A List of Virtues For Psychotherapists
Some are not born hard. A true psychologist, like an artist, must love his palette. Perhaps more kindness, more patience was needed. Do I strip before teaching how to weave new clothing? Have I taught him "freedom from" without teaching "freedom for"?
Yalom, 1992, p. 253.
Clinical practice involves spending hour after hour in the presence of the wounded of our society. Each day a parade of the depressed, anxious, anguished, bewildered, distraught, and disturbed pass by. How is one to cope with witnessing this stream of misery year after year? Each year dozens of books and hundreds of articles describe and advocate various techniques and types of psychotherapy. It seems that with each year that passes a "new" therapy is created. In 1960 we managed to survive with a mere sixty different forms of psychotherapy. During the next fifteen years the National Institute of Mental Health (1975) identified 130 different forms of therapy. It took only five more years till Herink (1980) noted there were over 250 different therapies. A mere six years later there were over 400 available therapies, which prompted Garfield to jest, "Needless to say, if this rate of increase continues, at some point we will have a different form of psychotherapy for every person in the United States" (1989, p. 19).
Rather than propose a "new" school of therapy or even technique, we examine those virtues which we believe are necessary for psychotherapists who desire to be effective agents of change as well as people who are able to obtain satisfaction from their interactions with sometimes extremely troubled patients.
A critical, and somewhat laughable, commonplace observation of mental health professionals is that mental health professionals —particularly psychologists — have a specific profile on the Minnesota Multiphasic Personality Inventory: the profile is characterized by elevations in three of the clinical scales, the "depression", the "psychopathic deviant", and the "social introversion" scales. The armchair interpretation of these elevations taken together is that psychologists are somewhat depressed; depression affects the ways that all people, including mental health clinicians, think and see the world; they tend to be negative in their interpretations and outlooks. Further, psychologists have a great deal of energy which leads them to try to control their universes as they know them. And, finally psychologists tend to not operate fairly rebelliousely with authority figures (people who tell them waht to do), hating to take direction. All of this adds up to the idea that psychologists in specific and mental health professionals in particular really hate to face the changes that have come with the modifications in psychotherapies and in the psychotherapy marketplac. Mental health clinicians are being challenged to change frequently in ways in which they do not want to change. They are being asked to relinquish control over their professional domains and to respond to externally imposed expectations from insurance companies, licensing boards, and lawyers in ways that have not been present for them in the past.
Further, when asked about how they respond to these market changes mental health professionals tend to somewhat cranky; they also protest that they will never adapt to the changes.
A group of mental health professionals (75) attended a workshop that had, as part of its focus the challenges of contemporary mental health practice. These workshop participants, when asked about how they respond to these changes, offered the following list of their issues about these changes:
Defensiveness about being challenged,
Devaluation of their spirits and loss of meaningfulness in their work,
Redefinition of what they see as real,
Redefinition of what brought them to the profession,
Experience of fending off not necessarily realized but potential problems,
Experience of powerlessness in their work and their lives,
Loss of creativity,
Belief in the idea that if they identify with the risk of an event, they heighten the potential for the event,
Sense of impending failure,
Experience of being pressed into a niche,
Sense of being caught in a bind with reference to loyalty to the client or the third party payers,
Redefinitions of the rules of psychotherapy
and. Sense of denial.
These eleven items can be summarized into the following statements about resistance to change particularly the changes that are driven externally:
Mental health clinicians feel defensive about being challenged, and they interpret that because they have been challenged, they must confront their own denial about how market changes will affect them and their practices.
These clinicians, respond from their negative view of the world, experience themselves as powerless in their work and in their lives. They elaborate their fears by fending off not necessarily realized but potential problems; they also begin to overidentify with the risks involved in the challenges and changes. They tend to focus on potential, impending failures and to deny their capacities to adapt to change. They become resentful about "being" pressed into a "niche" and about being asked to leave the niches that they occupy. The niche that they currently inhabit is one in which they define what and how they do their work, rather than following another’s redefinition of the rules of psychotherapy or of the marketplace.
Moreover, they are fearful of confronting their loyalties between clients who need and use their services and the external forces which govern their practices.
The existential crisis for mental health professionals comes as they face redefining what they see as real, reassessing that which brought them to the profession initially, and believing in their own creativity. They must recapture their beliefs in their own values and the meaning of their work.
And, when the mental health professionals have vented their spleens and confronted their demons, they realize the virtues that in the past brought then to their work and that in the present keep them in the work of psychotherapy. These are the virtues, momentarily eclipsed by fear, that led them to the work of psychotherapy and that leads them to do that work well.
Many readers may balk at the term virtue, thinking it quaint and believing it belongs in a work of theology rather than psychotherapy. Indeed if one scans the indexes of texts utilized in graduate programs for the training of psychotherapists one is unlikely to find a single reference to virtue. Still we insist that virtue as Webster defined it, "general moral goodness; right action and thinking; uprightness" accurately describes the psychological posture we are promoting (McKechnie, p. 2042).
Detached Compassion
Is detached compassion an oxymoron? The word compassion comes from the Latin cumpassio or with suffering (Skeat, 1980). Noticing the order of these two words is vital to understanding compassion. The word means to be with one who is suffering, not to suffer with the other. This is the basis of the mutual-help group Al-Anon (Al-Anon, 1975, 1978, 1981).
The skillful psychotherapist is able to strike a balance between being an empathic ally who is involved with the client, and yet enough detached as to permit the client the experience of being treated as a competent individual. Too much compassion leads to emeshment and the violation of professional boundaries, excessive detachment causes the client to see the psychotherapist as uncaring, cold, and distant.
Integrity and Discipline
Integrity involves having an internal locus of control. One's ethics ought to be internalized to the point that one behaves ethically because it is the right thing to do and not because one might get sued or lose one's license. To have integrity is to be aware of one's values and to behave in that fashion, as wells as be true to one's self.
Discipline is not mindlessly trudging through life doing what is required to get by. It is the practice of sticking with something even when the going gets tough. Being a licensed professional means having the privilege of doing things that those who are not licensed are forbidden to do, but it also means having the responsibility to do things that others would rather avoid.
Skillful Means
If one is to be a psychotherapist then one ought to master those skills that make for effective and efficient change. In other words, do what you do, and do it well. Psychotherapy involves numerous skills. The psychotherapist is mental juggler, shifting awareness between dozens of variables during a single session: How much time is left in the session?; What transference and counter-transference dynamics are currently active?; What is the client trying to tell me by discussing this material? and; Has the therapeutic relationship developed to the point where I can make use of humor as an intervention?). The therapist who is going to find satisfaction is the one who is able to find enjoyment in learning, practicing, and mastering the skills of the craft.
Self-actualization
In the language of the United States Army this means, "Be all you can be." Processing skillful means is necessary, but not sufficient to becoming a virtuous psychotherapist. It is not enough merely to have learned certain professional skills, one must strive to be a better person. The person who makes excessive emphasize on being the role of psychotherapist at the expensive of not growing as a family member, friend, lover, etc. does not provide a good role model to clients, and eventually will find providing psychotherapy unrewarding.
Although there are many roles that do not require one to be a good role model as a person it is a demanded of the psychotherapist. One may not care if the plumber or the attorney beats their children as long as the toilet gets unplugged, or the will gets written properly, but one expects the psychotherapist not to be violent at home.
Healer Heal Thyself
While self-actualization focuses on living up to one's potential, the virtue in "healer heal thyself" focuses on one's short-comings. Since we expect our clients to examine themselves in painful ways, we ought to be willing to do the same. If we truly believe that psychotherapy is a meaningful endeavor and not a farce, then we ought to be willing to partake of it as patients and undertake our own therapy. Not only does being a psychotherapy client provide one with the opportunity to witness another demonstrate the virtues of detached compassion and skillful means which will help make one a better psychotherapist, but it also makes the process of one's self-actualization easier.
Tikkun Olam (To heal the world)
In order not to become cynical or develop learned helplessness psychotherapists must think beyond the individual, couple, or family who is seeking treatment. The client is not merely the people in the room, but the society that fostered the attitudes that bring people to need psychotherapy. Psychotherapist, who want to enjoy being psychotherapist for a life time can not afford to be bottom feeders, just sitting in an office, waiting for those damaged by society to appear at the door. The goal must be to change the conditions that create the need for psychotherapy, not merely to patch up the wounded and sent them back out into the battle. One must to seek social justice, not merely insurance reimbursement.
Good Value For The Money
Although most psychotherapists have a difficult time thinking of themselves
as businesspersons, we are in fact in the business of providing a service for a
fee. Regardless of whether the payee is the client, the government, or an insurance company, someone, somehow, is paying for service of psychotherapy. That customer ought to be provided with a quality product. This means that the client who is being seen for a reduced fee gets the same level of high quality service as the client who is paying full fee.
Psychotherapists must also be mindful of their ethical obligations to third party payers. Often psychotherapists sense insurance companies and other third party payers to be faceless enemies, set on earth to complicate the process of clients and therapists. If therapists benefit from third party reimbursements, they sign on to honor the rules of the third party reimbursement process.
Pleasure and Joy
For the most part, psychotherapy deals with the unpleasant aspects of life. Most people are not motivated to pay another to listen to how well their lives have gone. It is only when things have not gone well that psychotherapists are sought. However, this does not mean that psychotherapy is a glum task. Finding pleasure and joy in one's work offers an excellent model for clients and helps a bond develop between client and psychotherapist. Just as we tell our clients crying is an acceptable expression of emotion we show them that laughter is equally important in psychotherapy. Being playful makes coping with clients’ problems easier for both the client and the psychotherapist.
Wonder and Mystery
There are moments in the therapeutic relationship during which something wonderful and mysterious occurs; when the awe inspiring and yet indescribable takes place. This is when the psychological becomes the spiritual. These are the experiences that make being a psychotherapist worthwhile; these moments are to be treasured.
Gratitude
One must not rely on wonder and mystery to make the therapy hour interesting. These events occur too infrequently, and demand too much of the client and the psychotherapist. While wonder and mystery are the stuff of the grand, gratitude focuses on the little things. When one is psychologically and emotionally present one is able to find significance in the common and ordinary.
Although gratitude tends to result from concentrating on the unpretentious it too can be a spiritual experience. As Lessing wrote, "One single grateful thought raised to heaven is the most perfect prayer" (1767, p. 7).
Summary and Conclusion
References
Al-Anon. (1975). Al-Anon faces alcoholism. N.Y.: Al-Anon Family Group Headquarters, Inc.
Al-Anon. (1978). Living with an alcoholic with the help of Al-Anon. N.Y.: Al-Anon Family Group Headquarters, Inc.
Al-Anon. (1981). Al-Anon's Twelve Steps and Twelve Traditions. N.Y.: Al-Anon Family Group Headquarters, Inc.
Garfield, S.L. (1989). The practice of brief psychotherapy. New York: Pergamon.
Herink, R. (Ed.) (1980). The psychotherapy handbook: The A to Z guide to more than 250 different therapies in use today. New York: New American Library.
Lessing, G. E. (1767). Minna von Barnhelm.
McKechnie, J. L. (1983). Webster's new universal unabridged dictionary, 2nd ed. New York: Simon and Schuster.
National Institute of Mental Health (1975). Research in the service of mental health. (Report of the Research Task Force; DHEW Publication No. ADM 75-236). Rockville, MD: author.
Skeat, W. W. (1980). A concise etymological dictionary of the English language. N.Y.: G.P. Putnam's Sons.
Yalom, I. D. (1992). When Nietzsche wept . New York: HarperCollins.
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