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Priorities
Balance
Power
Exploitation
Boundaries
Chapter 9: The Therapeutic Relationship
Therapist Priorities
Thinking of yourself as having a hierarchical list of goals is very helpful. When you have a conflict between two desirable actions, your priority list will tell you which to pursue and which to let go of. The following list is suggested.
1. Prevent harm: This ancient principle always comes first and applies to everyone, patient, family, yourself, others. You may not always be able to prevent harm, but you are required to do any and all that you can in that direction. Pain and stress are different from harm. They are not permanently damaging. On the other hand, there are more kinds of harm than physical ones. For example, failure to act when a marriage was being destroyed for unsound reasons could be thought of as irreparable harm. This priority takes precedence over all those below.
2. Protect the therapy: Perhaps this priority seems misplaced, but when the therapy is in the patient's best interest, it is your job to protect it. The "strategic retreat" mentioned earlier is a move to protect the therapy. At the same time, there are occasions when the patient will unconsciously propose a "devil's pact." For example, a chemically dependent patient presents the argument that social drinking is necessary to maintain business relationships. If you accept this dubious premise in order not to lose the patient, you may have compromised the therapy anyway. You have implied the promise that recovery will not require abstinence. Either way, the priority is to protect the future of the therapy.
3. Do the work: Once safety and the future of the therapy are in the clear, you can concentrate on fostering the needed exploration, understanding and change processes. Within this general formula, the specifics depend on your evolving hypothesis about the work that needs to be done.
4. Minimize costs: Costs include money, time and emotional costs like pain and discomfort. Therapy may not be comfortable, but your sense of humor or knowing when to back off may go a long way to making it easier. Professionally, you are expected to bear in mind the patient's best interests. When the requirements of the therapy are met, the patient should expect you to do anything else you can do to enhance the cost/benefit ratio.
5. Be helpful in other ways: Unless it interferes with the above priorities, in my view, it is OK to be helpful. When Freud offered his patient something to eat, he did not feel he was compromising the therapy. There are many situations where such a move would be compromising, but the question is still worth asking. If your patient asked for a medical referral, would you refuse?
Balance
The therapeutic relationship exists for one purpose, to help the patient. This one-sidedness is appropriate, but must be balanced. It would be unfair to expect the therapist to give without receiving equally. What makes this paradox only an apparent one is that the therapist gives in one currency and receives in another. We give time, attention, caring, understanding and emotional energy. There are times when our job may require us to listen to strong criticism and to tolerate uncertainty. This can be hard work. If there is not compensation to balance it, then resentment is the inevitable consequence. Such resentment will inevitably undermine the therapy, so it is part of the therapist's job of preserving the therapy to make sure the balance is kept.
Non-monetary currencies: Trainees aren't paid as much, but they receive training and experience. These are legitimate currencies. The patient who cannot afford an experienced therapist will be happy to have one whose efforts are driven by the desire to learn. This more complex balance requires care and thoughtfulness to avoid exploitation or resentment on either side.
Power
As a therapist, you have a great deal of power. Often you have the power to impose your own values or beliefs on the patient. You have a duty to act to prevent this. Sometimes this means withholding your views, sometimes it means telling the patient about biases that you cannot help showing, and sometimes it means working out your personal issues in therapy or supervision.
Therapist Enjoyment
Doing psychotherapy is often gratifying for the therapist. Just as sessions can be trying, they can also be very pleasurable. As long as the therapist priorities come first, then, as a byproduct, it is not exploitative to enjoy one's work. On the other hand, any time that therapist gratification is at the expense of the patient or the therapy, then it is not proper, and will cause harm.
Mistakes
The above ideals are fully appropriate, but all of us make mistakes. We react automatically from our own unresolved issues, we misjudge, etc. A willingness to acknowledge an error demonstrates that the patient's interests really do come first. Defensiveness confirms that the therapist's self-esteem is more important to the therapist than helping the patient. The errors most likely to damage the therapy beyond repair are those seen as willful failure to act in the patient's best interest.
Boundaries
Much has been written about the necessity of maintaining boundaries, physical, personal and emotional. The only thing to add here is that for every potential boundary violation, one or more of the principles already articulated will have been violated:
1. Follow the therapist priorities.
2. Maintain balance in the relationship.
3. Exploitation of patients is not acceptable.
4. Do not make or imply promises you cannot keep.