My Framework of Therapy
scaffolds framing a work in progress in a dark room, an apt metaphor for the outline of the therapeutic container
A common question I get is “how do you work” or “what can I expect in sessions”. My answer is that I work as a guide to aid in self-discovery, to help each client uncover and claim their knowing of self and personal agency through a unique and tailored set of discussions. It’s true, and my approach is very much custom-tailored to each individual and their specific needs. However, as I thought more about these questions, I came to realize that I actually really wanted to have an ongoing list of the skills and tools I bring in as well. So I sat down and made a rough outline of the framework that I use for therapy. This is a peek “behind the curtain” so to speak, as I believe that my clients should always have knowledge to inform consent and agency in the therapeutic process. It’s a bit like scaffolding surrounding a work in progress. I don’t use all of this with any one client, nor is this list exhaustive in all that I may bring into sessions, but it is a good starting place to see “the process”. This is mainly geared towards my individual therapy clients, though I do often weave elements of this through with couples, or those coming in for relationship concerns, as well. As always, I’m open to any questions!
What brings you in for therapy?
Getting to know each other and identifying the symptoms, setting a “style” for treatment
For couples, identifying the treatment unit (who is to be treated, and listed on the client on any paperwork) and any blockers in place
Discuss any underlying traumatic episodes or anything else in personal history, such as addiction, that will influence the frame of therapy
Identifying the connection between symptoms and problems, determining a diagnosis (this is less formal when not using insurance)
Coming up with a diagnosis for medical necessity if using insurance
Understanding what the problems are, how they impact quality of life, and what life could look like without those symptoms. What does “being happy” look like?
Identifying personal goals to work towards, treatment plan
Discuss therapy as a guiding process, as an inside out disco ball
Discuss the need to become your own champion, and reinforce that no one is coming to save you
Understanding it is really hard to hit targets when we don't know what to aim for
Discussing the concepts of chasing happiness, purpose and meaning, personal and social desires, and hedonic adaptation and the hedonic treadmill
Setting overall goal as improving personal agency to increase a sense of control and reduce anxiety and depression
Identify and develop SMART goals
The therapist will set up initial frameworks and modalities at this time to support the client’s SMART goals
Identifying current maladaptive strategies, and identifying adaptive replacement behaviors
What have you been doing? In what ways has it been working (there are certainly some)? In what ways is it no longer working?
Discuss the concept of mal-adaptive behaviors, that we do things for a reason, and how it doesn't always lead to the desired result
“We’re doing the best we can, and, there is always room to learn and improve”
Connecting action and outcome, encouraging the connection to personal responsibility
Discussing the circles of control and influence,
Reviewing the serenity mantra, focusing efforts on agency, reinforcing the idea of self-championing and becoming indomitable
Discuss radical acceptance
Identifying replacement behaviors to get desired outcomes and specific discussions to help support these new and more adaptive habits
Discuss historical and traumatic personal elements that influence the stories driving personal behavior, and examine them
Integrate the Enneagram framework if useful to assist in self-understanding and learning how to break free of the prisons already in place
Understanding the role of our story, how we came to be who we are, through our culture, society, family, etc…
Learning and implementing initial coping strategies for the most troubling symptoms
Target the biggest improvements from the biggest problems first, and managing smaller problems first if required to access the larger ones
If relevant, discuss depression as a mal-adaptive control mechanism
If relevant, discuss small steps towards activation
Discussing the role of mindfulness and supportive practices, learning initial self-regulation practices, and healthy coping strategies.
Learn the physiological sigh tool
Discuss the connection of the vagal nerve system, how we can use conscious control of breath to influence heart rate and stress hormones, and how this can be powerful enough with practice to quell overwhelming anxiety and anger in tense moments
Discuss the Viktor Frankl quote about the space between stimulus and reaction, and discuss how meditation is practicing accessing this space through structured efforts during calm times to prepare for more challenging moments
Discuss the concept of window of tolerance, and how this changes with the day’s stressors. Discuss how to do self-check-ins to assess capacity, and how to avoid triggers and stressors when capacity does not exist
HALT and other check-ins for capacity and readiness
Discuss how to tolerate distress and limit damage when capacity does not exist, how to take space and healthy boundaries in the moments when you need them
Discuss increasing resilience by leaning into the edges of comfort zones when capacity exists
Discuss other related somatic practices, such as the accordion, for additional calming strategies
Discuss the power of journaling, both as an ongoing practice, as well as a targeted intervention for stressful moments or difficult decisions
Learning about metacognition and the cognitive restructuring process. Learn about mental heuristics (biases) and how they impact worldview, such as biases, automatic thinking, and impulsive and compulsive behavior.
Discuss how automatic thinking works, and normalize intrusive and unwanted thoughts as normal
Discuss the elephant and the rider if it hasn't been already
Talk about anxiety as a necessary and useful system for our survival. Learn the difference between helpful and unhelpful anxiety impulses.
Discuss the triune brain theory, and the usefulness of the reptile brain, as well as its limitations
Discuss the useful binary of “love or fear” and how to use it
Discuss the necessity of biases for information reduction, and discuss how to use them as tools, instead of being driven by them, discuss the most common biases, and the ones most specific and relevant to the client
Discuss the concept of observing your own thoughts and the STOPP protocol for catching and challenging these habits in the moment
Learn the 3C/4Q system as additional support
Discuss the concept of worldview and how it can be changed, how we can challenge the automatic nature of our thinking and mold it through conscious effort (neuroplasticity)
Discuss the concept of the upward and downward spiral as a process made up of stepwise choices
Discuss graduated exposure therapy if relevant
Hone in on metacognition, cognitive reframing and restructuring, habit formation and reinforcement
Discuss habit formation practices (such as those in atomic habits)
Chaining, cascades, reward structures, stepwise goals, and relationship to purpose, reinforcing SMART
Refining SMART goals at this time if relevant
Discuss the underlying reasons of WHY these changes are desired (reinforce SMART framework)
Can be a good time to discuss Cambell’s Hero’s Journey and Maslow's Hierarchy if relevant - focusing on the ideas or purpose, actualization, and transcendence through belonging to greater meaning
Discuss the necessity of positive reinforcement versus punishment, and how this relates to a kind internal voice, and the history of Pavlov's dogs
Discuss the idea of changing our minds through the concept of neural plasticity, how practice makes practical, and the concept of Hebb’s “neurons that fire together wire together” to help understand how we model behavioral change
Learn and practice additional supportive skills
social skills in communication and establishing healthy boundaries to support agency, to protect self and sanctity
Prosocial communication skills to improve asking for needs and getting desires met
Personal skills in routine, habit commitment, and personal boundaries
Discuss concepts of healthy relationships in partnership, friends, family, and work circles
Discuss deeper practices for self-knowing that can carry on for the rest of a lifetime
Discuss NVC, i-statements, the DEARMAN, scheduling conflicts, the emotional bank account, and other related concepts for relational health
Transition to fewer sessions, eventually ending regular therapy once the client is ready
Continue to practice skills, focusing on troubleshooting the application of specific skills
Discuss the Hacking of the American Mind, the relationship to dopamine and serotonin, and how to take control of our consumption in support of our mental health
Discuss Beginner’s Mind and the Dunning-Kruger Effect to support continued practices
Discuss anti-fragility, and moving progressively more out of our comfort zones by embracing our growth zones with sanity and safety
Discuss Maslow's hierarchy and the concept of transcendence in relationship to meaning and purpose and legacy
Discuss the hero’s journey if it hasn’t come up yet
