Change in psychotherapy.

I had a good one the other day. It’s good for the therapist when this sort of thing happens.

Goal setting or contracting for change in psychotherapy is big business. Much has been written about it over the years. One can attend entire workshops on how to set goals or make effective contracts with the client. In many different approaches this is considered a most important part of the therapy process. The client and therapist must both be clear and in agreement about what the contract for change is or the goals of therapy.

For example in Transactional Analysis it is called contracting. At the beginning of the session the client states what their contract for change is for that session. This is either accepted by the therapist or if not it is negotiated between the two until an acceptable contract is arrived at. An example of how this is done is shown in the diagram above. It shows seven different aspects of a contract that must be clarified in order to make an effective contract for change.

Sometimes clients change in response to therapy without any contract or therapy being done on the area of the change. The other day I was discussing with a client who can suffer episodes of depression and dissociation how she felt the therapy was progressing. I had seen her about 10 times. Initially I thought the therapy may not go so well or last very long. She began by talking in a very medical way about her difficulties such as about her serotonin and depression. It’s not that I disagree with it, it’s just not what I do when I treat depression. If she wants to do that then she needs to see a psychiatrist not a psychologist.

However she continued and kept making and attending appointments and then we had this discussion. As we talked about how her therapy was going at one point she stated:

“I feel like I have got my hope back and also my diet is much better than it has been before”.

Neither of these had ever been raised by her nor discussed in any of the sessions. I had no idea she even thought of these as possible contracts for change. Indeed she may not have been aware she wanted those until they happened. For example she may not have been aware that she had lost hope. 

These are called spontaneous changes and as has been described sometimes occur in therapy. I have always felt these are a good sign. The Child ego state is sitting by watching the therapy proceed, starts to feel a bit better about self so these spontaneous changes occur.

Also in this instance we have two things that are completely unrelated - hope and diet. If it had been something like hope and trust or hope and closeness then that is a bit more understandable. She was of average weight and neither fat nor thin, it was just her eating habits had changed spontaneously such that she was eating healthier. This indicates the kind of random nature of such changes and that she had never raised either of these in therapy before.

It’s good for the therapist when this sort of thing happens.

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Goals of therapy - practical

Kahless says:

Well I look at where I am at the moment. I am in my early 40s. I exist in a state of not happy and not unhappy thanks to the medication propping me up. I am thankful to the anti depressants that I am not in that low point of nothingness that I felt earlier this year.
I don't know what I want not what I don't want. You suggest a don't get my needs met injunction, but I don't even know what my needs are. I am by most people's standards, successful. I don't have to worry about money and I have a successful career and am in stable relationship with a partner who cares deeply for me.
But I am not happy. I do not know what will make me happy.

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Her comment raises three interesting points for me.
I will address the first one here and do the other two at a later time.


I saw a piece of research once that outlined the best predictors of the outcome of psychotherapy. Or the importance of things in psychotherapy. It isolated three aspects of it
1. the techniques employed
2. the relationship between client and therapist
3. the practicalities of one’s life at the time

The results were something like
1 = 20%
2 = 40%
3 = 40%



However you can’t quote me on this because I can’t find it so these may not be fully accurate. I recall looking at it and being a bit surprised about the practicalities of life being that influential, but after some consideration it does make sense. This includes things like having a decent income, having relationships in life that are reasonable, living circumstances are OK such as having a home that is reasonable, diet that is OK, having a social life and so forth.

The more one has of these the better the prognosis when the client enters therapy. This is a bit sobering because it is easy for therapists to get lost in their fancy therapies and fancy techniques and so forth. It notes that therapists should initially at least focus on such practicalities in the treatment plan. This may seem a bit basic, and it is, but it is most important at least at times.



Many years ago I recall working in drug rehab with this guy who had a long term heroin problem. He was a nice guy and we established quite a good working relationship over some time. I recall we used to laugh a lot together. At one point he came into quite some money. Of course I did not ask how he came across the dollars, I just noted that he did.

Since our first meeting I had noted that his top front teeth were not too good, being quite discoloured and somewhat decayed. He had never mentioned them as a problem. I was the one who brought it into therapy. I suggested that he use some of the money to have his teeth repaired, whitened and so forth. He responded that he did not care what his teeth were like and he was unconvinced by my suggestion. I persisted with the suggestion through a couple of sessions and he finally did seek out the appropriate dental work, had it done and it did look decidedly better. Whilst I did think it was a good idea, one reason I suggested the dental work in the first place was because if he did not spend the money on his teeth it is highly likely that it would go on drugs.

However the surprising thing was the therapeutic results that it caused. He said that after it was done he felt so much better about himself. He reported that when ever he looked into the mirror he saw a reflection of himself that he liked. He had not not even aware of how this had effected him for so long. That he had disliked the image of himself every time he looked at it almost everyday.



I have never forgotten that. I could have spent my time doing fancy relationship building and fancy techniques to assist him to express his anger at his mother and so forth, when one of the things which turned out to be significant in the therapy was getting his teeth fixed. Something that simple. One of the simple practicalities of life turned out to be a significant factor in his recovery.

And my point is?

When Kahless says:
“I don't have to worry about money and I have a successful career and am in stable relationship with a partner who cares deeply for me.”

I know this is a good prognostic sign should she ever decide to take up therapy with a male therapist

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People’s expectations

I had another person ask me the other day about this video that I have on my YouTube. Why did I do it, how I did it?



The glasses, the solarized effect and the apparently odd manner of my presentation on a serious topic like panic attacks. People apparently who know me or have seen my work as a psychologist in some way expect a video presentation of a more ‘professional’ style. So I get asked why did I do it like that? To which I answer, there is an old rule of psychotherapy - don’t give people what they expect. Its really a rule of human communication in general - don’t give people what they expect.

After they hear this explanation they seem to be satisfied because no more is said or asked by them. This has struck me as a bit odd because my answer I think begs another question - why not?

Why not give people what they expect?



If anyone ever asked me this I am not sure what I would answer. My first thought is that it would depend on the situation where the unexpected communication occurred. In psychotherapy I think it certainly has its place. If a client comes to therapy they will have an expectation of what is going to happen what they will say, what I will say and so forth.

If they leave with what they expected then the session was OK to average, to not much good. If the person gets what they did not expect in the session then it is much more likely that the session was more effective. Of course not every session a client attends can provide some kind of profound epiphany. But in the overall approach there needs to be at times unexpected communications by the therapist.

This will stop the therapy becoming routine. In one way psychotherapy is about unbalancing the client or putting them in a state of disequilibrium. They enter therapy with a psyche or psychological makeup that is a functional whole. That functional whole may be causing them pain but it still is a functional whole. If therapy can destabilise that functional system then the parts of that system are more able to be rearranged such that a new structure is obtained. That new structure can then lead to less pain being experienced by the individual. It seems reasonable to conclude that if the client gets something they did not expect then that will have a destabilised effect.



Society is like personality. Revolution destabilzes it. Once done then change is more likely to occur. Psychotherapy can be seen as creating a revolution in the personality.



Another reason is something far less ethereal and recondite. It gets the Free Child of the client into the room and that is something you certainly want in therapy. If that video was of me standing there is psychotherapist type clothing, in a psychotherapist type manner in front of a white board with a pointer what ego states of the viewer are going to be elicited. Probably Adult with maybe some interested Child if the topic of panic attacks was of interest.

Because of my presentation I would suggest that much more Child ego state in the viewer is elicited. First they are far more likely to remember it than if it was done in the other way. As indeed would happen in a therapy session if something unexpected happened. If I can get the client’s Free Child into the communications with me that is a very good thing for a successful outcome for the session.



However we now have another problem. Because I have let out one of my trade secrets people will now begin to expect the unexpected. Thus we end up back to where we were before.

However there are ways and means to deal with these things and I can’t tell all my trade secrets. Well not all at once.

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