Dichotomastery: The Hidden Talent of Good Therapists
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 manydichotomies 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.
1. Are you a good listener?
Above all other traits, a psychologist must be able to pay attention not only to what the patient says, but also the patient’s subtle body language. Personal information revealed through therapy often comes slowly and with effort, so great care must be taken to understand all forms of communication to help determine a proper course of treatment.
2. Can you keep a secret?
Another cardinal rule of therapy is that nothing said between psychologist and patient is ever divulged, unless mandated by law, as stated in the American Psychological Association’s Code of Ethics. Therapists should never share gossip learned during a session or bring their work home with them.
3. Do you genuinely care about others?
This may seem like a silly question, but it’s important to ask. Empathy is the backbone of the psychology industry and cannot be faked. It’s important that psychologists understand a patient’s emotional pain and to show compassion. Those who get easily frustrated with the problems of others and want them to “just get over it” will not last long.
4. Are you naturally inquisitive?
While listening to patients, psychologists must also guide the therapy process with their own questions. This is a good profession for those who are astute observers, like to ask follow-up questions, and are able to analyze vague statements by patients to hunt for hidden meanings.
5. Do you know yourself well?
No analysis is conducted in a vacuum, so psychologists must take into account their own natural biases, based on their education, background, social status and religious beliefs. They must know how to step back from their own lives to ensure that they can make objective observations.
6. Are you comfortable with talking to all types of people?
Therapy patients will come from diverse racial, political, socioeconomic, moral and cultural backgrounds. A good psychologist will have the interpersonal skills to hold conversations with every personality type and inspire trust in patients.
7. Are you a generally stable individual?
No one expects psychologists to be perfect; after all, they’re only human. But before they can sit patients down on the couch, psychologists must make sure that their own “mental baggage” has been addressed first. Hotheads need not apply.
8. Are you a tolerant person?
During therapy, psychologists must uncover the deepest, darkest thoughts and fears of clients to help them deal with their problems. By doing so, psychologists must refrain from passing judgment on anything being said, even if it runs counter to his or her personal and moral beliefs. In addition, therapists must be patient with incremental progress and with occasional push-back and periods of regression from clients.
9. Are you good at solving puzzles and riddles?
Good therapists are often those who can use logic to piece together solutions, often from limited information. Psychologists must be able to drill down through extraneous data to determine the root causes of patients’ distress and provide an accurate diagnosis.
10. Are you creative and flexible?
Psychology requires analytical skills, but it’s also an evolving art and science. The most effective therapists must be open-minded enough to challenge previously held assumptions about human behavior and consider new theories as society changes. The human mind is highly complex and ever-changing, and psychologists must be equally adaptable to new findings in the field.