How do you get your kicks? Or, to put it in a more subtle way, what kind of things do you find yourself spending a lot of your time, energy and commitment on because you feel they validate you as a person?
One of the things that some people get a kick out of is helping others, but the self-validation that comes from helping others is not always entirely wholesome.
If you speak to people in the caring professions, and also to caring volunteers, you’ll find that some of them attach great importance to helping others, while some of them don’t. The ones who don’t, attach more importance to other aspects of their work, perhaps the camaraderie or the intellectual challenge.
People in the second group are easy to understand. They explain why they do the work by telling you exactly what they get a kick out of, what it is that makes them feel alive and important.
What’s in it for those who say they do their work primarily to help others? It’s a more difficult thing to understand because it’s an indirect kind of self-validation.
There’s a clue in the kind of help provided.
Ways of helping
If it’s very specific help, like a professional service, and you could easily define in a written contract exactly what the service delivers, then it’s very likely that the challenge of the work itself is more important than the simple fact of helping others. Specialists tend not to see themselves primarily as helpers.
If it’s help that relies on a team, then it’s very likely that camaraderie is important to the people who do the work. And within a team there is usually some specialization of roles too.
If it’s help that is delivered one-to-one, and if it is very broadly defined so that it is not exactly clear what is being delivered, then it’s very likely that helping others is the most important thing.
Now we can turn these clues around and hypothesize about the helpers who say they do their work primarily to help others. They tend to be the kind of people who don’t find self-validation by achieving a high level of skill in the delivery of a specific service. They don’t find self-validation by having a well-defined role as a team member. They find self-validation by having a wide range of low-level skills and by acting alone.
Now I’m stuck. The next step requires an intuitive leap.
To get there, first imagine an extreme case. Imagine someone who actually dislikes having skills, who is much happier being seen as incapable of doing anything much. Imagine, too, that this person actually dislikes being part of a team with a specific role, and is much happier just blending in to the background.
The person you’re imagining suffers from low self-esteem.
Normally, being skilled and being part of a team reinforce our sense of self. Low self-esteem turns this upside-down. Being skilled, and being a team player, become negatives because they clash with a pre-existing self image. They are felt to be uncomfortable or even painful.
Now back off from that imagined extreme case a little and imagine someone who can just about cope with having some skills, and who can just about cope with being a team player, though neither of those things is very rewarding in itself.
How could a person like that find self-validation in the world? By helping others. Being in the presence of others who are even less skilled and even more socially isolated makes people with low self esteem feel good about themselves. It’s how they get their kicks. They are drawn toward helping roles.
Implications for therapy
There are uncomfortable implications for therapy, and for mental health care in general. Professional roles working with the mentally ill are a magnet for people with disguised self-esteem problems.
Within the field of mental health, certain groups of more vulnerable patients — children, the elderly, and the chronically ill — are more of a magnet than others. Mental health professionals who have a personal preference for working with those groups are very likely to be doing it for self-esteem reasons.
It doesn’t feel like that to the helpers, of course. They feel that they do what they do because of a genuine desire to help others. But if that were really true, then they wouldn’t be picky about who they help, they would place a positive value on acquiring specific helping skills, and they would feel good about having a strong team role.
What’s the harm?
When a therapist has a self-esteem problem, it harms patients in two direct ways, in addition to the indirect harm caused by the therapist being relatively unskilled and a poor team player.
The harm comes about because the patient’s vulnerability matters personally to the therapist, and makes the therapist feel rewarded. In the course of therapy, this makes the therapist treat the patient’s problem areas as areas of closeness, as common ground. So the patient gets a feeling that being ill is good.
Conversely, the therapist treats the patient’s normal capabilities and strengths with distance, because those capabilities and strengths trigger uncomfortable feelings of low self-esteem in the therapist. The patient gets a feeling that normal capabilities and strengths do not count for much.
The second way in which this harms patients is that even when patients recover for some reason, the therapist may be reluctant to admit this and to discharge them. The attraction of working with someone seen as vulnerable may be so strong that the therapist wants to hang on to it, and hang on to the patient. As a supervisor, noticing a reluctance to discharge may the be first clue you get that a therapist you are supervising has this problem.
Locus of evaluation
It would be nice if therapy training courses could eliminate trainees with the kind of hidden self-esteem problems that make them get their kicks from patients’ vulnerability. Wishful thinking, alas.
Therapy is meant to be done with the therapist’s own feelings about life strictly suppressed. When a judgement has to be made about any aspect of the patient’s life, it’s the patient’s own judgement and only the patient’s own judgement that’s used in therapy.
For example, a patient might say some things that don’t appear to make much sense. The therapist will go along with what’s said, using the patient’s own evaluation of whether it makes sense or not. Afterwards, in supervision, the therapist might take the view that the patient was simply lying, or keeping some things back, but that’s in supervision. In the therapy session, the therapist does not break out of the therapeutic alliance and make that judgement.
The technical description of this is that the locus of evaluation remains with the patient. I don’t know how the Latin word locus got to be used. It means that the patient is always where the evaluation is at. The therapist does not do evaluation, does not make judgements.
Beginner therapists sometimes find this hard. There can be a fine line between pointing out a fact or a logical consequence (which are allowed), expressing a genuine feeling within the therapeutic alliance (which is allowed), and breaking out of the alliance to express a judgement (which is not allowed).
And there’s no fine line between positive and negative judgements. Beginners sometimes think they can say “Well done!” because it’s meant to be encouraging, but it’s a judgement that takes the locus of evaluation away from the patient just as much as a negative judgement would have.
A therapist who identifies with a patient in some specific way is at risk of letting that identification grab the locus of evaluation. For example, a therapist suffered from panic attacks as a teenager. Her patient suffers from panic attacks now. The risk is that the patient’s description of panic attacks will evoke feelings that fool the therapist into applying her own experience to her patient’s life.
In general terms, therapists who have been through a lot themselves find it a great advantage, because they know with the absolute certainty of experience that bad times do not last, that recovery is always possible. But in specific terms, strong parallels between a patient’s life and the therapist’s life are a risk, because they can tempt the therapist to make judgements.
Therapists with self-esteem problems risk making their own self-esteem the whole basis of their relationships with patients. The locus of evaluation is then firmly with the therapist, because the therapist needs it to be that way to feel OK.
A mixed bunch
People who work in mental health are a very mixed bunch. Success as a therapist comes mainly from your technical skill in your work, and to a lesser extent from the way you cooperate with fellow professionals. If these are the the things you enjoy about being a therapist, then these are the things you will put your energy into, and your patients will benefit.
Paradoxically, if what you enjoy is helping others, and if the reason for that is that you have hidden problems of self-esteem, then you could actually be harming patients by linking your closeness to them with aspects of their illness, and by applying your own evaluation to their lives.