With a proper therapeutic alliance, the emphasis of the therapist on one side and the client on the other changes. It is shifted to the medium in which the communication occurs. It focuses not so much on what the therapist can do, but whether a milieu has been nurtured such that the client feels safe and trusting enough to take the hand offered, as it were, to get out of a difficult situation.
As therapists, we must bear in mind that we are not the only ones doing the assessment in an assessment interview. Your patient, after waiting for a few months to see you, has more invested in this venture than you. They are assessing whether they can trust you enough to share their innermost vulnerabilities, their most private concerns. If you don’t establish the ground for that therapeutic alliance, if you have not engendered the feeling of safety, space and time to open up, then it will not happen.
It is in this context that the effectiveness of CBT (cognitive behavioural therapy,) EMDR (Eye movement desensitization and reprocessing and DBT (dialectical behavioral therapy), all recommended therapeutic approaches for cases of trauma, dissociation, and borderline personality disorder, must be evaluated. Without considering the importance of a therapeutic alliance, it is misleading to say that CBT, EMDR, DBT or any other therapeutic model are the treatments of choice.
When a psychiatrist offers you an antidepressant pill for your depression, in the absence of the correct therapeutic alliance – even if it is an appropriate prescription – you will remain locked in your belief system. That will counteract the psycho-active effect of the drug. It is noteworthy that most people understand the placebo effect; the beneficial effect that cannot be attributed to the pharmaceutical properties of the drug itself and must therefore be due to the patient’s belief in that treatment. People are less aware of the nocebo effect, which is the opposite. The nocebo effect is that the patient’s disbelief in the treatment lowers the positive pharmaceutical impact of that drug.
Therapists take heed: One’s therapeutic effectiveness is directly related to quality of the therapeutic alliance we create in each and every one-to-one therapeutic session. It depends on how you say “hello” or even months prior to that, when and how the appointment was made.
The genuineness of a therapeutic alliance often explains how a history of early trauma is sometimes given to one therapist in the first visit, while other psychiatrists may have spent years with that same patient and still missed it.
This is the mechanism by which some world known professors and heads of major universities as, well as the chief editor of a major national journal of psychiatry, erroneously declare that dissociative identity disorder is non-existent, is a fake disorder or created by over-enthusiastic therapists. They assert it is impossible because they never have encountered one such case. In fact, the odds are that they simply failed to recognize those cases. Instead, they decided upon common misdiagnoses such as treatment-resistant depression (which should usually be more correctly identified as drug resistant depression), bipolar disorder(s) and borderline personality disorder.
With self-reflective insight, they might come to understand that they have never given the time, space and safety for their patients to show them their innermost pain and suffering. The fact is that when a patient feels safe enough during therapy, spontaneous catharsis happens without asking. Our duty as therapists in such an event is to protect the patient from inadvertent re-traumatization throughout the cathartic process.
Focus on the process of healing, not the detail of the trauma. As always, the right therapeutic alliance guides the therapist to be sensitive to the need of the patient.
Being a brilliant scientist is of no use if one forgets that one is basically human. Religion is not about arguing whether or not God exists, whether or not God has this or that quality. The men I have quoted in Part 1 of this post are all from different religious backgrounds. Ultimately, it is about being reminded that we are human.
I offer and will repeat to offer the following guidance of Carl Rogers’ emphasis of a person-to-person relationship between the therapist and their client, one that is characterized by genuineness, acceptance, and empathy. That emphasis is worth more than any diploma on your office wall.
