A psychotherapist thinks out loud about Being Human, and stuff…

Such A Business…..

I think a lot about what I do for a living. In fact, that is one of the major reasons I’ve wanted to write a blog. I think there are a lot of misconceptions about what psychotherapists do, and this bothers me, sometimes.

First, I can’t say often enough that I cannot speak for all psychotherapists, nor am I an authority in the field. I can only speak for myself and much of what I have to say is opinion. I’ll try to make it clear when I’m stating an opinion, and feel free to “bother me with facts” when I stray from the factual path – as narrow as it gets, sometimes.

I’m in a crazy business – irony noted, but no pun intended. There is probably no profession more beloved of cartoonists, who invariably picture us as bearded men, scribbling on a pad while another guy (usually) emotes on a sort of chaise lounge. There is the strong suggestion, usually, that the couchee is being scammed in some way- that is, that he is being charged for the privilege of being fleeced by a cynical huckster with too many diplomas on the wall. I collect these cartoons (many of them are very funny) despite the fact that they sometimes make me grimace. Let me tell you a little about what we really are:

Most of us- at least in California- are middle aged women. Men are a pretty small minority in my field. (I speak here of licensed psychotherapists- Counselors, Licensed Social Workers and Marriage and Family Therapists, or MFTs- the license I hold. I have no figures on Psychologists or Psychiatrists, who may or may not do clinical work.) Many of us come to this profession relatively late in life, having already worked in other fields, perhaps until retirement. Most of us struggle to stay in the middle class- but, of course, so are most of the people we see. So, for that matter, are most of our fellow citizens. Don’t get me started on that.

I have never- and for some reason this is important to me- seen a chaise or “fainting couch” in a therapist’s office. Not as a client, in my own therapy, nor as a visitor to colleague’s offices. Papa Freud had one, as did his various disciples, and I suppose those who continue to practice some version of Psychoanalysis still do it, sitting next to a chaise, behind the patient, avoiding eye contact for fear the transference will be compromised. (Slight snarkiness noted.) For most of us, that aloofness is as alien to what we do as the couch. What we do- what I do, in fact- depends on the exact opposite of aloof detachment. Study after study shows that the single best predictor of a successful course of therapy is the relationship between the people involved. If the client feels comfortable with the therapist, if she feels the therapist is honest (in the sense of being authentic), and can be trusted, the therapy is likely to go well, whether it’s long or short term therapy, whether the practitioner is coming from a “cognitive behavioral” orientation or a “deep, psychodynamic” place, like me. Simply put, if the two (or more) people hit it off, the outcome is likely to be useful, whatever tools the therapist has in his or her bag, or even if the therapist/counselor has minimal training. A lot of people have been helped by “Trainees”, or “Peer Counselors”, who have only learned the rudiments of our craft, but who know when to speak and when to listen, and have the ability to care about the person in front of them, just enough, but not too much. That’s a tricky balancing act, and there’s much speculation about whether it can be taught at all, whether you either have it, coming in, or you should be in some other racket. opinions differ.

By the way- continuing my obsession with the iconic Couch (which has now acquired its own capital letter)- most of us do have one, but it’s just your basic living room number- a two or three seater- often passed along from therapist to therapist as we retire or move up to better furniture. I’ve had my couch for nearly twenty years and (in the way that I often overbond with inanimate objects) I’m terribly fond of it. It’s more of a love seat, I suppose, too short to take a proper nap on, although I do my best. It sags a bit, and could use a good cleaning, but it’s become sort of my lucky charm. Hundreds (feels like thousands, some days) of people have settled into that couch with a sigh, commenting on how comfy it feels, and I’m not sure I’d be as good a therapist with some snappy new number from Ikea. The pillows need to be put out to pasture, though. But I digress…

Continuing to use the cartoon therapist as a foil, the implication is that the person on the couch has come to be told what to do, in order to be happy, or just “sane” instead of “crazy”. The scam is often that the person in the chair is just as hapless and nutty as the patient on the couch, but, because of the pieces of paper on the wall, the patient doesn’t get that, and is paying for nothing.

Where to start? First of all, yes, sometimes I do have to take charge, as much as possible, and tell my client what to do. If she’s in crisis or some kind of life threatening situation (hers or someone else’s), or she’s so disabled she’s unable to care for herself, I have to act in what I believe to be her best interest. I’m mandated to do so – to act responsibly in the interest of those unable to do so themselves, and in the interest of Society. Thankfully, that’s a rare occurrence. A grayer area might be my work with an addict who has come to a place of desperation and hopelessness. My training and my life has given me a pretty good idea of what will probably help, if I can get the client on board. In such a case, I’m going to be pretty directive: here’s what others have done. How about trying it?

For most of my clients, though, however much I might think I know what they need, my job is to nudge them into the experience of figuring it out for themselves. Most of the people who plop themselves on my couch have lost a lot of whatever faith they may have had in themselves. Maybe they want me to tell them what to do, like the therapists in the cartoons. Often I’m itching to do just that – but what good will that do them? I’ll be just another authority figure, telling them (however indirectly) how inadequate they are. Infantalizing them. That’s not my job. In most situations, it’s actually more important for the client to blunder his way to his own answer than for someone like me to tell them what to do. In most cases – and I’d put this in all caps if it wasn’t so hokey – I Don’t Know What The Client Needs. I might think I do, but I believe it is the height of presumptuousness – even arrogance for me to put myself in the ever-so-tempting role of Wise Man Who Knows What You Need. You are on your path, as I am on mine. We share humanity, but we are separate humans. You are paying me to help you discover your path, not to tell you what it is. Unless the situation is dire, the journey is more important than the destination and (ready for it?), “All who wander are not lost”. (My geek credentials are now established.)

I think that’s it for this installment. Clearly, this subject is going to take more than one entry. I’ll get back to it soon. Feel free to comment on anything I’ve said. Love to hear from you.

Until we meet again, happy trails to you….

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Comments on: "Such A Business….." (7)

  1. Speaking as one who has been on the patient side – the kind of couch you describe having is the perfect kind. Not a lay-down couch, but a “fort up in the pillows” couch. A snuggle couch, a comfort couch. The only thing as good is a nice deep, wide wing back chair.

    Not that I want you to think I judge a therapist by his furniture!

    • Kate, I’ve been on the other side of the couch, too, for a lot of years. As a client, I’ve sat on wooden straight chairs, folding chairs (not counting those at the occasional 12 step meeting), and, yes, big, old comfy chairs. My experience is that it really doesn’t make a lot of difference what you’re sitting in or on, when things get intense. A hot seat is a hot seat.

  2. So happy you are doing this, I love it! Thank you.

  3. Mary sent me your blog and thought we had some things in common. I am a therapist in Renton WA, and was intrigued with your comparison of “things are done” by fixing or building something and looking at it, and “things might be done” in this profession. I’ve often had to keep in mind it’s not always about me … a client recently thanked me profusely for helping him through a though time in his life, and on my voice mail to hear afterwards was another client, “Bill, you son-of-a-bitch, I want my money back! You haven’t helped me in the least!” Perspective has got to be important.

    • That’s what I meant when I said this this job was humbling, Bill. Any time I start thinking that it’s about me and that, just maybe, I’m hot stuff, I know I’m heading for a fall. It usually happens pretty quickly, too.

      • Right on. This phone message was moments after bidding goodby to my client, feeling satisfied that I was doing well and in the right place. Nature abhors an imbalance.

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