A Collective NYC Therapist Conversation On Building Trust In Therapy

Matt: I’ve been thinking a lot about trust and the ways that we understand it to be the opposite of distrust (The prefix “dis” makes this pretty clear). That understanding is so very wrong, and supports some pretty unself-protective ways of operating. In this construction, trust is a thing, for one who struggles with it, to be nudged forward incrementally.

I’ve come to appreciate trust and distrust as mutually dependent on one another–a dialectic that can only develop in tandem. Folks, who struggle with a hesitancy to trust, need to also learn and embrace not trusting. Folks, who trust too easily and who don’t fully protect themselves, need to learn how to embrace healthy trusting. In practice, these folks are nearly always the same.

In therapy, the idea that someone should trust a therapist, particularly when they have been harmed by people they should trust, which is a common feature among those who seek therapy, seems to be, on the surface, both absurd and dangerous. And so, in a particularly provocative move, when a patient expresses hesitancy to open up to me, I have been inclined to say once or twice: “Don’t trust me. You have no reason to trust me. I know myself to be trustworthy, and am confident that, if we do this right, you will come to trust me over time. But we need to build that.”

This brings me to my questions: What do you think about trust and distrust? How do you build trust? How do you teach patients self-protection?

Nora: I think it can be an amateur’s trap to think, as a therapist, that disclosure from patients means intimacy. To let a patient tell you too much before the relationship has enough trust and strength can leave someone feeling unsafe and overexposed. In some cases, a patient telling a therapist too much information too soon can also be a way to keep the therapist from actually getting close.

A huge part of the work for me with patients is to teach them that our relationship is real, and not something that happens in a laboratory or “doesn’t count.” I think the therapeutic relationship, when done well, provides a safe environment to practice connecting and attaching to others in a healthy way. Working from this idea, I try hard to make sure that disclosure happens when it is safe, and that I reflect the progress of our relationship to the patient so they can understand more fully what we’ve built, how we’ve built it, and how to bring that knowledge to other relationships in their lives.

Kelly: I fully co-sign everything Nora said. I love this topic so much because it’s so rare to be able to have a trust conversation like this outside of therapy. Society promotes this notion of trust as binary: either you have it completely or you have none of it. In actuality, building and extending trust is a skill that exists in increments. The value comes in the process of building and earning, not in achieving.

As therapists, we have to be able to hang with patients who haven’t extended trust to us, and do so without being impatient or hungry for it. When a patient says, “I’m not ready to talk about that,” my response is almost always to believe them. To echo Nora, disclosure isn’t intimacy, and getting someone to talk about something they’re not ready for isn’t a win. In fact, I see it as an expression of the therapist’s narcissism, and need to feel important and special.

Rachael: You’re right, Kelly, the word trust has been so colored in binary terms. I think a key thing for a therapist and patient to figure out in regards to building trust in therapy is: can we connect in conversation in this space? Can we handle this messiness together or tolerate the closeness? Early in my work, especially with parents and kids, I played, sat and read books, or drew before we talked about why they came into therapy. Sometimes with patients, as Nora and Kelly said, I talk about topics that we would consider “surface,” but they are therapeutically important to building trust in the relationship. I also question if we’ve built enough trust for me to say some hard things. It’s not safe to say too much too soon for lots of reasons between the therapist and the patient.

I also trust when someone says they do not trust me and need to not trust me yet. It’s important as therapists to let go of our ego and hang in with this. We need to give deference to the building, not to the fact that we have the title. In fact, if there’s not trust, I haven’t yet earned that title. While, yes, I am a therapist and they are my patient, we essentially haven’t built what that means. When we let the building lead, then trust usually follows. It grows, changes and moves as the relationship is established and continues.

Kelly: Yes. We haven’t earned our title yet. I love that framework.

Liz: I love the frame of trust as incrementally developing and being earned rather than a binary, static entity. My question is: how do we work when a patient discloses something, perhaps when they aren’t ready, in an effort to be a “good patient,” to relieve themselves of immediate discomfort, or because that’s what they think therapy should look like? Yes, we can process the experience after the fact, and look for expressions of retreating or regret in the following sessions, but is there something more?

I definitely get nervous in the days following a session if a patient discloses something significant, especially if it’s shame-heavy in the beginning of treatment, when trust hasn’t been built or, like Rachael said, I haven’t earned what therapist means. I worry that it was unsafe for them, and think a lot about the potential ramifications. Do we proactively make the statements Matt suggested in the intake, even if they don’t bring up hesitancies, to prevent unsafe disclosures? Is it our job to prevent or facilitate disclosures because we have the experience and knowledge about what the course of treatment looks like? On one hand, no, because we recognize our patients co-create treatment with us, but on the other hand, it is our responsibility to create a safe environment.

Matt: This is an area where a therapist’s role and a healthy parent’s are quite different. It’s not like how a child trusts blindly, and a parent merely needs to receive that trust (to be trustworthy). A therapist’s job is two-fold: to be trustworthy, but also to mediate that trust, to attend to the process as it’s built. It’s a funny sort of dual role: to be both the object of trust and the trust coach.

Heather: I’m still sitting with Matt’s initial comment about the absurdity of how we understand trust and distrust. By building trusts with patients, we are essentially doing exposure therapy. The only way to cure relational trauma is through relationships. It’s almost like a séance, with the ghouls and ghosts of relationships past, joining us in the room. This is such a precious and important job we do.

Karen: Heather, I just love how you use the language of a séance. The people from the past are always so in the therapy room with us. This is what I would call family therapy with one person. I also like the language that Matt uses of building trust. This can look so many different ways with our patients, and continuing to learn how to do this with patients is incredibly important and absolutely where I love to grow myself as a therapist.

Recently, I have been so inspired by how both Heather and Rachael use play in their work. There is a deep, deep level of respect for where the folks they work with are at, which is incredibly powerful. I see how they build trust by being with folks in a very attentive, creative and full-of-play way.