Therapists sometimes reveal themselves despite their training not to. For example, in psychoanalytic treatment, Freud made himself a blank slate. He thought the patient’s troubles would become evident if he didn’t intrude upon the process. Remember, Freud sat behind the patient lying on the couch. Sigmund’s facial expressions and body language could not be observed. He said little, instead encouraging the analysand’s free association of thoughts. Then, if the client displayed positive or negative feelings about Herr Doktor Freud, the psychiatrist believed it due to underlying unresolved issues, usually about mom or dad. The heart of the problem having thus been uncovered, Dr. Freud could begin his “heart” surgery.
Still, patients wish to know “personal” things about the mysterious humanoid who treats them and will comment on the imbalance in unfolding that which is most intimate: the therapist gets to ask, the patient mostly does not. Spacefreedomlove, a provocative and prolific blogger, raised worthwhile queries in her post, Five Things You Always Want to Ask Your Therapist but are Afraid to Ask. I will try to answer, speaking only for myself. I encourage other therapists and clients to add or subtract by posting comments.
Question 1. “Do you ever wish you never met me or that you referred me out after the initial consult?”
A therapist works hard to find the best in the people he treats. This is a cliché, but it is true. You otherwise make both yourself and your patient miserable. I rarely if ever wished I had never met a patient, but occasionally thought later it would have been best to refer them. Careful readers will distinguish two questions here:
A. “Do you ever wish you never met me?” The reason I’m glad I came to know my entire clientele is because they enriched me in knowledge and experience. I grew because of them. Many are wonderful people with whom it was a privilege to work.
With respect only to my enrichment, however, I would even say I found value encountering some nasty folks outside of work. Of course, I didn’t love those who did me wrong at the moment of injury. Strong feelings of anger and dislike touch everyone, therapist or thespian, “butcher, baker or candlestick maker.” A psychologist realizes he learns from some lessons only pain offers. Thus, if you ask me, “Do you ever wish you never met me?” I can pretty much say no, because you taught me about life, work, and myself. Past your tutelage, however, I might say I’d rather not meet you twice! This last comment refers to only a few people I met in the office, however.
B. “Do you ever wish you referred me out after the initial consult?” The simple answer is yes, but read on before taking the statement to heart. First, a different therapist might have worked wonders I did not. I remember one intelligent and sweet young woman early in my career who I didn’t diagnose as Bipolar Disorder until she arrived at the clinic with a bunch of “gifts.” The package included a box of condoms for me! She was hospitalized soon after. Had I been quicker to make the proper diagnosis, she might well have avoided being temporarily institutionalized. The young lady had some bad feelings about me as a result and I deserved them.
Therapists don’t predict the future without error. Only in retrospect do we realize an earlier referral was required. That said, I think the real issue being raised by spacefreedomlove is found in her second question:
Question 2. “Am I too much? Do I wear you out?”
The answer is yes, counselors get worn out, but not necessarily because of you. Once the therapist realizes he is exhausted, two more queries should pop up: a) Am I trying to do too much instead of allowing the patient’s own energy to carry therapy forward? b) Do I have some countertransference issues? Countertransference refers to the feelings the therapist has about the client, negative or positive. These can go back to the therapist’s own unresolved emotional concerns, so I’ll address this in response to Question 4. “Do I remind you of anyone from your past?”
As a young psychologist, I was keen to heal the world. This delusion is common among new therapists. Experience informs you of your inability to save everyone and, indeed, perhaps you can’t save anyone! By that, I’m thinking of the lifeguard who tries to rescue someone trying to drown himself. In other words, you need a person who isn’t going to fight your efforts every session and who has the therapeutic integrity to endure the pain of treatment. He must do everything he can to wrest a good life from the wreckage of his previous existence.
Therapists can burn out if they don’t recognize and calm their own frustration when progress is stalled. A counselor might exhaust himself by meeting his patient too early or late in the day, discounting fees to the point of feeling ill-compensated, and by overworking. Phone availability is still another potential complication, especially in non-emergency situations. Private life stressors create a trip-wire, as do multiple late cancellations without strong reasons.
A wise doctor will discuss issues during appointments, but not before healing himself or seeking his own outside support if the problem is his, not the client’s. Psychologists need to set limits. Being “on call” day and night can feel like guard-duty in wartime, causing sleeplessness and fatigue to the point of being less good when it really counts, in session. Remedies might include talking about the patient’s level of determination; a change to the time, day, or frequency of sessions; renegotiating the fee or the cancellation and phone policy, etc. Without improvement, referral is another option.
Question 3. “What do I bring up for you? What do you struggle with in our sessions?”
As stated earlier, I only speak for myself. The best answer I can give is a long one, so I will refer you to a post called, What is Your Therapist Thinking? In addition to what is contained there, I struggled with how best to be helpful. Were a patient decompensating (getting worse) as the session progressed, I considered how to get the train of treatment on track to a safe place. The post I linked illustrates the manner in which your “doctor” head can be in a number of different places depending upon the flow of the therapeutic encounter as it happens. After the appointment, the counselor needs to reflect upon his efforts and whether they helped, were ineffective, or indeed caused the decompensation.
An inexperienced healer risks identifying with his patient’s pain so much that both he and the client are adrift at sea, and he is unable to offer a steady hand from the shore. Experienced therapists, on the other hand, risk becoming jaded to the point of equally worthless emotional distance. I believe I was eventually able to find solid ground in the middle.
Question 4. “Do I remind you of anyone from your past?”
Much like parents who are better suited to raising one child than another, counselors are not equally well-suited to each client. This can be a matter of skill, temperament, age, experience, or background. The question, however, seems to suggest you (the therapist) suffer issues from your past impinging upon your relationship with your patient in the present: your patient’s resemblance to someone else is the trigger. I remember a 16-year-old victim of sexual abuse. Her face reminded me of an old girlfriend, who I met when she (the girlfriend) was only a year older — 17. In the session during which the abuse surfaced, the client’s pain contributed to my own. While this was not a unique experience (my eyes can moisten hearing such stories), I was more than usually touched because of the invisible presence of tender feelings toward someone I’d not seen in many years. Nonetheless, my emotions settled and did not appear to derail treatment progress.
A few patients reminded me of my mother, with whom I had a “complicated” relationship. Please do note the euphemism! Once, however, I resolved my “mom” issues, I observed such similarities without undue emotion interfering in treatment. So, at least, I told myself.
Question 5. “What would you say to me if you were not my therapist?”
I am a pretty direct person. Not undiplomatic (most of the time), but direct. From childhood I found it almost impossible to be false. Should you care to know more, an amusing post on this congenital failure describes a kindergarten catastrophe: Gone in Sixty Seconds: How to Lose Three Girlfriends in a Minute. I don’t take full credit for my discomfort with being disingenuous (since I seem to have been born with it). Nonetheless, because of the trait, my client heard whatever I thought was most important to say. I tried to hold a mirror so that he might better recognize himself. If his vision was cloudy and it was essential that he perceive more (in my opinion), I often said more. I made good use of Socratic dialogue, asking questions designed to lead to self-awareness. Telling someone he is missing something is rarely helpful. A therapist says things like “What does that way of being cost you?” in the hope of allowing the patient (upon answering and thereby taking responsibility for his behavior) to grab the therapeutic initiative to change. The same comment in the form of a statement, by comparison, might cause him to feel scolded. It is easier to reject the therapist’s conclusion than your own.
No one gets to know every thought a therapist or a friend thinks about him. The truth of the previous statement does not mean, however, you would hear more from me as a friend than you would as your therapist.
In the end, as worthwhile as the above questions are, I believe it is most important a therapist know the truth of what Leo Tolstoy described in War and Peace — the role of medical doctors in early nineteenth century Russia:
“They satisfied that eternal human need for the hope of relief, the need for compassion and action, which a human being experiences in a time of suffering. They satisfied that eternal human need — noticeable in a child in its most primitive form — to rub the place that hurts.”
Dr. Gerald Stein 