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Tuesday 12 June 2012

Process: The Dangers of Therapeutic Altruism

I saw David Burns speak recently about the problems that impede therapy.  I’ll paraphrase something he said that resonated with me a great deal but hadn’t put into words.  (Burns is quite precise by what he means and how he says it, so doubtless my paraphrase won’t live up to his standards.  I’ll give it a shot anyway.)
The inimitable Dr Burns.

In effect, he stated that one of the biggest handicaps therapists face is their desire to help.  They assess a client, figure out what’s going on, settle on their own idea of what needs to be fixed, and race in to try to fix it.

The client almost inevitably resists, and therapy runs the risk of devolving into a power struggle in which the clinician attempts to impose his or her will on the hapless client – who is supposedly the customer/employer in this whole enterprise and whose life it is.

For example, we might learn that the client drinks more than is, strictly speaking, a good idea.  We decide that it would be a good idea for the client to cut back, and obviously they came to see us, so they must expect us to do something.  So we begin mapping out a reduction plan and the client doesn’t cooperate.

I’ve seen this pattern repeatedly, and notice that the usual consequence is that the client gets labeled as resistant, and possibly as a passive-aggressive or self-defeating personality disorder (neither of which are real DSM diagnoses, but they serve the important function of preserving the therapist’s ego).  A better consequence would be for the therapist to be labeled as “meddling and intrusive.”

Burns points out that clients are perfectly entitled to drink as much as they want, stay at home due to agoraphobia, live a socially isolated life, or be dysfunctional at work.  It is, after all, their life.  It isn’t the business of the therapist to decide what needs to be changed and to push the client into conformity.

Of course, none of us went into this racket for the money, so obviously we all want to help people.   But this honorable intention can lead us astray by ignoring the fact that the client gets to decide what they want to change, when they want to do so, and how they’d like to go about it.  All we are is advisors.

In recognition of this basic principle, we need to hear the client’s story and resist the impulse to race in with our toolkits.  We need to ask the client what they would like to change.

I do this by having the client imagine a good outcome to therapy.  “What would be different?” Sometimes I’ll have the person imagine someone following them around with a video camera for a week.  “We can’t see what you feel or how you’re thinking.  All we can see is what you are doing.  What do we see in this movie that would tell you things are better?”  This helps us specify concrete change.

But we’re not done.  We still have to ask the client HOW they imagine getting to that goal, and what might hold them back.  Let’s save that for future posts.


  1. What if the client asks, "What do YOU think I should change?"

  2. I can always reflect on what the client has told me, make reference to the literature on what seems to help a large swath of people, and offer suggestions based on what seems to present the possibility of large gains with smaller efforts. But I will make it clear that the client is the one who will be doing all the real work, so it is vital that they make the choice themselves.

  3. Once the client chooses, I imagine that goal setting comes into play.