You go to a psychotherapist in private practice. You are broken, vulnerable, depressed, anxious, grief-stricken, traumatized, anxious. You need to believe the person on the other side of the room, in the other chair, can fix you, or help you fix yourself and is wiser than you. You sometimes even believe, or need to believe, they have magical healing powers or pixie dust.
But they can’t fix you. They sometimes aren’t wiser, and they don’t have pixie dust. Beyond the credentials, awards, psychological approach and glowing referrals, while there are good and effective therapists, some of them are ineffective or even damaging.
Good therapists are ethically sound in their practice. They know their scope of expertise, are attuned, and are psychologically self-aware. Often they are financially independent, which frees their treatment mindset to make sound decisions independent of income. They are reflective, not righteous, open to alternative theories, and have a clear goal of fostering clients to gain skills, tools, and insight. They want to help clients live their own lives independent of therapy and their therapist.
From a Winnicott perspective, good therapists are “good enough.” They are human and make mistakes. Errors are processed and repaired in ways to foster clients’ emotional growth. Good therapists, every day, are saving clients’ lives. They are just sometimes hard to find.
For every good therapist there are more bad therapists. Clients often describe seeing five or six therapists before finding the right treatment and therapist. While some of this has to do with the “goodness of fit” or lack thereof between a therapist and client, a great deal of these failures have to do with bad therapy and bad therapists.
Bad therapists can be subdivided into categories:
- Those who make mistakes based on unethical and immoral practice.
- Those who are inefficient but continue treatment regardless.
Despite the conditions, either of these situations risk the client not getting better or even getting worse. In the most damaging condition, clients are consciously or unconsciously manipulated into replicating and maintaining the problematic behaviors, actions, experiences and patterns that brought them to therapy in the first place for the first time or even time after time.
I am sad to say I have lost faith in my own profession. I am a therapist. I have spent thousands of hours working with clients, hundreds of hours in workshops, training and supervision. Over a span of 20 years I have spent $642,000 on my own therapy combination of five bad therapists and two good ones. I have helped many clients. The clients I didn’t believe I could help I have referred. I don’t know if they ever received the help they needed.
Through these experiences I have been changed and affected by my clients. They have been my greatest teachers. After experiencing many bad therapists, professionally working with many bad therapists and having clients who had many bad therapists, my mindset has been on not being one of them.
Being a therapist is hard. It takes an enormous amount of self-awareness, patience, and attunement. It takes resiliency from burnout, and secondary trauma all the while knowing and feeling burned out and even traumatized by what is heard and felt.
Therapists are trained to lend their egos to clients until they find their own ego strength. They listen to trauma, horror, bleakness, and at times the very worst of people, their mind states, and society. Therapists are a container for their client’s pain. The wounds a therapist experiences can be can be likened to asking a surgeon to cut herself every time she performs surgery on a patient. There is a risk to the work. There are good therapists who succumb to these risks and become bad therapists and there are bad therapists who get worse under those conditions. In either case the outcome may be similar: failed treatment.
Therapists are taught never to ask clients to give anything up unless it can be replaced. In many forms of therapy, defenses are main targets. The goal is to provide healthy high functioning defenses such as humor, sublimation, and altruism so the client might let go of destructive defenses such as splitting, denial, and passive-aggression. Other therapeutic orientations may provide coping skills such as self-soothing, and affect tolerance to replace self-destructive behaviors such as substance abuse or eating disorders.
The difficulty is that destructive defenses are also protective. The defenses developed to help the client survive. In the most abstract term, therapists are offering clients a shirt while removing their skin, an unpleasant trade-off. Less skilled therapists fall culprit to removing skin first, leaving the client wounded and naked.
Therapists can and do play God. They disseminate diagnoses. Sometimes the wrong, or even the right diagnosis can derail or damage a client. For example, I know of a client who was functioning moderately, ready to go to a prestigious university, and was diagnosed with Aspergers. Suddenly, given a diagnosis she disagreed with, this client lost confidence and was unable to go to school. This client became socially withdrawn and became the diagnosis she was given.
More destructively, therapists, although not commonly, engage in gross violations of conduct. This is often manifested as boundary violations such as therapists who become overly involved with their clients. Therapists have been known to request clients’ house keys, have them walk their dogs, invite them to dinner, go on vacation with them, and have sexual relationships with them, or enable their spouses to have sexual relationships with them.
Therapists are privileged to hold the most intimate details of their clients’ inner and outer worlds. They hold the key to their kingdom. Therapists have been known to terminate therapeutic relationships only to go on and have personal relationships with clients. In clear abuse of transference and acting on countertransference therapists have been known to move their clients’ lives around like chess pieces and insert themselves in the role of friend, parent, or partner. In these cases the therapist violates pertinent therapeutic boundaries, trust, and behaviors in ways that potentially destroy clients’ psychosocial lives.
The ways in which the therapeutic relationship can be damaging are the same context in which it heals. Therapy must be emotionally intimate. Clients’ biggest demons, deepest shame, and most entrenched pain are often revealed. The good therapist must respond in an attuned and empathically connected way. In these moments of emotional intimacy, boundaries may be breached by the bad therapist and the client can be irrevocably harmed.
Regardless of the therapeutic model, the therapist’s attunement and empathy are emerging as the key variables in psychological healing. Socially and culturally, many people are deprived of attunement and empathy. Because of this void, therapists both consciously and unconsciously function like drug dealers. In ways remarkably similar to the methods of drug dealers, therapists initially offer free drugs. Initial hits of empathy from therapists can feel like heroin. Empathy and attunement, desperately needed yet lacking in our society is like a drug, and clients can become hooked. With a skilled and good therapist this attachment will be nurtured with diligence. The client will learn to internalize empathy and attunement, separate and live their lives. In a bad or damaging therapy the therapist may mishandle the natural transference-countertransference dyad, and the client’s addiction to empathy may lead to dependency, sometimes co-dependency, and even disastrous therapeutic outcomes.
Attachment theory describes how therapists can be a secure base for clients. In Bowlby’s model, clients can safely explore the world and live their lives because the therapist is safe to return to. Although the theory is elegant and eloquent, the harsh truth is that therapists are not parents and adult clients are not children or their children. While the model does work, it does so only when the therapist has a metacognition of the potential risks in the dynamic and the implicit need and goal of separation. Otherwise the therapist becomes both pimp and parent, in a destructive dynamic.
Therapy can work. There can be good therapists. But there is no pixie dust or magic. There should be no false hope or promises. What’s needed is genuine attunement, empathy, boundaried connection, and unburdened emotional contact. Therapists must continue to learn from their clients, never believe they know all of the answers, strive to be good enough and always remember the goal is for the client to go forth and live.