Why did he drop out?

“How do you ease people into the emotional side of ISTDP? I’ve had patients come in with different problems, and with some focusing in the first session they got in touch with their feelings. One had grief over a suicide years ago and never cried except in our session. Another externalized. I kept returning him to an internal focus and he eventually cried about childhood trauma.  

            They all said it was fantastic to be able to cry even though it was embarrassing and strange. But some of them stopped coming after that. Should I have eased them into it? Did they have sort of transference resistance or anger towards me I didn’t pick up?” Thanks to Albert for this great question!

Without seeing the video, it’s hard to know. So let’s think about our checklist:

1) Was there consensus on the triangle of conflict?

2) Was there consensus on the therapeutic task?

3) Was the patient’s will online?

4) Once you accessed feelings, did you assess what that experience was like for the patient? 

5) When they felt deep feelings, did you help them notice the relief they now experienced? Did you show them that this demonstrated that they had more capacity than they imagined?

6) Did you assess any hesitation or anxiety that was triggered by the experience?

That helps you assess whether you got resistances out of the way in advance or whether resistances emerged as a result of experiencing their feelings. 

When you review the video, here is one other clue: write down a one-sentence statement about each relationship they mention. For instance:

“I am thinking about leaving my girlfriend.”

“I feel like my boss is pushing me to do things I don’t want to do, so I’m looking for another job.”

“The violinist in my string quartet is so irritating, I’m thinking of joining a different quartet.”

In each example he is thinking of leaving. That is his unconscious view of therapy: He is thinking about dropping out. These cues in the “latent content” are an early warning system alerting you to possible dropout. In 99% of sessions where a patient drops out, I hear these cues in the therapists’ transcripts. If you catch these unconscious cues, you can address the patient’s resistance right away in session and dramatically reduce your drop out rate.

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