The alliance is the therapy.
The great Jeffrey Kottler and the late (and great) Jon Carlson asked me to consider four questions about what made my work effective. This is the second of four blogs that addresses these questions. (If you need to revisit my answers, here's a link to the first of the four.)
What do you think is most important in identifying or defining an extraordinary therapist, one who stands out from her or his peers?
I have discussed in previous blogs and videos that the therapist accounts for most of the variance of any treatment offered. Therapists vary significantly in their ability to bring about positive outcomes. The big question, of course, is what makes one therapist better than another. No need to hire a detective here. The answer is the therapeutic alliance. Therapists who form strong alliances across more clients get better results, period. The alliance engages the person in purposeful work and is the fuel of all change. The alliance is the therapy.
In the 80s and 90s, I used to direct a training institute that also housed a big group practice. I was very fortunate to witness the work of several very talented therapists. We regularly consulted with therapists and agencies having trouble with a given client. We took turns being the therapist in the room with the client while the team and the primary therapist watched behind a one-way mirror. It was the most enriching learning experience of my career and one that I will always look back on with great fondness. While all the therapists on the team were very good, Greg Rusk stood out. He stood out because of his remarkable ability to engage clients from all walks of life, facing all kinds of despair and destitution, in this thing we call psychotherapy.
Peg was a particularly memorable client of Greg's. She was referred to us by her psychiatrist/therapist and was taking max doses of two antidepressants as well as pain medication. Peg suffered severe pain because of a fall in an elevator shaft two years prior, and had not been able to return to her job as a night cleaning person in a large office building. She was “profoundly depressed” and “perpetually suicidal” and the referring therapist wanted an opinion about ECT and involuntary hospitalization because many changes in medications had been tried and she refused hospitalization. In addition, the psychiatrist reported that Peg didn’t make eye contact, gave barely audible one sentence replies to questions, and seemed to punctuate every utterance with “I have no reason to live.”
Greg greeted both Peg and her husband Wayne in the waiting room, and asked Peg if it was okay if Wayne joined them. True to form, Peg never looked up and responded in a low voice that it was okay. On the way back to the consultation room, Greg started chatting with Wayne about his “Hooked on Fishing” hat and Wayne shared that actually Peg was the true fisherman of the family. They arrived in the therapy room, and Greg, while ushering Peg and Wayne to the couch, asked Peg if she remembered the first fish she ever caught. And Peg looked Greg right in the eye, and told him the story of her first fish, a sun granny, and moreover, about her very special relationship with her father who taught her not only to fish, but also about life. She spoke of her father’s death as a blessing after his horrible bout with cancer which happened right after her accident, while Wayne added that many in Peg’s family compared Peg’s gentle parenting style and overall compassion to her father’s. Wayne proudly said that Peg was the rock of the family, and told about how she stood by him when he was struggling with alcohol and ongoing unemployment (Wayne was now sober and ironically was employed as truck driver of a beer distributor).
It was a very touching conversation, and Greg, visibly moved, commented on his heartfelt admiration for this couple as well as the difficulty of the situation. From there, it emerged that Peg felt useless to the family, that she was unable to contribute financially and more importantly, to parenting their two daughters. Wayne chimed in to say that both their daughters were honor roll students because of Peg. Greg replied in earnest that no wonder Peg believed she had no reason to live given that her identity had been stolen by the accident. From there, a lively discussion ensued about how Peg could recapture her usefulness and identity. The couple outlined ways that Peg could start to contribute more to the family, which included a frank discussion about the merits of the medications and their effects on her ability to function. The beginnings of a plan surfaced, and most importantly, so did hope. This was Greg Rusk. He engaged people, even those who seemed impossible to engage, in meaningful conversations about how their lives could be better.
The Art of Engaging
The research about what differentiates one therapist from another as well as my personal experience suggest that the ability to form alliances with people who are not easy to form alliances with — to engage people who don’t want to be engaged — is what separates the best from the rest.
The Partners for Change Outcome Management System and Better Outcomes Now ensure that we don’t leave the alliance to chance — that we have our finger on the pulse of the client’s perspective of change and their experience of therapy.