The Dilemmas of Therapy

I’ve been seeing a psychologist for the last few months. This is a kind of miracle – I stopped seeing my last therapist in 2003 – but it’s more low-key than it sounds. Anyway, something that happened last week made me think of the differences between different kinds of mental health professionals, and the way these differences have played out in terms of my own experiences and the various life stages at which I’ve seen therapists.

My therapist is a registered, or counselling, psychologist. This means she’s a full member of the Australian Psychological Society and is entitled to practise as a psychologist, but she doesn’t have a Masters degree in psychology or, I assume, the extent of supervised clinical experience with the mentally ill that a Masters would entail. This is the first time I’ve seen any kind of psychologist for any length of time. Previously, in my early to late thirties, I saw two psychiatrists consecutively over a period of about nine years.

She’s good at what she does, and has a talent for ‘reading’ people, which I think makes up for her presumed relative lack of clinical experience. But I sometimes feel as if I know the ‘rules’ of therapy better than she does; and the arrangement as a whole, with her modus operandi as part of it, is very different from the therapeutic relationships I’ve had in the past.

For example, my psychologist is never on time, and she never apologises for being late. Sometimes the lateness is a piddling few minutes but it’s usually more. Once she was almost fifteen minutes late and appeared at the door of the dollhouse-sized waiting room with nary a ‘sorry’.

As someone chronically deprived of my mother’s attention, this presses all my buttons. What’s most fascinating about it is not that as a patient my reactions to such a situation might be overblown – that would be expected. It’s that these reactions aren’t – can’t be – a key part of the therapeutic relationship. They can’t be examined and their underlying dynamics unearthed.

Such a situation simply wouldn’t have occurred with my previous therapists – for one, if a rare example of extreme lateness had occurred they would have apologised; for another, they would probably have raised for discussion in the consulting room the feelings that such an episode would have aroused in me.

Inevitably the therapeutic relationship, as it applies to my psychologist and me, does have some degree of the type of parent–child dynamic that occurred with the two psychiatrists – I feel needy before I see her, relieved when I can sit opposite in the tiny, untidy room and pour out my fears and triumphs. But this dynamic is underlying rather than dominant, and it’s not being used as part of the therapeutic process.

This is not just because of her perceived lack of qualifications, of course. It’s also partly due to the fact that I don’t, consciously at least, want to put her in that position – how many parent figures can you have throughout your life (an infinite number, it seems, as I still treat people in authority as parent figures); partly that my therapist is either about my age or slightly younger (it’s hard to tell – she’s very good looking, and probably botoxes); partly due to my lowered expectations as a result of my excessive aloneness in the last few years; and partly because of the way the Medicare (national insurance scheme) operates – the rebate is limited for psychological help compared with psychiatry, a maximum of 12 visits a year or 18 if the GP approves, so the sessions are widely spaced (once every two or three weeks) and they’re very practically oriented.

My psychologist and I mainly talk about strategies, tactics and techniques in relation to examples I bring up of problematic episodes that have already occurred or potential scenarios I’d like to venture into. We’ve looked at the past, but mainly in terms of how it affects my perceptions of others and of relationships today.

My therapist was chosen for me by my GP and I listened to my gut feeling in deciding to see her, and then to stick with her. I had to rely on my gut feeling because I was desperate to see someone at the time, and I knew that if I checked on her credentials before my first appointment and she wasn’t sufficiently qualified my head would say all sorts of judgmental things about her.

And my gut feeling was on the money. The fact that she wasn’t a clinical psychologist initially quietly horrified me (‘But I’m sick! I have about five different mental illnesses all blended together in an indivisible whole – how can she possibly help me?’). She does, however, have a human resources background, which was perfect for the issues I was grappling with at the time. She continues to be great at putting my many work issues into perspective.

So the current situation has both advantages and disadvantages. Because of her not being a clinical psychologist, as well as all the other reasons outlined above, I still feel as if I’m essentially on my own.

In some ways this is good for someone like me, who was never parented properly and has spent their lives searching for the perfect parent. In the past I relied on my psyches to be excessively parental, and while I was seeing them, I didn’t ever really take full responsibility for seeking sustainable adult relationships.

This had serious and long-term implications for my emotional development. Neither of my previous psyches fully realised the extent to which I needed to be ordered around when it came to relationships. There was one crucial point in my life when I needed to be told very firmly to have sex with the first realistic contender that came my way, to be set sexual ‘homework’ if you like. But the extent of that need simply wasn’t evident to my therapist at the time, and I didn’t have the maturity or self-awareness to articulate it.

Realising the limitations of my psychologist’s skills (and she is skilled in many ways) puts the responsibility onto me for my own recovery. And I’m hardly a rank beginner. I have a friend with OCD who has been practising exposure for so many years now he’s virtually an expert, and we have regular debriefings about it. I’ve also done plenty of my own reading as well as attended a social phobia group that included CBT and exposure.

Yes, my social phobia is complex and difficult, as it’s combined with a compulsion to display my symptoms to particular people and an underlying terror of making meaningful connections with others. My therapist works with me on exposure, but because of the nature of my problem, I have to tailor the program in conjunction with her. It would be wonderful if my therapist could tailor a program exactly to suit me. But exposure is exposure. I know enough now to tailor my own program with her help – she is my back-up.

And I have another weapon in my armory, a weapon that only I can wield – meditation. I finally have the self-love to use it regularly, and it’s beginning to show subtle but noticeable results.

Those are the advantages of not being able to completely turn my therapist into a parent figure. There is also a major disadvantage.

Because I can’t go through the ‘transference’ (when the patient falls in love with the therapist as an all-powerful parent figure) it means that I don’t feel emotionally ‘held’ during the session. And this means that the scary feelings that come up for me whenever I am in close contact with a person for any period of time can’t be taken out and looked at honestly.

Oh, I suppose they could if I insisted, but it would all be terribly awkward. I like my psyche and she says amazing things at just the right time, but she’s not really ‘mine’ – and to talk about some of the feelings that come up for me in relation to her (as opposed to the outside world – I can talk about that, no problem) would be more than my fragile self-image could cope with.

I think I’m a bit frightened that if I reveal those feelings, she won’t be on my side any more. And that inability feeds on itself – if I can’t articulate those feelings then I may start to display them through my panic symptoms in the consulting room, and that would be extremely embarassing. And my fear is that I’d then be on my own again, just as I was before I started seeing her. This is not a positive therapeutic situation!

My current way of dealing with this problem is to see the sessions themselves as part of my exposure therapy. It’s difficult for me to sit in the same room with just one other person for an hour. The session becomes part of my (self-administered) treatment, with the psychologist as unknowing resource.

Of course, this may not work indefinitely. My symptoms are already clamouring for attention in the consulting room and there may come a time when I can no longer manage them adequately without acknowledging them. I guess that will be a time of reckoning: the time either to seek another therapist or to attempt to turn the therapeutic relationship into something more challenging for both of us.

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