Psychotherapy: Guiding Principles

In considering what I've learned over the years that has most served to guide me, I believe that the following principles have significantly shaped my work.

The relationship between therapist and client is not exactly a partnership after all.

It's the therapist's job to serve the client. Determining goals and (with assistance) destination, becomes in my view, the responsibility and right of the client, while the therapist develops the road map so to speak. How can we promote autonomy and independence if we insist on steering the course? If the process of therapy were likened to that of a journey across the ocean, then from my perspective, the individual served would be the captain while the therapist faithfully navigated.

A therapist should be a visionary while remaining grounded in the present.

Although it's important that we remain focused on the facts at hand, possessing a clear vision for which we strive is of equal value. Webster's dictionary defines a visionary as, "a dreamer; one who tends to accept fancied things as facts; one who is not a realist." My personal definition reads, "one who believes in possibilities; one who is not immobilized by the realities of the present but pushes forward to transform 'fancies' into facts." When a client tells me, "I can't", the visionary in me might respond, "You just haven't yet". When I hear, "It will never happen to me," I'm likely to reply, "It hasn't happened yet." We must believe in possibilities, and our language should consistently reflect faith in our client's abilities to transcend their limitations and achieve their goals.

Utilizing time creatively and flexibly should not remain a good idea to be implemented as often as possible (or when demanded by managed care), but rather a standard by which the conscientious therapist consistently operates.

This is far from a novel idea and has been suggested by many of our mentors. The creative and flexible use of time places a premium on the needs of the client versus the convenience of the therapist. The 50 minute once-per-week format is much more conducive to a predictable schedule for the therapist rather than being what might best meet the unique requirements of the client. For one client, 50 minutes once per week eventually shifting to every other week might make sense. Another client may need one-100 minute session on a bi-monthly basis; while still another benefits from one thirty minute session per month.

For years the typical contract between client and therapist was that the pair would work on specific issues and once the problems were resolved they would "terminate" their work together. Thus the relationship existed for a finite period of time. Countless novice therapists (including myself) were informed that an integral component of therapy involved working from the beginning towards termination. I'm humbly proposing that it's not necessarily so that the client and therapist need to be always working towards termination. Instead, the proposal that the relationship between client and therapist might be viewed as intermittent (involving periodic visits)is far more realistic to me. When are we ever truly finished before death? Rather than saying goodbye forever, a common and often traumatic practice in therapy, how about if the relationship were not to officially terminate at all? What if the client and therapist contracted to do a specific piece of work, mutually agreeing that when the goal has been completed they will part ways but with the understanding that the therapist will be available at some point in the future should the client require further assistance. What truly amazes me is that not too many years ago this was a novel idea.

There is no ultimate formula for providing the best possible treatment to all clients.

Each client is unique, with differing needs, motivational levels, and resources. In order to meet the various needs of the clients whom we serve, we must be prepared to be flexible, creative and responsive to the varying needs and perspectives of our clients.

Therapists must never presume to have all the answers.

Our client's generally want answers from us, and sometimes we're fortunate enough to be in a position to deliver. They expect wisdom, too, and many of us do everything in our power to oblige them. Still, as the late psychotherapist, Sheldon Kopp, gently and sagely reminds us, "In the world of adults, there are no mothers and fathers, only brothers and sisters." While we can act as guides and facilitators, I think that it's important that we not forget what most of us know deep down in our hearts, and that is, that we are all struggle in one way or another in the stew together. We shouldn't inflict our values and personal opinions on our clients. When we offer advice, we may want to consider that the price our clients may pay (in addition to dollars and cents) is of far greater value--and that is their autonomy. It's flattering to be made larger than life, to be sought for our knowledge, and professional expertise. It's enormously gratifying to know that those who seek us out do so very often with a significant degree of faith in our abilities. Faith is defined in part by Webster's dictionary as, ''...trust and confidence in another..." We must never violate the trust and confidence placed in us. When we even imply that we know for certain what is best for another human being, then we do exactly that - we violate their trust and confidence. We can never truly know what is best for another in spite of our ideas from time to time to the contrary.

The client, not the therapist, is ultimately responsible for change.

Clients (and some therapists) need to be informed that while therapy may be part of the solution, by itself, it's seldom the answer. While it's common practice for therapists to hand clients forms that outline certain key responsibilities of the client such as that the client will pay on time and give a 24 hour notice prior to cancellation. I have never seen a form outlining expectations such as that the client will be expected to work on their goals outside of the therapists office, complete agreed upon homework assignments, and be expected to assess their progress.

We can present, point out, clarify, encourage; but we should never dictate.

I recall a client who I referred to a psychiatrist for a consultation. The psychiatrist told her in no uncertain terms that she must leave her husband and that until she did, she would be wasting her time in therapy. The client canceled her next three sessions with me and her depression deepened. I was furious. How could this doctor possibly know after a brief meeting that this woman should terminate her 14-year marriage? What if the psychiatrist was right and that she should leave her husband? What if, however, the woman was in no position at the time to act upon this reality? If she cannot leave him for real or imagined reasons at this time, does this mean that therapy is useless? What if the therapy were aimed at assisting her in acquiring the resources she will need to possess in order to carry out any decision she might make?