The Three Step Question of Therapy - clinical decision making made simple

One of the greatest challenges in concrete practice of psychotherapy skills, is the connection between theory and practice. Too often students and supervisees will complain that they know the theory all too well, but don’t know how to implement the theory in session. This is true in the case of Deliberate Practice as well, where skills are often practiced in isolation, without improving our ability to decide when to use each skill.

The Three step question is a simple method designed to put therapy skills in context, thus tying theory and skills into concrete clinical moments. The three-step question can be used to two main benefits. The first, is the refining of clinical decision making. By looking at clinical moments and addressing the question, you are rehearsing your ability to analyse and execute in real life clinical moments. The second benefit of the TSQ is in finding your learning goal. If you find a clinical moment challenging, start by answering the three-step question, at the end of which you will find what skill it is you should be rehearsing and receiving feedback on.

Embedded in this article is an AI trainer that can help you with the process. It can create fictional clinical moments for you to practice with or provide insights and feedback on a clinical moment that you share with it. This trainer is designed and developed by Dan Sacks, to bridge the gap between theory and practice. but,

What is the Three Step Question?

The Three Step Question (TSQ) is a simple process for thinking about clinical moments. We look a t a concrete moment from therapy and ask:

1.     Where is the client currently at? - This question focuses us on the most relevant client behaviour that we want to address in the specific moment. Is the client ambivalent? avoidant? is he disengaged from the conversation?

2.     Where do we want the client to be? - what change would i want to see in the client in the moments following my intervention. Do i want to client to be more emotionally engaged? Do i think it would be most helpful if the client states his ambivalence openly?

3.     How do we get him/her there? - which intervention could i use to effectively bring the client from 1 to 2? An empathic reflection? open ended question? maybe an interpretation of the transference?

This string of questions is first done artificially in supervision. Following practice, it becomes an intuitive component in a supervisee’s clinical thinking, helping guide interventions in a more goal-oriented fashion towards treatment goals. Staying close to specific real-life therapy moments allows for a quick transition from the conceptualization to the operationalization of clinical interventions. When asking ‘where do we want the client to be’ we are also setting a clearly defined goal for our intervention. With this clear goal it is much easier to assess whether the chosen intervention worked or not.

The benefits of practice with the TSQ

By practicing in session decision making, you will be achieving a number of things. Firstly, as mentioned above, you will be a master of translating theory into interventions, as well as recognizing what’s happening in session and conceptualizing therapeutic moment.

Secondly, your speed and quality of decision making will greatly improve. Use the three-step question slowly here at first, and when i becomes more intuitive you can use it in real-time during therapy sessions, when you need to make a clinical decision about the best intervention or direction for therapy.

The third and last point related to psychotherapy integration. Using the TSQ for decision making makes it much easier to integrate interventions from different psychotherapy models into your work. Read more on this benefit further down the page below the trainer.

How to use the trainer

To begin with, as always, let the trainer know you are ready. The trainer will then ask you for your preference as far as a theoretical model goes. The trainer is capable of working with popular theoretical orientations, such as CBT, EFT, psychodynamic etc. within these, you can ask for more specific models, such as CBT with a more behavioural focus, or Relational Psychodynamic. If you go too specific, the trainer might not be effective.

Following this intro, the trainer will guide you through practice. Feel free to interact with the trainer as you would do with a teacher. If you are stuck, as for an example or explanation. If you feel the trainer has made a mistake, feel free to point it out. These interactions will help the trainer better fit the practice to your needs.

Bring your case, to make learning personalized to your skills. Share a clinical challenge you are struggling with, and practice on that. Remember, this is the internet, so please do not share any personal information that may allow for the identification of your clients.

TSQ for psychotherapy integration

Looking at the dots, what do you see?

A tree? a house? a flame? perhaps a clown? or none of the above. When connecting the dots, there is an infinite number of possible stories we can tell. This is what happens in therapy, We have some facts, client behaviors that we can observe, and then we tell a story - our case conceptualization, our theory. Now look at the image below. Who is right? The argument could be endless… It’s a TREE! no! it’s clearly a house! you get the point.

Empirical Therapy where N=1

This is where it gets so important to put the story aside and focus on the dots. Do we both agree that the client is avoiding his emotions? Do we both agree it would be better if he became more in touch with those emotions? It doesn’t matter so much if I call it a defence mechanism, experiential avoidance, or ambivalence. I can clearly describe where i believe the client is, and where I would like him to be. Then, I can choose a relevant intervention. Following the intervention, I can ask - can I see the change I expected in the client? If the answer is yes - excellent. keep moving ahead with the process. If the answer is no - lets rethink, is he not where I thought he was? was this the wrong intervention? or did I not execute it well enough?

Once we have a clear map of what intervention we chose, in a concrete therapy moment, we can then empirically assess our performance, constantly learning and refining our clinical choices. This possibility for ongoing assessment of skill performance is key for the  Deliberate Practice of skills, thus using the feedback you receive withing the TSQ framework will make you a better therapist after every session.