My goal as a therapist: to make myself obsolete

Traditional psychodynamic therapy is often caricatured as endless, with a complacent therapist silently growing cobwebs, listening to a patient who never plans to leave.  This isn't completely unfounded: there are therapeutic advantages to losing track of time, "swimming in the material," and letting one's therapeutic focus be broad.  The patient's chief complaint, i.e., the ostensible reason for coming, often gives way to more troubling underlying conflicts and concerns that might never appear in more directed or time-limited work.  Highly defended material may be uncovered and worked through in the fullness of time.

All the same, and as many critics have pointed out, this is a cozy arrangement.  If the therapist is happy to have a paid hour, and the patient is gratified to pay for the undivided attention of a caring doctor, nothing need change.  Ever.  Many patients fear becoming emotionally dependent on their therapists, i.e., finding it too comfortable to stop.  And some therapists, being human, are not above maintaining a pleasant status quo.

Psychoanalysts and analytic psychotherapists anticipate this concern, and hold that a patient's dependency, like everything else, can be explored, understood, and overcome.  However, in highly non-directive therapy, i.e., with a mostly silent therapist, this can take a long time and be painful for the patient in the meantime.

My approach to dynamic work is more interactive.  While I believe transference and countertransference are highly useful tools, and that both manifest and latent content are important, I also strive to help paients in the here and now, whenever doing so doesn't interfere with long-term gains.

In this light, I often tell patients that I aim to make myself obsolete in their lives.  Saying this can quell dependency fears, but it's open-ended enough that I'm not promising how long (or briefly) we'll work together, nor that I guarantee they won't feel dependent along the way.  I can't promise these, because I don't know.  But I can give my word that I won't allow myself to get so comfortable with our arrangement that I forget why we're meeting at all.  It's a comforting statement that has the advantage of being true.  It feels good to have a patient not need me anymore, a little like the bittersweet feeling when a child goes off to college.  And in a way, hearing myself say so out loud helps me remember it.

The trade-off, a psychoanalyst might point out, is that I short-circuit any fantasies patients might harbor that I seek to trap them, that I want them to feel dependent.  Patients might gain more insight about themselves if I let such fantasies germinate, and then collaboratively explore them.  It's an important point to keep in mind, but on balance I usually feel this modest bit of support helps the therapeutic alliance much more than it forestalls exploration.

A successful psychotherapy is when a patient leaves with the satisfaction that she "got what she came for," and no longer needs, or even wants, to see a therapist.  And a successful psychotherapy practice is one where patients come (in need) and go (improved), the therapist becoming obsolete one patient at a time.

Therapy for therapists

Tara Parker-Pope of the New York Times blog Well featured my prior post, on the feelings some patients have as they imagine whether their psychotherapists have been in therapy themselves.  My post was about patients' fantasies, not the reality of therapy for therapists.  Nonetheless, many of the comments argued for the great value of such therapy, and one or two expressed amazement that such therapy is not universally required.  I agree that psychotherapists have much to gain from personal therapy, and in this follow-up post I'll offer some reasons why. Is therapy required in order to become a therapist?  In the U.S., generally not.  According to Geller, Norcross, and Orlinsky [1]: "In most European countries, a requisite number of hours of personal therapy is obligatory in order to become accredited or licensed as a psychotherapist.  In the United States, by contrast, only analytic training institutes and a few graduate programs require a course of personal therapy."

A "training analysis" is required to become a psychoanalyst.  I.e., one must be analyzed oneself.  However, in the U.S. personal therapy is not required to practice other schools of psychotherapy, nor to obtain licensure in mental health disciplines such as psychiatry, clinical psychology, etc.  Specific training programs within a discipline may require it, and certainly a large number of programs recommend personal psychotherapy for their trainees.  Indeed, many strongly encourage it by offering referrals to therapists, low-fee therapy, time off from training to attend therapy, and so forth.  In a 1994 survey of psychologists by Kenneth Pope and Barbara Tabachnick, 84% reported having had psychotherapy themselves, although only 13% had attended a graduate program requiring personal therapy for therapists-in-training [2].  Whether by mandate, urging, or independent choice, many practicing psychotherapists can claim experience in "the other chair."

At the most commonsense level, a therapist who knows what it is like to be a patient may be more empathic, and may anticipate unstated feelings more readily than a therapist without this first-hand knowledge.  For example, vacation breaks can feel extraordinarily disruptive to patients, a fact that can be taught in lectures or textbooks (or blogs), but may not be fully appreciated until it is experienced oneself.  Transference in general is better understood experientially than learned academically.  Even non-analytic therapists can benefit by recognizing transference and other common "real-time" emotional reactions, conscious and unconscious, in their patients or clients; these can affect rapport, treatment adherence, and so forth.  Psychodynamically informed practice is a hallmark of psychiatry, even when psychodynamic treatment is not offered.  The same, I would argue, is true of other mental health disciplines.  Psychologists conducting CBT and clinical social workers leading support groups should know about psychodynamics too.  And the best way to learn dynamics is experientially, in one's own psychotherapy.

The argument is even stronger for therapists who practice traditional psychodynamic therapy, where transference and countertransference are essential treatment tools.  As I wrote last year, it takes self-knowledge to use countertransference therapeutically. Without this self-knowledge it would be impossible to sort out the patient's issues from one's own.  In seminars for psychiatry residents, I point out that our field has no blood test or brain scan to directly measure thoughts and feelings in the interpersonal space.  Our own feelings, countertransference broadly defined, is the sensitive instrument we bring into the consultation room.  The therapist's own psychotherapy "calibrates the instrument" so he or she can better trust its readings when applied to patients.

To me, this is the main reason to recommend therapy for therapists.  In addition, others have argued that it normalizes and destigmatizes being in therapy (assuming the therapist discloses his or her personal therapy to the patient); that it improves one's performance as a therapist non-specifically, by relieving stress and tension; and that it may give the therapist "a valuable perspective on what works and what doesn't." Several commenters on the NY Times blog believe the therapist's own therapy encourages humility, and may decrease errors based on hubris and unexamined countertransference:

We are to be one of the self monitoring professions, responsible in a unique way as the stewards of our treatment with our clients.... Having our own issues worked with ... goes a long way toward ensuring a unique quality of care.

I would be very wary of a therapist who had never sought therapy for him or herself. To me it would smack of an "I don't need it — it's for messed up folks like you" attitude.

I am also frequently shocked by the stories my patients will tell me about being in therapy with someone who clearly hasn't worked on their issues. It can be very damaging to a patient...

A personal psychotherapy does not guarantee that a therapist will be caring, non-abusive, technically proficient, or effective.  But there is little in psychotherapy, or in life, that is guaranteed.  Psychotherapeutic work, particularly the psychoanalytic and psychodynamic varieties, seems closely tied to the therapist's self-knowledge and willingness to self-reflect.  If we are to use our own perceptions and reactions as sensitive instruments in the consultation room, we are well-advised to take good care of the equipment.

[1] Geller JD, Norcross JC, and Orlinsky DE, The Psychotherapist's Own Psychotherapy: Patient and Clinician Perspectives, Oxford University Press, 2005.

[2] Pope KS and Tabachnick BG, "Therapists as Patients: A National Survey of Psychologists' Experiences, Problems, and Beliefs" Professional Psychology: Research and Practice, 25(3), pp 247-258.

Is your therapist biased by money?

Earlier this year, blog commenter TK wrote: "Isn’t this the greatest countertransference, in this age of fee-for-service psychotherapy as opposed to psychotherapist-on-salary: How do I work around my own economic motivation in deciding whether to continue with a patient or terminate?

"In other words, how does one reconcile the consistent economic incentive to keep a client coming back to your office, particularly when one is being paid by the therapy hour instead of by salary? After all, there’s always something to work on, to improve, to understand better…

"In other, other words — and this is only partially tongue-in-cheek….Is there truth to the adage that you don’t ever want to see any psychotherapist who has openings in their practice?" 

In a similar vein, a reader named Cynthia more recently posed a challenge:

What would you think about a patient asking a therapist at the outset of therapy to report to her at the start of each session how many client/patient hours you have scheduled for that week? That would give her real insight into what’s going on in the therapist’s practice, and would help determine how important it is for the therapist for her to keep coming back. Would you personally be willing to provide that kind of information?

To me, this seems far more important to know than any therapist personal life information that would arouse normal patient curiosity.

I replied to Cynthia's comment, noting that such disclosure might appear to be a useful consumer tool not only for therapy clients, but also for anyone hiring an electrician or plumber, a lawyer, a music teacher, or a medical doctor.  For each of these, financial incentive may be a factor in determining how "important" it is for the customer, client, or patient to return.  However, none of these service providers offer this information, and presumably all would consider the question intrusive and overly suspicious.

Of course, even having this concrete information may lead to different conclusions.  An underemployed service provider may be relatively unskilled, and/or more desperate for income.  As TK offers: "you don’t ever want to see any psychotherapist who has openings in their practice."  On the other hand, overly busy providers may not be available at all, may be hard to schedule, or may not give you their full attention.  Nor is busy-ness always a sign of quality.  Some providers market themselves better, or offer faddish services that are popular at the moment.  All of this applies equally well to hiring a house painter or a psychotherapist.

Seeing a therapist is different than hiring a plumber or painter, though.  Popularity (e.g., high ratings on Yelp, or on one of the dedicated rating sites for doctors or therapists) is no guarantee of a good personal connection with you as an individual.  Rapport with a therapist is more idiosyncratic and subtle than that, a matter of chemistry.  Also, since therapy quality is more subjective than the quality of a plumbing or paint job, the impressions of others may not be as reliable.

However, even if we agree that a busy therapist is apt to be a good therapist, TK and Cynthia share a somewhat different concern.  They worry that therapist economic incentive may lead to unnecessarily prolonged therapy.  "Isn't this the greatest countertransference...?"

In a sense, yes, the wish to be paid for providing psychotherapy is the greatest countertransference.  There are important ancillary gratifications of the work — the satisfaction of helping troubled people, the intellectual challenge — but being a therapist is, first and foremost, a livelihood.  A therapist who lacks the money to buy food, or who faces eviction or mortgage foreclosure, is not in a position to "bracket" his or her own needs and put the patient's first.  I confess that when I first opened a private office in 1995, retaining my first few patients mattered more to me than it should have.  While I don't believe I harmed anyone, or kept anyone in treatment longer than needed, the economics loomed large in my mind.

However, this situation passed quickly.  I cannot speak for all therapists or all psychiatrists, but on the whole we make a decent living whether our practices are full or not.  Patients come and patients go; the economics surrounding any one patient is not a major consideration.  As in many features of the therapy relationship, the dynamics feel weightier to the patient than to the therapist.  This makes good sense, as the patient only has one therapist, but the therapist has a number of patients.  (And transference magnifies these issues for the patient more than countertransference does for the therapist.)  Thus, a vacation of either party usually matters more to the patient.  Fees and money issues usually matter more to the patient, and so forth.

As I read the comments of TK and Cynthia, I recognize a core of realistic concern that the therapist may be biased by economic incentive.  But barring specific evidence of desperation or money grubbing on the part of the therapist, I can't help but think of this as a concern magnified by transference.  Economic incentive is the default situation when hiring anyone for anything.  Do you worry that your car mechanic, tax preparer, or personal trainer is just stringing you along for the money?  We all need to keep our eyes open, but there's a point at which one's natural suspicion can give way to trust and a sense of security.  Healthy relationships reside in the sweet spot between gullibility on the one hand, and paranoia on the other.  If suspicion persists, whether in therapy or elsewhere, there is a problem.  Maybe the other person gives subtle signs of untrustworthiness.  Maybe one's own "trust meter" (transference) is a bit askew.  Figuring this out is itself the stuff of dynamic therapy; it can shed light on one's relationships inside and outside the therapy office.

Countertransference, an overview

I attended a very good lecture this week on contemporary views of countertransference.  It inspired me to write a brief overview of the concept here, with more to follow. To understand countertransference, it helps to tackle transference first.  As I've discussed previously, transference was a word coined by Sigmund Freud to label the way patients "transfer" feelings from important persons in their early lives, onto the psychoanalyst or therapist.  Psychoanalysis was specifically designed to encourage transference.  Intentional opacity and non-disclosure by the therapist promotes transference; the patient naturally makes assumptions about the therapist's likes and dislikes, attitude toward the patient, life outside the office, and so forth.  These assumptions are based on the patient's experiences with, and assumptions regarding, other important relationships, such as childhood relations with parents.  In this way the patient's formative dynamics are re-created in the therapy office for both participants to observe.  Patients discover that some of their assumptions about others, and themselves, are unfounded or outmoded and do not serve them well.  This is an important type of insight that can lead to lasting psychological change.

Freud realized that transference is universal, and therefore could occur in the analyst as well.  He did not write much about this, except to say that "countertransference" could interfere with successful treatment.  The analyst experiencing countertransference should rid himself of these feelings by having further analysis himself.

Since the 1950s, psychoanalysts and psychodynamic therapists have held a more benign view of countertransference.  It is no longer seen as an impediment to treatment (at least not inevitably), but instead as important data for the therapist to use in helping the patient.  Countertransference can serve as a sensitive interpersonal barometer, a finely tuned instrument in the field of social interaction.  For example, a therapist who feels irritated by a patient for no clear reason may eventually uncover subtle unconscious provocations by the patient that irritate and repel others, and thereby keep the patient unwittingly lonely and isolated.

In using countertransference this way, the therapist must consider multiple sources of his or her feelings.  Some feelings, positive or negative, may be evoked by the patient.  These are particularly helpful ones to notice, especially when the cause is not immediately obvious, as in the example just given.  Often, however, feelings may be stirred up by irrelevant characteristics in the patient (e.g., the patient physically resembles the therapist's sibling or spouse), by the prior patient, or by factors unrelated to therapy (e.g., bad traffic getting to the office, a quarrel at home, an upcoming vacation).  This strongly argues for dynamic therapists to pursue such therapy themselves: It "tunes the instrument" to better distinguish countertransference evoked by the patient, versus similar feelings that arise from other causes.  Freud's advice for analysts to seek additional analysis themselves in the face of countertransference is wise, although not for the reasons he gave.

I teach psychiatry residents to go through a mental checklist whenever they become conscious of possible countertransference:

(1) Is this feeling characteristic, i.e., does the resident have it much of the time?  If so, it may say a lot about the resident, but probably nothing about his or her patient.

(2)  Is the feeling triggered by something unrelated to the patient?  Feelings caused by hunger, one's personal life, bureaucracy in the medical center, and so forth are not useful data for helping the patient.

(3)  Is the feeling related to the patient in an obvious way?  Feeling irritation toward a patient who is screaming obscenities and viciously destroying the office is countertransference of a sort, but not very illuminating.  And finally,

(4) Is the feeling uncharacteristic of the therapist, a reaction to one particular patient, and yet the exact trigger is not immediately obvious?  These are the most helpful feelings to notice in oneself, as they often shed light on subtle yet important dynamics in the patient.

Countertransference is not always helpful.  Particularly when it is unexamined — or, worse, unrecognized — it can indeed interfere with effective treatment.  This can occur even with positive countertransference, as when a therapist is so entertained by a patient's jokes that the underlying bitterness is ignored, or when an attractive patient is never challenged because the therapist desperately yearns to be liked.  More often, though, countertransference is problematic when it is negative.  The therapist feels bored, irked, paralyzed, or contemptuous in the presence of a particular patient.  It is the therapist's job to recognize these feelings and deal with them.  Occasionally a therapist must refer the patient to a colleague when the original therapist's countertransference is unmanageable.  Fortunately, in most cases these uncomfortable feelings, once recognized by the therapist, can not only be understood but also used constructively in the treatment.