April 24th, 2007

Feeling too much of your pain: therapists and clients

Are clients best served by therapists who’ve had life experiences and backgrounds similar to theirs? Clients certainly often seen to want this, but do they need it for the most effective therapy to take place? And, in fact, can such similarity of experience sometimes be counterproductive?

Ann Althouse discusses an article on the subject by psychiatrist Richard A. Friedman that appears in today’s NY Times. Friedman says similarity of background is not necessary, and that empathy and understanding are not limited to those who’ve shared a certain experience, but are products of imagination. Althouse asks how a patient is supposed to know how good an imagination a therapist has.

Therapy is a funny thing—funny-strange, that is, not funny ha-ha. Although it’s an experience that’s morphed from something exotic and only for the rich and leisured into something relatively mainstream, the process is still poorly understood by some clients (and even some therapists, as well). From an endeavor that initially focused on the psychoanalytic, it has branched out into so many schools and approaches and theories of personal change that the bewildered client can be forgiven for not knowing where to turn or whom to call.

There’s a school of thought that gay patients are best served by gay therapists, abused women need counselors who’ve been there too, alcoholics require those who’ve been through a twelve-step program themselves, and so on and so forth.

But I think this idea springs from an oversimplification and misunderstanding of the process of therapy. And I think Dr. Friedman’s emphasis on empathy and imagination is simplistic, as well.

It’s not that those traits aren’t important: they most definitely are. And anything that helps a client to trust a therapist enough to speak freely is a good thing—and that trust can often be fostered by having a therapist who seems to share a similar life experience and background.

But therapy is a great deal more than empathy and understanding, or being able to give good advice because one has walked in the same shoes. Therapy requires a peculiar set of traits on the part of the therapist: an ability to understand through leaps of intuition and empathy, as well as an ability to distance and to look with an objective and evaluative eye on the situation.

Therapists are human—all too human, I’m afraid—with the full complement of humanity’s foibles and emotions. And yet, in order to be effective, they must develop the ability not only to look at their patients in that dual intuitive/objective way, but also at themselves.

Two of the pitfalls all therapists must traverse, no matter what school they belong to, were recognized by Freud early on, and are known as transference and countertransference. These terms relate to the sometimes very powerful emotions the therapeutic relationship can foster in both parties, “transference” being the feelings a client brings from his/her earlier relationships (such as, typically, his/her parents) and redirects towards the therapist while in therapy. “Countertransference” is a similar phenomenon a therapist feels towards the patient.

There are special perils inherent in dealing with clients whose experiences are too close to the therapist’s own. Both transference and countertransference can be enhanced in such a situation.

This can make for a great feeling of bonding (especially if the transference and countertransference are mostly positive rather than negative). But it can also lead a therapist down false paths, imagining he/she knows more than he/she actually does about this patient, using the therapist’s own experience as a guide when it is inappropriate.

Unless the therapist has done an exceptional amount of working through of his/her own related issues, the emotions that still remain can cloud judgment. For example, a therapist can think that the way he/she worked through a similar issue is the best way, the way a client should follow, and fail to pay attention to the unique characteristics of that client that would dictate otherwise.

So, paradoxically, it’s often best to have a therapist who hasn’t had an experience too close to one’s own. Therapists aren’t just glorified friends or hairdressers who listen well—although, again, that’s certainly a skill they need to have. They are understanding listeners who can also detect a client’s patterns of behaviors and reactions; and can suggest to that client other ways of perceiving, feeling, and acting, in the interests of fostering desired change in that client’s life.

One of the most fascinating and moving aspects of therapy for some clients is the growing realization that, despite the fact that the therapist does not share the exact (or even similar) life experiences, that therapist can still understand deeply and listen with compassion to the client’s story. Many people who come to therapy (and many who don’t) have the idea that “no one can understand me,” and whatever expands their idea of the universality of their experience and the ability of even the “other” to understand them is a good thing.

Althouse asks how a patient can know that a therapist is sufficiently imaginative to empathize well. My answer is that, surprisingly enough, that’s one of the things most patients ordinarily can tell about a therapist, although not from the yellow pages or a recommendation. The only way to sense this is to have an initial consult, and usually the feeling of being understood or not understood will come through very quickly, on a gut level. Not all therapists are alike, and not all therapists are good matches for certain patients, but the patient is the one who has the final say in the matter, and should leave the therapist if there isn’t that feeling of basic rapport.

As referenced in the Friedman article, patients often come with pre-existing prejudices and preferences about what they want in a therapist. Some of these are considered therapeutically valid, such as a woman who’s been severely abused by men being more comfortable with a woman therapist. Some are arguably less so, such as a request for a therapist of the same race. I disagree with Friedman that the latter request should be refused; if a client is that uncomfortable with someone of a different race, whether it be a black person uncomfortable with someone white or vice versa, than the therapy can and should deal with the issue. But it’s not best dealt with by placing the client with a therapist who makes him/her acutely uncomfortable at the outset.

A lesser-known issue is that of therapist discomfort with certain clients. Theoretically, therapists can work with anyone, but in actuality they tend to specialize and refer out those patients who press their buttons (such as, for example, child molesters).

And, although this sounds like some sort of bad joke, I know quite a few therapists who say they would have difficulty treating a client whom they know to be a Republican. So it’s not just clients who want therapists who are as much like themselves as possible—some therapists return the favor.

32 Responses to “Feeling too much of your pain: therapists and clients”

  1. sigmund, carl and alfred Says:

    Very good post.

    If ‘life experience’ is relevant, how can a non divorced counselor help divorced individuals? Is it always true that a therapist who has yet to ‘work out issues’ cannot detach themselves in a professional way?

    You deal with those and similar issues in your post, concisely and clearly.

    Still, there are other real issues.

    Whether the chemistry exists between patients and therapists or not, in the end, it is the quality and kind of therapy that the patient best relates to that is the final arbiter.

    In the end, successful therapy is best measured by the willingness of the patient to effect positive change, and not by the ‘quality’ of the relationship the patient has with the therapist.

  2. reader_iam Says:

    washingtonpost.comDid you see this article, by a Tennessee physician, writing about personal biases and how that effects health care? Interesting–not exactly on point, but there is some relevance.

  3. slick Says:

    A rare pleasure to read such intelligent thoughts. Thank you.

  4. Ymarsakar Says:

    The world of therapy, Neo. Alice in Wonderland?

  5. Jimmy J. Says:

    Having experienced therapy at one time or another with five different therapists, I found that each one had a positive impact in helping me change. I definitely had better chemistry with two of them and worked with them longer.

    “I know quite a few therapists who say they would have difficulty treating a client whom they know to be a Republican.”

    Back then I was definitely a libertarian with conservative overtones, but politics never entered into my therapy that I can remember. I’m not shocked to hear that however. I’m in a writers’ group and the liberals are very combative. They do seem to think Republicans are the scum of the earth. Maybe I’d have trouble finding a therapist today since it appears that most are left leaning. (Thank goodness for Neo, Shrink, Dr. S. and Siggy!)

  6. Ed Driscoll.com Says:

    “Empathy Ends Where Political Correctness Begins”…

    Interesting posts by Neo-Neocon and Dr. Helen on matching patients and therapists. Neo writes:And, although this sounds like some sort of bad joke, I know quite a few therapists who say they would have difficulty treating a client whom they……

  7. Nanonymous Says:

    I have to say that, while racism is undeniably a repugnant belief, I thought the psychiatrist’s offhand dismissal of it as a treatable condition was chilling. One of the worst trends of this century has been the tendency to define contrary political belief as mental illness.

    The state really has no greater power, when you think about it, than the power to declare someone crazy. It removes any need to debate or even discuss your beliefs, and it becomes the grounds for the most invasive of all medical treatment.

    Language like “an appropriate target for treatment” doesn’t make me feel any more confident in the unbiased, objective judgment of a medical professional, either.

  8. Robert Speirs Says:

    Is there any evidence “therapy” has ever helped anyone? I’m not being cantankerous, I’d really like to know. I’m especially impressed by the response above by the “patient” who has seen five different therapists. Is therapy perhaps just a form of expensive recreation?

  9. Jimmy J. Says:

    Robert Speirs,
    I’m the commenter who saw 5 different therapists over a period of 14 years. Job transfers and referrals were reasons why I saw different people. I might also note that I was never in therapy for more than one year continuously.

    Did it do me any good? My opinion, and I’m obviously prejudiced, is that it did. Change is probably the most difficult thing a person can attempt. One must be in a great deal of psychic pain or the motivation to change will just not be there. I wanted to change, but it took me a long time and much effort. Some people might say that I had transcendental experiences that changed me and they might be right. However, I think the therapy put me in the right frame of mind to finally come to terms with myself even though it arrived
    via a transcendental pathway.

    Should you be interested in more detail about this I posted about my mental and spiritual journey in a three part series on Shrinkwrapped’s blog here: http://shrinkwrapped.blogs.com/blog/2006/11/one_mans_journe.html

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  32. Bill Martin Says:

    I was researching a topic and found your post about therapy. I thought it was great. Very insightful, intelligent, and helpful for therapist and clients alike. I will link this post on my site. You’re a great writer.

    Bill

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.
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