Untrustworthy Therapy

Exploring the therapist’s responsibility to work through and claim their own ethical and theoretical orientation

When I was starting out as a clinical psychologist and my caseload was not yet full, I had some time to spare during the day and decided to embark on a four-day-a-week psychoanalysis. During grad school I had learned psychodynamic theory and practice, but never having been in psychoanalysis, I was quite curious.

Like most psychologists and other psychotherapists who undergo years of coursework, supervised training, post-graduate fellowships, certifications, and ongoing independent supervision, I have benefitted from many teachers, mentors, and therapists, in whose presence and care I have been challenged and nurtured. I learned to face my fear of uncertainty, first with a supervisor at a summer camp, then again and more deeply with a grad school teacher who was instructing us in the art of clinical supervision. I was able to heal childhood wounds through the deep work I did with my clinical internship supervisors over the two years I spent meeting with them at the college counseling center where I worked. And I am grateful and blessed to have many more examples than I can name here of receiving wise counsel and therapeutic sustenance from good teachers.

I have also had plenty of teachers, therapists, and supervisors who were lackluster, disappointing, or emotionally unreliable. Upon meeting her and beginning our work, I found my psychoanalyst boring. I didn’t feel any spark or excitement when meeting with her for our initial consultation. But she seemed solid and confident that she could help me, and I was eager to dive into the process.

I had come to this particular analyst by recommendation. The person who gave me her name said she was smart. I admire intelligence in a therapist, and she was also generous with her time, charging me only five dollars per session (I was just starting out, making only about twenty thousand dollars a year with a child to support). I gratefully committed to working with her.

But as we met day after day, I found myself dreading the sessions. I showed up, did what was asked of me, lying on the couch with the analyst out of my sight-line, free associating and talking about my feelings toward my mother and all that. The analyst never said anything inappropriate nor crossed any ethical boundaries. She mostly listened, asked questions, and occasionally gave interpretations. I would talk and cry. But oddly, instead of feeling relief or clarity, as I had with many previous therapists and supervisors, the feeling I most often left sessions with was a sense of shame. I didn’t think the things I was talking about warranted feeling ashamed. Yet, again and again after I shared, trying to work through what was in my mind and heart, after being honest and vulnerable, I felt shame. Why?

Blank slate as a disguise

none of us can ever be a blank slate

About nine months into the process, I must have been talking about my professional musings and I asked my analyst a direct question: What is your theoretical orientation? I expected her to say something like, “Freudian,” or “Kleinian,” (I knew for sure she wasn’t a contemporary relational analyst¹). Even a general, “I pull from many strands of psychodynamic theory” would have sufficed. But her answer shocked me: “I don’t have one.”

I don’t remember anything that happened after that point in the conversation. She had said enough that I instantly realized I couldn’t trust her. How could she claim to not have a theoretical orientation? The entire premise of doing psychoanalysis, its format and content, was based on theoretical frameworks. When she said she didn’t have an orientation, it occurred to me she was playing a role that felt dishonest, in which she disowned or denied her own subjectivity so that she could act the part of the old school “blank slate” analyst - just waiting for my projections. It felt like she was waiting for me to assume something about her, so she could use my “transference” to expose a distorted inner construct. I had often felt like she should have included a Miranda warning in her Informed Consent paperwork: “anything you say can and will be used against you.” I began to suspect that my shame in the therapy was actually related to her evident therapeutic stance – this ludicrous claim of perfect neutrality, as if one could just not have any theoretical orientation.

I told one of my sisters, a deep lover of being in therapy, about my experience and how I felt dread before each upcoming session. “It’s not supposed to be like that,” she emphatically reminded me. You should love your therapist, or at least feel good about the process. Not long afterward, I let my analyst know that I would be terminating soon. She didn’t think that was a good idea and told me that I hadn’t even started the real analysis. (Four days a week for nine months and I hadn’t started?) I ended the next week and have never regretted that choice.

Two recent Substack posts got me thinking about those nine months of unpleasant psychoanalysis. Liz Bucar’s post Faith as Trust: Why Religious Frameworks Matter Right Now (Even If You’re Not Religious) which is excellent, and I highly recommend, and then this re-stacked quote from Joshua Coleman, Ph.D.:

Over the past half century, numerous cultural analysts have suggested that therapy filled a void created by the decline of organized religion, the erosion of communal norms, and the weakening of traditional authority. Where religion once provided the answers to a quest for meaning and the reduction of suffering, therapy now serves that aim. While we once sought to eliminate sin, today, we seek to eliminate negative, self-limiting thoughts.

It’s true, therapy has been given the task of addressing a spiritual void in our culture. That is a huge responsibility, whether we want it or not. I’m not saying that therapy is the right place for this, or is up to the task. But there is no doubt in my mind that many patients are looking to their therapists as ethical and spiritual guides in a world where they feel unmoored.

One of my long-standing patients once said to me, as if to justify (to me and to herself) why she was still seeing me, “Some people go to church every week, I come here.”

If therapists are occupying that space for at least some of our patients, having clear theoretical, ethical, and spiritual frameworks that guide our work is a must. I don’t mean you can choose to have a framework or not. You have one. But if, as a therapist, you aren’t clear about it, then you don’t even know what you are transmitting. It’s not that patients have to ask you what you believe or what they should do. You don’t have to be directive or self-disclosing for it to come across. Your ethical and spiritual framework, along with your theoretical orientation, automatically biases your questions, your methods, your way of listening.

Therapists may have many different frameworks that inform their practice. Not everyone is a strict adherent to a particular school of thought and that is fine with me. We also don’t need to broadcast our spiritual and ethical beliefs in our therapy. Doing so is often counterproductive to the client’s needs. We need to make space for the client to find their own spiritual ground without having to worry about falling into line with ours, or foreclosing their search by adopting our values to please us. And yet, we must do our own work to clarify to ourselves what we believe, what informs our practice, and how we make meaning of the human condition. We must not disown the responsibility of articulating for ourselves an operating framework, however eclectic and multisourced it might be.

One personal belief informing my work that I’ve written about before is the value and necessity of lifelong learning. I wrote about this in the context of my history of being tone deaf as a child and then finally learning to sing mostly on-key as an adult. This is one of the many experiences that help me know on a felt level that I can help my patients learn to do things that they never learned to do as children and haven’t yet developed capacity for. I know what it feels like to go from no capacity to a workable amount of capacity.

Now, I attend a monthly Friday night sing along service at a local synagogue. I find the music immensely powerful, and singing in community is one of my favorite ways to feel both spiritually engaged and connected with others. (Most of my best friends in middle school and high school were in bands, and I was their biggest groupie). After one particularly beautiful Friday night of singing, I went up to the song leader who organized it and thanked him. He said he noticed how into the music I was and asked if I wanted to join the song leaders’ circle. I felt flattered and said I’d love to, but couldn’t yet sing well enough. But if he knew a good voice teacher, I’d love to learn.

The opposite of shame

And so I had my first ever voice lesson this week. It was thrilling. Leaving the lesson, I was filled with the opposite of shame. Was it pride that as a forty-six year old mom, busy with my work and responsibilities, I was taking the time to learn something new? Yes, there was that. But there was something more than that. In my voice teacher’s presence, I could allow myself to try something totally new, to make strange sounds using parts of my body I had never used in this specific combination. She asked me to copy the different sounds she was singing. I had no idea how to do that, but without thinking, I made the same sound. She made another sound and this time when I tried to make it, it fell flat. She then made the gesture of throwing a ball and told me to throw the sound, so I imagined throwing the sound as I let it out of me. I felt in my bones that I didn’t need to know or understand it all in order to jump in. I could just trust and do it. I threw the sound and it hit. I’m still giddy thinking about it. How exhilarating to trust and use my body in that way. The true opposite of shame, I realized, is trust.

Shame is a relational emotion and so is trust. Shame gives the message: some part of you is unacceptable. Something in you will be discovered or exposed, and then rejected or deemed wrong. Trust is feeling that it’s okay to let go. It’s okay to not be on guard, ready, or protected. You will be held, accepted.

Bucar’s piece I mentioned above describes an interview with James Talarico saying,

He tells this story about learning to swim at his neighborhood pool. His instructor told him: Don’t fight the water. Let the water carry you.

That was the feeling at the voice lesson. Not having to struggle with or censor what might come out. Being free to make whatever sound and being astounded at how well I could match her note when I stopped holding back. Trusting my body to know what it was doing because I could trust this other person and the space she created, and let that carry me.

Owning your frameworks

In our opening conversation, the voice teacher asked about me, what kind of family I had grown up in, if my parents sang, what place I was in the birth order. She shared that she was classically trained, but didn’t love performing classically in conservatory. She was happier singing Dar Williams covers (which, by the way, she did so beautifully that hearing her sing just one bar from “Let Your Love Cover Me” made me cry). She told me that her work was spiritually rooted and she loved teaching people to sing in a way that they could express themselves more fully or be a part of singing in community. She had a framework, a spiritual and ethical orientation and she didn’t pretend otherwise. In that first hour, I knew that my sounds would never be used against me.

I often think about hourly rates and how it is that, miraculously, I’m able to make a living doing this job I feel so privileged to do. I am paid to listen deeply and guide people through their deepest struggles toward healing, better functioning, and greater fulfillment of who they are and want to be. What an amazing job description. Sometimes I visit a massage therapist for migraine relief. I am so grateful for a good massage now and then. How is it that I can pay less for an hour of pleasure and relief than I am paid for helping people confront their greatest difficulties and discomforts? Yes, people sometimes feel good after leaving therapy - but does it feel that good? I know it’s not actually about how good we make people feel² . People pay well for good therapy because it is a supreme act of trust. Even more trust and vulnerability than is required for most of us to undress to our underwear and lay on a massage table.

Patients need to trust that their most vulnerable moments won’t be used against them in therapy. When a patient is reluctant to share something, there is an unasked question underneath: “Is this beyond the pale of what’s acceptable? Does this make me unlovable or unworthy?” Theoretical and ethical frameworks allow the therapist to respond to this unasked question honestly and directly.

These frameworks help the therapist see beyond their own preferences and comfort, to distinguish between shame that comes from a fear of being rejected versus shame that points to behavior that is harmful to others (healthy shame). Clear theoretical and ethical principles, for example, can help therapists communicate that mean, aggressive, or socially deviant thoughts don’t make you unacceptable. Our shadow qualities are part of being fully human. There is a difference between an ethical responsibility to notice if you are hurting others, and the healing imperative to acknowledge and integrate parts of you that aren’t pretty. Jungian psychoanalysis and Internal Family Systems both make this concept central in the task of psychotherapy - whatever is unconscious and disowned gets acted out or judged in others. This holds true for therapists as well. Whatever the therapist disowns in themselves can seep out as unspoken judgement, subtly shaming the patient.

Therapy patients trust their therapists to have coherent, reliable, ethically grounded frameworks that they employ and embody for the patient’s benefit. Indeed, these frameworks are a large part of what makes therapy safe and effective enough to be worthwhile. Some other large and important parts are being well trained and registered with a professional body (as Skye Sclera writes about here.) Careful supervision, adequate coursework, ongoing learning, and professional accountability help therapists be technically skilled, not cross ethical boundaries, and not exploit their patients. My psychoanalyst from years ago was well trained, herself a teacher and supervisor. But these are not enough to be trustworthy because they don’t speak to how the therapists organize their own thinking about what psychotherapy is for and what makes it therapeutic. The best supervisors and therapists, like my new voice teacher, have “done their own work.” They are aware of their biases, they situate themselves and their thinking. They don’t claim to be neutral or objective. They back up their skills and learning with their whole human, limited, particular selves.

1. Relational psychoanalysts acknowledge that therapy is the interchange between two subjectivities in the room. They often work face to face, rather than with patients lying on the couch, and they prioritize acknowledging that the therapist’s own subjectivity affects the client’s experience. For a great explanation and exploration, see Santiago Delboy’s discussion of Lewis Aron’s landmark paper, The Patient’s Experience of the Analyst’s Subjectivity.

2. That’s partly why AI therapists are NOT therapists at all.