What should the relational and emotional stance of the therapist be? Just who exactly is the therapist in relationship to the person coming to see the therapist? What is the therapist’s job, exactly? What should the therapist’s disposition be toward the person sitting across from them? What kinds of assumptions or presumed power come with the label therapist and are those assumptions harmful or helpful?
These are the questions that I believe anyone doing the work of “therapy” should be asking and re-asking throughout their career. Too often in my experience, therapists do not actually think deeply about these questions. Instead, we often rattle of the supposed “right” answers that we all learn in undergraduate and graduate school. Therapists should be empathetic toward their “clients,” practice “genuine listening” and maintain a disposition of “unconditional positive regard.” I don’t disagree with any of these points in theory. It’s just that too often I see fellow therapists giving this automatic response when asked and then relating to their own clients in very different ways. So let’s skip the talking points and think about what therapy has too often looked like in practice:
The Old Model of Intervention and Treatment
Two of the most common terms in clinical vernacular are “intervention” and “treatment.” Traditionally the practical work of a therapist is largely described as the selection and application of interventions on behalf of a client. Using the term intervention to describe therapeutic activity reveals some telling assumptions. First, it assumes that the role of the therapist is one of authority and expertise that supersedes that of the client. Second, it is a non-collaborative by definition – intervention is something you do to someone, not together with someone. The picture painted by the word is one in which a helpless, broken person comes to a lofty expert and describes their woes, after which the expert steps in and prescribes a set of actions to “fix” the problem, or the person.
Sometimes the term “treatment” is used in place of intervention. It suffers from all of the same implications as the former term, but with a few additional ones as well. Treatment is a term that comes out of the medical world. In implies that there is an ailment within the client coming to therapy that it is the therapists job to treat. If also implies that we therapists actually know with any kind of certainty of an exact “treatment” for a person’s problem. This certainly pairs well with a medical model of “mental illness,” but stands largely at odds with any attempt to view the person as an equal, or any belief that the best solutions to a person’s problem lie somewhere within themselves.
The consequences of this old model of the prescriptive therapist have led us to some dark places at times. No matter how well-intentioned these prescriptive models might be, they have nevertheless contributed to bigoted and prejudicial attitudes toward clients. It’s difficult to see oneself as a superior authority on the life of another person without slowly drifting into patronization and paternalism. Once there, the path to pathologizing and reductionism is an easy one. And once there, the road to coercion and dehumanization is almost unavoidable. The tragedy is, this downward spiral into prejudice and dehumanization usually happens without the therapist ever recognizing the decent, and asserting every step of the way that they listen, love and care about the people they inadvertently demean.
A New Model of Service
In place of words like intervention or treatment, I prefer the language of “service.” It is my intention to see myself as a “servant” of other people, and as a therapist that offers “service” to individuals. Being a servant of another person is a humble role. As a servant, I am not above the person I am serving. Ultimately, I am not the decision maker in the relationship. As a servant, it would be presumptuous of me to suggest that I am an expert on the needs of the person I am serving. Certainly I have resources of specialized education and lived experience to offer into the relationship between myself and another person. But the usefulness of that knowledge is not certain, and it is up to the person I am serving to “try it on for size and see if it fits.”
Being a servant is a role of less power and less control. The individual being served is the source of power and control. This is an important distinction, because I believe it is essential for me to remember that I do not “fix” people. At best, I provide resources and relational support sufficient enough for a person to “fix” their own problems as they define them. Remembering that I do not fix people means accepting that I have very little “interventionist” power in the relationship, and sometimes that can be difficult when a person’s suffering is immense. But the flip side to this belief is also comforting: I also do not kill people.
Ultimately a person’s choices, even choices that turn out very poorly, are not within my control, nor are they my individual responsibility. My responsibility is to serve. I serve by making diligent effort to understand the needs expressed by the person with me in the room. I serve by offering reflections and empathy that might assist that individual in clarifying their own thinking and feeling. I serve by helping the individual explore all possible options to address challenging life situations. And, I serve by asking permission to offer advice, then giving that advice as one possible course of action, without trumping the individual’s right to make their own choice.
The person in the room with me gets to make their own choice, even a very bad choice. They have that right, and I am not individually responsible for the outcomes of another human being’s decisions. I don’t fix people, and I don’t kill people.
The “Don’t Be A Dick” Therapeutic Stance
The way I see it, the only real difference between me and any person that I might work with is that I get paid to try and be a good person. Lots of other people simply do that for free. What I mean by that is, while its true I have a certain amount of specialized education and training and sometimes that background helps me think about the human condition or social problems in interesting ways, doing my job “well” really comes down to this:
- How much love and empathy I can convey to another person
- How much patience and flexibility I can offer to another person
- How much respect for another person’s humanity and autonomy I can demonstrate
- How much hope I can offer and how much faith I can place in another person, and
- How willing I am to defend another person from systemic abuses, even when those abuses may come from colleagues or “superiors.”
None of the things I just mentioned require an advanced degree in anything. And yet I believe these things represent the heart of the “therapeutic stance” for counseling or “therapy.” By contrast, the antithesis of the therapeutic stance can be described like this:
- Belief that I get to define the problem and prescribe the solution for another human being
- Belief that it is helpful or appropriate use coercive tactics to force another person to accept my plans for them
- Allowing a sense of personal resentment, frustration or even protective fear to dominate my emotions when another person does not do what I have planned for them
- Getting caught up in an emotion-based power struggle in which I seek to “beat” another person, “punish” behavior I deem to be bad, or “win” a power game
- Insistence on actions or behaviors from another person that I would never expect from myself.
This is what I very happily call the “Don’t Be a Dick” model of therapeutic interaction. I like to see myself as plainspoken and direct, and the non-professional and humorous way of stating this appeals to me. It’s also a very easy heuristic for me to remember. I quite literally find myself muttering, “Don’t be a dick, Andrew” before entering the room with another person. These ideas are the heart of the model of service I seek to bring to my work as a therapist.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.