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The Therapeutic Relationship

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The Therapeutic Relationship © On Good Authority, Inc. THE THERAPEUTIC RELATIONSHIP INTRODUCTION Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading our program on The Therapeutic Relationship. Throughout the years, On Good Authority has been presenting you with cutting edge information about therapeutic practices to enable you to become more informed, more learned, more effective. We have brought you interviews on psychotherapy ranging from the work of psychoanalytic practitioners, to short term time-limited practitioners, to cognitive behaviorists, to family therapists, to narrative constructivist therapists, to Jungian dream analysts, to bio-psychotropic medication providers, on ethical issues, and more -- all in the interest of giving you the widest possible range of thinking. In this program, we bring you the latest thinking about the heart of therapeutic practice – the therapeutic relationship. We are going to look at many aspects of the constantly evolving therapeutic relationship, taking into account important new knowledge gained from neuroscience, infant research, theory about attachment, and the seismic changes in our culture which affect all aspects of our world view. Decades of research indicate that the provision of therapy is an interpersonal process in which the main curative component is the nature of the therapeutic relationship. Probably the most significant change in the treatment process has come with the opening up of the therapeutic relationship. Once a stiff, one-person, ―blank screen‖ model, where the therapist was the all-knowing, powerful ―expert,‖ now psychotherapy is viewed by virtually all the varieties of ―talk therapy‖ as a collaborative process. Also called ―the helping alliance,‖ ―the therapeutic alliance,‖ and ―the working alliance,‖ the therapeutic relationship refers to the relationship between a mental health professional and a patient or client. It is the means by which the professional hopes to engage with and effect change in a patient (we will be using the terms ―client‖ and ―patient‖ interchangeably throughout this program). The therapeutic relationship has provided fuel and fodder for portrayal in the entertainment world. Some of the interviews in this series will make reference to the award winning, HBO television series, ―In Treatment.‖ But whether the brilliant sessions in ―In Treatment,‖ the comedic therapy sessions between Mike Nichols and Elaine May, Robert deNiro and Billy Crystal, Woody Allen with himself interminably, Dr Malfi and Tony Soprano, or thousands of cartoons, therapy has been celebrated, portrayed and pilloried for decades. 1 Still, with all the paradoxes, dilemmas, and devaluations of psychotherapy and the therapeutic relationship, would we rather stick our heads in an MRI machine, swallow a pill, confess on television, or instead, look for the deep meaning in our lives? Not that these things are mutually exclusive, but for the purpose of this program, we are going to focus on the experience of being listened to and understood. We are going to treasure those people who want to search for a truth about themselves that goes beyond symptom relief. To begin our program, we will take a look at what makes one therapist ―better‖ than another. And yes, some therapists are better, as indicated by their higher scores on all sorts of performance measures. In our first interview, we‘ll see how we can, and must measure and evaluate our work. Then we‘ll go through the treatment process itself. Using ―In Treatment‖ as a backdrop, we will look at the opening session. Then we‘ll see how attachment theory, combined with self psychology and intersubjectivity have given us powerful tools for therapeutic change. We‘ll see how understandings from neuroscience can help us in a non-verbal way, and we‘ll learn about the meaning of crying. One thing that can really interfere with our effectiveness is our lack of awareness of diversity issues, and we‘ll learn how to assess our biases, our ―isms‖ which, like it or not, we all have. In these times, the economy has had a great impact on our practice and on the therapeutic relationship, which raises the question of what we do about it, so we give you two interviews on the subject. Then, along with the opening up of the therapeutic relationship comes the inevitability of self disclosure, and we‘ll learn about a new paradigm for the use of ―deliberate self disclosure.‖ Finally, we will focus on the termination process, a highly important and understudied aspect of the therapeutic relationship. So here goes. Now to our first interview. 2 © On Good Authority, Inc. THE THERAPEUTIC RELATIONSHIP “Super Shrinks” SCOTT MILLER, Ph.D. Interviewed by Barbara Alexander, LCSW, BCD (Edited slightly for readability) SCOTT MILLER, Ph.D. Post Office Box 180147 Chicago, IL 60618-0573 Tel: (773) 404-5130 Fax: (847) 841-4874 cell (773) 454-8511 [email protected] www.scottdmiller.com. Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading interview #1 of our program on The Therapeutic Relationship. Therapists differ in their ability to affect change. We may not like to think it, but it is so. How many times have we heard someone referred to as ―a gifted therapist?‖ Is this some inborn talent, like musical talent or artistic talent or athletic ability? And if so, are the rest of us ―un-gifted‖ folks doomed to mediocre performance? ―Not so,‖ says Dr. Scott Miller, our first speaker and co-founder of the Center for Clinical Excellence. Citing research going back to 1974, Miller tells us that the evidence is incontrovertible: who provides the therapy is a much more important determinant of success than what treatment method is provided, and the key to superior performance simple as it may seem, involves constantly working harder evaluating and improving one‘s performance. To do that, we first have to know our baseline performance, and then engage in more ―deliberate practice‖ to improve our work. This willingness to engage in deliberate practice is what makes some therapists, ―Super Shrinks,‖ and the rest, well, simply average. What‘s really scary is that we might not know which we are because, in the words of Sherlock Holmes, ―Mediocrity knows nothing higher than itself.‖ But we‘ll let Dr. Miller tell you about it. 3 Scott D. Miller, Ph.D. is a co-founder of the Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavior health. Dr. Miller conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of "invited faculty" whose work, thinking, and research is featured at the prestigious "Evolution of Psychotherapy Conference." His humorous and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policy makers to make effective changes in service delivery. Scott is the author of numerous articles and books, among which are Psychotherapy with Impossible Cases: Efficient Treatment of Therapy Veterans (with Barry Duncan and Mark Hubble [Norton, 1997]), The Heart and Soul of Change (with Mark Hubble and Barry Duncan [APA Press, 1999] and Bruce Wampold [2nd Edition, 2009]); The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, Outcome-Informed Therapy (with Barry Duncan [Jossey-Bass, 2000], and Jacqueline Sparks [Revised, 2004]); and the forthcoming Achieving Clinical Excellence: Lessons from the Field’s Most Effective Practitioners. ALEXANDER: Dr. Miller, you say that who provides the therapy is more important than what treatment is used. Is that really true? MILLER: Well, I think the evidence is actually fairly convincing that the provider of services has a greater impact on the outcome that the particular treatment model employed when it comes to the provision of psychological services or behavioral healthcare services. I‘m certainly not against evidence; the question is what evidence we use to guide the services that we offer? Right now, there is a very particular and I would even call ―peculiar‖ view of what constitutes evidence. Somewhere back in the eighties, our field decided it was going to ape medicine, and medicine, in what is now recognized as a fairly limited model, decided that the randomized clinical trial where you pit alternate treatments against one another, or even more often, you simply pit a treatment against no treatment at all, or a sham treatment was the best research design we could use to decide what would be the best treatment approaches. So our field took that up. We‘ve been running randomized clinical trials and claiming that certain models are more effective than others when in fact, the evidence doesn‘t say this. We‘ve run very cutting edge, scientifically sound meta-analytic studies comparing treatments for a variety of conditions in children and adults, from depression to post- traumatic stress disorder, to alcohol abuse and dependence, and we find no difference in outcome between the treatment approaches that are intended to be helpful. You find a dramatic difference, of course, when you compare a treatment approach against no treatment, and some difference when you compare it against a sham treatment. 4 This leaves open the question then, ―Well, if there‘s no difference between treatment approaches, what treatment approach do you use?‖ If I‘m talking to consumers, what I say is, ―Choose your provider carefully,‖ because the amount of variability and outcomes directly attributable to the provider of services is eight to nine times greater than the variability attributable to the particular approach that provider happens to use! So yes, it‘s absolutely true. ALEXANDER: That‘s amazing because when you think of all the time that‘s spent in conferences, seminars, workshops, talking about this treatment method or that treatment method, it‘s very wonderful to hear something different; that it doesn‘t matter whether you make an interpretation here or there, it‘s more like who‘s doing it.
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