Error #5: Failure to Set the Agenda

* ©2013 by David D. Burns, MD

Do not copy, publish or reproduce without the written permission of Dr. Burns.

In this blog I will focus on the biggest therapist error of all, by far—the failure to set the agenda. This may come as a surprise to therapists who think they do know how to develop a meaningful therapeutic agenda. Most therapists think this means making a list of the patient’s goals for therapy at the initial evaluation and then working together to achieve those goals in subsequent therapy sessions. There’s nothing wrong with that, but that’s not at all what I mean by Agenda Setting,  or more correctly, Paradoxical Agenda Setting, (PAS).

PAS is an amazing new approach that can lead to vastly faster recovery from depression, anxiety disorders, relationship problems, and habits and addictions. However, PAS can be very challenging to learn because it kind of goes against human nature to some extent. And, after all, therapists are human, and therapist narcissism and codependency can pose formidable barriers to learning these new treatment methods.

I’ll give you a feel for how PAS works, using a real case. If you find it intriguing, and want to learn how to do it, you’ll definitely need additional study, training, and practice. I’ll suggest some additional learning steps for you at the end of the blog.

At the start of each therapy session, it’s important to empathize, using the Five Secrets of Effective Communication. When you empathize, you don’t try to help the patient and you don’t give advice. Instead, you can paraphrase the patient’s words (Thought Empathy), acknowledge his or her feelings (Feeling Empathy), find the truth in what the patient is saying (Disarming Technique), and gently probe for more information (Inquiry). It is also helpful to express warmth and compassion (Stroking), and it can also be appropriate for the therapist to share his or her feelings with the patient as well (“I Feel” Statements),

Skillful empathy requires discipline and training. Most therapists believe they are reasonably empathic and have good listening skills. In many cases, this is not actually true. I have developed an Empathy Scale that my colleagues and I require all of our patients to complete in the waiting room at the end of every session. The score will show how your patient actually experiences you. Most therapists get failing grades initially from most of their patients. This can be upsetting, and a shock to the system. However, with practice, your scores can improve significantly, or even dramatically.

Carl Rogers believed that empathy was the necessary and sufficient condition for personality change, and his contributions were legendary. However, research and subsequent experience have shown that empathy is not enough. If a patient is struggling with severe depression, or OCD, or a troubled marriage, or a habit or addiction, you can be the greatest listener in the world, but nothing will change. The patient may think you’re wonderfully supportive and caring, but he or she will still be struggling with the symptoms that brought him or her to therapy in the first place.

That’s why we need methods. I have developed more than 50 powerful techniques that can help people overcome mood and relationship problems and addictions. But you can’t just jump from empathy to methods. This is where Paradoxical Agenda Setting (PAS) comes in. You might think of it as the bridge from empathy to methods. When you use PAS, you find out what, if anything, the patient wants help with in today’s session. Then you bring the patient’s subconscious resistance to conscious awareness, and melt the resistance away using a number of innovative techniques. If you do this skillfully, then when you come to the methods portion of the session, you will get much better and faster results. In fact, the impact of PAS on recovery can be dramatic.

There are five steps in Paradoxical Agenda Setting:

  • The Invitation
  • Specificity
  • Conceptualization
  • Motivation
  • Methods

The Invitation Step

Let’s see how it works, using a real but heavily disguised case. A young man named Rameesh sought treatment from me in Philadelphia for severe anxiety and depression. He was working as a computer programmer, and those were the early days of programming.

Of course, I took his history first, and then spent most of the first treatment session empathizing with him. Then I issued the Invitation by saying something like this: “Rameesh, you’ve mentioned a number of problems, and you’ve told me how anxious and depressed you’ve been feeling. I can see that you’re in a lot of pain. I’d like to offer you more than just listening and support, and I’ve got some wonderful tools to share with you. I’m wondering if this would be a good time for us to roll up our sleeves and get to work on one of the problems that’s bugging you, or if you need more time to talk and have me listen, because listening is also important, and I don’t want to jump in before you feel ready.”

This is called a “Straightforward Invitation,” and it conveys several important messages to the patient:

  • “I care about you and I’m aware that you’re suffering a great deal.”
  • “Venting and getting support won’t be enough to get the job done if you really want to change your life.”
  • “I have powerful tools to help you.”
  • “You will have to ask me for help in order to make some magic happen.” This is based on the Biblical notion of “Ask and ye shall receive.”
  • “You will have to let me know when you’re ready to get to work and begin using these tools.”

Specificity Step

If the patient ignores your Invitation, or doesn’t feel ready to focus on something specific, you can empathize for a while longer, and then repeat the Invitation step.

Rameesh indicated that he did want help. Then you go on to the Specificity Step, and there are two levels of Specificity you can ask about. First, you can ask what problem she or he wants help with, with a simple question like this:

“Rameesh, I’m glad you feel ready to work on something together. You mentioned lots of problems that seem important, and any of them would work well, I think. What problem would you like to work on first?”

Rameesh indicated that he wanted help with his low self-esteem, but it could be anything that’s bugging the patient, such as procrastination, or panic attacks, or a marital conflict. It could be anything at all.”

Rameesh wants help with his “low self-esteem,” but we don’t really know what that means. To bring the problem to life, you go on to the second level of specificity—you can ask him to describe one specific moment when he was struggling with that problem. This is what I said to Rameesh:

“Rameesh, I’m glad you want help with low self-esteem because I would enjoy helping you with that. Although it’s incredibly painful to have low self-esteem, there are lots of tools we can use to help you boost your self-esteem and feel greater joy in life. But I need a bit of help from you. I’m wondering if you can describe a specific moment when you were struggling with low self-esteem. That way, I’ll have a better idea of how to help you. For example, you might be experiencing low self-esteem right now, sitting here in my office, or you might have been feeling bad about something that happened yesterday, or at any time in your life.”

Once Rameesh describes a specific moment when he was upset, you can ask him where he was, what time of day was it, and who he was interacting with. What did the other person say to him, and what did he say next? What was he thinking at that moment, and what was he feeling?

During the Specificity Step, it can also be helpful to ask questions along these lines:

“Rameesh, let’s assume that you and I successfully solved this problem. What would the solution look like? What would change? How would things be different?”

This question can be tremendously useful. Sometimes you will see why the patient is stuck, because the type of solution he or she is looking for may be unrealistic or self-defeating. For example, someone who is overly submissive may think that the solution to a relationship problem involves the opposite of submissiveness, such as becoming more aggressive, demanding, or argumentative. These strategies are almost certain to stir up hostility, rather than intimacy, collaboration, or respect.

Or, the person who is procrastinating may think the solution will involve developing great motivation before tackling the task he or she has been putting off. This strategy is doomed to failure, because the motivation will probably never come. If you want to overcome procrastination, you’ll have to make a commitment to get started in spite of the fact that you don’t feel like it. Once you’ve gotten started, you may realize that the task is not as bad as you imagined, and then you might experience some motivation.

When I asked Rameesh for a specific moment he was experiencing low self-esteem, he described a conflict with his boss the previous day. He’d met with her to review his performance evaluation. She said that she’d received numerous complaints about his work from his colleagues. They said that he was defensive and hard to get along with, and that he wasn’t a good team member.

Rameesh found the feedback from his boss very upsetting and got defensive. He insisted that his colleagues were jealous of him because he was from India, had dark skin, and was smarter than everyone else. He shouted that there was a conspiracy against him, and that he should be at the head of his computer team.

I asked Rameesh how his boss responded when he said that. He sadly explained that his boss put him on probation and threatened to fire him if he didn’t shape up. He said that he walked out of the meeting feeling like a total loser.

Now we know what Rameesh needs help with. If you ask 50 patients to describe a moment when they were struggling with “low self-esteem” you’ll get 50 completely different situations, all requiring individualized solutions. That’s why the specificity step is so important, and why formulaic, manualized therapy based on a diagnosis or problem is doomed to failure for many if not most patients.

Conceptualization Step

Now we come to the conceptualization of the problem. You can do this step on your own, in your head, or in collaboration with your patient. Ask yourself if the problem is an individual mood problem, such as anxiety or depression, or a relationship problem, or a habit or addiction, or a so-called non-problem, such as uncomplicated grief.

Rameesh asked for help with his “low self-esteem.” Now that we know what really happened, how would you conceptualize his problem? If you’ve printed this blog out, tick off any that apply. If you’re reading it on the website, make a mental decision before you continue reading.

1.    An individual mood problem, such as depression or anxiety

2.    A relationship problem

3.    A habit or addiction

4.    A non-problem, such as uncomplicated grief

The conceptualization step is vitally important for two reasons. First, each type of problem is associated with its own type of therapeutic resistance, so when you conceptualize the problem, you can begin to ask yourself about the kinds of resistance the patient will probably have when you try to help him or her. You can also think about what techniques you’ll use to melt away the resistance.

In addition, each type of problem responds to different types of techniques. I train my students and colleagues in how to use 50 basic psychotherapy methods, such as the Hidden Emotion Technique, the Acceptance Paradox, the Interpersonal Downward Arrow, the Externalization of Voices, and many others. Some methods are especially effective for depression, while others work well for anxiety disorders, or relationship problems, or habits and addictions. So when I do the Conceptualization Step, I’m also  thinking about the methods I’ll use once I’ve melted away the patient’s resistance.

Did you make your choice(s)? Please don’t continue reading until you’ve decided. Does Rameesh have a mood problem? A relationship problem? A habit / addiction? Or a non-problem?

Most therapists say that Rameesh has a relationship problem, and that’s definitely true. I’m sure you recognized that as well. Clearly, Rameesh isn’t getting along with his boss or his colleagues. In fact, he sounds pretty paranoid, angry, and narcissistic.

But he’s also severely depressed and intensely anxious about losing his job, so he also has individual mood problems. Often, your conceptualization of the problem will involve more than one dimension. That means we may have to deal with several forms of resistance, and that we will have many kinds of techniques to help the patient as well.

Motivation Step

Rameesh has a fairly severe problem and we have some terrific tools to help him. This sounds like a marriage made in heaven. Should we jump in and help him now? That, of course, is the biggest therapeutic error at all. Before we try to help Rameesh, we need to think about why he might not want the very help he’s asking for. Then we need to figure out how to antidote that resistance. Here’s where the new PAS techniques can be invaluable.

When we’re suffering, most of us have one foot in the water and one foot on the shore. Part of us wants to change, but part of us resists change and clings to the status quo. Why might Rameesh forcefully resist our efforts to help him?

We’ll need to think about two different kinds of resistance. I’ve called them Outcome Resistance and Process Resistance. In its simplest form, Outcome Resistance means that the patient doesn’t want a positive outcome from the treatment. If the patient is depressed, Outcome Resistance means that the patient would strongly prefer depression, shame, hopelessness, and misery over joy, self-esteem, hope and productivity. That might seem odd to you. Why would a depressed patient want to remain depressed? In fact, there are many very good reasons for this, and as long as they remain unexamined, the patient is likely to remain stuck.

Process Resistance is a little different. Process Resistance means that the patient might want a positive outcome, but doesn’t want to do the thing he or she will have to do to produce a positive outcome. In other words, there is some process—such as psychotherapy homework, or exposure—that the patient will resist doing.

Let’s review some of the most common sources of Outcome Resistance:

Target

Outcome Resistance

Process Resistance

Mood disorders

Depression, shame, guilt, self-criticism, inadequacy, worthlessness, and hopelessness.

The self-criticisms reveal the patient’s value system; the hopelessness protects against disappointment; and the relentless negative thoughts will seem to be true. Patients probably won’t want to do daily psychotherapy homework, such as recording negative thoughts on the Daily Mood Log or scheduling more satisfying and productive activities on the Pleasure Predicting Sheet.

Anxiety disorders

Phobias, OCD, Panic Attacks, Shyness and other forms of Social Anxiety, GAD, PTSD, Body Dysmorphic Disorder

Magical thinking—the patient thinks the anxiety or compulsive rituals will ward off danger. Patients probably won’t want to have to use exposure techniques because it will be so anxiety-provoking.

Relationship problems

Anger, marital conflict, disagreements with friends or colleagues/

Giving up the intense rewards of blaming the other person, feeling “right,” feeling morally superior, or fantasizing about revenge. The patient may not really want to get close to the person he or she is complaining about. Patients probably won’t want to pinpoint their own role in the problem because they’re so convinced it’s the other person’s fault. They may insist on endless blaming and complaining and fight hard against learning to change themselves.

Habits and addictions

Procrastination, overeating, drinking or drug addiction, having affairs, shopping, internet porn addiction, or dating someone who is abusive

Giving up the tremendous physical and psychological rewards of the habit or addiction. Patients probably won’t want to face the discipline, anxiety, deprivation, discomfort and hard work of giving up the instant gratification of their favorite “fix.” For example, the patient who wants to lose weight will not want to diet and exercise.

Once you’ve conceptualized some possible reasons why your patient may NOT want to change, in spite of the miserable status quo, you’ll need to learn how to share this information with him or her in a paradoxical but respectful manner. Here’s what I said to Rameesh:

“Rameesh, I have some powerful tools to help you with your low self-esteem and the problems you’re encountering at work, and I’d love to work with you. I believe you’re very smart, and I like you, and it would be a joy for me to show you how to turn your life around. I have no doubt that we could do exactly that. But I’m not sure it would be the right thing to do, and I’m really reluctant to share these tools with you.”

Notice that I’m not trying to “help” Rameesh and I’m not trying to persuade him to change or to work with me. Instead, I’m Dangling the Carrot—letting him know that I have some great tools, and that I want to work with him, but I’m also letting him know that he’s going to have to persuade me. I’m not going to try to persuade him.

Like most patients, Rameesh seemed taken aback. He insisted that he was tremendously interested in working with me and wanted to know what the problem was. Here’s what I said next:

“Rameesh, there’s a problem I’m struggling with. You’ve said that your colleagues treat you unfairly and that they’re jealous of you. That must feel extremely unfair, and I can imagine that you might be feeling incredibly angry and frustrated. You’ve said that they’re jealous and talking about you behind your back and treating you in a shabby way. Some people might think you’re being paranoid, but we know that’s not the case. We have proof that they’re bad-mouthing you, which is unfair. That’s what your boss told you in the evaluation.

“So I’m entirely on your side in this battle. But here’s the rub. They’re not here asking for my help. So if we work together, you’re the one who will have to do all the changing. You’ll have to learn to change the way you think and feel, as well as the way you communicate with them. And you’ll have to work your butt off during sessions, and you’ll have to do psychotherapy homework between sessions as well. But that seems rather unfair, since they’re the ones who are screwing up. Do you see what I mean? Why should you have to change when they’re to blame for the problem?

“What are your thoughts about this? Can you help me solve this dilemma?”

Here’s why I made this statement. First, I wanted to find the grain of truth in Rameesh’s complaints, so he’d feel accepted and so he’ll feel like we’re on the same team. Second, I wanted to convey some warmth, liking and respect, especially given his pretty strong narcissistic streak. I knew that if he felt judged, criticized, or belittled, he’d probably put up a wall and drop out of therapy before we even got started.

And I did like him, so my statement was genuine. But most important, I wanted to head off his resistance at the pass and let him know that he’d have to persuade me to work with him, and not vice versa.

Notice that I have become the voice of Rameesh’s subconscious mind. I am verbalizing all the reasons for him not to change. When you do this skillfully, the patient will nearly always suddenly let go of the resistance and buy into the treatment program. The effect is almost as basic as the law of gravity, and the results can be spectacular. We call this Paradoxical Agenda Setting because the therapist becomes the voice of resistance. If you do this skillfully, in nearly all cases the patient will suddenly become the voice of change.

Rameesh told me that he definitely wanted to work with me, and would do practically anything if I would agree to work with him. I told him, once again, that he would have to do all the changing, and that he’d have to do at least one full hour of psychotherapy homework every day, 7 days a week. Once again, I emphasized how unfair that seemed.

He said he didn’t care how unfair it was, and that if I’d work with him, he’d do more psychotherapy homework than any patient I’d ever had.

I told him that was the message I was hoping for, and that I’d love to work with him.

Then he suddenly broke down and started crying. When he pulled himself together, he told me that he had a confession to make, and that he’d been lying to me. I asked what he’d been lying about. He explained that his boss didn’t really put him on probation—she’d fired him. And he confessed that he’d been fired six times, from six different jobs, in the past two years. He said that everywhere he went it was the same thing over and over. And if I could show him how to change his life, he’d do anything I asked him to do.

Methods Step

Rameesh was a joy to work with. He did more psychotherapy homework than anyone I’d ever worked with. I used basic tools, such as the Daily Mood Log, to help him with his depression and anxiety, and the Relationship Journal to help him with his conflicts with others. He worked relentlessly, and within a few weeks his depression had vanished. He also became a master at using the Five Secrets of Effective communication to deal with criticism and conflicts with others.

He was unable to find work in Philadelphia, since he’d pretty much burned his bridges at the only companies using his type of programming. But then he got an offer from a software engineering company in Georgia. He asked for my advice about whether to make the move.

I suggested he could tell them that he could only accept their offer if his new boss would agree to meet with him 15 minutes once a week to criticize his performance. They were taken aback, and said they’d never had a request like that, but agree since they were desperate to hire a programmer with his skill set.

Rameesh called for a phone tune-up about six weeks after he moved. He said things were going swimmingly, and he’d actually won the “Employee of the Month” award, and his picture was posted in the lobby of the company. He said the Five Secrets of Effective Communication worked like magic when he was receiving feedback from his boss.

The next time I heard from him was a second phone tune-up six months later. He was still on a high and explained that he’d gotten several promotions, and his salary had doubled. That was our last therapy session we ever had.

I didn’t hear from Rameesh again for many years. Then, one December, I received a Christmas card from Rameesh, with a note inside that was written on his company’s official stationery. He said he hoped I hadn’t forgotten who he was, and explained that things were still going great—he’d gotten married and had a baby, and was still working at the same company. But he wrote that he wanted me to take a look at the letterhead on the stationery and that he hoped I’d be proud of him. I checked it out and noticed that it said Rameesh XYZ, President and CEO, XYZ Software Company!

I was bursting with pride in Rameesh and what he’d done. Now he had more than 600 employees working for him. If I hadn’t used PAS, he’d probably still be my patient, insisting that he was a victim of other peoples’ insensitivity.

That’s just a brief overview of how PAS worked for one patient. If you think you might want to learn more about PAS, there are several tools that could help you, including:

  • Read my psychotherapy eBook, Tools, Not Schools, of Therapy, and do the written exercises in it.
  • Get mentoring / individual training from a certified T.E.A.M. Therapist at the new Feeling Good Institute.
  • Attend one of my two-day workshops, or even better, a four-day intensive.
  • Attend one of our free (or paid) weekly psychotherapy training groups in Northern California.
  • Purchase and study one of the interactive training videos at TeamTherapyTraining.com
  • Watch my free video on the Motivation Revolution on my Hot Links page.

[*]   Copyright ã 2009 by David D. Burns, M.D.