Trustworthiness: A Cornerstone of Effective Psychotherapy

Therapists, patients, and students view trust as fundamental to psychotherapy. Sprinkled throughout the psychotherapy literature, “trust” almost invariably is used merely in passing, as if we all understand it adequately. Moreover, trusting is reasonable only to the extent that the trusted person is trustworthy.

We therapists take our understanding of trust and our trustworthiness for granted when we focus our attention exclusively on our patients’ distrust. Without questioning therapists’ character, I advocate that we think about trust in more depth and take the challenges in becoming trustworthy to our patients more seriously.

We psychotherapists have no grounds for complacency; our field is in disarray and rife with conflict. We have hundreds of brands of psychotherapy tailored to myriad psychiatric symptoms and disorders. Scientists and clinicians wrangle. Researchers struggle to demonstrate consistent differences in effectiveness among methods of therapy while the overriding contribution of the quality of the patient-therapist relationship has been affirmed for decades. Correspondingly, individual differences among therapists contribute as much or more to treatment outcomes as do differences in their methods, and these individual differences are especially significant in the treatment of patients with severe disturbance, wherein therapists’ trustworthiness looms large.

I advocate shifting our attention from developing therapies to the personal and professional development of therapists. Trusting relationships exemplify a joint commitment to the shared goal of promoting the well-being of the trusting person and entail complementary roles of trusting and being trustworthy. Unreflectively, we develop the capacity to form trusting relationships by age 3. Yet this early and ongoing personal development hinges on the quality of our close relationships, as documented by decades of research on the value of secure attachments and the pernicious impact of traumatic relationships.

By the time we start conducting psychotherapy, the ground floor of trustworthiness—our skill at relating with patients—will be firmly established, although not immutable. Then our professional development will require navigating competing attitudes, theories, and methods. Brand loyalty is tantamount to developmental arrest; we must start with a particular method and theoretical orientation, but we should not stop there. Ideally, we will continually expand our knowledge and experience in an integrative fashion while inevitably being influenced by specific institutions, patient populations, and clinical challenges.

Five decades have elapsed since I saw my first psychotherapy patient, and I continue to learn. Writing about trusting in psychotherapy in my latest book demanded integrative thinking. On top of the personal knowledge acquired in childhood, I learned about the practice of psychotherapy from treasured mentors and colleagues throughout my career. My love of philosophy complemented my affinity for science. Becoming a jazz pianist helped: I learned how to improvise.

But we need anchors to orient our clinical practice, and trust is a weighty one. The effectiveness of our methods hinges on creating a personal relationship in which both members are trusting and trustworthy. Patients with a history of relational trauma enter psychotherapy with reasonable distrust, which we should validate. But they are missing opportunities to trust those who are trustworthy. For such patients, trusting will not be the precondition for therapy; it will be the work of therapy and a primary benefit—to the extent that trust generalizes to other relationships. Our trustworthiness will depend on interpersonal skill along with professional knowledge. Our personal influence will be enhanced by transparency in the form of natural emotional responsiveness and our ability to explain what we are thinking. Along with a conversational style, I jot down notes, draw diagrams, and write extensive personal formulations akin to letters.

Jeremy Holmes wisely construed the practice of psychotherapy as a craft. Mastery of a craft is a developmental process and the work of a lifetime—never completed. From this developmental perspective, I see becoming trustworthy in relationships as composed of two broad dimensions: caring and competence. Philosopher Ludwig Wittgenstein neatly epitomized their amalgamation in a letter to his memoirist, Norman Malcom: “I have an immensely kind doctor who isn’t a fool either.” ■