Questions and Answers: Second Opinion

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Janet wrote:

I've been working with a therapist for nearly a year. She has gone over and above the call of duty at times, being available to me via her cellphone, our relationship feeling extremely close and she's mentioned to me that she's shared parts of her life that she hasn't with any other clients.

She has a history of moving a lot. Has moved every couple of years or so all over the country. She is 50, divorced, not in any relationship, and has nothing to do with her family, which has lots of conflicts.

She left the clinic where I began seeing her after she'd been there for eight months, and after I’d seen her for six months. She continued to see me at an office she established in the same city as the clinic, so she could have a private practice.

Then she moved out of the city to a remote suburb, where she took a job at an agency, but continued to drive back and forth twice a week to see clients at the private practice. When I asked why she moved she said to work at an agency and be in the country. It feels like she doesn't even know what she wants--first leaving an agency to be in private work, then taking a job at one? Moving, but staying at a bed & breakfast, as she is currently doing, seems like an unstable lifestyle.

Last week, her usual, empathetic persona became defensive, angry and actually mean as I expressed being angry at her for something. She now says she will not allow me to be "abusive" (all I said was I was angry that she hadn't called at all that day when she e-mailed me saying she would). I hardly call that abusive.

She then decided we should cut back on our sessions and maybe I don't want to be helped. She is NOTHING like the woman I have known for the past year and seriously think she's got some personal issues or serious countertransference going on. All I know is that I no longer feel she can be trusted, I don't feel safe telling her anything about myself, never mind knowing it's not ok at all to express any anger or disappointment with her.

Can I assume that my gut telling me this isn't a healthy therapist to continue with is correct? She is scaring me a LOT right now and cannot have a dialog about our relationship w/out making me the "crazy one".

Suggestions?

Thanks,
Janet H.

Dr. Einhorn replies:

Janet’s question raises issues of, “When is it time for a second opinion?”, and, “What might a second opinion in a therapy case look like?” A second opinion would involve a professional exploration of the situation, including one or more conversations with Janet, and preferably also with her therapist. My reply to Janet’s question, therefore, is not a second opinion about her therapy. Instead, it is a reflection on what issues a second opinion might try to bring into focus. I hope that Janet, and others, may find such consideration useful, and thank her for her question.

There are a lot of ways in which a second opinion in therapy might work out. A client may seek second opinions by making an appointment with another therapist. She may or may not tell her therapist that she is doing so. The consulting therapist may or may not want to speak with the current therapist, and may or may not be available to take the case if the client wants to switch. The client may or may not authorize the consulting therapist to speak with her current one. If I were doing the second opinion, I’d advise Janet to tell her therapist that she was consulting me for a second opinion, and I’d request that she authorize her therapist and I to discuss her therapy.

Lets take a few points as given. First, that Janet has been honest in describing her feelings and impressions about her relationship with her therapist. Second, that her description is incomplete; there is more information that she could have included, but hasn’t, and her therapist hasn’t had an opportunity to provide her point of view. Third, fairness includes the possibility that the client, while reporting her true feelings and impressions, may nevertheless be misreporting the actual situation. Fourth, Janet’s description of all the changes that her therapist is going through in a short time raises the possibility, at least, that her therapist might be struggling with her own issues at this time in her life, which might spill over into her work with Janet. Therapists are people, people are human, and we could easily see, from Janet’s description, how this might happen.

Having established this groundwork, let’s consider some issues from Janet’s question that a therapist might consider in approaching a second opinion consultation.

Janet notes that her therapist seems to have turned against her. The consulting therapist might wonder whether Janet has a pattern of feeling that people she becomes close to turn against her, and even whether that tends to happen a year or so into a new relationship. Maybe Janet does something that provokes it. It might be Janet’s pattern, rather than her therapist’s, that is expressing itself. Or, Janet might be seeking a second opinion in the context of some sort of power struggle with her therapist.

But what if Janet’s description of her therapy actually does portray how it really is? In that case, matters may be even worse than Janet thinks, because the therapy that she has received up to the time that her therapist “changed”--therapy that Janet apparently felt benefited her--may have actually delayed her progress.

As Janet describes her therapy, her therapist has been treating her as altogether too special, for my taste. She’s been calling Janet outside of therapy, telling Janet things about herself that she hasn’t told anyone else, and then telling Janet that she’s done so. All that makes Janet feel very, very special, indeed. But, how therapeutic is “feeling special” for Janet?

Aside from feeling special, has Janet learned anything about herself, acquired any insights, become any more honest or integrated, learned anything more about human nature, understood her life any more comprehensively, taken any steps toward becoming a healthier, more self-respecting person? Has she done anything to address the issues that brought her into therapy in the first place? There is nothing in her question to indicate that her therapy has helped her accomplish any of these. If we take Janet’s letter as a good enough description of her therapy, then it would appear that what her therapy has mainly accomplished is to help Janet feel that she is special to her therapist. And, if this impression is correct, it leads to the question: How therapeutic is that?

I generally do not talk with clients between sessions; when I do, I generally charge them for it. I generally do not disclose personal information about myself unless it makes a good fit with whatever my client and I are discussing at the time. In that case, the purpose of my sharing is to deepen the therapeutic conversation, not to make my client feel special. When I do share a personal situation with a client, I don’t tell her that I’ve never shared that with any other client, even if that happens to be true. My clients are special to me, but I’m not trying to make them feel that way. I’m here to add value to their understanding of self and life, which is different from making them feel special as an end in itself. When they do feel special, it’s because I take them seriously and do my best to partner with them in a substantial mutual exploration of the issues that are important to them. It may be that I help them to understand something about themselves or their lives in a way that they haven’t before, and that can make them feel special. But they also know that I’m going to do the same with the next client who comes in; and the next, and the next.

A client once compared me unfavorably with her former therapist. She said that her former therapist had always made her feel better by the end of each session, but I didn’t; sometimes she even felt worse after her session with me. I told her that I was not trying to make her feel better by the end of her session, I was trying to help her learn to understand herself and her life better, so that she could live a healthier, more successful life; avoid undermining herself as she so often did, make better choices. When I asked her what she had learned from her former therapist, she couldn’t really say.

The concentrated attention and relationship of therapy can be important ingredients in emotional healing. But if they’re the only ingredients, then the therapy would appear to exist for its own sake, and how therapeutic is that?

Therapy should be adding value beyond itself into the life of the client.

If the client merely becomes dependent on the therapist to make her feel special; and the therapist, in turn, becomes dependent on the feeling of power she derives from being able to make her client feel special, what we would then see is a cycle of mutual dependence, a sort of two-person cult, rather than the healthy interdependence that characterizes a good therapeutic (or any other healthy) relationship. A healthy relationship, whether in a therapeutic setting or any other, is characterized by mutual respect, including respect for one another’s time.

So, if Janet’s description of her therapy is on target, it would appear that the therapy went wrong long before her therapist changed from “her usual empathic persona.” In that case, Janet would be correct in saying that her therapist had “serious issues” and “countertransference,” but these issues would have affected her conduct throughout Janet’s therapy, right from the very beginning. When Janet’s therapist’s issues led her to make Janet feel special, Janet liked it; she calls that, “empathy.” But if the only thing that Janet has learned is to come back to her therapist for more of that special feeling, that is not the product of therapeutic empathy, but rather of mutual dependence.

Therapeutic empathy is the combination of intuition and knowledge, within the therapist, of what the client’s issues are, and of how to speak to the client, within the therapeutic relationship, in such a way as to enable the client to become emotionally healthier, more integrated, and more effective in life outside of therapy.

If Janet’s description of her therapy is accurate, then what she can learn--which would be really therapeutic--is that mutual dependence cannot be therapeutic beyond a very early stage, and that we tend to get the therapist, and the therapy, that we really want.

It might help Janet to write down what she is looking for from her therapy. What are her goals, aside from the relationship itself? Why is it so important to her to feel special to her therapist? She could review that with her current therapist, to see if it’s possible to reorient her therapy toward her goals. If it isn’t, or if Janet feels that she can't raise that issue with her therapist, she could seek a second opinion from a consulting therapist who might be able to help her to achieve a more goal-focused therapy, either with her current therapist or a new one.

In any case, I wish her the best of luck.

Dr. Einhorn

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