Therapeutic relationships

Back at the beginning of my practice as a psychotherapist, a patient once asked me why I was a therapist. I thought of several answers. Helping others is a good thing, I thought, an answer that would have pleased my grandmother. Bill, a therapist who was my consultant, laughed and said "Bullshit. It's an easy way to earn money sitting down". I thought at the time that his answer was both honest and clever. It certainly minimized altruistic and "helping" sorts of motives, both of which I was beginning to distrust. I now recognize that his answer was only partially true and in fact trivialized an important question: What does the therapist get out of doing therapy? Is it just money? Is there something wrong with enjoying one’s work?

Why had I learned to distrust altruism? Painful self-examination in my consultant’s office showed me how often other more selfish and personal motives were concealed behind the altruistic label. When I gave the "helping others" answer, I was concealing from the patient AND from myself the pleasure I got from imagining myself in a "superior" and knowledgeable position, of being the helper to a less wise person than myself. I liked the idea of being admired, of being thought of as wise. One of the problems with being paid off with admiration and humble gratitude is that there is no way to enforce being paid in that coin. My self-worth was entwined with the patient rewarding and reassuring me with gratitude. So the patient would gradually become aware that he or she owed me more than money, and that our contract had been somewhat dishonest from the beginning.

Bill's point, poorly made but valid, was that the patient owed us no reward of any kind other than money He meant we had no right to exploit patients who rely on us. The idea that the patient owes us something besides the fee, such as gratitude or admiration or even love, is a betrayal of the trust we rely on for conducting therapy. But we're not just in it for the money; Bill was wrong when he said that it was easy work. It's hard work, in fact. There are many easier ways to make money, but there are intangible rewards for me in addition to the money, even though those rewards don’t come directly from the patient.

On a surface level, it's important to me to believe that I help people, that in some way I help them diminish their suffering. On a more primitive level, I am rewarded as well by having the opportunity to gratify my interest in solving puzzles. Every time I see exactly how a patient’s previous life experiences, choices and thoughts give rise to present puzzling and complex behaviors, I have a sense of satisfaction. I see once again that there is after all a logic in human behavior. Behaviors that appear to be puzzling and even self-destructive are meaningful, sometimes in a primitive way, but they can be understood. No matter how irrational or even bizarre, they are not random. They are the direct outgrowth of decisions and choices the patient has made in the past. When the patient and I recognize this we have a sense of things falling into place and making sense. The patient recovers his sense of autonomy and power and feels less controlled by forces out of his awareness.

Patients begin the therapeutic relationship experiencing much of their own behavior as puzzling, illogical and painful. They have lost some of their sense of autonomy in their lives, and yet they do not see how they can behave differently. They experience important aspects of their lives as out of their control, and their self-deception conceals from them their own responsibility and their power to change. I often feel frustrated and alienated from them as their friends and families must be. I feel distanced by the apparent impossibility of understanding their behavior and feelings. Intellectually I am curious, then frustrated by their unwillingness to behave “reasonably”. The conflict appears to be initially between the patient and me, but is really inside the patient even though not clearly a part of their awareness. I struggle to understand them; they struggle to communicate with me more clearly, and in that struggle issues begin to clarify and emerge. The need to be honest, as honest as we can be with each other and ourselves, and at the same time to be understood by another human being, makes the therapeutic relationship more intense than others.

As time goes on and as the struggle continues, I begin to understand the patient more. Their behavior begins to make sense to me and to them. As we begin to see how the previous habitual and only partially conscious choices the patient has made have led them almost inescapably to where they now are, they begin to feel the freedom to make new choices. At the same time, I see increasingly how much alike we are, how human and essentially simple we are, and I feel re-connected to both the patient and the human race. Our struggle and attempt to be honest with each other reinforces and teaches us how to be connected.

I was recently re-reading Irv Yalom’s excellent book of therapeutic vignettes, Love’s Executioner. In particular I was struck by the recurrence of one theme: his finding a way to like and show liking to people who were not easily likable. More and more I notice that the patients who do the best in therapy, who make the most profound changes in their lives, are exactly the ones I find that I like. My liking for my patient grows with my understanding of the patient’s life. I wonder frequently if this capacity to find a way to like difficult people is something that characterizes competent therapists. Perhaps people only feel the freedom and confidence to change in an atmosphere of genuine liking and mutual respect.

In therapeutic relationships there is a built-in imbalance that is not tolerated in regular (i.e. not paid-for) relationships. In normal healthy friendships and within the intimate conversations that accompany them, there is a certain balance in the flow of revelation and honesty. We expect to share thoughts. We expect to take turns listening to one another. We need to experience mutual respect and equality of power or status in the relationship. The flow of help, understanding and tolerance must generally be two-way and over time it also must be in balance.

Therapeutic relationships, by their nature, are unbalanced. We need to find balance and reciprocity in our relationships, and when they are more one-sided, where the flow is predominantly one way, they can become toxic. Partners in unbalanced relationships experience increasing resentment and feelings of exploitation or alienation. The money or other value that changes hands serves an important role in maintaining the balance in therapeutic relationships, without which they eventually become toxic.

So Bill’s clever response has an important element of truth in it. What the patient owes me is only money. Money is an OK thing, but there are many ways to get it. What I get from the relationship (not the patient) is the chance to practice my craft well, the opportunity to grow in understanding, to solve riddles, and to become more connected to my own humanity and that of others. And it feels good to like people.