All his nerve endings were programmed for me to tell him that it is indeed awful that he has to cope with the ineptitude—and sometimes the selfishness—of others. He wanted to be stroked. Instead, I told him that his head was up his asshole and that we’ll be working on ways for him to learn not to let those irritants govern his life. I wanted to challenge his destructive assumptions. He needed to work on them to become empowered to learn not to get irritated. It was a losing strategy to allow his capriciousness to run his emotions. He was becoming a righteous hermit.

As opposed to that of a friend, one job of a therapist is to give honest and direct feedback and help patients gain better approaches to their problems. Patients often crave and deserve sympathy, but that is not enough to stimulate change and promote the development of skills. One patient, who was very socially motivated, found herself being beaten by children she volunteered to help. She wanted me to say, “Isn’t it awful that such a good person like you gets treated in such a rotten way.” Instead, I said, “We’ll explore what you do to be consistently treated badly.” Stroking would not empower her. However, my telling her that she whined and that whining annoyed people led her to relate differently. We also worked on her being appropriately assertive and setting limits on people around her. Once she did not posture herself as a victim, people stopped victimizing her.

Clearly, therapy does not progress without an alliance between the therapist and the client. That alliance includes direct feedback to the client. However necessary, that feedback is sometimes unwelcome. The action in therapy is to stimulate changes inside the skin of the patient. We complain to our friends about the faults of our spouses and they better agree. My response is that the spouse in not in the office and our agreeing that the spouse should change doesn’t help the patient. I know they want me to agree with them and stroke them. It’s better to work on learning how to deal with their spouses. Therapists, unlike friends, must be free to give usually welcomed feedback to the patients about better alternatives than they currently have.

Friends rarely have the same liberties in giving direct feedback that therapists have. Indeed, the old ad for Listerine capitalized on this by stating, “Even your best friend won’t tell you” that your breath stinks. Friends take sides and that is good. Friends usually can’t tell each other that they screwed up and offer better ways of handling problems. Yet, it is just that information that is central in therapy.

Currently, issues about the effectiveness of psychotherapy abound. Insurance companies for one, are legitimately concerned about the costs and benefits of therapy. All of us feel good to have someone to talk to who is not evaluative, and is supportive. I would love it if someone agreed that I am a martyr to live with my wife, a saint to put up with my children, and that I’m getting ripped-off by my plumber. After all, friends should give support.

The therapist’s role is different. It is to help the patient learn insights about how we create problems, and therefore the skills to deal with problems. Rarely will a friendship accept that obligation.