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Chapter 46

Helping patients assume responsibility

As long as patients persist in believing that their major problems are a result of something outside of themselves — the actions of other people, bad nerves, social class injustices, genes — then we therapists are limited in what we can offer. We can commiserate, suggest more adaptive methods of responding to the assaults and unfairness of life, we can help patients attain equanimity or learn to be more effective in altering their environment.

But, if we hope for more significant therapeutic change, we must encourage our patients to assume responsibility — that is to apprehend how they themselves contribute to their own distress. A patient may, for example, describe a series of horrendous experiences in the singles world: men mistreat her, friends betray her, employers exploit her, lovers deceive her. Even if the therapist is convinced of the veracity of the events described, there comes a time when attention must be paid to the patient's own role in the sequence of events. The therapist may have to say, in effect, "Even if 99% of the bad things that happen to you is someone else's fault, I want to look at the other 1% — the part that is your responsibility. We have to look at your role, even if it's very limited, because that's where I can be of most help."

Readiness to accept responsibility varies greatly from patient to patient. Some arrive quickly at an understanding of their role in their discomfiture; others find responsibility assumption so difficult that it constitutes the major part of therapy and once that step is taken, therapeutic change may occur almost automatically and effortlessly.

Every therapist develops methods to facilitate responsibility assumption. Sometimes I emphasize to a much-exploited patient that for every exploiter there must be an exploitee; that is, if they find themselves in an exploited role time and time again, then surely the role must contain some lure for them. What might it be? Some therapists make the same point by confronting patients with the question, "What's the payoff for you in this situation?"

The group therapy format offers particularly powerful leverage in helping patients comprehend their personal responsibility. Patients all begin the group together on equal footing and over the first weeks or months each member carves out a particular interpersonal role in the group — a role that is similar to the role each occupies in his/her outside life. Furthermore the group is privy to how each member fashions that interpersonal role. These steps are far more obvious when tracked in the here-and-now than when the therapist tries to reconstruct them from the patient's own unreliable account.

The therapy group's emphasis on feedback initiates a responsibility-assumption sequence:

  1. members learn how their behavior is viewed by others;

  2. then they learn how their behavior makes others feel;

  3. they observe how their behavior shapes other's opinions of them;

  4. finally, they learn that these first three steps shape the way they come to feel about themselves.

Thus the process begins with the patient's behavior and ends with the way each comes to be valued by others and by themselves.

This sequence can form the base of powerful group therapist interventions. Imagine this scene: "Joe, let's take a look at what is happening for you in the group. Here you are, after two months, not feeling good about yourself in this group and with several of the members impatient with you, (or intimidated, or avoidant, or angry, or annoyed, or feeling seduced or betrayed). What's happened? Is this a familiar place for you? Would you be willing to take a look at your role in bringing this to pass?"

Individual therapists also take advantage of here-and-now data as they point out the patient's responsibility in the therapeutic process — for example the patient's lateness, concealing information and feelings, forgetting to record dreams. Responsibility assumption is an essential first step in the therapeutic process. Once individuals recognizes their role in creating their own life predicament they also realize that they, and only they, have the power to change that situation.

To look back over one's life and to accept the responsibility of what one has done to oneself may result in great regret. The therapist must anticipate that regret and attempt to reframe it. I often urge patients to project themselves into the future and to consider how they can live now so that five years hence they will be able to look back upon life without regret sweeping over them anew.