therapeutic alliance

What is Transference and Countertransference?

On this week’s episode of the podcast, I talk about transference and countertransference. It’s the fourth episode in my four-part therapeutic alliance series where I discuss best practices on dealing with the doctor - patient relationship.

Here are the three previous episodes:

Part 1 - Introduction

Part 2 - Logotherapy and Meaning

Part 3 - What is empathy and how to improve it

What is transference?

Historically the term “transference” refers to the feelings, fantasies, beliefs, assumptions and experiences unconsciously displaced on the therapist that originate in the patients’ past relationships. More recently, transference is seen as the here and now, valid experience the patient has of the therapist.

It is “a mixture of real characteristics of the therapist and aspects of the patient’s figures from the past—in effect, it’s a combination of old and new relationships.” (Gabbard)

How does transference work?

The patient’s early experiences develop organizing principles, constructing a framework for future interpersonal interactions. (Maybe their dad was an abuser, so they project that you will abuse them.) Transference is the continuing influence of these ways of organizing and giving meaning to experiences. They crystallized in the past, but they continue in an ongoing way in the here and now. The therapist’s actual behavior is always influencing the patient’s experience of the therapist because of this.

When a patient visits a therapist, they seek a new developmentally needed experience, but they expect the old, repetitive experience.

There is often misattunement to painful circumstances that can't be integrated into a person’s emotional world. For example—a child who can’t demonstrate his emotion in a way that his parents can handle causes the parents to move away from the child, creating distance. The child then subdues the emotion and creates a new “ideal self” so they can interact with others and no be rejected. The child then doesn’t know how to deal with strong emotion, even moving into adulthood.

Unintegrated affects become lifelong emotional conflicts and vulnerabilities to traumatic states.  To handle the difficult situation, they develop defense mechanisms. Those defenses against affects become necessary to maintain psychological organization.

That “ideal self” will stay in place with others until you come along. If they see you as a safe person, they will express their emotions—anger and all—towards you.  


This is where it’s important to understand transference, and to be able to give your patient a safe place to express their emotions.

When we understand transference is happening, we can listen from the patient's world, acknowledge their subjective perspective, resonate with them, look for their meanings, and form and alliance with the patient's expressed experience.

Of course we must expect their hesitations to trust us, avoid us, have feelings of shame, guilt, and embarrassment...it is uncomfortable to share what one feels.

Positive Transference

Negative transference isn’t the only type of transference—there is also positive transference, where you remind the patient of a positive relationship they had, so they feel deeply connected to you. People with borderline personality disorder are very quick to attach, usually commenting that they have never felt so close to a therapist before. When someone does say very positive things to me, especially in the first few sessions, I let them know that it’s also okay to express negative feelings towards me as well.  

Transference-focused therapy

Kernberg wrote about transference focused psychotherapy. He hypothesized about the developmental birth of borderline personality disorder. By exploring and integrating these “split-off” cognitive-affective units of self and other representations, patients will be able to think more coherently and reflectively. They will be more realistic and accurate in their thoughts, feelings, intentions and desires about themselves and others. Integration will allow for increased modulation of affect, coherence of identity, increased capacity for intimacy, and improved functioning (Kernberg 2008).

Levy (2006) studied transference focused psychotherapy (TFP) vs dialectical behavior therapy (DBT) vs supportive psychodynamic psychotherapy for borderline personality disorder. He found that TFP had increased secure attachments (whereas the other 2 did not change it), with increased narrative coherence. It also improved reflective function—the ability to mentalize the thoughts, feelings, goals of another person.

What are some common transferences?

  • Sibling rivalry

    • Competitiveness, comparing, jealousy.

  • Maternal

    • Possibly see you as nurturing or abusive.

  • Paternal

    • Possibly wants you to solve their problems, asks for direct advice.

  • God

    • Where they want you to be all powerful or omnipotent.

  • Erotic

    • One of their primary attachment figures might have sexualized them, so they might yearn for erotic attention and affection. Perhaps a patient falls in love with you, or someone similar physically to you.

  • Idealizing or contemptuous

    • They could view you as a savior, or feel contemptuous to you.

  • Passively hoping for a miracle

  • A person prone not to trust will view the therapist with suspicion

  • A person who struggles with anger will have anger towards the therapist

  • Transferences are influenced by age, gender, clothing, bodily attributes, context, vocabulary & choice of words, personality characteristics

  • Be a certain way to have you stay connected with them  

How do deal with transference in therapy:

Here is the main, overarching principle when dealing with transference: have empathy. Be empathic. Be open to their feedback. Don’t take things personally. Be connected with your patient. Developing a therapeutic alliance requires you being connected, and being connected requires you to allow your patient to explore their emotional world with you. That requires psychological safety.

When you are a safe place, they will hopefully be able to connect, and you can help them identify their transferences so they have a chance at developing healthy relationships in the future without bringing their past with them.

If my patient had a previous therapist, I always ask them, “What went well and what did not go well in your past therapy relationship?”

Other questions I ask are:

  • “How would you like your past therapy to have been different?”

  • “When you felt disappointed and misunderstood, were you able to share that feeling with your therapist?”

  • “In what ways would you like your relationship with me to be like your experience with your last therapist?”

  • “What are some of your worries about what you might experience in your treatment with me?”  

When I can tell they don’t want to come to therapy. I normalize their feelings so they feel like they can share with me.

  • “This is a laboratory where we look at what goes on between us, and when you tell me you are mad at me, I am going to be excited about your sharing your feelings, good or bad.”

  • “What are you feeling about leaving me for the day?”

  • “What did you do when you were young and something bad happened to you?”

    • “Go to mom? Go to Dad? Go out alone?”

    • “When you looked for help how were you responded to?”

    • “Were you comforted? Did it help?”

    • “How did it make you feel when you wanted somebody to help your upsetness?”

    • “I want to be with you in this moment of sadness and loss.”

When you sense an empathic strain, mending it is priority number 1. I might say, “Help me understand what I might not have understood here.” Or, “If I said something that makes you feel worse about yourself then let’s talk about it now.” Try to prevent an empathic strain from progressing to an empathic rupture in your relationship by catching the strains early on.

Here are a few tips to handle when patients exhibit strong emotions towards you:

  • Be enthusiastic and curious about patients’ experiences when coping with intense feelings.

  • Be particularly encouraging about them discussing their feelings, and especially their feelings towards you. Whereas in the past there might not have been a  safe place to get angry, they are entitled to want to have a different experience with you.

  • Say explicitly that they are allowed to have all of their feelings (including loving and hating) in the therapy relationship and that they will be dealt with in words and not in actions.

  • Convey to them that they can feel secure and accepted and not reproached or rejected, even if they have negative feedback or feelings towards you.

  • You can work cooperatively to help them process and modulate their emotions.

  • You can explore together what actions might be appropriate for them when the flooding feelings erupt and they are unsure about what might happen as consequences.

  • Complicated emotions are inevitable: the opportunity we offer is to enhance ways of coping with desirable as well as disruptive emotions. Emotions may be congruent with experiences in the past, but not necessarily appropriate in the present context in which they recur.

When we are young, we are unable to metabolize emotions correctly, especially in the face of trauma or an unsafe caregiver. When we age, we transfer those patterns of belief onto every other relationship in our life, trying to recreate that. When you, as a therapist, offer a safe environment for a patient to experience those strong emotions, you are helping them rewire their belief system around those emotions. It allows them to interact with every other person in a new way.

Countertransference:

The original and narrower definition of countertransference centered around the therapist unconsciously experiencing the patient as someone from their past (similar to transference). Now, countertransference is seen as the therapists’ total reaction to the patient.

First, it’s important to note that therapists need to practice what they preach: do the work in your own therapy so you can identify your own transferences. The less clouded your vision is of what’s happening in sessions, the better. For example, one therapist saw nearly every patient as a trauma victim, and occasionally led them to believe they’d been traumatized as well in the same way.  

Countertransference is seen as a source of important information about the patient: it can be a major diagnostic and therapeutic tool. “Countertransference is an instrument of research into the patient’s unconscious.” (Paula Heimann)

Now it is seen as a jointly created reaction in the clinician (some reactions from the therapist's past, some induced by the client's behavior).

There are continuously fluctuating levels of influencing the transference and countertransference by contributions from both patient and therapist during all their interactions. My mentor, Dr. Tarr, said, "To every relationship we bring learned expectations from past encounters.”

One way to handle countertransference to make sure you are coming from a healthy place is to use your left brain to integrate with, and therefore dampen, the right brain. Learn from what you are feeling during the session, but observe yourself with curiosity.

Another form of possible transference is sexual attraction towards a patient. Studies show that 85% of male therapists at some point have erotic arousal towards a female patients. Obviously, it is important to not act on or tell your patient about those feelings.

You should also allow yourself to mirror the patient’s emotions, as to follow the patient’s emotional movements and unconscious content.  

Before a patient enters the room, check in with yourself. How are you feeling? What are you feeling?

Here is a checklist I like to use before my sessions with patients. It is based on 7 basic emotions:

  •  Disgust

    • I dislike him/her.  

    • I feel repulsed by him/her.

  • Attraction

    • I have compassion for the patient.

    • If they were not my patient I would want to date him/her.

    • I feel sexually attracted to him/her.

    • If he/she were not my patient I would want to be their friend.

    • I look forward to sessions with him/her.  

    • I wish I could give him/her what others never could, protect him/her like no one could...

    • I feel I understand him/her.  

    • I have warm, almost parental feelings towards him/her.

    • I self-disclose more about my personal life with him/her more than with other patients.

  • Sadness

    • I wish I had never taken the patient on...

    • I feel sadness/depression in sessions with him/her.

    • I feel guilty about my feelings towards him/her.

    • I feel guilty when she/he is distressed or deteriorates, as if I must be somehow responsible.  

  • Angry

    • I feel dismissed or devalued.

    • I feel annoyed in sessions with him/her.

    • I feel criticized in sessions with him/her.

    • I feel angry with him/her.

    • I feel anger at people in his/her life.

    • I feel competitive with him/her.

    • I feel used or manipulated by him/her.

    • I have to stop myself from being aggressive or critical with him/her.

    • I feel pushed to set firm limits with him/her.

    • I feel resentful working with him/her.

  • Dissociation/Shut Down

    • I feel confused in sessions.  

    • I am overwhelmed by strong emotions with him/her.

    • I feel hopeless working with him/her.

    • I feel like my hands are being tied or that I have been put in an impossible bind.

  • Sensorium issue

    • I feel bored in sessions with him/her.

    • My mind wanders to things other than what he/she is talking about.

    • I feel sleepy when talking with him/her.  

  • Fear/Anxiety

    • I feel anxious/frightened working with him/her.

    • I fear I am failing to help him/her.

    • His/her sexual feelings towards me make me anxious or uncomfortable.

    • I fear being incompetent or inadequate to help him/her

    • After treatment ends I worry about him/her more then most patients.

It is completely normal to have feelings—both good and bad—towards patients. We are humans, not robots! Sometimes it might seem like you’re supposed to be perfect or void of feelings towards your patient, but that doesn’t allow a living, growing, healthy therapeutic alliance towards them. The important thing is to notice how you feel, without self judgement. Then, deal with those feelings in a healthy manner, like through seeking out your own therapy, getting a mentor, etc. However, sometimes merely allowing yourself to notice the feelings and owning up to the feeling of anger, attraction, boredom, or sadness, is enough to dissipate it.

It’s easy to be busy after a session. It’s better to practice noting your feelings. After all, how can we help our patients express and normalize their feelings if we cannot do it for ourselves?

Conclusion

If you are a mental health professional, I would love for this to be your community. We are in these trenches together, and it’s pretty common for therapists to feel totally exhausted and burned out from all of the countertransference. I hope that through this community, we can develop better practices, help each other, and grow together.

If any of you have any questions or listen to the podcast, I’m active on social media. I’d welcome any feedback you have. My social handles are: Instagram @Dr.DavidPuder, Facebook: @DrDavidPuder, or Twitter @DavidPuder




How Empathy Works And How To Improve It

What is empathy?

Empathy is the ability to understand another’s state of mind or emotions. It is also is being able to feel, understand and share with someone else in what they are saying, their meaning of life, their motivations and values.

In research there are 3 types of empathy that are commonly described: cognitive, affective, and compassionate.

Cognitive empathy

Cognitive empathy is also known as perspective taking, and it can help someone understand another’s personal experience. It also tends to reduce interpersonal aggression. Cognitive empathy is exactly what it sounds like—cognitively understanding someone’s situation, emotions, and motivations. When we understand someone else, we are more likely to view their behavior as similar to our own.

  • One study of Asperger syndrome showed they had lower cognitive empathy but NOT affective empathy. (Dziobek, 2008)

Affective empathy

Affective empathy is about a shared emotional experience, one of feeling together. It uses the mirror neuron system, which I will discuss later on in the article. Affective empathy forms powerful emotional relationships.

  • Boys with higher aggression had ½ the affective empathy, but the same level of cognitive empathy, as the non aggressive control group (Schechtman, 2002)

Compassionate empathy

The third form of empathy is compassionate empathy, which is also called empathic motivation, prosocial concern, or sympathy. This is when you feel moved to help another from how to experience their reality.  

The science of empathy

Mirror Neurons are sharing neurons

Our brain has neurons solely designed to mirror other people. From birth, when we focus on another's movements, emotions and intentions, our brain lights up automatically, and largely unconsciously, around 10% the same way. Our own body-state can be derived from someone else outside of us. We can therefore understand and map out the mind of others by placing ourselves in a comparable body state. This process is important for empathy, intuition, transference, countertransference, enactment, projection, internalization and intersubjectivity.    

The discovery of mirror neurons:

In 1992, while studying a monkey's brain with electrodes attached to the motor area (the area that lights up when movements by the body are made), researchers accidentally discovered that not only would the neurons become activated by the monkey reaching out to pick up a piece of food, but also when the researchers made a similar movement. Later, the same team published a paper that showed that there were mirror neurons responding to mouth actions and facial expressions. Further studies confirmed that around 10% of neurons in certain areas of a monkey's brain had mirror abilities. Later, these studies were expanded to humans.  

Current research:

A recent study summarizing the data of 125 fMRI studies of humans (brain imaging that shows what is active), found that there were many areas of the brain with this capacity. (Molenberghs, 2012) Beyond seeing actions performed by others and having them represented in our brain, there are 3 other areas of the brain that are activated in a similar fashion:

  • Ever wonder why watching people embrace enthusiastically at an airport is fun? When you observe someone being touched, a similar area in your brain (the secondary somatosensory cortex) activates in a similar way as the person being touched.  (Keysers, 2004)

  • When you only hear something, like someone cracking open a peanut, how do you know what is occurring? Another study showed that there was a similar brain circuit firing in both doing the action and hearing it, and just hearing it. This study also showed that those with higher scores on perspective taking (ability to slip into another's shoes) had stronger activation of mirror areas! (Gazzola, 2006)   

  • When we watch someone grieve at a funeral, ever wonder why we feel their sadness?  When you feel emotion, you experience the emotion in your brain, like they are to a lesser extent.  (Gaag, 2007)

    • When normal college students looked at photographs depicting emotions, out of their awareness their own face muscles depicted the same emotion on an EMG.  

    • “We are hard-wired to feel what other experience as if it were happening to us.” (Marco Lacoboni)

    • We used to say, metaphorically, that ‘I can feel another’s pain.’ But now we know that my mirror neurons can literally feel your pain.

    • “Mirror neurons dissolve the barrier between you and someone else.” (Vilayanur Ramachandran)

Now researchers are saying that the mirror neuron system is involved with:

  • Understanding another's actions and intentions

  • Neural basis for the human capacity of empathy

  • Learning new skills by imitation and rehearsing

Non-empathic types—the Dark Triad

The “Dark Triad” refers to three types of disorders that cause people to have low empathy for others. The big common denominator for these people is a deficit in affective empathy, but after matching for primary psychopathy, the others are no longer predictors of low affective empathy (Wai 2012). The Dark Triad consists of: narcissists, Machiavellians and psychopaths. People who have narcissistic traits and machiavellian traits often have some primary psychopathy traits as well.  

Individuals high in narcissism had positive feelings when looking at sad faces and were accurate at recognizing anger (higher cognitive empathy may be bias at grandiose self reporting). Individuals higher in primary psychopathy (they can usually maintain cool composure and carefully execute planned behaviors with a lack of morality, whereas those with secondary psychopathy respond to their negative emotion when they harm others) felt positive when looking at sad, angry or fearful images and more negative when looking at happy images, and were rather inaccurate at identifying all emotions.

Machiavellians felt negatively with happy images and positively with sad images, while they tended to inaccurately identify happy or sad emotions.

Empathy and the medical field

  • Studies show that empathy declines in third year of medical school (both for men and women, but women are higher in empathy in general)  (Hojat, 2009) but that doctors can also increase their empathy through certain practices. (Riess, 2012)

  • In a study of 20,961 patients, primary care providers with high empathy have been shown to have lower rates of metabolic complications compared to moderate to low scores (4.0 per 1,000 patients vs 7.1 and 6.5 respectively) (Canale, 2012).  

  • There have been many studies that show both cognitive and affective empathies ability to change patient care when high and low empathy are demonstrated. For example, there is a correlation to a doctor’s ability to more accurately diagnose depression and anxiety, understanding interactions, more positive patient outcomes, increased therapeutic alliance, more patient satisfaction, and fewer malpractice claims. Doctors who showed higher empathy were more likely to have their HIV patients take their medications (Flichinger 2015).

Research on “Therapist Effect”

  • Some doctors or therapists have better outcomes. Empathy seems to be important in therapist effectiveness and can be increased.  

  • Different studies show outcomes vary between patients, of which 5-12% can be attributed to a particular therapist.   

  • One study of 91 therapists over 2.5 years: the best therapist showed a change of 10 times the average mean, the worst showed the an average increase in symptoms.  (Okiishi, 2003)

  • Higher interpersonal skills has been linked to better outcomes when studying therapist effect. (Anderson, 2009)

  • Higher-empathy therapists have higher success regardless of theoretical orientation. Lower-empathy therapists linked to higher dropout rates, relapse rates, and weaker therapeutic alliance. Empathy was shown to have an effect size of 1.22-1.43 when independent observers rated empathy for substance use outcomes. (Moyers, 2013)

  • In a big study on therapist effect (69 therapists, 4,580 patients), they found that years of experience, gender, age, profession, highest qualifications, caseload, degree of theoretical integration did not predict outcome. The amount of time spent targeting improving specific skills and reviewing therapy recordings predicted client outcome.  

Can we improve our empathy?

Studies show that we can. Here are some things that can improve your ability to empathize:

  • Optimize your sensorium—keep yourself healthy. When you are tired, hungry, chronically stressed and with poor focus, it will be harder to enter into the experience of another.

  • Try to understand the person’s emotions that you are with.

    • A study showed by trying to pay attention to emotion mimicry was increased (linked to affective empathy)

  • Read fiction (Bal, 2013) allow yourself to be transported into the book.

  • Work through our “countertransference”

    • Talk through difficult situations

    • Patients have different ways of relating—learning to understand others, to see their way of being as “adaptive,” can be empathy promoting.

  • Learning to read emotions and body language more accurately  

  • Learning to accept feedback

  • Calming your own hyperarousal through practices like mindfulness

  • Tuning your mirror neurons

  • Noticing when connection or disconnection is occurring

  • Practice empathy towards viewpoints that are not your own

    • Becoming mindful of the emotion, the distress, the meaning behind the distress

Can therapists lose our empathy?

Studies show we can experience empathic strain and rupture. Empathic failure may lead to aggression. It is hard to empathize when we feel subjected to powerful influences from patients: complaints, requests, accusations, subtle seductions, bits of blackmail, challenges.  Throughout history, rulers have decreased empathy in their warriors and people by stirring up disgust towards those they seek to kill.

We are more likely to empathize with those we interact with frequently, find similar to us, or find thoughtful and kind.  We need to humanize people’s actions and see them like us, to not lose the part of us that could consider that we too could be in their situation.

Consider the stages of empathy:

I think of empathy in terms of 3 categories: the moment to moment emotional experience, the meaning and context of the emotion in their life, and the subjective experience evoked and created by the unique connection I am having in the here and now with the person.  

Level 1: There are moment to moment flashes of emotion on someone’s face, changes in body language, and current distress. Empathy can be experienced by just witnessing a flash of emotion and allowing the person to know you see it and that you hear them. During this, we can try to understand the person’s emotions, and ask them to verify what they are feeling, if we are correct in our questions, such as if they are feeling sad or angry about something.

Tuning into their experiential state and then asking if you are on the right track: (note if the patient gives a different word then do not contradict) can be helpful.

  • Ask them a few questions to clarify:

    • Perhaps you feel happy?

    • Perhaps you feel frustrated?

    • Perhaps you feel sadness?

    • Perhaps you feel disgusted?

    • Perhaps you feel concern or fear?

    • Perhaps you feel a sense of pride?

    • Perhaps you feel disconnected or numb?

    • Perhaps you feel a sense of embarrassment or shame?

  • Use their own words and repeat what you hear from them:

    • Patient: “I just feel so tired and sad all the time.”

    • Doctor: “It makes sense you feel tired because you have been so busy with your new jobs. In light of your recent losses your sadness also makes sense.”

  • Matching rhythm of voice, tonality, emotionality.

    • Matching an infant's cry rhythm (but not intensity) calms and regulates the infant

  • Imitation

  • Recognition of what the patient hopes for:

    • I hear you have hopes for… desires for… dreams for… aspirations for...

Level 2: This is where we try to know the context of the flash of emotion, the distress either in the distant past (how early relationships informed it) or recent life situations. Sometimes the quantity of distress is only as high as it is because it is linked to prior loss or prior trauma. We can find the context of the emotion by matching their emotionality, their demonstration of emotions on a level that we feel is appropriate. We can look at the meaning of the emotion and the context of the meaning of that emotion in their lives. We can also empathize with the meaning of the emotion once they’ve identified its context.

Even if they flash anger towards themselves, but maybe they in doing that are not accomplishing the energy of the emotion, and they are missing how the anger can help them accomplish their goals. Thus when the anger is pointed at themselves, we can explain that the anger should be pointed outward, and give energy to action.

  • Example: anger towards self looks like, “I am worthless” instead of anger towards abuser: “he should not treat me like that, I will set up a boundary.” The empathic statement can be “it must be hard to feel the anger pointed at yourself, telling you that you are worthless, and perhaps although it was adaptive to do this growing up, makes it hard to set boundaries now.”

Level 3: This level is when the person is having emotion that occurs because of their relationship with you. It is the interpersonal, and commenting and empathizing with any distress (or positive emotion) that your relationship is creating is a level 3 empathic statement. When a patient demonstrates anger towards their therapist, it’s helpful to ask if they are feeling anger towards you and if they feel comfortable talking about that emotion.

We can create psychological safety for a patient to give feedback to us by telling them we like to hear what they are feeling towards us. For example, my mentor, Dr. Tarr, tells his patients:  

“I very much want to hear your positive and negative feelings, particularly about me, and particularly negative ones. It will be helpful for you to share any feelings of disappointment, feelings of not being understood, feelings of not being responded to or criticized, or mannerisms or things I say that affect you undesirably. I hope you can understand that this is not a usual social situation, where you don’t tell people negative thoughts, here I hope you have the courage to say them out loud. It will be very helpful to say it has it is happening; we can learn much more than if it comes out later; we know it’ll be hard—but this kind of a laboratory where we discover what goes on between us.”



Therapeutic Alliance Part 1

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What is a therapeutic alliance?

The therapeutic alliance is a collaborative relationship between the physician and the patient. Together, you jointly establish goals, desires, and expectations of your working partnership.

Every interview with a patient, whether it’s for diagnostic, intake, evaluative, or psychopharmacology purposes, has therapeutic potential. The treatment starts from your first greeting—how you listen, empathize, and even how you say goodbye.  

It’s built from a partnership and dialogue, like any other relationship. It’s not built from medical interrogation. It’s not about pulling medical information to be able to make a diagnosis. We have to make it a positive experience for patient, so they can begin to talk about what's negative in their lives.

The therapeutic alliance is full of meaning, and it uses every emotional transaction therapeutically. If they get angry, sad, or have fear you will abandon them, as a therapist, it’s our job to figure out how to help them through that feeling within the relationship. The doctor can express desire for the patient to share, in real time, how the patient is feeling, even about his or her relationship with the doctor.

Why do we care?

We all know that some talk therapists have better outcomes than other talk therapists. What’s interesting though, is that some some psychiatrists’ placebos worked better than other psychiatrists’ active drugs. One study of NIMH data of 112 depressed patients treated by 9 psychiatrists with placebo or imipramine, found that variance in BDI score (a score that measures depression) due to medication, was 3.4% and variance due to psychiatrist was 9.1%. One-third of psychiatrists had better outcomes with the placebo than one-third had with imipramine.  

Another book argues that the therapist is more important to outcome than theory or technique. Many other studies have shown that therapeutic alliance directly correlates to success rates.

What builds a therapeutic alliance?

Research shows there are a few things that grow therapeutic alliance:

Expertness

  • Facilitating a greater level of understanding

  • When residents are worried they are an imposter, I tell them that humility is good, but realize that you have experience that most will never have, medical school, being highly educated, being around vast different ways of thinking and reflecting on the world...

Consistency

  • Structuring your office to run on time.

  • Being consistent to respond to refill request, lab results, or patient’s questions.

Non-verbal gestures

  • Eye contact

  • Leaning forward

  • Mirroring of emotion occurs naturally when people pay attention to emotion

Maintenance of the therapeutic frame

  • A dual relationship (eg, dating) breaks down therapeutic alliance. Patients will test the frame. It can be helpful to say, "There will be positive and negative feelings between us and what will be safe is to talk about them."

Empathy, attunement, positive regard

  • Patient: “Therapist is both understanding and affirming."

  • Patient: “Therapist adopts supportive stance.

  • Patient: “Therapist is sensitive to patient’s feelings, attuned to patient, empathic.”

  • Research has found that for beginning therapists, setting and maintaining treatment goals is harder

  • Research has shown that strength of therapeutic bond is not associated with level of training

  • Therapist should appear alert, relaxed and confident rather than bored, distracted and tired

Foundational concepts of the therapeutic alliance

Our profession gives us a privileged glimpse into the human heart and mind. Each patient is idiosyncratic, unique, precious. Each patient has unique strengths which we should place focus on.  Some therapists can be in a hurry to find out what's wrong, but we should also want to find out what's right with our patients.

Our own feelings, as therapists, about the session are not intrusions but clues. If you are experiencing boredom, perhaps you are not understanding the main point the patient is trying to explain. Be curious for what you are missing. If you start feeling something different than you did at the beginning of the encounter, notice it. Try to empathize for the patient with what changed.

Our goal is for the patient to feel understood, heard, accepted, felt. To be understood is to be accepted.

A strong alliance will provide a "Corrective Emotional Experience"  (Franz Alexander), which means past relational pain and difficulties are worked out in a new relationship. When your subjectivity (your feelings, thoughts, goals) come into contact with the patient's subjectivity, a unique "intersubjective relationship" is formed from your mutual influencing of each other. A new dyad (2 coming together) is formed by looking at new meanings, understandings and connectedness. As a therapist, you are a “participant observer” as you observe the patient’s behavior and also become a “significant other” in their life through your interactions (Harry Stack Sullivan).

Here are some things to consider on a first encounter with a patient:

The patient will feel: examined, fear being seen as crazy, fear of not being liked, discouraged, hopeless, helplessness, needy, fear you are a mind reader, or even fear that you sleep with your patients.

In developing this relationship, it’s important to understand they can formulate defenses that are adaptive. Try to empathize with that underlying emotion. Starting with what's an adaptive response and solves something, looking for what’s maladaptive does not.

The patient may question your competence. They might say you look very young to be a doctor. The appropriate response would be to dig down and see why they are feeling what they are feeling. Say something like,"Perhaps you were looking for someone who looks older; of course you’re entitled to worry about how competent I am and how much I may be able to help you."

Therapists are always worried about being ineffectual. It's very natural to feel like an impostor in our position. It’s also normal to feel—when someone's angry at us, our mirror neurons lead us to be angry back.

Always face the patient, without desks between you, lean slightly forward, give appropriate eye contact, and do not do excessive note taking (you should be observing at least 90% of the time). Ideally, a clock is positioned behind the patient which can easily be seen by you without making obvious movements.

On Listening: An Active Process

Connection is non-verbal, and is equally as important as verbal communication, sometimes more so.

  • Omissions (what is not said) in the patient's stories and memories are important.

  • Point out common patterns you hear.

  • If every time you say something to the patient he says "no, that's not it" then point out that to the patient.  

  • Be aware when asking "why" questions, you are likely going to arouse the same defensive emotional reactions that occurred when the patient as a child was asked "why did you do that?" by the parent.  At times, "why" can communicate disapproval. For example you ask, "Why do you feel that?" And they say, "I DON'T KNOW! Are not you the doctor!"

  • Dr. Tarr has some good advice on nonverbal communication: "I participate. I respond. I react to my patient and to his verbal and nonverbal communications.  At the same time I observe what's going on, what the patient is saying and what he is not saying. I am particularly attuned to evidences of anxiety, to what I am feeling and thinking, and where, if anywhere, the interchanges are going. I am wondering how best to formulate for this particular patient what I observe that may help him feel understood and responded to."

  • Observe that defenses (sublimation, reaction formation, intellectualization), although they reduce anxiety, may misrepresent reality.  

  • Assume an attitude of "reverie," like a good maternal object, receiving toxic stuff from patients and then giving it back to them in a detoxified form (Wilfred Bion).

  • Create a "holding" place for patients in which patients have a transitional or play space (Donald Winnicott).

  • Listen in a way that notes what the patient is trying to say about your relationship.

    • Patient: "I feel lonely even when I am with people."  Doctor: "Do you feel lonely here with me now?" Patient: "No, I feel you understand me somewhat."  Doctor: "I want to know if there are any times where you feel more lonely in our sessions, it will help me to understand what is going on between us."

  • Listen to their moment to moment change in emotions.

    • Try to enter a bit into their feeling, be present with them, mirror the emotion/feeling, use their own words, ask them to find their own words.

    • If you don’t get why they are sad, then stay with it, ask them more questions, have them deepen your understanding of it.

    • Once they feel you truly understand the effect will change. When people feel heard, deeply understood, it is pleasurable.  

    • Shame- patient looks down

      • “I can understand why talking about this must be difficult.”

      • Perhaps as you talk about this you feel…”

      • Try to find the adaptive function: “I hear switching to a new doctor is hard, I think that is a common experience, I think it is adaptive to be hesitant at first in what you share, we are just meeting."

    • Anger/Frustration:

      • “Would you say that as you mentioned this you feel frustrated.”

      • Find the adaptive function: “your anger here seemed to have the goal to protect you and your family”  “your anger likely kept you alive!"

    • Sadness

      • “Perhaps you are feeling sad as you say this?”

      • Find the adaptive function: “it makes sense that you feel sad here, I think crying and feeling sad shows how much you valued your dad and therefore the loss hurts that much more."

    • Disgust

      • “I am wondering if you feel disgusted by this?”

      • “I hear you feel disgusted…” (ask with a questioning tone).

      • Find the adaptive function: “Feeling disgusted by how your sisters turned on you and cast you out of the family makes sense, it sickens you to see the level of their resentment and bitterness."

    • Fear

      • “I hear a deep concern or perhaps fear regarding this.”

      • “Might there be a deep concern or perhaps fear regarding this?”

      • Find the adaptive function: “After your traumatic event, it makes sense that you would no longer want to put yourself in that situation, it sounds like you are trying to protect yourself."

Listen to the patient’s goals, purposes, aspirations, fears, hopes, values, meanings.

How do you create and maintain a working alliance:

Be sensitive to empathic strains and prevent them from developing into empathic ruptures.  

Ask for feedback. Reflect on the "we" aspect of the encounter. If the intervention/participation failed to have the desired result then look at what went wrong with the communication.  

  • “As we were talking together when did you really feel we were on the same page?”

  • “When did you feel we were understanding each other?”

  • “When did you feel we were communicating meaningfully?”  

  • “When were you feeling disappointed?”

  • “When did you fell I was not responding enough?”  

  • “When did you feel frustrated, misunderstood, or impatient?”

Be able to define and predict interpersonal conflicts that may cause a disruption of the shared empathic relationship. Set the groundwork for openness.

For example:  

Doctor: "Tell me about your past psychiatrist?  “What worked and what were your disappointments with your past psychiatrist?"

Patient: "He was kind of a jerk."  

Doctor: "Can you tell me more about that?"  

Patient: "He always would just stare at this computer, and often answered his pager during sessions."  

Doctor: "Thank you for sharing that, I will stop typing and finish this later, I hope that if you ever have any feedback for me you will know that I will want to hear it, even if it is negative, and will appreciate knowing your experience of things."

Patient: “Ooo I was not talking about you.”

Doctor: “Ok, nevertheless it is a good reminder to not be focused on the computer, but if you are bothered by things or frustrated it will be helpful to know.”

The therapeutic alliance is an incredibly powerful relationship, and if it is managed with care, it can affect positive change in a patient’s life.

In future episodes on therapeutic alliance I will dig deeper into specifics of it, and pull upon the depth of my mentorship from Dr. John Tarr.

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