What do therapists think about when they are with their patients?

Or, to put it differently, what does your therapist really think of (and about) you?

First things first. In order to be able to be of any help, a therapist needs to conceptualize the job he is doing. If he believes it is to “fix” the person, he is setting his patient and himself up for disappointment.

A therapist is not a surgeon who takes an instrument to excise old behavior out of you or insert new thoughts and feelings into you while you are unconscious. Rather, both you and he should see him as someone who is knowledgeable about human problems and their solution; someone who has been trained to help you if you are prepared to make the effort to help yourself. The counselor ought to have lived long enough to have acquired a bit of wisdom about life, along with the humility that comes from his own set of ups and downs.

Ideally, he should know himself quite well, so that his own relationship issues don’t get in the way of treating you. The healer must be hopeful, encouraging, and experienced in addressing the particular difficulties that you are having. And, he can only be helpful if he grasps more than a little about what makes for a good life.

Finally, the counselor must be open to the possibility of learning something from the therapeutic exchange, rather than taking a position “on high” and seeing himself as an unassailable authority who hands down proclamations to you.

This is the person who you are about to meet. Of course, new patients are often uncomfortable in coming to a psychotherapist’s office, knowing that they will be talking about difficult subjects, and aware that they will be evaluated.

You will be evaluated. You must be. That is the first part of the healer’s job.

A good psychologist, within a few minutes, will get a first impression — an almost instant “take” on you.

All the things you might expect him to observe will be observed: how you dress, how you walk and stand, the strength of your handshake, your ability to make eye contact, your voice, body language — what you say and how you say it, with particular attention to the presence or absence of emotion, as well as your own understanding of yourself.

This “physician of the soul” is also noting whether you are confident, nervous, and/or open. He is assessing your verbal capacity too, since your ability to conceptualize and understand the things that are put into words — either those you say or those that are said to you — is essential to a good result from treatment.

Sigmund Freud

Does your counselor like you? He will try hard to look for the best in you. It is much easier to treat someone who you feel good about than someone you find despicable. You don’t have to be perfect for the therapist to appreciate you or enjoy your company. A good therapist finds most people pretty likeable and some extraordinarily admirable, even if there are major things they’ve done of which they are ashamed. If he has been at his profession for a number of years he has heard an enormous range of stories. It is doubtful that what you say will floor him.

All the while, the clinician is trying to make “sense” of you. Calling upon all his training and experience — all that he has read, been told, and discovered in the course of his career — he is trying to formulate who you are diagnostically and as a person. The shrink is taking the combination of your presence in the room, your history, your weaknesses and strengths, your likes and dislikes, and the problems you are reporting and trying to put them into a pattern that will lead to a determination of “what is wrong” and how to put things right; in other words, a plan of treatment.

A clinician must be in three places at once as he listens to his patients.

• He must know and remember what you have said to him before; both the words and their sometimes obscure meaning, as well as any fluctuation in mood over the history of his relationship to you.
• He must be intensely focused on what you are saying now and how you are presenting yourself in voice, body language, and emotion.
• He must be thinking into the future, asking himself some subset of the following questions:

Where is my patient going with this? Should I continue to listen or should I comment? If I do comment, what is the best way to do so; how much or how little? Should I offer an interpretation of what the patient is saying? What is the most important thing to respond to? Which topics should be discussed now and which should wait? Am I missing anything, possibly including the patient’s disaffection from me? Is the pace of therapy too fast for the patient or too slow? Are my own feelings or actions getting in the way? Is the treatment working and if not, why not? Is there another — better — approach to take?

At the same time the therapist must be aware of the clock. Is there sufficient time left in the session to open difficult topics? Is the person too agitated and should the troublesome issue be closed down (if possible) before the end of the allotted time?

Let me give you an example of how all of this works. I received a referral of a woman who was approximately 35 years old. She was in the hospital due to a Major Depressive Disorder, as well as other diagnoses. I also knew before I saw her that she had a deformity.

When I met her I noticed the deformity immediately. It was impossible to miss. I introduced myself and we began to talk about why she was in the hospital. As I listened, the dominating thought on my mind was when to address the question of the disfigurement. It could not be simply ignored, since it doubtless affected all her relationships (producing, at least, an immediate impact), not to mention her self-image.

The question then was how to bring it up and when. As this pleasant lady was talking, these thoughts were being weighed in my mind. She seemed relatively comfortable discussing the very serious problems that brought her to the hospital and that had nothing directly to do with her deformity.

I therefore reasoned that she would probably also be able to address this physical problem without too much discomfort. Moreover, I also knew that until I brought it up, the fact that I had not brought it up would be between us, getting in the way of developing a good treatment relationship, with both of us likely to be waiting uncomfortably for the inevitable confrontation with the topic.

In the event, I did ask her about it within the first 20 minutes of our initial session. She told me of a failed history of surgeries to correct the imperfection, but minimized the social problems that doubtless attached to it. It became apparent that it was a topic that she could address, at least on a superficial level. While we did come back to the subject later in her treatment, for now it was out-of-the-way as an obstacle to our therapeutic alliance and we could get on with the issues that were more pressing.

New therapists, like novice drivers, find that there are entirely too many things to be conscious of all at once. But like the new driver, with enough practice, all the meters and gauges on the dashboard and all the cars and traffic signals on the street eventually can be managed almost instinctively, without being overwhelmed by their sheer number.

Does your therapist think about you after the session is over? Sometimes he cannot help it, simply because something touching or troublesome (or even funny) happened in the session. As my patients know, I laugh a lot with most of them.

Then too, the therapist needs to document what has happened in your medical record and plan for the next session. He needs to review his notes and the treatment plan just before he sees you next, as well. Sometimes, he will have to consult a supervisor or colleague (without revealing your identity) for assistance. If he is required to be in touch with a managed care company in order to obtain treatment authorization, that too will demand that he takes some time for telephone or written observations about you and your treatment.

Will your therapist remember you long after you have seen him? If his memory is good and the course of your treatment is not brief, it is likely that he will. Of course, certain people stand out, both those who made astonishing progress and those who didn’t progress despite every effort. And then there are some you remember because they were unusual or because something about them was especially poignant; because of a story they told or the crucial knowledge or experience you acquired in your time together with them.

The clinician is enriched by his contact with people. It really is a rare privilege. People you might never get to know in the course of a different career not only come to see you, but reveal their most intimate secrets.

You think about them because it is your responsibility, yes. You think about them because it is a way to make a living, yes.

But you think about them most — if you are well-matched to the work of a therapist — because they are fascinating, challenging, sad, beautiful or less than beautiful, handsome or plain, anxious, thoughtful, decent or unkind, skilled, clever, energetic or beaten-down, and all the other things that make us what we are.

You are two people in transit, who come together on a subterranean road toward, one hopes, something worthwhile.

If you are the therapist in this pair, for a while you may be the carrier of the only torch that lights the way.

Onward toward the light.

—

Freud’s Sofa, pictured below the “Question Mark Man,” is now housed in the Freud Museum, London. Freud typically sat behind the patient who was lying down on the sofa. This psychoanalytic style of relatedness is not typical of most therapists today, who instead sit across from their patients, face to face. The photo comes from http://www.Londonleben.co.uk/ The third image is Sigmund Freud taken in 1926 by Ferdinand Schmutzer. The bottom picture is of Light at the Eastern End of Newchurch No. 2 Tunnel, taken on September 18, 2008 by Alexander P. Kapp and featured on http://www.geograph.org.uk/ The last three images are sourced from Wikimedia Commons.