Psychotherapy costs a lot. If paying full fee for for weekly outpatient therapy, it is usually one of our most significant monthly bills. It begs the question of what makes it worth it, and why therapists deserve to get paid such a high hourly rate.
I recently participated in a verbal tussle on an online listserve of clinical social workers. Mostly everyone in the dialogue was well intentioned. We mostly shared common values of a commitment to wide-spread communal well-being of our citizenry and a socially just world. We all had surely entered the field with a desire to ultimately help people live better lives. Our conflict was how we get there. SOme where arguing we should all basically be Rose Nylund from the Golden Girls. Some of us were more interested in being Dr. Melfi from The Sopranos.
The conflict on the listserve debate felt like a style issue but ultimately was more about the tools we use to help create change for our clients. Some of the clinicians were arguing that we help people through stances of loving kindness. Others of us were arguing for a journey that wasn’t always that pretty. The argument became increasingly polarized, with one group claiming that a non-judgmental, compassionate, loving approach was required through-out the therapy process, and the other group calling for a clear, brave, rigorous accountability that sometimes looked like conflict and tension in sessions.
There is a stereotype of social workers that routinely makes me cringe. It characterizes us as soft, gentle, kind, loving, sensitive, thoughtful, compassionate, caring, do-gooders. I could go on. We love and care about everyone and everything, likely cry at hallmark commercials, don’t get mad or impatient, are consistently emotionally gentle, want to save the world and everyone in it, don’t judge anyone because we feel bad for them instead. This does not describe me.
I mean, I am some of those things, some of the time, but I am other things too. And not just when I am off duty, but in the consulting room too. Here are some of the other qualities I rely on in the room. I am bold, courageous, incisive, direct, articulate, insightful, containing, and clear. I rely on sharp critical thinking, making connections, hearing discrepancies, seeing blockages, and pushing for new, original thoughts on the part of my client. While I suspect nice is a word that fits me okay enough in life and even in my work, I am not predominantly nice in session. I am there to do hard, complicated work, that is all-consuming. I am not there to smile demurely. I do not believe my work to be an effort in loving kindness. I consider my job one of courageous thinking.
Love happens in sessions. From the client to the therapist and from the therapist to the client. It exists in the many ways love can present itself in life. We can love an interaction, love a moment, love an energy, love a quality, and sometimes even feel a type of love, even deep love, for the client. But as with any relationships, we often have quite a range of feelings about clients.
Clients, like all people, and sessions, and therapy, can be very frustrating, irritating, boring, unpleasant, deadening, enraging, nauseating. As clinicians we have clients we like and love more than other clients, that we enjoy more or less than others, some that we even dread. This isn’t bad. Those emotions are information for us about the work at hand.
Clients aren’t there to entertain us, or make us feel good, or provide us with a pleasant way to pass the time. Their job, consciously as well as unconsciously, is to bring us the worst of it. We are there to help people with their most stuck places, their ugliest, darkest parts of self, the aspects of themselves they generally work hard to hide from others in life but hopefully expose to us.
One of the phenomena that happens in therapy is that whatever dynamics a person typically creates in their primary relationships, they will also attempt to illicit in us. If they typically feel judged by others, they will feel judged by us. If they typically judge others, they will judge us. Our work is to feel the pressure to react in a certain way, but instead of acting on it, to turn it into thoughts for analysis. This can be super unpleasant. If love were the tool, we were supposed to use to help clients, how can we help clients whose trauma makes them super unpleasant to be with? If love is the method of repair, how do we handle the client who was injured by people who loved them and so become deeply suspicious of loving connection?
Wilfred Bion argued that all interactions could be categorized as an act/expression/effort towards (L)ove, (H)ate or (K)nowledge (Also negative L, H and K, but that is way too complicated to explain here!). He proposed that psychotherapy acts should be limited to K links, and that if we found ourselves acting in L, or obviously in H, we were in trouble.
The reason L and H are trouble, is then we are “in” a relationship with the client, rather than using our relating with them to understand them. Once our actions in a session are motivated by feelings, then we have put ourselves and our own needs into the relationship … like our need to be helpful, or loved back, or valued. Bion wasn’t arguing that we should try to stop ourselves from having feelings in session, including of love and hate, but that they should become objects for contemplation rather than the basis of actions or reactions.
I remember a professor of mine in grad school, Jeffery Applegate, who was inviting the class to challenge our beliefs about what we thought would help our clients heal. He suggested some of us come into the field imagining we will bring kindness and goodness to bear on our client. And then we meet our first client who is defended against/repelled by/triggered by kindness. How will we help that client?
Some of the greatest trauma in human existence happens with a context of love. Most survivors of incest had perpetrators that they loved before, during and after the incest. The same with physical and verbal abuse by parents, as well as Intimate Partner Violence (domestic violence).
The fantasy that love would be universally experienced as good and safe is naive. Love is something a great number of people defend and protect themselves against. Even when not due to extreme transgressions of violence, all of us have been hurt, let down, disappointed, and confused by love. Introducing love into sessions with clients is introducing an unstable element and should at a minimum be introduced with great caution the same way we introduce all potent issues in sessions.
Many of us enter the field with the false hope/assumption that we can somehow give clients a sufficiently reparative experience in therapy to essentially heal them of past experiences. For instance, if a client was not sufficiently mothered/loved as a child then we can provide them with an experience of maternal love in sessions that can heal that injury.
While it is true that we can provide a client with a taste of an emotionally corrective experience, clients know and we know, that we could never possibly give them enough of what they need within the confines of our relationship. We also know that to get now what we needed in childhood does not change that we didn’t have it back then.
It is true in my practice that part of what I hope can happen in sessions is that clients can get a taste of what healing and goodness can taste like. But the essential next step is to unpack how we achieved it so that they may go out in the world to re-create the opportunity. I often feel like my work is to prepare people to be able to access healing through an intimate partnership in their lives.
In order to do that though, first clients need to know what they did not have. They need to be able to access the truth of their early suffering and absences. In psychoanalytic psychotherapy, which is what I practice, our intention is not to attempt to fill the absence, or somehow replace what they did not have, but rather to contend with the loss.
Contending with losses, absences and injuries in our lives requires open, clear eyes, understanding connections and nuances, and coming to terms with the ways we have protected and defended ourselves. Defenses that helped us survive are frequently behaviors we will need to let go of if we are going to allow others in our lives to step in to help fill/heal our childhood selves. Therapy can help clients lay the ground work for entering loving relationships to help them fill/heal themselves, but we are not the loving relationship. We are the place clients grieve all that they didn’t have, accept that they can never fully fill that void, so they don’t enter every connection sabotaging them with an insatiable amount of need and unrealistic expectations.
I am not suggesting that love is not a variable in sessions, both inside the client and the therapist. But psychotherapy by its design encourages transference. Transference is the displacement onto another person, in this case the therapist, of feelings, thoughts, and experiences associated with another person, typically parental figures. For us to make good use of transference, clients might need an opportunity to love us, but they also need an opportunity to hate us, distrust us, feel judged or misunderstood by us. If we approach the therapy in loving ways, it is hard for clients to make use of us in whatever ways they need to. It is no fun to be hated by a client. But it can be an incredibly helpful step in their journey.
The purpose of significantly limiting exposing elements of themselves in a session by the therapist, sometimes referred to as being a “black screen”, is in an effort to enhance, or at least not limit, opportunities for transference. Therapists who practice psychotherapy versus analysis, typically do not subscribe to an approach characterized by a full blank screen, but most of us are aware that anything we put into the space can easily be used by the client.
For instance, if a therapist wears a wedding ring, a client is more prone to put their conscious and unconscious fantasies about marriage onto the therapist, perhaps imagining the therapist has an ideal marriage, as opposed to their single life, or has a conflict filled marriage, like their own, or like their families. It is just as easy for the client to project fantasies onto the therapist who wears no ring; that perhaps they are lonely and sad, or single by choice of fierce independence. What is true is that we know very little about a person wearing a ring or not wearing a ring, even about whether or not they are married.
Projections are helpful in the therapy. The therapist will notice what the client imagines about them, the transference, and will be able to use that to glean information about the client’s fears and anxieties that they project on others as well. Every detail we give to our client about ourselves reduces, or skews, their ability to use us as a screen for projections.
Despite my understanding of this premise, I actually tell clients lots of information about myself, not with a specific goal of to reducing projection, but to decrease idealization of the therapist. I sacrifice the usefulness of the blank screen so that I can attend to one of my first orders of business in early therapy work, which is reducing shame. I experience shame as such a debilitating barrier to doing the hard and courageous work of therapy, that reducing it is my first goal, and idealization of a therapist gets in the way.
But back to loving. If the therapist behaves in a way that appears to be motivated out of love, kindness and generosity, then the client is thwarted in projecting ugly, angry, disappointing transference materials onto us. How can they imagine we are envious of them like their mother was if we are always so kind? How can they imagine they are a disappointment to the therapist like they were to their father if we are always lovingly telling them how great they are? There are a multitude of ways clients need to be able to make use of us as clinicians, which include opportunities to hate us, fear us, judge us, etc. and being overtly kind and loving prevents that.
As evidenced by my list serve debate, there are plenty of therapists available who will use loving kindness as their primary tool to help their clients. They will dabble in things like dream interpretation, but won’t notice when the dream is related to the client’s hate of the therapist. Still, they will be able to help: the way a loving aunt, or good friend might help. And that is great. And if someone doesn’t have a good, loving listener in their life, surely it is good thing. But in my not very humble opinion, that isn’t what I spent decades of education learning to do.
I remember a neighbor of mine once saying she was surprised by the amount of education it took to learn how to say “tch tch, there there, it will be better in the morning”. Surely there are many with this disparaging view of therapy, in part because of the mushy loving therapist stereotype. Between my Master’s degree, which is what allowed me to get a practice license, and then my advanced clinical education, which helped me start to understand the mechanisms of suffering and repair, and the proceeding decades of intensive study and supervision groups, I do not get paid to be a good listener. I was a pretty good listener when I was 12 which is why I landed in this field.
Therapy isn’t a vehicle to just feel better on a particular day. Therapy is a vehicle for untangling from the core the patterns and thinking that trip us up over and over, and that limit and distort our approach to ourselves, life and others. Transformational therapy requires getting into the muck, traversing unknown territory, deciphering clues from our unconscious, allowing ourselves to freely associate and make use of a therapist to grabble with distortions in how we relate to other people. When we visit with a loving friend or auntie, we typically feel a lot better after the visit. That is not reliably true with therapy. We frequently feel downright worse, even devastated, after a session. Unless our client is in active crises, we are not trying to sooth over their pain, and cheerlead them into positive thinking. We are trying to explore a tangled mess of suffering, anguish, hate, confusion, etc., to find its roots and tendrils. Therapy is not a bandage over an infected cut. We will have to painstakingly clean out the infection before it can be allowed to heal. Clients may well get enraged when we pour on some antiseptic. While tending to an injury with antiseptic can be done as an act of love, it can also be done simply as a commitment to helping other heal. Unlike a cut, which adults understand must be cleaned out and disinfected, it is much less clear in sessions, particular to clients, what their injuries looks like. Sometimes as therapists we are scrubbing away at an infection that a client thinks is their super-power.
My therapist and I have knock-down drag outs when he is battling my irreverence for instance. I love my irreverence, and sometimes insist it is only a good thing that needs no antiseptic. And then somewhere in the battle to inspect my injury so he can treat it, I understand the link to my suffering, and am willing to let him help me clean out that infected mess. He may or may not have feelings like love when we are battling it out. If so, they couldn’t possibly be at the surface because I am a bear when my wounds are being tended. He surely has a steadfast commitment to doing his job, which is to help me understand myself better, or he would never put up with my very defensive resistance.
Smith is an analytically oriented psychotherapist with 25 years in practice. She is additionally the Founder/Director of Full Living: A Psychotherapy Practice, which specializes in matching clients with seasoned clinicians in the Greater Philadelphia Area.
If you are interested in therapy and live in Philadelphia or the Greater Philadelphia Area, please let Full Living: A Psychotherapy Practicematch you with a skilled, experienced psychotherapist based on needs and issues as well as personality and style. Request an Appointment Today.
Here are some other posts on similar topics:
Up Selling Psychotherapy: Are Therapists Even Allowed to Do That?
In Defense of Long Term Psychotherapy (a video blog)
Go to Psychotherapy Now
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The confusion evidenced by this question is the view of psychotherapy itself. It assumes therapy is for crazy people, or at a minimum people who are not well. Psychotherapy is a tool for crafting the person we want to be and the life we want to live.
Therapists aren't just really good listeners, or solid shoulders to cry on. We aren't sages with wise advise when you are gathering opinions from folks around you. What we bring to our work is expertise in how the unconscious communicates.
It is Freud's Birthday and most Americans, even psychotherapists, see him as a joke. These same therapists routinely rely on his concepts like denial, repression, displacement, unconscious, super-ego and the like. Face it: we are ill informed.
Psychotherapy exists in the realm of the symbolic. The target of change is not the drama of the week. Therapists are not sounding boards or shoulders to cry on. We offer those things, but we have significantly more sophisticated tools to offer clients.
Psychotherapy is not meant to be limited to addressing external, concrete dilemmas of the week. The realm of psychotherapy is the resolution of central, ongoing, internal conflicts.