Clare Pain - Psychotherapy Essentials to Go: Achieving Psychotherapy Effectiveness (Go-To Guides for Mental Health)

Producing Psychotherapy Essentials to Go has depended on and benefited from the support and expertise of many people. We wish to acknowledge and thank the many experts who provided the foundations on which the approach described in this book was built: Peter Fonagy, Anthony W. Bateman, Jon G. Allen, Ephi Betan, Jeremy D. Safran, J. Christopher Muran, Bessel van der Kolk, Ruth Lanius, John Bowlby, Donald J. Kiesler, and John C. Norcross. We are grateful to the Ontario Ministry of Health and Long-Term Care who provided funding to the educational outreach pilot project team of the Northern Psychiatric Outreach Program at the Centre for Addiction and Mental Health (CAMH); Nancy McNaughton, Wayne Ward, and the University of Toronto Standardized Patient Program; Robert Swenson and Robert G. Cooke and the Ontario Psychiatric Outreach Program; the University of Toronto Department of Psychiatry; the Mount Sinai Hospital Department of Psychiatry; the Mount Sinai Psychotherapy Institute; the Morgan Firestone Psychotherapy Chair; Scott Mitchell and the Canadian Mental Health Associations northern Ontario branch executive directors and healthcare workers. We also wish to thank all the actors who brought the material to life, Tom and Reet Mae and Jory Lyons of Mae Studios, and Connie Kim, as well as Andrea Costella-Dawson from W. W. Norton for her persistence, help, and support of the series.

(Refer to the enclosed DVD for the full video.)

ROLE PLAY #1: Joel Walker and Dr. Leszcz

Establishing a therapeutic alliance and exploring psychotherapy goals

In this role play of the first session, we are introduced to Joel, who is clearly an unwilling participant in the process of psychotherapy.

C: You know I was referred here, right? This is not my gambit. Im not throwing myself at your feet.

T: And Im going to ask you some questions[C (interrupts): Okay, yup, fine, sure, fine]. Hopefully this will be useful to you [C (interrupts): Okay]. Alright? Appreciate that.

T: Tell me why your family doctor is recommending this. What your understanding is?

[Eliciting the clients perspective]

C: Well, Im not a mind reader I mean, I dont know what hes thinking, but, I mean, hes saying to me, like, I dont think its as much about what hes thinking as it is about what my wifes thinking.

T: Uh huh.

C: So, you know, I think shes behind this more than anything, so thats, thats where Im stuck [T: Um hum]. Right? So, you know, I mean. Yeah, thats just where Im stuck. Its less him than it is my wife.

T: I see.

C: So, so Im here. Taking up your valuable time. Like I end up being the guy who has to, has to, ah, you know. Anyway, so you know, I mean, do your worst. I know whats coming.

T: You know whats coming.

C: Yeah.

T: Tell me what you think is coming.

[Exploring expectations in the here-and-now]

C: Well, you know, youre gonna, youre gonna ask me about my childhood and stuff and then youre gonna tell me why Im so messed up. And you know, I just keep working, and ah, and maybe we humor some people and my wife softens up a bit about some things that she should chill out about.

T: So, in meeting with me theres something in this for a lot of people but not for you.

T: So, if you were to move on from where you are right now, Joel [C: yeah], Joel, what would that look like? What would that be like for you in your life? How would you be feeling differently?

[Exploring treatment goals]

C: How would I be feeling different? Its not about feeling different, its about taking care of other people who, who gather these opinions because periodically people point their fingers at me and say, you know, loser, so you go do this.

T: Youve made a couple of comments about yourself that you attribute to other people about being a loserwhats happened recently that this has come to a head?

C: (Exhaling) Look, the situation, what Im talking about is that, um, my wife gave me the boot recentlyso I could just leave and I could just leave it all behind, I dont really want to do that. My wife also has our daughter. So she kind of gets to call the shots.

T: And your daughters a, a big piece of this for you. Whats your daughters name?

C: Charlotte. Shes three.

T: So part of what brings you here is trying to get something back on, on the rails so that you can continue to see Charlotte.

[Validating the chief concern]

C: Well, thats the power shes got, doctor. I mean, she can say, well, you know, I mean, you do this, you do that, or you dont get to see Charlotte. And you know, I could argue that because Im her dad [T: Right]. But I mean we could argue to the point where were going to court and how much time and money is that going to waste?

T: Sure, sure. Why is your wife blocking you from seeing Charlotte at this moment?

C: Shes not so much blocking me, she wont let me, ah, see her on her own but you know theres no reason for it. Its a power move. My daughter and I have a fine relationship. I always do everything I can for my daughterwherever she is, shes not gonna have the same house that, that, I grew up in. Shes just not gonna have that.

T: Right.

C: And, and so, its a power move. Cause you know she, my wife, um [pause], my wife, um, my wife knows that she can, she can control me that way.

T: So your wife recognizes because of your attachment to Charlotte, she can use that for leverage.

[Expressing empathy]

C: [continues]... so thats, you know, thats why Im here.

T: I still need to get a sense of why your wife feels she needs to use that leverage to get you to do something or to be different or to change something. I need to understand that if I can.

[Using a not-knowing stance to challenge]

T: There may be value...

[C (interrupts): Im not some wacko creep, right, you know, thats not, theres nothing like that going on, okay? Theres nothing untoward happening in my family home, okay? Lets make that absolutely clear.]

T: Do you think thats what Im thinking?

[Using metacommunication to process the alliance tension]

C: I dont know what youre thinking. But Im not, Im not gonna let you ask that question. Okay, just, end of story.

T: I can tell you what Im thinking. Im thinking that youre pretty angry, pretty threatened, pretty unhappy, and so far experiencing me as part of the problem and that, that may be... Id still like to see what else is going on so I can see if I cannot be part of the problem.

[Silence]

T: So if its alright with you, Joel, Im going to continue to ask you some questions.

C: Im trying to tell you everything I know.

T: What do you think Sarah wants to be different in how you are that led her to say youre leaving and you cant see Charlotte until you get some help?

[Asking the client to mentalize]

C: You know, I just think that maybe what she wants is a different guy.

T: Are you different than youve been recently? Have there been some changes going on for you?

C: Changes? No, well, you know Ive been working; Ive been working a lot.

T: Have you been feeling more angry, more upset?

C: Im always under pressure.

T: Yeah, what kind of pressure?

C: I have a business job. I have to perform and sometimes its tense. And thats just the way it is.

T: What do you do, Joel?

C: I control, ah, I control inventory for a department store, all the inventory. We do the buying, we do the choosing, we get it to the stores, so theres a lot of decisions to be made. Theres a dozen people under me.

T: And this is a tough, tough climate for that kind of business.