The relationship between a therapist and a patient is the most delicate but also the most unusual one. The patient is expected to be completely honest and wiling to expose their innermost secrets and vulnerability to the therapist. On the other hand, the therapist remains distal and objective, who offers the uttermost care while maintaining clear boundaries. While the patient sees one therapist and the therapist perhaps matters a lot to them, the therapist sees many patients and compartmentalizes their time and mental resources. It is a strange relationship—the therapist knows the patient so well that perhaps no one else understands the patient better than the therapist, while the patient knows almost nothing about the therapist, and yet, a therapeutic relationship could not and should not become friendship.
To make this relationship even more complicated, the therapist is paid by the patient, either directly (private practice) or indirectly (public healthcare). Therefore, the therapist is the service provider and the patient is the customer. However, unlike other customer relationships, the feedback channel is absent here. The therapist does not know (in most cases) how the patient likes or dislikes therapy—because it would be a very awkward conversation. In fact, we therapists never know if our patients like us or not, if our patients find therapy useful or not, if we are giving them what they need or not, we can only make educated guess.
In-between sessions, I often wonder if my patients ever think of me and I also find myself thinking of them a lot—not just remembering what happened in the last session and preparing for the upcoming one, but appreciating who they are and reflecting on what they said. There is a part of me who applauds this caring, but another part of me worries that I might be over-invested in this therapeutic relationship, which might render my ability to help my patients and compromise my own well-being.
Sometimes I wonder what matters in therapy—is it my skills and tactics, or my caring? What do my patients appreciate—is it my doing or being? We therapists pride ourselves for our training and clinical experience, for example, the number of patients that we have helped, the toolbox that we have developed over the years, and our past success. But is it true?
I remember one patient who said the following to me. It was after a very fruitful and empowering session and she had started making incredible changes. She said, “I like this non-biased, non-judgmental relationship,” and added, “everyone should go for therapy”. She clearly did not applaud my skills. In fact, I tried many of the skills that are supposed to work but did not. In my opinion, it was when I expressed my concerns about her daughter and processed our relationship openly (to show her bias in other interpersonal relationships) that she reached the tipping point in therapy. It was the therapeutic relationship that did the healing!
This book is not particularly readable, but it tells a marvellous story. The therapist (Dr. Irvin Yalom) offered individual therapy to a young woman who struggled with her inability to experience emotions, write, and assert herself, provided that the therapist and the patient would keep a journal of each therapy session. Over the span of two years, they had sixty sessions in total and they also exchanged their writings several times. Not surprisingly, the therapist and the patient had very different understanding of therapy. I would say that we therapists are often delusional—we think we know what is best for our patients and we believe we understand what our patients experience because we make the agenda. However, the patient might have a completely different agenda and they might be looking for totally different things in treatment. The patient we know is what the patient wants us to know. The therapist, on the other hand, is the one who does not know but thinks he knows. The skills and techniques that we take pride in mean nothing to our patients. Instead, it is our care and love and the resulting trivial words/acts that matter to our patients. Who would have thought about that?