Roots Of Psychotherapy

Carl A. Whitaker, Thomas P. Malone

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317758686
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

First published in 1994. This monograph proposes a scientific formulation of the art of psychotherapy. The recent recognition of this treatment process as a separate discipline makes imperative the understanding of its nature and the comprehension of those features common to all forms of psychotherapy, regardless of differences in technique or in school orientation. The book is divided into three sections: (1) Foundation deals with the relationship of psychotherapy to general biology, especially to growth and adaptation, and with the common features as well as the differences in the major approaches to psychotherapy; (2) Process presents a formulation of the essential phases and the dynamics of any psychotherapeutic relationship; and (3) Techniques presents some techniques which the authors have found useful in their own work as psychotherapists.

9

The Patient as a Person

THE PEAKL

Said one oyster to a neighboring oyster, “I have a very great pain within me. It is heavy and round and I am in distress.”

And the other oyster replied with haughty complacence, “Praise be to the heavens and to the sea, I have no pain within me. I am well and whole both within and without.”

At that moment a crab was passing by and heard the two oysters, and he said to the one who was well and whole both within and without, “Yes, you are well and whole; but the pain that your neighbor bears is a pearl of exceeding beauty.”

Gibran*

The general public has accepted for years the quip that to the psychiatrist every person is a patient. Although we deny this publicly, the accusation comes very near to the truth. It has many implications. Among ourselves, we recognize that a person sees in others only what he has seen in himself. It may be then that the psychiatrist sees others as patients since he so frequently faces his own patient facet. This appraisal may provide us with a more honest basis for our orientation in psychotherapy. As we will see further on, the therapist sees himself as a person only after he has been a patient. From this we recognize that all persons have similar potentialities and that, therefore, all persons are potentially patients. We must, however, differentiate between these potential patients and the actual patient who comes into the office for treatment.

The Genesis of a Patient

Psychotherapy can be utilized in two fundamental ways: It can provide help for the patient in need of psychiatric treatment for very specific symptoms, and it can help the socially adequate and fairly mature individual to become more creative than formerly and, in general, to develop more of his capacity to function as a well-integrated adult. Accordingly, psychotherapy may help the “sick” individual, or it may actualize the potential capacities of the average “normal” person. Potential patients fall, roughly speaking, into three groups: those who come with pathology grossly apparent to the outside word (society), those whose pathology becomes obvious only in the interviews, and those whose pathology is discernible only to the patients themselves. The mere fact that the individual has gross pathology, however, does not mean that he becomes automatically a patient. Many people continue to operate on a compensated level and repeatedly deny all offers of help. In this group, even those who obviously should be patients are not. As a matter of fact, one of the growth experiences of the young therapist evolves from his effort to convert a sick person into a patient. In his enthusiasm as a professional person, the young therapist will often respond in a professional manner to a bit of pathology revealed in a social setting. He thereby shows little recognition of the importance of the patient’s initiative in bringing his problem to a therapist, or the importance of isolating his “therapeutic role” from the realities of ordinary social living. Thus, the young therapist may respond to the depression of a friend while at a cocktail party. Such an approach often succeeds in freezing the depressed friend and making him more anxious. The next day, the therapist may realize he has lost a friend, or be startled by the distant reaction of his erstwhile friend and “patient.” Furthermore, even a patient who comes to the office with gross pathology may reject his offer of help in the same way. Both these individuals could be patients and could benefit from therapy, but they do not accept their patient status. What does this mean?

Previously, we discussed the implication that psychopathology represents, in one sense, a request for therapy. This request may be consistently and aggressively denied consciously and may be detectable only on a symbolic level. A patient, then, is simply defined as a person who asks for help from the psychotherapist. An individual may be able to ask for help from one therapist and not from another. Even when the patient asks for help, there remains the problem of the therapist’s “hearing” him. Some therapists can hear a request for help even when expressed in the obtuse symbolic language of the schizophrenic, whereas others seem to have difficulty unless the patient demands help more directly. One schizophrenic patient, who had rather rigid paranoid feelings, kept demanding in the initial interviews, “I want to get out of here. Please let me out of here. I’ve got to get out of here so that I can lead a normal life.” Superficially, she was talking about leaving the interview room. On a symbolic level, she was speaking of getting out of her schizophrenic isolation and, in this sense, symbolically begging for help. Even with this request, she still was not a patient. She was not a patient until the therapists not only theoretically knew, but more important, subjectively felt, that she was asking for their help. With the concurrence of her need felt in both herself and the therapists, she became a patient.

Patient status, in general, involves acceptance on the part of both parties of a felt need. Patient status has, therefore, two ingredients. First, the concept “patient” as used here becomes a biological concept. It implies the existence of a discrepancy between the individual’s current effectiveness in his living and his biological potential. This deletes from the concept of “patient” the cultural relativity which has caused psychiatrists so much concern in the past. One culture may satisfy certain needs more fully than others or accept one type of personal deficiency more readily than another. However, the objective basis of the individual being a patient is precisely the difference between what he is and what he could be. The second ingredient of patient status is a subjective acceptance of his need, and its presentation, whether consciously or unconsciously, to another person in order to obtain help with it. Finally, the therapist must accept that need as something with which he can struggle. Only when these objective and subjective ingredients occur together can it be said that this person has become a patient.

Patient status, then, is defined by the therapeutic process itself. It does not antecede it, nor does it exist apart from therapy. It is not equivalent to pathology. An individual may have gross pathology and not be a patient, or have minimal pathology and be a patient. In the case of the deteriorated schizophrenic previously discussed, she became a patient when the therapist developed the capacity to recognize her need so that it became meaningful to him personally, and consequently provoked some emotional response in him. As this developed, she demanded, with increasing urgency, the rights of her patient status.

The above dynamics appear most openly in collaborative therapy. The authors frequently qualify their acceptance of a patient with the understanding that his parent or spouse obtain therapy simultaneously. This poses a difficult task since these individuals see themselves as normal in comparison with the “real” patient and have no conviction of their own need. The problem has additional facets since, just as frequently, the therapist to these latter individuals has little advance conviction of their need. The initial struggle in this therapy, thus, seeks to achieve a bilateral, felt acceptance of their need on the part of both patient and therapist. The relative’s acceptance of his patient status usually follows the therapist’s recognition of his emotional involvement in it. We have belabored this point to give force to our conviction that the process of psychotherapy is bilateral, even to the extent of insisting that the therapist’s reaction may constitute the determining factor in bringing about patient status in an individual. From here on, we are going to discuss, primarily, the patient’s dynamics despite the artificiality of such an abstraction.

Barriers to Patient Status

The patient’s decision to see a therapist is no easy one. What brings the patient to the therapist? The pressures which force him to take this step must be fairly urgent ones. He has essential barriers to overcome. The first, and probably most important of these, evidences his unwillingness to upset his own neurotic equilibrium. This compromise, even though it limits his gratifications in life, also satisfies him in certain ways. For example, it provides him with some kind of protection and enables him to live on a fairly safe, though sterile, level. He senses that therapy may cause him to reverse the defensive compromises of a lifetime. The fact that he lacks much appreciation of the possibility of achieving a more adequate level of living makes it all the more difficult for him to seek treatment. Sometimes the patient comes to the therapist because he wishes, not so much to grow, as to repair those self-therapeutizing patterns through which he has obtained certain “subsistence level” gratifications, and which, for various reasons, are now breaking down. For example, one overt homosexual wanted to make sure that he would not fall in love. Yet, despite all this, the patient’s coming to the therapist, in the face of years of compromise living, implies a deep recognition of the tremendous power of the long-suppressed growth impulse in himself as an individual. To see the almost unprovoked stirrings of the need to grow in the deteriorated schizophrenic forces one to respect the dominant role of this urge in the hierarchy of living impulses.

The person who comes to a therapist defies, in a sense, many of his own cultural values. This constitutes a serious deterrent. For example, in seeking therapy, he tacitly blames his culture for its failure to provide him with adequate “growth nutrition,” i.e., with therapy. Thus, the very act of coming to the therapist points up many of the deficiencies of the community within which he lives. More particularly, he implicates those members of the community who live in close association with him. One wonders, therefore, just how much of the hostility which our culture expresses against psychiatry, and against psychotherapy, reflects some latent recognition of the fact that the need of its members to seek therapy constitutes a reflection upon the community in which they live. Be that as it may, the patient comes only because something powerful in him overcomes both a lifetime of compromise living and the cultural pressures enforcing submission to the parents and parent substitutes. The patient must also overcome the anxiety mobilized by the recognition that his auto-therapeutic functions have failed. Indeed, he has to reject the culture and its therapeutic function in order to isolate himself from the culture by coming to the professional therapist. Lastly, he must reject an earlier therapeutic relationship to some individual (social therapist) within the culture, e.g., the referring physician. Even the individual who has not been referred has usually struggled for satisfaction of his emotional needs with some other individual or group in his community at some time in the past.

The Social Therapist

Patients seldom, if ever, come to a professional therapist without having first experienced some growth in a previous therapeutic relationship. Social therapists often help patients therapeutically, though their relationship may not be a professional one. Everyone in the community functions at one time or another as a therapist to the needs of others. We call this process “social therapy.” They usually are not conscious of the process of therapy and, as therapists, have marked limitations. Nevertheless, in their relationship with a specific person, they frequently provide a modicum of gratification. This measure often gives the patient a first glimpse of the possibility of growth through therapy. In this sense, we are convinced that most, if not all, patients are referred from social to professional therapists. What happened to the patient prior to his first interview with the professional therapist represents what we will call, in a later chapter, the “pre-interview phase of therapy.” This implies that an increase in the number and adequacy of social therapists in any community might be a partial answer to the problems of preventive psychiatry.

Many difficulties beset the transfer of the patient from a social to a professional therapist. An almost inevitable hostility develops toward the social therapist, resulting from his failure to be completely effective. Part of this hostility toward the social therapist represents transference of infantile feelings of rejection. Whatever its source, these feelings are transferred onto the professional therapist to whom the patient responds, early in their relationship, much as the patient had responded to his social therapist. We frequently hear such remarks as, “You sound just like my husband,” or “I don’t see why my doctor sent me to you.” This last illustration contains the core of another difficulty. Patients develop deep transference to their social therapists, e.g., referring internist which, later on, hinders the development of a deep relationship to the professional therapist.

The therapist must “work through” his own response to this hostility and his competition with the social therapist before the relationship can go beyond the point of the previous rejection. This “working through” on the part of the therapist brings to the patient, at the outset, some indication of the limitations and immaturities of the therapist. Acceptance of these by the patient expands the initial professional relationship into a more personal one. In a sense, it implies a recognition by the patient that the therapist has a fantasy life of his own, which will inevitably play a part in the development of his own fantasy life.

Culture: The Last Barrier

As mentioned above, the patient’s fantasy of therapy includes the fear that therapy is possible only in defiance of the culture. In order to conform to his culture, the patient has had to develop a façade of maturity. He has denied repeatedly those deeper needs which he felt were antagonistic to cultural demands. Now, confronted with an opportunity to express his childlike needs, the patient must first break through his pseudo-adult pattern. In doing so, he fears that the therapist will respond to his needs as his culture has done, i.e., by denying these infantile needs. Were this to happen, he might then be unable to re-establish his protective façade. Furthermore, he intuits that the therapist will offer him such satisfactions that he will become a helpless child and might be held forever dependent. Patients frequently say, “I’m afraid that if I really let myself become a little baby, I’ll never grow up (again), and you wouldn’t take care of me.” This wish opposes the hostile, aggressive demand that the culture (or therapist) take care of him. The ambivalence of dependence and assertion of adequacy characterizes the initial period of psychotherapy.

The patient turns to the therapist as a possible escape from the struggle within himself. His concept of the therapist reflects a cultural stereotype which includes some of the following characteristics: the therapist has all the magic which the child ascribes to the parent, i.e., in his presence the patient will suddenly and miraculously be cured. In this sense, the physician becomes the witch doctor of our culture. In his fantasy, the patient depends on this omnipotent parent to share his burden and to carry the onus of his disease. The therapist also engenders hate, as someone who deprives the patient of part of his individuality. The unique needs of each individual patient mold his interpretation of the cultural stereotype. Its specific characteristics are determined by the constellation of that individual’s “intra-psychic family.” When the intra-psychic family of the patient comes to include in this manner also the doctor-therapist, the process of therapy, as an intra-psychic phenomenon, begins. Conversely, and in much the same manner, the patient is, in turn, an introject, and so becomes part of the intra-psychic dynamics of the therapist. This means that the process is a bilateral one. The patient’s stereotype of the therapist fuses with the members of his own intra-psychic family. In this sense, the doctor may be anybody—God, teacher, the devil, the nurse, or society. The individual patient’s projections are numberless.

These cultural barriers to the patient’s obtaining psychotherapy find their most direct expression in the patient’s family. The family has a deep sense of guilt since the patient’s sickness attests to their failure to mature him adequately. They have further difficulty in bringing him to the therapist, since often the emotional homeostasis (economy) of the family centers around the patient. They sense that if the patient changes, they too must change. For example, the “martyred” wife of the alcoholic patient not only fulfills a mother role, but satisfies her own neurotic needs by keeping her husband dependent. Therefore, if the alcoholic husband comes for therapy, this disrupts her compensatory neurotic patterns by breaking up the dovetailing of two previously complementary neuroses. Often the resentment, guilt, and neurotic dependence of the family expresses itself as a fatalism about the patient being able to recover. They say to the patient, “We want to give you whatever is necessary for you to get well,” but beneath this is the fatalism and resentment engendered by their own failure to have given him what would have kept him well. When the patient comes to the therapist, much of the family’s ambivalence falls upon the therapist, and the patient now has to adjust to the added problem of their feelings about the therapist.

In spite of the projections of the patient and the cultural barriers, the therapist must maintain himself as a person in his own right, so as to be able to alter the make-up of the patient’s intra-psychic family. Antagonism between the patient and the culture (particularly the family) presents the therapist with many administrative and personal problems. A psychiatrist often accumulates hostility toward the family of the patient. He senses how the family rejects the patient, and he resents this. This resentment in turn increases the family’s antagonism toward him. Ordinarily, neither the family nor the therapist can openly express their resentment since each feels bound by the culture. Should the therapist express his personal feelings to the family, he frees himself for a more adequate relationship to the patient but endangers his professional status with them.

This may only become a problem after therapy has begun and the patient begins to get well. For example, the father of an adolescent schizophrenic, recovering at last as a result of intensive therapy, decides suddenly that the treatment has failed and withdraws the patient from therapy. The patient’s recovery apparently provokes guilt and anxiety in the parent, which he resolves by this withdrawal. Not only does the patient’s therapy upset the family by removing the patient from them and thereby changing the family’s dynamics, but often in removing the pre-psychotic from the family, one deprives the latter of its most functional therapist member. A portion of the family’s aggression toward the professional therapist originates in these same dynamics.

Confronted with such uncertainties, the patient brings to therapy all the mechanisms at his command in order to protect himself from further rejection. These protective mechanisms, when manifested in therapy, are thought of as resistances.

Resistances also have a very specific therapeutic function. They do not simply provide the patient with protection from anxiety but, on a deeper level, they also protect him from this new parent whose feelings and capacities he presumes but must discover for himself. Resistances thus occupy a central place in the beginning phase of therapy, and require a bilateral relationship for their resolution. If one looks at resistance from this point of view, one notes at once that the therapist, too, frequently brings to the initial interview a good number of his own resistances, and uses them in the same manner. In both persons, resistances function to provide protection against rejection by the other person. A new rejection would be more painful than the mere re...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Introduction
• Introduction to the 1981 Reprint
• FOUNDATION
• PROCESS
• TECHNIQUES
• Glossary
• Bibliography