hello again my name is Dr Patricia Cogan today I'll be talking with you about how to achieve agreement with your patients regarding the therapeutic task so far John Frederickson and I have talked with you about how to get an agreement about the problems to be addressed as well as some shared understanding of the driving forces responsible for the problems now we must also get clear and get agreement about the treatment goals and the therape itic tasks required to achieve those goals patients often want a positive outcome but don't necessarily want to face what they have
to face to get there they might have a wish that you alone could cure them for example we need to remind patients and ourselves that only hard work will result in the goals they seek to some extent all patients enter therapy with this kind of ambivalence they want to feel better but don't necessarily want to have to do what they need to do to get there in istdp we do not shy away from such conflicts in fact Dr davl discovered that the best and most direct Pathway to change is to intensify this conflict between the
healthy part of the patient willing to do whatever is necessary to heal and recover and the part of the patient that resists and even sabotages this process so let's look at some examples a middle-aged man came to to see me to get help with temper outbursts that were very distressing to him and to his family this man had grown up with a violent and tyrannical father and he had promised himself never to repeat that pattern while in fact he had never physically harmed anyone as his father had he found himself having verbal outbursts and he
realized that these were also very damaging so the problem was clear these temper outbursts when I asked him about the goal he was Al very clear he said I don't want to do that anymore now while that might sound like a fine goal at first blush it's actually what we would call a negative or avoidant goal the patient knows what he doesn't want to do but that doesn't lead us anywhere we don't proceed until the patient can articulate a positive approach goal what does he actually want the patient was stumped when I asked him what
he wanted he only knew what he didn't want as we began to examine specific situations in which he would explode it became clear that the triggers were relatively benign in fact he was so afraid of his anger that he habitually suppressed and avoided it the result of this avoidance was a buildup over time of anger and resentment that made blowing his top inevitable he was surprised to discover that his original solution to the problem of anger which was to avoid it at all cost was actually responsible for his current problem verbal outbursts so once he
saw this clearly we could begin to map out the therapeutic task since the underlying cause of his Outburst was the habitual suppression of anger and irritation the task was to become aware of anger even at low levels so he could deal with it immediately and constructively as long as he continued to stuff is anger then this pattern of avoidance buildup explosion remorse and renewed avoidance was just going to continue so we were able to agree that our task was to help him face his anger directly it turns out that he was not only suppressing his
anger but he was also displacing it as we began the work of paying attention to his anger retaliatory rage toward his brutal father emerged we were then able to work this through at the source so that his need to displace his anger onto others disappeared not only did he stop having these verbal temper tantrums at home he actually started to open up and develop real emotional closeness with his wife and children he became especially close to his son and was finally able to achieve what he really wanted a happy healthy family now let's look at
another example a young woman married for 3 years with a 2-year-old daughter came to therapy wondering if she had married the wrong man while she described her husband as loving and devoted she said that she had Lost That Loving Feeling for him she began to wonder if she'd ever had those feelings in the first place perhaps she had simply married the wrong guy she also found herself fantasizing about the man she dated before she got married he was a handsome and charismatic fellow but chronically Unfaithful and often cruel how is it that she could be
pining for such a man so here was the problem she was half in and half out of her marriage and wondering if she should end it her goal was clear to get clear about this and make the best decision we could agree on the content but I noticed something very striking about the process of how she was expressing herself as she spoke about herself she tended to laugh and make light of things that were were clearly very serious I started to block those defenses do you notice that you're laughing as you talk about these very
serious matters it's not funny so what's the laugh about I wanted to assess how present and aware she was of how she was communicating she was in fact aware of her laughter and she said she did it all the time now if we proceeded in this way both taking her lightly laughing it off we could certainly not achieve her goals while laughing over her true feelings clearly wasn't helpful we needed to get clear about the healthy alternative so I asked her are you willing to take yourself seriously she began to cry and reveal that this
was a huge problem for her she had never been able to take herself her feelings her needs and her desires seriously in fact she went on to report that she had a tendency to actively sabotage and under mind herself whenever she started to experience success whether at school or in sports she would suddenly quit and drop out now we were getting a Fuller and deeper view of the problem at hand in fact the current issue with her husband was only the most recent example of an entrenched pattern of sabotaging everything and anything that was good
in her life so we could now agree on the task which was to take her seriously and have an honest look at her feelings needs and desires therapy could now begin in Earnest once patient and therapists agree on the goals and the tasks required to achieve those goals they can work together and solidify their collaborative Alliance failure to achieve agreement about the task can result in stalled therapies or outright disagreement about how to achieve therapeutic ends often patient therap IST have very different ideas about how to proceed we do not try to convince our patients
that it's a good idea to face their feelings instead we inquire about the nature of the problem we examine examples in detail until it becomes clear that avoidance of their feelings is the driving force to their symptoms and suffering if we don't get this agreement the conflict is going to be between the patient and the therapist rather than between the forces within the patient we want to intensify the patient's internal conflict until he decides which way to go if the patient chooses not to have an honest look at himself which is certainly his prerogative then
there's no basis for Psychotherapy I'll never forget a man who came to see me at the insistance of his primary physician he had been having panic attacks as well as intrusive thoughts and images about hurting his son he wanted this to stop and when to see his physician to get some medication well the physician thought this sounded like an emotional problem and he wanted him assessed by a therapist so this was the doctor's wish not the desire of the patient still the patient was there in my office so I began to inquire about the symptoms
when it began what triggered it after about 10 minutes he stopped and he said listen doc let me tell you something I think you're probably pretty good at what you do and if I ever decide that I want to understand myself and why I'm having these thoughts I'm certainly going to come to see you but you know what I don't want to know I just want them to stop and I want some medication I'm only here because the doctor said I had to see you before he would prescribe now this was as clear a communication
as he could possibly have given me in fact I had no permission to continue to inquire about his inner life even though we agreed about the problem these intrusive thoughts and images and about the goal to free him of this torment we had no agreement about the therapeutic task he wanted medication and I was offering Psychotherapy ultimately it's up to the patient to decide which way he wants to go it's not our job to hook or persuade patients but to be fully available to those who have some desire to examine what is going on inside
of themselves again without agreement about the task patient and therapist are often working across purposes when therapists are first introduced to istdp they're often so motivated to get to these feelings that they jump in prematurely asking patients about their feelings and impulses before having any agreement that such a task makes sense then the patient either complies with the will of the therapist or feels misunderstood a misalliance can develop if the therapist and the patient patient are not in agreement so take your time one of my first istdp teachers taught me go slow in the beginning
and then you'll go fast in the end if you take your time and get agreement about the nature of the problems to be addressed the patients goals and the therapeutic task your therapies will become smoother and more effective thanks for visiting the istdp Institute website
