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In This Section:
Practical Interventions
Active Therapy is more efficient
Chapter 11: Beyond the Classic Session, Part 2: Active Interventions
Active Interventions for Entrenched Defenses
In the previous section I discussed how to use a task or objective to focus the therapy. This takes place at the beginning of treatment as you educate the patient and develop a working hypothesis treatment plan and contract. Now it is time to look at interventions that can be used in sessions. The ones described below go beyond those outlined in the three step dance. These powerful interventions can be more effective and more efficient in working with stronger defenses.
So far I have argued that an active, supportive stance is fully consistent with the goals of psychotherapy. Active interventions do have potential side-effects, but I believe we do better to use them with eyes open, than to abandon them entirely or opt for an approach of nonspecific restraint.
Primarily the liabilities of active interventions, as indicated in the chapter on Stance, are two: Implying promises you cannot keep and losing of the degree of distance implied in a stance of optimal expectancy. Keeping those in mind, let us review a number of possible interventions:
Educating: You are expecting the patient to work hard at the agreed upon task. It is much easier for the patient to be a partner when he or she is "sold" on the therapy and clear about what to expect. Education is your way of giving useful background information to create a sense of predictability and clarity about the therapy. Imagine how much easier it is to work with negative transference when you have described in advance how the patient may feel negative things about you, and that you will welcome this eventuality.
Motivating: Coaches know that people perform better when they receive recognition for their hard work and strengths. When they are discouraged, it helps for them to be reminded of the eventual payoff. Of course when you do this, it is important to be careful not to take ownership of the therapy or make false promises. Recognizing the patient's strengths and successes is perhaps the most powerful and safest way to give encouragement. Your words move what the patient already knows from implicit, to explicit, where it feels much more "real."
"Making Bricks:" One of the most useful motivating opportunities comes when the patient has successfully traversed one of his or her classic transactions. An example would be going through the process of adopting a healthier behavior, traversing the expected backlash and coming to the point where the new level of functioning can be taken for granted. I would be likely to tell the patient that he or she has just fabricated a brick, and having done so, will be able to make many more, and use them to build anything.
Active Exploration of Transference: Simple metacommunication is often just what is needed, changing the focus to the defense or resistance, and describing how it works. When you encounter transference resistance, a more active technique will help. Waelder tells us that the essence of the transference, the part that is the source of the patient's emotional reaction is the perceived motivation that is attributed to you. When you encounter a reaction to you that does not belong to you, denial that it pertains to you will only confirm your desire to cover up. You will have to go further and ask for the patient's idea of what possessed you to do the thing the patient is reacting to. This is where there will be the widest, most clear divergence between what the patient knows about you and what his or her emotional reaction is based on. Further, you are showing a willingness to examine yourself, which is precisely what the patient does not expect.
Witnessing: One of the key requirements for catharsis to take place is a context of empathic attunement. Empathic attunement is what happens when you are a witness. Of course this is the silver bullet of the three step dance, but I wouldn't want to miss an opportunity to underline its importance.
Modeling Values : While we do not want to impose our values on our patients, therapy is by definition, against dysfunctional patterns of reaction. Values are embedded in the therapy from the beginning, and the patient identifies you with these values. Rather than trying to eliminate or hide your values, acknowledging them is a better way to protect the patient's right to have his or her own value system. Your non-judgmental attitude and your enthusiasm for health are powerful and beneficial sources of values. When it comes to things not directly relevant to the therapy, such as your politics or spiritual beliefs, obviously these should be left out, or if you can't cover them up, acknowledged as your own.
Permission to Rest: As mentioned in the previous section, it is occasionally very helpful to be explicit in indicating that there are times when the patient may have worked hard enough. These allow you to be more expectant at other times.
General Support: Many things you can say or do are supportive. Unless they undermine the patient's capability, draw the attention to yourself rather than the patient, or imply false promises, then these things will tend to energize the therapy. For example, your willingness to lower your fee or make accommodations in your schedule is very supportive. Your (genuine) liking for the patient and enthusiastic greeting are supportive. Your willingness to make a referral, your expression of condolence or congratulations are all supportive things that that are common to any strong working relationship.
Your recognition of the patient's limitations and readiness for a strategic retreat are supportive. Your measured expectations are supportive. Your accurate assessment that the patient can work harder is supportive. In sum, recalling the order of priorities, support is good for the therapy as long as it does not do harm.
Summary
I hope I have made my point that an active, engaged and supportive approach to therapy is more efficient and more effective. Working in this mode allows the work to go faster with lower frequency of sessions. It makes it easier for the patient to let go of defenses and take risks.