Psychiatry & Psychotherapy Podcast - Therapeutic Alliance Part 1

Episode Date: September 6, 2018

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. By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join and discuss this episode with David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Welcome back to the podcast. This is your host, Dr. Puter. Today I'm alone, and I am going to be going through the Therapeutic Alliance part one. This is kind of an introduction to the idea of therapeutic alliance. It's going to be fairly practical, but also talk about some of the

ideas behind it, the science behind it, and why it's important. Why, I think it's something I focus on in my own practice as a constant reminder that I need to remind myself to do, you know, even into practice now four years, I am constantly needing to remind myself of, you know, be empathic, connect with the patient, get outside of my own head and get into the patient's head. What are the patient's goals? How do I realign to those things?

How do I connect with the patient? And out of that bond that forms, you know, you have better outcomes. That's what the data shows. So big ideas. is going to be how to form a therapeutic alliance. And in this series, and it may be spread out, you know, so in like maybe in a month or two, I'll do part two. But there is a series I will take you through regarding the therapeutic alliance.

This lecture was formed out of a lot of sort of time being mentored by Dr. Tarr, about Dr. John Tarr. He's a 90-year-old psychoanalyst out in Pasadena who has a huge commitment towards education and sincerely has influenced my life. He is just a great mentor, a great person to listen to, to understand. And if you know, Dr. Tar and you've been in his lectures, I hope that you might see some of his ideas come through

in this series. He's a true master, and I don't say that lightly. He really understands this science, and I remember when I was a resident, I started, this was like my first lecture with him, and I was just blown away, that there's people who care about this so much as he does. and so I'm dedicating this series to Dr. John Tar and with that I'll begin. So the big idea is that every interview, diagnostic, intake, evaluative, psychopharmological, has therapeutic potential. Usually in medicine, in internal medicine and family medicine, you know, the interview is to get a diagnosis so that you can start treatment. but in psychiatry and in psychotherapy, the treatment starts from your first greeting,

how you listen, empathize, and subsequently how you say goodbye. It's built from a partnership and a dialogue. It's not a medical interrogation. You're not just trying to pull pieces of information so that you can come to a conclusion. You make it a positive experience for the patient to talk about something. that's negative. So they're coming in, they're talking about some of the hardest things in their life, and you're trying to generate from that a connection which allows for a positive experience talking about something that's negative. You try to use every emotional transaction

therapeutically. And what I mean by that is if the patient gets angry at you, if they get sad, if they fear you're going to abandon them, abandon them. You think about it. how do I use this transaction, this emotional transaction, therapeutically, to help them, to help them in their journey? And that's what your focus is. So what is a working or therapeutic alliance? It's a collaborative relationship between a physician or therapist and a patient. So it's a collaborative, meaning it's not like you are the expert. It's your, joining with them. It's collaborative. You have jointly established and spoken goals, desires, expectations from your partnership. So I think it's good when a resident's getting

confused or someone's getting confused. Why is this person here to think through how do I, um, how do I help them find out what their goals are? How is this person here? How is this person here? How do I, how do I help them find out what their goals are. How do I get them to voice that? What are their desires? What are their expectations? A lot of the times people don't know from the first time they come in. They have sort of superficial things that they'll say, but they can't quite get to what are some of the deeper reasons for being here. A working or therapeutic alliance is also a positive transference towards the therapist. So Freud in 1913 wrote about this,

and it's the positive feelings that are placed on the therapist, sometimes originating from earlier positive relationships, I would extend transference as well to be the complete reaction towards the therapist. So this is defined as the positive transference, towards the therapist. It's an agreement on goals, an assignment of tasks,

or a series of tasks, and the development of bonds. That's according to Borden, he wrote about the therapeutic clients back in 1979. So here's a little example. The doctor says, I hear you came in because you want to be less depressed.

Help me understand what that would look like for you. The patient said, says, I really just wanted to talk to someone. I'm so lonely, the doctor says. I hear you have been feeling lonely. It is very helpful for us to know if you feel lonely all of a sudden while we are together. Sometimes if I don't quite understand you, you might feel more lonely and it'll be helpful to look at that together. I want to make it safe for you to tell me. me how you feel about me directly. So what's going on in that little dialogue?

The patient is expressing that they feel lonely. And the doctor is starting to prime the patient or sort of educate the patient, teach the patient, how to express that loneliness in the session, especially if there's some moment that that the doctor says something or does something that causes the patient to feel more lonely in that moment. Okay. So here we go. Why do we care? Well, there was a study by McKay in 2006, which I'll put on my website, if you follow the show notes. And it was a study where they looked at the NIMH data of 112 depressed patients treated by nine psychiatrists with placebo or amypramine. And they found that the variance of the BDI score, the BDI score, which is a score of depression.

So the variance of that score due to medication was 3.4%. Whereas the variance due to psychiatrist was 9.1%. they found that one-third of psychiatrists had better outcomes with a placebo than one-third had with amypremine. What an amazing and challenging study that they looked at how one psychiatrist may have better outcomes than another psychiatrist. I've actually looked for this, and I can't find that many studies. They've done a lot of these studies on psychotherapy and psychiatric.

comparing different therapists with each other, and they found that there are some therapists that have better outcomes than other therapists. But this is the only study I could find on psychiatrists and this, and I wish they did this more often, but I imagine drug companies wouldn't really be interested in that. They want to show something else from their results. But this was a re-analysis of a bigger study, of a different study. What they found was that there were some psychiatrists whose placebo worked better than other psychiatrists' active drug. Now, you can say, well, amypermine is a tricyclic, and we don't really use that anymore for depression, but tricyclics usually are pretty good. And in this study, it did show that amypremine was better

than placebo overall. But there were some psychiatrists that had a better outcome compared to the placebo. So you can think more about that if you want. Another resource for this type of dialogue is Wampolt 2013, the Great Psychotherapy Debate, Models, Methods, Findings. And this book shows that the therapist, it's specifically looking at psychotherapy. It says the therapist is more important to outcome. than theory or technique. And they found that working alliance correlates to outcome. Well, that's nothing new.

There's a lot of studies that show that working alliance correlates with outcome. But that's a resounding sort of challenge to the multiplicity of different psychotherapies out there. To say that the therapist and how the therapist is interacting with the patient, is more important than the theory or the technique. It's a bold statement. It's bold. So what research shows, what does research show

in regards to how a therapeutic alliance is built? If the physician or therapist has trustworthiness and expertness, it builds a therapeutic alliance, specifically expertness is shown by facilitating a greater level of understanding, realizing that you have experience that most will never have. This needs to be packaged in a way that the patient can understand. So sometimes I'll explain things to patients that I know it's like the tip of the iceberg. Like I'm just explaining a little bit of the brain science or what's going on.

And I try to put it in such a way that, shows how I'm thinking about the decision making. Even if I know they won't completely understand it, I'll try to make it so that they know that I'm thinking about this and I'm thinking about them and why I'm ordering different things and so on and so forth. The second thing is consistency. So, you know, having a consistent way to get a hold of you, having a consistent way that you interact is helpful.

Non-verbal gestures such as eye contact, leaning forward, signs that you're paying attention are helpful. Maintenance of the therapeutic frame helps strengthen the therapeutic alliance. For example, dual relationships, you know, like you form a business partnership or a dating relationship or friendship outside of the treatment, this forms a dual relationship, which kind of can make the therapeutic alliance break down a little bit.

Patients will often test the frame, and, you know, it can be helpful to just kind of have those non-negotiables. Like, you know, I don't do relationships with patients outside of the office. If they do have sort of desires towards relationships outside the office, and you could say there will be positive and negative feelings between us. And what will be safe, and it will be safe for us to talk about it here. You know, so it's kind of like you allow that opportunity to have a therapeutic potential. It's like they're soliciting you or eliciting something from you, a desire to be friends,

let's say. And, you know, you kind of reduce the shame of them wanting that and, but allow them to put it to words and don't follow through on breaking the frame. So the next thing is to have empathy, attunement, and positive regard. So patients were quoted saying the therapist is both understanding and affirming. The therapist adopts a supportive stance. The therapist is sensitive to patient's feelings, attuned to the patient, empathic. Those are all sort of things that are affirmed when the patient feels like this is a therapeutic, therapeutically strong alliance between them.

So research has found that beginning therapists have a more difficult time finding those sort of goals that the patient and the therapist can collaborate on. And that the bond itself, the therapeutic bond, is not associated with the level of training. So the capacity of someone to form a bond didn't seem to change much. Other things that show or can build a therapeutic alliance is the counselor is seen as flexible, and the therapist appears alert, relaxed, confident, rather than bored, distant, and distracted. Now, if the patient tells you that you're bored, distant and distracted, and that's true, that's one thing, but if they tell you that and, let's say it's not your experience and you're very interested, and you could empathize with the distress of their feeling that you would be that way

and then come back to sharing your experience. Like, you know, or let's say there's something else on your mind, you could share that as well and that might be helpful to them. Or, you know, I wouldn't go into the details of like, let's say someone died in your family. You could just say there was a loss in my family and I may be a little bit more distracted today and I apologize for that, if you can tell that they're sensing that. Okay, foundational concepts of the Therapeutic Alliance. So our profession gives a privileged glimpse into the human heart and mind.

We get to see patients and all of their uniqueness, their preciousness, their idiosyncrasies, and we get to know people and more people, then most people get the chance to know and understand. And each person has their unique strengths, which we should focus on. We're often in a hurry to find what's wrong, and we should find out what's right as well. I'd say a lot of the times it's finding what's right

and allowing that sort of pull them out of the hole that they found. That can be very helpful. Our feelings that we have are not intrusions but clues. For example, if you experience boredom, then you may be not understanding the links and why the patient is saying what they're saying. So you may need to focus on being curious

about what you're not understanding that you could be understanding. If you start to feel something different then at the beginning of the encounter, notice it. Try to empathize with the patient with what has changed. And what I mean by that is, let's say you come to the room feeling pretty normal for yourself. And then after a couple minutes, you feel like curling up in a ball in your room and just turning off the lights and covering yourself.

And you usually don't feel like that. Let's say you never feel like that. But that's the kind of feeling that you have all of a sudden. you could say to the patient something like, I'm wondering if as we're feeling here, and you're telling me these things, you ever just feel like curling up in a ball in your bed? And when I did that to a patient once,

they started weeping and they said, yeah, that's how I feel all the time. That's exactly how I feel. So there's things that are coming to us. They're coming across to us. And we need to kind of find those things. and then be able to help those sort of intuitive and mere neuronal experiences that we have

to be embodied into an empathic statement that allows the patient to know we're there with them, we're experiencing in part what they're experiencing. So the goal is to help the patient feel understood, heard, accepted, and felt. To be understood is to be understood is to be accepted. And this is really the goal of what leads to the building of a therapeutic alliance. We have to realize that our patients are on a continuum of coping and adapting.

And we need to look at what is going on in their life, even the maladaptive things, was this once adaptive? And if you can kind of center them on the, yes, this was once adaptive, then you can reduce their shame for experiencing maybe something that they have a hard time even saying out loud. So a strong alliance provides a corrective emotional experience. That word was coined by Franz Alexander. And it means that past relational pain and difficulties are worked out in a new relationship.

a corrective emotional experience. It's there having an emotional experience with you through the therapeutic alliance, through the new relationship that helps them work out difficulties of the past, relational issues of the past. One example of this might be a patient I had who was raised in kind of a very chaotic family where she felt like her parents were completely checked out and they were and she was like a ghost and just coming to therapy once a week for a couple years and not feeling like a ghost feeling heard and understood it's like all of a sudden the world opens up to the person they form new relationships they don't need to feel like isolated alone like they might be more

might have felt most of their life. So another concept to kind of introduce here is the intersubjective relationship. So when your subjectivity, your feelings, thoughts, and goals, come into contact with the patient's subjectivity, a unique intersubjective relationship is formed. And it's mutually influencing each other. It's a, another word is a dyad, two people coming together. and you're looking at the meanings, the understandings, and the connectedness. It's a new type of relationship.

It's maybe a more honest relationship than most people have. And there's this kind of third space in between you, which is like the intersubjective relationship. That's the third. It's the piece that's only. there between you and the person because you are in a relationship. And you can look at that. You can examine that. That may be a little bit too theoretical, but we'll come back to it. So another quote or kind of idea came from Harry Stack Sullivan. He said, you are the participant

observer as you observe the patient's behavior and also become a significant other in their life through your interactions. So you kind of, as they're going through different events of their life, different emotional events, if you can empathize with the distress, if you can help them regulate their emotion, you do become a significant other. And that's the privileged space that I talk about. So things to consider from your first encounter.

The patient will feel examined, fear of being crazy, fear of not being liked discouraged hopeless helpless needy they'll fear that you are a mind reader they'll fear you sleep with patience

they'll fear that you're somehow going to abuse them people come in with all different fears they're not all going to fear all of them they're not all going to feel all of those but they will feel some of those often say like shame will be in the room

usually pretty early on especially if the patient has never been to a psychiatrist. It's like all of a sudden, something must really be wrong with me. I'm in a psychiatrist's office. And I think to that, we have to realize that we are also human. We also, if haven't been there ourselves, which a lot of us have, we could need, we would feel those same things in this sort of situation, number one. Number two is a lot of those thoughts are adaptive.

Stranger anxiety is adaptive. So we can, if we can see it, we can empathize with the distress of it. So we want to formulate some of these emotional reactions, some of the reactions that push the emotions down as adaptive. And we want to empathize with the underlying distress, the emotion. and we want to help the patient understand what's adaptive and how it solves something and what's,

and how perhaps they're not as crazy as they think they are. And it's not that I'm just saying this to say it to build a therapeutic alliance. Like I actually believe it at this point. Like I actually believe a lot of what we do as humans, although it seems really maladaptive as it seems like it can be even destructive at time, it does serve an adaptive purpose. And if we can see that, it helps us reduce the shame that might be in the room. And by shame, I mean, I am bad. I am wrong. I've done something wrong.

Or I've done something wrong. That's often guilt. I am wrong. I am bad. That's shame. The patient may question your competence. You look very young. young for a doctor? Are you just a student? Perhaps you were looking for someone older. Our response to this is to empathize with their entitlement to be concerned, to empathize with their worry to some degree, to empathize with their distress, you know, not, we don't need to apologize for being young, but we can, if the distress is there, if there's, if there's concern there, you know, they're entitled to feel that concern. And I sometimes say, you know, I hope, or when I was young and I got asked this, I would say, you know, I hope we can work together.

And if I can't solve your issue, I know a lot of different people in this hospital that will be able to solve it. And I can get into contact with those people. So I can be a first kind of step towards this and by me collecting the history and documenting it in the chart, we'll be able to have a more accurate understanding on what's going on as a medical team. I think it's best to face the patient without desks between you. You're leaning slightly forward. You have appropriate eye contact. You're not obsessively or excessively note-taking. So you're able to watch them, to observe them, you know, at least 90% of the time. I see some people, medical students and residents,

kind of like when they're doing the medical history, they'll be facing the computer, pretty much the whole time, and I'll try to get them to sort of document less or document later and really just kind of be present with a patient. Another practical point is, ideally the clock is positioned somewhere where it's not obvious if you're checking the time.

Obviously, we need to check. the time to know kind of in plan accordingly. But we shouldn't be disrupting the session by that kind of movement. So I'm moving into a portion where I'm going to be talking about listening. And in psychotherapy, it's an active process. I'm going to read some quotes. So Liu Tzu said, it is as though he listened and such listening as his and folds us in a silence in which at last we begin to hear what we are meant to be it is as though he listened and such listening as his and folds us in a silence in which at last we begin to hear what we were meant to be

It's this idea of as you listen to someone in a certain way, it's as if the person starts to come alive and understand what they were meant to be or how they were meant to be. Aristotle said hearing contributes most to the growth of intelligence and hearing is crucial for receiving communication. Everything that is said has meaning. Nothing is trivial. Sequences are connected and thoughts and feelings are connected.

This is what we call psychic determinism, which means everything has meaning. Everything that comes out of a patient's mouth has meaning. We may not understand it. The patient might not understand it, but it's not trivial. And there is no meaninglessness in what they're saying. and so it's listening in such a way as to look for the meaning in the midst of what people are saying and sometimes there's meaning also in what they're not saying or there's meaning also in how they're saying it or the emotions that come when they say it or the micro expressions the emotional flashes

that flash on the face so before verbal language comes connection is nonverbal, right brain to right brain. You know, the left part of the brain, Broca's area in Warnikis, understands words and speaks words. Warnakey understanding words, Broca speaking it. And before that's developed, connection is a very nonverbal thing. It's a give and take. It's a playfulness. It's a cooing back and forth.

It's a mirroring of the emotions. It's the listening to the child when the child wants to retreat and allowing the child to retreat. The omissions, what is not said in the patient stories and memories, are important. So it's a nonverbal process. And there's an emotional, relational stuff going on there. And that's very important to listen to. sometimes it's important to point out patterns that we hear. The patterns come out through the patient talking, through them telling the stories, and all of a sudden

patterns start to mirror, and we can kind of gently point those patterns out. One thing that I learned from Dr. Taras, he said, be careful when asking why questions. Like, why do you feel that way? Why did you do that? The why seems to arouse a little bit of shame. It communicates disapproval. It asks them to justify themselves. Let's be careful of why questions.

Here's a quote from Dr. Tar. 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 evidence 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 or her feel understood and responded to. So much there. so much there. But I love the end part. I'm listening so as to formulate how I can communicate to him in such a way that he feels more heard and responded to. So another part of listening is to listen to the defenses. Sublimation, right, where you maybe have a sexual desire and you go out dancing. reaction formation where you instead of getting angry at your spouse you go clean the house intellectualization where instead of feeling the emotion and feeling sad you jump into a bunch

of theoretical you know sort of explanations that are very distant from the emotion so people do this all the time and there's adaptive reasons for doing it so we don't want to necessarily point it out like that they're doing it, but we can listen to it and see how by listening to it, it can allow us to understand the person, how they're adaptively coping with the emotion, and the distress and the emotion underneath, and what that might mean. Assume an attitude of revelry, like a good maternal object, receiving toxic stuff from patients and then giving it back to them in a detoxified form. That's some Bion, Wulford Bion.

And basically the idea there is, to some degree, a good therapist is a good maternal object. An object is a person, an internalization. And this person is receiving toxic emotional content and giving it back to them in a detoxified form. an example from when my child was really young, she was in the bath with me, she was very, very scared, and she was super alert, super alert and overstimulated.

And she looked up at me and she was just with this intensity. And I tried to take the intensity in and then breathe back to her calmness. And within about one minute, she was calm. And then she started to enjoy the bath. and from that time on she was a lot more calm in the bath. But it's this idea of you're taking in that intensity with children. It's very raw and with patients as well because patients are experiencing the traumas, experiencing some of the greatest tragedies of their life with you.

They're experiencing that and then you're sort of giving that back to them in a detoxified form. So we create a holding place for patients in which patients have a transitional or play space. Now that was Winnicott, Donald Winnicott. A holding place. This is a place that is safe. It's like a play space is like, you know, when kids are playing, they're having fun. And it's always best to try to engage some play. some disconnection with my son. He tipped over the cat's food and was making a fuss about cleaning

it up. But afterwards, I kind of like did my play thing where I pretend I'm an animal and he kind of pushes me and has a lot of power and I fly across the room and he giggles and then I put a blanket over myself. But we're not talking about that type of play, but with patience, it's a type of play that's kind of got that similar sort of vibe of connection. In connection mode, there's a playfulness that's there. There's a safe place to be yourself, to explore things, to explore emotions, that we're not going to put judgment on anything. So, Winnicott.

That was some of Winnicott there. Listen in a way that notes what the patient is trying. trying to say about your relationship. So the patient says, I feel lonely even when I am with people. Sometimes people will say that in front of me to elicit, it's sort of a way of telling me that they're feeling lonely even when they're with me. And so I might say, do you feel lonely here with me now? Patient says, no, I feel you understand me somewhat.

doctor may say, I want to know if there's any times where you feel more lonely in our sessions. It will help me to understand what is going on between us. So once again, coming back to this like getting the patient to be more honestly expressing things in the here and now is going to help the therapeutic relationship and it's going to help the patient grow. It's going to help them grow. So the next one is very important, and I'll go into it in a little bit more detail later in another session, but the basic idea is to listen to their moment to moment change in emotions. So try to enter a bit into their feeling, be present with them,

mirror the emotion feeling, use their own words, and ask them to find their own words. I say use their own words, like if the patient says they're feeling frustrated, to use that word frustrated, I hear you feel frustrated. That would be very frustrating. If you don't get why they are sad, then stay with it. Ask them more questions. Have them deeper your understanding of it. Once they feel you truly understand, their affect will change.

When people feel heard, deeply understood, it is pleasurable. I found that it is pleasurable. And what I mean by that is, as someone expresses the parts of them where they could be very, very raw and distraught within, but then they feel very, very heard by you and feel connected with you. There's a sort of pleasure there that can come. So different emotions you might want to take into account is shame. You know, when the patient looks down, you could say something like,

I can understand why talking about this must be difficult. Or perhaps as you talk about this, you feel, you know, dot, dot, dot. Try to find the adaptive function, as always, with the emotion. The adaptive function being, you know, switching to a new doctor is hard. Coming to a doctor at all is hard and talking about these things is hard. so I can understand why you'd be hesitant at first to share this. So we're looking for like adaptive reasons for why they would be hesitant to share. If they have anger or frustration, we can look for the adaptive function of the anger.

For example, you know, they're wanting to move towards a goal and they feel some sort of obstacle in that path towards that goal. or with sadness maybe the adaptive function might be it shows their value of the person they lost it shows how much they loved you know if we didn't feel sadness then we after we lost something then it's like well did we really value what we lost and so sadness is a it's sort of a message that we valued something what is the meaning and adaptive function of disgust? You know, like let's say, you know, it sickens them to a point of wanting to spit it out. You know, they're revulsed by it.

They want nothing to do with it. And so the disgust is adaptively telling them to get away from it. With fear, the adaptive function can be to protect themselves. to be able to run away to avoid something, protect their family. So we listen to the patient's goals, purposes, aspirations, fears, hopes, values, and meanings. We're going to have a whole session in this series on Therapeutic Alliance on Meaning. So a couple more practical points on how we create and maintain a working alliance, a therapeutic alliance. we can be sensitive to the empathic strains

and prevent them from developing into ruptures. So we have to look for the smaller moments of tension between us in a relationship and put some focus there and be sensitive to those and empathize with the distress that comes from that. To find those strains earlier on, we can ask for feedback So there's a we-ness in the encounter that, you know, as we reflect on we, as we are here together, and as we are talking about this, are we understanding each other? Are we communicating meaningfully?

Are we talking about what is important? Are we touching base on your goals enough? So we want to be able to define and predict. interpersonal conflict that may cause a disruption to our relationship. And to do that, we may set a groundwork for openness. We wanted to be safe to be given feedback if there is a slight disruption. And to do that, sometimes I'll elicit stories of their past psychiatrists or therapists. What worked well and what didn't work well?

What were some of their disappointments? what were some of the things that they were excited about? What were some of the things that they wish they had more of? You know, if they say, you know, oh, he was a jerk, he was on his computer. The sessions were, you know, five minutes, and I feel like he didn't really care. He just asked me, you know, blah, blah, blah. And unfortunately, that is the true experience of a lot of patients. And so when they tell me that, you know, I may say,

say to them, that would be very distressing to not feel heard or to not feel like they were really understanding what was going on. And I hope that we can, I hope that you can feel like you have enough time. And if you need more time, then we can schedule extra visits. And usually if, if, if, if I do that, it starts to, to allow the patient to get what their needs are and get their their needs expressed. So this is the end of the episode. Therapeutic client session one. I hope it was helpful for you.

I will be posting it on my social media and you can post a comment if it was helpful. If you had any thoughts coming out of it, any situations, questions. And I will leave it there for today. Thank you.