“The patient should give some indication of wanting not only change but 𝘵𝘰 𝘤𝘩𝘢𝘯𝘨𝘦, that is, of dissatisfaction with something that resides in the self” —Otto Kernberg When the patient recognizes that they are contributing to their own difficulties, it’s easy to develop a working alliance and shared treatment purpose The purpose is to understand how the patient is contributing to their difficulties and develop alternatives to that—so they don’t have to spend their lives repeating and reliving the same painful, self-defeating patterns. This becomes the shared work of psychotherapy When patients do not see that they are contributing to their own difficulties, the work of the therapy shifts. The work is now about helping the patient to recognize and understand their own role in their difficulties This is difficult work, requiring genuine therapeutic skill, sensitivity, tact, and compassion. It may take weeks or months to help the patient to truly grasp that changing their unhappy outcomes requires changing something about themselves There’s no foundation for doing any other work in therapy unless and until patient recognizes this and desires to change (Alternatively, if the patient really has no role in their difficulties, then their problems are not problems that psychotherapy can solve, and the patient has come to the wrong place. They may need help, but it’s not help that can be provided via a psychological treatment) If it becomes clear that it is impossible to create this foundation of shared purpose, treatment should not proceed. And the therapist must understand that treatment never really began. There was no working alliance and no foundation to build on