Thread by @JonathanShedler

These are the 3 necessary elements of a working alliance in therapy. Most clinicians miss #2 or #3.

1. There is attachment—both parties are invested in relationship
2. There is mutual agreement about purpose of the work
3. There is mutual agreement about the methods to be used

#2 is the tough one. The key word is "mutual." It means clinician must 1) develop a psychological understanding of the causes of the patient's difficulties (which will not be the same as patient's—if it were, clinician would be superfluous), 2) communicate this understanding to

Patient in an experience-near way that patient can regognize/resonate with emotiuonally, and 3) reach a meeting of minds w/ patient that this is what both people want to focus on. This is not a linear or sequential process. It's not a didactic process. It is a *mutal* process

of exploration/discussion aimed at reaching a shared understanding & a genuine meeting of the minds. It may take multiple sessions. Generally, the more psychological disturbance, the more work it takes.

Note that it is is not always possible to reach this meeting of the minds.

Patient may have a very different understanding of what they want from therapy, or the roles they and therapist should play in therapy relationship.

This is #1 reason why treatments fail—lack of a shared understanding/agreement about the purpose of the work. If therapist and

patient cannot reach this shared understanding, therapy should not proceed. This is not a treatment failure. It is an authentic and honest acknowledgment that there is not a shared foundation to build from. It may be more honesty than the patient has ever experienced before.

And sometimes, that is the most effective intervention there is.
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