Wednesday, February 14, 2007

A Special Kind of Relationship

We've had a whole series of posts on psychotherapy, what gets said, who should have it, who should do it, and does it matter what gets said. I'll put some links below for anyone who's missed out on the sometimes heated discussion.

We've talked about why it would help for someone to come to treatment and talk about their day to day activities, and I've mentioned a confabulated patient who talks about the price of beef (comparative, of course, checking out the sales at various grocers) and we've wondered how that might help.

Sometimes it's about what gets said: the act of saying something effects the cure. This can be particularly true if the problem is directly related to an event-- secret, traumatic, tragic, or just plain troubling.

Sometimes it's about what gets said: a patient listens to himself and figures out his own solutions. The therapist is a sounding board and the patient does all the work.

Sometimes it's about what gets said: a therapist can point out patterns in a patient's feelings, interactions and reactions, and it helps when such patterns, unseen by the patient, are elucidated. Maybe the patient can change these patterns if he's aware of them, or maybe there's something about us that just likes being understood with a sprinkling of those "ah ha" moments. People like it when a therapist is able to say: "You're the type of person who...." and the therapist is right. Patients especially like it who the thing they're hearing is something good, such as "You're the type of person who cares deeply about others." It's feels a little bit magical when a therapist does this in the first session, especially if they hone right in and put into words something that hasn't been put into quite those words before.

Sometimes, it just doesn't matter what gets said.

It's about the relationship.

I've been wanting to write about this for a while. I haven't because, well, I haven't known what to say. There are all sorts of things that have been said about why the therapeutic relationship helps, mostly unproveable, some just feel wrong, or it feels like the therapist is trying to force the pieces into the puzzle. Unconditional Positive Regard? I'm not sure that ever really happens and it wouldn't feel genuine. In fact, a mandate for unconditional positive regard entails dictating the therapist's feelings in a way that might call for dishonesty. The idea that the therapist is consistently present and accepting of the patient's difficult feelings is helpful, though I'll point out that such consistency comes at a price, a literal by-the-hour dollar figure, and really, there are no guarantees-- therapists move, quit, get sick, and even die. We just like to think we offer consistency and acceptance (and that we don't die).

What therapy (or at least good therapy) does offer is a safe place to talk about difficult stuff. It's essential that the patient feel that the therapist either understands him or is trying very hard to understand him, and I believe that it has to be an honest relationship-- a safe place to hear things one might not otherwise be willing or able to hear. It's a narcissistic endeavor, it's all about the patient, and that's how it should be. I use the word narcissistic loosely here --I could probably find a better, more accurate, and less loaded word, but I like this one. In friendship relationships there's a give and take-- I tell you my story and if you're a guy, You tell me how to fix my problem. If you're a girl, you tell me about the time something happened to you that was just like what just happened to me. Either I get an answer or I get some much-needed empathy, but either way, I hear about You.

I could talk about transference helps a patient to understand and work through difficulties in past relationships as they play themselves out in the here and now. Really, I can talk about it, it even sounds good, I just haven't found that it plays out in therapy the way it sounds like it should, at least not as a neat package where I can articulate each step.

I'm left to ramble.

Sometimes it's about the relationship. I don't always know why.

Happy Valentine's Day from the shrinks at Shrink Rap!

Links to past posts about psychotherapy:
Talk Therapy
What Makes It Therapy?
What People Talk About In Therapy
ClinkShrink's Couch Time
Transference To The Blog



Heck, people like it when fortune cookies say, "You're the type of person who cares about others." And then you get to eat the cookie, which you just can't do with a therapist.

Gerbil said...

One of my graduate school hurdles was to present an interesting case and write it up as though for publication. The tradition was to do a CBT sort of case, 10-12 sessions with pre- and post- assessments and all that, but I have a special place in my heart for one-size-fits-all-CBT and it's not a very warm and fuzzy one. So I said the hell with it and did a longer-term case in which the therapeutic relationship was the treatment itself.

This case was a powerful illustration for me that doing isn't nearly as important as being.

(Of course, the CBT old guard wanted to know what measures I could have used to gauge the strength of our relationship over time. So predictable.)

So, if a manual ever comes out on how to build a therapeutic relationship, and in what sessions to say or do which thing, I'll be the first to buy it. Till then, I'll just keep flying by the seat of my pants and hope it continues to work.

Gerbil said...

Oh, and Seamonkey--one can, in fact, eat one's therapist. But this makes one either Hannibal Lecter or half of a dual relationship! ;)

Sarebear said...

Seamonkey! I'm giggling . . .

Yeah, one book I've read calls it an or the "approximate relationship".

It's wierd, how one appt. where I was having a really REALLY hard time, to the point where I could tell he was assessing and trying to decide inside about the possibility of hospitalization . . . . it's funny, how everything from that appointment, where he was trying to get through to me, and THE NEXT DAY I have a breakthrough, and call him, and say that I just couldn't stop thinking about how much I felt "connected" emotionally in our appointment, in a therapeutic way of course, how much I felt his desire to really help me through the hard time I was going through; how much I really felt and appreciated his EFFORTS on my behalf, to help me and stuff.

It was my feeling these things, and being able to tell that HE was feeling stuff (I could see him kind of wrestling with the serious, serious options given what I was discussing; I could sense a bit of an emotional process on his part working through it, maybe) . . . it's funny, given the "benevolent neutrality" that often is part of therapy, and given that I have a REALLY REALLY hard time feeling emotionally connected with people . . . . it's funny, given the issues and problem-solving and solutions and work we did that session, that after all that, it was the strength of our therapeutic relationship, the caring between us, his caring about my welfare, his concern for me, and my part in presenting things honestly and openly so that I knew the things I was sensing from him were in regards to true and real things on my part . . . . that it was the RELATIONSHIP, these very undefinable but real parts of therapy, that is what really, really helped me come to a better place and breakthrough, after a day of thinking about it, and marveling that someone could actually be concerned for me and stuff. Among other things.

Anyway, it was cool. Sorry to go on so long, it WAS relevant . . .

Anonymous said...

I think one of the key components to "good therapy" is finding a therapist who has his/her own act together. I had a therapist who had an abundance of psychological issues of his own. He wanted me to bring a stuffed animal to therapy so I would "feel safe." I just stared at him. I'm an adult I don't play with stuffed animals. It's almost like he wanted me to be a child. It was all very sick and weird. Therapy can be a good thing, but it can also be really, really bad. Do your homework in advance. Check their licensing board to see if there's been any previous trouble. Talk to someone who has been treated by them. But, bottom line - trust your gut. If things seem really off base, then they probably are. In which case, do not walk...RUN far, far away!

~~~In recovery from therapy

Anonymous said...

I've had different sorts of therapy and whilst I can make sense of CBT (with reservations), I can't make sense of the longer therapies, which seem to go nowhere. Maybe it's because I'm in the UK and I'm stuck with whichever therapist I'm allocated to on the NHS. Maybe it's also because I'm sceptical of the notion of a "relationship" with my therapist. He's paid to help me, not to befriend me. It's an uneven relationship in which he can put me in hospital if he chooses. That's always going to limit what I say to him.

ClinkShrink said...

Uh oh, I was locked out of Old Blogger today. Looks like Thelma and Louise are trapped on the cliff.

Sarebear said...

Roy, you'd better fix the brakes on this car before they go over the edge . . . .

Dinah said...

Roy's comcast is down.
ClinkShrink can't get into blogger.
I can get into blogger sometimes, with difficulty and haven't figured out a clear pattern of when it works.

I think if you can feel like you're getting as much out of your fortune cookie as your therapist, you should stick with the fortune cookie, it's cheaper and takes less time.

There is something really weird about a therapist instructing a patient to bring a stuffed animal to a session (this may, in fact, be fine if the patient is a young child--I'm not a kiddy shrink and I'll defer on that issue). Therapy is supposed to help increase coping skills. I'm not much for anything that encourages regression. Mostly the weird stuff, even if it can be rationalized by a therapeutic schema, is unproven and can lead people into very uncomfortable situations.

To anonymous in the UK: I wasn't using the term relationship as being interchangeable with friendship. Relationships come in all shapes and sizes.

Dinah said...

from Roy to Dinah for posting (Ha! He's relying on ME for technologic assistance):

My internet is out so I'm blogging from my Treo.
Sara, great comments above. The connection is indeed important.

Once I get my internet back by Comcast, I will backup the site, then
we will cross our fingers and knuckle under to Google's
passive-aggressive techniques to switch to the no-longer-beta version.

I hope I did this right.


I've been thinking a lot about the idea of therapy (and I'm restricted to the idea since I've never actually been in therapy). I have a sort of inner therapist whom I call on whenever I'm under stress or in doubt. She's a composite of all the people I admire and who have loved me and given me good advice in the past: my parents, my friends, my teachers. She's always asking me good questions like "what are some of the ways we could solve this problem?" and "what do you really want out of this interaction?" and "why do you think they're acting that way?" She tells me to be empathetic and responsible, puts a check on any nasty impulses and encourages me to think rationally. She's a bit judgmental, but also very forgiving. I'm often adding to and occasionally taking away from my composite, making her better. A 'real' therapist could certainly give her some food for thought, but there could never be a substitute for the MiniShrink sitting on my shoulder.

Anonymous said...

"To anonymous in the UK: I wasn't using the term relationship as being interchangeable with friendship. Relationships come in all shapes and sizes."

I can see where you're coming from, but I prefer just to see whoever's duty clinician, not see the same person each time. If you see the same person each time, they seem to want a continuity of conversation that my memory doesn't permit. That's why I prefer to talk to the Samaritans. I probably do speak to the same people but I don't remember them and they don't raise the issue.

But I can see that there would be people that would want to talk to the same people each time. It's good that you help those people that want that.

Patient Anonymous said...

Therapy is so hard. I find it true work.

At times I am incredibly resistant to it but I know I have to stick with it. After long separations I feel that "resistance" to go that is even stronger than when it sometimes occurs, even when seeing my therapist on a regular, non-interrupted basis.

I've even had "disagreements" but not really fights with my therapist. We've had to work some things out when we haven't been communicating well. But that's okay.

Your relationship with your therapist can become quite intimate--whether you want it to or not. In fact, it probably needs to be if you're going to get anywhere in the process.

Curtis and Shae said...

I love this post, because it really gets down to the nitty gritty of therapy. We are taught a lot of techniques in school...a lot of theory. But you can't teach "Relationship 101." It just doesn't work that way. From both points of view (as a psych major, and a client) I understand that therapy is nothing without the relationship. Thanks for this post. I really enjoy reading what you guys have to gives a lot of perspective to what I want to do with my life.