What we’ve said about Therapeutic alliance

“Two out of the three major elements are agreement on the problem and the goals, and agreement on the solution to the problem or the method to get to the goals”

“This is applicable to every part of your practice, no matter what setting you're in. And I'm also going to say this. If you are feeling burnt out these days, and I think everybody is, I do also think that focusing in on this is going to help you feel and do better as a clinician”

“if you're doing something in a clinical session, it needs to be serving the greater goal. That's basically the short version. And the greater goal has to be the building of the therapeutic alliance, because the therapeutic alliance is more of a frame concept that applies to any therapeutic process”

“So much of what actually makes a patient better is the therapeutic alliance. And that's specifically, most of it is a understanding of what the problem is, what the goals are, and how to get to that goal and how to treat that problem”

“the technique is to notice when you or the patient are stepping out of the frame or to notice when there are ruptures in the alliance and how you would repair that”

“Developing a good rapport and a patient that trusts that, you know, they feel that I'm trustworthy. We have a good relationship. That's probably infinitely more important. It's more important than the nitty gritty of the medications you pick”

“none of the medications including the mood stabilizers and antipsychotics strong and side effect producing medications were better than a stable and trusting therapeutic relationship with any clinician okay that is the primary treatment”

“trust in a provider and having a good, strong therapeutic alliance is such an enormous factor and is as big if not, is bigger than what the actual underlying, can be bigger than what the underlying diagnosis is”

“rupture repair predicts good outcome. So it's really that unrepaired ruptures lead to poor outcome. Repaired ruptures have been so associated with good outcome”

“When I say that trust is so important in the treatment, I don't mean that you, the clinician, trust everything the patient says. I mean that you need to demonstrate that the treatment and that you, the clinician, are trustworthy of the patient”

“just because you have a white coat and a stethoscope, you do not deserve the trust of these patients. And it really needs to be earned. It needs to be acknowledged that it's okay to not trust me”

“You can't just say these things. You have to just make them true. You have to be available to the extent that is realistic. You have to actually be interested, investigate, and help in some fashion. And you have to keep your promises”

“because she felt understood by me and because we reviewed the her history and i i went through her past even aspects that didn't feel directly connected to what she was experiencing now she trusted me more because she felt like i understood her as a person”

“A lot of our terms are loaded and have lay person understanding that's inaccurate. you need to spend some time communicating why because you are uh showing your work to the patient number one”

“My goal is to balance them feeling warmth towards me, but also understanding that this is a professional relationship”

“you really have to come from who you are in an appropriate way, right? You're going to suppress the parts of yourself that are clinically inappropriate”

“you gotta get comfortable with being socially unusual as a mental health clinician, the whole, endeavor is socially unusual we have to understand that you know while we try to replicate certain early experiences for treatment purposes or at least echo them”

“I think patients always know when you're documenting and I think we've got to be open about it. In fact, I'll even sometimes say, give me a moment. I don't want to write that down. I don't think people mind if you document. I think what they mind is if you're doing things that really aren't about their treatment”

“to really get a feel for a person, you have to Let their story impact you, feel what it stirs up in you, hear the themes, the music behind, just the notes”

“I think you need a good therapeutic alliance to be able to do it for the patient to receive it”

“You got to get an idea first, not of your ideas, but of the patient's ideas of how do you feel like this is going to go and what's a problem for you? So that's what I start with. So what's been a problem for you”

“You need to ask, what do you see as the major problem that you're having? And then you need to compare that to your conceptualization of the problem. And then you need to talk openly with the patient about, do we agree on this? Why or why not”

“if you're starting between the clinician and patient with a mismatch in conceptualization and understanding, then you'll have to get to a shared understanding of it more directly and specifically”

“this is the core, that you want to find something you can work on together. And in order to do that, you have to agree that something exists”

“it generally avoid challenging overvalued ideas head on. And I think that applies to patients, you know, understanding of themselves, if they have delusions, it applies to a broad range of topics”

“there's a way to frame beliefs that will keep you from progressing. And there's a way to frame them that may give you a chance to progress. And that's why I frame it that way. So, you know, you've heard this before. Don't argue of overvalued beliefs or delusions”

“explaining that to the patient is not going to make them say, oh yeah, totally. I have schizophrenia and I should take Haldol, right? I mean, how many times does that work for you? It doesn't work, right? And so instead, it's more important to say, OK, what's a problem for you”

“There's no point talking about a pathology or a problem that someone doesn't think exists. Right. It will be exactly the same as talking to someone that is convinced that their problem is not their personality, but is instead, let's say, I don't know, anxiety”

“It seems as though when you take the medications, you stay out of the hospital. When you're off the medications, you end up in the hospital. I think we should just make our treatment goal keeping you out of the hospital”

“no matter how concerned you are about patient psychosis, it's technically not an emergency, even if it's not good for them. Because what we talked about before, if you don't get to an alliance with a patient and you prescribe medication, they just won't take it”

“What I say to trainees is, I don't care what you call it. Give the right treatment. And that's my approach. And so whatever a patient prefers to call something, we're going to go ahead and call it that”

“I try to be extremely clear about two things. Why we're meeting, basically the modality of the treatment, and also diagnosis. Okay, and treatment recommendations”

“I always save the last like 15 minutes for discussing my case formulation. And patients at the end are like, oh, you're definitely not a reductionistic kind of doctor”

“if you can explain this patient's problems in a way that a completely uneducated person will understand, that's better because that's how you should formulate with the patient in plain language”

“I think a lot of that comes from misunderstandings about what your role is. So another important thing is to make your role clear from day one and to remind people about your role and the limits of your powers as needed”

“You need to have clear in your mind who are all the agents of treatment and whether or not they should be agents of the treatment. Because if you don't, The attention field gets split up between the various agents, and that makes it extremely hard to forge a therapeutic alliance with the patient”

“there's a part of the patient that wants to get better and change. There's a part of the patient that wants to stay the same. feel safe or at least avoid new and scary things. And so you have to ally yourself with the part of the patient that does want to change against a part that doesn't”

“what you are doing is that you're engaging the patient in the process where you mutually discover the what is important to the patient, what they want, and what they see is or is not a problem”

“Patients can make decisions, and I always think of our job as the lanes on a bowling. When you go bowling, they have those little kid lanes. That's our job. The patient decides where they go, but within certain parameters that we provide”

“the best approach to take is to go slow, to listen, to eventually get to a point where there's a good enough alliance with the patient that you introduce the idea that maybe you don't have six different psychiatric illnesses, right”

“Helping people understand things begins with what is important to them, understanding what's important to them, and then reminding them that they said that, that's important to them”

“I say, you know, my role is not to make you have medications. My role is to communicate to you the role of medications and what they can do to help you and work together to see if it's something that works for you”

“If you're prescribing these things from a stance of, I am a gatekeeper, I give you the meds and this treats your thing, you're going to have so much worse outcomes”

“don't sugarcoat things um and also like allow like empathize with patients for how annoying these medications can be. I think it's helpful. I think you have to stay hopeful but also stay realistic”

“I take them not as trying to manipulate me, not as trying to get this drug. I take them as an innocent person who heard that Xanax is helpful for anxiety and calmly lay out my reasoning as to why I don't think it'll be helpful long term and why we won't be going that route”

“I tell all the patients with trauma disorders that the medication is supporting their treatment but that the primary treatment is the things that they're doing in their lives and the psychotherapy if they're willing to engage with it”

“Important for me not to lose therapeutic alliance by being like, you're wrong. They're terrible for sleep. I explained to them, it's like, you're right. So it does help you fall asleep”

“we really do need to be genuine in how little power we have uh to help people and then that's where we can actually start helping people if we can say to them You know, this is basically what I can do for you”

“a lot of these substances, they can cause effects in the brain, sometimes short term, sometimes long term, that can really make things confusing, both in our treatment of you with medications and in our diagnosis”

“Don't talk to them. Listen to them. Why is it that you are going to bed at two in the morning? How did you get there? And acknowledge because they certainly recognize it would be a good idea not to be doing that”

“the word rupture sounds like a big dramatic clash between two people but we use it more broadly to include even very subtle signs of not being quite on the same page not being completely comfortable with each other”

“it's inevitable that at points those needs are going to clash or collide or conflict with each other. So in that sense, some kind of rupture is inevitable”

“you're going to make mistakes, right? That's human. And... They present these really amazing opportunities to learn more, better understand, and actually become closer and have a better working relationship on the other side of it”

“if you detect any kind of a problem, a divergence or mismatch in the therapeutic alliance, a rupture in the therapeutic relationship, or some kind of a boundary crossing or a frame violation, I recommend that's addressed explicitly and relatively quickly, if not right away”

“I say, how do you feel about how things are going, your treatment progress? How do you feel about how I'm doing? OK. Now, I want to know just overall, what do you see as the main problem that we're trying to get better, that we're trying to work on”

“framing it as a we and an us. So it's not that you're doing this thing, or I'm doing this thing, but like we are. So like what's happening between us right now? Are we getting lost? Are we getting off track? Are we avoiding something”

“You seem irritable today. What do you suppose is going on? The way we're interacting now seems to be kind of bringing up a lot of irritability. We're not really on the same page. What do you suppose is going on? Probably much more effective”

“both ruptures and repairs, we say they're co-constructed, like both people are part of creating it. So that's also for therapists, we can't say do these five things because that leaves out the patient”

“we're arguing about something and it's that ability to go wait a minute process-wise what's happening here you know and and can we recognize that and go and pause for a second and talk about it”

“it's usually some version of therapist anxiety right something is is getting kicked off in me that's getting in the way of me accessing my empathic abilities um so so i see a lot of our alliance focused training not so much about giving people alliance skills”

“Helping therapists recognize when that's happening, giving them these ideas that might help them reframe some of that away from I'm being a bad therapist or they're being a bad patient to this is just human interaction and we can talk about it”

“just as I have to respect their boundaries, I have to respect mine. And there may be times and maybe this is also like, you know, it's it's it's communion and agency and the therapist has both, too”

“maybe audit your own cases just twice a year, specifically ask yourself, how is the quality of the alliance with this patient right now? Okay, do we agree on what the problem is and where we're going to take it”

“Splitting, right? The idea that things can be perceived as or treated as all good or all bad. This is a very common scenario in clinical treatment. You, the clinician, are going to be made all good or all bad sometimes”

“You don't have to intervene every time. If it's important, it's going to come back in a future session”

“So far, research comparing online therapy and in-person therapy are finding little to no difference”

“my responsibility here is to really do a thorough assessment of you and what happened. and to figure out whether it's safe for you to leave and there's really no way for me to do that unless we can talk to each other”

“the purpose of the frame is not only to intellectually tell the patient what is actually going to happen, but also to try to establish some common ground between you and the patient”

“being transparent as to how you're thinking about the case can help the patient understand why you want the information. Not just that if he says you sent the text, then you're going to be locked away forever”

“this even applies to incompetency treatment. You know, if you're on the team that's restoring people to competency, feel free to refer to the courts or to the incompetency rules”

“Rather than looking directly at the patient, imagine that you two are two people looking at a third party. You should try to arrange the dynamic of the encounter instead of two people looking at each other as to two people looking at a third party”

“I've seen a lot of novice providers go up to patients, especially like in the emergency room and go like, Any thoughts are hurting yourself or hurting other people. And the person obviously is going to get defensive and blocked down”

“the patient-clinician relationship is one where the patient comes in with a lack, okay? There's something that they're lacking or they don't have and that your job as a clinician is to find that thing and give it to them”

“A psychiatric treatment shouldn't be one medication and then you're done. That works for about 4% of patients. But the 96% of patients, they need something more”

“If you're expecting that the treatment's going to fail, if you're expecting that you're not going to get along with the patient, you're going to make that true to some extent, or you're going to make it more likely for it to be true”

“I think a lot of providers have a tendency to let things go unsaid. And it mucks up the treatment”

“Telling someone they have a personality disorder is about the most invalidating thing you can do. Right. I mean, it's it's it's it's frankly insulting. And, you know, a lot of patients aren't going to engage in that”

“I think denigrating your formulation is not helpful to the patient. What you can do is say, and I've done this a million times with patients on intakes, as I say, maybe not intakes, because you need to build some rapport and gauge whether you think the patient will accept it”

“People do come in and they think how this works is I'm going to tell my doctor all my traumas. I'm going to trauma dump on the doctor or I'm going to tell my doctor about my crisis of the day or I'm going to tell my doctor about my past and my story”

“if you try to make this shift way too fast or without explaining yourself, people will rightfully get angry at you. They're going to leave treatment with you. They're going to say, what are you doing to me? OK, I'm used to this”

“there are a ton of patients that I feel used by and I feel dumped on by. And then there are patients that will have almost the exact same session, but in the context of my relationship with the patient, I find it's something that is necessary for them and helpful for them and therapeutic for them”

“I don't just go like, oh, no worries. You're 10 minutes late. We still have 10 minutes. Let's get this done. We focus on it and we talk about it”

“I appreciate you telling me that. I'm curious by what you mean by special. As I see it, we have the typical special. doctor-patient relationship that I try to have with all my patients, you know, a good working alliance”

“you have to keep strict boundaries in frame. then you have to refer back to that frame and the therapeutic alliance when you notice anything that is amiss”

“by having this framework, you know, I stopped projecting my ideas of all the problems of the world and work with the patient in a way that works for both of us”

“you can't just be a passive person who's perfectly good at listening and perfectly supportive. So you have to practice doing things that might not come natural to you”

“oftentimes I'll have a patient will push back or or fight with me in the moment and and then the next month i'll see the positive change happen so in some sense you have to have faith that what you're doing is the right thing”

“adherence is a iatrogenic phenomenon. It's up to you to figure out the regimen that you're inviting people to participate in and make it something that they want to do, not something that they don't want to do”

“you should try to stick with one therapist or psychiatrist longitudinally. Why? Well, first of all, the ability to gather information about your case and your mental health, that relies on time and repeated observation”

“the easiest way to tell if you are in a good therapy or not is how your therapist responds to you bringing up issues about being in the therapy itself”

“I think therapist skill has enormous variability. And when a patient says, you know, the therapy didn't work, the analogy I like to work is if someone says like, oh, I read a book and it didn't help. Well, what book did you read”