Q: I have many practices to pass on to my clients that will help them outside of therapy, but it’s often hard to engage them in these practices in a lasting way, even when I give them handouts to take home. What can I do?
A: Every clinician has experienced illuminating moments in a session when the haze of cloudy, dull thinking gives way to the bright light of clarity and certainty. Let me explain with a real-life example. It had been only a week since I’d demonstrated a physical grounding practice to my client Joanna. The practice, which I call Palming the Present Moment, is a simple mindfulness technique for bringing one’s awareness to the present moment and turning it away from negativity, stress, anxiety, and even trauma. It involves bringing the palms together very slowly, doing progressive muscle relaxation, and visualization with the breath. In our last session, Joanna had been quite receptive to this practice. But when I asked her if she’d used it during the week, her brow furrowed, and a confused expression spread across her face. “I didn’t really use it,” she replied somewhat evasively.
“Interesting. Help me understand why,” I said.
“Well, I guess I didn’t exactly remember it,” she answered with a shrug.
Now it was me with the furrowed brow. Had I not taught the method properly? Had I rushed through it? It seemed so simple and straightforward. I decided we’d try it again together. Afterward, I inquired, “So how did that feel for you this time around?”
“Much better,” she affirmed, adding, “I felt like I was really experiencing it and not just trying to learn it.” So far so good, but had she retained it? That’s when I asked her to demonstrate it for me, just for repetition’s sake. She raised her hands up to the starting position, but then froze. “What comes next? What are those steps again?” she asked.
That was a moment of clarity for me. Aside from my embarrassment at not having been able to teach her a simple practice, I recognized that I’d failed to really engage her in learning it and provide her with anything concrete so she could remember it at home. This was the beginning of my journey to developing a four-step approach to help clients master practices used in session. The steps are priming and preparing the client, engaging with learning style, slowing the pace, and providing detailed instructions for repetition and mastery.
Priming and Preparing
Attachment researchers have long known that priming words such as closeness, love, peacefulness, and safety can help people who’ve experienced trauma feel more open, secure, and trusting. When you think about it, we’re “primed” all the time, and in various ways, by stories and images in the news, on social media, and through myriad other sources. How you prime a client for receiving a handout on a practice is vital to its successful implementation. You might think of this as getting buy-in and helping the client get prepared for accepting and trying the practice. But priming and preparing are most effective when you understand a client’s history.
For example, my client Roy had developed acute depression as he faced the challenges of a degenerative neurological disorder, whose symptoms forced an end to a career in architecture that he loved dearly. Whenever Roy experienced a symptom in his body, it triggered the story of the devastating loss of his career. In other words, the sensations in his body had become fused with his story of loss. I felt that the body-scan practice—a mindfulness method of noticing body sensations in a neutral way, as neither good nor bad—would help him separate sensations in the body from the story about those sensations.
That’s where Roy’s history came into play. During my initial intake with him, I’d learned he was an avid fly fisherman. Since this was a safe, positive activity for him, I decided to use that as a link to the body scan. When the time came for me to introduce the practice, I said, “Roy, I was thinking about us trying a practice I thought would be helpful today. And I thought of it because I remembered you telling me about fly fishing and how calm and peaceful you felt being out on the water. This practice reminds me of that. It’s called the body scan, and it’s a quiet and safe way of flowing along with the currents of sensations as they occur in different parts of the body. This practice lets you catch sensations, just like fish, and release them back into the river of the body. It’s a way of coming to a greater sense of peace and acceptance with what’s happening in the body.”
Simply using fly fishing as a metaphor for the practice was a major source of priming for Roy, but I also incorporated several priming words in my introduction of this practice—words like helpful, calm, peace, quiet, safe, and acceptance. So he was excited to try it, and the body scan soon became one of his favorite practices. In a similar way, I always remember to include a short written introduction to any practice handout that includes priming words and statements.
Engaging with Learning Style
Ascertaining how clients most vividly take in and readily access information—visually, kinesthetically, interpersonally, intrapersonally, verbal-linguistically, and so forth—can make the difference between spinning your therapeutic wheels and using interventions that get real traction.
Personally, I engage most deeply with new ideas through language, verbalizing, and journaling. But I quickly learned that this approach was often ineffective with certain clients. This became clear to me with Kristy, a client in her mid-20s, who’d been in recovery from an eating disorder until various life stressors had caused her to relapse into old thought patterns around restrictive eating behaviors. To help her manage stress, I began using CBT, a key intervention used in the eating disorder clinic where I’d previously worked for several years. It seemed like a natural way to challenge her thinking errors.
But after a couple of sessions, Kristy wasn’t improving. Despite her reticence, I doubled down and handed her some CBT worksheets to use during the week. These worksheets required her to write in evidence for and against her distorted thoughts and to journal an alternative perspective. When she returned the following week, the worksheets were still blank. I was frustrated—not at her, but at myself, for forcing my preferred verbal-linguistic style on the client.
I knew I needed to find a better way to engage Kristy. So after inquiring about her hobbies, which turned out to be drawing and photography, I suggested that she take a short online survey of learning styles called the Multiple Intelligences Self-Assessment, developed by Edutopia, George Lucas’s educational foundation. In just five minutes, it was clear that Kristy’s primary learning style was visual. That’s when I shifted gears.
Together, we came up with a plan for Kristy to carry her sketchpad and camera during the day, so that whenever she felt triggered, she’d find the most interesting spot in the cityscape to sketch or photograph: a building, a rose, a bridge, a person, whatever. At the eating disorder clinic, we might have called this a distract-and-delay technique, but this intervention was going a step further than simply delaying unhealthy behavior. The visual focus let Kristy engage in something that was meaningful and joyful, thus calming down her body’s sympathetic arousal system. (In CBT terms, this was still helping her find the balanced view, but in a more visual way.) The key therapeutic element is to clearly identify the learning style that best fits with each client and to tailor practices and any handouts around it.
Slowing the Pace
Do you remember the first time you rode a bicycle? You might’ve been awed by your shiny new ride, but so many things were happening at once—balancing, pedaling, pointing the handlebars—that staying upright probably seemed impossible. This is what clients experience when learning any new practice.
That’s why it helps to get them calmed and centered before teaching any practice. And you can build this into your handouts. I always start by writing something like, “Before you begin, get centered in your body. So right now, feel your body in the chair. Press your feet into the floor and get rooted like your favorite tree or plant. Now, let’s take a couple of nice, soothing breaths before we start.” You might notice the priming words in this introduction as well.
When actually teaching or demonstrating a practice in session, do this as s-l-o-w-l-y as possible, and in bite-sized pieces. Pause frequently. Allow space for silence and reflection on the part of the client. Often that silent reflection gives the client time to have an insight or thought that might be missed if you speed along too quickly.
Similarly, your handout should be paced. You might break down any practice into several steps, including a blank space for writing in reflections or insights. In this way, clients can process handout materials fully and move on to the next part of the practice when they’re ready.
Detailed Instructions for Mastery
Recommending practices to clients isn’t too different from what happens when a doctor prescribes a course of medicine. The prescription needs to specify the dosage, how to take the medicine, and how frequently. And just like a doctor’s prescription, one size doesn’t fit all. You’ll want to be sure clients find an ideal time and place for them to apply the practice. How can they best integrate it into their day?
I once worked with a client, Bill, who because of an abusive family background would often get into physical fights. He’d been in prison because of this, and one more violent altercation would land him back there again. So I taught him some practical methods for calming himself in moments when his emotions might escalate. After demonstrating these practices, I stressed that he needed to repeat them a minimum of 15 to 20 minutes a day for the entire week. “If you don’t do that, this may not work,” I added with concerned expression.
Bill’s jaw clenched, and he was clearly annoyed. “I don’t have a quiet place to sit around and do this. I don’t have that kind of time,” he told me.
I took a deep breath. “Good point. Let’s figure that out right now,” I responded. “We’ll find a way to make it work for you, even if you practice three minutes at a time, five times a day. You need to hardwire this in your brain so you can access it automatically, without even thinking.”
Fortunately, Bill took my words to heart. It was probably no more than three weeks later that he was shopping in a big-box store and encountered someone who, in his own words, “was really pissing me off.” But he went to another aisle and started doing the practice. To help him focus, he even pulled out the handout I’d made for him, which he kept folded in his back pocket. It detailed each step of the breathing practice with pictures—since he’d told me he didn’t like reading, and large chunks of text made him nervous. “It calmed me down quickly,” he reported with pride.
Perhaps the most important aspect of engaging your clients with practices and handouts is to listen to their feedback. What worked best? What was a challenge? What was most helpful? How clear were the instructions? Was the amount of practice time doable? I suggest you even integrate these questions as open-ended reflections into your handouts. Even when you think you’ve designed the perfect handout, rewrite and try it again. It’ll take time, but when it comes to creating engaging and customized handouts, your clients are your best guides.
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Donald Altman, MA, LPC, is a psychotherapist, award-winning writer and former Buddhist monk. He is also a faculty member of the Interpersonal Neurobiology program at Portland State University and teaches various classes blending mindfulness and Interpersonal Neurobiology. A prolific writer whose career spans more than 25 years, Donald has authored several pioneering books on mindfulness, beginning with Art of the Inner Meal. (HarperOne, 1999). His book, The Mindfulness Code (New World Library, 2010) was named as “One of the Best Spiritual Books of 2010.” He has also authored The Mindfulness Toolbox for Relationships: 50 Practical Tips, Tools & Handouts for Building Compassionate Connections (PESI, 2018), Stay Mindful & Color: Find Calm, Clarity and Happiness (PESI, 2016), and many more. Donald works extensively with mindful meditation in his own life, as well as offering these tools to others through his books and classes. He teaches mindfulness and spiritual values around the country.