“The town drunk is an elected office.” Mark Twain

When I ruminate about how much better the healing professions could be, that process sometimes elicits a memory of a discussion that took place during one of the classes in my post-doctoral training in family therapy.  The five of us in the class, two psychologists, two doctoral level social workers and a psychiatrist would meet weekly for a year in the office of the psychiatrist who was the director of the program.  One of the discussed topics stimulated the two psychiatrists to guiltily reminisce about their feelings during medical training and the disconnect between their lived experiences and the current buzz about a need for a more humanistic approach to medical care.  They commiserated in a shared understanding that what they said was a too common experience for purposely overworked interns – almost a mirror of what it is like when one pledges a fraternity.

Each of them laughed sardonically, with eyes downcast in recalling being awoken in the middle of the night after being asleep for only a few hours while trying to recharge after having worked 36 straight hours.  They knew they shared with their fellow interns the unseemly, hard to dismiss wish that if the patient they were summoned to attend were to die, they hoped he would die quickly so they might get a few more hours of sleep.

This memory evokes some of the difficulty a therapist faces in the conflictual role of being there for the client, yet ultimately being an agent of the state who is legally required to break confidentiality under specific legislated conditions.  Thomas Szasz attributed the inability to maintain absolute confidentiality as the foremost barrier to providing effective psychotherapy.  He lamented that therapists had less legal protection to maintain confidentiality then the absolute privacy of confessions made to a Catholic priest.

Whether it is in psychiatry or general medical practice, the pressure to be quick and impersonal runs counter to good practice.  Too much of the healing balm of compassion and empathy is missing.   It is very difficult to provide aid that can be life-changing in a culture where healers are functioning with a mandate to be risk averse and having to conform to reporting requirements that sacrifice trust.

In my work, I try to use what I think will help a particular individual discover alternative ways of thinking and feeling about past and present constructions of self, and how old and new possibilities might be acted upon.  I strive to work with the following principles to achieve these goals:

  • Trust – Avoidance of all forms of force and coercion
  • Believing in the essential goodness of all who come to see me – unless clearly demonstrated otherwise
  • Being flexible, adaptive and creative
  • Knowing the limits of my impact
  • Courage

As a therapist I believe that all of the guiding principles in our work must be continuously examined and altered according to the unique make-up and needs of the people with whom we work.  Difficult as it is, I must navigate and dance within shifting terrain; to know, understand and judiciously exercise influence so as not to overpower the potential development of a mutually acceptable perspective and desired destination for our therapeutic journey.

Relationships are key.  As therapists practicing in a western culture, we fill a relationship void for people who are going through confusing and extreme cognitive and/or emotional states.  We take on the role of “rented strangers,” a role once filled by caring Dutch uncles, friends, spouses, lovers, uniquely empathetic family members and accepting communities.  We therapists would be naïve to think that psychotherapy is the only way for a person to get unstuck, heal and develop.  A trusting bond, one of mutual acceptance with a friend/lover, a new job in which one re-connects with a buried competency, attention to ignored health and well-being, a new environment, a believed possibility, spiritual inspiration; any of many combinations can be transformative.  I see my therapeutic role as an attitude engineer, a venture capitalist of the psyche collaborating on a blueprint for a yet to be built bridge – a bridge from a life mired in confusion and pain to a shore line denoting ever-expanding hope and possibility.  I may need to pitch in to do some of the bridge construction, maybe even carry my client onto the bridge, but she must believe that the bridge is sturdy enough and long enough for her to do the bulk of the work to succeed in making her goals attainable.