Practicing Psychotherapy: My Response to the Seven Questions
By Jared DeFife, Ph.D. in The Shrink Tank
PsychologyToday Blogs
Feb. 12, 2009
Ryan Howes has done a wonderful job of putting together the Seven Questions project, a collection of responses to seven questions about psychotherapy posed to numerous practitioners in the field. His stated goal for the project has been "to illuminate the various clinical approaches to psychotherapy". As Ryan has frequently encouraged others to respond to the Seven Questions in their own blogs, and since I'm here to write about psychotherapy, I wanted to take a shot.
Seven Questions:
1. How would you respond to a new client who asks: "What should I talk about?"
First, I ask any new client to "please tell me about what's most important in your life right now". I hope to learn what people care most about, how they identify themselves, and what directions they would like to go with their lives. As a general approach to therapy, I also ask people to do the very difficult task of saying whatever is on their mind, and to talk about their most important wishes, fears, concerns, feelings, and relationships. As part of this process, I frequently review with clients a Socialization Interview, adapted from the writing of Lester Luborsky. This material discusses what to expect from the therapist, what things may be important to discuss, how therapy may help with their concerns, and what the treatment frame will look like. From my clinical research, I have written about the importance of preparing people for what to expect in treatment, describing how treatment may help with their concerns, and the effectiveness of collaboratively identifying treatment goals.
2. What do clients find most difficult about the therapeutic process?
Trust. As therapists, we are asking people to talk about personal and intimate details of their thoughts, feelings, and life experiences. And we're asking them to tell these things to a complete stranger. It's quite healthy to feel hesitant to be so revealing to another person. Trust is a quality that builds in a relationship over time and experiences together. Furthermore, it can be extremely difficult to talk about and experience powerful emotions. Such work needs to be done in the context of an engaging, encouraging, collaborative, and supportive relationship. Being open, vulnerable, and honest with another human being is an incredibly brave and courageous act.
3. What mistakes do therapists make that hinder the therapeutic process?
I think it's hard for anyone to say what a mistake in therapy is. There are no referees to blow the whistle and throw a flag. Where one therapist sees as a mistake, another therapist might see a brilliant intervention. Therapy is a series of choice points, and what direction they may lead is impossible to know.
Some therapists try to give too much advice. If a problem was easily solved by advice, a person probably would have found or figured out that solution before coming to therapy. On the flip side, some therapists are not active or suggestive enough out of fears of unduly influencing the client. Well, people come to therapy for help, they are asking for some sort of influence to move forward in their lives. If a person wanted a blank slate, they could talk to a tape recorder. It's not possible to be "neutral", nor would it really be desirable.
Another huge difficulty comes when therapists are too dogmatic about their treatment method. Good therapists integrate techniques from different treatment modalities (e.g. psychodynamic, CBT, experiential, DBT) and are flexible in their approach.
Many therapists, especially novice ones, run into trouble with clients when they feel there is some subject they can't talk about. In times where that happens, therapists often take their own discomfort and blame the patient, saying that the patient is "too fragile", "not ready to hear that", or talking about something will "retraumatize" them. Of course timing is important, but if there's a topic that the therapist feels is off-limits, something is going wrong in the therapy, and often the therapist needs to explore their own difficulty with the issue. This is one reason that personal therapy for the therapist is an invaluable tool.
Finally, too many therapists seem to mistake empathy for niceness. They feel like they should never get angry clients or establish firm boundaries/reinforcements even when they do something angering and disrespectful (e.g. not paying the bill, always coming late, excessively demanding, constantly denigrating). A therapist is doing their client a disservice by allowing such behavior to pass unaddressed because such behavior will absolutely not be adaptive for the patient in their relationships with others. Therapists give the benefit of working through such difficulties in the therapeutic relationship; others in the client's life will not necessarily allow the space for such discourse.
*At the end of this post, I give citations for two papers that would likely be useful for any clinician. They review empirically identified characteristics and techniques that either enhance or diminish the therapeutic relationship.
4. In your opinion, what is the ultimate goal of therapy?
Depends on the person and whatever we've agreed is important for him/her to cultivate in life. Obviously, psychiatric symptom reduction is important. Furthermore, developing the ability to engage in productive and fulfilling work, maintaining sustained and satisfying relationships, feeling able to adaptively manage conflicts, being able to experience and express a full range of emotions (joy, sadness, love, pride, excitement, anger, etc.), caring for one's mental and physical health.
5. What is the toughest part of being a therapist?
It's mentally and physically taxing work (who knew sitting and conversing all day could be so tough?). Sustaining alertness, patience, thoughtfulness, memory, and attention all day, everyday is a difficult task. I also have to say something about the bureaucracy...notes, scheduling, billing, dealing with insurance companies, managing risk...there are times it can get pretty ridiculous. Also, people treat you strangely when they meet you at cocktail parties and find out what you do.
6. What is the most enjoyable or rewarding part of being a therapist?
You get to talk with people for a living, how great is that? People let you into their hearts and minds, and what you find there is always touching and fascinating. You also get to learn tons about yourself and about life.
7. What is one pearl of wisdom you would offer clients about therapy?
Two quotes:
"The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts."
-Bertrand Russell
and
"When you share pain, there's less of it, and when you share joy, there's more of it."
-Spider Robinson, from the short story "Fivesight"
_____________________________________________________________________________
*Ackerman, S., & Hilsenroth, M. (2003). A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review, 23, 1-33.
Ackerman, S., & Hilsenroth, M. (2001). A review of therapist characteristics and techniques negatively impacting the therapeutic alliance. Psychotherapy, 38, 171-185.
By Jared DeFife, Ph.D. in The Shrink Tank
PsychologyToday Blogs
Feb. 12, 2009
Ryan Howes has done a wonderful job of putting together the Seven Questions project, a collection of responses to seven questions about psychotherapy posed to numerous practitioners in the field. His stated goal for the project has been "to illuminate the various clinical approaches to psychotherapy". As Ryan has frequently encouraged others to respond to the Seven Questions in their own blogs, and since I'm here to write about psychotherapy, I wanted to take a shot.
Seven Questions:
1. How would you respond to a new client who asks: "What should I talk about?"
First, I ask any new client to "please tell me about what's most important in your life right now". I hope to learn what people care most about, how they identify themselves, and what directions they would like to go with their lives. As a general approach to therapy, I also ask people to do the very difficult task of saying whatever is on their mind, and to talk about their most important wishes, fears, concerns, feelings, and relationships. As part of this process, I frequently review with clients a Socialization Interview, adapted from the writing of Lester Luborsky. This material discusses what to expect from the therapist, what things may be important to discuss, how therapy may help with their concerns, and what the treatment frame will look like. From my clinical research, I have written about the importance of preparing people for what to expect in treatment, describing how treatment may help with their concerns, and the effectiveness of collaboratively identifying treatment goals.
2. What do clients find most difficult about the therapeutic process?
Trust. As therapists, we are asking people to talk about personal and intimate details of their thoughts, feelings, and life experiences. And we're asking them to tell these things to a complete stranger. It's quite healthy to feel hesitant to be so revealing to another person. Trust is a quality that builds in a relationship over time and experiences together. Furthermore, it can be extremely difficult to talk about and experience powerful emotions. Such work needs to be done in the context of an engaging, encouraging, collaborative, and supportive relationship. Being open, vulnerable, and honest with another human being is an incredibly brave and courageous act.
3. What mistakes do therapists make that hinder the therapeutic process?
I think it's hard for anyone to say what a mistake in therapy is. There are no referees to blow the whistle and throw a flag. Where one therapist sees as a mistake, another therapist might see a brilliant intervention. Therapy is a series of choice points, and what direction they may lead is impossible to know.
Some therapists try to give too much advice. If a problem was easily solved by advice, a person probably would have found or figured out that solution before coming to therapy. On the flip side, some therapists are not active or suggestive enough out of fears of unduly influencing the client. Well, people come to therapy for help, they are asking for some sort of influence to move forward in their lives. If a person wanted a blank slate, they could talk to a tape recorder. It's not possible to be "neutral", nor would it really be desirable.
Another huge difficulty comes when therapists are too dogmatic about their treatment method. Good therapists integrate techniques from different treatment modalities (e.g. psychodynamic, CBT, experiential, DBT) and are flexible in their approach.
Many therapists, especially novice ones, run into trouble with clients when they feel there is some subject they can't talk about. In times where that happens, therapists often take their own discomfort and blame the patient, saying that the patient is "too fragile", "not ready to hear that", or talking about something will "retraumatize" them. Of course timing is important, but if there's a topic that the therapist feels is off-limits, something is going wrong in the therapy, and often the therapist needs to explore their own difficulty with the issue. This is one reason that personal therapy for the therapist is an invaluable tool.
Finally, too many therapists seem to mistake empathy for niceness. They feel like they should never get angry clients or establish firm boundaries/reinforcements even when they do something angering and disrespectful (e.g. not paying the bill, always coming late, excessively demanding, constantly denigrating). A therapist is doing their client a disservice by allowing such behavior to pass unaddressed because such behavior will absolutely not be adaptive for the patient in their relationships with others. Therapists give the benefit of working through such difficulties in the therapeutic relationship; others in the client's life will not necessarily allow the space for such discourse.
*At the end of this post, I give citations for two papers that would likely be useful for any clinician. They review empirically identified characteristics and techniques that either enhance or diminish the therapeutic relationship.
4. In your opinion, what is the ultimate goal of therapy?
Depends on the person and whatever we've agreed is important for him/her to cultivate in life. Obviously, psychiatric symptom reduction is important. Furthermore, developing the ability to engage in productive and fulfilling work, maintaining sustained and satisfying relationships, feeling able to adaptively manage conflicts, being able to experience and express a full range of emotions (joy, sadness, love, pride, excitement, anger, etc.), caring for one's mental and physical health.
5. What is the toughest part of being a therapist?
It's mentally and physically taxing work (who knew sitting and conversing all day could be so tough?). Sustaining alertness, patience, thoughtfulness, memory, and attention all day, everyday is a difficult task. I also have to say something about the bureaucracy...notes, scheduling, billing, dealing with insurance companies, managing risk...there are times it can get pretty ridiculous. Also, people treat you strangely when they meet you at cocktail parties and find out what you do.
6. What is the most enjoyable or rewarding part of being a therapist?
You get to talk with people for a living, how great is that? People let you into their hearts and minds, and what you find there is always touching and fascinating. You also get to learn tons about yourself and about life.
7. What is one pearl of wisdom you would offer clients about therapy?
Two quotes:
"The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts."
-Bertrand Russell
and
"When you share pain, there's less of it, and when you share joy, there's more of it."
-Spider Robinson, from the short story "Fivesight"
_____________________________________________________________________________
*Ackerman, S., & Hilsenroth, M. (2003). A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review, 23, 1-33.
Ackerman, S., & Hilsenroth, M. (2001). A review of therapist characteristics and techniques negatively impacting the therapeutic alliance. Psychotherapy, 38, 171-185.
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Execellent article.
