"What Am I Paying For?"
An introduction to prosocial psychotherapy.
Posted Jun 28, 2019
A few years ago I received an email from a client, Katherine, ending with a question: “What am I paying you for?” A gorgeous woman in her mid-70s, Katherine’s a novelist and author of several books of short stories. She’s good, so good, she’s the kind of writer you can’t put down once you start reading. We’d been meeting for a few years, and I admit, I still found her slightly intimidating. She’s frankly brilliant. I’d had moments of jealousy, wishing my writing was that good. And once every six weeks or so, she’d arrive, announcing, “You aren’t really interested in me.” She’d add, “I don’t know if this is working.”
By the end of the session, she always felt better, we’d connected, sometimes we’d find a solution to whatever problem set her off that morning. It’s not easy to be deep into a discussion with someone who looks like she might have one foot out the door; it doesn’t leave room for casual mistakes. I make them anyway.
When I’d hear Katherine’s plaintive, “I don’t think…” and “I don’t think...” inevitably my heart sank. I’d feel heavy. I’d feel rejected.
Thinking like a clinician, I know that when I start feeling rejected during a session, it’s likely the client is testing something about rejection. I knew Katherine had been dealing with how rejected she’d felt as a child. Rejected and unprotected. Whatever happened to her years ago, she was demonstrating it, making sure I felt it. Reading Katherine’s email and thinking about my response, it clicked. She was paying me to think like a clinician. Not to react the way I would in an ordinary situation, but like a clinician.
Responding to Katherine’s question has turned into a book. For the last three years, I stopped writing blog posts here, for Our Empathic Nature. Instead, I’ve been trying to answer the question, working on How to think like a clinician: Essays in prosocial1 psychotherapy. I started writing to Katherine, and soon I was writing to my clinical students, to my other clients, to the many colleagues I know, aching for a different spin on the nature of their client’s problems and how to help them. I have to qualify: This is about how to think like a practitioner of Prosocial Psychotherapy (PPT), the kind of therapy I do, and how it differs from other psychotherapies while being similar. Prosocial Psychotherapy was derived from feminist theory and a theory of therapy developed by Weiss (1995) and studied empirically by Weiss & Sampson and the Mount Zion Psychotherapy Research Group (1987). Weiss’s theory was known as Control Mastery Theory.
1Prosocial behaviors and emotions are altruistic in intention, aimed to help others, and characterized by a concern for the well-being of other people. Behaviors described as prosocial or altruistic include feeling empathy and concern for others and taking actions designed to help or benefit other people.
What differs about prosocial psychotherapy are two underlying basic assumptions about the unconscious human mind: First, beneath the level of conscious awareness, we’re fundamentally adaptive, and second, because we’re such social animals, we’re also profoundly prosocial.
Shaped by evolution on multiple levels, the prosocial mind—our human mind—has a great capacity for empathy, the motivation for altruistic behavior. As social animals living in relatively large complex groups, we’re not members of a species in which individuals can go off forever, living alone, without contact with another human. We need relationships, and we need our prosocial nature, our drive to altruistic actions in order to maintain our relationships and hold our groups together. Without groups, we simply can’t survive. We need to be fundamentally adaptive, in order to survive—by being able to adapt to the constantly changing conditions on our planet. Because we’re so adaptive, we’ve been able to live and thrive in a huge range of environmental conditions all over the planet. Further, we’ve been able to adapt our cultures to suit the land in which we’re living.
The prosocial perspective has great implications for the therapist.
When a new client comes into my office I know absolutely that she wants to overcome the problems from which she suffers. I know she’s not gratified by her symptoms, and I know she’d never “resist” treatment, unless of course, I was going in the wrong direction, in some way not helpful. There’s no guarantee that she will be successful at solving her difficulties, but she definitely wants to. Knowing that all people want to transform their lives, to make them better, puts me and my client on the same page, it makes my work easier than if I believed—as do many working from other theoretical perspectives—that my clients are gratified by their problems or that they’re deliberately “resisting” my efforts to help them.
As a psychotherapist, my job is to figure out what new clients want and need, their aspirations, the life they’re hoping for. Together, we work to help them get there. From years of practice, I know it’s likely that they’ve lived their lives holding themselves back, plagued by the constant worry that if they do the things they’ve dreamed of, the things they know will help them succeed, they risk hurting others—parents or siblings, partners or friends—who might feel inadequate simply by comparison.
They may be stuck in jobs they hate while feeling they owe it to their boss to stay there. Or perhaps they’re stuck in a miserable marriage, believing that if they tell their partner they’re going to leave, their partner will be absolutely devastated, their life destroyed.
- A woman might be staying with an abusive man, because she believes he’ll commit suicide if she leaves him.
- A young woman might be a rising executive at a major tech firm with a salary beyond anything anyone in her family ever dreamed of, doing work that’s grown tedious and dull. She watches new teams built around her, seeing only young male techies being invited to join. When she reaches out to the executive above her, he refuses to be a mentor. She can’t tell her family she’s ready to walk away from money like that; no one thinks she can do better.
- A man might be stuck in a career he hates, believing that if he pursues his dream of working as a professional musician, he’ll break his father’s heart, because his father believed his son had to be an engineer or physician in order to avoid a life of failure.
- A woman might be afraid to go back to school and pursue a career because “women in our family don’t do that, they stay at home taking care of the family”—or so her mother insisted.
- A young heroin addict, a graduate from college, might walk out of the 30-day inpatient drug treatment program in which he’s being successful, because he always goes on summer vacation with his parents. They were leaving in a week, and he believed that if he failed to go with them as usual, his father would be terribly lonely without him—they always went fishing together and played tennis during these family summer breaks.
- A woman may quit graduate school and instead find herself working as an administrative assistant, because as a child her mother told her to avoid talking about her accomplishments in school, lest she give her learning-disabled brother an inferiority complex.
In Prosocial Psychotherapy (PPT), therapists are going with their clients, never against them.
I began here with Katherine, whose question sparked a long series of essays. I skipped over the details of her story, her life before and during therapy, only mentioning a few moments when she was giving me a hard time, and I’d figured out why it was happening and what it meant. It was at the heart of how to think like a therapist, and that was what Katherine was paying for. But there’s more, what I actually ended up telling Katherine.
Despite many years on the couch—over the years Katherine had seen many therapists—when we began meeting, she had little sense of herself as a serious thinker and powerful writer. Her email, like many of our discussions, was provocative—Katherine made me think. She was writing about the day she’d just been through…
“I wanted to stay home and write this afternoon, but my daughter called, said the nanny called in sick. She asked me to pick up Mary Ann—she’s 8 now, in 2nd grade. She sounded frantic, almost breathless.”
Taking on her daughter’s voice, she said, “ Mother, I’m so sorry, but it’s urgent. I absolutely have to go to this meeting—and afterwards, I’m supposed to go out for drinks with some colleagues; it would be rude if I don’t show up.” Pause, then adding: “Please, Mother.” Of course. Katherine’s daughter, 35, an executive at a tech firm, always assumes Grandma will fill in when the nanny’s sick. And she adores her granddaughter, so it’s not that she minded. Katherine continued:
“So there goes another day, I’m exhausted. I took MaryAnn to the mall with one of her friends. Now I can’t write, I’m too tired and too depressed.” Her email ended with: “So Lynn, tell me, what am I paying you for?”
I didn’t answer immediately. I waited six hours. Then I wrote back:
“You’re paying me to make sure you get your next five books written, published, and on the Best Seller’s List.” That was true. Katherine didn’t need me to help her better manage her adult children and grandchildren or her barely tolerable marriage to a rather boring real estate attorney, other than to be a supportive co-solver of ordinary problems. What she needed was someone who knew how brilliant she was, who was willing and able to serve as a weapon against the steady stream of insults coming from an ageist, sexist culture. She needed me to help her overcome the pathogenic belief that as a woman, she wasn’t supposed to be smarter and more successful than her husband, a belief she had formed growing up with a beautiful but dysfunctional mother, who was, if anything, jealous of her amazingly talented but sometimes depressive daughter.
I suspect many of our clients have wanted to ask the same question: “So tell me, what am I paying you for?” But they’re too polite, or too afraid, to question our authority. So what, then, are we paid for? What’s happening when we sit in our offices, talking with our clients? How do we understand what’s happening when conducting psychotherapy?
We’re being paid to think like clinicians. We’re being paid to have an intimate conversation in which we’re operating on at least two levels at the same time, and during which—even though we’re often flying by the seat of our pants—we’re responding to the patients’ unconscious testing of pathogenic beliefs that have caused them so much trouble. What’s more, when this subtle interaction goes well, when we’re passing these tests with flying colors, whether or not we know it, clients are slowly changing. Old beliefs are fading, more optimistic expectations are emerging. This is the experience that Katherine, and all of our clients, are paying for.
Pathogenic beliefs warn believers against pursuing normal development goals, such as success at work and in relationships, by predicting harm coming to other people. They warn that if the believer achieves something good, it will make others—siblings, parents, partners, and friends—feel inadequate, simply by comparison. Pathogenic beliefs are usually related to a fear of harming another person, not the self. Pathogenic beliefs may often be seen as “if…then” statements. For example: “If I do well in school, then I’ll make my disabled brother feel bad.”
Or: “If I tell anyone I got three internship interviews, then they might be jealous, and I know they’ll feel lesser."
“If I go out and play with my friends, then I’ll be leaving my mother alone all night, and she might get lonely..."
How Therapists Think
The essays that will follow are about how therapists think. They’re an effort to more thoroughly answer Katherine’s question. They’re written for seasoned therapists ready for a change in how they view their patients’ unconscious mind, for student therapists, for our clients, and for anyone interested in psychotherapy and how it works. There’s no reason to make psychotherapy mysterious for either the therapist or our clients. I hope to open a window on what’s been an endeavor clouded by secrecy when it ought to be entirely transparent. We may be paid for silence—that is to keep everything about our clients and their lives “confidential,” i.e., secret—but the process of therapy itself should be enlightening, often fun, mostly successful, and bring sunshine into our clients’ lives.
Foreman, S., (2007). Breaking the spell: Understanding the things kids do the very thing that drives you crazy. New York: Book Surge Publishing.
O’Connor, L.E., Berry, J. W., Lewis, T. B., & Stiver, D. J (2011). Empathy-based pathogenic guilt, pathological altruism, and psychopathology. From Oakley & Wilson (Eds), Pathological Altruism. London: Oxford University Press.
O'Connor, L.E., & Berry, J.W. (2018). The social and contextual nature of emotion: An evolutionary perspective. In Wilson, D.S., Hayes, S.C. & Biglan, A. (Eds.), Evolution & contextual behavioral science: An integrated framework for understanding, predicting, & influencing human behavior. Oakland, CA: Context Press.
O'Connor, L. E., Berry, J. W., Lewis, T., Mulherin, K., & Yi, E. (2007). Empathy and depression. In T.F.D. Farrow & P, W, R. Woodruff (Eds.), Empathy and mental illness. Cambridge, UK: Cambridge University Press.
Silberschatz, G. (2005). Transformative relationships: The control mastery theory of psychotherapy. New York: Routelege.
Weiss, J., Sampson, H., Mount Zion Psychotherapy Research Group. (1987). The psychoanalytic process. New York: Guilford Press, New York.
Weiss, J. (1995). How psychotherapy works; Process and Technique. Guilford Press: New York.
Wilson, D. S. (2015). Does altruism exist?: Cultures, genes, and the welfare of others. New Haven: Yale University Press