Front Matter

About the Author

Foreword

Preface

Acknowledgments

Introduction: The Scope of Trust in Psychotherapy

1 From Trusting Therapies to Trusting Therapists

Evidence-Based Practice

Common Factors and the Therapeutic Relationship

Individualizing Psychotherapy

What Happened to the Therapist?

Psychotherapy Integration

Personal Knowledge

Knowledge of Ethics

Mastering the Craft of Psychotherapy

2 Developing Trust and Trustworthiness

The Intentional Stance

From You and I to We

Secure and Insecure Attachment

Mentalizing and Epistemic Trust

Cultural Diversity: How I Mistook Ethics for Science

Basic Trust, Epistemic Trust, and Social Trust

3 Trusting

The Ethical-Moral Basis of Trusting

Trusting in Community

Trusting Beyond Reliance

Degrees of Trust

Trusting in Care and Competence

Distrusting Well

Trust and Distrust in Couples

Trusting and Distrusting Yourself

Hoping in Trust

4 Becoming Trustworthy

The Ethical-Moral Basis of Trustworthiness

Therapeutic Neutrality

Relational Trustworthiness

Writing Personal Formulations

Parting Thoughts

References

Index

Jon G. Allen, Ph.D., holds the position of Clinical Professor as a member of the voluntary faculty in the Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. He is a member of the faculty emeriti at the Center for Psychoanalytic Studies in Houston and an adjunct faculty member of the Institute for Spirituality and Health at the Texas Medical Center. Dr. Allen received his B.A. degree in psychology at the University of Connecticut and his Ph.D. degree in clinical psychology at the University of Rochester. He completed postdoctoral training in clinical psychology at the Menninger Clinic. While remaining engaged in education and research, he retired from clinical practice after 40 years at the Menninger Clinic, where he taught and supervised fellows and residents along with conducting psychotherapy, diagnostic consultations, psychoeducational programs, and research on clinical outcomes. He is past editor of the Bulletin of the Menninger Clinic and a member of the editorial board of Psychiatry: Interpersonal and Biological Processes. His books include Coping With Trauma: From Self-Understanding to Hope; Coping With Depression: From Catch-22 to Hope; Restoring Mentalizing in Attachment Relationships: Treating Trauma With Plain Old Therapy; and, with coauthors Peter Fonagy and Anthony Bateman, Mentalizing in Clinical Practice, all published by American Psychiatric Publishing. He is also author of Traumatic Relationships and Serious Mental Disorders and coeditor, with Peter Fonagy, of Handbook of Mentalization-Based Treatment, both published by John Wiley and Sons, as well as author of Mentalizing in the Development and Treatment of Attachment Trauma, published by Karnac. He has authored and coauthored numerous professional articles and book chapters on trauma-related problems, psychotherapy, the therapeutic alliance, hospital treatment, and psychological assessment. He is also a jazz pianist and composer.

To fall in love with a book is a new experience for me. I have been a deep admirer of Jon Allen for decades and have always appreciated his exceptional scholarship and almost unrivaled capacity to put things simply, no matter how intricate, controversial, complex, or multifaceted they might be. Perhaps it is because I manifestly lack this capacity (and have built my own career on making simple concepts unhelpfully complicated) that I have been in awe of Allen’s ability to tackle such issues as depression (Allen 2006), attachment (Allen 2013a), trauma (Allen 2005), and psychotherapy (Allen 2013b) with a lightness of touch that reminds one of the most skillful of musicians recreating the sounds of the most intricate score with a facility that disguises the hours of painstaking practice behind it. (As an aside, besides being a brilliant scholar, Allen is exactly such a jazz pianist.) Allen advocates deliberate practice in psychotherapy, operationalized as systematic learning from experience, which for him consists of personal, jargon-free case formulations. But somehow I doubt that I will ever reach his virtuosity of scholarship and writing, despite years of practice. It takes something else—something less easily systematized—to write like Allen does. I guess it is called talent. I would never think of describing meta-analyses as “homogenizing fruit salads into smoothies” (p. 41).

I always knew that reading Allen’s manuscript over the Christmas holiday was going to be a treat, which is why I left this seasonal present under the tree to be opened last, after a number of dissertations, papers to review, and commentaries to write. What I was not ready for (at my age) was being swept off my feet, admiration turning into something closer to passion (I stopped short of writing adoration because it seemed unseemly, although it would by no means be totally inaccurate). Scholarly books are not easy to fall in love with, yet, just like with the most intense of relationships I recall, I felt compelled to revisit again and again moments where I experienced an intense sense of identification with Allen’s subtle narrative of a scientifically guided personal journey along the sometimes joyous but also quotidian route that psychological therapists carve through their professional careers. It is a wonderful book because it stands as proof of the case it intends to construct: that trust is the key to the privilege of changing lives, whether the lives of patients or readers of a scholarly volume. To testify in brief, this is the most theoretically clarifying and practically helpful book on psychotherapy I have read in decades, as will be evidenced by the numerous times colleagues and I will be able to refer to it in our writings.

Allen speaks to me—the book continuously addresses the audience—on what feels like first-name terms. Allen adopts a conversational style that disguises the weight of the issues he brings, presents, and solves. He establishes himself as a trustworthy source by this quality of communication, bringing his experience to the task and again and again evidencing that he knows the challenges faced by the practitioner from inside. As a result, we read the recommendations at the end of each chapter with a feeling of “Oh yes, of course, I always thought that. Well put, Dr Allen!” What he has communicated now forms part of my personal knowledge because as a writer, he has established the epistemic trust he describes. Without fanfare, he has opened our minds not just to learning (as the continuing professional development seminars he is skeptical about) but as a new part of our tacit knowledge about the world.

The book starts with a magisterial review of the psychotherapy process within its philosophical context, with Allen pointing to the irony of the theoretical fragmentation of even psychotherapy integration. As he poignantly notes, we should move “from developing therapies to developing therapists” (p. xxvii). He shows how personal experience (tacit or implicit) grounded in relational understanding manifesting in action, not insight, has a moral presence in the life of the therapist. At the heart of the book is a view of psychotherapy as a technique that is intertwined with the person of the therapist and his or her ethics, values, and personal knowledge along with his or her professional knowledge—all these domains are called on in the task of addressing mental distress through psychological means. Although research findings are relevant and helpful, the craft of therapy is essentially an interpersonal endeavor that requires a holistic perspective on human complexity and cannot be limited to understandings arising from quantifying interactions in the therapeutic setting alone. Thus, Allen acquaints the reader with half a century of psychotherapy research only to politely set it aside (as one might a cantankerous relative at a family celebration, settling him or her with a drink, reassurance, and a firm instruction to stop interfering) and proceed to create a novel and exciting dialogue between psychotherapy and more distant relations in philosophy, particularly ethics and epistemology.

Allen presents the complex ideas of others in a way that we can easily learn from and confidently integrate. How does he achieve that? Well, that is what the book is about; by the end you, too, will know. But here is a spoiler: he is able to attune to our reading of his book and captures (implicitly and unconsciously) our struggles and supports our imperfect reading with generous elaboration and well-placed examples, illustrations, and, yes, simplifications of complex philosophical ideas. We join him on a journey, and he guides us and ultimately persuades us that the issue of trust is the key issue of psychological therapy. By ceasing to take this idea for granted unthinkingly, we will be more helpful to our patients.

At the heart of the book is an account of current thinking around the origins of human social cognition, most notably described by Michael Tomasello (2018, 2019). Humans possess an evolutionarily unparalleled capacity to transfer information between agents, which enables remarkable levels of cooperation between partners across infinitely variable environments and knowledge domains (in other words, what we know as our culture). Allen places psychotherapy in line with a conception of the human mind not just as a product of the social, but rather as an intrinsically social formation (Gallotti and Frith 2013), and therefore psychotherapy might be considered a paradigmatic human activity. An adequate psychological treatment of the concept of trust needs to take into account the development of social as well as individual aspects of cultural behavior, considering a range of capacities including, but not limited to, human cooperation (Tomasello et al. 2012), group conformity (Claidière et al. 2014), memory (Causey and Bjorklund 2014), and the social transmission of information (Csibra and Gergely 2011). This is partly informed by evolutionary thinking: in order to protect the survival of our DNA, we are motivated to promote our children’s adaptive fitness by supporting their social learning. Such social teaching and learning are driven by trust, which reflects our capacity for “thinking together”—joint attention, intellectual collaboration, empathic entanglements in relation to understandings and misunderstandings—that involves interpersonal engagement and functioning at quite a sophisticated level (O’Madagain and Tomasello 2019; Tomasello 2020).

Allen points out that these capacities require robust and at times highly reflective mentalizing, which remains for him at the center of the psychotherapeutic effort. Reflecting the assertion from evolutionary sociobiology that working together toward a shared goal is our essential species-specific attribute, Allen puts collaboration at the heart of his account of what psychotherapy is (Tomasello 2018). He shows, following Tomasello, that trust assumes joint attention: the experience when the infant and the infant’s partner understand themselves to be attending to the same thing at the same time but to be doing so from different perspectives (Tomasello 2018). Allen suggests that in psychotherapy, as in any human interchange, this joining of minds is the crucial element of interpersonal trust in humans. Joint attention involves identifying a common object while also recognizing that our collaborators’ view of that object will be different from our own. An awareness of difference in perspective is the essential first stage in reaching an alignment of attention, which in turn makes cooperation possible.

Allen’s study of trust pinpoints the significance of the joining of minds in a particular cognitive mode, designated the “we” mode. Developmentalists (e.g., Tronick 2008), primatologists (Tomasello 2019), philosophers (Tuomela 2005), psychoanalysts (e.g., Winnicott 1956), and, more recently, neuroscientists (e.g., Gallotti and Frith 2013) have identified this mode as irreducibly collective. The we mode may be organized around cognitive and neural structures that are intrinsic to our individual makeup and are the product of a distinct developmental and evolutionary history (Tomasello 2019). When we build on joint intentionality—the shared focus on reaching a particular outcome—a joint, “we” agent appears, in which cognition is aligned for the purpose of reaching that shared objective and within which each individual has an agentive role (Tomasello 2016).

There is an important subtlety to Allen’s conceptualization. The we mode remains individualistic in the sense that separate individuals are the possessors of we mode intentional states. However, these individually held but collectively existent “we” mode mental states are distinct from “I” states. The we mode is manifest only at the level of joint action. The we mode does not obliterate the I mode; rather, it qualifies it to be an I mode engaged in social action—more accurately, it is an “I with you” mode (Higgins 2020). The implication is not that the individual, while operating in the we mode, feels like a different person; it does not even necessarily involve reflective consideration of oneself as somehow socially modified. It simply assumes that one’s epistemic stance (one’s position in terms of communicating with the world) demands alignment with others and therefore implicates an awareness of one’s position as both separate and joined with other minds. Thus, there is no mysterious leap into a mystical interpersonal space of “we-ness” (Di Paolo et al. 2013): the we mode is an individual state characterized by voluntary subsuming of the I mode into one where the dominant goal is joint action and collaboration, and it necessarily implies some level of interpersonal trust. At moments in psychotherapy, the content of individual intention is transformed so that patient and therapist each see themselves and the other as intending to play a mutually collaborative role in working together. Allen proposes that in the case of the formation of trust, we may assume the shared goal to be the well-being of the trusting person, which then requires trustworthiness on the part of the trusted person.

Allen links his ethical perspective of a “good life” with trustworthiness and trust via the shared intentionality described by developmentalists (Tomasello), attachment theory, and the epistemology of culture. In pointing to it he also reframes attachment theory, giving it a goal beyond secure emotional ties: the establishment of a capacity for basic trust and basic trustworthiness. At this point, I should declare that Dr. Allen and I have collaborated over some years around these issues (Allen and Fonagy 2014, 2019). He weaves our joint work into his beautiful conceptual tapestry, and it is as if it was always designed to be there. Mentalizing joins Tomasello; issues around the cultural competence of psychotherapy are woven in with the struggles of attachment theory in relation to its recent anthropological challenge (Keller 2018). The issue in contrasting Western with non-Western societies is not about promoting more or less instruction that is consistent with the Western, Educated, Industrialized, Rich, and Democratic (WEIRD) world. Rather, the questions are as follows: 1) Is it possible to have a model of socialization that is (rightly or wrongly) the dominant mode of cultural transmission globally? and 2) Can study of aspects of non-WEIRD approaches to mentalizing and shared intentionality highlight different expressions of these social-cognitive processes and inform a more sophisticated understanding of these mechanisms? Examples of such different ways of thinking together might involve a greater emphasis on mentalizing the other in more collectivist cultures, as opposed to a focus on the mentalizing the self in more individualistic cultures (Aival-Naveh et al. 2019) or a view of the infant as apprentice rather than master.

What comes across in this book is a curious combination of hyperclarity of thinking alongside a deep humility about the level of understanding and competence Allen experiences himself as having achieved—perhaps not surprising in light of his voracious appetite for enhancing his personal knowledge of current philosophers and researchers. The book opens a new chapter in our understanding of the process of psychological therapies: moving from what we have already accepted from infant research, it takes us to a completely new level of understanding about the nature of the social process of therapy from an evolutionary standpoint. By the final chapter, we see that trust itself is curative in therapy. Aligning the views of therapist and patient in a joint vision of an aspect of reality can restore faith and enhance the capacity to cope, not least by reviving the capacity to collaborate in individuals whose trust has been profoundly undermined by attachment trauma. Achieving a trusting relationship in therapy and generalizing that trust to others is critical if our patient is going to fully join the socially collaborative pursuits of the human race. The technical advice that follows each chapter is written in a style true to the principles of pedagogy Allen espouses—that didactic teaching has impact when directly connected to practice—and he supplies exactly this essential link. For example, Allen describes how writing personal formulations to articulate the therapist’s understanding of the patient and the therapy is a potential means of promoting trust, and this whole book can be understood as a personal formulation and establishes Allen as a trustworthy interpreter of the many domains he covers.

Among the many unique features of this book are the fluidity and fluency with which Allen moves between psychological (psychotherapeutic) and philosophical discourse. In these discourses, Allen is bilingual. He brings depth to his psychological advice by reaching into ethics, moral philosophy, and epistemology. When we read about counseling couples, we are not used to reaching into some of the key philosophic contributions to understanding such concepts as communication (Paul Faulkner), the morality of reliance (Karen Jones), moral integrity (Carolyn McLeod), the decision to trust (Olli Lagerspetz), vigilance (Hugo Mercier), trusting relationships (Annette Baier), and the nature of hope (Adrienne Martin). What is extraordinary and massively enjoyable in reading Allen is that he has preprocessed the work of these thinkers for us and is presenting not a list of alien ideas but a well thought-out elaboration of issues exquisitely selected from the perspective of a practicing psychotherapist and immediately illustrated with an elaboration of an important clinical problem: couples therapy and John Gottman’s extensive contribution. As you read the book, you will find yourself thinking more deeply about issues that you had been aware of (e.g., distrust among married couples) and issues that you may not have considered (e.g., the dichotomy between presumption and despair, which has hope at its point of equilibrium). With this book Allen opens the door to the depth of his own thinking and enables the reader to reap the benefit of a range of great intellects, and in this I include Allen’s own.

In the final chapter, Allen cites the case of a patient unable to trust him until the moment, several sessions in, when she insists on turning the tables on him and interviewing him about his past. Beginning with relatively factual and easy questions, she then asks Allen what he found hardest in graduate school, and he admits finding learning to do psychotherapy difficult because of a lack of structure. She recognizes that his insistence on structure for their therapy may be rooted in this unease. Allen’s patient was astute in her line of questioning. This book is beautifully structured. It grows from a close study of trust in developmental theory to a scrutiny of trust in adult relationships, leading to an examination of its organizing role in psychotherapy. Trust is core to our social nature, and its absence deprives us of our human agency. Trust is key to communication, which is our sole means of preserving accumulated knowledge. Trusting someone does not simply involve relying on that person: it implies that we can anticipate an affective commitment that justifies our dependence. The issue of trust is rarely all or nothing: Allen shows how qualified (three-place) trust restricted to a specific set of conditions can be distinguished from two-place trust, which may describe general relationships without situational qualifications. Therapy may then be thought of as a widening of the contexts or domains in which a person is able to feel trusting in relation to another. Building on the evolutionary social cognitive model he has adopted, Allen advocates that creating and maintaining an experience of “we”—including the capacity to reinstate it when it is lost—paves the road to a trusting relationship. The technical implication is that increasing the amount of time the patient spends in the “we” mode with the therapist in the room and the opportunity the patient has for shared intentionality may provide a basis for an empirically robust and potentially rigorous evaluation of the process (and progress) of a treatment and could be a useful predictor of therapeutic outcome. It is a small matter of being able to work out how we quantify that pesky synchronicity.

On the basis of insights from Kantian philosophy, Allen locates where productive psychotherapeutic exploration is most likely to be fruitful. The guiding lights of love and respect, closeness and distance will, in combination, generate the stance of optimal collaboration, and the clarity of Allen’s advice will empower practitioners, regardless of their level of experience. Allen positions us as therapists with a ready acceptance of our limitations in living up to a therapeutic ideal. Although that is helpful in itself, identifying how to reach the balance between reacting and being distant as we inevitably make judgments, using natural curiosity as the antidote, is the kind of practical technical support this book offers. Taking us beyond the shared vision of the world curiosity can deliver, Allen illustrates the essential role of compassion without which curiosity may be experienced as persecution. Allen is an educator; you will leave this book a better person in terms of your knowledge but also, potentially, ethically and morally. It will set you standards that not only have positive impacts on your well-being but also enable you to assist your patients in a more effective manner.

What can be new in psychotherapy? After all, surely it has all been rehearsed before. The situation is the same: two people talking to each other in comfortable armchairs. What can be said about that room that has not already been said? But taking that attitude ignores one of the great mysteries of modern medicine. The talking cure remains in many instances the strongest intervention we have in the psychiatric armamentarium. Its effectiveness is underpinned by more randomized controlled trials than for any other medical therapy. Why is there a need for so many studies? The answer is that it is not trusted. Why not? Most likely, as Allen outlines in his excellent review, because its processes remain mysterious. For example, sometimes the benefits come faster than the supposedly effective component of the treatment was delivered (e.g., in the first five sessions). We are still uncertain about why and how psychotherapy works. The variability of components claimed to be the effective ingredient is large; the cumulative page numbers devoted to speculations about theories, techniques, and processes are probably comparable to, if they do not already outstrip, the number of patients who have benefited from these treatment methods. New therapies are developed, but the prevalence of mental disorder remains unchanged, regardless of supposed new discoveries. And each effort to produce something new spawns more attempts to reach new conclusions: a sure sign that we have not arrived at definitive answers.

Take my word for it. Without promising definitive answers, Allen offers clear guidance on how to become a (better) trustworthy therapist. However, he has produced something even more valuable: a way of thinking about what happens in psychotherapy that is pragmatically and philosophically robust and inspiring. You are holding in your hand a book that might, just might, focus the thinking of scholars and scientists, clinical researchers, and practicing therapists on a specific mechanism which could generate the next generation of psychotherapy development and training.

Peter Fonagy, OBE, FMedSci, FBA, FAcSS

University College London

I saw my first psychotherapy patient more than 50 years ago, and it took me a decade thereafter to develop a modicum of trust in myself as a therapist. I did not know what I did not know, and I am still learning after having retired from clinical practice. I continue to be engaged in teaching and research as well as educating patients, but—abetted by being sequestered during the novel coronavirus pandemic—retirement has afforded me time to pursue a long-standing interest in integrating science with philosophical work in ethics insofar as both inform the practice of psychotherapy. My appreciation for the cardinal role of trusting in psychotherapy grew out of that interdisciplinary orientation.

Consistent with my training and identification as a psychologist, I have been invested in science and research throughout my career, but I also have become increasingly impressed with how indelibly personal the practice of psychotherapy must be. Accordingly, I have devoted much of this book to the personal as well as professional development of the therapist as it pertains to trusting in psychotherapy and being trustworthy in conducting it. Broadly knowledgeable and open-minded as we might aspire to be, each one of us psychotherapists brings an individual perspective to bear on our practice. Each perspective will have its strengths and limitations. Therefore, readers should be aware of my perspective because it bears on their trust in what I have to say.

I gravitated toward the social sciences quickly in college, homed in on psychology, and thought that clinical psychology would be the most practical specialty. My undergraduate teachers were academically oriented and critical of clinical practice, but by virtue of personal connections I entered a graduate program with a heavy clinical focus. I conducted psychotherapy but never felt a special knack for it and planned on an academic career, which I pursued for 4 years beyond my doctorate degree. Yet I continued to teach and practice psychotherapy as well as seeking ongoing supervision; alas, I discovered I had a limited knack for academia. The challenges of working with a few severely disturbed patients (whose disturbance I understood fully only many years later) led me to pursue postdoctoral training before shifting into a more clinically oriented career. I never gave up my interest in teaching and research.

I developed an interest in psychoanalysis even before I went to college, reading about Freud while sailing aboard an aircraft carrier. I maintained my interest in psychoanalysis despite academic antipathy toward it throughout my early career, such that I applied for a 2-year postdoctoral fellowship at the Menninger Clinic in Topeka, Kansas, which embraced the psychoanalytic orientation of its psychiatrist founders in the 1920s. Given the breadth of my interests, I never undertook psychoanalytic training, but the broad developmental orientation focused on the thorough understanding of individuals shaped my career over the course of the 40 years I practiced there.

I conducted long-term psychotherapy (sometimes lasting several years) throughout the first part of my career and shifted to short-term therapy during the latter years, largely as a result of the social shift to managed care. I gained considerable experience in outpatient therapy, but my practice was predominantly in the context of hospital psychiatry, engaging in long-term and then short-term therapy with inpatients. By contemporary standards, this shorter inpatient treatment (lasting several weeks) was lengthy, allowing for a dozen therapy sessions (and sometimes many more). Working in the Menninger hospital throughout the bulk of my career was both broadening and narrowing. I worked intensively with patients struggling with the full range of severe psychiatric disorders, acute and chronic. In collaboration with a group of colleagues, I developed an interest in trauma in attachment relationships that can begin in early life and persist into adulthood. As a group, we came to appreciate the profound role of attachment trauma in a wide spectrum of severe psychiatric disorders. Pervasive distrust and social alienation were common concomitants of this form of trauma and posed great challenges to developing therapeutic relationships.

Although long-term hospital treatment was narrow in its specialized role in the mental health landscape, it provided a rare opportunity to come to know patients thoroughly, consistent with its psychoanalytic orientation. In addition, hospital treatment provided a unique opportunity to work closely with the full range of mental health professionals, including nurses, psychiatrists, social workers, activities therapists, chaplains, and other psychologists. I did not fully understand my professional identity as a psychologist until I worked in an interprofessional setting. I found it especially valuable to my role as a psychotherapist to collaborate with social workers who were working intensively with the patient’s family. For many of the patients I saw, the success of the treatment hinged on the family work, without which the psychotherapy would have been of limited benefit. Furthermore, in the context of both long-term and shorter-term inpatient treatment, I came to appreciate the immense value of a therapeutic community, which exemplified the ethos of the Menninger hospital from its inception.

Although I had shifted from an academic to a clinical setting early in my career, education and research were fundamental to the mission of the institution, such that I could pursue my enduring academic interests. I continued to do some university teaching and ultimately came to develop and conduct a wide range of educational groups for patients in the hospital. I began by educating patients about trauma (eventually coming to appreciate that they were educating me) and then developed other groups on depression, relationships, attachment, and mentalizing that spread throughout the hospital.

In other respects, working at Menninger for the bulk of my career narrowed my perspective. I never developed expertise in the multiplicity of short-term, symptom-focused treatments, which continue to play a major role in the practice of psychotherapy. I came to appreciate the value of contemporary versions of cognitive-behavioral therapy—the predominant form of psychosocial treatment—only later in my career as the practice of the hospital became more eclectic and I had the opportunity to work more closely with some of my cognitive-behavioral psychologist colleagues. Perhaps most significantly, consistent with the social context in which I grew up, the patients I worked with were predominantly white and from the middle and upper socioeconomic classes, owing largely to the costs of long-term intensive treatment (including the insurance that covered some of it). To put it plainly, with all the professional resources at Menninger—clinical, academic, and medical resources as well as extended time to work with hospitalized patients—working there was a luxury, as was obtaining treatment there. Only belatedly in the course of writing this book did I fully appreciate the influence of my narrow cultural perspective on my way of thinking about psychosocial development, including trust. I address the import of limited cultural diversity in this book.

To reiterate, I am interested in the personal aspects of psychotherapy, which I am addressing in this preface. I have begun with a conversational style that continues throughout this book, as I do when speaking with a group of therapists or patients. But the conversational style does not obscure the demanding nature of the substance, which includes reviews of research on psychotherapy as well as challenging conceptual material. I am fond of saying that I like simple ideas, but I like a lot of them. In my aim to give trust the full consideration it merits, I have packed this book tight, and parts of it will be slow going. With less than complete success, I have aspired to minimize technical language, and I have confined acronyms to one paragraph. Apart from the short introduction, the chapters are long. When I read a challenging book, I dislike having to wait a long time for a place to put my bookmark. Therefore, I’ve included numerous headings and subheadings not only to provide conceptual signposts but also to give you abundant places to rest. To help pull the material together as we go, I have included summaries of key points followed by recommendations for clinical practice at the end of each chapter.

Although psychotherapists are my primary audience, the book is intended to be accessible to those who are not mental health professionals, including patients who might wish to listen in on the conversation and who are the primary subject of it. More broadly, the book is about trusting relationships; psychotherapy is an exemplar, and anyone with a serious interest in trust will have much to learn.

A long professional developmental history will include a large cadre of mentors too numerous to mention, and mine is no exception. Amerigo Farina launched my research career when I was an undergraduate. Len Horwitz, who supervised and then hired me at Menninger, nurtured my continuing interest in research in the context of clinical work and continued his mentorship as I wrote this book. A great boon to my writing was Paul Pruyser’s invitation to join the editorial board of the Bulletin of the Menninger Clinic, where I ultimately came to succeed him as editor. Along with Paul, the staff, including Mary Ann Clifft and Phil Beard, cultivated my skill in writing. As illustrated in this book, Paul’s thinking also has played a large role in my appreciation for the role of hope in treatment. I also was fortunate as editor to have Karl Menninger’s mentorship in turning cumbersome manuscript titles for articles awaiting publication into crisply worded headlines; no author ever objected to our intrusion.

In the late 1980s, when the psychiatric impact of trauma was becoming more widely apparent, Alice Brand Bartlett and Bonnie Buchele formed a study group with a focus on sexual abuse that captured and informed the interest of a group of us clinicians who had worked together in the hospital, including David Console (psychiatrist), Mike Keller (social worker), and Sondra Murray (nurse). We all found dissociative disturbance (including what was then called multiple personality disorder) to be most bewildering, and I relied heavily on Bill Smith (director of psychology) for his long-standing expertise in dissociation and hypnosis. As I was developing an interest in attachment theory and research, I was extremely fortunate that Peter Fonagy started to commute regularly to Topeka from London to direct research and shape clinical practice. Fortuitously, he arrived in 1995, coincident with the publication of my first book, Coping With Trauma. My 25-year friendship and collaboration with Peter in research and writing has played a formative role in my thinking about trauma and psychotherapy as well as psychological and social development more generally. His thinking has infused all the books I have written since 1995, including this one. I am also indebted to two successive chiefs of staff at Menninger, Richard Munich and John Oldham, for providing steadfast administrative support for my writing after the clinic’s transition from Topeka to Houston, where the partnership with the Baylor College of Medicine was formed.

I am grateful to many colleagues who have read various parts of this manuscript in sundry drafts and provided helpful commentary and suggestions, including Estella Beale, Mel Berg, Tom Ellis, Chris Grimes, Michael Groat, Len Horwitz, Barton Jones, Jim Lomax, Susana McCollom, Cynthia Mulder, Shweta Sharma, Helen Stein, and Amanda Yoder. Numerous discussions with Michelle Patriquin informed my writing about treatment outcomes. I am also grateful to philosopher Adrienne Martin for exchanging ideas about hope and expanding my understanding of it. I thank Michael Tomasello and Jessica Benjamin for their careful reading of my account of their writing and their helpful comments. I am particularly grateful to two colleagues outside the mental health professions for reading the entire manuscript carefully and providing extensive feedback: Andy Achenbaum and Roger Verdon. They have bolstered my confidence that the book is understandable to a wider audience and has personal relevance; it hits home, as writing about trust should do. In addition, I am indebted to Carrie Farnham, Senior Editor at American Psychiatric Association Publishing, for her masterful and meticulous editing of the manuscript.

Finally, in the company of legions of authors, I am most grateful to my wife, Susan, for her careful reading of multiple drafts and for her intermingling of discerning criticism with unalloyed enthusiasm. Helpfully, she is not a mental health professional, although she has decades of relevant experience as a school counselor. Over the course of writing several books, I have come to trust her judgment to the point of giving her veto power: if she cannot understand something, does not see its relevance, thinks it is unduly technical, or finds it uninteresting, it goes into cyberspace and I rewrite it—sometimes more than once. Innumerable conversations with Susan about topics in this book have enabled me to articulate my thinking, consistent with one of the main themes of the book: minds need other minds. After extensive exploration, Susan also discovered the perfect evocative image for the cover. Most important, over the course of more than five decades of life, I have learned more from Susan about relationships, attachment, and trust than from any other source.

In the course of writing this book, I spoke with diverse groups—therapists, students, and patients—about trust. In each group, I started by asking, “How many of you think trust is crucial or highly important in psychotherapy?” All hands went up. You will find the word trust sprinkled throughout the psychotherapy literature. Yet, to my knowledge, only two prominent leaders in the field of psychotherapy have homed in on trust, making it a primary concern in their treatment approach: Peter Fonagy (Fonagy et al. 2017) and John Gottman (2011). Bruce Wampold (Wampold and Imel 2015) placed trust at the starting point of his comprehensive contextual model of psychotherapy, but he did not elaborate on trust per se.

For the latter part of my career, I have taken a major interest in attachment theory, wherein secure attachment takes pride of place. If we were to locate the heart of trust anywhere, it would be in secure attachment relationships. Yet “trust” appears in the index of only one volume of John Bowlby’s (1982) classic trilogy, in a reference to Erik Erikson’s concept of basic trust. “Trust” is indexed only nine times in Jude Cassidy and Philip Shaver’s most recent edition of the thousand-page Handbook of Attachment (Cassidy and Shaver 2016) and invariably is employed in passing, without elaboration. Do we therapists understand trust so well that we need not think about it in any depth?

When trust comes transiently into our therapeutic purview, we focus on the patient’s problems with it. But trusting makes no sense unless the trusted person is trustworthy, and trustworthiness is almost entirely neglected in the psychotherapy literature. Perhaps our starting point should be: What makes a therapist trustworthy? Moreover, I think psychotherapy goes best when trust is reciprocal, that is, when the patient and therapist are trusting of each other and trustworthy to each other—as it should be in any close relationship.

I chose a deliberately ambiguous title for this book, Trusting in Psychotherapy, with two senses in mind. We can trust in psychotherapy as a professional practice, as we might trust in medication, surgery, or acupuncture. Of course, we would be more discriminating than that, trusting (or not) in some types of therapy, medication, surgery, or acupuncture. We are trusting in methods or procedures, often on the basis of their reputation and research support. Alternatively, we can trust in the person providing the treatment: the person conducting the therapy, prescribing the medication, performing the surgery, or inserting the needles. Ideally, we trust in both the practice and the practitioner, often trusting the practice on the basis of trusting the practitioner. Moreover, a trustworthy practitioner must trust in the practice, in effect, regarding the method as trustworthy. We might say that the patient borrows trust in the practice from the practitioner’s trust in it—if the patient trusts the practitioner.

Trust and trustworthiness are prototypical examples of what philosopher Bernard Williams (1985) called thick concepts, comprising fact and value, objective description and ethical-moral judgment. We can describe someone informatively as untrustworthy, but this description carries heavy moral freight. We generally approve of trusting, aspiring to promote it in therapy. My commitment to understanding trust in depth stemmed substantially from my broader conviction that the practice of psychotherapy has been unduly dominated by science to the neglect of scholarly ethical thought; trust takes us straight into interdisciplinary territory with philosophy that psychotherapists explore too infrequently (Burston and Frie 2006). In the past three decades, philosophers—many of them women and brilliant writers—have generated a rich literature on trust and trustworthiness that is highly pertinent to our thinking about psychotherapy.

Once we dig into it, we discover many senses of the word trust: you can trust your car, your dog, your best friend, or your doctor. You can trust what someone says or what he or she will do—or you can trust the person. Trust has degrees and limits. Then we have distrust in various forms and levels. Just as we must learn to trust well (in proper relation to trustworthiness), we also must learn to distrust well (in proportion to untrustworthiness). To make a broad point, many of our patients have learned from past relationships to distrust well, but they overgeneralize from the past to the present, failing to trust others who are trustworthy. Trustworthy therapists can provide significant help with this pernicious problem. Philosophers think carefully about such distinctions, and we therapists might do well to consider them. I blend science and philosophy throughout this book.

This book’s title, Trusting in Psychotherapy, might be misleading in implying that I am concentrating exclusively on psychotherapy relationships. On the contrary, this book is about trusting and trustworthiness as they pertain to our entire range of relationships. Certainly, we therapists aspire to create trust in psychotherapy, but the major value of doing so is fostering discerning trust as well as trustworthiness in relationships beyond psychotherapy. This book is about trust, full stop. But I wrote it with psychotherapy and psychotherapists in mind as the primary audience I am addressing directly (i.e., as “you”).

We have already gone a considerable way from using the word trust merely in passing. Yet we have a long way to go, starting with Chapter 1, “From Trusting Therapies to Trusting Therapists.” In this chapter, we take up the problem of trusting in the practice of psychotherapy and its primary source: Hundreds of brands of therapy have been developed in the context of competing schools of thought. The broader culture clash between academics and clinicians compounds the problem of knowing where to place our trust—a problem for patients as well as therapists. As a clinical psychologist, caught between science and practice, I have been in the middle of this conflict for several decades. I think trust in the practice of psychotherapy should be based in part on a broad knowledge of the field, the acquisition of which is no small feat. I provide an overview here with the invaluable help of several recent compendia synthesizing decades of research.

The broad exploration of the psychotherapy research literature in the first part of Chapter 1, necessarily guided by my personal predilections, led me to a simple conclusion: we should shift the balance of our efforts from developing therapies to developing therapists. This conclusion derives from research indicating that individual differences among therapists influence the outcome of the therapy more than the therapists’ particular methods do. With both science and ethics in mind, I advocate thinking not only about professional development but also about personal development, proposing that a broad base of personal knowledge informs the practice of psychotherapy—more or less consciously. Accordingly, in Chapter 1 I include an account of the relevance of ethical thought to psychotherapy along with an overview of professional literature on the development of expertise in conducting psychotherapy. In subsequent chapters, I apply the ethical thought to various aspects of trusting and trustworthiness.

Throughout most of my career, I have employed a developmental approach in psychotherapy, and Chapter 2, “Developing Trust and Trustworthiness,” reflects this mindset. A number of philosophers are mindful about the developmental origins of trust, but science rules here. Developmental psychologist Michael Tomasello’s (2019) work anchors my thinking; although he does not focus on trust, he provides a detailed analysis of social-cognitive and moral development over the first 6 years of life that I use to articulate the basic capacities for trusting and trustworthiness. My interest in Tomasello’s contributions stemmed from the influence of my long-standing collaboration with Peter Fonagy, with whom I became fully immersed in the literature and research on attachment theory; concomitantly, I came to appreciate the central role of mentalizing (i.e., understanding behavior in relation to mental states) in secure attachment. In the context of secure attachment and mentalizing, in Chapter 2 I highlight Fonagy’s emphasis on the centrality of trust in psychotherapy and the significance he accords to epistemic trust in particular. Here we consider the role of attachment trauma in the development of distrust; my long-standing professional interest in attachment trauma has motivated and informed my thinking about trusting in psychotherapy when it is hardest to achieve. The chapter concludes on a disconcerting note: the cultural specificity of the work on attachment and mentalizing that I have enthusiastically embraced. Trenchant critiques of the ostensible universality of attachment theory have pointed to its disproportionate reliance on populations that are—by global standards—WEIRD (Western, Educated, Industrialized, Rich, and Democratic). Disconcerting as it may be, this cultural critique is consistent with the pressing need for psychotherapists to respect cultural diversity, and it also points our attention to trust beyond dyadic relationships.

Having established the developmental foundations, in Chapter 3, “Trusting,” I focus on adulthood. Early in life, we develop the capacities to trust, but we do not employ them consistently or optimally, especially when there is a history of adverse experience in relationships. Although my main concerns are clinical, I make ample use of philosophers’ thinking in elucidating the various forms of trust to which I have alluded thus far. Accordingly, the chapter has a broad scope, with topics including the ethical-moral basis of trust, trusting in the community, the distinction between trust and reliance, and varying degrees of trust. With psychotherapy in mind, I also make a broad distinction between trusting in care and trusting in competence. Here I review John Gottman’s (2011) clinical and research contributions to promoting trust in couples therapy. I also address the challenges in trusting oneself. The chapter concludes with a way of thinking about hope that I find essential to understanding trust.

These first three chapters establish a framework for broaching my main point: We psychotherapists should move beyond concern with our patients’ problems with trust to considering our own trustworthiness in the psychotherapy relationship. I am not questioning psychotherapists’ character but rather advocating a different way of thinking about trust. Chapter 4 is titled “Becoming Trustworthy” to counter a natural tendency to take our trustworthiness for granted and to put the onus for trust on our patients. To a great extent, trusting and trustworthiness are relationship-specific, and they must be created anew in each relationship: developed, maintained, and repaired when disrupted. The creation is interpersonal. Again, I begin the chapter with the ethical-moral basis of trustworthiness, with a focus on the complex balance of closeness and distance in the psychotherapy relationship. This balance has been a highly controversial matter under the rubric of therapeutic neutrality. With this backdrop, I make extensive use of psychoanalyst Jessica Benjamin’s theoretical and clinical work, which exemplifies the enormous challenges of becoming trustworthy in the treatment of patients with a history of attachment trauma. From the vantage point of my long-standing interest in attachment and mentalizing, I find remarkable consilience in Benjamin’s and Tomasello’s thinking inasmuch as both writers—coming from highly divergent backgrounds—explicitly incorporate a moral context into their understanding of development. I also include my experience in writing personal formulations for patients as a way of promoting trust in psychotherapy by means of making my understanding fully known to them.

With a cue from psychoanalyst Jeremy Holmes (2010), I was converted from thinking of psychotherapy as an art to considering it a craft. There is ample room for art as well as science in craft. In my view, coming from a developmental perspective, mastery of a craft is the work of a lifetime. This book reflects my current understanding of the craft of psychotherapy as viewed from the perspective of trusting and becoming trustworthy.