A Therapist’s Dilemma: Telling the Whole Truth vs. Healing the Wound

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Does anyone tell the “whole truth” all the time? No one, I suspect. There is a difference between answering direct questions honestly and offering opinions not requested. The therapist lives in the space between. He does not tell his patient everything he thinks about him.

This is no surprise. His job is to heal, not harm. Our best friends, for example, are careful not to say too much unless the information is essential. Indeed, many people will not offer any hard “truth” ever. Some are afraid of hurting the friend even if the buddy’s mate is having an affair of which he is unaware. As Shakespeare’s Othello says when he is led to believe his wife is sleeping with Cassio:

What sense had I of her stolen hours of lust? I saw ‘t not, thought it not, it harmed me not. I slept the next night well, fed well, was free and merry; I found not Cassio’s kisses on her lips. He that is robbed, not wanting what is stolen, let him not know ‘t and he’s not robbed at all.

Simply put, ignorance of the offense is bliss. Othello maintains the injury is not so much the infidelity, but the knowledge of betrayal. This is doubly true in his case, since the report of his wife’s affair is false.

To the extent a therapist is viewed as an authority, his opinion carries particular weight. Patients will, on occasion, request reassurance or ask what his assessment of them is. The counselor’s answer might be any of the following:

  • “Why are you asking?” The healer attempts to turn the conversation to the client’s motives.
  • “My opinion isn’t the one that counts.” The doc deflects the question, pointing out the need for self-esteem independent of anyone else’s viewpoint.
  • The shrink offers a few positives and tactful negatives (not couched as weaknesses or personality flaws), thus addressing the request as a diplomat might.

What if the therapist is in a position to provide information crucial to the patient’s well-being that he might not otherwise receive? For example, let’s say the client has body odor of which he is unaware. I suspect some therapists would shy away from anything as personal as this, but I recall an occasion with a supervisee when I dealt with it head on.

The trainee in her late-20s appeared well-groomed, but the scent always trailed her. Indeed, others on the hospital staff suggested I address the problem for the individual’s good, as well as to make contact with her less noxious.

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Making matters even more delicate was the gender difference between this lady and me. Still, it was essential my supervisee be informed how others reacted to her. I was not eager to impart the information, but my responsibility was clear. This decent and intelligent young clinician could serve her patients well only if she knew what was common knowledge. Failure to inform her would have been a disservice.

Now imagine she’d been a patient in treatment because of dating failures and loneliness. Would it have been responsible to shy away from any mention of a body odor?

A very different situation is more typical. I treated many middle-aged people who were concerned about how an adult child, now out of the home, turned out. Some of these parents felt rejected by an offspring, were depressed, or angry at the child or former spouse to whom they assigned responsibility. Often these folks found little fault in their own errant parenting.

If the patient wanted to improve his relationship with his adult child, the conversation would then involve what he might do differently now. If the offspring blamed the parent for historical wrongs, then self-reflection would be grist for the mill. But what if the relationship was over? Would the patient profit from awareness of his imperfect parenting? What gain might follow from a fresh and excruciating knowledge of the irreparable harm he’d done? Most therapists, I suspect, would allow the person’s rationalizations about his behavior to go unchallenged.

A therapist is not a palace guard barring the way to some heavenly reward, weighing the good and evil in any life, opening or closing the door to the pearly gates. He is not a moral arbiter. The job of harvesting or harrowing souls is left to “fire and brimstone” preachers and others who claim a divine purity far above the counselor’s pay grade.

The healer must keep in mind what the client came for. Most likely he did not ask for administration of an ethical purgative designed to expunge imperfection and cleanse his soul of sins past and present. If the counselor does not remember that, then the therapist, not the patient, has lost his way.

The top photo is called The Mouth of Truth, located near Lipnice nad Sazavou in the Czech Republic. The author is Jarda 75. The second image shows “Michele Linger, left, Sexual Assault Response Coordinator (SARC), lending an ear to a Joint Task Force Guantanamo service member during a counseling session at Guantanamo Bay, Cuba, March 25, 2010.” It is the work of Army Spc. Juanita Philip. Both photos are sourced from Wikimedia Commons.

If Therapists Have Problems, How Can They Help?

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I’ve never met anyone without problems, in or out of therapy. Some are more serene, optimistic, or luckier, but no one escapes the downside of life: frustration, heartbreak, and aging. What then, despite those troubles, enables such a person — aka your therapist — to help?

Part of his capacity to relate to you is the very fact that he can’t escape either. The counselor and you are members of the same species, no matter how different in significant details. Basic experiences are common to each of you: learning, making a living, finding love, communicating in words, inhabiting a fragile body, losing people, and facing your own demise.

He is also damaged, if not necessarily as severely as you; and ideally, not suffering acutely in the moment he treats you. Yes, there is a point beyond which the one treating needs treatment before he can assist others. Perhaps his own demons are triggered by what you say or do, even how you look. Maybe he will be unreliable or poorly trained, using outmoded theories or failing to keep up with “what works.” A counselor can also be overwhelmed by his own life circumstances and lack the energy to help while he is trying to stay afloat himself.

These concerns excepted, you will still be dealing with a flawed person. Best if he is not also either too young or too old. A youthful counselor is inexperienced by definition. He brings enthusiasm, boundless effort, and (we hope) knowledge of the latest research, but hasn’t spent enough time in the trenches. Still, he must learn his craft somewhere.

Caution also applies to seasoned doctors who just go through the motions or have run out of gas. Too often they are tied to routine ways of thinking and are no longer “alive” to what it means to be in the springtime of life. They, too, should be avoided, perhaps even more than earnest young people who will, at least, invest themselves in you.

Part of my hesitation in recommending young therapists, however, has nothing to do with their limited patient contact. Rather, most have not been hurt enough. To be adequate to treat, life must have its way with us for a time. We need to find out who we are and what life is. Ideally, counselors also need a body beginning to show signs it won’t last forever — to be informed of their own mortality. A future therapist should be humbled by life and find a way to come back for more. His rebound approximates the journey you hope to make yourself, the one on which he will accompany you.

Consider the kinds of preliminary encounters the legendary conductor Bruno Walter thought necessary for making music. Imagine how his opinion applies to a therapist’s need for life experience. The language is fulsome, characteristic of the time he was born (1876), but the message transcends it:

“He who has not experienced the stormy sea with a feeling heart will fail to find the elemental force of expression essential for the Overture of Wagner’s Flying Dutchman … Beethoven’s Scene by the Brook (from the Pastoral Symphony) will sound empty unless the conductor’s own delight in a purling brook and a smiling landscape is joined to the musical soulfulness of (his) interpretation … (And) he who is a stranger to ecstasy cannot convincingly conduct Wagner’s Tristan and Isolde.”

Simply put, should you visit a shrink who lacks the education acquired by passing through times both rough and wonderful? Read Homer’s Odyssey and ask yourself how the hero, Odysseus, might have been changed by a 10-year war at Troy, returning home by sea, fighting the Cyclops, and the additional 10-years required to find his way back? Few therapists experience anything close to this, but do learn a few things down a less remarkable path.ulises

A shrink should be like The Velveteen Rabbit, who only became “real” by being worn from use and transformed by love.

Therapists and non-therapists alike are survivors. Indeed, we are all the offspring of shipwrecked fellow men who endured. A shrink without personal acquaintance with travail and romance would be like a Martian trying to understand mankind. Yes, your doc has his own “stuff.” Would you prefer a virgin psychologist, untouched by life as well as sex?

Yet, he must also be different than his patients. A professional combines his training and experience to form an understanding of the “full catastrophe*” of existence. His daily practice allows refinement of the technique required to aid others. Thus, a seasoned counselor’s personal hardships and learning meld with the experience of helping patients (from whom he also learns, especially by making the mistakes novices usually do).

The practitioner ought to know more than you do about the healing art. Moreover, he is useful because he is NOT tied to you at the deepest level. A therapeutic perspective is essential: the dilemmas of your life are yours, not his, nor those of his loved ones. He can keep his head because of this, even though he does come to care about you as a particular person with increasing contact. Therapeutic distance permits him to remain calm and thoughtful in the presence of your pain.

Perhaps, too, the shrink has been luckier than you, without which he could not lend you his hope. He knows good things can happen and the darkness is followed by the dawn, at least much of the time. You are better off for his self-assurance and clarity of mind. They enable him to see the dimly lit road out of the woods. You would not wish him to be looking for the breadcrumbs left by Hansel and Gretel.

None of this is to suggest the counselor is some sort of god. Rather, he is the master of a limited situation — the small chamber in which he does his work. He is also an illusionist, of sorts. If you observed him unshaven, in his underwear, without the mirrors and smoke, arguing with his mate, worried about his kids, upset because the newspaper delivery service keeps leaving him the Tribune instead of the New York Times, then you might think less of him.

The illusion is a necessary one. You overgeneralize and come to believe that he is a wizard everywhere and all the time. He doesn’t stop you, as if he could. You need to believe.

So, dear reader, we therapists are quite mortal. We’ve got our own issues and the bruises sustained on our part-way-completed expedition through life. If we are any good, then we are observant and sensitive. We’ve seen the world’s unfairness. Judgment is set aside for the most part. We are each, as Seinfeld’s George Costanza used to say, “master of our domain,” although in a rather different context than George intended.

Some of our imperfections enable us to help. When we have too many? That’s another story.

*The facetious phrase, “full catastrophe,” comes from the 1964 movie Zorba the Greek. It has become associated with the book Full Catastrophe Living by John Kabat-Zinn.

The first image comes from the 1954 movie Ulysses (the Roman name for Odysseus). The ship is a model, not a full-sized boat. An illusion, yes? The movie poster is from the same film. The title role was played by Kirk Douglas. Anthony Quinn portrayed “Zorba” in the 1964 movie and took a supporting role in Ulysses.

How Therapists Fool Themselves

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The above photo of Kyle Young’s album “Snowball Therapy” is not meant to suggest anything negative about his music. Unfortunately, however, there are probably a few therapists who are using forms of “therapy” that are nearly as preposterous as that name implies.

The fallibilities of therapists could probably fill several books. I will not win much applause from colleagues by telling you how therapists sometimes fool themselves. The list below does not apply to all healers, but the self-deceptions are more common than one would wish. Here are a few of the ways that counselors sometimes lack a realistic appraisal of themselves and their work:

1. “I’m not doing this for the money.” While almost all therapists come to the profession in order to do some “good,” most also have to make a living like everyone else. Quite a few will discount their fees for certain patients, but most set some number as the very bottom-line that is acceptable compensation, meaning that clients without medical insurance coverage or a heavy wallet go without.

Those practitioners who do lots of marketing and employ other therapists clearly are mindful of the potential for profit. All this is fine, but it also means that there is more than one reason that therapists do the work; and that for some, money is of equal or greater importance than the work itself. Keep in mind the old joke about the MD who is asked about his specialty. His answer is: “My specialty is diseases of the rich.”

2. “I can treat almost any diagnosis.” There are too many different ways a life can go wrong and too many areas of skill and knowledge required to help put things right. No one has seen them all and knows them all, but some think they do. If your counselor claims omniscience or anything close, run — run fast!

Watch out for a therapist who thinks of himself as some sort of therapeutic comic book hero.

Watch out for a therapist who thinks of himself as some sort of therapeutic comic book hero.

3. There is no research supporting what I do, but I know it works.” Some therapists go so far as to write books about their style of treatment despite a lack of research support. They claim that their experience justifies their approach, citing anecdotal evidence which no scientist would take seriously. They ignore the fact that empirically validated treatments exist for conditions like Obsessive Compulsive Disorder (OCD) and Social Anxiety Disorder, to name only two.

In effect, these healers practice the rough equivalent of using an unproven folk-remedy to cure cancer. They tend not to read scientific journals that publish rigorously designed, peer-reviewed articles, dismissing them as too “academic and impractical,” and may not even have the training to adequately understand such research reports. Good luck if you are the patient of one of these people.

4. “We need to continue; you aren’t where you need to be yet.” Several potential problems are found here, even though it might be true that the patient could benefit from something more. First comes the question of why therapy hasn’t already accomplished what it needs to do. The therapist may have taken this person as far as he is now capable of going, regardless of who might treat him; or else lacks the skills needed to take him further. Is the healer’s desire to extend therapy motivated by money? What is the treatment plan to get the person to the finish line and is the patient prepared to make the effort and pay with his time and hard-won dollars?

The truth is that we humans are never perfected in all the things that could make our lives better, yet most of us continue without lifelong therapy. The decision to end must come sometime.

5. “My personal issues haven’t compromised my ability to do therapy.” I have known (or known about) therapists who treated obesity despite their own considerable overweight, who treated addiction despite themselves smoking two or more packs of cigarettes a day, and who were cheating on their spouses (sometimes with patients). I’ve heard of therapists practicing with their own untreated (and perhaps undiagnosed) Attention Deficit Hyperactivity Disorder (ADHD); others with undiagnosed or untreated Bipolar Disorder.

The list of human weaknesses in therapists is not much different from the list you will find in non-therapists. Having problems at home, as therapists sometimes do, can be enormously distracting, to say the least. The more chaotic and disturbed is the healer’s life, the less effectively can he help anyone.

6. “My values don’t influence my ability to do therapy.” I’ve known therapists who were very religious, going so far as to encourage their patients to adopt a similar view; and atheist counselors who were troubled by patients who had strong religious beliefs. I’ve known those who can’t easily talk about death because they are terrified of it, a problem when dealing with someone who has mortality issues. Therapists must either refuse to see certain people, refer them to others, or heal themselves in order to practice honorably and well. Unfortunately, some practitioners deny their own limitations and the extent to which their own beliefs and issues can affect therapy.

Finally, the biggest self-deception of them all:

7. “My patients get better — I’m a good therapist.” Maybe not. Remember that most people come to therapy at a low point in their lives, perhaps even a crisis. Time passes, whether in therapy or out. Most of us tend to bounce back. As researchers know, the real question is whether the person you are treating would have done as well or better with a different treatment, without treatment; or with someone like a relative, a friend, or a clergyman who did little more than listening and hand-holding.

A few therapists forget the admonition made to physicians: “First do no harm.” Indeed, there are counselors who believe they are doing just fine, but who have failed to diagnose the difference between Bipolar (Manic-Depressive) Disorder and other varieties of depression; or missed recognizing that a patient has partially compensated for his non-hyperactive problems of attention and concentration by dint of intellect and effort, and thereby effectively disguised his need for medication.

Those diagnostic failures virtually guarantee frustration and discouragement in the patient, who then has one more life disappointment to add to a long list; and who might never return to therapy with a genuinely competent therapist. The “doc,” meanwhile blames the client (or the severity of the patient’s problems) instead of his own incorrect evaluation.

Part of the dilemma for prospective patients is that most don’t investigate therapeutic options years in advance of the decision to seek help, nor can they reasonably be expected to. Indeed, they usually spend much less time researching potential treatments than they do when investigating which car to buy. Rather, clients typically come to therapy at life’s low ebb, review the list of people who accept their insurance, and look upon the therapist as a licensed authority who will surely have all the answers. Yes, we are licensed, but that doesn’t guarantee our competence any more than it does for cosmetologists, physicians, cemetery managers, real-estate agents, or barbers, all of whom need to be licensed in the State of Illinois.

There is nothing better than knowing what you are getting into and with whom, even if you are out of gas; especially if you are out of gas. Get recommendations from your friends or your MD if you can. Early on, find out what your diagnosis is and do research on the web concerning empirically validated treatments for that condition.

Therapists generally mean well and some are really terrific. Literally, life-savers. But, like any other group, we are subject to our own self-deceptions. A few counselors should be placed on a pedestal, a few underneath one.

Advocate for yourself.

You may find the following related post of interest: When Helping Hurts: Therapists Who Need Therapy.

The top photo is from Kyle Young’s fourth album. The second image is of “Retman,” an actual therapeutic comic book hero. The first three initials, R.E.T., stand for Rational Emotive Therapy. The cartoon is the work of Razvantonescu, International Institute for Advanced Studies of Psychotherapy and Mental Health. Both works are sourced from Wikimedia Commons.

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.”

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