Two of the most commented posts on my blog are about charging patients for missed sessions and how psychotherapies end. As there is no single correct approach to either of these, there’s plenty of room for practices legitimately to vary, and plenty of room for patients, i.e., most of my commenters, to express their likes and dislikes. By my reading, many commenters assume that cancelation and termination policies mainly feed their therapists’ wallets; they tend to dismiss clinical rationales that are not obvious common sense. I’m often drawn to defend the field and their therapists, and to point out that insight doesn’t always come painlessly.
Other times, though, I’m just dumbfounded (or the more hip term, gobsmacked). One therapist reportedly starts sessions ten minutes late on a regular basis, and repeatedly cancels with less than a day’s notice for home furniture deliveries and the like. Another conducted a therapy session “lying half dead on the couch. Her eyes were literally half closed — she was sick but didn’t call ahead of time to reschedule.” Yet another disappeared in mid-treatment and was later found to be practicing without a valid license. Another psychotherapist left a voicemail at 6 p.m. to cancel a 7 p.m. appointment because her 6 p.m. canceled and she wanted to go home.
And most recently, a patient wrote that her therapist revealed her own diagnosis of borderline personality disorder “with narcissistic overlay,” then went on to cancel the writer’s regular weekly therapy appointment, without advance discussion or notice, following an apparent misunderstanding.
It’s important to consider that these reports may be distorted. That is the nature of transference. For example, patients have accused me of “yelling” at them when I clearly had not; some are certain that I want them to end treatment when that isn’t true. It’s possible that these therapeutic missteps are fantasies or exaggerations of the truth. But I have no reason to think so. The reported behavior sounds all too human.
Why do therapists — my colleagues — act like this? We all have momentary lapses due to fatigue or personal crises. These are unfortunate but usually rare and short-term. A good therapist gets back on track quickly, acknowledges (and apologizes for) any hurt feelings, and repairs the damage done. Sometimes a particular patient really “pushes our buttons,” i.e., stirs up strong countertransference, and we lose our composure as we are swept up in the patient’s narrative. Ideally, these enactments are also brief, lasting only until we step back and gain perspective. According to some schools of psychotherapy, they may even be helpful. However, since countertransference can be partially or wholly unconscious, they may, unfortunately, go on much longer than ideal. The therapist’s own therapy may mitigate, if not eliminate, these reactions.
Beyond this, however, some therapists seem impaired. A psychotherapist who has little tolerance for strong emotion, who routinely engages in power struggles, who can’t stand rejection, who is excessively self-interested (or self-sacrificing!), or who has outsized needs for adoration or deference — well, that’s like hiring a one-armed surgeon. (Not to denigrate any actual one-armed surgeons out there, but you have to admit it’s a disadvantage.) Certainly in traditional dynamic psychotherapy, and to some extent in any professional helping relationship, our own personalities, and social skills are part of what we offer. We need to be healthy enough to “be there” for patients, and not add to their problems. Surely it’s possible to pursue a career as a psychotherapist even if one suffers “borderline personality disorder with narcissistic overlay.” But it’s a significant handicap, much like the challenges facing a surgeon who is missing an arm.
Don’t get me wrong. Overcoming such challenges is courageous and noble. I’d have great respect for a one-armed surgeon if I ever met one. I have similar respect for those who overcome debilitating psychiatric conditions to pursue their dreams. But from the patient’s point of view, the idea is not to give the underdog a chance. The idea is to get help. Given the choice, most patients would not opt for a one-armed surgeon. Most would not opt for a psychotherapist who acts in erratic or traumatizing ways. The difference is that the surgeon’s impairment is obvious, and the therapist’s is not.
There’s a cliche that mental health professionals (MHPs) enter the field to figure ourselves out, or to deal with our own inner demons. Like most stereotypes, it contains a kernel of truth. What’s important is the degree to which we’ve succeeded in gaining that insight and conquering those demons. What’s even more important is how our personality affects our patients — however far we’ve traveled and whatever we’ve overcome.
Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.
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