Maryland Psychiatrist Spring 2013
By Don Ross, MD
Now that we are coding psychotherapy as an “add on” to an E&M code, it is worthwhile to review how it impacts the doctor-patient relationship. I would argue that as psychiatrists who are also psychotherapists, we modify our relationship to the patient in a way that allows psychotherapy to happen. This is most clearly true for longer-term psychodynamic psychotherapy, where much of the change requires a deep appreciation of the complexity of this relationship. In fact, the therapeutic relationship may become the primary avenue in which psychotherapy works for some patients. This is much more than a simple addition of time or a different focus on the content of what is being discussed. Psychotherapy, and in particular psychotherapy that attempts to change long-standing interpersonal patterns, requires key differences in the relationships we establish and maintain with our patients. Thus, one cannot separate out psychotherapy from the doctor-patient relationship. It is not so much a “procedure” that can be “added on”; instead it is more a way of being with the patient. In the following paragraphs, I will outline some of these key areas of consideration for the psychotherapist.
The therapeutic alliance is the platform upon which all the collaborative work is done between patient and therapist. It stands on two legs:
- It is built upon a rational foundation: the relationship between a patient who is suffering from psychological distress and a therapist who is an expert in relieving this type of suffering;
- Under the surface, it is also built upon an emotional foundation: a child in pain who is looking to the good parent for comfort and relief. This is also called the benign positive transference.
When the therapeutic alliance is damaged, the first order of business is to attend to that. This may happen when the therapist loses empathic touch with what the patient is reporting or when the therapist inadvertently disappoints the patient, e.g., goes away on vacation, is late, etc. The most common cause of ending therapy too early is a broken therapeutic alliance. Thus, when the alliance is damaged, it must be repaired via acknowledgment, understanding, apology if indicated, and resumption of an empathic stance. Through multiple mini-breaks and repairs the therapist and patient gain confidence that the therapy will be able to withstand the emotional pressures it likely will face as deeper material comes up in the sessions or in the transference. Understanding breaks in the alliance can be extremely valuable in getting to understand underlying dynamic issues that repeat themselves in the patient’s life elsewhere.
Pacing, Leading, Modeling, Encouraging
Whether the patient or therapist is aware of it, a good amount of change in the patient occurs through the actual behavior of the therapist. This is likely to be more effective if the therapist is conscious of these forces and can use them to effect change in a positive direction. There is a concept in hypnotic induction (and in salesmanship) of finding the patient’s stream of thought, both content and rate/rhythm of speech, and joining it. The patient and therapist become fellows on a mutual journey. This is called “pacing”. Once the therapist has joined the patient, they feel more allied with where the therapist wants to take them. The patient is more likely to follow at this point. For example, a patient may start talking in a choppy, agitated way about someone they have encountered in the elevator who frightened them. The therapist joins the patient in the experience, but then slows into a more settled voice and soon reminds them both that now they are in the safety of the office. As the patient calms, the therapist shifts to understanding why this experience triggered such fear.. The encounter becomes a subject of mutual inquiry now that emotions are better regulated.
It may be that this scary elevator encounter provided a (missed) opportunity to practice a new behavior, e.g., assertiveness or mindful attention without escalating emotions. The therapist might suggest a role-play in which one takes the role of the scary person and the other the role of the patient. Roles may be switched. The patient has the opportunity to see how one might do it differently and to practice it. There are many less formal opportunities for the therapist to model effective behavior for a patient, including healthy self-disclosure and healthy boundaries. Over time, the therapist models to the patient how to be his or her own therapist, which the patient internalizes and uses between therapy sessions and long past the period of formal sessions.
Sometimes, patients need more than simple validation in order to attempt a new attitude or behavior. They need actual encouragement and the sense that someone with more knowledge (the therapist) believes they can do what they are setting out to do. Active praise and encouragement can be effective reinforcing agents to encourage change. However, the therapist must balance that with remaining accepting and neutral about the outcome. When the patient fails, the therapist must also be there to pick them up and help them try again.
Transference, defined as the patient’s experience of the therapist based on past relationship patterns from childhood, is the unconscious, come to life in the therapy. There is always a kernel of truth or reality in the transference. The patient does not create this out of thin air, but is picking up on something going on in the therapeutic relationship. However, transference also is regressive, and, to that extent, it is exaggerated or distorted by the childhood pattern.
It often serves as a resistance to therapy. It gets in the way of the work, pulling the patient away from making changes in real life. It may be a reason for the patient to quit therapy if it is not adequately understood in a timely way. Transference is also a way for the patient’s unconscious relationship patterns to enter into the therapy. It recreates, in the form of a drama, what cannot be remembered and discussed in words adequately yet.
Typical examples of transferences are:
- Erotic transference: The patient “falls in love” with the therapist. This can derail therapy, as the patient struggles with sexual or loving wishes towards the therapist rather than directing them to an appropriate and available person in the “real world.” Often, the therapist must help the patient overcome considerable shame for having these wishes before they are openly expressed. Once expressed, they can be analyzed as the pattern of loving that has trapped the patient in their unhappy romantic life.
- Superego transference: The patient sees the therapist as a critical, demanding, unsympathetic figure who mirrors the strict parent from childhood. The patient works hard to please the therapist and get approval.
- Idealizing transference: The patient sees the therapist as bigger than life, representing either an experienced powerful parent or the wished-for powerful parent who will protect the patient (child) and help them feel special within that relationship.
There are many, many varieties of transference. The key is recognizing both the kernel of truth and acknowledging it, and examining the nature of the regressive, unrealistic aspects so they can illuminate the patient’s inner world of relationships.
Freud noted that in the end, successful psychoanalysis or therapy will depend upon the handling of the transference. If it can be recognized, elaborated, and understood, first by the therapist and then by the patient, therapy will be successful. If not, the therapy will founder on the misunderstandings that arise.
Countertransference is the therapist’s “transference” to the patient. The therapist is human, and like the rest of us, has thoughts, feelings, fantasies, and behaviors based upon early childhood relationship patterns. As with transference, there is a “problem” side to countertransference and a “useful” side to it.
Countertransference becomes a problem when it persistently clouds or distorts the therapist’s understanding of the patient. This can lead to overt acting out with the patient or can be subtle and go unnoticed. If countertransference is noticed and then understood by the therapist, it can serve as a way of understanding what is going on in the patient’s inner world. As with transference, countertransference does not come out of thin air, but represents some truth about the patient and the relationship, often about a covert transference the patient is having to the therapist. It can be useful and even necessary for a therapist to get supervision to better understand ongoing countertransference.
The “holding environment” is the physical and emotional environment in which therapy occurs. It needs to provide adequate safety, privacy, and intimacy for the patient to gradually open up their private, internal world. Attention must be paid to space, time, money, confidentiality, and other “rules of engagement” (phone calls, treatment plans to insurance companies, missed visits, etc.). The therapist must be caring, empathic, and non-judgmental. Only a truly engaged therapist will be able to make a difference in the life of a patient who really needs therapy. The therapist must also be detached, neutral, and expert enough at their craft to handle the intensity of emotions that in-depth therapy unleashes. The therapy space must remain “sacred.” The therapist does not invade the patient’s real life, which allows the freedom for all sorts of necessary, regressive feelings to emerge within the safety of the therapeutic space. The therapist also needs a “holding environment”, aware of and respectful of their own limits, having balance in their life. Use of supervision and peer support when indicated, and having access to personal therapy, is important to free them from their own symptoms and inhibitions. It allows for maximum personal growth and awareness of their own patterns and tendencies. The therapist “must grow a spacious heart” to accommodate the emotional troubles of their patients.
Dr. Ross is the Medical Director of The Retreat at Sheppard Pratt, a psychotherapeutic residential program for adults with depression, anxiety, and axis II disorders. He serves as the Director of Psychotherapy Training for the University of Maryland/Sheppard Pratt Residency Training Program in Psychiatry, where he is Clinical Associate Professor. He is also a Supervising and Training Analyst with the Washington Psychoanalytic Institute and has completed training in the Fundamentals of Dialectical Behavioral Therapy.
Opinions expressed in the article are the author’s own, and do not necessarily reflect the opinions of the Editorial Advisory Board or the Maryland Psychiatric Society.