Articles by David H Jacobs Ph.D

Who Does What In Beneficial Psychotherapy

It’s useful to distinguish between what the therapist can supply towards feeling and doing better and what the client needs to do in order to benefit from psychotherapy.

The therapist can be sympathetic, empathic, patient, interested, involved, caring, an insightful listener, give sound advice on occasion, protect confidentiality, be on the client’s side, and so on. The therapist can offer a relationship that is dedicated to the client’s psychological welfare without demanding or expecting reciprocity. That’s what the therapist can do. The therapist can provide supplies from the outside, so to speak. Supplies from the outside can help the client feel less alone, less misunderstood, less blamed, more cared for, etc. The therapist can offer himself as a trusted ally. There is no doubt that such supplies can frequently have a positive impact on the client. Supplies from the outside are indispensable. You might think you are being unfairly blamed, for example, but you cannot listen to your own story as an empathic other. Self-confirmation has its limits, even for the psychologically robust. In the main, people who need therapy have not had the kind of background growing up that fosters robust self-confirmation and self-assurance. Supplies from the outside are needed.

The client has a role to play in therapy that is much more psychologically challenging than the therapist’s role. The client has to talk about emotionally difficult matters. The client has to risk and endure feeling ashamed and embarrassed. The client has to disavow saving face as the number one priority guiding what he talks about and reveals. The client has to come to feel over time that the therapist can be trusted and really is an ally if the client is to derive significant benefit from therapy. The client has to persist in doing this difficult work for an indeterminate but probably substantial period of time. Oh, and the client has to pay. This can be very significant beyond practical financial considerations. The client for example has to pay even though it may seem there is no immediate benefit and he must continue to pay even if he cannot at the time envision how and when benefit will materialize.

I’m trying to say that in order to benefit from therapy the client must really dig in. Just going through the motions will not produce significant and lasting benefit. The therapist cannot treat a person in the manner a physician or dentist can treat the body. In the latter case the patient has nothing to do but show up and endure what is done to him. This is not a model for psychotherapy. Nothing much is going to happen in therapy if the client does not dedicate himself to making an effort. The effort is to endeavor to do what I cited in the previous paragraph.

Having a trusted ally in life can be very strengthening. The catch is trust. The usual background of people who need therapy has not fostered trust. It’s possible to disclose things to a therapist without really trusting him. It’s understood that the therapist must keep what you say confidential. It’s understood that the therapist’s job is to listen to your disclosures. The trust I’m talking about is trusting that the therapist actually cares about you and is sincerely interested in your welfare and in trying to help. It’s strengthening to feel you can trust someone in that manner. Just revealing things because you know the therapist is bound by confidentiality and is doing his job isn’t the same thing at all. So just coming to sessions and revealing things you would not reveal to other people is not strengthening, although there may be some benefit to getting things off your chest. But probably the benefit of just getting something off your chest will not last long.

I have said the client must try to make the sessions emotionally meaningful in order for therapy to be beneficial. Of course the therapist does what he can do to make the session meaningful, but he can’t dance without a partner. It might be said a big part of the therapist’s job is to coax the client into making an effort to make the sessions emotionally meaningful. This usually is not an easy job precisely because (in the main) people who wind up in therapy have potent experiential reasons to be guarded, wary, etc. It’s no use for the therapist just asking the client to be less guarded, wary, avoidant, and so on. It is pointless to request of a person that he trust you. Asking for trust is a good way to evoke even more wariness. What the client will be inclined to talk about’”what will occur to him to talk about’”cannot be divorced from how safe and trusting he feels with the therapist. This can’t be rushed. The therapist must show over time he is safe and worthy of trust. A dance of sorts is always going on. But if the client just cannot be coaxed (reassured) over time therapy will be superficial or over because the client will have left. Many clients do leave soon. This is a sad observation because people come to therapy for help they cannot give themselves or get anywhere else.

I recognize that the most popular psychological therapies today do not regard frequent contact between therapist and client and the development of an emotionally important relationship with the therapist as essential for significant and enduring therapeutic benefit. The conviction that significant and enduring benefit can occur without frequent and prolonged contact between therapist and client and without struggling to connect emotionally is attractive to many interested parties. It is attractive to the insurance industry. It is attractive to non-psychiatrist practitioners because all non-psychiatrist practitioners realize they operate in a field in which the combined efforts of psychiatry and the pharmaceutical industry has rendered psychiatric drugs the first-line treatment of choice for just about every personal and interpersonal problem under the sun. It is attractive to clients who (naturally) wish to avail themselves of treatments (whether pharmaceutical or psychological) that do not require struggling to develop trust and intimacy with a therapist. Everyone wants the quickest and least painful fix possible. The market demands quick fixes that do not entail wrestling with one’s inner demons. The market has delivered. The catch is that significant and enduring change for the better does require struggling to develop an emotionally important relationship with a therapist. The fix for problems that are relational in origin (essentially all problems that psychotherapists see) is an important new relationship that can to some extent repair the damage inflicted by important old relationships. This is hard work and takes time. I don’t like it any more than you do, but that’s reality.

Unfortunately psychotherapy is demanding. The client must if anything make more of an effort than the therapist. Or maybe the better way to say this is that each party has a difficult part to play in beneficial psychotherapy. I have felt for a long time that it really is unfair that the client has to work so hard to make therapy beneficial. Just showing up and paying the bill won’t do it. It’s unfair because the client did not grow up under circumstances he chose. Yet it is up to him to work hard to lift the burden of the legacy of his growing up years. The therapist is willing to work hard as well, but he can only do his part.

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