You’re the Boss

Back in the days before Noah’s flood, a psychiatrist would take care of both the medical and the psychotherapeutic needs of a patient. Of course, we all knew that it took “a different kind of doctor.”  In the old days they said it had to be a Jewish doctor who was afraid of the sight of blood. I am not.  I mean, I used to be a surgeon so I put that one to sleep.

Then there was some kind of a cost imperative, probably heavily endorsed by insurance companies. Patients saw a doctor for the “medical stuff” and a therapist (who had definitely spent more time learning to be a psychotherapist than the psychiatrist had.) Now, I hear that, with a wild increase in the prevalence of psychiatric illness, there are less people in therapy than ever.

Just last week, a very ill patient told me she did not need a therapist. “You talk to me very nice.  I don’t think I need to talk to anyone else.” I never tire of explaining, “with a therapist, as with me, you are the boss and a doctor or therapist is the employee.  You have to agree what you want to accomplish, and then do it.” If you don’t know what you want, it is unlikely to happen.

I have heard too many open and indefinite relationships where therapists and patients do not have a clear map.  We used to call it a “therapeutic contract.” People want to accomplish things when they pay for therapy.  Some people make and sign written contracts of what should be accomplished and how many therapy sessions before progression to the goal should be evaluated. If you want to drive to a city, you have to find it on the map before you plot a route there. You are the boss.  With insurance or cash or something, you are paying a piece of a doctor or therapist’s salary. You are the boss. Make sure your therapist is doing the job you hired them on for.

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