I am a psychologist, although one with provisional registration. I am still under supervision by more experienced psychologists. I’m grateful for this supervision. My supervisors see patterns I can’t yet see and provide feedback on how I approach challenging scenarios. My provisional status also means I still need to attain my full registration to practice. I am partway through a 1500-hour internship. This internship is (for me) the sixth and final year of full-time equivalent training to become a psychologist.
Part of this internship involves 500 hours of direct client contact. I work directly with clients in private practice. I also work with organisational clients. These types of clients can be groups of employees. I also work with operational leaders looking to bring about changes within the organisation.
Do I find private practice organisational clients more interesting? Both are on the same par in my eyes. They both offer complexity and nuances. My role is to delve into the complexity and understand how individuals and organisations function. Both cases operate within a system that maintains the status quo. This status quo keeps the client the client either unhappy or stuck.
I am nearly at 1000 out of the 1500 hours in my internship. So what have I learned so far?
I have a lot more to learn. Psychological practice is a mixture of art and science. Whether it’s working with an organisation looking to influence hundreds of employees towards more ‘agile’ thinking. Or assisting a private practice client in dismantling life-long beliefs about their own worth. The diversity of client presentations is fascinating and humbling. So too is my apprenticeship towards being a better psychologist. This apprenticeship will reach far beyond my internship, and I love it.
I recently experienced an uncomfortable tension between the art and science of practice. Luckily I read a thought-provoking book recently — Creating Impact: The Four Pillars of Private Psychology Practice. Four Australian psychologists wrote this book. Daryl Chow, one of the authors, wrote about reimagining psychotherapy education. Daryl’s insight helped my understanding of professional practice. He saw four aspects to practice: art, science, design and philosophy. Each act as quadrants in a ‘clock’.
He also saw the challenges in training psychologists. In the first five years of my psychology training, academia sought three things: a modicum of intelligence, conscientiousness and conformity. So much helpful knowledge filled my head — concepts, models, ethics and research. I learned to think like a scientist/practitioner: “Is an intervention backed by evidence?”
All well and good…until I’m sitting in front of real-life clients. I need a clear head to be present with my clients. Their story, emotions and body language provide valuable clues for me. Models, ideas and solutions don’t have a place until I better understand my client. Have I earned the respect of my private practice client? This takes time. The executive who seeks my organisational change expertise needs someone who parks their ego at the door. There’s probably enough ego that they contend with. Someone who listens, sits with ambiguity for some time and asks insightful questions — at the right time. This is someone an executive may find is worth trusting.
I remember feeling disappointed with my years of scientific training. For weeks, I think this training wasted my time given the art involved in helping clients. Yet this thinking evolved yet again.
Daryl went on to share a valuable way of thinking. We move from university training to real-world contexts. The ‘science’ needs us to apply the ‘art’ of psychology to client situations. We move from nomothetic (one solution ‘fits all’) to idiographic (‘it is all about the client’).
The ‘science’ part includes consuming and applying the latest research to client presentations. Learning about treatment options, systems concepts related to my clients, and how to adapt treatments to them? The intervention part of this ‘science’ part alone will take many years. Gaining experience in applying this science to individual clients is yet another aspect that will take years to become good at. Some clients may adopt various interventions that you propose. Research-backed interventions indeed look helpful to most clients. But consider client culture, their current mental state and other factors first. Yet often, trust needs to be in place after many sessions, and even then, the client may want someone who listens to them. Playing a mirror to my client works!
Science breaks down evidence into hierarchies. At the top of the hierarchy, quantitative research is king. The research design also helps place particular evidence at the top of the hierarchy. Meta-analyses (studies of studies) provide wide-scale evidence on often thousands of clients. Randomised-controlled trials, or RCTs, are valued research designs. RCTs are double-blind studies. Participants are randomly assigned to either an intervention or control group. Do the test administrators know which participant was assigned where? No. Imagine a Coke or Pepsi taste test. The test’s consumer scientist doesn’t know which participants are tasting either Coke or Pepsi. The participants don’t know which option they are sampling. This ‘double-blind’ test is an example of an RCT. A meta-analysis of RCTs? Or a systematic review of clinical trials? These research papers go to the top of the evidence hierarchy.
Towards the bottom, individual case studies sit. These case studies are qualitative by nature. Case studies examine the experience of one client undergoing an intervention. Have I thumbed my nose at this evidence at the ‘bottom’ of the research hierarchy? I thought I would until I had a client with a tricky client presentation. Off I scurry to individual case reports examining a particular psychopathology. I’m feeling imposter syndrome, and my client might expect miracles from me in our next session. Maybe I’m putting undue pressure on myself. But I’m back to reading these case studies for a divine answer. What did the clinician do that I could? How did the client respond, and how will mine be?
My frustration about how different the art and science of practice changed when I was stuck with a tricky client. I ran back to science for help — and supervision too. At least I know now that science and art form two parts of a quadrant. Design and philosophy form the other two parts.
Knowing relevant science linked to your client is one thing, but reading the room is another. Melding client desires with our concept of what is right for them brings us to the ‘art’ of psychological practice.
What about the ‘art’ part? I learned very quickly in my internship that the art part is vital. You need to think on your feet, improvise, go off-textbook and adapt to your client. Being well-read (beyond textbooks) and having life experience gives you a vast toolkit. My life experience includes my failures in relationship dynamics and misreading the room. These failures aid both clinical and organisational client scenarios. Patience, flexibility and boundaries play equal parts in helping clients. I enter the therapy room or an executive stakeholder engagement. While I have a fair idea of what I want to cover, improvisation and going with the flow is far more important. After all, it’s about them — not me.
Daryl Chow’s thinking moves us from science to art — but then to design and philosophy as psychologists. Design ferments knowledge from practical client work and reflection on underpinning research. Design is the way of linking form and function, according to Daryl. Design is about deep learning. As I sit at my computer on a Sunday night, my reflections on practice reveal my deep learning. I’m creating time right now for undistracted, focussed learning. It’s a deliberate practice. I do this with organisational work — planning on a Sunday for the week ahead. Or sitting in silence, crafting an organisational change strategy without interruption. For my private practice clients, I sit and think about how they can get in touch with their emotions (especially tough Aussie blokes). Or learn about a new way of thinking about someone’s fight or flight response during a trauma.
What have my clients taught me in the last few months?
Seeds grow into trees; some land on rocky soil. My clients are incredible people. So many people start their life in tough situations. Abusive families. Childhood trauma. Yet they grow into highly-functioning adults with kids of their own. These people are so much better than their past. They often make peace with their complicated past and don’t pass on their trauma to the next generation. They deal with the unfair reality that bad stuff happened to them. Yet despite swallowing this unfairness, they make a brave decision: the distress and harmful behaviours from this bad stuff stop with them. They choose not to pass this on to their family. They seek a mirror or sounding board to reflect where they could see things differently. Their willingness to ‘stare into the sun’ and face pain and discomfort is incredible. My job as the mirror is a privilege. Organisational clients have similar challenges. Their team is mired in a status quo. Fear, change fatigue, and interpersonal dynamics make change difficult. Yet organisations pay the price and seek change agents to shape the way forward.
People’s core beliefs make a huge difference. I’m sure that if we walked in a person’s shoes for years, their worldview would make perfect sense. Our life experiences, genetics and other factors shape this worldview. Yet when someone’s worldview — their core beliefs about the world — hinder rather than support them — they often turn to therapy. Sometimes therapy is mandated or strongly suggested by professionals for clients. Can we shape someone’s core beliefs so they support the client? Long-term therapy seems to be the only way forward for such a challenge.
People want to learn and embrace discomfort. Both my private practice and organizational clients are, for the most part, highly functioning. Yes, organisational clients can be dysfunctional even if they are flush with money, people and influence. Not all organisations adopt a growth mindset, nor have many strengths to draw upon. So too with the wonderful people who turn up for individual therapy. Some clients may have severe and persistent issues. They don’t have much money nor see the value in therapy. There are often many (comorbid) issues at play. Yet I am amazed at how clients find their own insights and solutions. I play a small part in how they find these solutions. Yet they are the ones doing the hard work in rewiring the way they approach the world. In private practice, I often ask “what’s right with you” rather than “what’s wrong with you”. The former question reflects on client’s strengths and values. Reflecting on strengths and moments of “what works” often instigates a sense of hope — and may be therapeutic for the client.
Curiosity, not solutions. Sitting with not knowing. My supervisors are so helpful. “Slow things down” is a mantra I hear from my supervisors. This applies to both clinical and organisational work. Quick, robust solutions may seem valuable — especially in organisational work — yet is this the stuff of junior professionals? Sitting with ambiguity, not knowing — this creates discomfort. This discomfort is the breakfast of a senior professional. One who has gravitas.
The final part of Daryl Chow’s quadrant: philosophy. Client data (and scientific research data) becomes information. Information becomes knowledge I can use as a professional. Knowledge ferments information with practice. Part of this fermentation asks us to sit with strange situations. In what unusual circumstances did I misapply this knowledge? What I learn becomes a pattern that is wisdom. For instance, I encounter an aggressive new client. Their aggression rattles me, and my confidence is shaken. I speak with my supervisor. They draw upon wisdom — patterns they see that I don’t. Under anger may be fear, they suggest. How can I elicit an understanding of what the client fears? I try this approach in my next session — bingo. I add this way of thinking to my toolkit. One day I may try this approach, and it goes pear-shaped. What could I have done better or differently? Could I have done anything at all to salvage the situation? My failures and wins alike become part of my wisdom.
Want to learn more about my organisational work? I wrote my book The Change Manager’s Companion. It’s available now. You can also check out my online course on Change Management.