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I knew I had only one shot at helping this family. The 12-year-old girl had been slapped by her stepmother and appeared in school with a reddened cheek. The child welfare worker scheduled a family assessment with me, the father and stepmother, the girl, and the parents' two younger children. The mother was, as they say, out of the picture. I wanted the point I would try to make to be immediate, lively, and engaging. I walked into the consulting room, introduced myself, and noted that if the oppositional girl caused any trouble, I would handle it by slapping her.

The father, initially slumped in his seat and appearing resigned, perked up. “You can’t hit my daughter,” he said.

This led to a discussion about who was authorized to hit her and who was not. Only a parent could hit a child. I asked, “Who decides who’s a parent?” They unloaded on the birth mother, agreeing that she would not be allowed to hit the girl. Then, the penny dropped, and the stepmother and the girl had a conversation about whether she, the stepmother, was her parent. I asked the girl if it would feel like a betrayal of her own mother to accept the stepmother as a parent. This helped frame the girl’s reluctance as an issue between the girl and the birth mother and not as a direct rejection of the stepmother. I think they got a lot out of this session.

This was in the days before the internet. Would I have started so dramatically if they had a way to post online that I had threatened to hit a child? No. Would they have still managed to clarify their relationships if I had started the session the usual way? I don’t know, but I doubt it would have been as impactful.

The philosopher Jeremy Bentham imagined a prison he called a panopticon. Its unusual feature was that each prisoner didn’t know if he was under observation at any given moment, but he knew that he might be. The experience of possibly being observed, Bentham knew, made people conform. He thought, mistakenly, that the conformity that prisoners learned while incarcerated would generalize to their release environments. He thought, correctly, that if the release environment also included a possibility of being watched (as by an omniscient deity), the conformity would generalize.

Conformity, of course, has its ups and downs. It would be great if therapists conformed to the ethical code. But it would also be tragic if therapists conformed to treatment manuals and lost the spontaneity and individuality that make the treatment relationship collaborative and effective. I am concerned that the rise in manualized treatments is partly a response to a generation of therapists reluctant to learn from their mistakes. Instead, they prefer not to make mistakes, and they end up making the huge mistake of turning therapy from mutual fingerpainting into paint-by-numbers.

What really helps therapy patients is not the therapist getting it right, but the therapist resolving the conflicts, missteps, empathic failures, and disappointments that arise in the relationship (Eubanks et al., 2023). This process demonstrates to patients that they can collaborate with others when things go awry. This, in turn, leads to a robust sense of resilience and a willingness to approach conflicts in their own lives. The process is known as “rupture and repair.”

If the therapist is being watched, there will be fewer ruptures.

Fewer ruptures would generally be a good thing in a restaurant. You aren’t there to resolve problematic patterns of relating as they arise in your interchange with the waiter or the chef. Online reviews make restaurants more consistent because ruptures go public and lower the restaurant’s ratings. The chef can experiment with new recipes and techniques on their own. After all, she isn’t cooking for you, per se, but for a generic customer. Your therapist should be cooking for you.

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Online reviews create a sort of panopticon, where the person providing the service doesn’t know whether or not she is in the public eye. They breed conformity. They make rideshare drivers, and rideshare customers, more polite. But if there’s anything we know for sure about psychotherapy, it’s that politeness is not welcome. Politeness makes patients cling to their social masks, and it makes therapists tactful and supportive of the social mask rather than empathic with what’s under the mask and giving voice to it.

I worked with a paranoid woman who got better quickly and then freaked out about her feeling close to me. She filed ethical charges against me and accused me of all sorts of things. For example, she claimed I painted my office walls and denied I had done so. After the investigation exonerated me, she called and said she was sorry, that she was not in a paranoid panic any longer, and that she wanted to resume therapy. I declined, explaining that it was not enough that she trust me; therapy also needed me to trust her. We parted on friendly terms as I referred her to someone else.

I imagine it would be unethical, not to mention unenforceable, for a therapy contract to stipulate that the patient will not leave an online review of the therapist. All these ways for patients to curtail a therapist’s creativity and impose conformity are great when the therapist is exploitative, unreflective, or venal. But the conformity diminishes the effectiveness of therapists motivated by healthy outcomes. Good therapists don’t need the public eye to course correct after a rupture. Good therapists look at themselves with the same welcoming curiosity and skepticism with which they view their patients. Bad therapists cheerlead and validate their own behavior as they do their patients’.

Eubanks, C. F., Samstag, L. W., & Muran, J. C. (Eds.). (2023). Rupture and repair in psychotherapy: A critical process for change. American Psychological Association.

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