Die unbewusste therapeutische Allianz als treibende Kraft therapeutischer Veränderungen
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by Jon Frederickson, MSW
Finding Positive Goals
These studies have been developed to accelerate the learning of effective therapeutic techniques by the Institute for ISTDP Training and Research. These studies are free. Feel free to copy them, send them to your friends, teach them to your students, and distribute them as widely as you want. want – provided that they remain attributed to me, are used non-commercially, and are used without modification (license: Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International).
If you find these studies helpful, feel free to buy the other skill-building packages we offer, so you can take your skill up to the next level. You can find these packages at www.istdpinstitute.com orwww.deliberatepracticeinpsychotherapy.com
Also, you can find hundreds of answers to therapists’ questions at my facebook page www.facebook.com/dynamicpsychotherapy
Skill building exercise 1: turning negative problems into positive goals
Skill building exercise 2: turning defenses into positive goals
Skill building exercise 3: turning negative goals into positive goals for therapy
Skill building exercise 4: turning a lack of capacity into a positive goal.
Skill building exercise 5: turning negative expectations into realistic hope
All of us work with depressed patients who feel little motivation to engage in therapy. Either they feel hopeless, they have only negative goals, they can think of only what doesn’t work. But they can’t think of a positive goal that would make the work of psychotherapy worthwhile. Thus, the most important thing we can do is to use their words in order to help formulate goals that would be positive and attractive for the patient---positive goals that would mobilize the patient to work hard in therapy. The following exercises will help you do that.
Remember: we all see the same patients and all of us deal with the same problems. These skill exercises are transtheoretical. That is, they will help you be more effective no matter what kind of therapy you do. Practice these skills repeatedly until you can do them in your sleep. Your work will improve, your patients will get better, and you will become the therapist you want to be. Enjoy!
A depressed patient has described problems to work on, but he seems discouraged and unmotivated. Thus, although a problem is declared to work on, he doesn’t seem to have the will to work on it. In the following exercise, you will turn his negative problems into potential positive goals to see if he would be motivated to achieve those positive goals. Often, depressed patients see negative problems. Therefore, they have no positive goals that would motivate them to try something new. Helping the patient see positive goals is essential. Otherwise, there would be no reason to engage in the hard work of therapy.
Principle: turn each negative symptom into a positive goal that mobilizes the patient
Pt: “I just feel anxious.” [“Would you like to take a look at the feelings underneath the anxiety, so you wouldn’t have to feel anxious instead?”]
Pt: “I feel depressed.” [“Would you like to take a look at the feelings underneath the depression, so you wouldn’t have to feel depressed instead?”]
Pt: “I feel so tired.” [“Would you like to take a look at the feelings underneath the tiredness, so we could find your energy?”]
Pt: “I don’t know. I feel so powerless.” [“Would you like to take a look at the feelings underneath the powerlessness so we could find your power?”]
Pt: “I don’t know who I am anymore.” [“Would you like to take a look underneath the depression to find out who you really are?”]
Pt: “I feel hopeless.” [“Of course. That’s how we feel when we’re depressed. Could we look under the hopelessness, see what it is covering up, and try to find the rest of you?”]
Pt: “I feel afraid of doing that.” [“Of course. Everybody does initially. If you avoid what you fear, the fear will be in charge. But if we face what you fear, you could be in charge. Would you like to take a look under this fear, so you can be in charge of your life?”]
Pt: “I feel weak.” [“Would you like to take a look at the feelings under the weakness, so you could regain your strength?”]
Pt: “I just am not sure I’m able to.” [“Sure. It sounds like you haven’t been able to alone. Shall we join forces together and see if we can help you discover your true potential?”]
Pt: “I feel sick inside.” [“Would you like to take a look at the feelings under your sickness, so you could feel healthy instead?”]
Pt: “I have so many physical symptoms.” [“Wouldn’t it be nice to know what you feel, so you wouldn’t have to have symptoms instead?”]
Pt: “What if I can’t do this?” [“Shall we take a look and find out your true potential? If we look underneath the anxiety, would you like to find out what you actually can do?”]
Notes to the therapists:
When you have completed a study, always practice it several times until you have mastered it 100% accurately and can do it automatically and easily. That way, in session, these interventions will happen automatically, so that you are free to think about the patient, rather than be puzzling over how to intervene. This repetitious practice yields the deep mastery that you see in other fields such as music, ballet, and chess.
When you practice these studies with a friend, do so straight through without stopping just like you would with a patient. That way you will increase your processing speed so that you can intervene as rapidly as the patient presents opportunities. This increase in processing speed will increase the effectiveness of your work.
And one more thing: when you practice these with a friend, make sure the person in the “patient” role has this sheet, and the person in the “therapist” role doesn’t. The purpose of these studies is to learn to think on your feet. If the “therapist” merely reads the sheet, s/he only gets better at reading (not a therapeutic skill). Instead, make sure the person in the therapist role has to think, intervene, and learn using his head rather than a piece of paper to refer to. After all, in therapy, there will be no paper to refer to. These skills have to be learned and inside you.
Sometimes patients present ways they hurt themselves. Of course, this doesn’t motivate them to do therapy. If anything, the fact that they hurt themselves merely discourages them further. Thus, it can be helpful if you reframe a defense as a positive goal the patient might want for himself.
Principle: turn the defense into a positive goal the patient might want to pursue in therapy.
Pt: “I’m too hard on myself.” [“Would you like to be kinder to yourself?”] [A depressed patient will say he cannot be kind to himself. But he can usually see how he could be a little kinder to himself. Always offer a goal that seems achievable to the depressed person. Otherwise, he will get more depressed if you keep asking him to do something he thinks he could never do. Start with small goals.]
Pt: “I always say yes to what other people want.” [“And would you like to be able to say yes to what you want too?”]
Pt: “I’d like to but I just don’t seem to be able to help myself.” [“Would you like to be able to help yourself?”]
Pt: “I’m not able to do good things for myself.” [“Would you like to be able to do good things for yourself?”]
Pt: “I do good things for others and hope they will do good things for me.” [“Would you like to be as good to yourself as you are to others?”]
Pt: “I’m not sure I can.” [“Of course. That’s why you are here. Would you like to find out if you can be better to yourself?”]
Pt: “I feel like over the past months, I closed down.” [“And would you like to open up to yourself, so you can find yourself again?”]
Pt: “I’ve tried to do things differently.” [“And it sounds like you couldn’t when you did it alone. Shall we join forces together and see if we could have a different result?”]
Pt: “I feel really disconnected.” [“Would you like to reconnect to yourself, so you can find yourself again?”]
Pt: “I feel really out of touch with myself.” [“Would you like to get in touch with yourself?”] Pt: “I cannot like myself.” [“Is that a capacity you would like to develop here?”]
Pt: “I prioritize other people.” [“Would you like to prioritize your needs too?”]
Pt: “I try to meet other peoples’ needs first.” [“Would you like to meet your needs too?”]
Often, depressed patients cannot tell us what they want. They tell us what they don’t want. For instance, “I don’t want to feel depressed.” That is a negative goal: what the patient does not want. Negative goals prime avoidance and more defenses. That’s why the famous psychotherapy researcher Klaus Grawe said that if the patient cannot offer a positive goal, you should not attempt therapy. After all, there is no motivation to work to achieve something negative. Instead, we must reframe the patient’s negative goals into positive goals. If there is something he wants that is positive to him, then he is motivated to work for that goal.
Principle: turn each negative goal into a positive goal for therapy.
The patient is a depressed and anxious man who has not responded to previous therapies because he has never had a positive goal for therapy.
Pt: “I don’t want to feel depressed.” [“What would you like to feel instead?”]
Pt: “I don't want to feel so anxious.” [“Would you like to find out what the anxiety is
hiding, so you could feel calm instead?”]
Pt: “I don’t want to feel so shut down.” [“Would you like to look under the shut down, so
you could feel your feelings instead?”]
Pt: “I feel overwhelmed.” [“Would you like to look under the overwhelm so we could find out what it is covering up? Wouldn’t it be nice to know what you feel so you don’t have to feel overwhelmed instead?”]
Pt: “I don’t want to feel stuck.” [“Would you like to take a look at the feelings underneath so we can get you unstuck?”]
Pt: “I don’t want to feel so isolated.” [“Would you like to be able to deal with this anxiety so you wouldn’t have to isolate yourself from other people?”]
Pt: “I don’t want to feel like a failure.” [“Of course. No one does. Would you like to find out what is driving your anxiety so we can help you succeed?”]
Pt: “I don’t want to be always crying.” [“Of course. Wouldn’t be nice to know what those tears are covering up so you wouldn’t be depressed instead?]
Pt: “I don’t want to keep screwing up my relationships.” [“Wouldn’t it be nice to know what you feel, so you could handle your relationships better?”]
Pt: “I just feel really bad.” [“Would you like to take a look under this anxiety, so we could help you feel better?”]
Pt: “I don't want to have these panic attacks.” [“Of course. Wouldn’t it be nice to know what you feel so you could feel calm instead?”]
Pt: “Nothing ever works out for me.” [“Would you like to find out what is getting in your way, so that things could work out for you?”]
Patients often become discouraged, believing that a weakness means therapy cannot work. Instead, we have to remind them that if they lack a capacity, together we can build it. In the following examples, take each patient capacity and ask the patient if building that capacity is something they would like to do in therapy. In that sense, no lack of capacity is ever an obstacle; it’s the doorway to the central therapeutic task.
Principle: turn a lack of capacity into the task of building that capacity
Pt: “I don’t know what I feel.” [“Would you like us to help you build that capacity?”]
Pt: “I can’t regulate my anxiety.” [“Would you like us to help you build that capacity so
you could regulate your anxiety?”]
Pt: “I can’t do this.” [“Of course. That’s why you’re here. You couldn’t do it alone. Shall
we work together to see if we can help you build that capacity?”]
Pt: “I can’t deal with conflict.” [“Would you like us to help you develop the capacity to
deal with conflict in relationships?”]
Pt: “I start to cry when I get angry with my boyfriend.” [“Would you like us to help you learn to channel your anger into healthy self-assertion so you wouldn’t have to dissolve into tears instead?”]
Pt: “I’m not able to assert myself with my boss.” [“Would you like us to help you build the capacity to assert yourself effectively?”]
Pt: “Whenever there’s a conflict, I just get depressed.” [“Would you like us to help you build the capacity to deal with conflict so you wouldn’t get depressed instead?”]
Pt: “I just get depressed when you ask about my feelings.” [“Would you like us to help you build the capacity to know and feel your feelings so you wouldn’t have to get depressed instead here with me?”]
Pt: “I don’t understand why it’s happening with you.” [“Me neither. Shall we build this capacity to know your feelings here with me so you can bring this strength to your other relationships?”]
Pt: “I don't know what I feel. I just get pain in my stomach.” [“Would you like us to help you build the capacity to know what you feel so you wouldn’t have to have stomach pains instead?”]
Pt: “I just think I’m stupid.” [“Would you like us to help you look under those thoughts, so we could discover what your true potential is?”]
Pt: “I can’t stop this anxiety.” [“Of course. That’s why you’re here. You couldn’t do this on your own. Would you like us to join forces so we can help you learn to regulate your anxiety?”
Neben dem bewussten und willentlichen Arbeitsbündnis ist vor allem der Aufbau der unbewussten Allianz für den Therapieerfolg ausschlaggebend. Die unbewusste therapeutische Allianz entsteht, indem der Patient durch Einsicht in die zerstörerische Auswirkung seiner Abwehrmechanismen mit dem Therapeuten zusammen eine Veränderung anstreben will.
initiales Fördern einer UTA Unbewusste Therapeutische Allianz und den eigenen Willen. ("unconscious therapeutic alliance" und "own will to change“).
Intensive short-term dynamic psychotherapy (ISTDP) was developed out of the need for relatively short psychodynamic psychotherapeutic treatment approaches to complex and resistant patient populations so common in public health systems. Based on extensive study of video recordings, Habib Davanloo discovered, and other researchers have validated, some important clinical ingredients that align the therapist with healthy aspects of the patient striving for resolution of chronic neurotic disorders and fragile character structure. In the case of character neurotic highly resistant patients, these approaches including "pressure," "clarification," "challenge to defenses," and "head on collision" can be used in a tailored and properly timed way to help the chronically suffering patient to overcome his or her own resistance and access core drivers of these pathologies. In this article the meta-psychological basis of ISTDP is reviewed and illustrated with an extended case vignette.
These two examples underline the central importance of the unconscious therapeutic alliance in the overcoming of the resistances. This presentation is focussing on the question how to mobilize the unconscious therapeutic alliance against the forces of the resistances. Of course, this is a wide focus, and I will have to narrow it on a few issues.