When I ask groups of therapists, patients and students how many of them believe that trust is highly important in psychotherapy, all hands go up. Sprinkled through the psychotherapy literature as it may be, “trust” is almost invariably used only in passing. Moreover, trusting requires trustworthiness, and focusing exclusively on patients’ problems with trust neglects what renders therapists trustworthy. We therapists should not take our understanding of trust or our trustworthiness for granted. I am not questioning psychotherapists’ character but rather the focus of our attention.
Psychotherapists have developed and researched hundreds of therapy modalities; proliferation continues unabated, notwithstanding the overriding contribution of common factors to the effectiveness of the treatments. Bolstering these common factors — empathy, acceptance, authenticity, capacity to create a cooperative alliance — requires developing interpersonal skills. I advocate rebalancing our efforts from developing therapies to fostering the development of psychotherapists.
Treatment outcomes research justifies our confidence in psychotherapy. Yet creating a trusting relationship requires more than scientific knowledge. Psychotherapists grapple with their patients’ problems, relationship conflicts prominent among them. Philosophers have reflected on these problems for millennia, generating a rich literature on ethics that includes a recent interest in trust. Integrating philosophy with research on social-cognitive development, I construe the core of trust as a joint commitment to the cooperative goal of promoting the well-being of the trusting person. Trust encompasses complementary and reciprocal roles: trusting and being trustworthy. Trust comes into play when you depend on another person; that person’s trustworthiness entails responsiveness to your dependence. You can trust your car to get you to work or you could trust a friend to pick you up. Your car might be dependable but doesn’t care if you get to work; your friend will show up because she knows you’re counting on her, and she will count on you to be there waiting for her.
Trusting in psychotherapy can be a high-stakes endeavor. Consider the patient in a dire plight who has a history of trauma in close relationships, having been neglected, betrayed and abused. Highly distrusting, the patient feels extremely vulnerable in reaching out for help. In this context, therapists should not be misled by the common ideal of creating a trusting therapeutic alliance as a precondition for implementing successful treatment methods. Rather, the therapist must become trustworthy to the patient over the course of the relationship, wherein a gradually developing alliance will be punctuated by ruptures and repairs that will render the therapist increasingly trustworthy.
From this perspective, developing trust will comprise much of the work of the therapy and could constitute its most important outcome. In a trauma-education group, I once proposed that psychotherapy should be a bridge to other relationships, and it can be hard to get on the bridge. A patient wisely countered that it can be even harder to get off the bridge. We can promote generalization by bringing others onto the bridge, as in group and family therapy.
I validate traumatized patients’ distrust and their prudence in being vigilant and going slowly. Rather than campaigning for trust, I aim to promote discernment in trusting and distrusting, which requires judging others’ trustworthiness — no easy matter. Self-trust is no less challenging for patients whose judgment has gone awry. I reframe: Distrust is not the problem; rather, missing opportunities to trust trustworthy persons perpetuate vulnerability associated with exclusive self-reliance, which leaves patients feeling alone in pain and suffering. Trusting trustworthy persons renders them less vulnerable. To the extent that it serves as a bridge, therapy can be profoundly helpful in promoting a sense of safety.
I view becoming trustworthy as a developmental process and an aspiration; we become increasingly trustworthy in each relationship and, more generally, over the course of a lifetime. Most broadly, trustworthiness requires caring and competence. We begin developing trustworthiness in childhood, initially in the context of family relationships and then in relating to peers. Throughout adulthood, we augment our trustworthiness with professional knowledge and skill.
Continuing experience will improve our trustworthiness to the extent that we work at learning from it. Given the broad comparability in effectiveness among different approaches to psychotherapy, the profession is in no position to prescribe particular methods; each of us must be guided by personal proclivities and professional opportunities to integrate whatever theories and methods we learn along a lifelong developmental pathway.
Our trustworthiness as therapists will depend on our personal well-being. I have been privileged to treat a number of stressed-out psychologists who sought intensive hospital treatment in the context of a plight — invariably dismayed by their failure to practice what they preached. Along with professional help, these psychologists most needed what we all need: trusting relationships.
Note: This content originally appeared on Mind Matters from Menninger, our blog on PsychologyToday.com. The author, Jon G. Allen, PhD, retired after 40 years of service at The Menninger Clinic. A clinical professor of Psychiatry in Baylor College of Medicine’s voluntary faculty, he remains active in teaching, research and writing. His latest book is Trusting in Psychotherapy.