Head Games Therapists Sometimes Use Counseling Sessions To Wrestly With Their Own Demons

The therapist spoke softly, but her words were hard.

“You’re smiley today,” she said as she greeted the grinning patient. “You’re often smiley, aren’t you?”

The patient, just arriving for an appointment, shifted uncomfortably and mumbled “yes.”

That actual exchange between therapist and patient reveals a subtle hostility that can impede treatment, according to University of Utah psychology professor William Henry. The smiley patient’s condition did not improve.

In his research on therapists, their self-image and their communication skills, Henry has shown that patients often do not fare well under the care of self-critical providers. Therapists’ poor self-image can translate into inappropriate, and sometimes damaging, communication with the patient.

Henry evaluated therapists to determine their self-images, then videotaped their sessions with patients. The therapists who felt hostile toward themselves were often hostile toward the patient, Henry said in a recent interview.

Henry’s studies, conducted first at Vanderbilt University and since 1993 at Utah, demonstrate that fundamentally, therapy is a relationship between two people. It is often evident in the first few sessions whether that relationship bodes well for the patient.

“Therapists bring in their own proclivities for problematic behavior,” Henry said. “I saw a lot of hostility. Therapists act out a lot.”

Allen Bergin, Brigham Young University psychology professor and co-author of “The Handbook of Psychotherapy and Behavior Change,” said such acting out can range from the barely detectable to the obvious.

“Sometimes therapists are clearly not well-adjusted and it’s clear from the literature that those kinds of people do have trouble with their patients,” he said.

Bergin, who invited Henry to write a chapter in his book and is familiar with his research, puts psychotherapists into three categories: the super-therapist, the average professional journeyman or journeywoman, and those “who really should be doing something else.”

Therapists who could be doing more harm than good to their patients may have a personality disorder. They may be narcissistic and get their highs from the feeling of power over other people’s lives. Some are charismatic and thus beloved by patients who develop an unhealthy dependency on the therapist.

Problematic therapists may also suffer from what is known as subjective distress. That includes anxiety disorders, depressive disorders, sexual disorders and dependency. Those disorders can manifest themselves in a variety of ways, including negativity and hostility in sessions with the patient.

Henry traces therapists’ blaming or hostile attitudes to how they were treated as children. Those subjected to excessive parental criticism tended to be more self-critical. In turn, those therapists were more belittling, blaming and neglectful of patients, his research shows.

He found a correlation between the number of statements by the therapist that were hostile and the number of statements by the patient that were self-blaming.

Henry’s videotapes, recorded more than a decade ago in Tennessee, show that the therapists’ damaging communication can occur in a seemingly gentle way. For example, the belittling comment to the “smiley” patient was made in a soothing voice.

Further, the therapist seemed to be paying a compliment, but her observation was subtly perjorative and placed the patient on the defensive.

Henry compares good therapists to good parents: They should communicate “cleanly” with acceptance and nurturance. By “cleanly,” Henry means without conveying sometimes contradictory thoughts.

Henry based his work on the Structural Analysis of Social Behavior. That analysis measures the actions and reactions of others, the actions and reactions of the self, and how one acts toward oneself.

Clean communication is important in psychotherapy, which entails extensive discussion between therapist and patient. The relationship between them may be as important as the treatment.

The patient going into therapy expects that the therapist will not “play the game” - respond to hostile behavior with hostility. But Henry’s studies show that some therapists engage in tit-for-tat with the patient.

What’s more, a play-by-play can be done with the hostile game. Henry did just that with his videotaped therapy sessions. He incorporates the sessions into a training program for students at Utah. The CD-ROM program helps students recognize when a therapist is acting in a hostile manner.

It also discusses appropriate responses to patients who say hostile things. Ultimately, the program may demonstrate how important interpersonal and communication skills are in psychotherapy.

“If the patient and therapist get along well and have a good relationship, the likelihood they will have a positive outcome is higher,” Henry said.