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.

Psychotherapy branding and marketing

I just read a mildly disturbing article in the New York Times called "What Brand Is Your Therapist?"   The author Lori Gottlieb was a full-time journalist who took six years to retrain as a psychotherapist — her website, but not the article, says she has a master's degree in clinical psychology.  Yet she found herself virtually unemployed after several months and in search of marketing consultants to attract clients.  The thrust of the article is that such marketing involves branding, i.e., defining a niche that promises quick, painless, easily grasped results, and then promoting oneself online and elsewhere using that brand. Gottlieb is clearly uncomfortable about the trade-offs inherent in branding and marketing psychotherapy services.  Traditional psychotherapy is often painstaking, uncomfortable, and lengthy, and thus hard to sell.  In contrast, one-time phone consultations and executive coaching are brief, feel-good interventions that lend themselves to snappy, positive catchphrases that sell better.  Such services may be "fast-food therapy — something that feels good but isn’t as good for you; something palatable without a lot of substance."  Moreover, she notes that many sales techniques clash with the tenets of traditional psychodynamic therapy.  Sharing personal details makes one more approachable and "human," at the cost of complicating and possibly precluding transference work.  Active use of social media such as Facebook and Twitter can attract potential clients and publicize one's "brand," but may also blur relationship boundaries essential for effective psychotherapy.  Gottlieb lays out the dilemmas well in her article, but her practice website illustrates the practical conclusion: Lots of "selling" of various services, few of which are recognizable as psychotherapy.

Of course, I am writing this on my psychiatry blog, which is linked to my own practice website.  I too have grappled with similar trade-offs.  I launched my website over five years ago, and started the blog about a year later.  Several months ago I heeded marketing advice I found online:  I re-wrote my website in the first-person and added photographs.  I expanded the sections on my hospital committee work and past research.  I included more practical information about my practice.

Like Gottlieb, I had mixed feelings about doing this.  On the one hand, helping potential patients make more informed choices sounds innocuous enough.  I want suffering people to be able to find me and to know what I can help with.  I want the process of engaging in psychotherapy to be as transparent as possible.  I explain what I do, and even list my fees on my website (most of my peers don't).

On the other hand, I'm concerned that branding and marketing commodifies a personal healing relationship.  It offers to treat psychological issues in little bite-sized pieces, misleadingly suggesting that therapy to resolve one's indecision about marrying, say, can be completely separate and distinct from therapy to deal with career indecision.  It conflates psychotherapy with counseling and coaching, all of which are useful but different things.  Mainly it risks dumbing down psychotherapy.  Psychotherapy is often complex if done carefully, and in my opinion it can't be conducted as well over the phone, by email, while sitting by the pool with Skype running on one's laptop, or in a guaranteed four-session package.

I haven't availed myself of the whole branding arsenal, since I strive to maintain a psychotherapy practice worthy of the name.  If I ever write a book, offer coaching services, or engage in public speaking, those activities will be clearly distinct from my role as a psychotherapy-oriented psychiatrist.  Moreover, patients and would-be patients seem to agree that informational websites are useful, but that too much branding and self-promotion by a psychotherapist is a turn-off.  That makes good sense, and encourages me to take another look at my own website — I may turn it down a little.  What do you think?

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.

Should therapists accept holiday gifts?

December brings the annual pleasures and challenges of holiday gifts and how to deal with them in dynamic psychotherapy. Although it is relatively easy to follow a simple rule about this, ideally a good deal of thought goes into a therapist's decision about whether to accept a patient's holiday gift. Below I will give a couple of examples of this from my own practice, and how psychodynamic theory guided my response. All beginning dynamic therapists are taught not to accept gifts from patients. This rule follows from the principle that the therapist should decline all gratifications from the patient aside from the fee paid. A therapist who is swayed by the patient's generosity, physical attractiveness, political connections, or other factors invites a conflict of interest in himself, and thus risks distorting the therapy in pursuit of his own needs and desires. Accepting a gift would be an example of this. Afterwards, the therapist may feel disinclined to challenge the patient, to induce anxiety or point out a contradiction. Conversely, the patient may feel the therapist should reciprocate the generosity, leading to disappointment and possibly anger when the therapist fails to do so.

Naturally, patients often do not know this rule, thus some arrive to a year-end session with a gift in hand. These gifts vary. Some are expensive, some less so.  Some are "for the office," others intended more personally for the therapist.  Some are homemade, or reflect something personal that had been discussed earlier in the treatment, while others are more generic.  Likewise, the nature of the treatment varies from patient to patient, from relatively supportive and concrete, to very "uncovering" transference-based therapy. Given these variables, there is room for some discretion in the no-gifts rule.

A number of years ago I treated a woman who painfully described feeling unvalued by others. Men only appreciated her because she gave them sex; her employer did not value her as a person, but only for her productivity. Our therapy was fairly psychoanalytic in nature. Arriving to a session around the holidays, she handed me a large, beautifully wrapped gift box. It looked store-bought and expensive.  I imagined she had taken significant time and trouble to purchase and bring it to me. With some apprehension I told her that we needed to discuss the gift before I could accept it. She was initially hurt by this. However, it soon became clear to both of us that her gift reflected her belief that I, like others in her life, did not value or appreciate her as a person — she hoped I would value the gift and therefore her. On that basis I thanked her but did not accept her gift, a decision she ultimately understood and agreed with.

It turned out very differently with another patient, an older Russian woman who saw me for supportive therapy. Around the holidays she presented me with a bottle of Kahlua, unwrapped if I recall. We had not been working with transference; I did not see how such a gift could damage our work. Also, it is customary in Russia to offer such gifts to one's doctors. I accepted the bottle with thanks, and pleased my patient. No harm done, and perhaps a bit of good in strengthening our working relationship.

Most dynamic therapies lie between these two extremes, somewhere in the midrange of the analytic-supportive continuum (more about that here). I have accepted inexpensive gifts in such cases, except when I sense that the offer is an unhealthy enactment, or that the patient is sidestepping a useful exploration. As is often the case in conducting dynamic psychotherapy, there is a balance between fostering a warm working relationship, versus encouraging reflection and insight.  In my view, a blanket rule of refusing all gifts is unnecessarily cold and inhuman for many patients, while accepting all gifts may appear "normal" but does not encourage reflection, and may introduce conflicts of interest.  The matter takes case-by-case consideration, neither unthinking acceptance nor unyielding refusal.  It should go without saying that I never expect to receive a gift; it's also helpful to note that most patients do not offer them.

Occasionally the opposite issue proves useful to explore: Whether the patient expects (or wants) me to give him or her a holiday gift.  As we all know at this time of year, both gift-giving and gift-receiving tap deep emotional aspects of our personalities, and sometimes highlight conflicts around themes of self-interest, self-sacrifice, guilt, generosity, reciprocity, and one's value in the eyes of others.  I do not offer my patients holiday gifts, but I do wish them, and you, Happy Holidays.

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.