Therapeutic Bond?

[Ceke2002]

Advertisement - Members don't see this ad

I know what the therapeutic bond feels like from a patient's point of view (or at least from this patient's point of view), but I'm curious to know what it feels like from the opposite side. How do you ('you' here taken to mean anyone who wishes to answer) experience the therapeutic bond as a Psychiatrist/Therapist? Can anyone quantify the nature of how it feels from a Psychiatrist or Therapist's point of view, either on a personal and/or over all general level? I find the entire process of therapy fascinating, and this is a question I'd love to read some input/discussion on*.

*Strictly asking solely for interest's sake, and not to elicit advice in any form.

 

[novopsych]

Generally, if a psychiatrist has undesirable feelings toward a client (dislike or sexual attraction), he/she is able to identify countertransference, and the identification alone usually gives us the ability to mitigate it. I don't as often as my colleagues believe that clients are eliciting countertransference in me.

I am of the school that believes there must be likability between patient and client. If I cannot handle countertransference issues, I will refer out. This is very rare, though. I have found that with a dance-oriented practice, I attract patients with whom I generally have a good rapport. What I seek most is a patient with vibrancy, and the service you offer dictates whom will seek your service. There aren't a lot of junkies etc who are seeking out a psychiatrist who practices primarily dance therapy and expects the best out of her clients. Basically, my practice is not for those who want to mope around. I attract vibrant customers because I offer a vibrant treatment option.

Now I did recently have a gentleman start up with me who has a rather unfortunate harelip. I'm not talking about the really bad ones you see in those charity commercials. It's worse than Joaquin Phoenix's, but not at all like those children you see on TV. At first I was hesitant about becoming distracted during the dance. But you know what I've found is that once you learn to look away from it, you really get used to being able to look at different parts of a person, like the neck for example, and it becomes more natural. There's always a way to find something you like a patient—almost always, at least.

Now would I do a tango with this man? No. The tango requires a lot of very direct face-to-face contact. But there are a lot of clients I don't tango with for a variety of reasons, including personal hygiene.

In short, feelings of countertransference are almost always manageable, and if not, patients can be referred out. But there has to be a likability. But if you set up shop with what you love, you're going to attract people you like. I went into psychiatry to help people, so of course I am going to generally like the type of people who seek out psychiatric services. And given my background in the dance, I am even more likely to have likability with those who seek dance therapy as a treatment modality.

 

[michaelrack]

There aren't a lot of junkies etc who are seeking out a psychiatrist who practices primarily dance therapy .

edit: tasteless you tube crack dancing videos deleted out of respect for those with cocaine dependence.

 

[Weinberg Angle]

...

 

[erg923]

When one conceptualizes individuals as "customers" rather than patients, then I don't think you should expect any unconditional positive regard to exist, which then makes the bond no different than any other human relationship.

I think the striving to form and maintain unconditional regard is what makes the bond unique feeling. I am not sure how to describe it in words really.

 

[novopsych]

When one conceptualizes individuals as "customers" rather than patients, then I don't think you should expect an unconditional positive regard to exist, which then makes the bond no different than any other human relationship.

I think the striving to form and maintain unconditional regard is what makes the bond unique feeling. I am not sure how to describe it in words really.

We can debate terminology (patients, consumers, clients, etc.). But regardless of terms, I, too, do consider myself a tad Rogerian. I do believe unconditional positive regard is important, which is why it's very important to get a patient/client (whichever term you prefer) into the hands of someone who can give them that unconditional positive regard. Not every psychiatrist will be able to have unconditional positive regard for every person he/she comes across.

 

[Ceke2002]

I think the striving to form and maintain unconditional regard is what makes the bond unique feeling. I am not sure how to describe it in words really.

Unique is a very apt way of describing the therapeutic bond. I'm not sure I could put it into words either. Most of my friends know I'm in long term therapy and they sometimes ask what I mean when I mention having a therapeutic bond with my Psychiatrist, and they ask if I can compare it to anything and it's like 'well, not really'. It's not familial, it's not friendship (friendly perhaps), it's certainly not romantic or sexual in any way - it sort of defies description or comparison unless you've experienced it yourself.

 

[Shikima]

When one conceptualizes individuals as "customers" rather than patients, then I don't think you should expect any unconditional positive regard to exist, which then makes the bond no different than any other human relationship.

I think the striving to form and maintain unconditional regard is what makes the bond unique feeling. I am not sure how to describe it in words really.

With this regard, one recommendation I have is to look up how Press-Gainey score are mattering to hospitals and the impact upon physicians.

 

[smalltownpsych]

That is a great question Ceke and very thought-provoking. I would like to hear from other people their feelings about it. I find that it is easier for me to have positive feelings towards patients who improve or is it the other way around? Some of my patients I get closer to than others and it seems that there a lot of variables that account for this. YAVIS is an acronym I have heard used to describe some of the patients we tend to like. I think it is youthful, attractive, verbal, intelligent, and I always forget the last one. Is it social, sophisticated?

 

[Ceke2002]

That is a great question Ceke and very thought-provoking. I would like to hear from other people their feelings about it. I find that it is easier for me to have positive feelings towards patients who improve or is it the other way around? Some of my patients I get closer to than others and it seems that there a lot of variables that account for this. YAVIS is an acronym I have heard used to describe some of the patients we tend to like. I think it is youthful, attractive, verbal, intelligent, and I always forget the last one. Is it social, sophisticated?

I think it's 'Successful', or in my case it would have been 'Suspicious'. Having come from a previous background that had included abuse in a therapeutic situation, I was extremely mistrustful when I first started therapy with my Psych. I thought I was actually keeping it all under wraps though, because outwardly I'd always go in trying to project a very polite, relaxed and chatty sort of image, but I was talking about those early days in a recent session and was almost surprised to find out that my Psychiatrist had seen right through that charade and pretty much picked up straight away that I did have major trust issues - I don't know why I should have even remotely been surprised at that revelation, I mean Psych's are supposed to have training to read what people aren't necessarily telling them (at least I assume they do, or it's something they develop). I have a really strong therapeutic bond with my Psychiatrist now and I often wonder if part of that is because the bond didn't just happen, it was forged over quite an extended period of time.

 

[smalltownpsych]

I think you are hitting on a key point of the bond - trust. If I'm not honest with my patients or they are not honest with me, we aren't going to get anywhere other than to replicate unhealthy patterns of relating.

 

[erg923]

Thats a good point. Some of my best breakthrough, as well as couple crash and burns, have come when I told patient that there were very difficult to work with. This wasn't always in the sense that they had personality pathoilogy either. Some just had very, very difficult circumstances that made climbing out the current rut darn near impossible (think angry chronic pain patients).

 

[clusterF]

The name's Bond. Therapeutic Bond...

 

[Ceke2002]

The name's Bond. Therapeutic Bond...

Someone needs to draw this, stat! 🤣

 

[Ceke2002]

I think you are hitting on a key point of the bond - trust. If I'm not honest with my patients or they are not honest with me, we aren't going to get anywhere other than to replicate unhealthy patterns of relating.

Yes, absolutely. The more trust that began to develop between us, the more I started to actually get out of the therapy itself, because I wasn't holding back as much or putting up a lot of false fronts thinking I needed to constantly protect myself against harm or disappointment.

Thats a good point. Some of my best breakthrough, as well as couple crash and burns, have come when I told patient that there were very difficult to work with. This wasn't always in the sense that they had personality pathoilogy either. Some just had very, very difficult circumstances that made climbing out the current rut darn near impossible (think angry chronic pain patients).

My Psychiatrist has a special interest in complex and/or chronic cases. I've recently transferred with him to his second clinic, but when I first started working with him at the previous clinic strictly speaking I was not supposed to be a patient there at all. The first clinic I worked with him at was actually an acute crisis intervention service, and although after I'd been assessed by a Psychiatric Nurse, Social Worker and one of the supervised Trainee Registrars it was determined that I did have a severe and chronic mental illness I still wasn't considered to be sick enough to access this particular service. As the lead clinician/dude that basically runs everything, my Psychiatrist reviewed my initial case notes and that's when I got a follow up phone call a few days later with an offer of a treatment placement with him. From what I understand he regularly goes through patient assessment reports and hand picks those that interest him (think chronic, complex, usually involving some degree of personality disorder co-morbid with whatever other diagnosis are present) to work with on a long term basis. Although I've never met any of the other patients, I know there's a whole group of us that his staff at the old clinic affectionately nick named 'J's Specials'. I've always wondered what draws him to cases that are particularly difficult, whether or not it does have something to do with the reward profile being higher in a way when he does manage to break through to someone and develop a therapeutic relationship with them. I should probably ask him, I know he's open to discussing that sort of stuff with me.

Like I said in the original post, the process of therapy is something that really does fascinate me, and I've found myself becoming more interested in it's 'inner workings', so to speak, since I've been in long term therapy myself.

 

[Nasrudin]

It's a great question. And a thread topic. One of the things that attracted me to psych was the time spent asking the sorts of questions that create a bond.

But in my short distance along this route I would say it does feel unique. In that you feel for a patient's problem and situation and you're aiming to be a pure agent of help. That's not exactly common in our interactions with people. So when I have felt it. It gives you something to come to work for.

I think in my case it's easier with people who have a good heart. Regardless of the folly or misfortune of their circumstance. I don't mind addicts for instance. As long as there's a fighter with a good heart struggling to pick up the pieces of their life, then the bond can be great.

On the other hand, I think I may have just had a borderline personality disorder patient on medicine wards. For that sort of conflict oriented mind it might require a more developed clinician to achieve some measure of bonding.

For now it usually happens for me when a patient and I generally like each other.

 

[Ceke2002]

But in my short distance along this route I would say it does feel unique. In that you feel for a patient's problem and situation and you're aiming to be a pure agent of help. That's not exactly common in our interactions with people. So when I have felt it. It gives you something to come to work for.

From a patient's point of view I think that same sense of 'when you feel it, it gives you something to come to work (or in my case, therapy) for' is true from the opposite side of the treatment equation as well. Those moments of real break through, and progress, where you can sense the energy in the room almost coalesce into a shared and equal experience of both pride and accomplishment. It does make you want to work harder, to strive for more of those moments, because they are a very unique and precious experience.

I think in my case it's easier with people who have a good heart. Regardless of the folly or misfortune of their circumstance. I don't mind addicts for instance. As long as there's a fighter with a good heart struggling to pick up the pieces of their life, then the bond can be great.

As a recovered addict I can definitely say that having someone be able to look past the addiction and respond to me as a person, with both potential and a sense of goodness buried underneath the destructive behaviours I was engaging in, went a long way towards encouraging and assisting my eventual recovery. I'd already gone through, and failed, what felt like so many different treatment programs that I reached a point where I really had just given up and was prepared to let the addiction run its course until I reached the grave, most likely by my own hand. As far as I was concerned not only had I run dry of any hope, I also wasn't worth saving as it was. I'd really lost sight of myself as a person and tended more towards seeing myself as nothing but a collection of negative labels - 'junkie', 'street prostitute', 'liar', 'scum' - a tendency that had been reinforced with every treatment failure, every person that walked past me on the street and looked at me like I was something they'd just scraped off the bottom of their shoe, and every Doctor that had rolled their eyes, or glared across the table when I approached them for help, and then hastily scrawled out yet another script for benzos and given me a 50 yard stare that said 'just try and come back to my office, I dare you'. Then an outreach group, consisting of former addicts and sex workers, along with social workers and nurses began to visit us out on the streets. They gave out clean needles, supplies of condoms and lube, offered basic health checks and counselling, but most importantly they spent time just talking and socialising with us like we were people who still mattered, and deserved to be treated with respect. I'm not saying it was a case of 'someone was nice to me, and behold I was cured', but the more time I spent with those outreach workers, and the more I realised they were looking past the labels and seeing the person buried underneath, the more a tiny little initial seed that had been planted began to grow, and the more I began to think, "You know maybe I do owe it to myself to give things one last try." It all eventually came together to produce a single moment of clarity, one of those classic 'the heavens have opened up, the veil has lifted' type epiphanies that occur when you're dope sick on a street corner around 3 am in the freezing cold, and later that same day I basically just walked straight back into a treatment program, said 'help me', and that was that. I'm celebrating my 12th year clean this year. 🙂

Never underestimate the power the right words and attitude can have on a person, no matter how deeply enmeshed in the quagmire they might seem.

On the other hand, I think I may have just had a borderline personality disorder patient on medicine wards. For that sort of conflict oriented mind it might require a more developed clinician to achieve some measure of bonding.

For now it usually happens for me when a patient and I generally like each other.

Yes I can definitely see my own therapeutic bond has most likely also been helped along a great deal by the fact that my Psychiatrist and I do seem to get along quite well. We're about the same age, have very similar personalities, similar interests, similar life attitudes, etc etc. Not that I'd ever labour under any sort of false notion that 'similarity equaled friendship', we are still Doctor/patient engaging within a therapeutic frame of reference, not a couple of buddies having regular catch ups to shoot the breeze with one another...even so I do think those similarities have gone some way towards enhancing the quality of the bond we have developed.

 

[smalltownpsych]

Another interesting aspect of the therapeutic bond is that it happens when we are talking about distressing topics. We ask the questions and have the conversations that other people don't want to have with our patients. Many people try to make our patients feel better and that often leads to invalidating responses. I rarely try to make my patients feel better, rather I try to understand/empathize/mirror/validate whatever their experience is. Some of these terms can be misconstrued at times, and usually because they are often seen from the "positive" perspective of trying to make everything better.

 

[Ceke2002]

Another interesting aspect of the therapeutic bond is that it happens when we are talking about distressing topics. We ask the questions and have the conversations that other people don't want to have with our patients. Many people try to make our patients feel better and that often leads to invalidating responses. I rarely try to make my patients feel better, rather I try to understand/empathize/mirror/validate whatever their experience is. Some of these terms can be misconstrued at times, and usually because they are often seen from the "positive" perspective of trying to make everything better.

This, so much this! You know if all it took was a heap of positive affirmations, a few rousing choruses of 'Everything is beautiful', and half a dozen or so friends banging on about how wonderful they think I am, heck I probably would have been cured a 100 times over by now. I think a lot of people have this misconception that therapy, especially long term therapy, is no different than sitting down with a good friend for a bit of a fireside chat. But unlike a lot of friends, who mean well but don't always know how to respond to certain topics of discussion, my Psychiatrist knows when I need to talk about the dark stuff without automatically invalidating me by reaching for the nearest light switch because he can't handle hearing about it, he knows when to just let me feel something without automatically wanting to rush in to make everything better, he knows when to empathise, when to make observations and give insights, and most of all he knows when to push and challenge me because at the end of the day he's not my friend and his only concern is to help me in a professional capacity and not to maintain some sort of social graces that tend to bound even the best of friendships.

 

[smalltownpsych]

One of my best supervisors helped me to see after I described my patient's severe depression as a bottomless pit of darkness and my own counter-transference reaction was to push those negative emotions away that the only way to help was to go there with him. Not an easy task and it requires good self-care to be able to do that effectively and consistently without becoming overwhelmed. Going into the dark places together is a big part of the bond I would surmise. I hesitate to use the metaphors because they are not scientific constructs but the biological mechanisms of the social network between brains is well-researched, the metaphors are more of a shorthand.

 

[Ceke2002]

One of my best supervisors helped me to see after I described my patient's severe depression as a bottomless pit of darkness and my own counter-transference reaction was to push those negative emotions away that the only way to help was to go there with him. Not an easy task and it requires good self-care to be able to do that effectively and consistently without becoming overwhelmed. Going into the dark places together is a big part of the bond I would surmise. I hesitate to use the metaphors because they are not scientific constructs but the biological mechanisms of the social network between brains is well-researched, the metaphors are more of a shorthand.

Yes, but I think it's more than just a willingness or ability to enter those dark places together, it's also the fact that you know the therapist has the training not to get trapped down in those places with you. With friends it's different, even those who are your most trusted and closest confidantes you still hold back from just that little bit, because you don't want to inadvertently drag them down into that pit with you - and then of course there are others who will quite willingly hurl themselves down the rabbit hole right along side, and then you both end up stuck, and how does that actually help anyone, exactly? Therapy is different, it's safer, and purer in a way, because it doesn't have that encumbrance of friendship holding either party back from giving or accepting help in its truest essence. I think that's part of what does make the therapeutic bond so unique and special (and something to be highly valued once it is established).

I'm waxing a tad lyrical here I know. I'd be very interested in taking a look at some of those studies of social networking between brains, if you have any to hand that might be accessible to me.

 

[masterofmonkeys]

...I think in my case it's easier with people who have a good heart. Regardless of the folly or misfortune of their circumstance. I don't mind addicts for instance. As long as there's a fighter with a good heart struggling to pick up the pieces of their life, then the bond can be great.

Another interesting aspect of the therapeutic bond is that it happens when we are talking about distressing topics. We ask the questions and have the conversations that other people don't want to have with our patients. Many people try to make our patients feel better and that often leads to invalidating responses. I rarely try to make my patients feel better, rather I try to understand/empathize/mirror/validate whatever their experience is. Some of these terms can be misconstrued at times, and usually because they are often seen from the "positive" perspective of trying to make everything better.

There is something very unique about the therapeutic bond. I gravitate toward more complex cases and especially toward people who despite their suffering, haven't given up. I don't need to feel unconditionally positive toward someone, but I do have to find SOMETHING positive about them. Sadly not always possible, but I do end up with a lot of patients that others have complained about in the past who I've developed a bond with simply because I make it my priority to search for that positive thing. Sometimes identifying it and framing it FOR THE PATIENT can have a transformative effect.

I remember one patient who was convinced she was worthless because of the number of mistakes she'd made and the things she'd felt she'd had to do to survive. And yes, she'd done a lot of bad things and made a lot of poor choices. It would be easy to slap a (BS) label of Antisocial Personality on her according to the (BS) criteria. I pointed out that despite that, her two oldest daughters are in college, her next is on the honor roll, and she (a GED holder) had taught herself pre-calc so she could tutor her youngest who was struggling in that class. That moment, in and of itself, was the moment she began crawling out of her depression. It's been one of he most powerful--and humbling--moments of my training.

I don't know. The therapeutic bond is different because as psychiatrists we arent' just helping with illness, but also playing a bit of a guidance role in someone's whole life. It's not quite a parent/uncle/older sib relationship but it certainly shares elements of it. From the youth pastors I've known (I'm not Christian, just from the bible belt) it actually sounds quite similar to what they do.

What I do know is that if you care about your patient, and want them to be better, you have a lot more flexibility to judge their BEHAVIORS (not them). And, oddly enough, those judgments seem to draw you closer together.

 

[LupaCupcake]

I had an interesting bond with a Psychiatrist years ago. He was my husband's physician primarily and he also seen me every so often. He knew of my interest in psychology/psychiatry and that instantly started a bond between us. It took time, but after awhile we grew to trust him and would just tell him everything without him having to pull for answers. He played the role of physician and mentor and to this day I remember some of his advice. He actually stepped up greatly when the military was treating my husband unfairly due to his behavioral health concerns that were flaring up (PTSD and Bipolar) and ensured that his discharge was medical and he was treated fairly. He went above and beyond for our family, always remembered our daughter's name and didn't mind how hyper she was in his office lol.

To this day I wish I could contact him and update him on our life, I wish I could tell him the new medication my husband is on that has finally leveled him out, I wish I could tell him about my experiences thus far working in behavioral health. I will also add he works for the VA overseas which meant a lot of PTs and little time yet despite his time restraint, he was an excellent physician that I wish I could catch up with. If I seen him on the street, I would want to run and hug him although I would not do that because it would be inappropriate, but you get the point.

On the other end, I used to be a psychiatric technician, now I am the patient advocate. My role is nothing like that of a physician, but I still talk to them and develop a bond with them while they are at my hospital. One benefit of my job title, they expect me to be on their side no matter what and that gives way to open discussion and trust. I often empathize greatly with them and in a weird way feel the weight of their burdens sometimes. Staff on our adolescent unit once said I was like the unit mother and I can see where they get that in how I work with our PTS.