Imagine that I suddenly sneeze uncontrollably and loudly during a therapy session with you. Your reaction to my embarrassing moment in the therapy room could be an indication of your relationship with me. This was how Dr Theodore Jacobs, a child and adolescent psychoanalyst as well as an adult analyst, perceived his client’s therapeutic alliance with him. In Dr Jacobs’ situation, his client offered him a hearty “God bless you” when Dr Jacobs could not hold back his sneeze while his client was commenting on Dr Jacobs’ “shortcomings”. To Dr Jacobs, his client’s “expression of goodwill”, was a sign of the strong bond built between his client and himself. This amusing story was captured in his book, “The Possible Profession: The Analytic Process of Change”. The Influence of a Therapist In my previous article, “Mapmakers and Travellers”, I shared the findings of a classic research, showing the influence a therapist might have, or could have, which is:
60% of “sense of control” over the psychotherapy outcomes, while a client has the remaining 40%.
Out of these 60%, the therapeutic relationship between both parties takes up 30%.
With this, it also means that a client could influence at least half of these 30% as well.
The importance of such a therapeutic alliance between a therapist and a client in determining the psychotherapy outcomes, can be illustrated with the story of an ex-client of mine. Old Happy Self Mr E (name changed for client confidentiality) was in his 40s, single and had been on a long-term medication for his Bipolar Disorder for many years. He had suicidal ideations and attempts before. He was living alone and was not close to his family and relatives. His social life was also very limited as he did not interact much with his neighbours, while his three closest friends lived overseas. Due to the episodes of paranoia, anxiety and depression, which were beyond his control at times, he seldom stepped out of his house. This further reduced his interaction with people whist enhanced his aloneness and loneliness. Although he had a successful career in the creative industry, he became unemployed for a few years because of his worsening mental health conditions. It was fortunate that he was able to sell some art pieces he made at home, even though he could have produced more for sale. Yet, with the sale of these art pieces, he was able to lead a very simple and humble lifestyle. It was a breakthrough for Mr E to finally realize that “enough is enough”. He had come to a stage where he could no longer “recognise myself” in a mirror anymore. It was during that moment he asked “Actually…Who am I now? I was not like this…I want to be my Old Happy Self again!” There is a Chinese saying, “Heaven helps those who help themselves” (天助自助者). As the first step to recovery, he took the initiative to reach out to the counselling centre that I was volunteering with. His case was assigned to me. Precious Moments Most of the therapy sessions were conducted virtually rather than in person due to his high level of fear and rumination about leaving his house. Each therapy session was “precious” to me as I would not know if that will be the last session as he might refuse to continue with the therapy. Or he would have hurt himself so badly that a subsequent session was impossible. Having this in mind, my main therapy goals were focusing on three areas:
Safety and Security:
These were the prime priorities for me to ensure Mr E would not self-harm and self-destruct physically, mentally and psychologically. For his psychological and mental wellness, we frequently identified and processed the various cycles of maladaptive thoughts and unhelpful emotions, feelings and moods as well. He was also psycho-educated on the differences between “being safe” and “feeling safe”; “perceived fear” and “real threat”. He was requested to record such awareness of thoughts and emotions for tracing some behavioural patterns for self-monitoring and self-acceptance.
Anchoring and Stabilization:
Emotional anchoring through some mindfulness skills was shared with Mr E for grounding and self-soothing. He was facilitated to gain back regularity and consistency in daily life. We co-designed a timetable of daily living routine for waking up, marketing and shopping, cooking and having meals, making arts and working, cleaning and washing, exercising and entertaining, resting and sleeping etc. Regulating his consumptions on the prescribed medication at the right dosages and timings was a vital goal for his mental health stabilization too.
Regulation and Relaxation:
Mr E was trained on some practical strategies and techniques such as progressive relaxation process and diaphragmatic breathing etc, for regulating and easing his physical and mental state. The goal was not only to minimise the frequency, duration, intensity and severity of his emotional disturbances and mood swings but to prevent these encounters through regulating his autonomic nervous system as well. With some mindful relaxation techniques, his emotions of anxiety and stress were usually replaced by the feelings of relaxation and calmness. Small Wins; Big Victories Well, it is always easier said than done. Mr E’s road of recovery was not a smooth journey. There were quite a few major episodes that he derailed from the therapy goals that we had agreed and worked at. To a certain extent, it was understandable because Mr E had been habitually thinking, feeling and behaving in an inappropriate condition and manner for many years. It was not realistic to expect him to have a revolutionary change (absolute change) but evolutionary changes (incremental changes) instead. As such, my objective was to let Mr E progressively experience some small wins, rather than big victories in a short run. A Therapist’s Role in Recovery It is said that a therapist is always “sitting big in a therapy room”, having the “power” over a client. Like the image I used in “Mapmakers and Travellers”, I rather be a clear map, a sturdy compass and a tough haversack, whilst playing my role as a “fellow traveller” with Mr E.
As a Map:
Mr E was facilitated to understand the meanings of self-directed growth milestones in a life map, striking to reach his full potential for a better life stance ahead. During a vital therapy session, under some intended and controlled confrontative intervention, his financial status was brought up on the table. Having a full-time permanent employment was not a comfortable topic for discussion as he had been in an avoidance stage for a long time. With a few resource-based options being explored and analysed, a decision was made by him, for getting employed again, within three months. The good news was that he did eventually land a full-time managerial position, which was related to creativity that aligned with his strengths and enjoyment.
As a Compass:
As for Mr E’s Bipolar Disorder, his moods could swing intensely, especially during those days when he was reluctant to take the prescribed medication. Sometimes, it would cause him to not even want to get up from his bed for days. During an in-person therapy session with me, he was in a deep self-doubt and low mood state. He raised his head, looked into my eyes and asked me, “Do you believe that I could lead a happy life?” I knew it was critical for me to support him to determine a route direction like a compass, but it was a difficult question to me. No matter what of my reply, as a “Yes” or “No”, it could be interpreted in different meanings and might direct to two extreme ends of psychotherapy outcomes and impact. I noticed that I had a pause for a moment, before telling him, “I choose to believe that, you could change.” Upon hearing this, his eyes filled with tears and smiled at me contentedly. It was at this moment, the therapeutic alliance between us raised to another higher level.
As a Haversack:
He was guided to believe that “strength is within”, by practising self-compassion as well as injecting hope and aspiration constantly into his life haversack for himself. He might be badly discouraged if he could not sustain the expected positive changes too. Thus, I supported him to regain himself with some success stories in a prolonged timeframe that he could accumulate for himself. This helped him to have more sense of self-control and resiliency. For instance, it was challenging for him to follow a “daily” living routine as such a more balanced lifestyle was relatively new to him. I guided him to revise it to become a “weekly” living routine. This allowed him to have more leeway and flexibility to slowly adapt to a more controlled daily living, without feeling frustration with himself. Similarly, I changed his perception of his “To-Do List”, to become a “Done List”. This worked for him as he could maintain his motivation in doing things that he set for himself, rather than having a sense of failure when he could not finish the targets. Leading and guiding Mr E to reach his final destination – to be his “Old Happy Self”, was a path filled with many thorns and rough terrains. An established rapport based on trust, respect, acceptance, non-judgemental, genuine care and concern between us, did motivate his determination to go on. Aesop said, “Little by little does the trick”. Along the way, Mr E was assisted to uncover what internal and external resources that he already had and could have, accompanying him to continue on the journey. In addition, the sufficient place, space and pace rendered by me patiently to Mr E, nurtured and enhanced his little voice for finishing his journey of recovery, louder and louder!
Courage doesn't always roar. Sometimes courage is the little voice at the end of the day that says I'll try again tomorrow. Mary Anne Radmacher
Note: As this article is mainly catered to general members of the public, the case conceptualisation, intervention formulation, discussion and terminologies used are deliberately simplified and presented for an easy reading, comprehension and relevancy. Image: https://learnpatch.com/2018/06/action-learning-can-accelerate-team-psychological-safety/#prettyPhoto/0/ Quotes: https://www.passiton.com/inspirational-quotes/7300-courage-doesnt-always-roar-sometimes-courage This article is written based on Krish Phua's greatest aspiration to be a mind healer, facilitating his clients to cultivate and explore "Inside Mind Insights" for improving their Wellness, Wholeness and Wiseness. Other articles of Krish Phua: Sow a Seed - https://www.oberdanmarianetti.com/post/sow-a-seed Last Man Standing - https://www.oberdanmarianetti.com/post/last-man-standing In or Out - https://www.oberdanmarianetti.com/post/in-or-out As It Is - https://www.oberdanmarianetti.com/post/as-it-is Mapmakers and Travellers - https://www.oberdanmarianetti.com/post/mapmakers-and-travellers