Is it OK to Break the "Rules" of Psychotherapy?

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by Jason von Stietz - November 28, 2014

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May neurofeedback practitioners are also psychotherapists, or started as one. Does Freud's conceptualization of the psychotherapist as a blank slate still apply today? Currently, many struggle with whether or not to abandon Freud’s old axiom. A recent article in The New York Times discussed this dilemma from the viewpoint of a psychiatrist:


When Julia first appeared in my office, she was approaching her 35th birthday. She had resolved it would be her last.


A hard-working surgeon at a nearby hospital, Julia endured a monastic, grueling existence even in the best of times. Then a deep depression struck. Soon it had shut out all remnants of pleasure, robbing her nights of sleep and locking her features into a mask of anguish. She began to think about suicide. Finally, a colleague of hers insisted she seek help.


From the start of therapy, and despite her weariness, Julia mustered the determination to protest what she called the “rules of therapy” — especially the notion that I would not disclose personal information about myself during her treatment. She’d manage a faint, defiant smile and rattle off interrogations: “Don’t you get bored listening to us mental patients?” “You’re holding your head in your hand — do you have a headache?” “Do you have children? How many?”


She hadn’t learned this rule from me. She came to treatment under the assumption I would adhere to it. This was understandable; the caricature of the infuriating Freudian analyst, stroking his beard and deflecting the patient’s question with another question (“And how do you feel about that?”), pervades popular culture.


And in fact, the rule originated with Freud. In a 1912 paper, he advised doctors practicing psychoanalysis that the physician “should be opaque to his patients, and, like a mirror, show them nothing but what is shown to him.”


In psychoanalysis, there is a specific rationale for this rule. The theory holds that patients tend to re-enact with therapists the relationships they had with their parents. This is called transference. By paying careful attention to this unfolding drama — as it plays out, right there in the office — the therapist and patient can uncover and resolve childhood conflicts. If a therapist interjects information about herself, she clouds the mirror and compromises the process.


But I’m not a psychoanalyst. I’m a psychiatrist, a medical doctor who treats mental illness with both medication and psychotherapy. And Julia had a biological illness — major depressive disorder — that required in part a biological treatment. Freud’s dictum was not necessarily central to my work with her.


Yet she doggedly tried to wrest confidences from me. Why?


Julia agreed to take antidepressant medication, which reduced her most immobilizing symptoms. Yet sitting in my office, wrapped in an afghan I had there for warmth, she looked like a sad and lonely waif. What was the origin of her melancholy? Unless we could better understand it, it would probably continue to predispose her to severe depressive episodes. So we embarked on more intensive psychotherapy.


Here, Julia’s instincts about my willingness to talk about myself were partially correct. I’m not doctrinaire, but neither am I one to divulge much about my private life.


Even if you’re not a classical Freudian analyst, there are good reasons for a therapist to adopt a posture of neutrality. For one thing, patients need to be free to take the discussion anywhere, including uncomfortable or taboo territories. If therapy were reciprocal, therapists might close off avenues of conversation that they themselves might want to avoid.


So I tended to be my usual “therapist self” with Julia: attentive, open and, I hoped, warm — yet neutral and withholding when it came to my own life. But the more I withheld from her, the harder she pressed me to open up. It was impossible not to wonder what lay behind her insistence.


Julia looked to the outside world like the very picture of competence. Her voice had a lovely composed timbre that seemed to be saying, “I’ll handle this.” And people routinely accepted this implicit offer. She was the solution to everyone’s problem.


But I quickly learned that behind this facade of proficiency was a fragile soul. During the most vulnerable developmental stages of Julia’s life, beginning in infancy, her mother had suffered from severe mental illness and a personality disorder that rendered her erratic and narcissistic. She was never completely present for Julia. Indeed, Julia was the one called on to calm her down. Julia had parlayed that skill into becoming what she termed a Sherpa — someone so skilled at carrying weight for others that no one knew anything of her burdens.


Julia presented me with a therapy challenge. She had honed the art of shifting the valence of a conversation toward the other person, hiding herself. She desperately wanted to attach to me, and this was her tried and true method of establishing intimacy — or her approximation of it. But by persistently asking me personal questions, she also threatened to repeat the dynamic that left her feeling isolated and alone in the outside world.


It seemed she was once again trying to be the Sherpa.


When I pointed this out to her, she withdrew. No matter how gently I offered this observation, she experienced it as a rebuke, a hurtful break in our growing closeness. However, if I failed to point out these moments, I feared she wouldn’t see that she was unconsciously trying to mold our relationship into yet another of those unsatisfying one-way relationships in her life. I was in a quandary.


There is a quotation from the psychiatrist D. W. Winnicott, the wisdom of which, at that point in my development as a psychiatrist, I had yet to appreciate. “It appalls me to think how much deep change I have prevented or delayed,” Winnicott wrote, “by my personal need to interpret.”


With Julia, I began to learn Winnicott’s lesson. As therapy continued with her, I heard how flat and tinny I sounded whenever I attempted to analyze what was going on between us. When I lapsed into too clinical a mode, our connection would wobble, and her alienation became palpable.


In contrast, as I began, in the face of her challenges, to let down my guard, our alliance grew stronger, and she became open to treatment. We would laugh together about her bringing me just the right greeting card or a flower from her garden — exhibiting her need to challenge “the rules” and exposing my need to interpret her actions. These interactions helped develop her capacity to observe herself in action, as she courted me in her Sherpa style.


I may have been a slow student, but eventually I understood: I was the one who had to change. From then on, when she saw that look in my eyes, I said yes, I did have a migraine. We followed episodes of the TV show “ER” together, and I told her where I was going when I left for vacation.


When I worried out loud that, in her engagement with my life, she was treading too close to a denial of the importance of her own, she answered, “I trust that you won’t let me go there.” With her heightened awareness of her pattern of creating intimacy, perhaps things could change for her.


Many years have now passed. What’s become of Julia? She inhabits a life unrecognizable from this vignette, a life changed in many ways for the better. Alas, she still has a chronic relapsing illness — severe depression — for which there is yet no magic cure. But she has succeeded in training me to become a better doctor for her, and she continues to come to me for treatment. Though modern psychiatry can’t always cure every disease, I can at least help Julia do some of the heavy lifting.


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