Wednesday, February 14, 2007

A Special Kind of Relationship


We've had a whole series of posts on psychotherapy, what gets said, who should have it, who should do it, and does it matter what gets said. I'll put some links below for anyone who's missed out on the sometimes heated discussion.

We've talked about why it would help for someone to come to treatment and talk about their day to day activities, and I've mentioned a confabulated patient who talks about the price of beef (comparative, of course, checking out the sales at various grocers) and we've wondered how that might help.

Sometimes it's about what gets said: the act of saying something effects the cure. This can be particularly true if the problem is directly related to an event-- secret, traumatic, tragic, or just plain troubling.

Sometimes it's about what gets said: a patient listens to himself and figures out his own solutions. The therapist is a sounding board and the patient does all the work.

Sometimes it's about what gets said: a therapist can point out patterns in a patient's feelings, interactions and reactions, and it helps when such patterns, unseen by the patient, are elucidated. Maybe the patient can change these patterns if he's aware of them, or maybe there's something about us that just likes being understood with a sprinkling of those "ah ha" moments. People like it when a therapist is able to say: "You're the type of person who...." and the therapist is right. Patients especially like it who the thing they're hearing is something good, such as "You're the type of person who cares deeply about others." It's feels a little bit magical when a therapist does this in the first session, especially if they hone right in and put into words something that hasn't been put into quite those words before.

Sometimes, it just doesn't matter what gets said.

It's about the relationship.

I've been wanting to write about this for a while. I haven't because, well, I haven't known what to say. There are all sorts of things that have been said about why the therapeutic relationship helps, mostly unproveable, some just feel wrong, or it feels like the therapist is trying to force the pieces into the puzzle. Unconditional Positive Regard? I'm not sure that ever really happens and it wouldn't feel genuine. In fact, a mandate for unconditional positive regard entails dictating the therapist's feelings in a way that might call for dishonesty. The idea that the therapist is consistently present and accepting of the patient's difficult feelings is helpful, though I'll point out that such consistency comes at a price, a literal by-the-hour dollar figure, and really, there are no guarantees-- therapists move, quit, get sick, and even die. We just like to think we offer consistency and acceptance (and that we don't die).

What therapy (or at least good therapy) does offer is a safe place to talk about difficult stuff. It's essential that the patient feel that the therapist either understands him or is trying very hard to understand him, and I believe that it has to be an honest relationship-- a safe place to hear things one might not otherwise be willing or able to hear. It's a narcissistic endeavor, it's all about the patient, and that's how it should be. I use the word narcissistic loosely here --I could probably find a better, more accurate, and less loaded word, but I like this one. In friendship relationships there's a give and take-- I tell you my story and if you're a guy, You tell me how to fix my problem. If you're a girl, you tell me about the time something happened to you that was just like what just happened to me. Either I get an answer or I get some much-needed empathy, but either way, I hear about You.

I could talk about transference helps a patient to understand and work through difficulties in past relationships as they play themselves out in the here and now. Really, I can talk about it, it even sounds good, I just haven't found that it plays out in therapy the way it sounds like it should, at least not as a neat package where I can articulate each step.

I'm left to ramble.

Sometimes it's about the relationship. I don't always know why.

Happy Valentine's Day from the shrinks at Shrink Rap!

Links to past posts about psychotherapy:
Talk Therapy
What Makes It Therapy?
What People Talk About In Therapy
ClinkShrink's Couch Time
Transference To The Blog