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In This Chapter:
Building a strong foundation
The treatment contract
When things get "hot"
Will it Fly?
Chapter 5: Structuring the Therapy
Therapy does not simply bring relief, it demands change. Therapy challenges the patient to acknowledge truths and change in ways that are not comfortable or natural. In order for the alliance to hold during these tough times, it must be firmly grounded and carefully maintained. The two most important principles in maintaining a strong therapy are:
1. Don't make or imply promises you can't keep.
2. Act consistently in the patient's best interest.
In my view, the traditional question of whether the patient is suited to the method is inappropriate. All or most of us, regardless of our strengths and weakness, have entrenched dysfunction patterns. Psychotherapy is an excellent tool for modifying such patterns. Rather than applying a method, we will be choosing optimal tools to work with the patient's strengths, mitigate his or her weaknesses and foster the healing and growth processes that will bring about change. This means working actively to design and shape the therapeutic process. Hearing your specific vision of the therapy will further strengthen your alliance with the patient and his or her motivation to do the hard work. This perspective will be reflected in the notes that follow.
Elements of a Well Grounded Therapy
The following potential flaws in the structure of a therapy are more common than one might think. They represent problems that need to be addressed as soon as you become aware of them. The patient will respect you for doing so, and conversely, will hold you responsible for allowing the therapy go forward without confronting them. Waiting for the patient to express dissatisfaction places you in a defensive position that is very hard to turn around.
Rule 1: Be sure the patient identifies the problem as internal, psychological, and within the scope of entrenched dysfunctional patterns of reaction. Less sophisticated patients may seek treatment without realizing that what they want is beyond what therapy can do. Perhaps the patient wants you to change someone else in their life. Perhaps he or she believes that the problem is purely biological, a "chemical imbalance," and expects to be passive in the repair process. Such unrealistic expectations, when expressed overtly, must be confronted and resolved.
Rule2: You should be the best available person to help the patient with the identified problem. If the patient has a better resource available, then when you come under question, the patient's dissatisfaction will be too strong, and the therapy may break. This is especially true for trainees, where the patient may have wanted a therapist of a different gender or a more experienced therapist, etc.
Rule3: The anticipated benefit must justify the cost. This must be true at the outset and throughout the therapy. If the cost/benefit ratio slips into negative territory, it is your job to confront the issue and resolve it. The implied promise is that your services are a wise investment.
The Treatment Contract: Non-Specific Elements
The treatment contract serves two purposes. First it is a means of avoiding misunderstandings and unrealistic promises. Second, you are making a proposal to provide services in an area where you are the expert. Unlike a business contract, where you might want to hide the flaws in your product, as a professional, the patient expects you to help him or her make a wise and informed choice. Your handling of the patient's vulnerability in this unequal relationship will show your commitment to the patient's best interest.
The treatment contract does not have to be written or formal, but before the patient agrees to continue, you should have a common understanding of at least the following topics:
1. What the patient should expect from you. The patient's experience and sophistication may determine how much you have to spell out. Your first session is a chance to show rather than tell how you work. Beyond what you have communicated, the patient will have expectations based on his or her understanding of your profession. Your exploration of the patient's expectations may do a better job than any speech you may give in making sure you have a common understanding. An average statement might be, "I would like to meet with you on a weekly basis. I will try to help both of us come to understand what makes you 'tick,' and why you have had these symptoms. We will work together to clarify how best to help you resolve them."
2. What you expect of the patient. Example: "I am going to ask you to talk about whatever is on your mind, especially regarding your efforts to understand and change the symptoms we have discussed." This is not the only approach, but is a reasonable starting point. With most patients coming on time and paying the bill are part of their unspoken understanding of how your profession works. I hate bristling with rules, so I wait to explain my 24 hr. cancellation policy till it becomes an issue. If I lose the fee for a session in the process, that is the price I am personally willing to pay for not having to discuss rules at such an early stage in the building of a relationship.
Case-Specific Elements
Your hypothesis about the case will lead you towards clarification of the work that needs to be done. Remembering from physics, the definition of work is moving an object across a distance against a resistance. Therapy involves an analogous kind of work and can be conceptualized as a journey:
A------------®----------->B
Point A represents the unsatisfactory place where the patient starts and B represents a desired place where he or she will have less stress and/or greater satisfaction and success in life. The symbol ® stands for the resistance against which you and the patient will work to make the needed changes happen. Note that in this conceptualization, the resistance may be the unconscious kind that it is your job to track, or the resistance the patient feels to doing things that are painful, frightening or simply difficult. Using this conceptualization or whatever partial formulation you have, your treatment contract will have two more elements:
3. What results the patient can expect. At the outset, you may not be able to describe exactly what B will look like or how long the journey will take. For example,"I think I can help you. We'll monitor your progress along the way so we will have a better idea of how you are doing and how long it might take. I would rather keep the meeting frequency at a level that you can sustain for whatever time it takes." To promise more might be dangerous, but if you can be more specific, that is even better.
4. Enough about the process and the alternatives for the patient to decide if your proposed treatment plan is the best choice. Here is an example with more specificity: "I think your background left you with a lot of negative feelings about yourself. We will try to help you come to experience yourself and treat yourself as a first class citizen. You may have uncomfortable feelings as you do that, and we will work with those as they come up. Alternatively you could see a cognitive therapist who won't be so interested in how you got this way, but I believe that understanding your past will make the job a little easier. It will be hard work for you, and I will try to help you keep moving forwards even when you want to go backwards."
After the Initial Agreement
As your understanding grows and evolves, the contract will, too. The purpose of having a contract remains the same, to avoid misunderstandings and to demonstrate your commitment to the patient's best interests. Thus, continuous monitoring of your mutual understanding, expectations and progress is in order.
As the therapy progresses, the patient's hidden agendas and transference expectations will become more insistent and may break into consciousness. As we will see in a later chapter, you will disappoint the patient, since you will not be fulfilling the patient's secret idea of a cure. Instead, you will be offering an "inferior" substitute, understanding. This will definitely strain the relationship. As this and any other possible misunderstanding or difference of opinion trouble the relationship, you will need to be ready to return to the treatment contract. If there are modifications to make, you will be able to renegotiate on the spot.
Reopening the Negotiation
Your readiness to initiate a review of your agreement and understanding is an important part of stabilizing the therapy. The fact that you carry a clear version of your mutual understanding will be reassuring to the patient. As you review what you set out to do, and how the work was to proceed, the patient will recognize that he or she did, indeed, have the same understanding. This mutual understanding will make it much easier to discuss the new elements that have come into the picture. You will not be on the defensive but will be able to listen to the patient and lead him or her to clarity about your work together.
If you have anticipated problems and explained them before they come up, you will be on even stronger ground when they become hot issues. "I am so glad you are expressing your critical thoughts about me. As I mentioned some time ago, you have tended to be afraid of your anger, so your doing so now is a sign of progress. I will listen to your criticisms and try to understand exactly what you mean. If I owe you an apology, you will certainly have it. No matter what happens, we both stand to learn a lot."
Will it Fly?
Chemists use something called an "energy level diagram" to analyze whether a reaction will go forward or not. Very similar considerations apply to psychotherapy. This is a more sophisticated version of the "cost/benefit ratio." I'll try to make it simple. The "energy level" equates to stress. The higher the energy level, the higher the stress. A lower energy level means less stress and more comfort.
"Energy Level Diagram" for Psychotherapy
1. Change is stressful. The increased stress ("Energy of Activation") involved in activating emotions is a deterrent to the therapy and cause of resistance. Some things like our own empathic presence act as a catalyst to lower the stress required for the therapy to go forward. Still, depending on the nature of the problem, the patient must be able and willing to cope with some stress in opening up and feeling. An understanding of this factor will help you look at the therapy from the patient's point of view. You will be a better partner in helping the patient decide if the gains will be worth the stress.
2. The "after" state must be less stressful and more satisfactory than the "before" state. In chemical terms, this means that the energy level is lower, in psychological terms, more relaxed and comfortable. The greater the improvement,"energy of change," the better the therapy will work. Of course, the patient has to have some way to believe that the result will make his or her effort worthwhile. Showing is much better than telling, so achieving early improvement will greatly benefit the therapy.