Guiding Principles of Psychotherapy

Pyschotherapist shares her guiding principles for conducting psychotherapy.

In considering what I have learned over the years that has served to guide me, I feel that the following principles have heavily influenced my work.

1) The relationship between therapist and client is not, in reality, a partnership after all. It is the therapist's role to serve the client. Declaring purpose and (with assistance) direction, becomes in my view, the responsibility of the client while the therapist develops the road map so to speak. How can one promote autonomy and independence when steering the course? If the process of therapy was like that of a journey across the ocean, then the individual served would be the captain while the therapist faithfully navigated.

2) The length of treatment is not a primary concern. Outcome, efficiency, quality of service, and timeliness is.

3) A therapist should be a visionary while sticking to the facts at-hand. Though it is important that we remain focused in our work, 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 definition is, "one who believes in possibilities; one who is not immobilized by the realities in the present but pushes forward to transform 'fancies' into facts." When a client tells us, "I can't", the visionary in us might respond, "You just haven't yet". When we hear, "It will never happen to me," we might 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.

4) 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 such as Gelso (1980), Wilson (1981), and Rabkin (1977). The creative and flexible use of time places a premium on the needs of the client versus the convenience of the therapist. As Wilson points out, the 50 minute once-per-week format is much more conducive to a predictable schedule for the therapist rather than to 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 session per month.

Further, Rabkin appears to reject the common notion that we are always working towards termination. He chooses to define the relationship between client and therapist as intermittent. In fact, he does not view the relationship as terminating at all, suggesting instead that we remain available to our clients on an as-needed basis.

5) There is no ultimate formula for providing the best possible treatment to all clients. Each client is unique, with differing needs, motivational levels, resources, etc. In order to meet the needs of each individual, treatment must respond to these differences.

6) Therapists must never presume to have all the answers. Our client's generally want answers from us, and sometimes we are in a position to deliver. They expect wisdom, too, and we should once again do everything in our power to oblige them. Still, as Sheldon Kopp has reminded us, "In the world of adults, there are no mothers and fathers, only brothers and sisters." While we can act as guides and facilitators, we must never forget what we know deep down in our hearts, and that is, that we are all in the stew together. We must not inflict our values and opinions on our clients. When we offer advice, we must always be aware that the price our clients may pay (in addition to dollars and cents) is of far greater value--and that is their autonomy. It is flattering to be made larger than life, to be sought for our knowledge, and professional opinions. It is gratifying to know that those who seek us out do so 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 what is best for another individual, then we do exactly that: 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.

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 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 that she should leave her husband? What if 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 may make? We can present, point out, clarify, encourage; but we should never dictate.

7) It is not a treatment issue that walks into our office, but a whole person complete with emotions, thoughts, a unique history, set of circumstances, a physical body, and a spirit. To not consider the effects of each aspect of a person is to fail to respond to that person in his or her entirety. While most (if not all) of us acknowledge the truth of this, we all too regularly do not proceed to operate in a way which reflects this information. How can one attend to each aspect of an individual within the framework of brief treatment? The answer is by addressing the presenting problem in a focused and yet holistic manner. If, for example, Mary has panic attacks, we might explore how her thoughts, emotions, physical status and manner of self-care may or may not be contributing to them. Initially, every therapist would probably respond that they do in fact consider these factors. But do they? In cases such as this, do they always inquire about caffeine intake, thyroid conditions, level of exercise, present stresses, self-care behaviors, etc.? In my experience, this is not always done. Further, in addition to our work with her on attitudes, thoughts, relaxation techniques, we might also strongly urge her to participate in activities such as yoga, exercise, meditation, a change in diet, etc. outside of therapy.

8) The client must be ultimately held responsible for treatment outcome. Clients need to understand that while therapy may be part of the solution, by itself, it is not the answer. While I have encountered many forms which are given to clients outlining their responsibilities (pay on time, give a 24 hour notice prior to cancellation, etc.), I have never seen a form outlining client's responsibilities that included such items as:

a) You will need to identify that which you specifically wish will be different when you have completed therapy.

b) It is expected that you will work on your goals outside of the therapist's office.

c) You will need to assess your own level of progress in addition to receiving feedback from your therapist.

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