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What Makes a Successful Therapist-Patient Relationship?

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Several weekends ago Daphne Merkin wrote a moving piece in the Sunday New York Times Magazine about psychoanalysis and the therapists that go with it. Aside from an eloquent account of her forty years in therapy, I found the questions she raised about its ultimate value intriguing. First, it caused me to reflect on my own experience with psychologists. I've had two. Both of whom kicked me out. Well, not exactly. It wasn't quite as cold and callous as that, but they did tell me in so many words that it was time for me to get my act together.

As I get older and witness the prevalence of this endless therapy syndrome and read articles like "My Shrunk Life," by Ms. Merkin, I realize what a selfless, professional and giving act it was for my doctors to send me out into the world where the expectation was clear that I apply and practice what I'd learned. I was always free to go back with other "issues," but they were not interested in keeping me on the couch, stuck, mired in something that I could not undo or change. It makes me think of how birds learn to fly. There is a reason why they get pushed out of the nest whether they want to go or not. And guess what? It works. They learn. They fly. They may flutter and flop, but after a few attempts, they're on their way.

I wondered why similar conversations never seemed to be a reality for Ms. Merkin. Of all those shrinks, had it not occurred to one of them that not being dependent on therapy might possibly help her? I also wondered what it must be like to keep digging at the same old wounds for 40 years. Would it not make them worse and less likely to heal, like scratching at a scab? I felt sorrow for her and others who have devoted valuable time focused on the past in lieu of living for the future. And, I struggled with my own desire to hold the doctors accountable for not calling it a day and evaluating themselves as to whether their efforts were working -- or not.

See, I think of shrinks -- the good ones, that is -- as teachers. We're there to learn how to look at ourselves and live life in a healthy way ... supposedly. And like anything else where we pay for "lessons," there should be levels, with criteria to measure whether one is making progress or not. But to swim around in the vapors of the past for no real gain or to not have a marker that deems the time (and money) well spent, is crazy at best and irresponsible at worst. Eventually, someone needs to ask -- and answer -- the question, "What's the point?"

I know people who religiously sit in their appointments week after week, month after month, year after year and all they are able to do at the end of the day (or week or month or year) is keep talking about what they talk about. At some point, someone must question if the effect of all that talk is paralyzing. At some point, someone needs to assess whether there has been any change and if not, make one. Change something. Try something else.

Personally, I benefited immensely from what both of my shrinks taught me because they did just that. They taught. As a result, looking back, this is what I learned about what makes a therapeutic relationship successful, effective and worth the time, effort and money.

No B.S. You need someone who is willing to tell you that you are full of shit. Otherwise, the game keeps going around and around and the patient goes in circles, only to end up right back from where he or she started. In many cases, the net outcome is that you create situations where current behaviors are justified with explanations from the past, and the cycle never ends.

Move on. Seeing the past is important, but not at the expense of stifling the future. A good shrink will balance what needs to be brought into the conscious mind with creating a new consciousness that will help his or her patient move forward. Bottom line, if you don't let go of the bogeymen, you will not be free to advance in the right direction.

Start doing, stop thinking. I got homework from my shrinks because of the value in turning cognitive thought to behavioral action. Again, we could have sat on our butts and talked about it all day, but if I was unable to put the learning into motion, the entire therapeutic effort would have been moot.

A chance to grow up. Good shrinks also understand the importance of a normal, healthy maturation process. They are able to sensitize patients to the feelings and needs of others rather than allowing the individual to exclusively perpetuate the self-absorbed environment that so often accompanies self-analysis. At the end of the day, analyzing one's childhood should not equate with being stuck in one's childhood for that prevents us from becoming adults.

The silent treatment is not so golden. Despite conventional wisdom, there is nothing wrong with psychologists speaking up and offering their knowledge and observations. What I appreciated most was that my shrinks didn't make me sit there in the dark groping around for information inside memories that may or may not be relevant to developing a healthy state of mind today. Instead, they talked to me like a fellow human being.

In the final analysis, the aim of good psychotherapy should be that of a therapist who creates the space necessary for patients to bring themselves into the room in an honest way and manage the destructive aspects of ego out.

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