Yoda and Columbo

Therapy is whatever people want it to be, and the therapist is, too. Some are looking for a spiritual/behavioral guide, others a detective. Some want a therapist to dress up and play the consummate professional; others are more comfortable with the cargo pant look. It is the difference between Detective Joe Fontana of Law and Order, who wore expensive shirts and asked pointed questions, and Columbo, an average guy in a crumpled hat and raincoat, who asked unassuming questions to solve the crime. Columbo even seemed a little slow. Therapists act like this, too, a little slow, like we’re just not catching on. We want the patient to tell us more, is all. The patient knows the answers, so we put a lid on our own thoughts and poke around in his.

Whichever methodology, no matter our school of thought, we are out to detect sources of pain and anxiety (diagnosis) and relieve it (treatment). It’s not all about the money (a little professional humor, here, a disarming tool, meant to relax the patient).

As are many detectives, we’re married—to some theory or another, perhaps several. There are many such theories; some even explain why therapy works. One builds upon the genre of relationship therapy, only that it is the relationship with the therapist that matters, or the therapeutic relationship. A weekly or bi-weekly schmooze with a nonjudgmental, wizened, objective, empathetic guru never hurt anyone. We all need a Yoda in our lives.

Not that the guru has to be your therapist, of course, but if you can kill two birds with one stone, why not? The force, any self-respecting guru will tell you, is within you. Therapists are only one cloth available to help you not only find it, but use it.

Whether the patient needs guidance for the present, or a fresh eye to the past, therapists who have had any professional training within the past twenty years see everything psychological as biological, too. That means our experience is in the here and now, which is why a visit back to the past to solve the mystery isn’t quite enough, even when the past is clearly riddled with trauma. A trigger may have originated in childhood, but the patient is suicidal today, and the family will certainly look at us as accountable if we don’t prevent it.

Whether it is the past raising its ugly head, perhaps the anniversary of the death of a child, or the memory of a sexual assault, or the thought of father pounding mother, or a nasty confrontation with a pit bull last week, therapists are quite worried about the state of the patient’s brain in the moment, the organic variable, or organicity—no matter our theoretical preference. Or we should be. The crime may be old or new, but the imprint is relevant today.

Thus the patient walks into therapy, for the first time maybe, or for the first time with a new therapist, and he is aware that he has issues, perhaps really old ones, or maybe new ones, or some relatively new, hoping to find experience and wisdom, at least one of the two, preferably both. It would be unnatural not to be skeptical under the circumstances, at least a little, and reticent, reluctant to spill the most intimate details of life, past and present, to a perfect stranger.

That perfect stranger’s ability to dispel anxiety quickly will influence the entire process, even if his skills are otherwise lacking. This explains so many bad therapeutic experiences: a prospect of great therapy, come to find, the therapist doesn't quite cut it.

And yet, to put a new patient at ease from the very start takes skill. Personality does matter. The relationship with the therapist matters, but training matters as much, perhaps more, in the end. Which is why we have consultants.

The goal remains, no matter the style, whether ala Columbo, unassuming, open, clueless at first, eventually annoying (like most good parents), or like Yoda, wizened over the years, to establish a safe, drama-free setting. And we want you to want to come back, naturally. Nobody likes to stop in the middle of a good story.



HenryCameron said…
This is great. I am going to repost on my site.
henry said…
This is a great post. I would love to repost it on my Facebook page.

Medkid said…
Ha! I love it! And so well timed...Today I printed out a goodbye letter to my own therapist I have worked with during years 2 through 4 of medical school (I'm moving 3000 miles away in a few weeks...), which leaves me with the situation of finding a new therapist. Neither of us are that happy about the situation frankly, but to residency I must go. I am DREADING those first interviews with new therapists as I try to negotiate the massive change it is to go from Medkid to Dr. Medkid. Dreading figuring out where I should be and who is skillful enough to weather the storms of the second half of my training with me (because I've been to some horrific therapists and one incredibly skillful therapist and there is a HUGE difference as you said). Mostly I'm dreading putting my trust in another therapist, and possibly choosing the wrong one/making a mistake in my choice, and getting hurt by ineptitude (probably the same thing my patients will fear when they are choosing a new physician!). Therapists have a unique ability and position to hurt patients deeply. Doctors do too, but I would argue therapists uniquely so because you play in the world of vulnerability, truth, self worth, emotion etc etc etc. I very much appreciated this post, it helps put a nice perspective on the next stage of the journey. Thanks!
therapydoc said…
Thank you, Dr. Medkid, and best of luck in sifting through us. I really appreciate that you understand what I said, and you are so right, the playground of vulnerability is a dangerous place. I am going to write about how to make it safer, too. Just have to find the time.
Anonymous said…
Hi, speaking as both a client and as a counsellor: I also think many therapists are also not great for a whole lot of reasons rarely mentioned. I used to know/feel when my counsellor was due for holidays, the therapist gets full of stories and cant take any more, compassion fatigue is a big factor, I could also tell when my therapist was bored, didnt like what I was saying and was unimpressed by my issues. I used to be able to tell when my therapist needed her supervision, and when she was frustrated with me. I have had therapists who remove themselves from emotional content and start rambling on a philosophical level about concepts discussing truth and authenticity, and the new breed of contemplative ACT therapists who continually try to calm/sedate you to the point of sleep, give me a fiesty, politically uncorrect opinioned realistic therapist any day. I once asked my supervisor why some are so incompetant, psychology attracts some asperger types to it who then feed of others emotional activity, emotional vampires. Others use their psych training to re-solve their own wounds,( have a look at the family of origin of some famous psychs) and some therapists just get old tired forgetful, and reach a space of well it all passes anyway. Some therapists will never admit it but they just dont like you and they dont care about your problems.Full Stop. I have found after many years of this field, psychology can also loose people thinking about thinking too much, and taking thoughts and their abilities a little too seriously, particularly academic existentialist european therapists in my study group-ooooh paradigms (lets use big words to impress)-oooo, people forget not long ago we were illiterate uneducated simple hunters and gatherers not real pre-occupied with feelings except hunger and fear of animals, therapy is a great field to get into..when it doesnt work you can always blame the customer, what other job gives you that power and unaccountability. I love it!!
Medkid said…
Sister mercy! Now I want to try to find another therapist even less after anonymous's comment! I might just pick up extensive yoga and meditation practice instead of therapy it seems safer... :O :P Sounds as if you have to have a stealy constitution to find a therapist, which is great for me to know in terms of being empathic and advising my patients in my future primary care practice (I think I got lucky this time :)!

Awaiting your next post eagerly Therapydoc!
therapydoc said…
Do I not have the BEST readers reading this blog? Thank you Anon, and MK, be patient. Lots of crazy personal stuff going on, am sure I'll want to share some of it soon, in some way.
Gary said…
This comment has been removed by a blog administrator.
Really good post. Though at times, I feel as a clinician the patient wants you to be more of a Columbo at the beginning of treatment and as treatment progress they want you to be the Yoda! I am going to re-post and link this post to my blog.
Tzipporah said…
This is very witty and very true, I can say, without even being a therapist. A lot of what you dascribe I come across in my work as a birth and postpartum doula.

Great post!
spldbch said…
Skill definitely matters. However, I've read several studies that suggest it probably isn't the most important thing in therapy. From what I've read, it is the "personal qualities of the therapist" that have the most significant impact on therapy outcome.
therapydoc said…
Certainly customer satisfaction.
Adel said…
Hats off to all the therapist in the world, they play a major role in our community.

Zero Dramas
Anonymous said…
i'm a different anon from above.

I've been working with a terrific therapist for four years. Every year, because she is just a bit insecure (perfectly secure people are smug), she seems to worry that I will end therapy at the end of the year.

Once it's clear I'm staying past year end, she then feels secure enough to let me know what she REALLY thinks of me . . . in a professional but nonetheless direct way. She'll get across that my ego is getting the better of me, that I'm overly rule-bound, that the way I push my mother-in-law away is unjust . . . stuff like that.

Do all therapists have this seasonal thing? Or is it in my (now deflated) head?
I came across your blog when googling for cool biotechnology articles – didn’t expect to find this, but enjoyed some of your posts. Keep it up.

therapydoc said…
Thanks, Neilesh.
ANON, re: Do all therapists have this seasonal thing? Or is it in my (now deflated) head?
Absolutely no idea. I can only speak for myself, and the answer would be no, but that has nothing to do with your head, which you probably need to pump up once in awhile. The whole humbling thing is very over-rated.
Psychotherapy is such a varied profession, the persona one chooses is often determined by the client. For instance, children require a non directive approach.