Shirah Vollmer MD

The Musings of Dr. Vollmer

The Therapist Needs The Patient: Is This So Bad?

Posted by Dr. Vollmer on January 30, 2014

Beginning psychotherapists, beginning psychoanalysts, depend on their patients to accumulate hours for a license or a certificate. Many times, the patient consciously or unconsciously is aware of this dynamic, giving some patients an opportunity to wield this power dynamic in ways which are further grist for the analytic mill. “Yes, I do need you to come to get my hours, but at the same time, I want you to do what is in your best interest and that is more important to me than getting my credit.” I propose that comment to my class, resulting in, what seemed like, a collective gasp. An active discussion ensued leading to a heated debate about honesty versus burden. “Is the ‘name it to tame it’ adage appropriate here?” I ask. Perhaps the honesty of saying yes, I do need the hours, but I also have integrity in my work, so that trumps my need for my hours, goes a long way towards diffusing the hidden issue in the room. Or, perhaps stating the need for the patient to come burdens the patient and thereby applies unnecessary guilt if the patient wants to discontinue treatment? My contention is that the therapist holds the anxiety that the patient’s termination compromises her training, then the analytic ear is sacrificed. One cannot listen when one is anxious, and so the ‘name it to tame it’ adage does apply. Putting the anxiety out there in a package which says there is a reality to my wanting you to continue, which is totally about me, and not about you, and that is a known limitation in our treatment, but having said that, let’s keep in mind the most important thing is that you do what is in your best interest, because, in reality, another year in training is something that I can deal with. This honesty takes away the potential for conscious or unconscious manipulation of the patient. My students proposed however, that the blunt statement of needing the patient, might, in fact be coercive. I countered by saying that the exposure of the reality creates an honest, although not ideal, relationship, which can then be discussed in an open manner. I was pleased to present a challenge to my bright and stimulating students. I was also knocked off-center by their startle response. I am thinking.

4 Responses to “The Therapist Needs The Patient: Is This So Bad?”

  1. Shelly said

    Are the budding psychotherapists paid during these accumulated hours? If they are, then admitting to their clients that they are needed to obtain their licenses would be like admitting that they are interns and not full-fledged therapists, thereby casting doubt on the professionalism of the therapists. If they are not, then admitting to their clients that they are needed is not coercive since it is a win-win situation: the client “gets” therapy and the psychotherapist “gets” the hours. How interesting that your students want to feel morally superior to their clients by hiding the fact that they need their clients to obtain their licenses. The therapist-client relationship is uneven to begin with; this only adds to the uneven balance on the scale.

    • Sometimes yes, sometimes no.
      The idea is that the hours obtained are done under supervision, so the patient is aware that they are seeing someone in training. It is like going to a hair salon with someone in training where there is a senior person supervising. The issue is that in certain training situations the patient has to stay for a year in order for the trainee to get credit so if the patient wants to terminate after 9 months the therapist gets very anxious. Should the therapist disclose this anxiety or pretend, to the patient, that this is not a factor in the discussion about termination. Yes, the asymmetry of the relationship is clear, but with that asymmetry comes a sense of power on both ends, but in different ways. Thanks.

  2. Shelly said

    Shirah, is the therapist under supervision required to inform the patient that he/she is under supervision and is still in training? When there is a senior person supervising, it doesn’t mean that the senior sits in the room during sessions–it means that the therapist meets offline with the supervisor separately to discuss the cases, doesn’t it? Therefore, how does the patient know the difference whether or not his therapist is a trainee?

    • The therapist needs to disclose to the patient that he/she is a trainee. Yes, the supervision occurs after the sessions, so, as with all of psychotherapy, it is art, and not a science. Thanks.

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