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.
/end
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1/ Contrary to what therapists are often taught, we don’t protect patient privacy & confidentiality because it’s an ethical or legal requirement, although it’s that too. We protect privacy & confidentiality because it is the 𝘱𝘳𝘦𝘤𝘰𝘯𝘥𝘪𝘵𝘪𝘰𝘯 for honest self-exploration
2/ We are asking the patient to share their most personal and vulnerable thoughts, feelings, desires, and fears. We are asking them to share things they may have never told another soul. We are asking them to tell us things they may have never previously told 𝘵𝘩𝘦𝘮𝘴𝘦𝘭𝘷𝘦𝘴
3/ No one is going to do that if there’s even the slightest doubt that what’s said in therapy stays in therapy, or that what’s said and thought in therapy could in any way impact their lives and relationships outside of therapy
Psychotherapy must become a special & sacred space
1/ The goal of psychotherapy is to insert spaces for reflection where they have not previously existed—and thereby create opportunities to know ourselves more fully, connect with others more deeply, and live life more congruently
2/ Psychotherapy is about slowing things down—so we can begin to see and understand the patterns that otherwise happen quickly, automatically, without reflection or awareness
3/ Pronouncements about "optimizing" or maximizing efficiency reveal a misunderstanding of psychotherapy at the most fundamental level. We find ourselves in difficulties because we cannot slow down to reflect. The rush to optimize every facet of life is the disease, not the cure
2/ The claims that CBT is science & "CBT Works" come from Randomized Controlled Trials (RCTs). The narrative is that RCTs evidence supports CBT not psychoanalysis
The problem is that RCTs of psychoanalytic therapy show equally good results (in long run, possibly better results)
3/ But CBT’s entire origin story is that RCTs show CBT is superior
See the problem?
So what do when your origin story is that science shows your approach is better… AND SCIENCE DOES NOT SHOW THIS?
You do exactly what some prominent CBT researchers & thought leaders have been
2/ which is pretty much all that’s ever studied in research trials) are inadequate treatment for most depressed patients most of the time
(Avg effect of antidepressants in research trials is < 2 points on Hamilton Rating Scale for Depression [HAM-D] compared to controls—which
3/ is clinically trivial)
4️⃣ The proper conclusion is not that exercise is more effective than two effective comparison treatments. The proper conclusion is that NONE of the treatments in this study are adequate treatment—and this is with patients who are not severely depressed
2/ tremendous pressure to do more with less, the clinicians are overwhelmed, and they just cannot spend the time with patients that patients really need
In large institutions, MBAs & accountants & lawyers may call the shots in the background, in ways that seriously impact
/3 patient care. Decisions about what treatments are offered are often driven by health insurance company reimbursement schedules, which are definitely not aligned with patient needs
Then cognitive dissonance kicks in with administrators & providers. It’s incredibly hard to go
1/ People’s misconceptions about psychotherapy are dismaying
In last 2 days, I've seen tweets from people who think its purpose is to calm or soothe, to forgive, feel gratitude, be in a loving state of mind, become happy
it all sounds warm & fuzzy but, NO
And while it’s true
2/ any of these things may occur in the course of a particular therapy, or may possibly follow from it, none of them can be the purpose or goal of psychotherapy
Meaningful psychotherapy has one purpose: psychological change
More specifically, it’s to change something about
3/ ourselves that is causing distress or or limitation, that we desire to change, that is realistically possible to change in psychotherapy. And, of course, to develop understanding and clarity about what does and does not fall in these categories