The Goal Structure of Psychotherapy

February 18, 2012

Are Your Treatment Goals Foggy?

First of all I apologize for the length of this posting. But it is great stuff!

In a recent session with a relatively new patient I asked about her psychotherapy. She expressed dissatisfaction with the process. I further inquired about the goals of the therapy. She was perplexed, stressing that the therapist explicitly told her that “that’s not the way therapy works”! The following is an edited version of a message I received from her a few days after our last meeting. She had fired the therapist after trying to resolve their four-year long unproductive relationship.

Hi Dr. Lynch,

As per our conversation yesterday at your office, here is the requested information.

The following is from Beware the Talking Cure, by Terence W. Campbell, PhD, a forensic psychologist and family therapist.

 

Evaluating Therapeutic Effectiveness

Directions: In taking this inventory, merely respond “yes” or “no,” and count how many questions you answer “yes.”

yes        no         Has your therapy limited itself to giving you a better understanding of the  difficult  situations in your life?

yes        no         Do you feel more worried and discouraged since you began therapy?

yes        no         Is your therapist so preoccupied with your insight that he neglects to outline specific courses of action for you to undertake?

yes        no         Is your therapist intensely interested in the minutiae of your fantasies, feelings, and/or   thoughts?

yes        no         Does a great deal of your therapy seem to focus on issues that are trivial or obscure?

yes        no         Is your therapist more curious about you than he seems committed to helping you (do you feel reduced to an object of study by your therapist)?

yes        no         Despite a situation where you have felt ready to terminate therapy, has your therapist repeatedly advised you not to?

yes        no         Does your therapist focus primarily on the events of your childhood and overlook the present-day issues of your life?

yes        no         Does your therapist overemphasize your deficits and shortcomings while ignoring your strengths and resources?

yes        no         Does your therapist frequently tell you things about yourself which seem wildly speculative?

yes        no         Does your therapist spend a good deal of time explaining how you supposedly feel about him?

yes        no         When differences of opinion exist between you and your therapist, does he almost always insist that you are mistaken?

yes        no         Does your therapist seem to see himself as intellectually superior?

yes        no         Does your therapist appear to distrust you; is he quick to assume that you are merely victimizing yourself and sabotaging your therapy?

yes        no         Does your therapist insist that he is a much more important figure in your life than he really is?

yes        no         Does your therapist frequently talk about other people in your life, but refuse to include them in your therapy despite their availability?

yes        no         Does your therapist attribute malevolent motivations to other people in your life, and indict them as a result?

yes        no         Does your therapist insist that you postpone important decisions in your life (marriage, job change, educational plans), pending his permission for you to make those decisions?

yes        no         Has your therapy created a situation where you feel pulled in one direction by your therapist, and pulled in another direction by someone else in your life?

yes        no         Is your therapist a remote, aloof individual who exhibits all the human warmth of a computer?

yes        no         Has your therapist insisted that you cannot discuss your therapy with anyone else in your family?

yes        no         Has your therapist become a good friend with whom you spend most of your sessions chatting amiably?

yes        no         Have you assumed that your therapist is competent merely because he seems to be a pleasant, personable individual?

yes        no         Does your therapist act as if he provides you with a uniquely important relationship that is unavailable to you in other sectors of your life?

yes        no         Does your therapist seem to assume that he is a charismatic figure?

yes        no         Is your therapist committed to pursuing ill-defined goals such as ‘growth’ and ‘existential quests?

yes        no         Does your therapist seem so bound and determined to be your friend that he disregards the resolution of your problems?

yes        no         Is your therapist preoccupied with telling you about his own feelings?

yes        no         Does your therapist seek to determine where some feeling or emotion is located in your body?

yes        no         Is your therapist more concerned about how you experience your feelings, compared to what (or who) influences those feelings?

yes        no         Does your therapist seem more interested by what transpires in a session, than by what transpires in your life outside of therapy?

yes        no         Does your therapist expect that you should imitate him and adopts his values?

yes        no         Does your therapist assume that his relationship with you will suffice to resolve your problems?

yes        no         Does your therapist often seem as bewildered and confused by your problems as you are?

yes        no         Does your therapist rely on sympathetic platitudes advising you to ‘trust yourself’ and/or ‘be kind to yourself?’

yes        no         Has your therapist subjected you to any kind of physical ordeal?

yes        no         Instead of planning a therapy session, does your therapist merely react to whatever direction a session spontaneously takes?

yes        no         Is your therapist unaware of who is included in your family and how they influence you?

yes        no         Instead of planning how to influence the behavior of someone else in your life, does your therapist merely hope that those changes will transpire by themselves?

yes        no         Is your therapist unresponsive to the idea of including other people in your therapy?

 

Here is how Dr. Campbell interprets the results of the list of questions:

“If you answered ‘yes’ to only one or two questions, the chances are better than fifty-fifty that your therapist is competent. You and he will probably be able to resolve whatever doubts you have about your therapy.

If you answered ‘yes’ to between three and five questions, it is imperative that you and your therapist resolve your concerns. Otherwise, therapy may deteriorate into a waste of your time, money, and energy.

If you answered ‘yes’ to between six and nine questions, you need to seriously discuss the direction of your treatment with your therapist. Nevertheless, do not feel too optimistic about the outcome of such a dialogue. A therapist who provokes this many ‘yes’ answers, is likely very entrenched in an antiquated paradigm. You may find it necessary to fire this therapist.

If you answered ‘yes’ to ten or more questions, you need to carefully question your therapist about the relevance of your therapy. If the outcome of this discussion fails to reassure you, decisive action is warranted. Rather than walk away from this therapist, or even trot, consider sprinting from therapy as rapidly as you can. Any therapist who elicits this many ‘yes’ responses is likely incompetent. He is probably doing you much more harm than good.”

 

Me again. We must work with our clients to develop a clear goal structure of the treatment. If it is not clear from the very beginning what our job is, the first order of business is to work to make it explicit. Without clear goals the measurement of progress is impossible.

What we want is to deliver a service that clearly optimizes our clients’ functioning.  Not only is that our job, it is the best way of generating word of mouth marketing.

Do you help your clientele set clear treatment goals? Do you have a different approach? Go back to the top of this post to “Leave a Comment”. Let’s talk it over.

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