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Sunday, May 1, 2011

The Imperfect Therapist

                                      What can you expect of a therapist?
Good therapists, bad therapists, outright quacks, inspired brilliant therapists, terrible therapists, therapists who have a seemingly endless reservoir of compassion, and, the truly gifted therapist---they're all out there.  I get some of the fall-out in my office from the not-so-good counselors and it is sometimes astonishing to me, the things I hear clients tell me that happened to them with another therapist.  Some of the outrageous things I have heard include, the therapist falling asleep in the session, the therapist reprimanding a patient for nervously wringing her hands in a first session, the therapist asking a question and then getting angry at the patient for their (honest) answer.  And the list goes on and on.  The resilience and determination of these people who got unlucky on their first try but still persisted until they found someone who could actually help, is laudable.
Therapy is a valuable and wonderful resource for us all.  In the post titled, Cute Client Comment, I have a link to a concise article about the benefits of psychotherapy.  But to be effective, it has to be the right match.  No therapist is going to be the best choice for everyone.  But, there are some, who are almost in a calling to the profession,  and those, will be best for most people.

You would think, with all the training* that we are required to get, that we would all be excellent helpers, but, just like doctors---some are better than others.  Part of the effectiveness of the therapist is in the match or, that elusive thing we sometimes call, "chemistry":   How do you feel in that person's presence?  How's the interaction between the two of you?  Do you feel accepted?  Does the therapist seem comfortable in their job, comfortable with you, and in considering the problems you present?  Does the therapist seem to have less anxiety than you do?!
 
As time goes on, you should begin to feel that you are in a real relationship.  A professional helping relationship is, of course, different from your friendships---you want it to be; that's why you're there.  It is mostly one-sided, you will not learn much about the therapist's personal life.  They may share a little, here and there-especially the more relaxed, experienced ones or they may share for a purpose:  There may be something you are struggling with and the therapist herself has a good example from her personal life to illuminate the topic.  Or, sometimes a therapist may share with you that something difficult is going on with them in their own life so that the patient doesn't sense something is wrong and misinterpret it to be about them.  I have done both of these.  But, generally, a therapist is trained to be not too revealing and there is solid scientific reason for that.


If you are currently in therapy, there are a few things you should not hold against your therapist.  The therapist may not always remember every detail of your life.  This is especially true if you don't attend regular weekly sessions.  There's something about that consistent contact that seems to keep the file on you in the forward position in the therapist's mind.  But, think for a minute how much a therapist has to remember...They have to keep the names, relationships, events, and facts of a person's entire life---whatever has been shared in the therapy office---in their immediate memory.  And the therapist has to do this for a number of people.  It isn't easy to remember all about a person you've never met but we must do that as, often, patients want counseling about their relationships with other people in their lives.  Thus the therapist has to remember and retain an impression of, and even facts about, that other person-so important to the patient but, only heard about-by the therapist.  Sometimes my patients will bring me a picture, a snapshot of their family or, a particular person they have issues with.  That helps me to fill out the image in my mind.
A reason that I may miss a detail (and so I imagine other therapists may do this too-I hope they do!), is that facts are not where my focus is.  I am looking for the deeper meaning for the patient or I am working on delineating a pattern in the person's functioning or I may be noticing an incongruency that seems important.  This kind of listening is what is different from what one can expect from a friend.  It is what you come to a therapist for.  So, try not to be impatient if a therapist forgets one little fact.  Try not to say to your therapist:  "I told you that!!"

Also, while it appears that therapists make big money, we don't.  The public sees us getting anywhere from $40. to $200 or more, per session, and multiplies that by 40 hours per week.  Well, with all the paperwork, phone calls, treatment planning, and, yes, sometimes worrying about people, we do clock in 40 hours, and then some.  However, a full-time practice is but 20 sessions per week.  Some practitioners can't tolerate even that much and only see a few patients---6 or 12.   (The last survey by my professional association reported an average fee of $70. per session and this does not subtract rent, phone, insurance, licensing fees, association dues etc., in other words, overhead). This  is why private practice therapists usually don't have secretaries or receptionists.  Sometimes in a building that rents to  therapists only, a receptionist salary can be shared.  But, by and large, therapists do all of your letter writing, filing, insurance claims, report writing, copying , etc. for you, themselves.  The nice part for you is that it all is, really private.  No one else sees anything to do with you but the therapist himself.  If you pay for your own treatment (don't use insurance), it is really exclusive because, in that case, even  insurance company personnel will not see your paperwork.
  So, just don't be annoyed if the therapist asks you to do some part of this yourself or maybe complains a bit about your insurance company (most are difficult and time-consuming to deal with), or isn't as quick as you would like with whatever---writing a letter for you, having your account at the ready, etc.  Each patient has a different payment method, and this the therapist also has to keep track of.  It can be complicated.  Most of us don't like this part as we are clinicians and were not trained to do clerical work (and aren't good at it!).  We want to do the interpersonal work.  So, if you have a therapist you respect and are fond of, help him or her out by keeping it (the business aspect) simple.
Most of us are used to the doctor's office where all paperwork is handled by support staff.  When you have a therapist who agrees to do this for you, they are actually doing you a favor.

Therapists  may sometimes behave in ways that seem really odd.  If you don't fully understand the powerful constraints of confidentiality, you may be taken aback when you accidentally bump into your therapist in a public place and the therapist doesn't run over to you to say "Hi!"  We must wait to see what you do---you may be with someone, you may have any number of circumstances at that time, you may for some reason  not want to reveal that you are acquainted with the therapist; so the therapist will follow your lead.  They try to gracefully await a sign from you as to whether or not you want to be acknowledged.  But, it is awkward sometimes.

The other part of that problem is, what if the therapist is out with someone?  If you were to speak to each other, the polite thing to do is to introduce people.  But, if the therapist introduces you to her companion, she cannot say, "I'd like you to meet Mary Smith, one of my patients."  This would betray confidentiality.  Probably, a friendly nod is really the best bet most of the time.

Therapists are not allowed to have what is referred to as "dual relationships".  It may seem so natural to you to invite your long-standing, beloved therapist to your daughter's wedding.  But, the therapist cannot attend.  The definition and protection of the therapy relationship requires it to be kept separate from the other parts of your life.  We can't go into business with you,we aren't even allowed to do bartering; we cannot exchange our services for yours, we can't ask you for hot stock tips, etc!!!  (You can, however, give us a raise...!)

You can and should expect to be treated with regard and respect by your therapist.  Your therapist should be genuine and straightforward but professional in conduct.  Your therapist should not be expected to be and should not pose as, a 'guru'.  Your therapist should be human and compassionate.
In this unique, not like any other, sort of odd relationship, can you expect your therapist to care for you personally?  Maybe, but, not necessarily:  I have heard some therapists say that they can treat anyone, whether they like the person, or not.  Not me.  I have rarely refused to treat anyone, but if I can't find something in them to feel for, I would.    I look for that loving part or that growth motivated part or some part that I can connect with in a positive way, personally.  But, usually I find it easy to like the people who come my way.  Many therapists will become quite fond of a patient if they see them regularly for a long time.  The close attention that a therapist pays to a patient, the effort to understand what is beneath the surface, the careful listening, the thinking about that person and their issues, all of this leads to feeling affection.  It's normal; therapists are human.  At the same time , the therapist must maintain a professional position in relation to the client so that the client can feel that they can depend on the therapist.  And the therapist always has to remain ready to hear that client decide to say good-bye.

 There's so much to say on the subject of what you can expect from a therapist but this is already a long post.  If it gets a lot of traffic, I'll write more on this topic.  Be sure to let me know if you have any questions about this.  In any case, I hope that, in your therapy experience,  you are happily surprised.  I hope what I've offered here  helps.
If you'd like to read another therapist's offering on this subject, here's a link to one I think is down-to-earth and thorough.  It's also a chance to see the difference in style between she and I.  As I've mentioned, each therapist is so different and thus, you have to find the one who is a match for you. http://www.therapist4me.com/what_makes_a_good_therapist.htm
Here is another one with yet a different tone:  http://www.
wheneverydaymatters.com/?p=96
 
*The training is slightly different for each license but for my license, this is required: 19 years of school (not counting nursery school!), 3000 hours of supervised (unpaid) internship hours, an oral and written exam from the state and 36 hours of continuing education every 2 years.

Please join the discussion and leave a comment.

Addendum:  I said I would write more on this topic if it got a lot of traffic.  Turns out this has become one of the All Time Most Popular Posts and continues to be.  So, I did write more on the topic, as promised.  Here is Part 2:  http://therapiststhoughts.blogspot.com/2012/03/look-before-you-leapthe-imperfect.htm  And, you can look forward to more; there is a Part 3, in draft.

24 comments:

  1. Excellent... talk about a summary of years of schooling all in one post, I can understand why you say it is long. There is a lot that goes into a therapist, what to say/do and how to do it all...

    I used to tell people, imagine Wal-mart being run by 2-3 people... it's can be very over-whelming... taxing, and... yes, I'll say it, sometimes impossible to do it all to perfection.

    Love the post. (and the ducks).

    Mikel

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  2. Thank you for this blog! I recently ran into my therapist of 1.5 years at a local place. I walked up to her and said hi, but told her I wasn't going to "talk". She said it was ok and proceeded to tell me that she was having a horrible evening and things that were going on in her life. I listened. She did ask how I was doing, but I kept it to rather idle chit chat and told her that I would be seeing her in a session soon. I just applied to graduate school for counseling, so she asked me if I heard anything. My therapist and I seem to have this great chemistry!
    I don't want to overstep any boundaries with her though.

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  3. Dear Anonymous, How wonderful that you have found a therapist who is such a good match for you. I enjoyed your comment and hope you will continue visiting my blog as you go through graduate school.

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  4. Paula,
    I'm the anonymous 11/13/11 poster. I haven't been accepted to grad school yet for counseling, but I will know by the end of next month.

    Have you had experiences with clients going to school to become a therapist while they were seeing you? What does your relationship look like with those clients? Is it more of a mentor-like type of relationship?

    The school that I may attend does encourage their students to go to therapy to see things from a client's perspective. Continuing therapy with my therapist seems to be the natural thing to do. For some reason I got it in my head that my therapist and I were terminating due to insurance reasons and the assignment she asked me to work on. I only see her every 3 weeks to a month to check in and discuss difficulties that I'm having or to explore things that come up. At my therapy session yesterday we talked about our relationship. She sees that we've worked through my crisis (marital discord to divorce and abuse issues) and that her role is more to be my guide and mentor as I go through school. I see it that way too and have for a while, but we didn't really talk about it. I think we had a misunderstanding a month ago, so it was nice to clear that up yesterday.
    Anyway, just wondering about your relationships with clients who are schooling to become counselors.

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  5. Dear Anonymous, Yes I have had a few students as patients; it was the same as any therapy relationship; all occurrences in the patient's life and thoughts, and feelings are 'grist for the mill'. The only difference is that the patient knows that their therapist has been through the experience they are having. I think it's best not to limit your therapy relationship by naming it something different like mentoring. It's a wonderful thing to have a place in the world where you can go and bring anything that concerns you.
    It's so good that you are able to talk out misunderstandings with your therapist; that, in itself, is gratifying. Let us know when you start school!

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  6. Thank you, Paula!

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  7. Hi Paula,

    Just wanted to let you know that I was accepted to grad school for counseling. I start classes mid June!

    I love your blog!

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  8. Congratulations dear Anon.!!! You are in for an interesting and rich experience. Keep us posted on your progress.

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  9. I just stumbled upon this.. I really like it! I am an LPC in Alabama.. thanks for writing about our profession!

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  10. Welcome BhamLPC. Welcome. I began writing this blog to offer stimulation and support for personal growth for my readers. But there was a clamoring for information about therapists themselves. So, besides this post there are a few others (Label: About therapists)and more on the way. As someone in the profession yourself, I'd be happy to have you add to these attempts to reveal what it's like to sit in our chair.
    I hope you will become a frequent visitor here!

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  11. After reading this, I wonder what my T really thinks of me as far as the whole "like/dislike" idea ... tempted to ask him, but also afraid of the answer. Do you think there is value in asking? As far as the memory, mine frequently has memory lapses about major things; I've learnt to accept it is his stuff and not mine which helps.

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    1. Hi Caz. Welcome. I think this is the 1st time I've seen you here. I think that you should feel free to ask your therapist anything you want to. It is on the therapist then to decide how to respond. Remember the other parts of what I wrote on that, regard, respect, compassion, etc. are some of the attitudes you should feel coming from your therapist to you. What you wrote about the memory part tells me that you are in an actual relationship in therapy-in other words, relationships require give and take; sometimes one or the other has to overlook something, esp. if everything else is good.

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  12. Thanks Paula :) I am just reading your blog for the first time today. Already it looks like a lot of helpful and interesting posts you've written (and some funny pictures). I do feel those other things and he has mentioned respect before and definitely shows compassion and care; maybe that needs to be enough and the desire to be liked set aside. It is definitely a relationship which I'm growing and learning in.

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  13. Hi Paula,
    I was the Anon poster from this past fall and spring. I just finished my two counseling classes for the summer. I loved it! All the work of one semester squished down into 6 weeks was tough, but I survived! I did really well considering I'm also caring for my two children, working part time and had to attend court ordered mediation with my ex during those weeks. I start my 3 fall classes in a few weeks. I'm looking forward to it!

    Thank you for writing your blog! I enjoy reading it. :-)

    Anon/B.D.

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  14. hi Anon! Good to have you back. Or, to hear from you again. Seems like you have a lot on your plate but, mostly really good stuff. I hope that your Fall classes are wonderful-I am excited for you-remembering my grad school experience. But, keep reading here too!

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  15. I'm going to read both articles that you linked. This was a very enlightening post for me. I went through the stages of transference at the start of therapy. I first had a hard time seeing my therapist as anything but perfect and when she didn't live up to it, it destroyed that world. I now see her as a person, but I realize I wanted her to be perfect because if she was perfect that meant I could one day be perfect. Whatever the hell perfect means.

    I am very grateful for my therapist. We are in an interesting position right now. I have a hard time with the therapist-client relationship and resisting the urges to push it into more of a friendship. I'm not used to the one-sideness. I have more to say on this matter, but I don't want to write a long essay in your comment section hahaha.

    THanks for the post.

    www.findingonespath.blogspot.com

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  16. I stumbled on this article when i googled "i gave my therapist pictures". I have a really hard time vocalizing my opinions, and so i typed out a letter with pictures of my family attached. I didn't expect her to read the letter out loud (i didnt know what to expect). Anyways, i've probably seen her 15 times this year weekly and i am becoming more interested in her life. I bumped into her right after a sesson ended i was grabbing lunch and it was a bit odd she seemed surprised to see me.

    It's takena REALLY long time to trust her becuase she doesn't seem very connectable but she does a really good job with answers, resolving things, and i think she genuinely cares about our sessions.

    going back to the business aspect, i was really annoyed with her for taking up 15 minutes of one of our therapy sessions to figure out how much she owed me because my deductible got met for a visit i had paid for. I felt that she should have figured that out on her own time, but reading what you wrote here it doesnt make me feel so bad anymore.

    I am really great with connecting with people, but she seems very standoffish. It's weird , and i know this has something to do with trying to keep boundaries in the therapy realtionship, but i just poured my heart out and shared intimate details about myself that i've never todl anybody, and then our hour is up, she says "ok, see ya" and that's it. I would love a hug or pat on the back, but it's just stone cold. So i dont know how a person can act like that, but i think she's trained that way. i'm rambling.

    thank you !

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  17. I constantly go off on my therapist then I feel bad. Hes never ever ditched me out . The crazy thing is, he sees me for free twice a week. I know he has paying patients but i found him through this program. Anyway after reading this blog I realize how lucky I am. Even with that being said, I still get nervous when I feel like I'm5 getting to close and I push him away bu being rude, or going off. He still hasn't given up on me, which is new and not what I'm used to.

    I guess what I want to know is if you have ever experienced that with a client and if so, do you get angry? And how is it that you're able to control yourself when a client responds to you like that?

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  18. We can, however "give you a raise"?? Are you kidding me? My therapist charges $175 per hour, and he has to keep track of fewer than 40 patients per week. Do you know how much I make as a substitute teacher? I make $8.00 per hour with no benefits, and I have to keep track of about 200 kids per day!

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    1. I'm sorry....but this made me laugh

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  19. hey Paula. I just recently came across your blog. I have been seeing my therapist for almost 2 years. I'm just now beginning to trust her fully and have notcied I'm very attracted to her. (I'm a lesbian and she knows this.) I know this isn't transference. Lately, I feel we have gotten significantly closer. I've began to open up a lot more to her. During this past fall I got really bad into doing xanax. I actually had overdosed before coming to therapy. I had completely forgotten I had an appointment until I got a phone call. My therapist immediately notcied I was high and something wasn't right. She got me help and looked absolutely terrified. She told me at my nezt appointment that she cared about me. I told her she didn't. But she convinced me she does and she has clients she could care less about. Well recently she has had me come to her DBT group. I've noticed when she signs us out she stand rather close to me compared to others. Also she's put her hand on my shoulder and then acted awkward and pulled away fast. in our last session I got a bit emotional and had my head down but could see thru my hair and it seemed she kept sitting further back and was looking at me then I realized my cleavage was exposed and covered myself which she then leaned forward. Is there a mutual attraction here? Its awkward for me I can't look her in the eye but she looks at me for long periods of times. I was to say something but I've never been able to connect to a therapist due to trust problems and a past abusive therapist. I'm terrified if I tell her that she will send me to someone else. She's voiced to me since things have gotten deeper in therapy she's afraid I will start cancelling my sessions. I look forward t seeing her tho. I feel disgusting for being attracted to her and feeling dependant. I feel like its become a problem in my dating life which is empty at the moment. What do I do? And what are these signs saying? Thanks.

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    1. Hi,thank you for sharing.Im a lesbian
      too and had similar experience with therapist,she actually was very close to me(not sexual,though i was attracted to her)she always was saying that she cares for me,she even cried when i told her about my mother committed suicide when i was 17(she was suffering from schizophrenia)and all that pain,loneliness,anger,tears.She didn't keep distance with me(that therapiest)i got very dependant on her,which wasn't good at all.I was on and off with her for 9years!was living in fantasy"what if,she really have fillings for me?"yes,she did have but not the one i needed in a real life.I understand you,but please don't waste 9years!;)its a torture leaving in illusion.Boundaries are there for a reason and its a red flag for you if she is patronising you among the others and you feel that.Be careful.Though it doesn't mean that she doesn't like you.Follow the rules and you will be fine.Love and light.

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  20. Hi Paula
    Thanks for what you've written. I guess it's natural curiosity to know how our therapists are thinking. I'm currently in therapy, but its only short term and I see a volunteer counsellor. My sessions are coming to an end and although I'm making good progress, I'm not looking forward to the last session. Should I be discussing this now to prepare? Do you think my counsellor will miss me too?

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  21. My T got mad that I didn't have more money to pay toward my outstanding bill even though she said I could pay it back when I got tax money back. When she got mad (when I was paying her), she said I think we should change our sessions to every other week. I've been seeing her for over 4 years. I was shocked and incredibly hurt. I'm not sure what I want to do...quit! I've lost trust in her. Not all trust but I'm sure guarded. Since...she has welded her power!

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