Tag: Homework

Telehealth Arriving Rituals

EllisLeave a comment

Telehealth Arriving Rituals

So, we know there are benefits to in-person work over telehealth (at least if we’re doing anything more than coaching/psychoeducation, and probably even then!). But we also know telehealth isn’t going anywhere. If you haven’t read the Teletherapy Rant, you might want to. Or you might want to skip that but look at the tip sheet for clients. 

But if we’re going to be telehealth (and we are), and some clients are only going to do therapy that way (and they are), how do we give them the best experience. One thing I’ve been playing around with lately is the idea of “telehealth arriving rituals.” 

Some therapists (and yoga instructors, LOL) use arriving rituals even for in-person meetings. In-person therapy has its own natural built-in ritual as well – the client drives someplace, they wait a bit, you collect them, you walk together to the room, maybe small talk along the way, you both enter the “sacred space,” and you settled into chairs or couches. Telehealth doesn’t get that (and often doesn’t get a sacred space at all!).

So, how might we do this? Here are some ideas, some of which I use:

  • I have one client and we show each other our coffee cups in a sort of “cheers” moment to show that we’re both “ready to begin”
  • With one client, we made mindfulness training part of the treatment plan, so we do a new (or requested) mindfulness activity in the first 5 minutes of each session
  • If you like to use a singing bowl or similar in “real life,” that’s the kind of thing that could work in a telehealth setting (but I haven’t tried this)
  • I’ve done variations on a body-oriented kind of thing, that I just started doing and then my clients have picked up on, like I stretch my arms up and then let them fall down and I say “mmmm, ok, I’m here, how about you?” (which I also sometimes do in-person, as well)
  • I’d be interested in doing some guided imagery work in one session, and creating a mental “perfect therapy space” and then inviting the client and I to enter that space as we get online (I have a client who “built” an incredibly beautiful, luscious hidden library as his therapy space and I sometimes go there by myself!) 
  • Just always starting with a homework check-in is something I do with some clients in-person and via telehealth. If agenda setting is your thing, that could work, too.
  • And maybe the thing to do is ask the client. Just explain that you’d like to make sure that the therapy time feels sacred, even if they’re in one of their many typical life-spaces, and ask “What could we do at the beginning of session to help you really get into the therapy mood/mindspace?”

As I think about it, maybe telehealth does have its own natural ritual in a way, as we ask the interminable but ethically required questions about where clients are and if anyone is also with them, and do the inevitable “I can hear you, can you hear me” rigamarole! Oy. At least I try to start that with, “Welcome, I’m so glad to see you!” 

As a side note, I also like to encourage clients to have a TINY bit of time set aside before and after their sessions, too, which they would normally get at least in the waiting room and driving. No one seems to, though. 🙁

Oh, and don’t forget your own between-session rituals when you’re doing telehealth all day! What do you normally do between sessions? This is my (preferred) regular in-office pattern – 9:50 notes and coffee refill, 10:50 notes and bathroom break, 11:50 notes and protein bar, 12:50 notes and deep breathing or a quick walk, 1:50 notes and a bathroom break, 2:50 notes and run like mad to get in the kids’ school pickup line. (Yes, I really do notes after every session!) 

 

Comment below: What ideas do you use or can you think of for rituals-of-virtual-arriving? 

 

 

 

 

They might be an alien…

EllisLeave a comment

They might be an alien…

If you haven’t read the Crazy, Stupid, Awful blog, go ahead and do that first. 

. . . . . . 

For fun, to help a couple who has a deeply difficult time understanding the other’s internal logic, I gave them an assignment to watch a sci-fi or fantasy movie for a date night, or even a family movie night. I requested that it be something neither of them had seen, and that they let me know what it was, so that I could make sure I watched it before we met again.

I suppose this could work with any kind of movie, but I thought the extra distance element might help. 

So, when we got back together, we spent several minutes talking about what makes sense in the movie that would NOT make sense in Real Life? And then taking it to the character level (which is why it might work with any kind of movie). When this heroine does this amazing thing at the end of the movie – does it make sense? (Yes, if the movie’s any good.) And would it make sense if any other character did that amazing thing at the end? (No, if the movie’s any good.)

And then we go through what we learn (that is, what the movie writers, directors, and editors teach us) about each character so that their behavior makes sense. In a well-done story of any kind, the writer has to give you certain pieces of information so that the characters’ actions are understandable. And because writers try to give readers/watchers at least a few different main characters (with different background, motivations, etc.), most stories will work for this exercise. 

Now, if your partner is an alien, you need them to teach you what things are like “on their planet” or “with their species.” You need them to teach you, as if they are the writer/director/editor of a movie about them, what you need to know about their biology/neurology/history/experiences/culture in order to understand why they – as a character in this story – do not behave in the same way you do. And you need to simultaneously realize – YOU are not the earthling. You are not the holder of all reality, and that’s where the sci-fi/fantasy thing helps more, I think. 

I don’t think this is specifically a lot different than any kind of empathy or phenomenological understanding or perspective taking work, but it was helpful with these clients who really struggle. And now they have a language to say to each other, “That’s not really how it works with my species” or “How is that different on your planet?” that is giving them a little more space to talk about their differences in a friendly way.

And they had a fun date night. 🙂 

Comment below: How do you help clients who really struggle with this?!

 

 

 

 

 

 

Office Supplies Volume 3

EllisLeave a comment

More Useful Office Stuff (Vol 3)

I don’t have infinite space in my office, so I like to make everything count. I’ve written about some of my office treasures before here and here, if you haven’t seen those.

Here are a few things I keep in my office that are especially good when it comes to client homework (and we know how important homework is, right?!) 

 

  • Homework “Rx Pad” – One of the things that clients get from therapy is permission. Permission to act differently, have a tough conversation, give themselves a nap, go someplace strange for social anxiety work, etc. Sometimes, that’s implicit, and the client just needed that permission for themselves. But sometimes, it really helps them enact their homework if they’re able to tell members of their system that “my therapist told me to!” To facilitate that, I made up a little prescription-size notepad that says “Therapy Homework” and has my name on it. I don’t use it all the time, and honestly sometimes it just gets used because clients forget homework if we don’t write it down, but when it works, it works! 
  • Brown envelopes – Somewhere along the way, I realized that I often assign homework that involves communicating in a written way with someone else, or with the future self. Because part of what helps therapy work is how special/sacred/novel it is, I like to have some plain (but special!) envelopes to give clients when I assign a homework like that. Kind of a way to take the sacredness home with them, but also nothing obtrusive that’s going to alert family members.  
    • And Red envelopes! I keep a separate set of red envelopes that I use sometimes when I give couples sexy homework. I have no research-based reason to do this, I just like to and feels extra fun! Sometimes, I’m giving them “secret” instructions and sometimes I just give them the envelope(s) to use to communicate with each other.
  • Cheap journals – I assign tons of different kinds of journaling homework. The classic Expressive Writing homework, worry-time journaling, dream journaling, ego state journaling, etc. And I have found that clients really enjoy receiving a little journal from me to start their work in. Not that they necessarily have to do it there! I just find it helps with investment, and frankly, clients like receiving gifts the way we all do! I use these – they’re lined and they have a nice, clean look. I think they’re 50 or 60 pages (which is usually plenty), and because I have a bunch of colors, clients can choose one they like. And they’re under $1 a piece! 

Comment below: What’s the most useful stuff in your office? 

 

 

 

 

Slowing Way Down

EllisLeave a comment

Slowing Way Down

I really like having couples for double-length sessions, at least 90 minutes. There’s just SO much work to do! And how often does that dream come true? Almost never. Which is one of the reasons I use this technique, even though – I warn you! – it’s going to seem counter-intuitive.

Couples are infinitely complex and unique…except in the beginning. Because in the beginning, they all have some of the same problems. In one of those problems is a basic difficulty with saying what they mean and hearing the other person. I’m sure you had the all too common experience, to; it starts out reasonable, then there speaking over each other, saying the same things over and over, getting louder and louder. When that happens, I quietly stand up, go over to my box of supplies, and pull out a pack of index cards. Then I sit quietly, and wait for their quite confusion.

Next I hand them each one index card and a pen.

Rules are pretty simple: First, take your time – because you get the front of this one index card to save the most important things that you want your partner to hear. (It’s surprising how much event held by the size of fonts they write with during this exercise!) After you’re both done, switch cards. Read the card as many times as you need to. Quietly; no speaking. As best you can, write what your partner told you in your own words on the back. After you’re both done, switch cards.

The next step depends on your intention in using the exercise. You might take both cards, read them both and help them make corrections on their interpretations of what the other person said. You might have each of them read their partner’s interpretation, and then use a new index card to write their initial statement more clearly. If they’ve done well, and the point was mostly just to cool the temperature in the room down a little bit, you might invite them to speak again about what they’ve just written (I use a random number generator to decide who goes first).

Yes, this takes basically an entire 50 minute session. For one note card. And you know what? They usually have communicated more during that session that may have in any session before we used the technique.

Bonus: this is a relatively easy task to then assign for homework!

 

Comment below: What pitfalls can you imagine using this task with a couple you have now? How would you handle them?

 

 

 

 

Just close your eyes and rest…

EllisLeave a comment

“Just close your eyes and rest.”

This is what we need to tell our kids, and ourselves. Trying to demand that you fall asleep, or that awful thing where you think “if I could just go to sleep NOW, I’d get 5 hours. … if I could just go to sleep NOW, I’d get 4 ½ hours…” NOT HELPFUL. Changing this language is just the beginning of the wide array of strategies we can use to help clients get restful sleep – something that’s associated with pretty much every physical and mental health measure there is! 

 

Sleep hygiene is maybe the thing that’s most applicable to virtually every client – more so even than journaling, I’d say! It’s a shame, I think, that many accessible resources for sleep hygiene are quite poor (even though they’re usually pretty accurate). I’d like to share with you the sleep hygiene handout I made for my clients – feel free to share (but, you know, obviously don’t SELL!).

 

It’s geared toward adults, but could pretty easily be modified. It doesn’t mention sleep meds (which are often antipsychotics or antianxiety meds – BEWARE; also the sleep specific meds like Ambien have some really alarming side effects!) or pharma sleep “helpers” (like antihistamines or melatonin). It also doesn’t mention some of the sleep re-set techniques for when sleep has gotten really out of control, e.g., the 24 hour re-set or the 5.5 CBT-I strategy .

 

 

Comment if you teach sleep hygiene to clients, or if you’ve learned a new sleep hygiene technique you can share! 

 

Making Homework Count

EllisLeave a comment

Making Homework Count

Your kids don’t want to do homework. You don’t really want to do homework. Clients don’t either, most of the time. But it’s important…clients who are compliant with homework do better in therapy – the effect size is .36 (according to a meta-analysis by Kazantis, Deane, & Ronan, 2000). For comparison, the effect size for therapy as a whole is usually reported at between .7 and .8.

 

So, let’s make it worthwhile! Here are some ideas:

  • Always check in on homework, first thing. Yes, even if they’re crying. (You don’t have to make a big deal about it, if you can tell that the session won’t revolve around it, but you need to mention it, even if you say “I can see you’re very upset, so we’ll check in about your homework later. What’s going on for you right now?”) Here’s a rule of thumb: the first time you don’t check it is typically the last time they do it! So, if you give homework, make sure it comes up next session.

 

  • Be a little stricter than you naturally want to be. It’s a nice idea to let grown-ups be grown-ups and trust that they’ll find the time and place to take care of the homework and make sure it’s done with intention. But they won’t. Help them by collaborating with them to set a time and place during the week for homework to get done. You’d like to believe they won’t procrastinate like a 16 year old with a girlfriend and a Netflix account…but that’s a fantasy.

 

  • Do it together, first. Think how ridiculous you would find it if your kid’s teacher sent homework home on a subject they hadn’t covered that day, or on skill building they hadn’t learned in class! Save 5 minutes at the end of session and do a practice run through with your client. Whether that’s a thought record, a communication exercise, even journaling – it’s worth it to do it in session first. Then clients have a better sense of self efficacy about the assignment, can get their questions/barriers addressed, and are more likely to actually do it.

 

  • Make sure you and they know why it’s important. Assign homework with intention. It’s so easy to get into the habit of just assigning and re-assigning the same 5 homeworks. Instead, make sure you have a clear understanding of the therapeutic value of the assignment. Be able to explain it to yourself, and be overt in telling clients why you are assigning what you are assigning, and what benefit you believe it will have for them. If clients believe the homework has value, they’re more likely to do it!

Kazantis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignment in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice (7)2, 189-202.

 

Comment with some of your favorite homeworks!