The Person Who Is the Psychotherapist

A description of subjective influences and patterns in the psychotherapist which are thought to be importantly influential in determining the success of the therapeutic process. Inappropriate gratifications for the psychotherapist in the conduct of intensive psychotherapy include seeking for one-way intimacy, imagining omnipotence, attempting to master contingency, protected and disguised giving of tenderness, and displaced rebelliousness. More appropriate or "synergic" gratifications include participation, personal growth, immersion in psychological processes, and contribution to the patient's growth. Maturity in the therapist is believed to be expressed though humility, selective participation, genuine encounter, an evolving conceptuum, and the acceptance of the guilt of being a psychotherapist.

It is a familiar observation that the psychotherapist is the latest descendant of a line which traces back to prehistory. The psychotherapist's ancestors are the medicine man, the wizard, the priest, the family doctor. In every age man has needed to have someone to turn to help him in contending with the awful unknownness of his fate. Inevitably, invariably, the one turned to has been invested by others and by himself with supranormal vision and potency. This has usually been both his greatest reward and his most terrifying burden. Certainly this is so for the psychotherapist today. The practice of psychotherapy, as well as the training and research for such practice, has increasingly become an area of attention for clinical psychology specifically and, to some extent, for psychology in general. There can be little doubt that the prime variable affecting psychotherapy (outside of the patient himself, of course) is the psychotherapist. Psychotherapy may in time take forms which reduce the essential significance of the individual psychotherapist, but at least as of today the personality, sensitivity, and skills of the therapist are of crucial importance. Despite this fact (and with a major exception of the area of psychoanalysis), little study has been made in depth of the qualities in the psychotherapist which most favor or militate against successful therapeutic outcomes in his work, The present paper addresses itself to this matter, employing the method of description based on observations of varied psychotherapists in a variety of settings and examining some of the principal influences within the psychotherapist which seem likely to influence the therapeutic process importantly. It is the intent of this presentation to provide sufficient description of the important variables that future studies may be able to derive hypotheses as to the nature of the therapist's subjective contributions to the therapeutic process. Working from the raw data of the therapeutic interaction in this fashion hopefully makes possible research dealing with more significant variables in that process. Concurrently, the sort of description which is here advanced may well be useful in planning and conducting programs for training and supervision of psychotherapists by providing variables for the attention of the teachers and supervisors and for the self-observation of the student-therapists. It can hardly be debated that there is selective process, operating largely at unconscious levels, which determines those who will come into the field of psychotherapeutic practice. By no means does this recognition imply that this is altogether a bad thing; nor does it reassure that it is altogether a good thing. For the moment let it rest that a great many psychotherapists have sought through becoming psychotherapists to deal with their own anxieties, both existential and neurotic.

It seems that anyone who becomes involved in the practice of intensive psychotherapy finds gratifications which are deeply and personally meaningful. Some of these are clearly neurotic or destructive; others are more "synergic." The following are among the less constructive.

One-way Intimacy
Allen Wheelis (1958) has described what he feels is a powerful selective factor operating in determining who will become a psychoanalyst. This is a hunger for closeness, a great desire for affective intimacy, and a great fear of it. The practice of psychotherapy makes possible a kind of one-way closeness of great intimacy, quite frequently with more affective expression than is to be found in any other relationship, not excluding the marriage relationship (Warkentin, 1963). Yet it is in many ways "safer" to the therapist in that he is enjoined by his ethics and training to withhold himself from the comingling which is potential. How beautifully, then, this practice fits the needs of those with a great affect hunger, a great desire for intimacy, and a great fear of affect in intimacy.

Omnipotence
Second, the practice of intensive psychotherapy provides rich nourishment for one's omnipotence and omniscience strivings. Most people today have these. Many who feel frightened and impotent in their own lives find in the practice of therapy a kind of splendid calm which they and their patients conspire together to believe the benign influence of the therapist's perspective. A frequent, special instance of the omnipotence striving is the myth of the curative effect of the therapist's love. A great many therapists at one time or another seem to pass through a phase where they become convinced that a vast amount of unquestioning, undemanding love from the therapist for the patient is the curative agent which can produce profound changes. This seems to come about because many patients are emotionally deprived people who seek the kind of concern from their therapists that they feel they never received from their parents. The response of the patient to seeming to gain that caring from the therapist is often dramatic and pervasive, for a period. Only when the therapist has worked with a truly dependent personality over a period of years, does he begin to recognize, if he is wise, that while the patient may indeed achieve remarkable reorganizations of his life through the benign influence of the therapist's love, these are all fragilely hung on the relationship. The patient resists with frightening ruthlessness any attempt by the therapist to reduce that dependence. It is not unusual for the work of months and years, all the hard won gains in life effectiveness which the patient and therapist have worked out, to be brought crashing down in a relatively short space of time when the therapist begins to try to free the patient of his dependence upon the sustenance of the therapist's concern.

Contingency Mastery
A third, important gratification in the practice of psychotherapy is the opportunity the therapist has for a vicarious and seemingly safe way of dealing with contingency, with the basic realities of life. Therapists sometimes say they have found themselves using the patient as "a guide dog to go through the mine field" of certain threats first in order to reassure themselves that it can be negotiated. One may respect the therapists who recognize this and be quite confident that nearly all therapists so use their patients in some measure, all too often without such candid recognition. We live in anxiety; we seek to become more self-trusting; we never achieve this fully. When, with full recognition of the patient's needs, we can encourage him to confront that which breeds anxiety within ourselves, we are heavily invested in the outcome.

Giving Tenderness
A fourth neurotic gratification in being a therapist is that it provides an opportunity to give tenderness, compassion, and love in a completely masculine way. A great many who are drawn into this field have fears of their own emotions, fears that these feelings represent weakness and perhaps effeminacy. Often these fears are completely unconscious, and may even be counter-phobically concealed by the therapist being overly expressive of his emotions. We document with research and learned papers the healthfulness of emotional expression and the disasters attendent upon emotional inhibition. And in the therapeutic hour, secure in our masculinity of being doctors and healers, we can dispense tenderness and love without arousing our own anxieties.

Rebelliousness
A fifth, very frequent gratification in the practice of psychotherapy is that it gives an opportunity to attack authority and tradition while armored in all the prerogatives of position. Study and observation confirm how the needless inhibitions of society complicate the lives of all: the taboos about sexual talk and actions; the guilts about ambivalence toward parents, spouses, and others; the shame of death wishes and other hostile impulses. With the authority of being a therapist; one can strike back at these influences. Notice how often psychotherapists, particularly in their earlier years of practice, become great users of the four-letter words (Feldman, 1955). Notice how often they are flagrant in their expressions of sexual and hostile impulses. It seems quite clear that this may be an acting-out, a counter-phobic kind of behavior which represents the celebration of the licenses of being a therapist. Thus one may pay back society, hit back at authority. It is not a matter of chance, for example, that most therapists tend to be political and social liberals. We would like to think that this is chiefly because they have had an opportunity to see the crippling effect of social ills, and this is one significant reason. On the other hand, the person who is in some revolt against what he feels is social injustice may find in the practice of psychotherapy a relatively safe way to express his rebellion.

Having listed some important aspects of the practice of psychotherapy which provide neurotic gratifications, it will be useful to describe now some creative gratifications which are also realized in such work. Maslow's (1962) term, "synergy," best delineates the common property these have. In a truly synergic relation that which most contributes to the fulfillment of one of the participants is most fulfilling of the other also. It should be evident that the present writer does not hold with the view that the psychotherapist has no needs seeking satisfaction in his work. To the contrary, the therapist must find important fulfillment if he is to be able to mobilize his total resources for the task, as he must frequently do. Some of the incentives to his doing so seem to be the following.

Participation
To the psychotherapist is offered the opportunity to participate with unique immediacy in the business of life itself. In psychotherapeutic practice one deals daily with the life and death of human personality and potential. This phrase intends no play on words, and the melodrama implicit in this characterization is that of the human experience itself. As the therapist accompanies his patient in his effort to confront the minor and the great issues of his life, to contend with the ever-present unknownness of choices and their consequences, to meet and live with the multiple emotional seekings and stresses of human relationships -- as the psychotherapist visits the heights of elation and self-affirmation, the depths of confusion and madness, the brink of suicide, the bleakness of relinquishment, and on and on - then the therapist must know at once his own humble gifts and his privileged situation it viewing the human condition.

Personal Growth
A good therapeutic relation is growth inducing in both participants. Growth potential is infinite, and the therapist who is an authentic participant in his work with his patient has repeated stimulation and opportunity to increase his realization upon his own potential. In a climate in which genuineness is requisite and yet always sought anew, that which is false and self-defeating in the therapist himself must ever and again be illuminated for the shoddy self-deception it is. The therapist who has come to love the realization of human potential -- and I am convinced this is a distinguishing characteristic of the dedicated therapist -- will be continually renewed in his own growth.

Psychological Processes
A high proportion of psychologist-psychotherapists entered their parent discipline of psychology because, among other reasons, of a fascination with psychological processes which may be likened to that some people show with mechanics, others with color and form in the arts and still others with mathematics and quantitative processes. There is no other opportunity in all the world like that of intensive psychotherapy for a person with this orientation to immerse himself in the working of psychological processes in their natural condition. All our familiar psychological topics of learning, motivation, attitudes, emotions, attention, remembering, perception, and so on -- all of these are displayed in endless variation and exquisite detail.

Patient's Growth
Most patients who come to the psychotherapist show improvement. The doubters to the contrary, the psychotherapeutic experience is generally one in which there is a gain in human effectiveness and satisfaction (although, albeit, not the magical one frequently initially expected). It is for the therapist, once he has adjusted his own sights to realistic dimensions, a deeply meaningful experience to have participated in his patient's emergence. There are, of course, the failures, the disappointments, the questionable outcomes. However, with experience, constant self-development, and much learning just to wait, the proportion of favorable outcomes increases, the pervasiveness of the changes becomes more evident. It is, then, an enriching feeling to have been an intimate participant in this growth.

We will describe now some characteristics which are found in the mature psychotherapist and which, it is believed, portray what this field means to the psychologist who dedicates his career to it.

Humility
Probably one of the first forms of genuine maturing in the therapist is his acceptance of the fact that he has but limited knowledge of his patient. Since, as a therapist, he gets to know his patients so much more thoroughly than he knows any other human beings in his life, he may often feel that he really knows the patients fully. This is a myth; this is the omniscience fantasy being enacted. As a therapist one never knows all about his patients, only some aspects. These may be terribly important aspects and certainly significant to know, but one needs to recognize they are but a part of what could conceivably be known about these patients.

Selective Participation
A second mark of the maturing therapist is his selective use of his own participation. This is to say he is able so to modulate when and how he intervenes that his participation is maximally effective in a restricted area. The maturing therapist participates verbally sparingly, but with precision. A very common fault of the tyro-therapist is that he talks too much or too little or at the wrong times.

Encounter
A third characteristic of the maturing therapist is his willingness genuinely to encounter his patient. This does not mean a kind of exhibitionism or display of himself. It does mean a willingness to "be there" with his patient, to confront his patient directly when appropriate, to take responsibility for his (the therapist's) own thinking, judgments, feelings; and to be authentic in his own person with the patient. Sidney Jourard suggests that this is indeed one of the main things that has a curative effect in the therapeutic relationship, that is, the therapist serving as a model of authenticity for the patient.

Evolving Conceptuum
A further evidence of growing maturity in the therapist is that he has an evolving set of constructions about himself, his world, the nature of psychotherapy, and what he means by the concept of personality. One may be mistrustful of the therapist who believes he has reached final answers on any of these points. Recognition of the dynamic quality of knowledge, of the continuing learning experience of therapeutic work demands that one be changing if one be dedicated and aware.

Guilt Acceptance
One of the most difficult aspects of therapeutic maturity is the acceptance of the guilt of being a therapist. Certainly all that has been said above about the neurotic gratifications of being a therapist will have indicated that there is inevitably a load of guilt in being a therapist. We will not re-elaborate on these points. Going further, however, we are saying that there is guilt for our failure to be all that we can be as therapists to these people who come and give us their lives and trust.

The other day I saw Jack again for the first time in five years. Initially I saw Jack eleven years ago; that was for vocational guidance. He came back a year later because he was having trouble with his marriage, and I was able to be of some help in patching up a shaky relationship. Seven years ago, when he cane to me, the marriage had collapsed at last, and he was readjusting his life to a new pattern of living. At that time we attempted intensive psychotherapy, and I saw him for several years. I think Jack was helped by the experience. However, I put it in this somewhat tentative fashion because I can see so many ways today that he could have been helped so much more. I look at Jack in my office today, and I see a man with the gray coming in at his temples. I see in him also virtually a boy of 29 as I first saw eleven years ago. The prime years of his early maturity are embraced by our relationship. As I look at Jack, I think of Louis, who I am currently seeing and who is about the age Jack was when he first came to me. Louis is going to have a much fuller life than Jack has had, because I am so much more able to meet him and to help him in becoming himself. To look at Jack is to look at my own guiltiness for not having been all that Jack needed. I comfort myself that I served him with sincerity with the best of my skill at that time. I comfort myself even that many another therapist might have done no more for him than I did, but this does not give Jack back his lost years.

This is a story of the therapist's guilt. If I am to be a growing, evolving person, each old patient I see again is an accusation; each patient of former years will be in some measure someone who trusted me, and whom I failed by today's standards. If I become despondent or self-punitive, I am acting out a neurotic type of guilt; but if I recognize the legitimate responsibility I had in this matter, I am revitalized in my own growth. But there is yet one further way in which this guilt operates. When I recognize that I am continuing to try to grow, to increase my awareness, skill, and competence in effectively being in the relationship with my patients, then I must look at my patients today and know that each one of them is getting less than I hope I will be giving his successor 5 years hence. There is guilt in this too. The reader may protest, "This all sounds very masochistic and self-punishing. It's just the way things are. There's no need to expend guilt, regret on it." In one sense this protest is very right; in another, it¹s very wrong. Yes, this is the way things are; but the fact that a condition is so does not mean that it is unladen with emotional significance. It is so that I can only do so much for my patients now and that that seldom is all I potentially can do, even today. If the sense of guilt becomes an interference with my effective use of myself rather than part of a heightened sensitivity, then it is clearly becoming a neurotic guilt and an attempt to forestall other anxiety. The kind of guilt that I am trying to characterize here is not forestalling of anxiety, nor yet laden with additional anxiety, but is an emotional fact of being.

I want to conclude by saying very briefly what it means to me to be a psychotherapist. I feel like one of the fortunate ones. I feel more fortunate than most. The men and women who come to see me, entrust me with that which is most deeply meaningful in all their experience. They offer me the awesome privilege of participating in the very essence of their lives. When I am most authentic, I am most humble in my appreciation of this opportunity. As I started this paper, I called attention to the lineage from which we psychotherapists take our vocation: medicine man, wizard, priest, and family doctor. This is a proud line, and we may be proud to be part of it. These are the bearers of man's hope and man's faith. These are the personifications of man's courage and creativity in confronting the immensity of the unknown. We are, for our brief time, hoisted on the shoulders of our fellows that we may catch some glimpse of the yet untouched reaches of what it means to be truly man.

References

Reprinted from JOURNAL OF CONSULTING PSYCHOLOGY, Vol. 28, No. 3, June 1964. Printed in U. S. A.

James F. T. Bugental, Ph.D., A.B.P.P. is an instructor of IIHS two year training program and a member of the advisory board.

© 2003 by James F. T. Bugental, Ph.D. All rights reserved