It is a reality that, like in all arts, the range of skill varies greatly amongst the community of therapy practitioners. One dimension of practice that is most commonly deficient in the less skilled is therapeutic discipline. Though therapy is an amorphous profession, somewhat like acting, within which the audience/patient experiences a seemingly free flow and naturalness to the process, the therapist/actor is very much aware of what she is doing and, despite the apparent spontaneity, is very disciplined in conducting herself.
The most common areas in which I see discipline falter amongst many therapists are in the management of time, contact with patients between sessions usually in the form of phone calls, and a lack of focus on the specifics of a patients psychology. Let me take up each of these in turn.
Time management is very important. Time is like the walls of a pressure cooker. While 'pressure cooker' has negative connotations in conventional usage, let's be frank, there is nothing better for certain vegetables than a pressure cooker; the latter provides just the right kind of energy to the food to yield a successful result. Patients do well if the therapeutic 'hour' resembles in some fashion the walls of a pressure cooker. Knowing when a session begins and ends helps the patient marshal the energy to focus his thoughts and sometimes sometimes this energy helps patients bring up difficult issues within a given time slot. To establish theraeutic time walls, it's best for therapists to begin and particularly end sessions on time. Patients are not affronted when their kindly therapist says, it's time to stop for today. A therapist who approaches ending sessions in the right way, sometimes even being explicit in explaining to patients why time management is important, will find that his patients get it.
A second area where therapists often falter is in extra therapy hour phone calls. It is tempting to stay on the phone for extended periods when a patient calls in distress, but doing so has subtle but important hazards. The principle one being what I call leakage. If a patient is in the habit of calling under duress and discharges tension over a phone call, there is the hazard that it may lead to that tension being less likely to be dealt with during actual therapeutic sessions when the thoughts and feelings are less acute, and therefore more workable on a deep level. I can say that in my career I have never spent more than 5 minutes on the phone with a patient between sessions. In that time I can determine whether emergency intervention is needed, whether the patient is comfortable waiting to continue the discussion until their next session, or whether they would best be served by scheduling an early appointment.
Finally, there is the discipline of knowing the psychological strengths and weaknesses of our patients. If a therapist does not have a model of her patient's mind, she can easily get lost in the woods. An awareness on the specifics of a patient's psychology is a lens that helps her translate to the patient the connections between the particular dimensions of psychological functioning and the myriad every day circumstances that the patient reports during sessions. A patient who is able to see these connections between events and his psychology will most readily grow. Another way of saying this is that good treatment has focus, focus governed by a conceptual understanding of the psychological strengths and weaknesses of the patients mind.
'Discipline' sounds like an unpleasant term. In fact it is an interesting word with myriad meanings including, a field of endeavor- a discipline, punishment- being disciplined, or being precise and systematic about something. In the context of what we are talking about today, it is the variable that assures our patients that they are under expert care.
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