As a therapist, each time I get a new client, there is both excitement for a new opportunity and challenge while there is also some trepidation about whether I am up to the task. One thing I hope for with each new client is a good therapist-client fit. Of course there are some inevitable mismatches that will happen from time to time, but my goal is to increase the chances of a good fit.
I imagine an entire book could be written on the creation of good therapist-client fit, what the therapist can and cannot control, what variables are at stake, the use of self, and so forth. Here I want to focus on something that is well within the control of the therapist.
Here I present Circles of Clinical Fluency. This concept was developed for therapists in training and beginning therapists, but might also be useful for mid and later career therapists as well. In masters training in Marriage and Family Therapy students are exposed to so many theories and models of therapy it can be difficult to know one way of doing therapy before it is time to learn the next one. It can be tempting to believe one has to know every single model of therapy perfectly, which is, of course, completely unrealistic. Circles of Clinical Fluency is one way of prioritizing and organizing theories and models of therapy which aims to broaden a therapists’ clinical fluency while preserving the therapists’ core sense of clinical identity and resulting in better therapist-client fit.
To grasp this way of organizing theory and therapy, imagine three concentric circles that look like a target with a center bullseye. The center bullseye is the therapist clinical heart language, the theories and models that resonate most with how the therapist is bent. The second circle is populated by theories and models wherein the therapist is clinically fluent and can pivot to seamlessly if needed. The outer circle is comprised of theories and models of therapy and other popular clinically related information that may be familiar to clients in which the therapist is conversant. When a therapist has a solid core, a strong middle circle, and an expansive outer circle, I hypothesize there is an increased chance of therapist-client fit.
Clinical Heart Language
Each therapist should have 1 to 3 models of therapy or perhaps an integrated model of therapy wherein they live their lives. This model of therapy is so similar to how the therapist thinks, feels, behaves, interacts, and engages the world that it hardly makes sense to limit its assumptions to therapy. It’s just how life works. It is how the therapist understands the world. This is the model of therapy that made so much sense in the training program. This is the model of therapy the therapist comes back to time and time and again. It is the model of therapy that when the therapist first met the model, there was an intense familiarity and maybe even some relief. It just made sense. Some therapists find that when they discover this model of therapy they learn more about themselves than any other model or perhaps anything else in their entire lives. The model has served to reveal something already true about the therapist.
This is the clinical heart language. Therapists find it easiest to do therapy while speaking their clinical heart language. It is easiest to be very genuine and authentic in therapy and it feels less like work and more like a meaningful and helpful conversation.
In order for there to be good therapist-client fit, the therapist must come to therapy and be fully present and full alive in session. It is often easiest to accomplish this task while doing therapy in the therapists’ clinical hearth language.
Clinically Fluent
Each therapist should be clinically fluent in 5-7 varied models of therapy. Clinically fluent means that even though it is not the therapists’ first clinical language, the therapist is competent to do therapy using that model.
When considering therapist-client fit, sometimes the client is simply not all that responsive to the therapist’s clinical heart language. Because of client factors, it may not matter how genuine and skilled the therapist is at CBT. If the client makes sense of the world in a narrative way, the CBT approach may feel too mechanical, too formulaic, and too constricting. It could be true the other way was well. If the client is responsive to the logical and straight forward approach of CBT, but is met with the therapist doing a master job at storying and re-storying, therapy might not get too far.
The point is that the therapist can work their model as much as they want, and most of the time that will suffice, but when it does not, it is incumbent upon the therapist to pivot to another model that may be better for the client and leave their cherished model behind.
In the common factors research, we understand that it is at least as important (and possibly more important) to be an empirically-validated therapist as it is to use empirically validated treatment models. When a therapist is able to pivot seamlessly from their heart language to another clinical language in which they are fluent, it increases the chancres of good therapist-client fit.
Clinically Conversant
Each therapist should be clinically conversant in as many models of therapy as possible as well other clinically related concepts that are in the zeitgeist of the general population. For example, although the MBTI (Meyers Brigg Type Indicator) is not a model of therapy, there are millions of people who are able to tell their letters (e.g., “I am an INFP”). Whether the therapist believes there is any clinical utility to knowing their type, clients often make major life decisions based on their beliefs about their type or the types of the people around them. Another example of being clinically conversant is with a personality typing system called the Enneagram. Again, it is not a model of therapy and it is not clinically validated, but it is emerging in popularity. Knowing that there are 9 types and being conversant in them might help to widen that outer circle and empower the therapist to increase the chances of strong therapist-client fit.
This third circle is sort of the ‘liberal arts’ of psychological and systemic consciousness. Being able to discuss anything can help pave the way to excellent client care.
We all strive to give clients the very best care we can. There are hundreds of models of therapy out there and there is no way to know them all. Circles of Clinical Fluency is a way to prioritize them with an aim toward therapist-client fit.