Chapter 11. Psychodynamic and Social Interventions

Many medical and perhaps most psychiatric conditions cannot be eradicated totally. The affected individual must often learn to manage a protracted or chronic condition. The scope of medical, surgical, and psychiatric intervention is therefore appropriately not limited to acute pathologic states in which a definitive therapy is applied and the person is restored to perfect function. Humans are subject to a multitude of adverse influences, both external and internal. Whether these adverse influences are from bad luck, bad genes, bad environment, or simply the effects of aging, suffering is inherent in the human condition, and the individual must learn to manage personal suffering. It is appropriate that physicians provide others with assistance in the management of suffering. Analogously, psychotherapy often is focused on modifying the patient's overall pattern of adaptation to life (personality). As Cloninger and others (1993) note, personality is best considered as an interactive combination of factors that are gene-based and relatively immutable with factors stemming from the nonshared environment. While the expressive psychotherapies may make some modifications in character as defined, there is very little that a psychological intervention can do to alter the gene-based expressions, which are conceptualized as “temperament” (novelty seeking, harm avoidance, reward dependence, and persistence). Thus, the psychotherapist must help the person accommodate to the more gene-based temperaments so that they are expressed in ways that create less havoc or irritation for the person's relational world.

Psychotherapeutic treatment is an important weapon in the armamentarium of the physician and a necessary component of the management strategy of many and diverse forms of human suffering. It is both common knowledge and the finding of considerable research that human suffering is eased by the ministrations of another caring human being. In psychotherapy, this easing of suffering is conceptualized to be a product of “the therapeutic relationship.” For example, children learn to comfort themselves via the comforting presence of their mothers, participation in therapy groups may enhance the immune response of patients who have malignant melanoma, and patients who have schizophrenia and who receive psychotherapy in addition to psychopharmacologic agents spend less time hospitalized.

Physicians need to learn the principles of psychotherapeutic management of human suffering in the interest of easing their patients’ pain and transferring to them an improved ability to self-manage. It is not clear that a particular type of psychiatric disorder (e.g., depression) should necessarily be treated with a particular type of psychotherapy (e.g., interpersonal psychotherapy). Individual human suffering is so unique, and the life circumstances of any individual so varied, that psychotherapy must perforce be custom designed, at least in part. It is therefore more important to learn to conduct a coherent and useful psychotherapeutic experience for a patient than to learn one narrowly defined therapeutic style and expect all patients to fit its Procrustean bed.

This chapter is also concerned with another form of management: that of the physician's career and life. A real and multifaceted peril coexists with the many blessings and pleasures that derive from the privilege of knowing other humans so intimately and from the position of power and influence that physicians hold in their patients’ lives. Physicians are subject not only to the same suffering that afflicts all people but also to the various forms of exquisite and potentially devastating suffering that can follow when mischief infects the physician–patient bond. In order for physicians to lead long, happy, productive professional lives, they must learn not only to manage their patients’ care but also to manage their relationships with their patients. The term “secondary traumatic stress” refers to the therapist's suffering that specifically relates to patients with posttraumatic stress disorder. However, suffering is a part of good physicianship in treating a variety of other diagnostic categories as well. By the attentive acquisition of the principles of professional life management, physicians can largely avoid a chronic state of fear of their patients. Physicians’ fear of patients derives from several related sources: (1) the patient will cross some boundary and render the physician uncertain how to behave. This leads the physician to an inability to be natural; (2) the patient will commit some act of aggression against the physician (sue him or her) because of some dissatisfaction; (3) empathic connection to any suffering patient is inherently a source of pain and sometimes almost diagnostic of certain types of psychopathology (the “praecox feeling” associated with treating individuals with schizophrenia.) Fear of patients is learned in residency training and must be unlearned in order for the physician to have a comfortable professional life. Fearful physicians cannot be creative, convey hope, or model joy in living. By doing three things the physician can come to enjoy life and the practice of the Art to which Hippocrates referred: (1) by understanding the nature of human vulnerability, both one's own and that of the patient; (2) by understanding the mechanisms whereby patients construct their experience of the physician and vice versa; and (3) by learning to apply the concepts of empathy, transference, and boundaries.

Psychotherapy can be defined in general terms as the use of verbal means to influence beneficially another person's mental and emotional state. Such a definition does not concern itself with training of the therapist and does not distinguish the activities of a well-intentioned friend from those of a paid professional. Psychotherapy will be understood here to refer to a process wherein an individual (the patient) participates in a structured encounter or series of encounters with another person who—by dint of training, licensure, certification, and ethical proscription—is qualified to influence the mental state of another in a way that decreases the suffering and/or increases the psychological, interpersonal, and behavioral options of the patient. There is no fundamental difference between the patient and the therapist other than the training of the therapist for the role. This point is made to emphasize that a psychotherapist is not superior to the patient, even though the therapist is the party responsible for the management of the therapeutic relationship. The patient may be inclined to think of the therapist as superior, but the therapist must avoid this prejudice. Nevertheless, the difference inherent in the training and preparation for the role is crucial.

Personal Traits

Although training is the chief distinguishing feature of a psychotherapist, it alone cannot make a good psychotherapist out of every individual. The potential psychotherapist is an individual who is fascinated by the human condition and is not consciously exploitative, significantly emotionally handicapped, or impulsive. Intelligence is important, but more important are thoughtfulness and sensitivity. Some individuals may be said (semifacetiously) to be “too normal” to be psychotherapists. By this, it is meant that some energetic and optimistic people become quickly impatient with others’ foibles. Other individuals have no diagnosable psychiatric conditions but do have strongly developed personality traits (pessimism, narcissism) or cognitive styles (suspicious, histrionic) that deter the patient. Some individuals represent a potential danger, both to themselves and to the patient, if allowed to assume the psychotherapist's role. This group includes the charismatic leader and (in contrast) the emotionally needy or love-starved individual. These individuals have powerful personal agendas that overshadow the patient's needs.

Training

Psychoanalytic institutes have, over decades, evolved a tripartite structure of training that can be criticized on various grounds but that is in principle fundamentally sound and provides a prototypical model. Ideally, a psychotherapist has first passed through some sort of screening to assess personal attributes as outlined in the preceding section. Other qualifications are generally specified (a particular terminal degree), but these requirements are usually in the interest of turf definition and are arbitrary. Having satisfied a training body that one is of reasonable character and is trainable, the student therapist then enters a course of theoretical study, supervised practice, and personal therapy experience. The length and content of such a training program varies considerably in practice. Some training programs emphasize theory; others emphasize the acquisition of specific skills and attitudes. The length of a training program (some months to many years) is a function of the ideals and scope of the learned method (a skill to be acquired or an identity to be forged). Mechanisms are in place to weed out candidates who do not pass muster and to graduate those who have achieved competence. Graduates are eligible to present their work to a national oversight organization that qualifies training programs, sets standards for the profession, admits new graduates into the profession, and requires its members to be accountable to its standards.

There are many such programs in the United States, although most are dedicated to teaching a specific psychotherapeutic discipline. Within these disciplines, the student is expected to master a particular body of theoretical knowledge. This knowledge, in conjunction with the student's personal therapy experience, is intended to provide a framework for understanding another's experience and for structuring therapeutic interventions while avoiding self-serving exploitation of the patient. In practice, a great deal of psychotherapy undoubtedly is practiced by individuals who have had less training than the ideal version outlined here. A typical psychiatric residency training program, for instance, does not require its graduates to have had a personal psychotherapy experience. Some therapists practice various forms of psychotherapy with little training and in an unregulated way.

There may be hundreds of forms of psychotherapy; considerable overlap exists, however, among the legitimate forms because the general principles on which they are based are mostly agreed upon. The different forms of psychotherapy place special emphasis on one or another general principle. Whether a given therapy is significantly different from another, or more the brainchild of its originator, is often a matter of debate.

Four major forms of psychotherapy result from the different ways workers conceptualize the nature and development of psychic distress: dynamic, experiential–humanistic, cognitive–behavioral, and eclectic or integrated.

Dynamic Psychotherapies

The dynamic psychotherapies are based on the belief that much of human behavior, especially that which is troublesome to the individual, is motivated by psychological factors outside of the individual's awareness, including mental blind spots for both the therapist and the patient. One is compelled, therefore, to maintain self-defeating perspectives, and repeat ultimately unsuccessful and maladaptive behaviors, for unknown (unconscious) reasons. Defense mechanisms operate to stabilize the individual's emotional state, but the price paid for this stabilization may be high. The development of these problematic behaviors, personality traits, affect states, and other symptoms is generally understood to have occurred because of some unfortunate mix between the individual's inherent traits (intelligence, temperament) and the caregiving surround (developmental interferences) into which he or she has been thrust. In the dynamic therapies, improvement is measured by improved function in various realms of the person's life and by results from the new understandings gained in the context of a therapeutic relationship with the therapist. Traditionally, the dynamic therapies have been seen to exist along a somewhat artificial continuum with support at one end and insight at the other. Developments over the past 20 years have placed increased emphasis on the quality of the therapist–patient relationship as a central factor in a beneficial therapy experience.

Experiential–Humanistic Psychotherapies

The experiential–humanistic models of psychotherapy attempt to eliminate the objectivist perspectives seen as inherent in psychodynamic models and replace them with perspectivalist attitudes. That is, the individual's lived experience is viewed as the most, or only, important consideration. No attempt is made to decode the patient's distorted vision of the therapist in order to reconstruct an infantile experience, presumed to be repressed but inferred by the therapist based on knowledge of the universal phases of development. These therapy approaches take the patient's experience, including the patient's experience of the therapist, at face value. Psychopathology is viewed as resulting from the failure of caregivers to provide the empathic responsiveness necessary for the development of a self-structure that organizes experiences in the most adaptive way. The therapist will play a wider array of roles than in the more classically dynamic approaches, determined by the patient's needs and characteristics. Therapeutic effects derive from the formation of a personal narrative that, in the atmosphere of a new self-object experience (patient with therapist in a safe, gratifying, and development-enhancing relationship), allows for a reordering of the processing of personal experience.

Cognitive–Behavioral Psychotherapies

Cognitive–behavioral models of psychotherapy view psychopathology as the result of faulty thinking (cognitions) based on illogical beliefs. Various forms of mental illness (anxiety, inhibitions, depression) result from the powerful influence of these cognitions, for which there is understood to be little or no rational basis. Little time is spent attempting to explain the etiology of these beliefs, and the concept of a dynamic unconscious is seen as unnecessary. The patient's unsubstantiated beliefs (“others would be better off if I were dead”) are challenged, with more adaptive beliefs implicitly or explicitly suggested and supported. The patient is thereby persuaded to discard irrational perspectives on the world (“no one will want you if you are not perfect”) and replace them with more realistic, validated beliefs. Although other psychotherapies frequently include cognitive elements, the behavioral components of cognitive–behavioral therapy (flooding, blocking) involve action interventions that carry these methods into a clearly different realm (see Chapter 10).

Eclectic or Integrated Psychotherapies

In the practice of psychotherapy, most patients and clients receive a therapy that is an amalgam of the dynamic, experiential–humanistic, and cognitive–behavioral perspectives. This is not due to an inherent difficulty in staying within the confines of a particular method. It arises from the failure of each of the methods to account for the multifaceted presentation of human psychopathology. Unless he or she is immune to the possibility of reductionism, views therapy as a tour de force, or simply elects to ignore certain material, the therapist will recognize that each patient presents clinical material best handled by first one and then another perspective.

It would be ludicrous to attempt to paint a picture of a typical psychotherapy patient. The following case is presented to illustrate the typical complexity of the clinical picture that confronts the psychotherapist, and the usefulness of being familiar with a range of theoretical perspectives and techniques:

The patient was an early-middle-aged mother of two healthy children. She was an intelligent, sensitive, and kind woman who had been married for 15 years to a hard-working man who she felt did not understand her. Indeed, he was frustrated by her manifest pessimism, her guilt, and her inability to enjoy the many fruits of their hard work. She was chronically depressed, anxious, phobic, and compulsive. She was also hypochondriacal, sexually unresponsive, and indecisive. Her father died when she was 12 years old, a critical time in a girl's life. Her older brother had sexually abused her, and her sister had committed suicide. As the eldest girl in the family, she had been assigned domestic responsibilities inappropriate to her age following her father's death. The first-born brother's presence, however, stood between her and a sense of specialness. She grew up embittered and thinking that she was not, and never would be, “good enough.” Her sense of self was defined by her failures. Her successes were discounted as aberrations.

Although the patient might have benefited from pharmacotherapy, she said that she did not wish to take medication. She wanted a psychotherapy experience that would help her learn to enjoy her life more and unlock what she experienced as untapped potential. She feared that she might be contaminating her children's worldview, and she felt she was being unfair to her husband and restricting their life together. She saw her problem as chronic and severe and worried that she might one day follow her sister's suicidal path, an act that, for her family's sake, she desperately wanted to avoid.

In planning a psychotherapy for this patient, the therapist was struck by the myriad symptoms she exhibited, noting that all were in the “neurotic” sphere. She did not abuse substances and had no psychotic thought content. She seemed to experience both irrational thoughts and personal isolation. Her low self-esteem was related to chronic abusive experiences, and her guilty fears and inhibitions suggested unconscious themes of an oedipal nature. The pervasiveness of the patient's suffering and the history of her personal losses suggested that short-term work would not be effective and might even be damaging. A purely cognitive approach seemed inappropriate given the patient's overwhelming symptomatology: It would not address her many interpersonal needs. An open-ended and eclectic therapy seemed indicated.

Patients approach psychotherapy with a mixture of hopes and expectations, many of which are conscious and some of which are unconscious. Some of the patient's goals are reasonable and some are not. Patients do not intend to be unreasonable; their demands are a function of their neediness and their lack of information, including information about subjective experiences, which are vastly different from their own (cross cultural matches between patient and therapist). Therapists have knowledge, acquired through training and experience, of what is and is not attainable from psychotherapy. The therapist's ambitions and goals for the therapy may not, however, coincide with the patient’s. More mature and experienced therapists become increasingly confident in the usefulness of a psychotherapy experience, while simultaneously becoming impressed with the unpredictable and nonspecific nature of the benefit. They understand the importance of allowing the patient to use therapy in a uniquely personal and creative way.

Therapists themselves are not immune to influences that induce them to place unreasonable expectations on therapy. These influences include pressures to move more quickly, more efficiently, and more definitively. The therapist may unwittingly accept the often somewhat seductive plea or demand to become a magician whose aims are accomplished by special power, not hard work. Some therapists feel apologetic for their limitations, ashamed of their imperfections, and guilty about their fees. These vulnerabilities, which signal a need for supervision or personal treatment, may combine with the patient's unreasonable demands to create an “unholy alliance” in which goals are implied but never stated, boundaries are fluid, and roles are not defined.

Patients and therapists should agree explicitly on the goals of the work they are performing mutually. If goals are not made explicit, they will likely become idiosyncratic and immeasurable as well as unreasonable and probably unattainable. Goals can be changed; indeed, it is good practice to compare notes from time to time, especially in a longer treatment, in order to assure that patient and therapist are still on the same track. In any event, one goal should always be to provide the patient with a positive, useful experience. The therapist may be the first significant other in the patient's life who has not wished to exploit the patient, or who has genuinely wished to hear and understand the patient. Such quite general influences may nevertheless be profoundly salutary. It is not necessary for “structural” change to be a goal of a therapy. Although some would distinguish between psychotherapy (change) and a supportive relationship (change not a requirement), setting any specific change as a goal runs the risk of dooming the treatment to failure and thus to its being seen as a negative event in the patient's life. Humans, most especially neurotic ones, are resistant to change. Neurosis is understood to describe the mind in conflict with itself over two opposing wishes—those that are reasonable and those that are unreasonable, or the wish to please versus the wish to oppose (Table 11–1) and suffering is experienced as the result of the conflict. Most humans will, regrettably, tend to continue to suffer rather than let go of one or the other wish. A positive experience with the therapist will likely have a continuing effect on the patient long after the treatment is ended, and changes will likely occur, albeit out of sight of the therapist.

Patient Selection & Therapy Planning

What principles should guide the therapist in deciding whom and how to treat? Many individuals may be recognized as needing therapy, in the sense that their loved ones or personal acquaintances recognize them as suffering or causing others to suffer. Needing therapy in this sense is not the same as having the potential to use a psychotherapy experience. The process of assessing the likelihood that a prospective patient can benefit from psychotherapy of any type begins with the first encounter (often via the telephone) and should continue until therapist and patient are ready to close the evaluation phase and begin the treatment.

The first level of screening involves the question of need for hospitalization or the likelihood that hospitalization will be necessary in the near future. Although many of the principles discussed here are applicable to inpatients, psychotherapy other than crisis intervention therapy is not feasible in the face of active psychosis or immediate suicide threat. Similarly, a patient who is in the throes of active substance abuse or who is currently involved in a legal proceeding probably should be referred to a specialized help provider.

The telephone call may be used to screen out patients who might become involved in an encounter with a therapist that will be frustrating and essentially a waste of the patient's time and money. The patient should be asked how he or she came to call the particular therapist, in the interest of assessing what the patient likely knows about how the therapist works, and should be told what fees will be charged. The therapist should consider the following questions: Does there seem to be a beginning goodness-of-fit in that the referral makes sense? What is the nature of the complaint? Is the problem within the competence or interest range of the therapist? Does the prospective patient indicate a degree of reflectiveness, or is there excessive, needful demandingness or entitlement? Does the patient “hear” the therapist during the phone call? The patient should be informed that there will be a professional fee charged for the evaluation session. This serves as a useful screen for motivation and ensures that the therapist will be compensated for the time spent, even if the patient elects not to return. Obviously, this strategy applies only in a fee-for-service setting.

An initial phone call need not be lengthy, but it can be useful, and the patient should not be scheduled for a first visit unless the therapist feels a sense of enthusiasm about working with the patient. The patient may also have some questions for the therapist, which should neither threaten nor offend the therapist.

Occasionally, the patient will ask the therapist a question that will indicate that referral to a colleague, or simply a refusal, is the best strategy. Although some questions may need to be answered, others may seem so provocative or challenging that they alarm the therapist. It is better not to begin working with a patient in the first place than to have to refer the patient to another therapist after treatment has begun.

First Session: Evaluating the Patient

The prospective patient is told that one session will be scheduled for an evaluation of the problem. At the end of that hour, the therapist and patient will compare notes and discuss options. Treatment has at this point not been offered and no such contract has been entered into. A first psychiatric session will generally be a mixture of medical interviewing, with a focus on the symptom picture and the patient's mental status, and open-ended interviewing, wherein the patient is given an opportunity not only to be heard but also to demonstrate ease with carrying the conversation. Given a reasonably cooperative patient, the first session should yield three things: (1) an Axis I diagnosis, if any; (2) a sense of goodness-of-fit between patient and therapist; and (3) an ever-growing sense in the therapist of “getting it,” that is, of the patient's story beginning to make sense according to the therapist's understanding of the nature and development of psychopathology often conceptualized in reference to one or more clinical “models of the mind.”

If the therapist is to plan a psychotherapy experience for the patient, an understanding of what is “wrong” with the patient must be developed. This extends beyond a clinical diagnosis and addresses the question of how psychotherapy will be designed to enable the patient to do a needed body of psychological work. The straightforward and succinct statement that forms in the therapist's mind is a basic version of the elaborate psychodynamic formulations from the heyday of psychoanalysis. It becomes the skeleton on which the flesh of the therapy will be hung. In the absence of the therapist's ability to explain to an observer (or to the patient) what he or she proposes to do and why or, better yet, what the therapist and patient will do together and why, it is likely that a kind of “chronic undifferentiated psychotherapy” will be undertaken. Such an enterprise will be unfocused. It may be pleasant, but it will lack thrust.

It bodes well for psychotherapy when the prospective patient engages the therapist in a personal way. Psychotherapeutic work in the realm of what has traditionally been referred to as the transference adds immediacy and zest to the treatment. Psychotherapy can be done without working with the patient's experience of the therapist, but such treatments are more sterile, intellectual, and distant. However, some patients cannot work effectively in this manner. Patients with narcissistic personality disorder, especially, need a considerable period of time before they feel comfortable revealing what to them represent humiliating notions about actually needing the therapist. The therapist cannot force transference into the foreground, but it can be a powerful tool when the patient will allow its use.

As the time allotted for the first evaluation session draws to a close, a number of complex and interlocking issues come to the forefront. If the evaluator is a psychiatrist, then four decisions must be made: (1) Is hospitalization indicated? If so, the whole psychotherapy matter will probably be tabled. The administrative details of getting the patient hospitalized become the focus of attention. (2) Is a different immediate intervention demanded by the patient's condition? If the therapist is required immediately to assume the role of active change agent (by prescribing psychotropic medication), certain other roles will be less easily established in the future. (3) How comfortable does the therapist feel about having “gotten it?” Generally, the patient will want to feel that the time has been well spent and that the therapist is forming a clear understanding of the patient's situation. The patient does not, however, want to experience the therapist as having decided too quickly about diagnosis and treatment. This will lead the patient to be suspicious of the therapist from the beginning. (4) Does the therapist feel that a therapeutic fit is likely to happen and is worth pursuing, or should this session be the last? Referral for whatever reason is best done at the time of the first visit.

A recommendation of no treatment should remain a possibility in the therapist's mind. If, however, the therapist is beginning to understand the patient and imagine a potential contract for a therapy, it is appropriate near the end of the first hour for the therapist to share with the patient reflections on the interview so far. This preliminary interpretive statement should be followed by the patient's invited response. Asking the patient if he or she has any preformed ideas about what the therapist might do to be helpful is often a useful strategy at this time. These exchanges will set the stage for an agreed-upon second evaluative session that explores areas that both parties feel are important but for which no time is left. In most cases the therapist can reassure the patient that things should be clear, both for therapist and patient, by the end of a second interview, and that a recommendation for treatment will be discussed at that time. The second interview should be scheduled sooner rather than later, preferably within less than 1 week. Patients who have made the decision to seek help generally have delayed for some time, but having begun the process, hope that it will move swiftly.

Second Session: Process & Contract

A second evaluation hour is necessary for several reasons. The therapist may not be ready to present the patient with a therapy recommendation because the formulation is incomplete, or he or she may not want to rush the patient or may want to test the patient's reaction to the first session. Will the patient be able to share thoughts and reactions to the first hour? Will the patient feel better already, more hopeful of an improved future? Was there evidence of self-reflection that generated fresh associations?

The therapist may begin the second session with a statement that it will be useful to explore further a number of areas, but first, what were the patient's thoughts and reactions to the first hour? An important clue to the patient's psychological mindedness may be gleaned from an invitation by the therapist for the patient to say “where the session went” after the initial appointment had ended. Such early alliance building demonstrates that much of the responsibility for the treatment rests with the patient. The patient will often tell the therapist that he or she feels better or will report that new information has been recalled. An exploration of this material generally will enable the therapist to call attention to areas noted after the first session that need exploration, with the upcoming therapy recommendation clearly in mind. If left unexplored, these areas (substance abuse, legal trouble, and experience with other therapists) may erupt later as major obstacles.

The therapist is also considering further the nature of the problem and the type of treatment to be recommended. This will inevitably result in a compromise between what is ideal and what is feasible. The therapist needs to know the patient's capacity to fund therapy, ability to conform to the therapist's work schedule and office hours, and ways of handling separations. The therapist is also assessing how easily the patient talks, and about what. Patients who wish to discuss situational issues may need more time between sessions to allow events to occur. Patients who have strong reactions to the therapy encounters may have difficulty waiting for the next session. Patients who live some distance from the therapist's office, or who must exert considerable effort to get back and forth, will have trouble sustaining their initial enthusiasm. How much is the patient suffering? How motivated does the patient seem to be to initiate change? How stable and supportive is the patient's social support network? Does the patient have the ways and means to effect change? At least a rudimentary developmental history of the patient (if not taken in the first session) is often invaluable for the development of the therapeutic contract.

By the midway point of the second session, an experienced therapist will generally feel comfortable with an extraordinary amount of important information. A less experienced therapist may wish to obtain supervision at this point, but the seasoned therapist will have assessed and decided upon three key issues: (1) whether or not to prescribe medication; (2) whether tests (psychological, chemical, neuropsychological) are needed; and (3) what type of psychotherapy to recommend and at what frequency.

These issues are matters of the utmost importance to the patient's life and to other lives that psychotherapy will affect. The therapist is now poised to make recommendations that will have such an impact on the patient as to be remembered possibly for the rest of the patient's life. The patient may need help in sorting through the most salient implications. If third-party payment will be used, does the patient understand that confidentiality cannot be complete and that the future may bring difficult questions regarding history of treatment? Can the patient defer making significant life decisions that could negatively affect the course and outcome of psychotherapy? What are the dynamic forces at work between the patient and most significant other over the need for and possible result of therapy? The need for informed consent is great in the case of the potential psychotherapy patient, who may have little appreciation of what is about to be undertaken.

The therapist will then tell the patient precisely what is being recommended and why. Three areas must be covered: (1) the name of the psychotherapy, its rationale, its frequency, its anticipated length, and its cost; (2) the hoped-for outcome of the treatment, couched in terms that express optimism for realistic and attainable goals, and the likelihood of that outcome; and (3) alternative treatments, their anticipated length and costs, and their risks and likely outcome.

A schedule for visits will be negotiated, and a clear description will be provided of procedures regarding payment of the bill, appointment cancellation and lateness on the part of the patient or the therapist, and vacations. A standard written policy statement may be used. If third-party payment or certification procedures (health maintenance organizations [HMOs]) will be a part of the picture, these procedures, including the provision of a diagnosis, should be outlined clearly. The therapist should explain to the patient the diagnosis and should tell the patient what is expected of him or her during the treatment and what can be expected of the therapist. Some issues may be addressed only when they arise and become integrated into the context of the treatment. These issues include details such as telephone calls, chance meetings outside the office, and what names will be used.

By the end of the second session, the therapist and the patient may look forward with optimism and anticipation to the beginning of a psychotherapeutic endeavor between an informed patient and a therapist who knows where things are headed. The framework of treatment has been carefully built. Both parties know what to expect. Therapy is off to a good start.

Beginning of Psychotherapy

It can be said justifiably that therapy has been underway since its conception as a thought in the patient's mind, and certainly since the patient's first encounter with the therapist. Nevertheless, the therapist has made a point of separating evaluation from treatment, because of the wish not to enter into a formal medico-legal contractual responsibility for the patient's ongoing welfare (beyond handling any immediate needs the patient may have) until he or she is confident that the treatment is manageable. The treatment phase has now been launched, and the therapist becomes concerned with those phenomena that characterize the opening phase.

Whatever goals for the treatment enterprise the patient and therapist have agreed upon, the therapist knows that there is one overarching goal: to provide the patient with an experience that will enable some measure of healing to occur. The therapist cannot will the patient into mental health, and the patient may find that personal resistances to change are too great to overcome. The therapist is confident, however, that careful attention to the application of considered strategies and tactics, informed by a detailed understanding of the nature of the patient's psychopathology against the background of his or her unique developmental experiences, and delivered with skill and sensitivity, will, over time, create a healthy atmosphere that the patient will use to the best possible advantage. To this end, the therapist considers the various or predominant role(s) to be played and the basic interventions to be undertaken. Staying in role, and consistently and effectively intervening over time, the therapist will have a corrective effect. The therapist must have the emotional well-being and personal attributes to make this possible.

Whatever the nature of the therapy, the opening phase is understood to involve two parts. First, the patient passes through the stages of engagement into the therapy process. The signs of the patient becoming “in therapy” will vary according to the structure of the particular therapy being used. In psychodynamic therapy, for instance, patients might be said to be “in therapy” when they begin to attach emotional importance to the therapist as a real person or to the nature of the intersubjective experience of patient and therapist. In therapy designed along more educational or supportive lines, the patient may report having been reflecting on the last session and provide additional thoughts about it. In some cases, the engagement will be revealed in a dream or in an unconscious but undeniable act of resistance.

After engagement has occurred, the second part of the opening phase plays out, with the unfolding and illumination before the eyes of the patient and the therapist of the nature of the problem. The way the problem is conceptualized is intensely personal. It is worked out between the patient and the therapist in language to which they will refer by mutual agreement. This language is a derivative of the blending of the therapist's methods of organizing the experience of the therapy with the patient's organization of the experience. The words used to describe the nature of the problem will reveal the predominant theoretical orientation of the therapist merging with the narrative that the patient is constructing. Once the problem has been defined in this mutual and cocreated manner, the opening phase is over.

Middle Phase of Psychotherapy

Before the middle phase of psychotherapy can begin, the alliance between patient and therapist must be established firmly and the core conflictual issue identified and agreed upon. The process of working through begins. The patient is confronted repeatedly with manifestations of problematic ways of organizing experiences and relating to others. In some therapies, this process occurs in the cauldron of the transference–countertransference. In other therapies in which the patient is unable to work with transference material, working through takes place once-removed, by examining relationships outside the therapy, both current and past. This confrontation has variable effects on the patient. There may be moments of new understanding and growth. There may be periods of flight away from the process via resistance maneuvers and regressive detours. The therapist's role is to “follow the red thread” of the patient's unconscious and automatic attitudes and behaviors and—through a mixture of empathic responsiveness, probing, clarifying, confronting, and interpreting—“hold the patient's nose to the grindstone” of the work of the treatment.

Many difficulties are encountered during the middle phase; some are inevitable and some are incidental to therapist error. All the desirable personal attributes and all the therapeutic competence that the therapist can muster will not ensure a smooth middle phase. Empathic failures by the therapist will lead to failures to intervene and to mismatches between patient need and therapist role selection. The therapist will lose sight of the patient's experience, and the patient's feelings will be hurt. A number of middle-phase problems are typical and are mentioned individually in the sections that follow.

Acting Out

The term “acting out” is used in different ways, but it is generally understood to refer to behavior that discharges the affects generated by the therapy process. A variety of behaviors are seen, involving both conscious and unconscious motivations. Individuals who are prone to impulsiveness or destructive behavior make relatively problematic psychotherapy subjects. The most flagrant behavior, such as substance abuse, suicide attempts, and middle-of-the-night phone calls, may be so difficult to manage as to make therapy impossible. If the therapist lacks the ability to bring administrative control to bear in order to preserve the treatment, he or she can be placed in the untenable position of being responsible for the patient's irresponsible acts.

Less dramatic forms of acting out must be recognized by the therapist, who should then confront the patient and bring the affects and associated thoughts into the therapy. The patient may quote the therapist to another person and arouse ire, especially if the other person is paying the bill. The patient may fail to pay the bill, miss sessions, cancel appointments, or be late; or the patient may make serious life decisions abruptly, especially regarding love relationships.

A single female mental health professional in her mid thirties sought treatment with a male therapist for recurrent major depression. She also described a disturbing behavioral propensity to make particularly poor choices for her romantic involvements. Her treatment involved pharmacotherapy for the depression and expressive psychodynamic psychotherapy. The latter was far more in-depth than her previous treatments, which were predominantly pharmacologically based. As the therapy unfolded, she began to recall experiences from her childhood, which involved sexually overstimulating “play” with a reclusive uncle who had been repeatedly entrusted with childcare and baby-sitting responsibilities. As this “play” was recognized as sexual exploitation, the patient increased the frequency of sessions in her therapy and became engaged in the therapy in a lively fashion. However, she soon found herself preoccupied with a female patient of hers who had characteristics of a borderline personality disorder. In a highly uncharacteristic manner, her preoccupation included urges to be involved in her patient's personal life in a way that would have clearly been both professionally damaging for the professional and disastrous for her patient.

The therapist suggested (interpreted) to his patient that she was displacing feelings of an erotic, loving transference relationship into the relationship with her female patient. This “displacement” was a compromise that transiently allowed her to feel less vulnerable, but also would result in the “punishment” she felt she deserved for her childhood sexual behavior with her uncle. Since their relationship was still rather early in its development, the therapist elected to communicate in a more direct and “educational” manner. The potential danger to his patient's professional well-being required greater and earlier activity than might be the case in a situation that did not involve such danger for the primary and secondary patients involved in this case.

Mutual analysis of these behaviors nearly always leads to an improved alliance and forward motion. Failure to confront the behavior retards or disrupts therapy.

The patient may demonstrate ego-syntonic acting out, in which he or she enacts unconscious themes through behavior that causes no harm. For example, the patient may come early for the appointment (the attendant hope being to see the therapist's other patients), or the patient may watch the clock so as not to overstay (the unconscious fear is of feeling dismissed). It is sometimes useful in therapy to look the gift horse in the mouth.

Acting in

Novice therapists are frequently troubled when patients do things in their presence that throw them off balance, disorient, or even frighten them. Many of these behaviors merely need to be experienced once in order to know how to handle them next time. Some behaviors may prompt the therapist to seek personal treatment.

A patient may put the therapist off balance by exhibiting overly familiar behavior. For example, a patient calls the therapist by her first name or asks to be called by his first name; a patient brings the therapist a small gift; or a patient asks personal questions about the therapist's life. The smooth management of these personal moments requires self-awareness, compassion, flexibility, and objectivity. It also requires factual knowledge of the nature of boundaries, boundary violations, and medical ethics, as well as theoretical knowledge of the nature of psychopathology and of the science of psychotherapy. Beginning therapists need regular forums in which they can process such events. Even very experienced therapists need access to consultation anytime they are inclined to engage in atypical therapeutic behavior or recognize that they are anticipating a “boundary crossing.” In general, it is best to err on the side of awkward, stiff refusal than on the side of boundaryless permissiveness. One's technique will become smoother with time.

Some behaviors by the patient are more provocative and troublesome. For example, a patient asks for hugs or other personal contact or asks for a gift from the therapist; a patient wears revealing clothing or directly propositions the therapist; or a patient requests out-of-the-office contact. In such situations, the therapist should begin with gentle limit setting accompanied by sensible explanations. One does not say “I’d like to, but the ethics of my profession won't let me.” One says, “Therapy is conducted through talk, not through action.” (In psychoanalysis as opposed to psychotherapy, the therapist often will “interpret” the patient's behavior without any further elaboration, somewhat like a sports announcer's “calling the play by play.” This use of words where there would more naturally be behavior is what led Freud to describe psychoanalysis as an endeavor for which there is “no model in other human relationships.”) Occasionally a patient will persist, despite firm but gentle limit setting. The therapist then confronts the patient with his or her seeming inability to take no for an answer and invites an exploration.

A common behavior on the border between acting out and acting in involves encounters between the patient and the therapist's office personnel. The patient may pump the secretary for personal information about the therapist. The patient may attempt to befriend or even romance the office staff. These situations are easily dealt with when the staff is knowledgeable and well trained. Considerable trouble can result, however, when the office person has no understanding of the nature of a patient–therapist relationship or, even worse, harbors resentment toward the therapist–boss. Beginning therapists must take nothing for granted in the hiring and training of office personnel. Such individuals represent the therapist to the public, for better or for worse.

Stalemate

The term “stalemate” covers a variety of conditions, the essence of which is that the patient becomes dissatisfied with the therapy, makes no progress, and threatens to quit. This phenomenon has traditionally been seen from an objectivist perspective and understood as a manifestation of resistance (negative therapeutic reaction). More contemporary views of the therapy process interpret these states as commentaries on the nature of the relationship between the two parties. Active interpretation is usually required to restore the alliance and the therapy, and generally some degree of therapist self-disclosure involving the immediate interaction calls to the patient's attention the failure to get something from the therapist that the patient very much wants. It is not, of course, the gratification of these wishes that is the purpose of the therapy but rather their identification. Awareness and acknowledgment that the therapist plays an active role in the creation of the “analytic third” is necessary to uncover and illuminate these states of depletion in the patient. Using first person plural language (“We are having a problem.”) when describing transferential problems and difficulties of the treatment is useful in communicating the therapist's awareness of his or her role in the creation of the therapeutic relationship.

Third-Party Interferences

Threatened spouses and parents are joined by third-party payers of all varieties in placing pressures on the very existence of psychotherapy. For example, an angry wife may request equal time to “set the record straight”; a jealous husband may knock on the door during a therapy hour; or an HMO may need more information before a claim for benefits can be processed. Sensitivity, flexibility, and strength are required of the therapist in order to protect the patient's confidentiality and preserve the life of the therapy.

Other Negative Effects

Many complications are possible in psychotherapy. Constant pressure against the frame of a therapy is created by necessary restrictions. It is not easy to avoid boundary violations, but the task is made easier if the therapist has knowledge of behaviors that are considered to be boundary violations. Experience shows that it is folly to expect the patient to understand and control these matters. It is the therapist's responsibility.

The vulnerabilities of the psychotherapist are all too real, and patients can present many attractions to a therapist. The therapist is of course in danger of participating in boundary violations but is also vulnerable to painful affect states tied to the rigors and restrictions of the work. Commonly experienced signs of untoward therapist stress include excessive fatigue at the end of the day; depression, depletion, and having nothing left for life outside the office; inability to take time off (“dance of the hours”); or loss of objectivity and intemperate identification with the patient.

Rarely, the therapist will realize that a serious mistake has been made in the original conceptualization of the therapy and that the therapy should not be allowed to continue. It is better to interrupt treatment than to persist in the face of an untenable situation. The therapist may, for example, realize that the patient has been misdiagnosed and that significant antisocial elements are present. The patient may become engaged in behavior that runs counter to the contract or that the therapist finds intolerable (an HIV-positive patient who continues to expose unknowing partners). Consultation with a colleague may show the therapist the way out of the dilemma. If not, the only path may be to make alternative arrangements with careful consideration of the therapist's legal and ethical responsibilities.

In a gratifyingly high percentage of cases, when the patient–therapist fit has been a good one and the alliance has held together, the patient achieves most of the contracted-for goals. The patient is easier to be with, both for the therapist and significant others. The patient reports that life is better. Symptoms melt away, and characteristic ways of organizing experiences become less rigid and stereotyped. Relationships with other people improve. The patient begins to talk about life without the therapy, and the therapist begins to think that a successful ending for the therapy is in view. The middle phase is finished.

Termination of Psychotherapy

The ending of a psychotherapy can occur under a variety of circumstances, some very satisfying for both parties, and some painful or traumatic, especially for the patient.

Termination by Mutual Agreement: Satisfied

In this situation, circumstances are optimal. The therapist and the patient are in agreement that the therapy should end because the work has gone well and the desired effect has occurred. If the therapy has been open ended, the classic phases of termination will be seen, colored by the patient's individual circumstances. The therapist will have begun to muse that termination has become a consideration, seeing that the patient is functioning well, both within and outside the therapy hour: There is no acting out, the original symptoms are no longer problematic, and the patient is being affirmed by the environment. When the patient raises the issue, it feels congruent to the therapist. It is discussed, and a mutually agreeable ending date is set. During the ensuing phase (brief or extended, according to agreement), a resurgence of symptomatology is typical, and the pain of loss of a relationship is experienced by both parties. The therapist knows the pain must be worked through by the patient and does not collude in any defensive maneuvers of the patient. The therapy ends on a bittersweet note, with recognition that good work was done and each party has devoted appreciated effort; but the work is over, and the patient is ready to move on. The therapeutic relationship is left intact. The therapist does not cross previously respected boundaries. The patient may well never return, but if the need arises, there would be no barriers.

Termination by Mutual Agreement: Elements of Dissatisfaction

More typical than the previously described ideal situation is one in which the patient and therapist agree to the ending of the therapy, but one or both feel a degree of dissatisfaction with what has been accomplished and would prefer to continue. The therapy may have been time limited from the beginning, either because the therapist conceptualized a time-limited treatment as optimal or because the patient had limited resources. Artificial limits may have been set by a managed care organization. Nevertheless, one or both parties may wish that either the therapeutic relationship or a new, personal relationship could continue when a useful change on the part of the patient seems highly unlikely. The patient and the therapist may agree that a hoped-for goal for the treatment will not be realized. These endings are painful to a degree, but they are not traumatic. The limitations of the experience are acknowledged, but there is a sharing in appreciation of the good work. The pain of separation is experienced, but there is no recrimination or bitterness.

Interruption of Psychotherapy: Disagreement

When one or both parties disagree with the ending of psychotherapy, the word “interruption” is a more descriptive designation than is “termination.” The treatment is ending over the objections of one or both participants. For example, the patient announces the intention not to return, the patient is told that the therapist is leaving (relocating for a career move, rotating off residency service), or the financial support for the treatment is withdrawn unexpectedly. In these situations, psychological trauma will be experienced, generally more acutely by the patient, although losing a therapy case can be a staggering blow to a therapist's self-esteem. In any case, the nature of the felt trauma will be a function of the reason for the interruption and the psychological structure of the injured party.

When the patient leaves the therapist, it is important that the therapist remain in role. Although shocked, insulted, or frightened, the therapist must help the patient deal with the emotions surrounding the decision. Any impulse to counter with threats or dire predictions must be stifled, perhaps to be worked through in an ad hoc personal therapy encounter for the therapist. Because of the chronic nature of psychopathology, there is a good chance that the patient who interrupts therapy will seek therapy elsewhere, sooner or later. Therapists should always endeavor to make any encounter with a patient as therapeutic as possible.

When the therapist leaves the patient, the scene is ripe for damage to be inflicted on the patient, although the degree of damage can be controlled by sensitive and thoughtful management of the situation. To do so, the therapist must transcend the narcissistic investment in the reason for the interruption. The excitement one is feeling over an upcoming relocation or graduation or new baby will not be shared by the patient, informed or otherwise. The patient will feel variously bereft, abandoned, devalued, jealous, envious, or a plethora of other feelings determined by circumstances and character structure. The patient must be allowed to explore these states and express the attached affects. The therapist must remain in role, acknowledging nondefensively as many of the facts as is consistent with his or her established way of working. The patient's pain is not underestimated, and the patient's individuality is respected within reason as a schedule for the interruption is worked out.

In announcing the interruption, the therapist has two decisions to make: (1) when to announce it and (2) whether transfer to another therapist is indicated. Patients need adequate time to process an interruption, but announcing the interruption too soon may cause the remaining time to be a “lame duck” period in which little is accomplished. Likewise, the patient may be soothed to know that therapy will continue, but the new therapist will immediately assume great importance in the patient's mind even if never met, and this will distract the patient from dealing with feelings about the interruption.

In some cases, it will be obvious that further treatment will be needed, and the therapist will offer help in locating a replacement therapist. In these cases, the therapist can leave the interruption announcement until relatively late in the sequence, perhaps with only several sessions remaining. Other patients may not need a replacement therapist. The patient may be near enough to a termination that the work can be truncated. The patient may feel that transfer to a new therapist is not worth the trouble involved. The patient may wish to find further therapy in the future but wants to take a break from the process after the interruption. The therapy will profit from avoiding a premature and unilateral decision to recommend continued treatment. Such a recommendation may be more defensive against the therapist's guilt over leaving than it is sensitive to the patient's individuality. In such situations, where there is a good chance that the patient's therapy experience will end with the interruption, the therapist must give the patient more time. The therapist must assess the patient's record of dealing with separations. Some patients may need 6 months or more, and various tapering schedules and other modifications of the usual ways of working may be useful. Therapist inflexibility is usually experienced as damaging.

The management of an interruption or a termination requires sensitivity and skill. Having had the experience of being in therapy oneself adds immeasurably to the therapist's ability to be sensitive to the importance one attains in the eyes of the patient.

Individual psychotherapy as the sole therapeutic agent is the best treatment for many of the patients who present themselves to mental health professionals. Individuals with common personality disorders such as narcissistic personality and borderline personality, and those troubled by what may be called disorders of the spirit, are frequently best managed in the containing acceptance of an individual therapy. Such patients may seek psychotherapy from psychologists, social workers, and pastoral counselors, reasoning not only that such professionals are uniquely qualified to help them but also that psychiatrists will be either too expensive or disinterested in their problems. Although this recent historical development is unfortunate for the field of psychiatry, it is hoped that the recognition that psychiatry is in danger of “losing its soul” will spur the field to reclaim its place in the psychotherapy tradition.

Many patients, especially those encountered by psychiatrists, need more than individual therapy to manage their conditions. Depression seems to have replaced narcissism as the illness of our time, and combined psychotherapy and pharmacotherapy for mood disorders has become commonplace. In addition, a new recognition of the important role of supportive psychotherapy in the care of the seriously mentally ill has led to more collaboration between psychiatrists and nonpsychiatrist psychotherapists. Debates about whether psychotherapy can withstand the resistances set in motion by combined use of medication, and about whether the therapist should have a psychopharmacologist handle the medication, have been replaced by concerns over the impact of contemporary agents (fluoxetine) on the core of personality structure. Amidst this sea of change, however, it is easy to trivialize truths about the patient–therapist relationship. Fortunately the concept of dynamic pharmacotherapy has provided a framework within which to consider the positive and negative effects of combining psychotherapy and medication.

It is now well established that problems with medication compliance in patients who have chronic illnesses such as bipolar disorder and schizophrenia are common and costly realities in psychopharmacology. The sensitive application of psychotherapy by the psychopharmacologist makes for more successful pharmacotherapy. In contrast, therapists may be concerned that their psychotherapeutic zeal could bias them against potentially helpful biologic agents. This may lead them paradoxically to recommend medication too quickly. In many clinical situations the determination of the need for a psychopharmacologic agent is far from clear-cut. In these situations many patients do not want to take medication; they want the physician's time, person, and perceptual, conceptual, and executive skills. Many patients do not like the way medication affects them and fear that the doctor will lose interest in talking to them. Psychotherapists, including psychiatrists, commonly see patients who have been dissatisfied with their experience with a physician who seemed too quick to prescribe medication in lieu of engaging them in even a brief psychotherapy. Psychiatric treatment is clearly more satisfying to all concerned when the physician has the time and the freedom to prepare a truly customized treatment plan.

In undertaking to learn the basic principles of psychotherapeutic management, contemporary beginning psychiatric residents and medical students considering psychiatry as a career are inclined to question whether the effort is worthwhile. The ideas and the history of the field intrigue them, but they are overwhelmed by what seems a mysterious skill set, vast in scope and only slowly acquired. They question whether they will be “allowed” (by managed care organizations) to perform psychotherapy. They question whether they or their patients will be able to afford to spend an hour (or any significant portion thereof) together. Trainees at this level may be reminded that psychiatry as practiced in the emergency room of a city hospital at 3:00 am, although necessary, represents only a small portion of the influence they can bring to bear on the toll taken by mental illness in our time. Advanced psychiatric residents quickly rediscover the lost soul of psychiatry and clamor for seminars and supervision in psychotherapy. They have learned again what was almost forgotten, what was almost buried under the avalanche of medical school facts and early residency sleepless nights. They rediscover the central role of relatedness in the definition of emotional well-being, and they learn to appreciate the pernicious impact of its loss in the manifestations of emotional despair. The road to the recovery of human relatedness is through the process of relatedness, and many times this requires a therapist. The quality and meaning of human life, both the professional's and the patient’s, derive from relatedness. No amount of bottom-line accounting or conceptual reductionism can alter that truth.