Psychiatry 101 - The Biggest Therapeutic Error of All

Bob, a psychiatric resident named was treating a divorced woman who complained bitterly about her ex, and constantly argued with him whenever he came to visit with the children.

Their relationship was clearly acrimonious, so Bob asked the woman if she wanted some help with the way she was communicating with her ex. She bristled and said that she was an attorney and that she could communicate just fine, thank you! Bob’s error was the same that many therapists make—of thinking that people with troubled relationships want help. Clearly, Bob’s patient was not asking for help. She just wanted Bob to agree that her ex was a bum!

In many cases, and perhaps most, individuals who aren’t getting along with someone—such as their spouse, sibling, parent, colleague, or friend—aren’t really asking for help. They just want to vent and persuade you to buy into their negative view of the person they aren’t getting along with. They just want you to know what a loser the other person is!

So how do we help people with troubled relationships? David emphasizes that empathy is always the first step. You try to see the world through the eyes of the patient without jumping in to try to “help.” Empathy, of course, is the "E" of TEAM therapy.

Once the person feels understood and supported, the next step is called Agenda Setting. That’s the A of TEAM. One of the most important tools in Agenda Setting for individuals with troubled relationships is to first ask, “Is this relationship conflict something you want help with?” In many cases, the patient will say no, so you can ask if there’s something else he or she wants to work on.

In the language of TEAM, this is called “Sitting with Open Hands.” The therapist has to let go of his or her attachment to “helping.” This is difficult for many therapists, due to the therapist’s compulsive urges to help.

If the patient does want help, the next step is called Interpersonal Decision-Making. You ask what kind of help the patient wants, and make it clear that the patient has three choices.

1. To leave the relationship.
2. To improve the relationship.
3. To stay in the relationship and behave in a way that will guarantee that the relationship will remain miserable.

David emphasizes that the last choice is by far the most popular. The second most popular choice is the decision to leave the relationship. And occasionally, you’ll find a person who wants help improving the relationship. As you can see, Interpersonal Decision-Making is simply a more sophisticated way of asking the patient if she or he wants help!

If the answer is still yes, the next Agenda Setting step is the Blame Cost-Benefit Analysis (CBA). You can ask the patient something along these lines:

“Who, in your opinion, is more to blame for the problems in the relationship? You? Or the other person? And who, in your opinion, is the bigger jerk? You? Or the other person?”

At least 80% of the time, the patient will say, “the other person!” You may feel the same way if you’re in a conflict with someone right now. However, blame is the most formidable barrier to intimacy, so before we can continue with the treatment, this issue must be skillfully addressed, or the treatment will probably fail.

David and Fabrice guide the listener in doing a written Blame CBA, listing the advantages and disadvantages of blaming others for the problems in our relationships with them. They encourage you to pause the recording and to the written exercise during the podcast, but warn you not to do it if you are driving!

Then they discuss how to process the results of the Blame CBA. If you would like to see a completed Cost-Benefit Analysis, click here. As you can see, the weightings at the bottom have not been filled out, so you can do that for yourself if you like. Make sure you put two numbers that add up to 100 in the two circles. Put the larger number in the circle under the column that feels more desirable. For example, if the advantages of blame greatly outweigh the disadvantages, you might put a 70 in the circle on the left and a 30 in the circle on the right.

If the patient concludes that the disadvantages outweigh the advantages, you can proceed to the M = Methods phase of the TEAM therapy session, which involves the Relationship Journal (RF). This is a powerful tool that David has designed to create interpersonal enlightenment and the death of the ego. David and Fabrice will discuss and illustrate the RJ in the next podcast.