Is the Patient the Expert in Therapy?
November 13, 2023
“The patient is the expert,” but therapists should not overlook the misguidedness of individuals trying to resolve their own suffering
Most therapists claim, “The patient is the expert” (Actually, they’d almost surely say, “The client is the expert,” which I consider part of the same problematic). On the surface, this is a fairly uncontroversial statement. A therapist has a remarkably limited view of a patient’s life, really. A therapist only spends an hour or two a week with a patient and very rarely meets the players in a patient’s life directly such as a spouse, friends, or that nagging coworker. My concern, though, is that in setting the patient up as the expert rather than an expert, we overlook the misguidedness that individuals can also bring to trying to resolve their suffering (including an understanding of suffering and themselves).
“Patient as expert” grew out of a movement to center patient experiences and autonomy
The notion of “patient as expert” derived from an important movement to center patient experiences, autonomy in decision-making, and a belief that humans have an innate drive to health that can be harnessed rather than overridden (or simply ignored). This was a response to a practice long prevalent in psychiatry (and deeply present in psychotherapy and psychology more broadly) to relate to the patient as the passive recipient of treatment, often coaching patients as in the way of treatment. This was—and is—a significant movement. To be clear, the patient is an expert—humans do have an innate desire and capacity to overcome, heal, and grow.
Unfortunately, this movement also paralleled a long slide in the amount and quality of training taken by those who provide therapy. Before World War II, therapy was largely practiced by psychiatrists, medical doctors with eight or more years of education. The practice, then, extended to psychologists, typically with five years of education. Beginning in the 1970s, social workers became the dominant providers of psychotherapy with two years of post-college education required. Since roughly 2000, many of these programs are completed online.
This has key benefits: Lengthy rigorous programs limit the pool of therapists and attract a certain kind of student who is more likely to be white and science/quantitative-focused. However, therapists do have less expertise than they used to. Granted, this, too, has been helpful. “Expertise” is always bound up in power structures that privilege certain points of view and assign greater value to the “expert.”
A patient may struggle with formulating the problem that brings them into therapy
The premise of therapy is that something isn’t working—that (usually) in spite of great self-effort (and often the support of friends and loved ones), a person has discovered they need more help. They can’t solve things on their own. In practice, we, as therapists, discover that the challenge isn’t simply the struggle to solve the problem but in formulating the problem itself. In other words, a patient seeking therapy for help with a given problem—with problems in living that are challenging enough to warrant paid help from a therapist—might not have an accurate understanding of the problem.
For example, a patient believes she’s always been lazy. In spite of good evidence that she’s smart, her grades never matched up and she believes she’s underemployed in her current position. This belief may present as a given. Perhaps in an intake, she says, “I hate my job, but I’ve always been lazy. I’ve accepted I’m just not going to do more.” Over time, a therapist notices real effort and perhaps effort at putting in effort—stretches of time when the patient really works to buckle down and has a few days of extra striving to get an assignment done. But, then, in the face of a small mistake or setback, she gives up. Is that laziness? Or is it an issue with self-esteem that can be perhaps understood as a consequence of a harsh parent who always undermined her as a child?
There is another level to this: A patient might not only struggle to understand the problem but also have a misunderstanding of themselves. For instance, a patient is much more acerbic than he realizes. He thinks his offerings of “constructive criticism” are benign—it’s just that no one wants to hear it. A therapist discovers that he’s bringing more heat than he realizes and then, strives to better understand what forces are at work that make it so.
A therapist’s expertise is in noticing what the patient says, what they’re not saying, and what they don’t realize they are saying
How can therapists discover these misunderstandings if their only primary data is through the patient? A therapist’s expertise is in noticing. We look for contradictions—say, if in one breath, a patient expresses anger at a spouse while in another there is a deep fear of losing them. This, in some ways, is one of the core skills of therapists. We listen to what the patient says but also what the patient doesn’t realize they are saying, as well as, importantly, what they’re not saying.
