In the realm of therapy, there exists a dance, a rhythmic ebb and flow, where connection is fostered through attunement. This dance is a crucial part of the the therapuetic process. But how does attunement occur when we introduce the concept of accountability and treatment interfering behaviors? Can these seemingly contradictory elements coexist and guide our roles as therapists?


Attunement is the process of building a therapuetic relationship.  Carl Rogers, a prominent figure in the field of therapy, emphasized the significance of the therapeutic relationship in the healing process. These principles of unconditional positive regard, empathy, and warmth are foundations for building relationships and for attunement, but there comes a point where a client's own barriers (treatment interfering behaviors) hinder progress.  

I recall feeling a sense of shame early on for being assertive and direct, these did not seem like Rogerian qualities.  I wondered how to integrate these aspects of myself into my work. I recognized that my approach differed from other therapists due to my urge to dive into the uncomfortable moments directly. These qualities guided me in holding clients accountable and helping me establish necessary boundaries. Yet, I questioned whether setting boundaries within the therapeutic relationship would be detrimental to my clients. Was I causing harm by imposing limits? Or was I causing harm by not doing so?

In the intricate dance of therapy, the therapeutic relationship serves as a microcosm of the client's experiences in the outside world. It encapsulates the very factors that contribute to their presenting problem. By failing to promptly and compassionately address these issues, I would essentially be neglecting my client's needs and perpetuating harm. It is crucial to explore these areas, considering that I bring warmth and understanding to the table. It is an opportune space to delve into these challenging aspects of their lives.


Undertreating, a common pitfall in therapy, occurs when well-intentioned therapists fail to adequately address and treat mental health issues. This can lead to a worsening of symptoms. Research on major depressive disorder (MDD) highlights the global issue of undertreatment, with only a small percentage of individuals receiving appropriate care. Therapists contribute to this problem by not reinforcing change and by not addressing treatment interfering behaviors promptly. Our empathy and understanding can sometimes hinder the necessary confrontation of problematic patterns like Treatment Interfering Behaviors.

What are Treatment Interfering Behaviors (TIBs)?

Comming to therapy late

Missing appointments

Not doing assignments/Therapuetic approaches between sessions

Private practice therapy presupposes a baseline level of functionality. However, if certain challenges arise from the severity of your clients' mental health issues, it may indicate a need for a higher level of care, so that we are not undertreating. We are always accessing for choice vs mental health severity. Its a dance that is we must assess in every client.

But is it possible to treat adequately without causing harm? The answer is yes. Dialectical Behavior Therapy (DBT) offers valuable skills for therapists and clients to address behavioral patterns that impact mental health. Holding clients accountable for the change they desire is essential in the therapeutic dance. We can embody Carl Rogers' empathy and unconditional positive regard while remaining attuned to the need for accountability. It's not a choice between the two, but rather a harmonious integration of both. This holds true regardless of the population we work with, whether it be individuals with Autism, Social Phobia, or addressing differences. The fact that DBT has been effective in treating Borderline Personality Disorder is a testament to the power of this dance.

We must answer the call within ourselves and face our discomfort with therapeutic confrontation.

Confrontation often carries negative connotations due to its portrayal in intervention movies. However, a well-executed confrontation can be a powerful tool when infused with compassion, and honesty. It allows us to address our observations and our clients' behaviors, ultimately fostering growth.  

If you find yourself experiencing discomfort while reading this blog, it's worth exploring your personal relationship with confrontation. What are your own biases, history, and baggage that may hinder your ability to practice immediacy in therapy? In my early days as a therapist, I interpreted Carl Rogers' approach as one-sided, and I realized that my own codependency and avoidance patterns were reinforced in the therapy room. It's important to acknowledge that we cannot separate ourselves from the therapeutic process, but we can do our own work when triggered.

Take a moment to reflect on how you address Undertreating, Treatment Interfering Behaviors, or your own feelings of annoyance during therapy session.  Instead of letting our feelings of annoyance drive our actions, we can use them as a guiding tool, asking ourselves whether our annoyance stems from our clients' Treatment Interfering Behaviors or is our clients doing something that might cause their loved ones to feel annoyance.  Regardless of the situation, it's griss the mill, as one of my former professors used to say.

Here are a few valuable strategies that I employ to address undertreating in therapy:

1. Seek consultation from therapists who are more experienced and knowledgeable in the specific issue that your client is struggling with.

Remember, consulting with experts in the field can provide valuable insights and guidance.

2. Consider paid consultation, as it can be extremely helpful in gaining a fresh perspective and accessing specialized advice.
3. If necessary, refer your client to a higher level of care. 

This may involve recommending more intensive treatment or connecting them with a therapist who specializes in their specific challenges.

It's important to keep in mind that referrals for undertreating may not always align with what our clients want or expect, but we make these decisions with their best interests at heart. As therapists, our responsibility is to prioritize their well-being, regardless of their initial feelings.

Being a good therapist means continuously reflecting on your practice, which allows for personal growth and change. This process transforms the tool into the object and the object into the tool. Engaging consciously in parallel processes can be a beautiful and transformative experience.

Expand your perspective by seeking guidance from a trusted therapist during consultation. Engaging in thoughtful discussions about your self-awareness will provide further insights and add another dimension to your understanding.

And always remember that prioritizing the best interests of our clients sometimes requires making difficult choices. Just like making an omelette requires breaking eggs and stirring them rapidly, the therapeutic process may involve challenging moments. Ultimately, our clients' best interests should always take precedence, even if it means navigating uncomfortable situations like addressing treatment interfering behavoirs or referring on.  


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