Jesse Wright and Denise Davis have written an excellent article about the therapeutic relationship in cognitive-behavioral therapy [Wright, J.H. & Davis, D. (1994). The therapeutic relationship in cognitive-behavioral therapy: Patient perceptions and therapist responses. Cognitive and Behavioral Practice, 1, 25-45.]
They have interviewed two dozen outpatients being seen at a university medical center mood disorders program regarding their expectations of therapy. They present a composite of the candid responses they received in the form of a hypothetical letter from a patient:
Dear Dr. Wright and Dr. Davis,
In response to your request, I am writing to share my thoughts with you about what therapists need to learn from the patient s point of view. I ve made a list of 10 things that a therapist can do that will make a big difference in the satisfaction of their patients. Maybe each one isn t equally important to every person, but I think that most people I know would want their therapist to provide these things.
First, provide a safe and professional setting for our meeting. The place we meet must be physically safe, private, confidential, free from distractions, and comfortable. Your office environment tells me a lot about you. It should convey a sense of frendliness and authority, encouraging me to feel welcome and willing to accept what you have to say. Occasional problems or distractions will usually be tolerated (e.g. cooling system breaks down, unexpected fire drill sounds), but too much of this will eventually bother me. A sloppy environment may say that either you don t really care about me, or that you are not very careful or up to date in your methods. I am especially concerned about how you handle information about me, and I want to be sure that you will protect my confidences. So be careful about how you handle files, phone calls, and hallway conversations.
Second, treat me with respect as a person. Show regard for my dignity and my sensitivities. Don t assume that it is acceptable for you to touch me or behave in an overly personal manner toward me. Using terms such as hon or sweetheart or other nicknames in reference to me is overly personal. But, if you re too distant from me, it will seem that I m treated like an object. If you avoid normal things like saying hello and goodbye, I ll think that you are distant and unfriendly to me. Paying too much attention to my looks, my weight, my status and title (or my lack of status and title) can all lead me to think that you don t really relate to me as a whole person.
Third, take my concerns seriously. Don t minimize them, ignore my pain, or brush me off as a hysterical patient. If I bring a problem or idea up for discussion, don t dismiss it as unimportant. It is discouraging to get the impression that you think I am being silly or that I want to feel bad. If you brush me off, I may think you don t want to take the time to understand my problem and that you may not provide adequate treatment.
Fourth, I want to think you have my best interests in mind. When it seems like your research or busy schedule comes first, my feelings might be hurt. I don t want to be thought of as a number or a case to be crossed off a list. If I ve telephoned you with a question or a request, I need to believe that you consider me important enough to return the call, even if it is not an emergency.
Fifth, I want you to know what you re doing. I don t necessarily require you to be the world s top expert, but I want to think you are good at what you do and that I can trust your judgement. I would like you to provide me with information about your ideas for treatment and to explain the basis for your thinking. At the same time I want you to recognize your limits and let me know when you are not informed about something. I appreciate your efforts to learn new things and hope that you will share anything that could be useful to me.
Sixth, give me practical information. Let me benefit from your experience in working with other people who have had similar problems. Don t hold back ideas about solutions that might help me make improvements in my life. I might not discover these solutions on my own. If you make suggestions, help me understand how to carry them out and how I might solve obstacles that could get in the way.
Seventh, allow me to make choices with your information and suggestions. Don t always push your ideas on me. Help me learn about the benefits and risks of different choices, but don t assume that you know what is best for me. I want to feel stronger in myself and not just reflect confidence in your judgement or your ability to persuade me. I am the one who will live with the outcome of my choices.
Eighth, stay flexible in your thinking about me. Don t allow your theory to determine everything about me, regardless of how well it may fit. You may be certain you have a clear understanding of my problems, but it s possible that you could miss something very important. Give some weight to my circumstances and how other people act apart from me. Don t automatically locate all of the problems within me. Sometimes my symptoms are the only way I have found to cope with a difficult situation.
Ninth, follow up on your recommendations. Ask about whether I have followed up your suggestions and check to see what happened. This tells me you care about what I do. If something isn t producing the desired results, I want you to make another suggestion. Be sensitive to any possible discomfort, even if I say I ll go along with what you ask me to do. If something is uncomfortable or distasteful to me, I want you to consider other options and not necessarily think I am a bad or uncooperative patient.
Tenth, pace yourself. If you are overworked, unhappy, or tense, I may think you aren t being a very good example. I may resent your rushing, being distracted, or having frequent schedule changes. I may feel inferior because I see myself as less successful or important may try to reverse roles and take care of you. If this happens, I ll fail to get what I need from treatment. I may think you re not doing your job with me as well as you could. More than anything, I may get discouraged and think your techniques must not work very well if even you can t successfully use them.
Best wishes in your efforts to help other therapists learn about how patients want to be treated.
Wright and Davis conclude: The therapeutic relationship is an essential, interactive componet of cognitive-behavioral therapy. We maintain that cognitive-behavioral therapists need to be sensitive to both the general and idiosyncratic expectations of their patients, without compromising the necessary limits or boundaries of the relationship. Non-specific elements of treatment can be translated into specific therapist responses for building effective treatment relationships... Attention to these principles can help us build productive therapy relationships.
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