Sunday, February 12, 2012

Our Guest Blogger Writes About Therapeutic Alliance

We're doubling on the guest blogging this weekend, due to the response Kerry (@kerrystott) received on Twitter regarding her post yesterday regarding Personality Disorder and questions on therapeutic alliance (the relationship between a therapist and client/patient).

It's worked out great for us, so thanks to everybody who asked her questions, because we have a guest post of our own to do in honor of Valentine's Day for our friend @singlemomdate over on The Single Mom's Dating Diary (even though we are in fact not a mom, thank God). Single Mom is the woman who introduced us to James/The Boyfriend, on Twitter last year.

After reading Kerry's entries if you'd like to read some of our entries (there are...LOTS) that vary in topics from current events, philosophy/opinion, to sex and relationships, food and more, as well as entries about mental health and our personal life with Dissociative Identity Disorder, click here to reach our recommendations page.
Therapeutic Alliance

After I wrote my piece on personality disorder I received quite a few tweets and messages, and there was an area that interested most people [which was] therapeutic relationship/alliance. So what it is, where does it come from and who wants it?

When you meet someone whom you are going to spill your guts to and tell them your inner most thoughts, secrets, desires, hopes, dream, fears, confessions; you would hope that they ‘got’ you and understood you. There is enough documented evidence to show that people don’t like to be talked ‘at’ but they like to be included with things such as decisions and plans and discussions. This is certainly my experience as a clinician and whenever I have been a patient (please see for further details of all the shit I got up to when I was a cancer patient). So, how do I ‘get’ people, how do I tune into them?

I am very fortunate to be able to do this, mostly I do it instinctively. It is my gift (we all have gift’s ladies and gentle men, what is yours?) to be able to tune in and comprehend where people are coming from and what they are saying. Psychologists that I have worked with and seen me talk to people, have commented that I am psychologically curious about people. I LOVE hearing other people’s stories and hearing about their lives; I simply want to know – I always took that as being as nosy as hell but apparently it is couched in these (more favourable) terms. I think the difference between being nosey and psychologically curious is that whatever people tell me, I am careful with it, I don’t gossip and I don’t dismiss it or minimise it. If someone is brave enough to trust me, then I should treat that with the respect that it is due. That is one of the essential tips/trick to being a good therapist. What people give you is similar to being given a very fragile present. Now whether you like the present or not is irrelevant, what is important is that they have decided to give it to you, and that it is FRAGILE and can be broken easily. Sometimes, even now, I am not sure what to do with some disclosures so I acknowledge that it is special and delicate and that I will be gentle. If this happens, I generally talk to the patient about what it means and what they would like me to do with this nugget of information. Admitting that something is difficult can be the first step forward, ironically.

Active listening is a skill that all therapists should use; I did say should because not all do. The phrase active listening is an odd one, most people think that listening is something that we do naturally and don’t give much thought to. However, when we are chatting to our friends, very often we are thinking about what we are going to say next rather than paying attention to what is coming out of their mouth. Or we may be pondering on what they have said a few minutes ago, or thinking about what we are going to have for lunch. Active listening is harder than you think and requires time and a lot of energy and can leave the therapist drained when they first start to learn this skill.

Active listening requires you to pay attention to what the other person is saying whilst not thinking of what you are going to say next, really pay attention. Every conversation requires clarification of some form or another, so the therapist needs to ask for it when the thread of the discussion gets in a tangle or they don’t understand something. Often I will ask for clarification when I am pretty damn sure I know what the patient means but I am also sure that they are using a euphemism to skate over something that I think that they may need to explore further. It may turn out to be nothing but mostly there is something to think about or reflect on. Pacing the conversation can be part of active listening too and this is done my paraphrasing (repeating back to the patient what they have just said but in your own words), reflecting (telling them what they have said using their own words e.g. patient ‘I hate my mother’ me ‘hate my mother?’), and summarising (giving a brief synopsis of the conversation so far or the topic we have been discussing). Using these techniques allows me to understand and hear and be able to really listen and give value to what the other person is saying.

On the other hand, some people find talking to a therapist/mental health professional difficult and intimidating. Sitting across from me whilst I am looking at them is just too much. So here is one (but not all) of my sneaky tricks I use to get people to open up to me! Number one in my sneaky tricks list is a slinky. Yes I do mean that brightly coloured plastic coil that is supposed to go down steps but never does. People who are nervous and anxious can twiddle, and play with the slinky and it means that they do not have direct eye contact with me, which takes a lot of pressure off. However, (and this is the sneaky bit) because they aren’t looking at me and they are fiddling around with a kids toy, they tend to tell me more than they thought that they would. The disclose more. As I said before, I am careful how I handle disclosures, but I can’t do my job unless people talk to me...I am a psychiatric nurse not a psychic nurse. Also the fact that it is a disarming child’s toy and it is brightly coloured makes them relax more. It is also a fun toy, not something you would expect to see in a serious therapist/nurses room, so the fact that it is fun relaxes people and gets their guard down faster. I DID say that it was sneaky.

Boundaries and rules are essential in any form of therapy, otherwise it is not a psychologically safe place to be. I tend to set my stall out on the first session right after they say ‘hello’ so there is no confusion. It is also a time where rules can be made by the patient so that they feel more comfortable. Boundaries I have to say by law are about confidentiality and its limits and when I will break confidentiality, most of the time I let them know what I will break it but not always and in some cases I am required by law to break it. Limits include if someone says that they are going to harm themselves, harm someone else or harm children or vulnerable adults. How long sessions will be, how people can contact me and how I can contact them are also discussed. Knowing where we stand reassures our psyche...all of us, not just patients. I will tell people how I react too, since this blog is in response to my blog on PD who have high suicide and parasuicide attempts, I tend not to get too excited and jump up and down when someone says that they are suicidal. Rather, I prefer to listen to them and hear what they have to say, kind of like gathering evidence, to see if I need to action anything.

People want a professional when they come to see me. They don’t want a friend (they have those already, I hope) they want someone who can cast their eye over their situation and come up with a plan of action. Part of the therapeutic alliance is about having empathy and being in someone’s ‘frame of reference’. However, they don’t want someone who is cold either. There must be a balance. In turn, people also talk to me about things I personally find distressing and I have to know how to deal with my emotions rather than let them spill out in a session. I have learnt this through reflecting about difficult situations, taking something difficult to supervision so that me and my supervisor can examine it in more detail and also personal therapy, it is the norm for therapists/mental health professionals to be in therapy too (so we can get the junk out of our heads too).

So here I am sitting and listening to my patients but what makes it an alliance?

The fact that I do not have all the answers and that there is team work between [how] me and my patient makes it an alliance. I will go with any suggestion that the patient will make, provided it is not a dangerous suggestion. There is negotiation, sometimes very tough negotiation where I have to take a firm line or it gets heated between the two of us, but ultimately it is their journey, not mine that the patient is on. It is this team work, this looking at things together as equals rather than as me being the one who is in control, that makes it worthwhile. I am just lucky/honoured/privileged to be allowed to join with their story in for a while.

And there is my final point; I discharge patients from my caseload. Mostly they feel better but for some it is not the right time or I am not the right person and they leave unsatisfied (I am human after all). People do not stay with me forever, and why would they want to? Hanging out with me implies that you are not as well as you could be.

So there you have it! A (very) brief overview of the therapeutic alliance, how I work with my patients not for them and certainly not against them.

Kerry x

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