There are few things more likely to make a therapist squirm than the suggestion of recording their sessions. People see it as a dreadful assignment that supervisors force them to do a few times, and then they mercifully get to forget the grating sound of their own voice. I really want to help reframe that, because reviewing session recordings is actually one of the surest ways to improve as a psychotherapist.
One of the most popular ways therapists like to “hone their craft” is through certification trainings. The dirty secret is that there is not a single psychotherapy training program that has been empirically shown to improve the outcomes achieved by the therapists who receive it. Even Ph.D.-level clinical training doesn’t improve client outcomes, so forget about that PESI video course. That certification you trot out is nothing but a security blanket.
One of the key figures in this area, Scott Miller, has worked for decades studying what actually makes therapists better. He concludes that not even experience makes you wise:
Despite the proliferation of treatment models, the overall outcome of psychotherapy has not improved in four decades;
Contrary to tradition and belief, therapist effectiveness actually declines as experience in the field increases;
However, there is something that has been shown to reliably improve the outcomes that therapists achieve, and that is deliberate practice. Coined by psychologist Anders Ericsson, it’s defined as individualized training designed to improve a specific aspect of performance through repetition and refinement. It’s the difference between just playing tennis and practicing your backhand for an hour with a specific goal. For therapists, one of the best ways to engage in deliberate practice is through self-supervision, by reviewing recordings of our work.
Again from Scott Miller:
The impact of deliberate practice on performance is twice that of “mere time spent”;
Engaging in deliberate practice slowly, steadily and significantly improves therapist effectiveness; and
Targeted deliberate practice training significantly improves the acquisition and generalization of fundamental relationship skills.
Mechanism of action
Why does reviewing session recordings improve performance? Because you don’t actually know what you’re doing in there.
During a session, we’re in the heat of a relational moment. Not only do we not always do things exactly how we would want to, but we also don’t have the luxury of pre-meditating all our responses. So we react reflexively, emotionally. We enact defenses of our own. And the fact that they are defenses means, by definition, that they are unconscious. The only way to make the unconscious conscious and begin to unravel your enactments is to watch them, to listen to yourself, and to pay attention to what you are actually doing.
This isn’t about critiquing your choices of intervention. It’s about analyzing your moment-by-moment process of interacting with the client. As you listen back, ask yourself the same kinds of reflective questions that you should be asking your patients:
Motivation: What made me want to ask about that right then? Why did that strike me as so important at that moment?
Intent: What do I seem to want from the patient with this line of questioning? Am I seeking validation? Am I trying to prove something? To change their mind?
Avoidance: What topics did I steer away from? What moments of silence made me uncomfortable? What emotions in the client (or myself) did I try to regulate or move past? Why?
Content vs. Process: What topics lure me away from working in the here & now?
Vocal Tone (and, for video, Physicality): How did my tone and inflection change around emotional moments? When do I seem to move closer, and when do I move further away? What feelings might be driving these changes?
Therapeutic Stance: Which moments can I see that I’m operating from a reflective (“mentalizing”) stance, versus trying to fix something or achieve an agenda (“teleological” stance), or getting lost in the details of a story or intellectualizing about the client’s experience (“embedded” stance.)
This is how you uncover what’s going on unconsciously so you can stop enacting your own issues on your patients. And that is how you develop and refine your ability to engage in a full healing relationship with them.
Why do we resist what makes us better?
We resist reviewing our own process for the same reason our clients resist engaging with theirs: because it’s threatening. If we were comfortable with this stuff, it wouldn’t be unconscious.
But in order to help more of our clients, we must expand our ability to create what David Wallin called “a maximally inclusive environment.” Our clients are all knotted up because they can’t tolerate the mixed feelings that life brings them; we help them get un-knotted by helping them face what they avoid and learn to tolerate it. But, to be able to do that, we must be able to approach and tolerate those same types of experiences ourselves. Otherwise, we’ll unknowingly collude with our patients’ defenses, and fail to help them face what they avoid.
We avoid recording our sessions because the recordings contain truths about us that we are afraid to face. The more we face the truth of our own experience, the more we gain the ability to help our patients do the same.