Building the Therapeutic
Relationship
It as axiomatic that
individuals seeking psychoanalytic treatment are not prepared to be patients
simply because they show up at our offices.
In fact, one of the most important tasks for the modern psychoanalyst is
to teach the patient how to be a patient.
Ideally, this begins to take place from the very first contact made.
Frequently, the prospective patient will make this first contact through
a telephone call, or through a third person; and as Dr. Hyman Spotnitz (1985, p. 116) has noted:
Before a firm appointment is made and
honored, they may oscillate for a protracted period between an intense desire
to be relieved of their misery and what seems to be an unconscious need to
defend themselves against the anticipated stress of
the analytic situation.
Yet, this
initial phase of coming together (including the first tentative contacts
between analyst and patient) is not regarded as a mere preliminary, but is
“governed by the general plan of treatment,” and is thought to “influence all
subsequent contacts between them.” (Spotnitz, 1985, p. 113).
It should be
obvious that these first contacts will often include resistances, perhaps even
treatment destructive resistances, just as in the therapeutic relationship that
is eventually developed. (See e.g.,
Fennessy, 2006).
If an initial
interview does take place, the modern analyst “… needs to gather only enough
information to help decide whether he could treat that individual effectively
and wants to work with him.” (Spotnitz, 1985, p. 118).
In this
respect, many modern analysts prefer not to review previous diagnostic records
for their patients. Their thinking is
that they do not want to be influenced by the diagnostic impressions of others
and that they want to use their own feelings in evaluating their patients. As a rule, no pressure is placed on
individuals to disclose information that they may have withheld during the
interview.
One of the few
questions asked during the initial interview might be “why do you want
treatment?” (See e.g.,
Spotnitz, 1985, p. 120; Spotnitz, 1976a, p. 140). Questions such as this help the modern
analyst begin to explore the patient’s attitudes and willingness to cooperate.
Practical
arrangements may also be brought up in the first interview. Towards the end of the interview, questions
such as “have you thought about how much you’d like to pay?” or “have you
thought about how often you’d like to come?” are not uncommon.
The discussion
of these and similar items may also be viewed as a part of the treatment itself; i.e., in talking
about all of these practical matters “(a)rrangements and rules are flexibly
formulated as dynamic tools of therapy.”
(Spotnitz, 1976a, p. 141).
If an agreement
can be reached, the therapeutic relationship will be based upon
… what can
reasonably be expected of the patient at the emotional level at which he enters
treatment. Provided that he agrees
verbally to participate to that extent, the analyst assumes all responsibility
for the treatment process… This changes, of course, as
the patient makes progress, he becomes more and more capable of assuming an
increasing degree of responsibility.
Eventually he assumes full responsibility for the success or failure of
the treatment. (Spotnitz,
1985, p. 122).
The therapeutic
relationship in modern psychoanalysis is therefore built “from the ground up,”
similarly to “the mother-child relationship.”
(Spotnitz, 1985, p. 113).
This modern
approach is particularly useful for those who would have been deemed
“unanalyzable” by classical analysts. As
Dr. Spotnitz (1985, p. 115, emphasis original) says:
The schizophrenic patient who can
cooperate… [to a great extent]… in the early stage of
treatment is rarely encountered.
Nevertheless, the patient becomes capable of making that contribution if
the analyst accepts the responsibility
for developing an effectual alliance with him.
If the analyst
accepts the responsibility and the patient begins talking, the analyst then
needs to consider all those other matters in the interest of the patient, such
as whether and when interventions might be necessary, whether and how a
transference might develop, and what the resulting therapeutic relationship
will be.
References
Fennessy, J. (2006). Free Association and Resistance. (Online at: http://modernpsychoanalysis.blogspot.com, August 03,
2006).
Spotnitz, H. (1976a). Psychotherapy of Preoedipal Conditions, N.Y., Jason Aronson.
Spotnitz, H. and Meadow, P. (1976b).
Treatment of the Narcissistic Neuroses, NY,
Spotnitz, H.
(1985). Modern Psychoanalysis of the Schizophrenic Patient: Theory of the
Technique, Second Edition, NY, Human Sciences Press.
© 2006, James G. Fennessy, M.A., J.D.
E-mail: njanalyst@hotmail.com
http://modernpsychoanalysis.org