A model of therapeutic alliance
The therapist can offer a patient new ways of thinking about relationships. This can be a valuable aspect of psychoeducation insofar as it involves outside relationships examined as patterns in therapy. What is going on in an outside relationship may be displaced and enacted towards the therapist, in some states of mind. These may help the therapist infer what the patient wishes, what they fear, and how the feared consequences of wishes may lead to behavioral avoidances. Therapist and patient can carefully listen to configurations of wish, fear, and defensiveness occurring in the present moment and to put these configurations into words.
The therapist may be frequently asked for advice such as: “What should I do?” or “what would you do?” Therapists tactfully avoid direct answers in order to create space for the patient to form new appraisals and make their own choices. This clarifies the therapeutic alliance transactions, in showing that the patient has to maintain personal responsibility for choices. Nonetheless, the patient may continue to ask for direct guidance. In that case, it may be helpful to say something like, “I am concerned that, if I give you the advice you want, then you are relying perhaps too much on me to make your own personal choices … but if I don’t give you the advice you specifically seek then you feel let down and uncertain about how to proceed. How should we understand this kind of situation?”
This kind of remark can focus the patient’s attention and enhance their self-reflective awareness. Success in self-reflective awareness is a capacity developed over time that requires repetition in many sessions.
When a patient continues to ask for direct advice, the therapist can try other responses. For example, the therapist might say, “You are troubled on whether to stay with or leave your unsatisfactory boyfriend. You are asking me to help you arrive at a choice, and you even want me to make the decision for you. Perhaps you find it frustrating that I seem to just want to explore the matter further.” The therapist is explaining the frustrations of the patient and defining for the patient the goals of therapy, which is to help the patient gain the capacities to make independent decisions, and the confidence in those skills.
An important aspect of such an approach is to ask the patient what he or she has heard the therapist say. In this example, a patient may reply, “You just don’t care enough to help me but you can’t come out and say that, so you say you are leaving the decision up to me.” When you encourage the patient to listen and observe what they just said, the patient may become self-reflective. If so, the patient may be able to move forward and say, “Can we discuss the pros and cons of my options with my boyfriend, and why it isn’t working well?”
Comparing and contrasting new and old relationship patterns
Personality growth represents the formation of new capacities for a variety of relationships. The patient learns these capacities by trying out new opportunities in new ways. The new ways develop new attitudes and schemas. The old ways tend to persist: the role-relationship models in the patient’s repertoire at the start of therapy are not erased. They become dormant in terms of being checked from compulsive repetitions, and they are modified to match new capacities.
Clarification of a maladaptive relationship pattern assists the patient in learning to check automatic responses and tendencies toward specific actions. While the patient is learning new relationship models, insight can aid the process of acquiring new patterns. Insight is achieved by comparing the old pattern, raised to reflective self-awareness, with new ways of interpreting reality, with a focus on identifying misappraisals and dysfunctional beliefs.
Old patterns may have worked as the best available ways of coping with past situations. “Best available” means not necessarily the ideal action, but what the unique individual could think to do at the time. Broadening the available choices of action facilitates new self-narratives, helps the patient understand current re-enactments, and assists in planning when to check the habitual response system.
Conversations about relationship situations enable learning process of insight and change. Clarifying a pattern usually requires many examinations of stories about both real and fantasy situations with other people. At different times in this process, the therapist and patient can focus on present, past, and future situations.
For example, a patient was discussing a dispute with her mother that happened the day before the therapy session. Following the levels of formulation discussed in Chapter 1, the therapist clarified what happened in the episode memory. The patient developed feelings of anxiety right at the moment when her mother said she should cook every meal for her family rather than ordering take-out. Then the patient shifted into an angry state and disparaged her mother’s mode of dress. While listening to the therapist’s construction of this plausible sequence, the patient tried to take back what she had said about feeling hostile towards her mother.
Going deeper into the use of formulations, the therapist clarified that the patient tended to stifle the irritation caused by the mother’s implied criticism. On a deeper level, the therapist was helping to clarify the relationship model in the present situation: was she an adult self in a squabble, or a child having an uproar at being criticized by her mother?
The therapist in this example was exploring a pattern in the current outside relationship between the patient and her mother, and looking at some possible roots of that current relationship pattern in the past. The patient might shift to feeling that the therapist was criticizing her, perhaps for “being childish.” The patient may have felt insulted by the therapist remarking on her stifling her feelings of irritation. If so, the therapist might switch attention to the pattern as under enactment in the therapy situation itself.
The therapist could clarify that the intention of dealing with an avoidance maneuver was not to criticize it is occurring, but to explore what was happening in a way that promoted understanding the patient’s reasons for potential anger. That is, the therapist may need to clarify a non-critical, learning-situation intention. This contrast between a critical role and a helper role builds the relationship experience of the deepening therapeutic alliance.
Once a working state in therapy was restored, the pattern of anger at criticism could then be clarified by examining how it developed in childhood. If unchecked, the pattern may continue. The therapist and patient together might then usually wonder what behaviors could replace it. How might the patient plan to react to such challenges to her self-esteem? The potential new action plan, of what to do when feeling insulted by a significant other, could be rehearsed in therapy.
For each period of time and each situation, the patient and therapist can explore emotional states, conflicts in exposing or stifling automatic emotional tendencies, and possible re-appraisals of new and old relationship patterns. Patterns are clarified by their replication across present, past, and anticipated future relationship situations, forming new narratives and promoting understanding. These general techniques are described in Table 6.1. In supervising training in exploratory psychotherapy, it may be helpful to use this table as a tool for discussion after clarifying a process in a therapy session presented by trainees. The goal in such a case is to identify effective techniques that achieve progressive change.
