Tuesday, October 13, 2009

Who's It All About?

In my last post, You May Leave Now, an anonymous commenter talked about how his/her psychotherapist steers the conversation to looking at the therapeutic relationship. She asks the patient if he/she feels abandoned during vacations or rescheduled sessions. The patient says "No, I understand you've got a life," and feels dismissed when the therapist doesn't take this at face value and continues to drift back towards a discussion of feelings that are (or are not) arising in the therapeutic relationship.

In traditional psychoanalytic practices (or those influenced strongly by psychoanalytic thinking) the "analysis of the transference" is a central theme to treatment. It means looking at and understanding the relationship with the therapist as a way of understanding feelings the patient carries with him from past relationships that continue to play a part in his present concerns.

None of the Shrink Rappers are psychoanalysts-- so this is my disclaimer. I ramble, but it's not clear I really know what I'm talking about.

What do I think of this technique? I guess I think it's important in the realm of someone who is inclined to look at the relationship and who likes to think this way. Many of my patients come to see me because of problems with their moods or anxiety, and to focus the discussion on the therapeutic relationship often feels forced. The discussion described by Anonymous feels kind of forced. It's not one that I personally am always comfortable with--- it assumes a degree of narcissism by the therapist-- that everything comes back to this one particular relationship. It's also just an uncomfortable discussion for me, unless some version of distress/disappointment or concern about the relationship is brought up by the patient. But for the average patient talking about their work or their family, or their distressing symptoms, it feels a little weird to inject the idea that it's about the relationship.

Lots of things in medicine are a little weird. There are personal questions and all sorts of body parts being palpated and fluids being infused or withdrawn from the oddest of places. It's not about the usual interpersonal transactions. It's about diagnosing and healing. So if analyzing the transference is part of what cures illness, improves functioning, or makes life go smoother in anyway, then I'm all for it, even if it's a bit awkward.

I haven't fully brought myself to that place for a patient who isn't initiating (unless it's otherwise obvious that this is an issue). My sense is that probing into the patient's feelings for the therapist in a repeated and unwelcome way may put some people off or may foster a dependency that can then become it's own focus of treatment. In people with personality problems, sometimes this is necessary, but it's not usually fun. It puts a lot of pressure on the therapist-- it's much easier to call a vacation a vacation and not deal with at a major abandonment theme.

My sense is that for the average patient with a psychiatric problem, focusing on the therapeutic relationship in a major way probably does not make people better. I don't usually do it, and people still seem to heal.

Any thoughts?