What are you getting paid for?

What are you getting paid for? Could be considered the central challenge to therapists in general. What exactly do therapists do that has a monetary value beyond that of the client? It also leads to a reciprocal challenge for the customer, couldn't you get that elsewhere? What about cheaper or free? I attempt in this article, to give you its customer, a fuller answer for my professional practice. Why, sometimes, it may be a good use of your money to pay for a therapist. At the very least, I hope you will agree, it is always a good idea to know what we are paying for.  

Good use of resources

Whereas some explanations of the monetary value of therapy would focus upon therapists training, qualifications, professional registrations, years of experience and commitment to developing the skill of psychological therapy. This article will not do that. Instead, it will consider the monetary value of another person making themselves deliberately more vulnerable than you. Vulnerable in being exposed to being attacked or harmed, either physically or emotionally. In doing so, proposing the work of therapists is perilous and their fee a form of danger money.

Danger money

Hang on, I hear you ask, how can therapists be considered vulnerable from their relatively privileged position in comparison to the customer? Well, the task of professional therapy is to create a therapeutic experience that leaves the client psychologically better off. How this occurs has been the topic of debate for as long as therapy as a thing has existed. However, I think, there are cultural realities that mean all therapists are both vulnerable and privileged. What then are the sources of therapists vulnerability?

Therapists vulnerability partially comes from being informed by evidence which was established in the past, about other people and largely in other contexts. Working without a guarantee of confidentiality and with higher expectations of behaviour than that required by law. Working in spaces that are not always observable. A commitment to be drawn in and become involved in other people's distress. Each reality making the outcome of therapy more uncertain and open to challenge. Therapists are paid to take the blame.

As I suggest these vulnerabilities are balanced by the privilege of being a therapist. The privilege of the therapist, I think, comes in terms of their identity, status, income and cultural protection. These privileges provide a secure enough base, in spite of vulnerabilities, to allow the therapist to be vulnerable routinely with the client. In this way, the therapist is in a position to chose to be more vulnerable. Vulnerable through choice.

We have considered how a mixture of privilege and vulnerability creates the conditions where a therapist may choose to be more vulnerable. That may be so, I hear you say, but what difference does it make to me, how vulnerable my therapist is with me?  Well, the level of therapist vulnerability is important in creating therapeutic experiences. In this assertion, I am indebted to the work of Jessica Benjamin (2017) who has articulated the process beautifully.

In short, just as in supervision for the therapist, the client pays for time with a vulnerable therapist so they can be vulnerable too. Different therapists and clients value vulnerability differently. I think this is because choosing to be more vulnerable makes the most sense within a relational approach to therapy.

A relational approach to therapy

A relational approach to therapy uses the relationship between the therapist and the client as the primary mechanism of change. For example, as a clinical psychologist, I apply psychology to achieve change. When taking a relational approach, I apply psychology deliberately, in the context of a relationship. The process is ideally as follows:

We identify your problem. I become part of your problem. I experience, and contain, our emotions involved in your problem. I accept, and communicate, my responsibility for being part of your problem. I then consciously, and transparently, struggle to change how I relate, to you, to become part of a therapeutic solution to your problem. Modelling responsibility taking and changes in relating as a possible therapeutic response to your problem. We then end or repeat. 

This process partially works because the older part of our brain struggles to distinguish between experiences i.e. it doesn't know it's therapy. Experiencing therapy as if it were a relationship outside therapy. Like actors playing a scene. Therapy then is not a performance but a series of rehearsals for life outside therapy. In this way, the therapist may need to proverbially ‘dress up’ and play different vulnerable roles for the patient.

The next clue, as to how this process works, is in the term clinical practice. In therapy, we practice at mutually helpful relationships. The therapist and patient being differently rewarded by the practice. The patient is changed in ways of their choosing, the therapist is changed in ways, not of their choosing. Being invited to become part of the client's problems for a while. The therapist leads with their vulnerability, then follows the patient's vulnerability, to a place of greater psychological health.

Similarities to relationships outside therapy

For periods in our best relationships, just as in our relationship with our therapist, we may be in the here and now. Have unfiltered experiences, spontaneity, cause offence, apologise and be known. Our mortality, personality, ‘warts and all’ are in the open. We are open to influence, open to misunderstanding or complaint. We can experience mutual dependency without coercion, allowing control. Sacrificing our own sense of reality to a new experience. These trusting secure relationships outside therapy take time, effort and skill to create and keep up.

I hope too, that in the above description, the contrast to these relationships to the role of the therapist has become apparent. For therapists, relationships with customers are a guessing game we have to get wrong. Therapists remain ‘ill’ while the client recovers. Making themselves redundant to the client. The therapist, like authors of articles, send out invitations, consistently making the needs of the client a priority over there own. Analogous to the caring parts of our best relationships. In order that the client may function from a more psychologically healthy place.

What is the monetary gain for the patient?

The monetary gain for the client is indirect. Increased psychological health puts the customer in a stronger position to accumulate resources including monetary ones. The flexibility to initiate, develop and end different patterns of relationships also increases the client's opportunities to operate in the economy in multiple ways. In these ways, the customer gains resources indirectly from effective therapy.

"It is amazing what you can accomplish if you do not care who gets the credit."  - Harry S Truman.

We have considered how in therapy the client gets the credit. The therapist succeeds by failing the patient's way. Bearing the consequence of that failure. Namely redundancy from temporary employment. In my experience, this is a disciplined and effective way of being with people. Admitting our mistakes and trying not to repeat them. Accepting the complaint, anger and disappointment of the client without retaliation. Responding in an adult way to the client's corrective criticism. Exploring what has happened between us. Breaking the comfortable lock of complementarity. Letting go of a fantasy of being the complete, innocent, blameless therapist. In these ways, the therapist is paid to change to help the client. And so in the end, what am I getting paid for? Paid to lead with my vulnerability, then to follow yours, to a place of greater psychological health.

Reference

Benjamin, J. (2017). Beyond doer and done to recognition theory, intersubjectivity and the third. Routledge.