As a psychotherapist, a teacher of therapists, and a psychotherapy researcher, it is not unusual for friends, students and acquaintances to describe frustrating or distressing experiences they are having in their own therapy, and to ask my opinion about whether they should stay in their current treatment, or consider looking around for another therapist. In some respects this is a difficult question to answer. Different therapists and therapeutic approaches are right for different people, and it’s hard to judge any relationship from the outside. If you’re wondering if your therapist is the right one for you, however, there are some general guidelines worth keeping in mind.
Over fifty years of psychotherapy research have demonstrated that a variety of different types of psychotherapy can be helpful for a range of emotional problems, that therapy is as effective or more effective than medication for many problems, that the benefits of psychotherapy are, as a rule, more enduring than the benefits of medication, and that therapy does not have the side effects commonly with medications.
Nevertheless, approximately 30% of people receiving psychotherapy do not benefit, and up to 8% experience a worsening of their problems. So if you are having concerns about your current therapist or the treatment you are undergoing, how can you know when it’s worth sticking things out for a while to see if things change for the better, or whether it’s time to say goodbye?
Over the last thirty years the research has shown that one of the best predictors of treatment success is the quality of what therapists and researchers call the therapeutic alliance. The therapeutic alliance consists of three dimensions: 1) the degree of agreement between therapists and patients about what the goals of treatment are, 2) the degree of agreement about how best to work collaboratively towards these goals, and 3) the extent to which patients feel their therapist are trustworthy, understand them and treat them in a respectful fashion.
Although a good therapeutic alliance essential for treatment success, problems in the alliance do not necessarily mean that the treatment is doomed. Over the last twenty-five years our research team and other researchers in North America and Europe, have found that problems or ruptures in the therapeutic alliance are the rule rather than the exception in psychotherapy, and that the process of addressing and working through them them constructively can be an important vehicle of change.
Patients are often reluctant to discuss their concerns or negative feelings about treatment with therapists and it is not uncommon for them to drop out of therapy rather than risk rocking the boat. Moreover, research findings indicate that therapists are often unaware of negative feelings or concerns that their patients have about their treatment.
What do we know about principles relevant repairing alliance rupturesl when they occur so that treatment gets back on track and therapeutic progress takes place? My colleagues, Chris Muran, Catherine Eubanks-Carter and I (at the Brief Psychotherapy Research Program at Beth Israel Hospital, New York) recently conducted a review of the relevant research (including our own) on this topic for an American Psychological Association Division of Psychotherapy Task Force.
Below I summarize some of the conclusions of this review, combined with guidelines for both therapists and therapists to keep in mind:
Guidelines for Therapists:
1. It is important to recognize that patients often have negative feeling or concerns about the way therapy is going that are difficult for them to be express, and to be attuned to subtle indications that such concerns may exist.
2. It is the therapist's job to notice subtle indications of ruptures in the therapeutic alliance, and to find tactful ways of drawing attention to them and exploring them when they occur.
3. When patients do express negative feelings or concerns about their therapists or the treatment, it is important for therapists to attempt to respond in an open or nondefensive fashion, and to accept responsibility for their own contributions to the interaction as opposed to blaming the patient for misunderstanding or having a distorted perspective on what is taking place.
4. It is also important for therapists to empathize with their patients’ experience and to support them broaching a potentially divisive topic in a session.
Guidelines for Patients:
1. Your therapist should be willing to answer any questions you have about what to expect in therapy, how change takes place, and how much his or her fee is.
2. If you have concerns or negative feelings about your therapist or treatment it important to make an effort to express these concerns to your therapist, or if feel your therapist doesn’t understand you, it is important to let them know.
3. If you think that you and your therapist see things differently, it is important to try to express your perspective.
4. It is important to recognize that even the most skilled and experienced of therapists can at times become defensive or blaming. The ultimate criterion for deciding whether your therapist is trustworthy and can potentially help you, is a demonstrated willingness and committment to working through whatever problems are emerging in the therapeutic relationship, and a genuine openness to exploring ways in which they may be unintentionally contributing to those problems.
5. Beware of therapists who try to keep you keep you in therapy when you want to stop. Therapists should respect your autonomy. It is one thing to explore your reasons for wanting to quit therapy, and another to imply that wanting to end treatment is a reflection of your problem.
6. It is important to recognize that even the most skilled and experienced of therapists can at times become defensive or blaming. The ultimate criterion for deciding whether your therapist is trustworthy and can potentially help you, is a demonstrated willingness and commitment to working through whatever problems are emerging in the therapeutic relationship, and a genuine openness to exploring ways in which they may be unintentionally contributing to those problems.
- Jeremy D. Safran, Ph.D. is Chair & Professor of Psychology at the New School for Social Research in New York & Senior Research Scientist at the Brief Psychotherapy Research Program, Department of Psychiatry, Mount Sinai Beth Israel Medical Center.