Category Archives: Treatment Planning

Psychotherapy: The Shortest Distance is Not Always a Straight Line

In psychotherapy the shortest distance between two points is not necessarily a straight line. The laws of math that apply to the physical world often seem to be suspended in the therapist’s consulting room.  And yet the geometry of straight lines has an orderliness to it that makes it appealing to clients and therapists alike…

The Therapist’s Fascination with Straight Lines

Were you to peek inside most “behavioral health” agencies today, you would see the logic of straight lines applied everywhere. The fascination with geometric rationality is here so dominant, that you would be excused for wondering if their psychotherapists had a background in engineering, rather than psychology…

Psychotherapy in these settings has become a very rational and well-planned endeavor that is usually centered around a geometrical road-map, also called “the treatment plan”.

Guided by the dictates of the treatment plan, therapists in these settings are asked to first identify the client’s problem, next help the client set some goals, and finally devise a plan to most quickly and efficiently achieve those goals. From then on therapy is supposed to follow the plan in a straight line from start to finish. Any deviation from the road map is considered disruptive and tangential. It threatens the geometric principles of treatment.

In line with this approach you can hear well-respected cognitive behavior therapists (the engineers of the field) speak of “potentially therapy-disrupting behaviors” that include “attempts [by the client] to overly control the pace of topics of conversation during the interview” (Wright, Basco, and Thase). You can also hear statements such as: “One of the challenges in this treatment is to avoid getting distracted by discussions of other problems the client may be facing” (Safren). In short, we must straight-jacket the process to make it fit with the plan. We must shape the territory to make it look like the map!

Two Different Views of Psychotherapy

So what is wrong with this picture? To the rational mind, planning psychotherapy ahead of time and directing treatment with an authoritative hand toward definite goals can seem very intuitive and appealing. And yet, I would argue that it misses the point altogether…

Psychotherapy is not about getting somewhere that is known in advance. In fact, therapy is itself a process by which we discover where we want to go and what we want. To determine the goals in advance of the therapy is thus much like putting the carriage before the horse…

If we use the metaphor of a road-trip to describe what psychotherapy is, then we can perhaps compare the two approaches in the following way:

In the first more “planned” approach, we are trying to get the fastest way possible from New York to Los Angeles. We therefore take the freeway in a straight line to the destination, missing all the sights along the way. We end up in Los Angeles in record time, but have learned very little along the way. We have reduced the journey to a simple means of transportation to get us from point A to point B.

In the approach I advocate, we might also begin our journey toward Los Angeles. Instead of zooming past all the sights, however, we allow time to get off the beaten path and leave ourselves open to new experiences along the way. What might then happen is that we discover that we would rather go to Cleveland, or that it isn’t really so important to get to Los Angeles right away. Maybe it is more interesting to make a detour to the Grand Canyon, or to follow our chance encounters.  We may even decide that our whole enterprise has been a mistake and return back home.

I am speaking metaphorically here, of course, about the nature of the human psyche: Contained within us there are many unexplored territories, and many memories and experiences that can teach us something new about what we really want in life. Going in a straight line may therefore not be the fastest way to get where we ultimately want to be…

Psychotherapy and the Dance of Life

The irony is that when we plan psychotherapy too much, we miss out on all the key therapeutic moments. The real “stuff” of psychotherapy is not about getting to the destination, but about all the little surprises that happen along the way. The goal of psychotherapy is not to get us from point A to point B in the most direct way possible, but to help us undergo a journey where the destination itself can change as we discover new things about ourselves. In fact, even if we ultimately end up in the same place, from a therapeutic perspective it matters how we got there. If we took the freeway, likelihood is we bypassed all the realizations and all the emotional twists and turns that would have given us the true conviction that Los Angeles is where we need to be. We would have exchanged one place with another without being none the wiser…

The intellectual insight a person can have in session 1 can also be the one they ultimately end up with in session 20. However, it took the twists and turns of therapy, to make the person know what they knew, in their gut. To the outsider it may look like nothing much has happened, since after all the person is back just where she started. And yet to the person who did the traveling, this place is completely changed now, and it feels like she has made a quantum leap in her understanding of herself.

Trying to bypass the journey to simply get to the result is to mistake intellectual insight for an emotional experience of truth. It is to cut out the “therapeutic middle” which is where all the action happens…

On this point, I am reminded of a very insightful video, based on the teachings of Buddhist philosopher Alan Watts. In the video we are shown how a linear pursuit of higher and better accomplishments ends up being a failed strategy in the end. Once we arrive at the promised destination, we realize that there is always another goal to be accomplished. Once we finally reach the top of the mountain in our final age, we discover to our dismay that all we are really left with is a sense of emptiness and hollowness; a bitter realization that it was all for naught…

Why? Alan Watts reminds us: Because life wasn’t about getting anywhere. It was about a dance. The point of a dance, as with a musical piece, is not to quickly get to the end. It is about the dance, and about the music. Therapy is also a dance, and if we get somewhere too fast, we might just end up missing the point…

To read more about the perils of a rational/planning approach to  psychotherapy, download my article: Cultivating the Therapeutic Moment: From Planning to Receptivity in Therapeutic Practice.

About me: I am Rune Moelbak, a psychodynamic therapist in Houston, Texas. Click here to visit my website.

Sources:

Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD. A cognitive-behavioral treatment program (Therapist guide). New York, NY: Oxford University Press.

Wright, J. H., Basco, M. R., & Thase, M. E. (2005). Learning cognitive-behavior therapy. An illustrated guide. Washington, DC: American Psychiatric Publishing.

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