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Dichotomastery: The Hidden Talent of Good Therapists

What makes a good therapist?

Paging Dr. Dichotomaster. Photo by ranmyaku.

What makes a good therapist? As a clinician, professor and supervisor, this question is always on my mind. But with all big questions like The Meaning of Life and Best Guitar Solo, it's an ongoing inquiry I don't expect to definitively resolve. Let's try anyway.

First, there are the easily identified qualities: a solid education, breadth of training experience, strong ethics, a working knowledge of theory and technique, good listening skills, empathy, clear communication, etc. These are the fundamentals, the sort of evidence we might find on a resume or letter of recommendation.

A less obvious quality is also crucial for this work, a skill we therapists use dozens of times each session. It's the ability to hold the tension between two (or more) competing forces and discern when to lean toward one or the other. I can't think of another term that fully captures this quality, so I'm going to do the cocky thing and coin my own: dichotomastery.

This pull between opposing forces is everywhere in therapy. Do we rely on theory or go with our gut? Charge for a missed session or let it slide? Give a hug or refrain? Share the interpretation or wait until next session? Gratify the client's wants or help him meet his own needs? Dichotomastery is holding this tension and deciding if and when to let the teeter-totter dip in one direction or the other. It's a characteristic that combines strength, discernment, resilience and wisdom. The best therapists are able to master the many dichotomies inherent to therapy, including:

Objectivity/Subjectivity - Every clinician will tell you the strength of the therapeutic relationship is the most important element of change in therapy. This means the therapist and client have to get along, communicate well and care about one another. To build this rapport, therapists must empathize with the client, to a point. If I take empathy too far and join a client in the depths of her grief, shame or hopelessness, we're both stuck. I need to keep one foot in the subjective experience of the client and one foot on the solid ground of objectivity: my theory, my evidence-based practice, my vision of health. Tilt too far toward objectivity, the client feels abandoned. Tilt too far toward empathy, we can't find our way out.

Emotion/Reason - Regardless of a therapist's therapeutic orientation, we must have access to both emotion and reason in therapy. In supervision I'll ask my students: "how do you feel sitting with the client?" as well as "what do you think is going on?" I don't want them relying solely on either, but use both their brain and their gut to gain understanding. We want to help our clients do this, so it should start with us.

Firm/Pliable Boundaries - Most of the time, therapists need to maintain firm, clear boundaries regarding the length of session, the type of relationship we have with clients, fees and other elements that form the "frame" of therapy. But sometimes this frame needs to flex. Glen Gabbard distinguishes boundary crossings, the occasional breach for effective clinical work, from the ethical taboo of boundary violations. If, when and how to cross boundaries is a common question for the dichotomaster.

Business/Personal - This is a sticking point for many clients as well as clinicians. We work to make a living, and we choose this particular work because we want to help people. Both are true, and both need to be respected. "You only care because I pay you" is a statement every therapist has heard at least once in their career. Some therapists undercharge or overextend themselves because they feel guilty for taking money to help. The true dichotomaster finds a way to manage this tension.

Self/Other - Therapists need to know their own baggage so they can distinguish it from the client's issues. It takes a lot of personal exploration to avoid reactivity or defensiveness when a client's issue hits close to home. We don't need to be the picture of health with a GAF of 100, but we should have an idea where the clients issues end and where ours begin. Even better, we should be in an ongoing process of discovering this through our own consultation or therapy.

Knowing/Not Knowing - This might be difficult to explain. When someone comes in with a list of symptoms, it's important for a therapist to know what those symptoms mean in terms of diagnosis, treatment plan, prognosis, etc. But it's also important to never be too certain for risk of putting the client in a diagnostic box. Symptoms change. People grow. No two people, stories or paths to healing are exactly the same. As Yalom would say, we need to create a new therapy for each client who walks through the door. When I start making assumptions or expecting one depressed client to respond to treatment exactly like other depressed clients, I could be missing something.

There are many other dichotomies for the list like mandated reporter/caregiver, directive/nondirective, advisor/facilitator, or even scientist/practitioner. The issue remains the same: our subject matter often pulls us toward either/or distinctions, but we strive to maintain a both/and mindset.

Does this quality deserve a new word? Several other concepts come close. Clinical judgement and critical thinking are certainly elements of dichotomastery. F. Scott Fitzgerald even said "The test of a first-rate intelligence is being able to hold two opposing ideas in mind at the same time, and still retain the ability to function." Well said, but these qualities pertain to cognition and decision making, while dichotomasters deal with more than ideas. Bowen's concept of differentiation and the whole object in Object Relations theory could also apply, but these terms are typically reserved for interpersonal situations (such as the self/other dichotomy). In addition to wisdom and the ability to navigate relationships, dichotomastery is the emotional resilience needed to hold the leashes of two dogs headed in different directions or attacking each other. I want to give the hug, but it may send the wrong message. What to do?

Good dichotomasters are able to wrangle opposing forces and discern when to use one without losing the other. They're aware of the dilemmas and take the necessary time to reflect or consult about them. Poor dichotomasters let the forces get out of balance. I would argue that many of the failed treatments and ethical violations suffered by clients are due to lapses in dichotomastery. Holding this tension is hard work, which contributes to the high levels of stress, fatigue and eventually burnout among many therapists. And when a therapist is burned out, not even the best resume will help.


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