People think that a working alliance means that the therapist and patient, you know, have a connection. They, you know, they get along. They feel, you know, they have, they feel positively about each other. That's not what it means.
For about the past 15 years, I've been doing lectures and workshops around the world for other mental health professionals. And they all include a clinical case presentation by, you know, somebody who wants to volunteer and get live supervision or consultation on their case. And I always ask for the cases where somebody is, you know, struggling, where the treatment is stalled or reached an impasse or lost focus or doesn't seem to be going anywhere. And after 15 years of doing this, what I learned is that when treatments go off track, it's almost always traceable to the very beginning of the treatment, right? The very first sessions.
And what became clear is that during the first sessions, the therapist and the patient never developed a shared, right? Shared as in mutually agreed treatment purpose or focus, right? A clear understanding of what are we here to do together? What are we trying to accomplish here? So you can think of it as like, you know, two people set out on a journey somewhere and they don't know their destination and they don't have a map and they wonder why they end up getting lost. So what I'm going to talk about is how to structure the first session of psychotherapy and home in on a treatment focus or purpose.
Treatments succeed when there's a working alliance around a shared treatment purpose. They tend to fail when there isn't. I'm going to talk about three things in this context. I don't know how to separate them at this point in my, you know, sort of professional development. They are so intertwined that I don't know how to talk about them separately. So I'm going to move between them. We're going to talk about a treatment focus, a clinical case formulation, and a working alliance. We can pretty much enter this circle anywhere. So, I want to start with a working alliance. What is the definition of a working alliance?
Most clinicians that I teach or supervise or consult with talk about the working alliance or the therapeutic alliance, but actually have lost focus on what a working alliance really is, or perhaps never really learned what a working alliance is. People think that a working alliance means that the therapist and patient, you know, have a connection and they, you know, they get along, they feel, you know, they have, they feel positively about each other. That's not what it means.
A working alliance has three elements or components. And that, you know, mutual attachment or, you know, sort of a mutual investment in continuing a therapy relationship is one element of a working alliance, and usually that's the one that's, you know, usually that's the one that's not a problem, right? If two people are meeting regularly, you know, they both have an investment in continuing the work. So the issue actually is the other two elements.
The second element of a working alliance is that there's a mutual shared understanding and agreement about what we're here to do together, what the purpose of this work is. So, when we come into therapy and we start a session, there really should be a feeling we're going to both roll up our sleeves and get to work. But what's the work, right? That's absolutely key. And the third element of a working alliance is that there's mutual agreement about the methods that we're going to use in order to pursue and achieve that purpose. Right? So attachment, mutual agreement about the purpose of the work, mutual agreement about the methods that we're going to use, how are we going to go about doing the work together? This brings us to the issue of what is a legitimate purpose of the work of psychotherapy, and I believe this applies to any therapy modality. You know, my background is in psychodynamic approaches, but I think this is absolutely universal.
At the risk of stating the obvious, sometimes you need to state the obvious. Psychotherapy is a psychological treatment. It's a psychological intervention. It ultimately has one purpose only, which is to change something about the patient's or the client's psychology, right? Something that's causing difficulties for them, something that's getting in their way.
So, of all of the things that you, right, all of the things that you might think you can focus on or change in psychotherapy, the truth of the matter is there's really, it's two people sitting in a room working together, right? One has come for help, one has come to provide help. The truth of the matter is that the only thing that you can realistically hope to change is something about the patient. Right? So when we say a purpose of therapy, a legitimate therapy purpose is to change something about oneself, right? Not another person, not the external world, not society, to change, you know, something about oneself that's causing difficulties or creating limitations for the person in their life, right?
Second, it has to be something that the person desires to change about themselves. Now, it might take a good amount of work to reach a convergence, a meeting of the minds about, you know, what it would be that would be in the person's interest to be able to change about themselves. The person doesn't, the patient doesn't come in necessarily knowing this from the get-go, right? It takes work to arrive at an understanding of what about the person is causing difficulties for them, right? But once you've arrived at that understanding, in order for therapy to continue, right, it has to be something that the patient would like to change, right? That the patient recognizes could make their life better or easier or free from suffering, freer from suffering.
And the third component is it has to be something that psychotherapy can realistically help to change. You know, people suffer for all kinds of reasons. I mean, life, you know, life can be really hard. I mean, you know, we have, I'm not going to start trying to list out the sources of people's suffering. I mean, you know, there's disease, illness, you know, poverty, legal problems, financial problems, etc., etc., etc.
But the purpose of psychotherapy isn't to help anyone with anything. Again, it's a psychological treatment. The purpose of psychotherapy is to help change something psychological, right, that's causing difficulties. So, these three elements have to be there. And, you know, this shouldn't be controversial, but in recent years, it seems like it's become controversial.
If those things aren't in place, you actually don't have a foundation for doing psychotherapy, and psychotherapy should not proceed. You, therapist and patient aren't on the same page about what they're trying to accomplish. The treatment cannot be effective. Right? So what we do in the first sessions is work together to develop a shared understanding of what's going on psychologically. What about the person is causing difficulties for them? Right? And what's going to be the focus of working together in therapy if we decide that we want to proceed with therapy?
