dual roles in therapy

April 19, 2015

How Would a Friendship with Your Therapist Work?

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The fantasy of having a closer relationship with one’s therapist occupies the mental space devoted to imaginary things. It must, because few counselors permit such a connection. Professional ethics generally prohibit the dual role of therapist/friend and therapist/lover. Yet, there is value in fleshing-out what this double-bond would look like in practice.

Responses to my recent post, Being Excluded From Your Therapist’s Life, suggest the fantasy dies hard. What follows is an effort to describe how the relationship would function if brought to life — the day-to-day lives of a shrink and his patient. I invite you, dear reader, to think along with me. Let me know if my concerns are off-base. Even more, once you finish reviewing my ideas, I’d love to read your own notion of how to create the connection some of you want with your therapist: an outline better than the current prohibitive model you say is frustrating.

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I will use myself as an example. First, were I to lower therapeutic barriers, I’d accept only unsolicited volunteers for friendship. No direct invitation would be addressed to patients. I’d then need to consider who I’d enjoy having as a friend from among those who expressed an interest. Let’s assume three people both want this and seem a good fit for me. Any number I might choose would be arbitrary. Pick a different one if you like. Remember, however, the bigger the numeral, the harder it will be for this system to work.

FIRST PROBLEM: Even without an announcement, I assume some folks would become aware of my possible willingness to pass time with them informally. This might happen by word of mouth, within a written statement of clinic policies given to patients beginning treatment, or due to a general change in the ethical guidelines applying to all clinical psychologists.

A therapist is human. He finds some people more compatible than others. This doesn’t mean the potential chums are better than anyone else, only that they possess the kind of personal qualities the doctor enjoys socially. Unfortunately, “no” would be the message delivered to some people. Imagine how those “blackballed” might be affected, including the negative impact on the therapeutic alliance. In effect, my partial openness to friendship necessarily establishes a three-tiered clientele:

a. Those clients who do not request friendship.
b. Patients who become friends.
c. The unfortunates who get rejected.

Might some occupants of the lowest tier infer I offer them professional services only to make a buck, since I don’t want to socialize? While not true, any alternative explanation sounds hollow, at least to me.

SECOND PROBLEM: How might I differentiate between time spent as a therapist and hours passed as a pal? That is, what if a client with me at Starbucks begins to talk about personal problems? How should I respond? I’d need to choose among three roles:

a. A sympathetic friend.
b. A therapist doing an unscheduled session out of the office.
c. A doctor who thought he was off-duty.

If I react as the doctor I must then remind my coffee-partner I am not at work. Indeed, I might emphasize that we are having a non-therapeutic relationship at his request. What do I do, however, if my friend ignores the boundary or gets emotionally overwhelmed in the restaurant? In addition, how do I deal with the question of a fee for my service if I find myself doing lots of therapy outside the office?

THIRD PROBLEM: I am the proud owner of a good social life, as complete as I’d like it to be. In our example, it has suddenly been enlarged by three people. My downtime instantly becomes “jammed-up.” My freedom to enjoy family and personal connections already present, many of long-standing, is now reduced. Disappointments among both chums and loved ones are inevitable. This will be predictably stressful. How do I choose which relationships to honor? Would arguments or resentments follow? Would some of my patient/friends experience surprise or worse when their expected access to me is less than they dreamed? Might this add to the history of rejection that triggered at least a few of them to enter counseling in the first place?

FOURTH PROBLEM: As noted in “Problem Three,” the abrogation of my former ethical restrictions leaves me trying to find time to do what I want, including contact with children, spouse, old buddies and recent dual role chums. Perhaps you’d advise me to limit new patient/friends from the start by saying to volunteers, “Yes, I’m open to being your friend, but I can’t because I just don’t have the time.” I doubt this would satisfy them forever and might seem phony.

Remember, too, I am introverted by nature. Were I to add the three newbies and try to keep the rest of my social network unchanged, I imagine draining myself. Might I become resentful about this? If so, would anger and fatigue intrude on all my relationships, as well as diminishing my competence as a psychologist? The answer would be “yes” to both questions.

FIFTH PROBLEM: Let’s assume the new ethical guidelines still prohibit sex, broadly defined. In other words, kissing, fondling, and everything more. Further imagine I have a fulfilling marriage (which I do). Now, however, I am spending time as the “friend” of a woman (or women) I find attractive. Age is not important, type is not important, whether you’d be attracted to them is not important. The only consideration of consequence is my susceptibility to the allure of such a person or persons. Yes, perhaps I could screen out those whose magnetism I felt from the start, but this wouldn’t prevent attraction from developing in the course of the friendship. Nor do I assume that both of us would experience the same beguilement, but I’m expecting sometimes we would.

You all know nothing stops two people who begin a relationship (casual, professional, or otherwise) from becoming sexually intimate down the line. All of us are the offspring of ancestors who had intercourse. Lots of it. We are built to reproduce. Oscar Wilde put it best, “I can resist anything except temptation.” Under my new rules, however, I’d have to do just that. Had I maintained the previous metaphorical moat between myself and my patients, those ethical principles would have helped in cementing this boundary. Avoiding temptation is far easier than resisting it. Our hypothetical scenario puts me pretty much on my own, doing enjoyable activities — as one does with platonic companions — a few of whom happen to be “hot.” The slope is slippery and my skis are on. If I begin this downward adventure I will destroy my patient, my family, and myself.

SIXTH PROBLEM: The decision to permit friendships with clients rests on an implicit assumption: I have something to offer as a friend no one else can provide. This is absurd. No practitioner I know, including myself, is unique in his capacity for understanding, affection, loyalty, wit, and all the other qualities present in a good chum. It only seems so to the client.

Moreover, by becoming the buddy of the person to whom you are ministering, you reduce his incentive to develop healthy connections outside of the office and to take the risks necessary to do so. Stealing the initiative of the people you serve harms them.

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By now you’re either on board with my concerns, believe I’m unnecessarily worried, or think I’m just plain wrong. What I hope I’ve done, however, is to make it clear that an extra-therapeutic relationship with a mental health professional can’t measure up to an imaginary nirvana. It holds enormous risk for the parties in the consulting room and dares causing permanent damage to each of them, as well as to others. By giving in to a client’s idealized dream of having MORE time and tenderness, the chances are increased of making a nightmare of complexity and disappointment for patient and doctor alike.

I know I have not dealt adequately with the depth of heartache experienced by those who suffer unrequited affection for their therapist; or perhaps I should say “unrequited access” instead. I can do no better than refer you to a wonderful, but exquisitely painful post written by such a person. Indeed, her blog is called Life in a Bind — BPD and Me, the first four words of which serve as a stand-in for both her topic and mine, examined from different perspectives.

You might not like the rules I chose to live by when I practiced, the same rules about which the American Psychological Association gave me no choice. Those ethical guidelines simplified my life and benefited my patients. They permitted me to focus on the most important responsibility my career demanded: helping people. Yes, they limited me and limited those on the other side of the therapeutic moat. We — both of us — needed some boundaries.

Perhaps it is too much to call the doctor’s office a “sacred space.” Yet, the external regulations enforced on patient and therapist are designed to protect each from the other; and, to safeguard each party from the injury he might do to himself if the barriers were lowered. As a therapist, you are therefore unable to assist people in the fulfillment of their dreams about you. As compensation, you have a chance to guide them safely to a healing place. We cannot permit you everything, but in our prohibitions perhaps we can enable you to find everything elsewhere.

In the end, if you don’t like the obstacles erected by all responsible therapists, I invite you to describe a more perfect system. Ideally you will design a new set of ethical principles superior to those psychologists use, less fraught with the problems I’ve described and others just as bad.

Good luck to you. I look forward to reading anything you fashion.

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The first photo is called Joy in Arm Wresting by Bernd Schwabe. The second picture is Two Interlocking Braided Hands by M. Koenitzer. Both are sourced from Wikimedia Commons.

 

January 20, 2012

The Pain of Counseling: When Therapy Turns South

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Turning points in therapy and in life are usually seen only in retrospect.

Sometimes — many times — therapy leads to a better life. But sometimes therapy creates pain in the process of trying to do its work. The patient can experience it as a necessary part of the process; or, as one more disappointment, frustration, failure, or betrayal in a life already filled with them.

It often depends on the type of discomfort that therapy is causing.

I’d like to describe four different categories of such therapeutic problems. Three of these involve failures of the therapist. But one (Item #3) is a frequent development in therapy that has to do with the nature of treatment and how people deal with emotional pain, rather than some shortcoming of the counselor.

1. Countertransference

Therapists can get frustrated or angry with patients, attracted to them or repelled by them, bored by them or fascinated by them. Therapists are human, so they are subject to all the same relationship issues as everyone else.

Of course, we are trained to keep a therapeutic distance and to know ourselves well enough to minimize all of the above. Unfortunately, self-knowledge is always less than complete and training can be an imperfect aid when faced with challenging relationships.

The psychoanalytic concept of countertransference was an early contribution to understanding these sorts of dilemmas within the doctor and patient dyad. It refers to the therapist’s feelings toward the patient, particularly those that may be unconscious and stem from unresolved relationship issues in his own childhood.

For example, does the patient somehow remind him of a mother who was insufficiently loving or too critical? Those are the sorts of feelings that can sneak up on the counselor without him fully realizing what is happening and why.

Therapists who are not aware of the shadow of their own past can be destructive toward the very people they are supposed to help. Similarly, healers who are themselves too needy or too stressed will not be at their best when someone else requires their undivided attention. Simply put, the therapist should be safe and stable — on land if the patient is at sea, so that he will not be sucked into a whirlpool of suffering and make things worse.

In other words, the therapist must be professional. And, if he finds that he is pulling too hard or being too critical, then damage to that person is likely.

How will the counselor react if he discovers that he doesn’t enjoy the patient’s company or thinks that the patient is too demanding or too dependent — too critical or cancels appointments too often — not improving fast enough? Will the therapist lash back, feel hurt, try too hard to win the patient’s approval? Under such circumstances, the patient can be harmed, even if he provoked the relationship complication himself.

Therapists are well-advised to reflect on their own feelings, work on their own unresolved issues, obtain advice or supervision about challenging therapeutic encounters, and sometimes refer the patient elsewhere; not to mention, get their own treatment if their issues are compromising professional responsibilities.

2. Therapists Who Cross Boundaries

There are two categories here. First, those therapists who mean well, but are not aware of their personal vulnerabilities and the necessity of inviolable boundaries between themselves and those they serve. These practitioners therefore fail to set firm limits on responding to the neediness (or attractiveness) of their patients. Second, there are those self-described “healers” who are frankly corrupt.

  • Let us begin with the first of these two categories. In an effort to help, some therapists simply do too much for the patient. A few examples:
  1. Discounting (or deferring) fees to the extent of feeling resentment.
  2. Agreeing to schedule appointments so early or late (or on weekends or holidays) to the point of wanting to help the patient more than the patient wants to help himself.
  3. Seeing patients outside of therapy in some sort of quasi-friendship.
  4. Giving patients a physical contact that they crave which leads to sexual contact.

I’ve known therapists who took too many calls in the middle of the night for their own good or that of their family, counselors who brought patients who were down-on-their-luck into their own homes, and those who did not (I don’t think) intend for a comforting hug to become sexual, but who found that it did.

  • In the second category, some counselors — thankfully not a great number (although one would be too many) — take advantage of the power relationship in treatment. An attractive patient can be used for sexual purposes, or for the ego-boost that such encounters can provide, without conscience; or with some sort of rationalization that it is actually therapeutic. It isn’t, no matter how much the patient provokes it, desires it, or the counselor rationalizes it. More on the problem of “dual roles” and boundary violations can be found on a previous blog post about damaged therapists: When Helping Hurts.

3. When the Patient Has Improved Somewhat and Now Has Less Motivation to Continue the Hard Work of Treatment

Naturally, when therapy is working the person who came to treatment starts to feel better. Sometimes, in fact, he feels better even when therapy isn’t doing very much. Many if not most individuals come to therapy in a crisis. Eventually such a crisis will pass or at least begin to be more tolerable, even if the treatment isn’t the reason.

Once the patient is experiencing less pain, he now has less reason to stay in therapy. The pain is what brought him in and the desire to reduce pain was the motivation to do the hard work involved in treatment. Now that there is less motivation, there just might be less cause to suffer the unsettling thoughts and feelings that therapy stirs up, not to mention its financial cost and the amount of time that it takes.

Take a look at the graph below. The red line (AB) is the pain of “life,” the distress that the patient finds outside of the doctor’s office — the upset, unhappiness, and disappointment that brought him to consult the psychologist in the first place.

The blue line (PQ) in the graph is the pain or effort required by the therapy process itself. Therapy is hard work. It is often also intense and wrenching, since it asks people to change, stop avoiding frightening situations, and face the demons that might have been covered over until the therapist worked to address them: those incompletely healed psychic wounds that are still excruciating to touch.

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On the left side of the graph you will note that the red line (AB) is above the blue line (PQ). That is, when the person enters treatment, the pain of the person’s life is greater than the pain caused by therapy’s effort to make life better. But, as I indicated, at some point it is likely that the pain of life is reduced, while the discomfort (effort or difficulty) of therapy remains constant or might even increase. Why increase? Usually because the most tenacious problems are the hardest for the therapist to successfully address and might include taking the patient deeper into traumatic memories that he has tried to look past.

Once the patient has improved sufficiently (where the two lines intersect at point C), he now begins to find that staying in therapy causes more discomfort than getting out of it, as indicated on the graph by the fact that the blue line is higher than the red line (on the right side of the image). When the point of intersection of these lines is passed, the patient often wants to terminate treatment. Only those with sufficient “therapeutic integrity” or courage will stay long enough to resolve the most intractable of the issues that brought them to the doctor’s office in the first place. Or, they will wait until another life crisis brings them back to finish the job.

4. Therapists Who Haven’t Done Their Homework

It has only been in the last couple of decades that research has begun to point clearly to those treatments that are most helpful for some of the conditions therapists treat. Broadly defined, for example, Cognitive Behavior Therapy (CBT) has been demonstrated to be the “treatment of choice” for most people who suffer from Social Anxiety Disorder and Post Traumatic Stress Disorder.

Despite this, many therapists who claim to treat such conditions do not avail themselves of these treatment approaches or don’t familiarize themselves with the research upon which they are based.

Why?

Some weren’t trained in how to evaluate research or in how to engage in this form of therapy. Some stopped reading about progress in working with these conditions or “don’t believe” in the conceptual grounding of CBT. Some are too busy (or think they are too busy) making a living to afford the time and effort required to be up to date. Some trust their intuition to the point of rejecting anything that doesn’t match what they have come to believe is most important about how to deliver service to the people who seek them out.

The difficulty here is that therapeutic models should not be like religious beliefs, based on faith rather than evidence.

While a failure to follow “best practices” for which there is empirical evidence is not as egregious a violation of trust as sexual contact with a patient, counselors must keep learning and growing in their field of alleged expertise, just as much as they encourage their patients to grow personally.

In summary, therapists are not unique in having the capacity to do injury, but their position of authority gives them a vantage point somewhat like that which parents have with their children, making it easier to accomplish quite inadvertently.

The remedy? Obtain recommendations about counselors from those you trust. Read up on the treatment of your condition. Collaborate in your treatment, don’t just count on the therapist to do exactly what you need at every moment. Let him know about any concerns that arise. If necessary, get a second opinion. And keep your eyes open for the things I’ve described.

Not least, have the courage to stay in therapy even when the process touches on important issues that are sensitive.

As the old saying tells us, “when the going gets tough, the tough get going.”

And, no, I don’t mean “…going out the door.”

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The above photo is called U-Turn by Zipley is sourced from Wikimedia Commons. Intersecting Lines is sourced from onlinemathlearning.com