I have been practicing primarily cognitive behavioral therapy in New York City for 20 years. Like most practitioners, I have conducted my work in the office. As the years progressed, I became quite good at building the therapeutic alliance with children, adolescents, and their parents. I would utilize good well-grounded evidenced-based approaches and used outcome measures within the office, relying primarily on self-report. Patients liked me, they reported feeling better and, initially, that implied success to me.
I began to realize that patients were able to learn the skills I was teaching them but did not always generalize these skills to other spaces and places within their life. Even with consistent homework and reviewing what they had learned in past sessions, I never got the sense that they were incorporating these new skills outside of the office frequently.
So, I began to go outside the “four walls of the office” and experimented conducting my sessions outside. Not uncommonly for a CBT psychologist, I would conduct exposure therapy at a Starbucks, Target or any other location where the client exhibited anxiety. But I also began to do therapy outside to help other skills, not just anxiety related, to generalize. I would meet clients at their home to examine their executive dysfunction, help those with mood related issues “surf through” their depression, model how to make friends for those with social anxiety or spectrum disorders and conduct parent management training in the home, where the parenting actually occurs.
I began to realize that “in vivo” treatment for most problems provides a better way to get the skills to generalize. I was able to observe, in action, my clients using the skills I had taught. For me, in office therapy can become stale and it was a challenge to measure change that mattered most (i.e., To what degree do they use the interventions taught?).
Many clients report improvement and I can observe the change as it occurs. In my practice, we are doing this “in vivo” work more often. This is not revolutionary but more of an outgrowth of my cognitive behavioral roots. Most importantly, we can obtain a more valid indication as to whether our interventions are effective.