"Home Again," What makes for good psychotherapy?
An anonymous and fictional person returns to psychotherapy after many years of treatment with me. As he enters the office with a smile he spontaneously and with relief said, "whew, home again." What does this say about psychotherapy?
We talk a lot about types of therapy from Psychoanalysis to Cognitive Behavioral and Dialectical Behavioral and then to EMDR and about the advantages and disadvantages of each. However, one of the things I have learned over the years of my practice is that regardless of the type of therapy that is practiced, it is the relationship between therapist and patient that is the most important ingredient towards regaining mental health.
What is there about the therapeutic relationship that I believe is important?
First, it is that the therapist listens carefully to what the patient is discussing. People want to feel listened to and many of those who enter psychotherapy experienced the frustration of not being listened to during childhood and in their present circumstances.
Second, people want very much to feel understood about the things they are explaining. Many people enter therapy with the apprehension that they will not be understood particularly because no one seemed to understand them in their relationships previous to psychotherapy.
Third, people want interaction with the therapist rather than being met with silence. Some patients complain that previous therapists were great listeners but rarely said anything. Whether this is true or not it is important that therapist be someone who comments and interacts. That is part of feeling listened to and understood.
Fourth, people want to believe that the therapist cares but without becoming emotionally involved. Many patients have reported to me that they prize my objectivity and know they can rely on that while being aware that I do care.
Fifth, the therapist's memory is extremely important to the patient. There have been many circumstances in which a patient was surprised that they did not need to repeat a story or description because I remembered. They simply assumed that I would not remember. This assumption is based on years of experience with parents and others of not being cared about and cared for. In fact, it is often a surprise to some patients that I find them interesting and am never bored. By the way, this is absolutely true because I am fascinated by human behavior and never seem to tire of listening.
Sixth, many patients are fearful that they will be judged by the therapist. Of course, this is often a projection of their self judgment but it is also transference of experiences being judged by parents and other authority figures.
Seventh and perhaps most fundamental to everything is that people want to know and feel that they can trust their therapist and feel safe in the therapeutic setting. Without trust and safety progress cannot be made. Trust and safety does not occur automatically but develops as patient and therapist work together and build the foundations of a therapeutic relationship. It is within the safety of that relationship that patients can learn new and healthy ways of relating different from what they experienced earlier in their lives.
Eigth, it is really important that the therapist's office be a warm and pleasant place that is comfortable for both the patient and therapist. The relationship with the therapist is also with his office and that is why the returning fictional patient above felt like he was home again.
All of these eight factors are important for therapy to work regardless of the type of therapy used.
What are your experiences with therapy and what are your points of view? Your comments are welcome and encouraged.
BITTERLY DISAPPOINTED - PAIDFORANEAR - Jul 6th 2009
After 3 major traumatic events and major depression mixed with gad, I finally talked myself into going to therapy. I did not trust people and that was part of what kept me away. So, I saw the same therapist regularly for about 5 weeks, and was hoping that this emotional risk would pay off in better mental health. The last time I saw this lady for therapy, she asked me something about how my mother was. Well, you see, the subject of those weeks of therapy was my trying to recoup whatever mental health was possible after the murder of my mother. I could not believe that she had forgotten my main problem after all the tears and hours of pain she witnessed. I stopped seeing her but continued seeing the psychiatrist at the same office. I reported this to the psychiatrist who, the first time, pretended that she did not hear me, and the second time a couple of minutes later advised me that she "..Could not speak to that." Trust violation number two, same office. I still "use" the shrink and I do mean "use" because their office has already charged me for the most expensive visit which is the intake, and mainly because I truly am impressed by her nurse, whom I have most of my dealings with; the psychiatrist just writes the script. Years earlier I had like 2 visits with a therapist and I had gained maybe 50 pounds and wanted help on how to fight the battle that I knew really was not really about food. She informed me, and I quote, " I refuse to discuss (your) weight issues." Now, being a person with a psych major who has great empathy for people in emotional pain, I am not impressed by the world of therapists out there. It seems many in the profession are not nearly as altruistic- or even as human- as they need to be. I now use whatever self-help I can find, which was one way that I coped all the years before therapy.