On Knowing What Your Therapist Really Thinks About You

Illustration for article titled On Knowing What Your Therapist Really Thinks About You

In his book Half Empty, the late David Rakoff humorously describes the ambivalence he feels upon finding out what his therapist — who he's terminating sessions with — genuinely thinks about him:

Turning things around, I asked him what his feelings were about our ending things. 'I'm incredibly angry,' he responded fondly. 'How dare you. You should at least have to come and have coffee with me once a week.' I asked if he felt this way about most of his patients. 'Not really,' he responded. Sigh. Should you happen to be possessed of a certain verbal acuity coupled with a relentless hair trigger humor and surface cheer spackling over a chronic melancholia and loneliness— a grotesquely caricatured version of your deepest self which you trot out at the slightest provocation to endearing and glib comic effect, thus rendering you the kind of fellow who is beloved by all yet loved by none, all of it to distract, however fleetingly, from the cold and dead-faced truth that with each passing year you face the unavoidable certainty of a solitary future in which you will perish one day while vainly attempting the Heimlich maneuver on yourself over the back of the kitchen chair— then this confirmation that you have triumphed again and managed to gull yet another mark, except this time it was the one person you'd hoped might be immune to your ever-creakier, puddle-shallow, sideshow-barker variation on 'adorable,' even though you'd been launching this campaign weekly with a single-minded concentration from day one— well, it conjures up feelings that are best described as mixed, to say the least.


When I found out what my therapist thought of me, there were no mixed emotions. I was elated that we both welled up in our last session and admitted that we were going to miss each other. Not only were those feelings true, but they also helped affirm the work we had been doing together. While Rakoff imagined that his therapist's opinion spoke only to his most shallow qualities, I felt the opposite. I had let mine see the darkest, least likable parts of me and she liked me anyway.

While we had very different reactions, both of us (and yes, I'm aware that this is probably the only time in my life where I'll get to refer to me and David Rakoff as an "us") had the privilege of experiencing a fairly honest relationship with the person we had put in charge of our mental healthcare. I say "privilege" because it worked for me — I liked having my therapist explain what she thought was going on in my head as it was happening instead of analyzing me in her notes for some grand diagnosis later. And if there was something she wasn't telling me, I trusted that she had a reason for it.

Allowing patients more access to their therapist's analysis is slowly gaining popularity. This can mean a therapist talking to their client in the open way that mine talked to me or, on the more experimental side of things, it can mean making their notes available online for their client's perusal — although this extreme is not without controversy.

Giving patients complete access to their therapist's notes has major risks. They can be confused or offended by the information they read, they can stop seeking treatment and it leaves their information more vulnerable to third parties — a particular danger if the client is in an abusive relationship. Yet proponents of the practice also argue for its benefits.

In "What the Therapist Thinks About You," an article recently published in the New York Times, Dr. Tom Delbanco — a Harvard professor of medicine who has launched a project to observe the effects of sharing notes with patients — claims that this kind of open communication is the next "revolution" of mental healthcare.


It could be. Or not. At this point, it's too early to tell.

From the Times:

The practice is so new that it is too early for a comprehensive evaluation. The Department of Veterans Affairs, which began making medical and mental health records available online last year, is only just beginning to study the effect on mental health patients.

Older studies from psychiatric wards where patients read charts with doctors found that the patients were confused or offended by the content. But as doctors helped interpret their notes, patientsbegan participating more in their care and trusting their team.


For some involved in Dr. Delbanco's study, the project has already had positive outcomes.

"Yes, the therapy notes can be hard to read, and sometimes I wonder, 'Really, I said all of that?' " remarks Stacey Whiteman, a patient whose multiple sclerosis has lead to severe self image and relationship issues. "But there's no question that reading this stuff just charges you back up to moving forward."


David Baldwin, who suffers from bipolar disorder, severe anxiety and depression, also finds reading the notes helpful.

"I have a tough time recognizing that I've made progress," he says. "So it's nice to read this as a reminder."


Whiteman and Baldwin are two of about 700 patients who are participating in the experiment. The doctors have found that most people, however, are actually not all that interested in reading their therapist's notes.

"I've offered to share my notes with patients and they'll say, 'No, I'm good.' But it's a good concept that should be researched," Dr. Kenneth Duckworth, medical director of the National Alliance on Mental Illness, tells the Times.


While having a good and communicative relationship with a therapist has always been important to me personally, I don't know if I'd find reading their notes terribly helpful or appealing. If anything, I'd worry that, in having the information, I would start subconsciously manipulating my behavior in sessions or, as David Rakoff put it, displaying only the"grotesquely caricatured version" of my deepest self.

That said, some might find the practice incredibly useful (as pointed out before, some already have) and it's certainly worth the research. There's no one kind of therapy that works for everybody so the more options there are, the better.


Illustration by Tara Jacoby.



I've found therapy for depression to be really frustrating. I have the impression both of the therapists I had were just bored or annoyed. I'm fascinated by people who have good therapy. How is that even possible? I was disappointed that neither therapist made suggestions. Just having someone listen is really useless to me. (I told them this it did not help.)

I think I must be missing the point.