, Zane very wisely said it will depend on the situation and you know, what is the reason for them not doing the, filling out the brief measure? So I'm going to give you two examples. I'll try and model both of them. The first is somebody who forgets to fill it out, like consistently forgets to do it. And I had a client that I work with who had an ADHD diagnosis and they had every intention to fill it out, but then they get distracted and they forget and then they come back to the next session and they hadn't filled it out yet. In that case, I got creative with a solution for them. And it's so critical that we get this. It really helps us to stay on track and to know, you know, what's working and what's not. And noticing we're having a struggle of getting that done, even if I send you a reminder. And so I'm wondering if we could try this out. And at the end of our session, you know, we use a 10 minutes where I do some notes. And before you log off, I would like you to fill it out. And I'll be online, you'll be online. You're filling out. I'll be doing my paperwork. We'll just be together. We won't actually be talking, but you'll be filling out the survey, the after session survey right then. And that works great. And then we found this pattern that worked for them. And so it was a little bit of creativity because I could have been very demanding and that pressure probably would have made it less likely that they'd fill it out. And so we figured a solution. The other situation is I had somebody who was reluctant to fill it out and hesitant. And this happened to me just yesterday afternoon, actually. And so what I said to this gentleman was, you know, and this is a first session and they were reluctant to fill it out. So, you know, the way I work. I. I'm really ineffective, actually, without these surveys before and after every session, it's like a really key tool for me. And it's kind of like my son is a is an auto mechanic. He fixes cars. And if you took your car to him and said, I'd like you to fix my car. It's not running very well, but you're not allowed to use your tools. He would say, I'm not effective. I can't. And so it's kind of how I am. I feel like I'm, you know, working blind and it wouldn't be fair to you to give you the impression that I can really deliver the kind of therapy that you're looking for, the results you're looking for without these. And so it's critical that we have them filled out. And if you're finding there's some barriers to getting in the way, then, you know, let's talk about it right now. But I'd like to actually to fill the before session right now before we get into our session and then, you know, afterwards, fill it out afterwards. And if there's difficulties, we can we can work through that together. But it wouldn't be fair to you for me to continue our work together without doing these. So that's how I would address them.

Jill Levitt: Ok, fantastic. Yeah, it's like we're not, you know, chasing our patients to do them, but we're really clear that if they want to work with us, they'd have to be willing to do this because we see it as so crucial to doing effective therapy. And so I just actually there's a question that came in from the audience. That's kind of I feel like would be a nice little place to put it in. And then we'll keep going with the other questions. Someone said, and I love the honesty here, but how do I hold myself accountable to all the tools and not just fall back on emotional support? And I love the honesty because, you know, like I said, I think that keeping your patients accountable also, actually, the number one thing is, are you willing to hold yourself accountable, right? And so kind of is attached to what Mike just said, which is, if you really believe in the power of these tools to help your patients to get better, and you really want your patients to get better, then you kind of need to be bought into the process, and then you hold yourself accountable, and you also hold your patients accountable. And I'll ask if you guys have any answer to this question, but the question is, how do I hold myself accountable to all the tools and not just fall back on emotional support? And my thinking is that you first need to do your own kind of decision-making, your own cost-benefit analysis, right? It's a question of your motivation. Are you kind of willing to do the extra work that's involved as a therapist, to assign homework, to use measures, to use methods, and to think to yourself, do the benefits of getting my patients better rapidly, not burning out, you know, really helping patients, those outweigh the costs, which is, it takes me a little bit more time. I have to kind of prepare ahead of time for my sessions. I have to, you know, go to workshops and seminars and learn tools. And if the benefits outweigh the costs, then I think holding yourself accountable to using the tools is not, the how-to is not as hard. It's the, do you really want to, that I think we have to ask ourselves. But do any of you panelists have anything to add just, you know, to that question?

Brad Dolin: Yeah, I could, I'd like to add a few words to that as well. I think one thing that I found really helpful is to kind of not force myself to have to think about it every session by baking in like a rhythm and a routine so that the, like last session's homework gets discussed at the make sure that we're decided about next week's homework at the end of the session. And that goes into the notes in a very specific place. So I think kind of just making it automatic in that way is really helpful. And also reminding myself of the distinction between niceness versus kindness. It can feel kind of nice in the moment to just say, oh, you know, I know you've got a lot on your plate. Like, let's just skip it for the next week or two. But that winds up being really unkind to the client because you're depriving them of therapy that's going to be effective.

Jill Levitt: I love that. So well said, Brad. So let's, should we move on to the question number four? Let's see. I'll ask this one to you, Zane. So, but how do I ask my patients to do homework without seeming demanding or seeming to scold them? You know, what can I say when they tell me they didn't have time or when they say my other therapist never asked me to do homework?

Zane Pierce: Great. So another wonderful question. It's kind of a three-part question. So I'll speak to each aspect. So the first one about how do I ask them to do homework, you know, without it seeming demanding or seeming to scold them. See, I don't really like the word homework. I usually call it self-help assignments. So my point is, I think practice and language is important, especially knowing your client's relationship to homework. But yeah, I think if you, if a person, if a therapist has a fear or real concern about coming off as demanding or seeming to scold them, I think that's why we have the evaluation of therapy session that we can fall back on and see if that's really what the person is telling us. Are we coming off as scolding? That would be a great and very illuminating conversation to have. And, you know, yeah, to see if your client is actually seeing you as acting demandingly or controllingly, or could that just be sort of in the therapist's mind? So if this is a real concern, you know, and you're trying to get away from, you know, language that sounds demanding or scolding, you know, one can actually write a script in which you're assigning a client, you know, a self-help assignment. And, you know, writing that using really client-centered language and keep revising it until you feel like you have something that you're really satisfied with. Let it pass the client for some feedback. And I know this is a new skill for some, so it might feel like you're developing a muscle. But you're really, at the end, kind of treating these self-help assignments as if they're, you know, a vital part of therapy. They're a given. They're really, they're built in. It's part and parcel of doing effective therapy. And again, this might be another example of, you know, therapists, cognitions interfering with their ability to build self-help assignments into the therapy. Like if I ask my clients to do, you know, this is homework, you know, they'll see me as being mean, you know, so one could do a daily mood journal on that or a cost-benefit analysis, one of the other tools that was mentioned. And then there's the aspect of the question, I didn't have time. Well, a lot of times, at least in my case, when I'm not interested in doing something, I don't really make time for it. If I don't see it as valuable, I don't make time for it. So this could be another really fruitful discussion with your client to help you understand where they're coming from and connect with them more. You know, could this be due to the client having a practical problem? Like maybe they tend to procrastinate, do things last minute, as opposed to really building in the self-help assignments throughout their week between sessions. Perhaps they've forgotten the rationale as to why it's important for them to do that. Maybe their ADHD was mentioned earlier. Maybe they're having some real problems with disorganization. That's a problem that you can either coach them to solve or help them to solve. Sometimes clients see the assignments as being too difficult, right? And so sometimes we as therapists, it's on us to give the client something at which they can succeed. And so those are all kind of, I think, things that I really keep in mind, you know, when addressing the practical sides. Of course, there's also these kind of psychological issues that come up from time to time. Like the client might be making negative predictions about the homework, maybe telling themselves, yeah, if I do this, it's not really going to work. They might be struggling with hopelessness. So those are all things to be addressed as well. Or perfectionism.

Sometimes that rears its head. So those are also, you know, barriers, obstacles to kind of keep in mind. So then I think, you know, as you're having these conversations, one is also really dangling the as well as to, you know, providing like information as to why these self-help assignments are indeed going to be valuable to the client, the therapy and make therapy more, you know, faster and more effective. Yeah. And then we've got the other question. My therapist never asked me to do homework. And I think we can kind of take this back to the beginning of the slideshow and just make this as part of your informed consent. You know, you're telling your client, you know, from the very beginning, like this, this therapy is going to involve you doing, you know, some kind of effort in between sessions. Is that something that you're willing to do? Is that something that you're feeling, you know, like you can do? Like Mike said, be really clear up front. And, you know, it also helps to provide a really, you know, solid rationale and take time explaining it and just really work that into, you know, the kind of the setup phase of therapy, if you will.

Mike Christensen: And I had one additional thought, and I just appreciate how you thematically keep coming back to what can we do as therapists and what is our responsibility? And one of the things I do early on is say, I am demanding. And I do that in a little bit of a carrot dangling way. And so, you know, when I was an athlete, I was a fairly high level athlete. I had a coach who was very demanding of me. She would push me really hard, actually. And the message that she was sending to me was, I believe in you. And I wouldn't want to deny you as my client of that because I believe in you too. And so, there's times when I can be a bit demanding. Now, I'll never ask you to do something you're not agreeing to. But at the same time, I want you to know right up front that the people that I've worked with, I just worked with some remarkable people who are stuck, but they're incredible and phenomenal what they're able to do. And I want to give you that opportunity as well. So, that's one way I work with that.

Jill Levitt: Yeah, I love that. And again, it is dangling a carrot, which Mike talked about, right? It's kind of incorporating the dangling the carrot with the gentle tomato, the kind of, I would love to work with you. And I think we could do this incredible work together, but that would require you to do A, B, and C. I just wanted to say someone from the audience also added, which I think is wonderful. One of our audience members has taken a stab at answering, or at least sharing her idea, which I think would be fun to share too. So, Kate in our audience said, I educate clients about effective therapy. And I discussed from the outset that simply talking might develop some insight and might feel helpful initially, but it doesn't reduce symptoms. But teaching you coping skills, doing homework, learning how to manage your issues effectively, presumably through this hard work is what will bring about change. So, kind of explaining these two different ways of working in therapy, and then kind of dangling the carrot about the one that's going to, you know, that we're proposing. She also said, I note that these tools will be in their toolbox to better manage their emotions for the rest of their lives, not just for a short period of time. Okay, so let's move on. Brad, I'm going to invite you to answer for us this next one. So, what challenges does the therapist face in holding patients accountable? I know you feel very familiar with this from your own work, and how can these challenges be surmounted?

Brad Dolin: Yeah, so Jill, you mentioned earlier that like so much of this comes down to like our own internal struggles. And so, I really want to speak to that, especially from my perspective as a more newly minted clinician who's more recently had to face, you know, my first encounter asking a client to do homework or to fill out forms. And, you know, one thing that's felt really helpful to remind myself of is just the value of empathy and leading with empathy. And our clients may be feeling and they may even say that, you know, we're asking a lot of them. And so, to me, it feels really important to agree with that because we totally are. You know, the homework could be inviting the client to face their biggest fears. And some of those forms ask the client to share, you know, their thoughts about therapy, even if they're feeling like really angry and frustrated. And so, I think it's so important to invite those feelings, acknowledge those feelings, and that can kind of help me feel like we're on the same side. I'm not asking them to do something that I wouldn't want to do myself. The second thing is I think it's been really pointed out so much, and there were some beautiful demos of this as well, but just really kind of emphasizing to myself and reminding myself that I'm not demanding something from the client so much as I'm inviting them with open hands to do something. And so, this is like a way I know how to help. I know it would be really effective if you can do this and just kind of really making something available. And that just helps me feel like we're in a much more equitable position. The other thing that feels really helpful, too, when we're thinking about homework especially, is just the idea of making this a collaboration. And so, you know, maybe there's a behavioral activation that you feel like would be helpful for depression. And so, you know, if you have a keen ear to what the client's saying and you recognize certain passions or interests that they've mentioned, that could become the homework. You know, oh, they mentioned pickleball. Maybe instead of just kind of a cookie cutter, like go on a walk and do some exercise, you know, maybe the invitation could be used to something that they've mentioned. And that feels like it's more kind of helping the client to recognize something that's valuable for them. And then just, I know from like the newer clinician perspective as well, I can feel a tendency to want to retreat if I sense some ambivalence on the part of the client. Or I could feel like I'm being invasive by asking these questions on the forum. And for that, again, it's helpful for me to remember this difference between niceness and kindness that I mentioned before. And also that you can't really reliably improve what you're not measuring and working on. So again, it comes down to like letting the client know that this is something that we're doing because it's helpful. And then I think also just to kind of capture it as a newer clinician, it's really helpful to kind of have structure to this and like our own, you know, that our own notes reflect what the homework was. It just kind of builds in that automaticity.

Jill Levitt: Wonderful. And Brad, I'm just going to keep it rolling with you. What important differences do you think there are between clients in terms of what is helpful or potentially the opposite, what might be harmful in harnessing accountability?

Brad Dolin: Yeah. So I think Zane's answer touched on some of this, you know, just the idea that not every client, for example, is going to be able to fill out the online forms and everyone's going to have their own learning style and preferences and attention span and resources available. And so it's important, you know, if the client's not comfortable with technology, maybe writing with pen and paper is going to work better, or maybe they don't love to read or that's a challenge for them. And so there might be podcasts or videos that one can send them to kind of help them digest material, or maybe they love music and that could be incorporated into the assignments. So I think, you know, just being really kind of custom and creative can be really important. I also think, yeah, one important difference I've noticed with clients is that they're all motivated in different ways. And so for some clients, they really like to have a very achievable bar, and then they like to smash through it. And it can be intimidating if the bar is set too high. For others, that would be boring. And they really want to have a kind of like really like a stretch goal. And that's very motivating. Some clients are motivated by check-ins, they really get something out of like sending a text message to me, you know, on a regular basis about how their habit is going or how the homework's going. And then I'll send them a quick message back. Or sometimes maybe a client can work with an accountability partner in their life to kind of check in outside of therapy. Spreadsheets are another useful tool. We can have shared spreadsheets and kind of keep all the PHI safe and separate. So that can be a helpful way. There's something called the Seinfeld strategy, which can be really helpful in supporting Seinfeld strategy. I don't know if we have time to explain it, but for folks who are interested, go ahead and Google it. It can be a cool approach just for kind of keeping a habit going. And there's all kinds of things. A lot of this too, just overlaps with like habit work. So that, you know, there's like some clients are motivated by, you know, a certain negative repercussion if they don't kind of engage in the homework or the habit like that. So maybe they donate to charity that they like, or even more motivating for some folks is to donate to a charity that they don't like.

Jill Levitt: Yeah. And I love, Brad, what you're saying. You can even ask a patient. I mean, again, it starts with a therapist being willing to dangle the carrot and use the gentle ultimatum. But I think this is more about like what once a patient is committed and doing work with you, you can creatively collaborate on what is it that's going to help you to stay on track. And that might be a conversation with the patient about what do you find rewarding? What do you want to do to reward yourself for doing the good work this week? Or, you know, do you need to have some negative consequence for not doing the work this week? That kind of thing.

Brad Dolin: Absolutely. Yeah. And this really comes down to like being specific, which is such an important part of TEAM and so important in working with clients. And I think it works as well on the kind of identifying potential challenges or problems. So sometimes I'll assign a homework. And the first question I ask is like, what might get in the way of you doing this? And we can even write down like, what are the potential problems that come up? And then how are you going to solve those? And then maybe the homework doesn't get done and we discover some new problems. And instead of that just becoming like a pain, we're actually kind of just like building out like a how-to manual of things that can come up and then how to address them. And I think it's really the specificity that helps there.

Jill Levitt: Great. And thanks so much. And let me, I'm going to read a couple of questions now. I have a few people who asked sort of a similar question. So I'll just pick one of the ways in which it is phrased. But the question is something around if a client comes in with a particular issue and you have collaboratively agreed on a treatment plan, but then they move the target every time they come in and they switch issues. So homework actually becomes obsolete because the homework they did last week is not related to the issue that they're bringing in to you this week. And I'm going to take a stab at answering this question. And then I'm going to ask you guys to add your two cents or we'll move on to another question because I have plenty and we're running out of time. So what I would say is again, this has something to do with the way that you structure therapy. And I think this also to me is what I expect from my patients in therapy. So I let patients know that actually in order for us to really make progress in therapy, we'll need to kind of pick one thing and work on it consistently until you're feeling better. So I'm going to teach you tools and strategies and methods, and we're going to see change over time. And so if a patient comes in with multiple problems, a relationship problem, a habit, anxiety or depression, we're going to pick one of those things, that specificity, and we're going to try to work on it consistently over time. So if a patient comes into me to session and they start talking about something totally different, I am going to empathize a little bit, and then I'm going to stop them. And I might even do this and say, I'm just going to stop you for a minute here. And I want to kind of check in with you. What you're bringing up today is really different than what we talked about last week. And I want to share with you that in order for us to really make progress and help you with your panic disorder, we'd need to get back to that and work on that today. And so it would be my preference. Like I'd vote for us kind of going back and doing the work from last week, going over the homework and how does that sound to you? So I'm going to try to keep my patient accountable, actually, to staying on track and continuing the work from session to session. Now, I acknowledge there will be times where a patient would be in crisis or something really acute comes up, and then collaboratively we decide together to focus on that. But the key word there is like we're deciding. It doesn't just happen. We don't happen to spend session after session bouncing around. We have a real specific conversation where we say, hey, what are we going to work on today? And there are consequences. If we switch topics every week, we're never going to make any progress, right? So again, it's about holding your patients accountable. Anything any of you guys wanted to add to that?

Mike Christensen: Yeah, I would just concur completely, Jill. Somebody just the other day I was working with and we were working on procrastination, but they were doing really well and we were kind of nearing the end of it. And so we put a little bit of a bow on it and then shifted to more mood work. Then I said, you know, so next week I'm just going to check in with you for five minutes on how the procrastination is going, but then we'll stay focused on the mood work. So even though we shifted from one to the other and we decided to shift one to the other, we still, you know, acknowledge that it was there, but weren't going to dedicate time to it. And so that's one way you can do it depending on where they're at. Now, if there was still a lot of procrastination going on and other things, then I would have definitely taken your approach, Jill, which is to say, you know, that'll really set us back. We'll have to kind of restart and, you know, which would you like to hone in on? And if we find this as a pattern, then we may notice there are some other things we need to address in this. So, yeah.

Jill Levitt: Great. I have one more question we'll do and then we'll, we have some kind of wrap up slides to share too. So this question says, what if after dangling the carrot, as you suggest, and offering the gentle ultimatum and sitting with open hands, the client continues to say, like, I have to go back to this multiple times. And the client continues to say, I don't know how to answer that. Like they can't come up with a decision on what they would like to do. Are they willing to do the work? And they kind of seem wishy-washy. What might you do? So let me know if you'd like to answer. I'm sure Mike is happy to.

Mike Christensen: Zane, do you want to take that one on?

Zane Pierce: Sure. Yeah. So it sounds like we have a situation where a client just doesn't know how to answer the question of like, are they going to do like therapy self-help assignments? Is that right?

Jill Levitt: You are. Yeah.

Zane Pierce: So yeah, I think it goes back to maybe offering some multiple choice. You know, could we talk, you know, empathy for X amount of sessions. Now this could be about, like a particular agenda that they want or a problem they want. Then you might offer sort of like, Hey, you mentioned, you know, this, this and that problem. And this would be my approach for each of those. This is how we would want to collaborate with you. You know, do any of these sound like they're particularly appealing to you? At least that's my approach. It's pretty, pretty rare as a patient who wants you to decide for them. I'd feel pretty comfortable doing that. Yeah. Although I would, I would give my professional recommendation of like, well, given that, I think we would make the most headway and the most progress if we were to start with this issue and then we would dovetail into this next one.

Jill Levitt: Thanks Zane. And Mike, let me ask you, I think the more broad question, which is you dangle the carrot, you do the gentle tomato and the patient goes, I don't know, you know, so tell me Mike, how might you respond to that?

Mike Christensen: Yeah. For me, if I'm not getting an enthusiastic, yes, it's actually a pretty strong no. And so they're just gently in a nice way. I love that word, Brad, in a nice way they're saying, no, I don't want to. And so then then I, you know, would fall back to empathy. Like Zane said, you know, get a sense of that and, and then, and then explore what the other options are, but I wouldn't move forward with them because that resistance will rise up.

Jill Levitt: Absolutely. Right. So in this context of the patients, you know, we're offering the gentle tomato or the carrot, and then we're saying, and you'd have to do A, B and C and the patient is saying, I don't know, I'm actually pretty direct and say, yeah, I think that sounds like a really nice way of saying no, thank you. Right. And I, by no means would I want to push you to do this. And so it sounds like maybe you're not really wanting to have to do homework and that would mean maybe this isn't the best therapy for you. You know, don't get me wrong. I'd love to work with you, but I'd never want you to, you know, be working with me kind of unwillingly. Right. And if you wanted to work with me, you'd have to be willing to do that stuff. And it sounds like you're saying, I don't think I am. I don't know that I am. So, you know, maybe let's think about what are other options for you. So the point is we have to be willing to let people go. It's not, it's not an ultimatum unless we're, you know, it's not a gentle ultimatum unless we're actually saying, and the alternative is that it wouldn't make sense for us to work together. Or in the case of the, I don't want to do exposure therapy. Maybe there's something else you wanted my help with. It doesn't sound like you're wanting to do that, but to Mike's point, if it's not a resounding, yes, then it is a gentle no, a hidden no. And that's how I respond as well. So Mike, if you could move forward on the slide, we're going to, we have just a couple of minutes left.

And so I'm going to share some information with you guys. If you enjoyed this conversation about trying to hold your patients accountable, holding yourself accountable, if you'd like to hear more examples of how to do this and also practice it with, in breakout groups with feedback, Mike and I are offering an upcoming workshop at the end of October. So all the info is on the slide, and we'll send you some follow-up info about it too, but we'd love to see you there. It's a four-hour workshop on Friday morning. And the cool thing about this is we will not just be offering didactics and answering questions like today, but we'll be teaching you very specific tools that you'll then go and practice in breakout groups with helpers and get feedback. So you can actually master these tools. And then the next slide, Mike. Also, a couple of you have written in the chat box, thanks so much for these free Q&As and free didactics. So thank you.

We hope that you'll put this on your calendar that the first Wednesday of every month at noon Pacific time, we are offering these trainings. So some months it's a Q&A like it was today, and there's no continuing education credit. And other months we offer continuing education credit and it's like a full didactic. So next month, November 1st, we are going to be presenting, Angela Crum is going to be presenting CBT tools for rapid recovery from social anxiety, teaching you self-talk, exposure and shame attacking. And so again, it's one hour, it's one CE, and we'd love to see you there. And you can find our monthly didactics on our website, which is feelinggoodinstitute.com. And then Mike, if you can share the last slide.

So yeah, we'd just like to say thank you to all of you for joining us for the webinar today. We hope that you found it valuable and that it provided you with some practical tools to help you to hold yourself and your patients accountable. Just to share a few additional resources with you on this slide. If you're considering furthering your training in TEAM CBT, which we hope you are, then we offer certification and training programs. And if you have any questions, you can reach out to us at certification@feelinggoodinstitute or check out our website. Also, if you know anyone who could benefit from our services, whether that's a friend or a family member or a patient of yours, you can go to our website and see therapists that have immediate availability and are happy to do a free screening. So yeah, as always, our commitment is to try to be helpful to you. We believe in the power of sharing knowledge and building meaningful connections. And so if you have any other questions or feedback, there is a feedback form on your workshop page. So I do hope that you logged in and you were able to get the Zoom. If you just click forward on that after the Zoom link, there's a really brief survey just asking you to give us feedback. The way that we can keep kind of refining and improving our trainings is getting feedback from you. So please give us some feedback and then let us know how we can help, how we can support you, and how we can offer better and better training. So thank you guys for being a part of the webinar. We really appreciate your time and your engagement and we look forward to seeing you at future webinars. And then I also just want to say thank you so much to our wonderful panelists, Mike and Zane and Brad. I think you guys offered a lot of wisdom today and also, you know, a lot of heart. So that's always wonderful to see.

Mike Christensen: Thank you to everyone for the great questions and also some of the suggestions. It was fun to be a part of. Great.

Jill Levitt: Thanks everybody. Have a great day.