Wednesday, December 31, 2008

#5 A Piece of Work

A Piece of Work

I am somewhat uneasy about writing at length about this brief psychotherapy because I am not an advocate of any of the many brands of this form of treatment which are currently available. In fact I have never been too enthusiastic about most models of brief psychotherapy because they have seemed like thinly disguised efforts to fit our work to administrative needs and another way to distract us from listening to what our patients have to say. For those of us who were trained psychoanalytically, however, it must be acknowledged at the outset of any discussion of brief psychotherapy that all psychotherapy is more or less brief. If we are to take psychoanalytic theory seriously, then, anything short of a full scale psychoanalysis will necessarily be incomplete and consequently brief. Unfortunately this fact has always made thinking about brief psychotherapy somewhat of an embarrassment. Models of brief psychotherapy have arisen, I believe, in order to relieve us of this embarrassment by convincing us that our incomplete work at least has a rationale.

Brief psychotherapy can, however, be looked at from a different perspective. From this perspective our motto as therapists ought to be that "less is more." I say this because I believe that whatever psychotherapy's potency as a treatment may be, the significance of its unintended effects are generally underrated. In our culture at least psychotherapy is generally understood as a treatment No matter how strongly we, as therapists, may believe that our patients play an active role in shaping their life dramas and in working through their conflicts in therapy, the fact that therapy is understood as a treatment is a powerful invitation for us (that is both patients and therapists) to view this work as something being done to someone and not by someone. We are all familiar with patients who we regard as dependent as coming to rely on their therapist and their therapy hour as if they were unable to conduct their lives without them. What we talk about less often, however, is the fact that the therapeutic situation forcefully encourages all of our patients, more or less, to adopt this view of themselves. I could speak to this point from my own experience as a psychotherapy patient and I could give many examples - some of my patients some of my friends-- to support the notion that people we would not ordinarily regard as dependent can come to feel quit helpless while in psychotherapy. It is this unintended effect of psychotherapy which has led me to adopt the motto "less is more."

I could go on at length about why I believe that we as a profession have given relatively little notice to this powerful effect of psychotherapy or have tended to attribute its effects to the shortcomings--that is, the dependency - of our patients. I am, however, not a sociologist but a clinician. As a clinician I would like to suggest that our tendency to ignore this powerful effect of psychotherapy grows out of our adherence to what might be called our medical orientation to patients. Viewing our patients behavior as symptomatic of unconscious forces is always, I believe, somewhat in conflict with listening to what our patients want. I do not mean by this that we do not try to listen to what our patients want or that psychoanalytic theory is unnecessary or unhelpful in our work. From my own experience, however, I must confess that trying to find out what is wrong with someone has often made it difficult to appreciate that what they want from me may have very little to do with what I think is wrong with them. After all the fact that we view ourselves as healers does not require our patients to seek us out to be healed.

Failing to recognize what people want can, of course, get us into serious trouble but by the same token recognizing what people want may allow us to be quite helpful in ways that have very little to do with the accuracy of our interpretations. Consider, for example, two lonely depressed women who consulted me. The first was depressed because she had lost a job. I proceeded to try to help her with her depression while ignoring that what she wanted was a romance with a successful professional man like myself. Needless to say, in time, we reached a very painful impasse. The second woman, whose depression did not have a clear precipitant, also wanted to develop a special relationship with me that would allow her to feel that someone could find her attractive. Alerted by her history of having allowed herself to be exploited by men, I was initially quite cautious that is to say, stiff and formal, with her. Frustrated by my inability to help her by focusing on her problems, I began to chat with her about little things, even allowing myself to express my feelings to a greater extent than I was taught to do. Because I could appreciate what she wanted, I was able to be friendly with her while helping her to avoid misconstruing that friendliness.

My topic is not, however "the use of self" or the "corrective emotional experience," as it used to be called. Nonetheless I do want to insist that how we treat people is altered by our ability to recognize what they want. A corollary of this it that a clearer recognition of what people want will often lead us to realize that we cannot or do not want to give people what they want. It is this corollary which has important implications for brief psychotherapy. Simply put many patients and therapists become involved in long and fruitless therapies because they are unable to recognize that what one of them wants the other cannot or will not give them. These patients are commonly called chronically depressed, chronically anxious or dependent. Their therapists are usually frustrated and sadly often come to hate their patients or to lose confidence in themselves.

Let me give two more examples: one of a nearly interminable therapy and the other of a therapy which might have become so. The first was a man I saw for nearly seven years. Diagnostically I would say that he had a narcissistic character disorder. Working with him was a bit like riding a roller coaster. In periods of grandiosity he would take on ambitious projects only to become terribly anxious and unable to complete them and then depressed and self pitying. With consistency he would come to sessions, slouch down in his chair and proclaim his inability to control his ambition, his anxiety or his depressions. An intelligent person, he would consume my interpretations but he would always end up by complaining that I wasn't doing enough to help him. I often felt frustrated and angry with him and I frequently found myself doubting my competence. When after some years we were able to agree on simple concrete goals such as holding a job and having decent relationships with women, he began to show some improvement. While focusing on his "character pathology" had created the impression that I would fix him, these concrete goals made it clear that only his efforts would get him what he wanted. As we both came to appreciate that I could not satisfy his boundless apetite for help, he began to see that he was competent to manage his life. I also began to feel more competent as I discovered that limiting my efforts to help him was indeed quite helpful.

The other patient I would like to mention at this point was also a lonely depressed woman. Her numerous efforts to form loving relationships with men had failed for reasons which standard interpretive psychotherapy was able to clarify. She began to feel better and confident that she could at least avoid getting involved in bad relationships in the future. Unfortunately she was still quite lonely and opportunities to get involved in new relationships with men were none too frequent. We were both quite aware of how attached we had become to one another. Fortunately, however, we were also able to talk about how her therapeutic relationship with me would never be more than a poor substitute for what she wanted. Because we were both concerned about her becoming a "chronic" patient, she was also able, quite courageously, I felt, to give up the comfort of our relationship with very limited prospects for the future.

What these cases illustrate is, I believe, is that recognizing the limitations of psychotherapy is in an important way crucial to successful psychotherapy. Unfortunately the theory of therapy that I was taught offers few guidelines for recognizing these limitations. Freud was very clear. Psychoanalysis is a curative treatment. While his reasons for adopting these pretensions for his treatment are understandable historically, these pretensions have made brief psychotherapy something I was taught to feel apologetic about. What I have tried to suggest is that focusing on what people want rather than on what is wrong with them makes brief psychotherapy not only more intelligible, but also an ideal to be sought after. Such a change in perspective accomplishes this by drawing our attention to the crucial question: "Can I give this person what they want?" With this question in focus we are in a much better position to recognize those circumstances when we are in fact unable to give people what they want. This in turn helps us say to people that while psychotherapy may be helpful to a point beyond that point their own efforts are all that they can count on.

Since most of our efforts do not bring people the happiness and satisfaction that they want from life, this is a difficult thing to say to them. It is particularly difficult because, as healers, we are committed to relieving the suffering of our patients. Their disappointment at recognizing our limitations is painful for us to bear. That our theory suggests that our aim should be cure is, of course, of no help. It is also true because we seldom have very good opportunities to follow up on work that we believe we have left incomplete. "Keep on trying" becomes our motto, although, over time, this becomes quite demoralizing.

When we do have opportunities for follow up, it sometimes makes it clear that, in their own time, people will make good use of what we have said. Recently, at a conference, a woman, who I barely recognized as the wife of a paranoid man that I had seen some years earlier, came up to me. As I was remembering my frustrated efforts to tell her that she had to learn to set limits on his rages, she told me that she had understood exactly what I had meant and that she had subsequently found the courage to divorce him. I was overjoyed. However I also found myself wondering how much better I might feel about my work if I had more opportunities to learn about the delayed benefits of therapy.

With all of these difficulties it is not enough, I'm afraid, simply to exhort ourselves to be aware of our limitations and to share them with our patients. This is all too negative to bear the weight of their disappointment and our demoralization. Thanks to my friend and colleague Matt Andresino, I have been able to find a more positive way to approach this important issue with my patients. Some years ago Matt presented a case to our peer supervision group which seemed as incomplete and unsatisfactory in its outcome as many of my cases. To my surprise he concluded his presentation by saying that both he and the patient were able to take considerable satisfaction from the fact that they had done a "good piece of work." What did he mean by that? While I can't answer that question, I would like to say what that notion has come to mean to me. Doing a good piece of work begins by recognizing at the outset of a therapy that a patient probably wants a great deal from me that I can't give them. Often the magnitude and intensity of these desires are misread as a measure of a person's pathology. This unfortunately leads us to dig in and begin to try to help them when we should be attempting to identify a piece of work that we can accomplish together.

If however, we can identify this discrepancy between what a person may want and what we are able to give them, we can begin to identify what such a piece of work might be. Generally I do not mean something as concrete as helping them to get a job, though this may be the case at times. What I do mean is listening very carefully for what a given patient's most prominent and realizable wish may be. I believe that is possible because, in spite of the great medley of wishes that patients may have, they generally have one primary aim in seeking psychotherapy. Of course this aim is most likely not to be expressed directly. Genuine psychoanalytic sensitivity will be necessary to infer what this is. Unlike psychoanalytic inferences about the causes of people's symptoms or problems, inferences about what people want can be rather readily confirmed. At times this can be done by sympathetically discussing our inferences directly with our patients. More often it is confirmed indirectly by their enthusiastic recognition that we are trying to help them get what they want. Accomplishing this primary aim, then, becomes the piece of work that we try to do together.

Lest this description become too schematic let me give some examples:

A homosexual man in the throes of coming out wants to talk to a sympathetic and knowledgeable man about the risks of what he is doing. He wants some confirmation from a straight, but not homophobic, man that he may be gay but that he is not “queer.”

A woman with an alcoholic mother and a schizophrenic father is devastated when her husband leaves her. She wants a reliable, consistent and available person in her life while she finds the courage to resolve her apparently conflicting desires for security and intimacy.

A highly religious Catholic man, who has secretely been having an affair for several years, is told by his doctor that his angina is stress related. He wants a non-judgmental man to help him explore the moral implications of leaving his wife.

What is most striking to me about these examples is the clarity and simplicity of my formulations. As clinicians, of course, you are all too well aware of the fact that people do not walk into our offices and directly present the kinds of wishes I have inferred. I am also not suggesting that I was immediately aware of these wishes in the form that I have given them. What is important about these formulations, or rather the process of arriving at formulations like these, is the clarification of what a good piece of work should be. During the course of the therapy patients also develop a clearer perception of their primary aim. As a result, it becomes easier for both of us to say, after a time, that we have done a good piece of work. Stopping our work becomes easier because we have not been drawn in by the lure making good some deficiency or reworking some nebulous personality structure.

By emphasizing that we focus on what people want, I am not suggesting that we ignore symptoms or diagnoses. As I indicated earlier, however, a focus on symptoms and diagnoses is to a significant degree in competition with a focus on desires. The necessity for my emphasis is that our usual medical focus often does not give us very clear guidelines as to what a good piece of work is likely to be. Diagnoses, when they do not serve as indications for the use of medications, are simply poor guides for psychotherapeutic work. Freud was well aware of this; and his work can be read as an effort to confront the same problems I am outlining. After all it was Freud who placed patient's desires at the center of psychiatric theory and it was Freud who taught us so much about how to infer the nature of people's desires from their indirect communications.

Indeed one of Freud's earliest and briefest treatments might serve as a fitting final example of the kind of approach that I am suggesting. In 1892 a governess, that Freud calls Lucy, consulted him about a disturbing hallucination of the smell of burnt pudding. In a remarkably direct and apparently brilliant interpretation Freud was able to point out to Lucy that her symptom was the result of her unwillingness to acknowledge the hopelessness of her love for her employer. While Freud rightly and understandably emphasized the role of his most important clinical discovery - the role of "defense" in the formation of symptoms - a knowledge of the typical conflicts of nineteenth century governesses allows one to put a slightly different interpretation on this case.

Governesses were hired because they were "ladies," but they worked because their families were too poor to let them do what ladies were supposed to do, namely, not work. Because they worked they were tarnished and their employers could never marry them. If they lost their jobs they were often forced into the poor house or prostitution. Viewed in this light Lucy's plight was indeed a poignant one. Her wish to marry her employer was futile. What she needed, and what Freud helped her find, was the courage to face this futility. In doing this they accomplished a piece of work. Having done this they concluded a very brief treatment.

Before concluding I would like to reemphasize one point. Identifying what people want also involves making a determination of whether we, as therapists, can give them what they want. Very often what people want is not something that we can give them. Romance, happy childhoods, whole bodies and absolution are examples of wishes that people bring to us that we cannot give them. Recognizing clearly and quickly that these are what our patients want is one only way to prevent subsequent bitter disappointments.

Telling people that we cannot give them what they want will never be easy, even when what they want is beyond our expertise, our professional standards and our own desires. Helping people do a good piece of work toward fufilling an atainable wish may be of some consolation. Only tact and sympathy, as well as an ability to confront our limitations, will help us help our patients to find the strength to bear the tragedies in their lives. Certainly Freud could do nothing to change Lucy's plight. In allowing her to take her leave, to bravely bear what she had to bear, he did, however, give her an opportunity to maintain her self respect. In allowing, and even encouraging, our patient's to bear what they must bear, we too may allow them a greater measure of self respect, even when we cannot offer them help in the usual sense of that word.

While focusing on what our patients want and attempting to find a good piece of work that we can do together may not always allow us to satisfy the guidelines for brief therapy that insurance companies and administrators may set out, this approach will, I believe, help us establish our own guidelines as to what useful psychotherapeutic work really is. By recognizing what we can and cannot do, by recognizing our limitations and by helping our patients to recognize them as well we will also afford them a greater opportunity for self respect and we will also be better able to sustain our own morale as we do our very difficult work.

This paper is a slightly modified version of a talk given in 1986.
Edward M. Brown

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