The patient is active, not passive

In therapy, the patient is not a passive being that the clinician works on or something broken waiting to be fixed – like a car at the mechanic.

They are autonomous individuals capable of their own thoughts, feelings, and behaviours. Therefore, the therapist and patient must enter into a collaborative relationship and work together to break negative cycles maintaining the patient’s problem and get them closer to their goals.

Unsurprisingly then, the therapeutic alliance, the relationship between the healthcare provider and the patent, is an incredibly important component of therapy. The therapeutic relationship provides a safe and trusting space to mutual work towards a shared goal.

Positive working relationships are found to improve treatment outcomes in virtually every disorder (Horvath & Symonds, 1991). To support a positive and equal working relationship, there are certain ways that therapists should view patients to support a strong and equal working alliance.

#1 Patients are inherently good

Even for the most patient of saints, there will be times that you will be annoyed or frustrated with your patient. For example, if they consistently don’t complete their home practice or if they disclose something having engaged in violent or disagreeable behaviours in their past that may be particularly sensitive to your own values.

Despite these instances, it is important to remind yourself that the patient you are working with has strengths and positive qualities of their own.

Try to focus on positive qualities of this individual. Perhaps they are always on time for their appointments. Maybe they are insightful about their struggles and grasp the material you provide well. Or they appear to be a very strong and caring parent to their children.

Pick something out and remember that. It is hard to be kind and compassionate to someone you do not believe is good or worthwhile. Carl Rogers, a founding figure in Humanistic psychology, believes that people are inherently good and simply need empathy and unconditional positive regard to become their best selves. This means trying to see things from the patient’s perspective and considering them a good person even if you do not agree with certain actions.

Fortunately, all patients I have worked with have had strengths and positive qualities – some of which became much more noticeable the more I positively worked with these individuals. It is also important to reinforce patients of these characteristics when talking to them.

#2 Patients have their own goals and values

It is important to remember that your patient has their own goals for treatment. You may notice other ‘problems’ to be solved or obvious goals if you were in the patient’s situation, but you should always focus on the specific needs of the patient.

Each person has distinct values – things that they find most important in their lives. As therapists, we can share our concerns and dilemmas; however, we should not impose our own values on the patient in terms of what they want in treatment.

For example, you might share your concern that the patient’s goals could lead to other issues, or that the treatment would not be a good fit for their goals. In this case, the patient may decide to work differently with you or you can work together to search for another clinician that can provide the treatment they are looking for.

Focus on where the patient is currently at and prioritize their needs in treatment over your own. One exception is if the patient is

#3 Patients are unique in what strategies work well for them

What works well for one patient may not work well for another. Therefore, therapists must be flexible and considerate about what might be most helpful for each unique patient.

For example, some patients may prefer to work cognitively on their negative thoughts, which may warrant the use of thought records.

On the other hand, other patients may find more utility in behavioural strategies, such as behavioural experiments or mindfulness strategies.

Use your clinical observations to inform how you think about the case and be willing to experiment with different strategies with your patient to see which one works best for them!

#4 Patients are shaped by past experiences

Past experiences can affect how patients view themselves, others, and the world. For example, if their parents were generally uncaring to them when they were young, they may be suspicious of why you are being kind to them and wonder whether you have underlying motives for being so nice.

Understanding how the patient’s past experiences affect their present cognitions and behaviours can be instrumental provides insight into what might be maintaining a patient’s problems. This insight also allows you to share how certain strategies might have been helpful in the past (e.g., being aggressive to get what you want) but may be problematic in their present life.

#5 Patients want to change

Although it may not feel like it sometimes when patients are pushing back against your every word and haven’t done their home practice for the third week in a row, patients are not intentionally being difficult and do want to change. That’s why they are in therapy.

However, there may be barriers or conflicts that make change difficult. For example, they may want to develop a stronger social circle but be paralyzed by fears of negative evaluation from their peers and deal with struggles of worthlessness. They may also be worried that the change in lifestyle may affect their ability to have alone time – something they also value.

All these components make the task of being more social a lot more difficult to approach. It is your job to unpack these challenges and work with the patient to help them decide what is best for their lives. This may be troubleshooting more practical errors, such as deciding who the patient should call up to spend more time with, or targeting cognitive beliefs about self-esteem or black and white thinking about having to choose between friends and alone time.

#6 Patients have different definitions of success

What the therapist thinks treatment success may not be the patient’s perception of success. For example, clinicians may want the patient to fully abstain from substance use, but the patient’s own goal may be to reduce their use but not eliminate it completely.

Although we may have well-intended reasons to have a different goal, it is imperative to follow the patient’s decision and not impose our own values onto them. Again, we can share our thoughts, but the choice should ultimately come from them. It is hard to follow through when something does not come from ourselves. Determine what the patient’s goal is and work with them to get them to where they want to be.

Summary

The therapeutic alliance is one of – if not the most – important factors for positive treatment outcome. At the very least, patients will have a positive experience working with you and be more likely to come back to treatment in the future. Hopefully, learning a bit about these components to a strong working alliance has been helpful

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Best wishes,

P