1/ It's not just 'helpful' to view the world from patient's/client's perspective, it's a basic requirement for doing therapy & goes without saying (if it must be said, something is already seriously amiss—unless therapist is a beginning student). Therapists strive to enter their
2/ patient's subjective world, see from their perspective, know their desires & fears & understand their experience of self & others "from the inside"—keeping in mind that something about how they are viewing & experiencing the world, self, & others has become a source of pain or
3/ distress. But—and this is key—we enter our patient's subjective world NOT in order to conform the therapy to the experience they are already having of the world, or to duplicate their existing patterns of experiencing self, other & the world in the therapy relationship.
4/ We do so to help them to be able to have DIFFERENT experiences, to create opportunities for other ways of seeing & experiencing that they cannot readily envision, or cannot envision at all. We keep in mind that their current ways of seeing & experiencing the world are
5/ intertwined with their difficulties.
So when a pt cannot conceive of being with another person & allowing themselves to be immersed in experience of the relationship—without monitoring their phone throughout, allowing it it impinge on their experience, allowing it repeatedly
6/ direct & redirect the focus of their attention—we should NOT address it by declaring it to be "an invaluable component of therapy," & couch that as if that were somehow a testament to our therapeutic skill & flexibility. We might instead become curious with our patient, and
7/ invite our patient to become curious with us, about the function the phone may be serving for them, how it may be altering or influencing our respective experiences of ourselves & of one another, and of our relationship in the room—and how it may be doing so in ways that
8/ can all too easily escape our notice & that we may or may not desire. That is therapy.
And why I find it highly problematic when author says, "Eventually I 'surrendered to machines & began viewing technology as... an invaluable component of therapy."
No. A thousand times no.
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1/ Therapy “outcome” is not a standardized scale a researcher, who's never met the patient, chooses in advance & superimposes on therapy process
Real outcome is a shared understanding of desired personal change that emerges organically from the therapy work—unique to each person
2/ Most therapy outcome researchers are not, in fact studying “outcome” in ways meaningful to patients or therapists. They’re making assumptions about what people they don't know want from psychotherapy, and the assumptions often have little to do with what patients actually want
3/ Then they distort the entire therapy process to orient it around their arbitrarily-imposed “outcomes”
Skilled therapists actually orient therapy around a shared understanding—developed with each individual patient—about 1) what is going on psychologically that's giving rise
1/ Rule of thumb, part 1
Most therapy patients will begin to feel somewhat better within first weeks. Expect 6-12 months to make headway with underlying psychological causes
part 2
Add 6 additional mos. for every prior treatment with manualized, "evidence-based" therapy
more⬇️
2/ what they have to unlearn:
-that there’s a quick fix
-that therapist has the answers / can tell them what to do
-that there's a bypass around the honest hard work of self-reflection and self-understanding
-that therapy isn't a procedure done to them, it’s a relationship &
3/ a collaboration
-that unpleasant thoughts & feelings can be disregarded or explained away
-that their difficulties are not encapsulated “illnesses” to address in isolation… they’re woven into the fabric of their lives & their relationships
1/ I’m not sure, but leaning toward the view that all the research showing that therapeutic alliance predicts therapy outcome may be leading us astray. Here me out
Just about any well-intentioned therapist can develop a decent working alliance with someone at the healthier end
2/ of the spectrum of personality functioning (reasonably securely attached, good object relations, mature defenses, no serious personality pathology)
But it’s incredibly difficult to develop a working alliance with people with more severe character pathology (impaired capacity
3/ for attachment, impoverished or malevolent object relations, more primitive defenses, etc)
What if “therapeutic alliance” is really a proxy for personality health vs. personality disturbance?
If so, “therapeutic alliance” research may tell us only that people with healthier
1/ I made a list a while ago, about therapy🚩 that should make you think long & hard about whether you’re seeing right therapist
Starting another, please add
-agrees with nearly everything you say
-diagnoses people in your life
-gives you advice
-mawkish displays of “empathy"
2/ -defaults to calming/soothing in response to everything
-acts like cheerleader/coach
-wants to play role of hero or savior
-wants to plays role of spiritual or religious guide
-validates & affirms whatever you say
-speaks in jargon or “therapy speak” instead of plain English
3/ -jumps in with worksheets or “exercises” instead of listening
-joins you in blaming other people in your life
-seeks to indoctrinate you in politics/ideology
-talks about themselves/discusses their own life
-does most of the talking
-promises a specific result or outcome
1/ Absolutely none of these conclusions are justified
1️⃣ Patients who exercised showed some minimal improvement—but not enough to matter
2️⃣ The patients were not severely depressed to begin with
3️⃣ We already know that antidepressants & brief therapy (8-12 sessions, which is
1/ “Therapists need to be oriented toward... patient’s degree of felt power to influence events.
Many people come to treatment feeling that things just ‘happen to’ them. The absence of a sense of agency is inferable when the therapist has asked a question such as, ‘Were you
2/ feeling sexual desire when you agreed to give oral sex to that guy?’ and meets a blank stare or a response like, ‘I don’t know. It seemed like the thing to do at the time.’ Patients who give such answers are often the same ones who wait passively for the therapist to tell
3/ them what to do, a stance that can flummox clinicians who know [therapy] is not a set of instructions but do not easily find their own sense of agency in the face of this non-participation.
Psychodynamic therapists want clients to feel increasing power to influence their