What Are Therapists Up To?

There was a man who came to me and told me that his therapist had comforted him on how to deal with his heart problem, and he was doing better now. Huh? Without telling him that I thought his psychotherapist was a lazy fool who enjoyed charging by the clock and seemed to believe that all he had to do was to keep his patient in the room and talking for the entire hour, I simply said I had probably spent more time studying the heart than his therapist had, so I could maybe be more help. Psychotherapy is subjective at best. Psychotherapists of any qualification known to me require “supervision,” or reporting of their cases to someone (presumably) older and more experienced who can “guide” them. The better of the psychotherapist supervisors will sometimes ask to see the patient, especially early on in supervision, to get at least a feeling for how the trainee is reporting the experience and the patient. Several trainees have approached me at various times in my career about supervision. I have supervised generations of psychiatric trainees and therapist trainees in university settings. I have even done a little in an insurance setting. Nobody has ever chosen me as a psychotherapy supervisor in a private setting. There are many reasons of this that I can figure out, judging upon what the potential trainees say.

1. I charge too much (more than doing the therapy myself, as I am giving people skills to use)

2. I actually expect people to work. I have been told I am too”results oriented” in many aspects of my life. Some people have even told me that my approach to psychotherapy is like an “ex-surgeon,” because I like to get the job done and get out. I think psychotherapy needs specific goals and objectives, a specific time frame, and specific ways that could actually achieve those goals and objectives.

3. I am “by the book,” although I have some flexibility as to which book. (This is a direct corollary of the above.) Although some people believe that psychotherapy comes from vague personal directives, and that the efficacy of therapies is impossible to measure, there is research done where therapists are given a “therapy manual” which they follow and document and there is good stuff. Sure, there is placebo effect, and that is hard to measure.

But there are ways to do real science here, not slumber into the poofie-cloud of feelings, which are soft, soft science in their stongest moments. If nobody wants to fund research in this direction, it is not my problem. I have tried to do things. An article like this one is courageous.

Now there are some things about psychotherapy which I know are true. Way back in the fifties, when the world was a bit more innocent, (and there was no internet) there were some nice, scientific articles in something called the “American Psychologist” Journal. It was shown, quite nicely, that the likelihood of someone to get better in therapy was a direct function of how much they wanted to get better, and of the degree of trust in the psychotherapist. The “type” of therapy used did not seem to matter much.

Seems to me this sort of data is useful today. Perhaps the worst hubris of modern science is the belief that people who came before us were stupider than us. They were not.

The following are absolutely true examples of how therapists have spent hours with patients, and gotten paid for it. I do not have and did not have any power over this, but I did the best I could to make sure I did not condone such things.

I need to say it again, these are real as far as I can tell. Patient reports to me, therapists who did “sidestepping dances” when I tried to call them on this.

One hour spent bungy-jumping. The therapist said it was to build the “patient-therapist relationship.”

One hour spent taking a patient to a wild animal farm. When I asked the therapist what was discussed during this visit, he told me “wild animals, of course.” Presumably another case of shared experience to increase bonding, but this therapist had not even the presence of mind to tell me that.

One hour spent in a darkened room, lit only by numerous candles, with rhythmic repetitions of “Om” and other “mantras.” The patient fell asleep for at least 15 minures by her estimate. (Obviously we did not know what the therapist did during this time.) The therapist said it was to teach the patient new ways to relax.

One hour spent (or at least the greater part of it, the only thing either patient or therapist could remember) discussing the fate of one or more local professional sports teams. This state of affairs was repeated to me by a few patients before I ceased using this therapist. Of course, as with everyone else, I talked to the therapist first. The therapist explained to me that this was an important part of male bonding and might be difficult for a heterosexual female such as myself to understand.

So the question becomes, how do you get the most out of a therapist in this crazy world? There is one concept which I love and live by, that is called the “therapeutic contract.” This highly credentialed British psychotherapist may have the most complete documentation on this I could find on the net. And yet, this tells you little about the quality or efficacy of therapy. And I personally would never, ever go for anything open ended. Periodic re-assessment is essential. But this gives the idea of how I would suggest thinking. Written documentation is not always needed. The important thing to know for a patient is why he or she is there, what he or she expects to have accomplished, how and for how long. Although there are no real guarantees, terms need to be discussed. People devote more energy to seeking out an appliance or automobile store than they do a therapist.

There are professional societies for those who are credentialed, with whom complaints may be filed. You may, however, not wish to be in therapy with the person about whom you are concerned if and when you file a complaint. You may actually need another therapist to help you decide on this. It can get complicated.

Keep it simple. Use your head. In this choice as others. Be careful of insurance companies running your life. Use your head.