Recently a patient asked whether I'd ever been in therapy myself. Without answering his question directly (see my thoughts on psychotherapist disclosure and privacy), I replied that many of us have, and asked what it meant to him. It would be a bad sign: "How can you help if you need help too?" We went on to discuss his feeling that being in psychotherapy marked him as defective or deficient. He would naturally prefer a therapist who did not share similar defects and deficiencies.

Many patients take the opposite view. They believe a doctor who knows what it's like to be a patient can better empathize with them. So this patient's concern stood out in my mind - he truly feels his psychotherapy is a mark against him, a kind of declaration or admission that he is damaged. I later reminded myself that professionals - and others, everyone really - regularly use services offered by others in the same field. Lawyers have their own lawyers, doctors see their own doctors. Chefs eat meals made by other chefs, barbers get haircuts from other barbers. The only problematic examples that come to mind are when the condition being treated is shameful or morally repugnant, or when the condition could directly affect the service being offered. Examples of the former: police officers who require the "services" of other police officers after committing crimes, and clergy who need spiritual or moral counseling for their own transgressions. Examples of the latter: a neurologist with brain damage, and a business consultant who cannot maintain his or her own business and needs outside help. How does this apply to psychotherapists, and what light does it shed on patients' feelings about seeing therapists themselves?

The need for psychotherapy feels to many people like a sign of defect/deficiency/damage. In speaking with patients I often highlight the "need" in that sentence, and contrast it with "want" or "could benefit by." Some patients make themselves feel worse by telling themselves they "need" therapy, when it would be just as accurate to say they are apt to benefit by it, or even that they desire it. I don't believe it devalues psychotherapy, or psychiatric medications for that matter, to note that they're frequently optional. Most depression improves on its own eventually, and people may choose to muddle along in life dissatisfied, angry, or in a series of bad relationships. Remembering that psychotherapy is a choice may take some of the shame out of it.

That's only part of it, though. No one worries or cares if one's proctologist also needed to see a proctologist at some point, even though proctological conditions feel shameful to many people. In addition to shame, there is moral repugnance associated with mental illness, even, or perhaps especially, the apparently milder problems that lead people into psychotherapy. Often unstated is the notion that one chooses to be emotionally weak, distraught, hotheaded, or whatever, and that this choice is selfish, unfair to others, or otherwise immoral. Moreover, that seeking professional help to "snap out of it" or pull oneself together is self-indulgent and akin to laziness. While the idea isn't totally groundless - there is some choice in how to act, and even how to feel sometimes - it assumes far too much conscious choice. Most troubled patients would give anything to be happier, at least consciously. In returning to my patient's question, perhaps he would not trust a doctor who willingly made himself dependent on others to help steer his life back on course. It may feel as morally suspect as the corrupt police officer or clergyman: a character flaw in the traditional sense.

Alternatively, there may be concern that a psychotherapist who needed therapy ("needed" in scare-quotes as noted above) cannot perform well as a therapist. This would be analogous to the brain-damaged neurologist or the business consultant whose own business is failing. The logic may be pragmatic: A psychotherapist should have his or her own life in order before claiming to be able to help others. Or it may be fear that residual pathology lurking in the therapist may be harmful to the patient. Or it may be a transferential need for an idealized, faultless therapist. Each of these can be addressed as it arises. We each have our blind spots, and can help others without necessarily being able to help ourselves. It is better to have sought treatment for potentially hurtful pathology, than to have ignored or denied it. No therapist is perfect.

Any or all of these concerns about the therapist may also apply to the patient himself. Being in therapy may make a patient feel ashamed, or morally bad or wrong. It may highlight a fear of incompetence or harmfulness. It may clash with a need to be perfect. Asking the therapist "Have you seen a therapist yourself?" may be an easier way for the patient to broach sensitive feelings about his or her own participation in therapy. This seemingly simple question can carry a lot of meaning, and if explored in detail, can help a patient understand himself better.

© 2011 Steven Reidbord MD.  All rights reserved.

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