There has been some discussion recently amongst BABCP members in private about whether or not it is desirable to record therapy sessions, either just the sound, or on video. Whatever your views on the subject, I’m sure you’ll agree that it’s good to know that professionals discuss these matters amongst themselves and learn from each other in the process.
There are arguments for and against.
Some of the arguments for the recording of sessions are that it can make supervision of the therapist more effective, and that it can make the therapy more effective for the patient.
The argument that it can make supervision of the therapist more effective is based on the idea that a supervisor needs accurate information about how the therapist does his work. It’s not enough for the therapist to report his own recollection of the sessions — he might be wrong.
For example, a therapist might report to his supervisor that he has an excellent therapeutic alliance with all his patients. On listening to the tapes, however, his supervisor might realise that this is not quite true. The therapist might be imagining a good alliance that does not really exist, or he might have some fault that he is not aware of.
The argument that it can make therapy more effective for the patient is based on the realization that patients do not always remember everything that is said to them in their therapy sessions. If everything is on tape, and they can take the tape home and listen to it, it will help them to remember things that they would otherwise have forgotten.
These seem to be tempting arguments for making recordings…but they are only tempting if you’re not a thoughtful and competent therapist.
If you are a thoughtful and competent therapist, you will understand that a vitally important quality that you bring to therapy is what’s called congruence — a quality of being genuinely yourself. How does supervision fit with that?
A supervisor has to be able to work with a therapist as-is, without creating conflicts for the therapist. That’s not to say that supervision cannot cause change. Supervision very often causes significant change. But any change that it causes must be completely absorbed, accepted, integrated by the therapist.
If the supervisor instead creates conflicts for the therapist, and if the therapist brings those conflicts to the next session with the patient, it means that the patient now has a therapist who is no longer congruent, no longer genuinely himself because part of him is trying to act the part his supervisor wants him to play.
A recording either confirms everything the therapist remembers of the session (in which case the recording is useless), or it conflicts with the way the therapist remembers the session. If it conflicts, it can create a serious problem for the next session.
You might think that checking the observable facts is the most important thing in supervision, but you’d be wrong. In psychotherapy, perceptions and relationships are far more important than observable facts.
Supervisors who jeopardize a therapist’s congruence are not taking their supervisory role seriously enough. It’s vital for effective supervision that supervisors work with therapists’ perceptions in a focussed and empathic way, avoiding the risk of conflicting material that could damage the therapist’s relationship with his client.
So supervisors who use recordings are barking up entirely the wrong tree. The best that can be hoped for is that the recordings make little or no difference.
If you are a thoughtful and competent therapist, you will also understand that an important part of what happens in therapy happens between sessions. Patients do not attend a session simply to memorize the advice that is given to them. They attend in order to create starting points for personal growth. But their personal growth does not take place in the sessions. It takes place in the space between the sessions.
When you make recordings of sessions for a patient’s use, you focus therapy too much on the content of the sessions themselves. Instead of moving forward and growing between sessions, the patient listens to the tape and is dragged backwards to the context of the last session.
An insidious side-effect of this dragging-backwards is that the patient comes to the next session in much the same state of mind as the therapist remembers him at the end of the last session. So for the therapist there is an apparently comforting feeling of continuity between sessions. Each session seems to start well because it is a seamless continuation of the last. But while this makes life seem easy for the therapist, it is at the patient’s expense.
The practice of recoding sessions for patients to listen to turns therapy into mere advice-giving, and turns the therapist into some kind of guru whose every word is to be treasured. Good therapy explores many ideas that are then discarded. The ones that survive in the patient’s mind survive by a form of natural selection. The patient is in charge. The patient decides what to build on and what to ignore. Therapists who use recordings stifle this process, and stifle their patients’ growth.
The current fashion for ‘evidence based’ medicine makes it seem natural to ask what research evidence there is for or against the use of recordings. Little evidence for it seems to have emerged so far.
As usual in discussions like these, some of the research quoted does not bear close scrutiny. For example, a study was conducted to try to assess whether supervisors’ feedback on audio taped sessions helped therapists to become more competent in a specific technique. The study was a randomized controlled trial. It is described in an online abstract, Strengthening Motivational Interviewing, and you can also see the slides of a symposium presentation about it.
Unfortunately the participants in the trial, both the therapists and the clients, were selected in advance so as to exclude those who did not want their conversations taped. This meant that the people taking part in the trial already felt more positive than average about the value of taping, before the trial even started. A positive outcome for taping was virtually inevitable because of this selection bias in the research design.
The therapists who taped their sessions had worksheets and extra telephone supervision that the control group did not have. It is impossible to say whether the use of tapes was a significant factor in the outcome, because the study entangled three separate factors without adequate controls. Again, this was because the research was inadequately designed.
It is even impossible to say whether the feedback itself was significant, because although the control group had agreed to be taped they were not actually taped. This makes it impossible to disentangle the effect of the feedback from the effect of taping itself. It could be that the very fact of having a tape recorder running changed therapists’ or clients’ behaviour, perhaps without their being aware of it, but the design of this study deliberately obscured all that information too.
The study took place in a training scenario. The aim was to increase the therapist’s general level of skill in a very specific technique, not to facilitate the therapist’s treatment of individual patients, which is the proper aim of clinical supervision. Even if the study had been designed competently, the relevance of any results obtained in a training context to supervision in clinical practice is very questionable.
Finally, the study did not even measure the outcome using real patients, but instead used actors. The level of therapists’ skill was not measured in terms of outcomes for patients, but only in terms of subjective ratings by observers of role-playing exercises.
All in all, the design of the study was a shambles from start to finish. Despite this, the magic words “randomized controlled trial” seem to make some people, people susceptible to magical thinking, imagine that the study provides useful information about the value of taping.
Still, it’s good to know, isn’t it, that therapists do discuss subjects like this amongst themselves. The only trouble is, the discussion is taking place after the BABCP’s ruling élite of academics, representing the training industry’s interests, have decided the matter amongst themselves.
Audio or video taping of sessions, or the actual presence of a supervisor in the sessions, is already compulsory for accredited BABCP therapists. Having the discussion now is completely pointless.
Lack of evidence in support of recording does not matter any more. The harm it may do to patients does not matter any more. All that matters is that some trainers thought it would be a good idea (and it possibly is a good idea in training), so it was made compulsory for everyone in clinical practice.
By the way, my own solution is that no recording ever takes place. All therapy sessions are off the record. A supervisor is actually present to observe a proportion of interactions with patients. However, patients do not know (unless they were to press the point) that the extra person present is a supervisor. The patient’s perceptions of what the word ‘supervisor’ means might distort the relationship between patient and therapist. This fudge complies with the BABCP’s foolish and irresponsible requirement while minimising harm to patients.