Ethics Workshop
Creativity and Madness
Santa Fe
29-30 July 2014
CONTINUING PROFESSIONAL DEVELOPMENT
INTRODUCTION
The stimulus of being alone with a patient creates the need to know more
about psychotherapy. Psychotherapy is learned on the job, in the therapeutic
relationship. The mental health professional in training has so much to learn.
Though learning techniques of a competent psychotherapist in four years of
training, it takes several more years to find the fit, the style, and the acquired
skill to be comfortable and effective as a psychotherapist. I have mentioned the
humane and warm presence of Elvin Semrad earlier in this text. Dr. Semrad
was an extraordinary clinician and gifted teacher. Pietro Castelnuovo-Tedesco
[1990] reminds us of Semrad’s style: “Dr. Semrad told us that if we wanted to
learn about psychiatry, we should each buy a good suit with two pair of pants
[he emphasized with his voice the word good] and then plan to sit with patients
until we had worn through the seat of both pairs.”
How long does it take to get a deep shine on a thinned out pair of pants?
Ekstein and Wallerstein [1958] state the acquisition of “basic
psychotherapeutic skills” are not enough to train the psychotherapist: “What
would still be missing is a specific quality in the psychotherapist that makes
him into a truly professional person, a quality we wish to refer to as
professional identity.” In their discussion, Ekstein and Wallerstein cite the
1955 report of Lawrence S. Kubie proposing the title “medical psychologist” as
an individual trained in psychodiagnostic and psychotherapeutic work. They
add: “As long as Kubie’s call for a special grouping of psychotherapists is not
heeded, and the indications in the present social structure are that it will not
be heeded soon, the identification with psychotherapy as a profession will be
merely part of a larger professional identity characteristic for today’s
practitioners in this field.” This is the 1955 position. And who said the last
century was marked by an urgency to get things done?
Fragmentation in our approaches to patient care continues.
Psychotherapy programs are disappearing off the menu of the academic plate
of offerings. Professionals have great difficulty developing a psychoanalytic
psychotherapy practice in this new century.
Ekstein and Wallerstein (1958) add:
“A Psychotherapy training program, as part of a general psychiatric
residency program, must be devised in such a way as to permit a process
in which ideal professional self-realization is possible, and in which
freedom of choice exists, so that the young psychiatrist can incorporate
into his professional self concept those identity aspects that will indicate
to what degree he wishes to and is able to become a psychotherapist.”
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Educational programs at the postgraduate level do not tolerate great
flexibility. There are specific segments of programming based in various
clinical services that are required. Electives are limited. Thus, clearing the
educational hurdles and completing the postgraduate training program feels
like the end of an era. Graduates feel a relief, out from under the apprentice
role, and look forward to clinical practice. Graduation is an important step
though it is really just the end of the beginning in developing ideal professional
self-realization.
THE BIRTH OF THE HUMANE PSYCHOTHERAPIST
The observational research of Margaret Mahler [1975] that organized into
“separation-individuation” theory has been of great value to me. I apply her
work to an understanding of the learner in the psychotherapeutic process.
Herein, I paraphrase the title of her 1975 report with Pine and Bergman, The
Psychological Birth of the Human Infant. Mahler’s work lends itself to a
description of the developmental process of the undifferentiated professional
moving through postgraduate training. Let me refer to a 1994(a) paper by
Gertrude and Rubin Blanck, “The Relevance of Mahler’s Observational Studies
to the Theory and Technique of Psychoanalysis.” Rather than restate the rich
description of the Blancks, I use extended quotes in the following two
paragraphs, all taken from the 1994(a) paper without further reference.
Central to Mahlerian theory is the description of mother-infant
interaction and the bridge to my application of her theory in becoming a
psychotherapist. There are parental figures in the learning environment
especially with mentoring and supervision. Mahler delineates three
preliminary phases after physical birth leading to “psychological birth” around
three years of age. Let me highlight this discussion.
After physical birth, there is the first phase “regarded as the time when
neonate and mothering person try to find a comfortable fit in order to be able to
enter the second phase, symbiosis.” Mahler, deriving theory from data,
“concludes that symbiosis is an essential experience that orients the child to
the world of reality.” She notes the ability to love and “the capacity for
empathy” are linked to this developmental step and introduces the concept that
“certain inborn capacities do exist.” The Blancks refer to the recent work of
Emde confirming, “Mahler’s discovery that the individual unfolds within the
matrix of the mother-infant unity and that the relationship between neonate
and caregiver establishes enduring patterns, a matter of great importance to
ego psychological object relations theory.” Subphases of the separationindividuation process “powered by an aggressive thrust in maturation of the
physical self” give rise to a differentiation process, separating from the
caregiver, in a practicing subphase where the individual reaches out to
experience the world. This is followed by a rapprochement subphase in which
there is a coming back together again with the caregiver. Interactional
experience bears heavily on the outcome of these subphases as the developing
individual moves to the final subphase, on-the-way-to-object-constancy, which if
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completed competently, provides the structuralization necessary for
psychological emergence and “full development of the capacity to engage in
conflict.” For Mahler, separation and individuation are “two separate, but
parallel tracks… the separation track is involved in negotiation between the
developing self-representation as it works toward ever-greater independence
from the object representations” while “the individuation track is more
autonomous… far less bound up in conflict between the two sets of
representations,” yet intricately bound to the right amount of separation and
distance, availability and connection or intimacy, in each successive
developmental step.
During postgraduate training, one starts to grow an identity as a
professional and learns to function in the most efficient, least conflict-bound
position possible. If you consider the brief description of Mahler above, better
still read the original sources, you may sense my proposed links to
understanding the complex developmental process of becoming a
psychotherapist. The undifferentiated professional enters postgraduate
education.
Can you recall the early days of your own learning experience? You had
certain knowledge, understanding, skills, attitudes, and problem-solving
abilities [which can be contrasted with the physical birth of the human infant]
but struggled to find your fit with the new maternal environment, in this case,
the clinical setting. The smiling response of the new professional at one month
of age could be the dawning awareness of the link with the new mothering
person  although it could just be gas  a temporary relief from tension. At
about one month, having struggled to find the fit with the new specialty
interest, there is a merging into a symbiotic phase, generally in the form of a
mentoring relationship in which the learner seeks caring objects to sustain,
nurture and inspire. At first there is simple imitation, a primitive incorporation
as we try to swallow the whole object. Gradually, there is a building up of our
internal mapping using introjects that align with our desired goal. Learners
will select traits in the figures we gather around us as we transit through the
educational environment. With experience and further ability to practice on
our own, we become more sophisticated. Though looking for mentors to
support and direct at each successive stage of development, we become
increasingly selective as our own separation-individuation process unfolds in
the educational matrix. As we learn new skills and experience mastery, we
practice being on our own, yet want and need a responsiveness, someone to
share our excitement, to help us label experiences and be available to steady
us when we extend too far. During the rapprochement stage we proceed with
further internalization, transitioning on-the-way-to-object constancy. This
initial process takes three years, sometimes four, and like any “childhood”
development is the base for entry into successive stages of growth and
development.
Completing our early work in this psychotherapeutic analogy to
separation-individuation is the end of the beginning. There are new
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developmental tasks challenging us. Each new task stimulates the repetition
and reworking of earlier separation-individuation experiences. Bad learning
experiences with inadequate mentoring and professional trauma carry into the
future, as do the positive learning experiences. Cycling through successive
stages of development in subsequent years of professional practice will reflect
the impact of this early milieu “for better and for worse.”
In psychiatry, and other mental health professional programs, the
learner is alone with the patient early in training. Unlike the novice surgical
resident who is the second scrub in surgery, the psychiatric resident sits alone
with a distressed, often disorganized individual. The universal response to
professional anxiety and inexperience is the need to know more. However, it’s
a time of real trauma! Learners recount missteps in their own learning
process, with early attempts to venture out being connected with panic. These
discussions of war stories are usually done in private with trusted peers.
The mentoring relationship, so important to professional socialization, is
akin to the mothering figure in our educational family of learner siblings, father
figures, assorted aunts and uncles and other significant adults. The work in
our educational family is filled with confusing multiple transference reactions
as each individual struggles to feel competent and to master the increasingly
complex set of developmental tasks. As learners we attempt to soak up and
integrate everything into our internal structuring of who we are and how we
operate in this evolving world. From the first encounter with the patient we
attempt to listen, to understand, to organize, to question data, define problems
and formulate psychodynamics allowing us to probe in a deeper and inquiring
fashion. Along with the occasional periods of mastery and panic, we experience
distress, confusion and depression as part of the educational process.
Experience as psychotherapists, as we develop a shine on our pants (in the
Semrad sense), contributes to a fascination with the inquiry process, and the
awareness of the need for further development. In an existential sense, the
developing psychotherapist is always “becoming.” From the fitting together,
and merging with the educational environment, one hopes the inborn capacity
to inquire is not stamped out by authority figures, and the separation drive
fuels an excitement within the learner in the surrounding educational
environment. Entry into clinical practice is a further stimulus and supervision
is an invaluable life-long aid to further learning and effective care.
SEEKING OUT MENTORS
Like the child longing for a response from an interested mother who can
share our secrets and fantasies, we long for a mentor, preferably several if you
please, to sustain and nurture us. Mentors and psychotherapy supervisors are
not necessarily the same, in my opinion. Survival, balance and development of
meaning within the “black box” of postgraduate education is dependent upon
key individuals the learner selects within the educational environment. The
mentoring relationships and supervisory contacts act as the lifeline for making
it through the hazards of early training.
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I recall a psychotic patient during my first year of training saying: “You
even walk like him.” For me it was just another part of the patient’s thought
disorder I labored to understand. During my third year of training, while still
working with that patient, she clarified the comment made two years earlier,
saying I modeled on my first supervisor’s clinical approach and listening
attitude, imitated his behavior - even walked like him. I’m sure she was
accurate.
Jensvold [1994] describes “good mentoring, lack of mentoring, and bad
mentoring that can occur as a condition of employment; a more senior person
mentoring a more junior person by mutual choice; co-mentoring and ‘role
model mentor.’” She notes “mentees are in a very vulnerable position” and
emphasizes the importance of good mentoring in helping the individual “to
become established professionally.” The mentoring relationship “formed by
mutual choice and not dependency” seems on the face to be a desirable
relationship, although it may mean that “credentials are dependent upon the
continued relationship, or at least upon completion of the position” placing the
mentee in a difficult position. Co-mentoring, in which “the people involved may
be peers, or may differ somewhat in their seniority” seem to have the more
positive outcome in which “both receive support and both careers are
advanced.” Interestingly, we may have, in our modern day society, many
mentors who have been role models, perhaps people not even met, but rather
read about or studied. A common example would be Osler as the great mentor
of so many future physicians, or Freud and his early disciples. A leader in a
field may be admired from a distance and their professional persona adapted to
the individual learner.
The mentor is a compassionate intermediary, a transitional object
between infancy and adolescence in our professional development. Bickel
[1995] has noted: “Key to a successful career is a mentor, someone who acts as
a guide, an advocate with regard to resources and who enduringly cares about
a protégé’s advancement.”
Just as the many vicissitudes in early personal development occur, so
too in professional education. Learners are dropped in the water to sink or
swim  a traumatic entry to the swimming experience. In beginning
psychotherapy and advancing one’s skills, we don’t jump into the consultation
room without risk of injury to self and patient. Finding the delicate balance of
structured preparation and balanced experience with the patient becomes a
critical variable in teacher student interaction. Just as the successful patient
extrudes the therapist from their life as they move out on their own, so too, the
student leaves the teacher behind with maturation. The learning process
unfolds.
EDUCATIONAL METHODS
Lectures, small group discussions, individual study, informal exchanges,
interactions with patients, peers relationships, mentors, and supervisors, the
shared insight of experiencing treatment first hand  all are well traveled roads
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to the deeper appreciation and developing ability to learn about and practice
the science and art of psychotherapy.
Anxious trainees read. Anxious learners attend case conferences,
although not wanting to present one of their own patients. As we become
desensitized to the clinical conference and find other people can make errors or
sound as inept as we can feel, we start to share experiences with colleagues at
the same level of training. During our middle years of postgraduate training,
we struggle to get on top of new and intriguing cases, we watch demonstrations
of psychotherapy and start to participate more actively in conferences. Toward
the close of the training program, learners may compete to present at case
conferences and seminars.
The stimulation of the national meeting or specialized workshop
observing and interacting with “national figures” read about in journals and
texts is a great learning experience. Professional socialization is an important
component of the developmental process.
Toward the end of training, and throughout professional life, any
opportunity to teach can provide a fine learning experience. When the teacher
prepares a topic for presentation and attempts to involve the learner in the
pursuit of their own education goals, the greatest gain falls to the instructor. It
goes without saying that anytime you are asked to address a public group or a
professional audience, you have the responsibility to present your material at
the highest professional level. You do not have the luxury of “winging it” when
you represent your professional colleagues and yourself in a public setting.
As early learners with the greatest need to know more, we collect and
collate all the bits of material from our educational universe, integrating
knowledge, understanding, skills, and attitudes that fit with our developing
internal map. The experience with the patient, combined with individual
supervision, comprises the essential building block. Although it’s time
consuming and sometimes feels inefficient, the one-to-one encounter between
supervisee and supervisor remains the cohesive thread in the learning of
psychotherapy. The individual supervision of the resident’s psychotherapy is
probably the most important alliance the psychiatric resident has in training,
with the probable exception of an analyst or psychotherapist encountered in
one’s personal psychotherapeutic or psychoanalytic experience.
Personal therapy or analysis?
Should every resident have personal experience with his or her own
therapy? A quotation attributed to the southwestern writer Edward Abbey
comes to mind:
“What is truth?
I don’t know and I’m sorry I brought it up.”
Psychoanalysis or psychotherapy may become the finest learning
experience for the developing psychotherapist. One cannot put the emotional
experience of being a patient into a series of words. Feeling the inquiry process
within oneself, sensing the role of the skilled therapist or analyst at work, and
experiencing transference and resistance, adds to the learning base of any
psychotherapist. To feel the struggles, recall the emotions, and apply ostensive
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understanding allows the fullest respect and compassion for the
psychotherapeutic process and our patients. The personal therapeutic
encounter provides meaning.
Should personal psychotherapy or analysis be part of the postgraduate
curriculum? I believe yes  at the right time. Personal psychotherapeutic
treatment should not occur as an elective early in training. There is quite
enough going on at the beginning. Educators need to differentiate between the
professional developmental process and the option of choosing personal growth
in personal psychotherapy or psychoanalysis. If a learner is having difficulties
that interfere with patient care or professional meaning, psychotherapy should
be entered into without question. However, on the question of the option early
in training, I am in agreement with Dubovsky and Scully [1990] from the
University of Colorado School of Medicine: They state psychoanalysis and
related psychotherapies can have adverse effects during the turmoil of
residency training.
Professional Identity
Psychotherapists come from a variety of disciplines. We are no closer
now to attaining Kubie’s desired medical psychologist than we were in the
1950s. There have been attempts to carve out separate pieces of professional
turf in the behavioral sciences. During the last three or four decades there
have been attempts to define a psychiatrist. See Langley and Yager [1988] for
an update on one study. The stigma of mental illness combined with the
advent of “managed” care has devastated professional training and clinical
practice. The only area of professional life providing financial incentive at
present is accepting increased administrative responsibility. There are limited
funds for careers in research and educator training programs. Reimbursements
for skilled clinical practice and community service activities are low. So how
does the professional concerned about comprehensive individual care,
including psychological medicine initiatives, maintain a sense of meaning and
satisfaction?
Fennig et al. [1993] note “there is inevitable conflict in connection with
the issue of identity,” adding a growing number of (psychiatric) residents have
begun to question the “necessity and relevance” of psychotherapy to their own
training. Using Erikson’s definition of identity, Fennig et al. touch on issues of
professional identity “built around various elements such as identification with
mentors, the acquisition of a common professional language and body of
knowledge, the mastery of certain skills, and finally, the attainment of
recognition by society. The ultimate result of the process is the feeling of ‘this
is me’.” Their discussion describes the basic principles of psychotherapeutic
practice to be totally different from the educational experience in the medical
school in which “the physician is a real person: encouraging, advising and
giving concrete help in the form of medications or other kinds of treatment.” In
contrast, psychotherapeutic physicians become participant observers, less
likely to offer patients any direct concrete help such as advice or
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encouragement, thereby entering a new field which could threaten a learned
role of being socially responsible and an authority in the field. “We find that for
some residents the giving up of the authoritative role, even for the duration of
the psychotherapy session, is threatening and anxiety provoking… in
psychotherapy, residents are more personally vulnerable because their selves
and their personalities are the major vehicles of the treatment, therefore failure
might be perceived as more personal. This kind of experience can be a source
of confusion, frustration and anxiety for young residents as well as for more
experienced psychiatrists.” Fennig et al. suggest residents should learn
“seemingly contradictory aspects of identity can coexist successfully,” and
emphasize confronting “this issue early in the training of residents and to
provide a setting in which a positive professional identity can develop. Failure
to do so can lead to frustration, anger, demoralization and devaluation,
inhibiting optimal development of skill.”
All around us we see evidence of commerce and merchandising.
Competing hospital-based programs, commercials for the wonderful advances
in managed care and the professional group providing the best care are on the
television screen every night. The politicization of health care reform and the
chronic shortfall in funding humane programs for vulnerable populations such
as the homeless, the mentally ill and those existing in poverty leaves us
frustrated and detached.
Multiple marketplace forces rather than the needs of the patient have
changed traditional practice. Traditional educational and practice models have
disappeared. Acute illness requiring a reasonable inpatient hospital stay
allows careful diagnostic evaluation and appropriate treatment interventions.
Those days are gone! For better or for worse? How can a suicidal patient be
evaluated and treated on an inpatient service with an average stay of 2.3 days?
The external forces of financing and managed care have developed ambulatory
outpatient programs with partial hospitalization, crisis clinics and medication
clinics making brief treatment the one size that fits all the mentally ill.
Appendix G continues the discussion of external forces changing clinical
practice.
How does this effect professional identity? I have seen and heard of
demoralized health care providers. Large hospitals, competing for their share of
the mental health dollar, have continued to decrease the length of stay with
high turnover maintaining occupancy rates. The outsider sees a vicious cycle
with appropriate inpatient care and long-term therapy being squeezed out of
contemporary practice. A physician can make a psychiatric referral and the
“evaluation” is done without the patient seeing a psychiatrist. Perhaps a
psychiatrist will consult for a fifteen-minute segment to prescribe a medication,
after the selective screening by a non-psychiatric mental health professional
who has defined the problems. There have been many lawsuits for wrongful
death and inappropriate treatment in the new management models. Results of
these negotiated legal actions are confidential with lawyers warning parties that
revealing any details of a settlement may void the agreement.
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Ethical practice of one’s profession gets tougher every year with each new
restriction. The costs of care have increased and the usual market forces do
not operate in sickness or in Health. Everyone wants the latest advance in
diagnosis or treatment. Should a child be deprived of a life-saving bone
marrow transplant when the parents cannot pay for the procedure? Do we let
someone die because the intensive care needed goes beyond the limits of their
insurance carrier’s decision? I do not have great wisdom here. I have the
dilemma you confront everyday.
Who am I?
What do I stand for in this situation?
A double agent? Am I the patient advocate, the defender of the system,
or what?
What is the cost in professional identity with a system of care selecting
out, or squeezing out, high-risk patients into the public sector, already
overburdened and underfinanced?
If you are not the patient advocate in the system, who will be?
In data derived from the Duke University Epidemiological Catchment
Area Project, Landerman et.al. (1994) found psychiatric disorder with a specific
DSM-III diagnosis was the more powerful predictor of a mental health visit
when contrasted with the availability of mental health coverage. Landerman et
al., conclude “findings suggest that attempts to reduce expenditures by limiting
the number of psychotherapy visits would reduce care among those still in
need once these limits were exhausted and coverage was denied.”
The focus on the patient is lost in discussions of the delivery system. In
1970, I saw a manual of the leading insurance company of the day, entitled
How to Deny Claims. The manual was more than two inches thick. How thick
is it now? Discrimination against patients with psychiatric illness is common
practice.
These changes go beyond our specialty to influence the
physician/patient relationship. The interested reader might turn to Emanuel
and Dubler [1995] who note: “The expansion of managed care and the
imposition of significant cost control have the potential to undermine all
aspects of the ideal physician/patient relationship. Choice could be restricted
by employers and by managed care selection of physicians; poor quality
indicators could undermine assessments of competence; production
requirements could eliminate time necessity for communications; changing
from one to another managed care plan to secure the lowest cost could produce
significant disruption in continuity of care; and use of salary schemes that
reward physicians for not using medical services could increase conflict of
interest.”
The impact on clinical practice and the educational milieu is alarming.
Traditional models are disappearing in the teaching and learning of
psychotherapy. An unprecedented attack on psychotherapy, despite the
consumer’s statement that it helps, has led managed care advocates to petition
Curriculum Committees for time in the training schedule so learners can be
properly initiated into the new models. Apart from the reality of a decreasing
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number of training programs, the prevailing approaches to treatment are
medication for severe disorder and brief counseling for crisis. Unfortunately
this model merges with the whole field of disorder leaving inappropriate care
and under-treatment the depleted remainder of the usual and expected
standard of care in most sectors of society.
Recently another unacceptable clinical practice within managed care
came to my attention. Selected patients in a specific program, while in hospital
treatment, received a letter stating their insurance plan and their attending
physician had reviewed the services being provided in hospital and determined
further inpatient care was not needed. This letter was sent without review or
comment by the attending physician and signed by a “Medical Director” no
longer in that position. This is another intolerable action, by persons unknown
within the administrative structure, who take action interfering with care,
adding a threat of discontinuing care frightening the patient. Of course the
patient can appeal the decision legally through a complicated process, but in
the meantime, continues hospital services at personal expense or leaves the
hospital before receiving appropriate continuing care. The physician and
patient should be able to determine what is best for the patient.
Such abuses are quite familiar to the practicing psychotherapist,
devastated by the cuts in clinical services to the mentally ill. Management
determinations reducing necessary care will not be sustainable for much
longer. In the meantime, the psychotherapist remains focused on therapeutic
connections and therapeutic goals that help the patient through this difficult
era in healthcare delivery. How long can this erosion of professional identity
continue without leaving the practitioner depleted and vulnerable to
professional (burnout) stress syndrome? Though my crystal ball is as difficult
to read as yours, the reversal of this depleting process is closer than we realize.
The patient-focused inquiry will require your attention and will oblige a new
and innovative approach to comprehensive care. Study of your clinical
effectiveness will sustain you and continue to strengthen your working alliance
with the distressed and disordered patients seeking your professional care.
Consumers will require change and government will develop initiatives to
restore humane care.
TOWARD YOUR CONTINUING EFFORT
Consecutive generations of therapists have been fascinated by the gains
of our patients. In 1934 James Strachey published a classic paper on “The
Nature of the Therapeutic Action of Psychoanalysis” expressing concern about
the dearth of literature on “the mechanisms by which its therapeutic efforts are
achieved” and “remarkable hesitation in applying these findings in any great
detail to the therapeutic process itself.” The Fourth Edition of the Handbook of
Psychotherapy and Behavior Change, edited by Allen E. Bergin and Sol L.
Garfield (1994) and the 1995 publication of Research In Psychoanalysis:
Process, Development, Outcome edited by Shapiro and Emde summarize
research findings and emerging questions over the decades since Strachey’s
comments. Recent clinical research efforts continue painstaking work yet fail
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to capture the essence of the treatment experience that any psychotherapist, as
a patient in analysis, “knows” has added to their life. As the King of Siam
addressing Anna in The King and I says, “It’s a puzzlement.”
The complexity of designing controlled research protocols in
psychoanalytic psychotherapy remains one of the “puzzlement” factors.
Research efforts documenting the efficacy and cost effectiveness of
psychotherapy are appearing. The clinician’s study and research begins with a
single case. Experienced therapists seem to have learned “things that work”
yet do not discuss their strategies openly. How does the learner gain and add
inquiry to the “puzzlement”?
Strachey (1934) states the analyst “offers himself to his patient as an
object and hopes to be introjected by him as a super-ego... introjected,
however, not at a single gulp and as an archaic object, whether bad or good,
but little by little and as a real person.” Thomä and Kächele (1987) describe
this process as “symbolic internalization.” Often on entry to therapy the “one
gulp” approach seems to operate. The desperate patient says, “Just tell me
what to do Doc.” Though resisting the invitation to take over, the therapist
may offer comment, advice and suggestions that pull the patient back into the
therapeutic focus. A question from an objective outsider, reflecting on what
has been said, can have a powerful impact on the patient. Discussion,
sometimes confessional in nature purging the system, powers a reawakening of
the individual’s conscience structure and alignment with the therapist has a
quality of shoring up super-ego functions.
With Anna Freud’s 1936 publication of The Ego and the Mechanisms of
Defense and Hartmann’s 1939 publication of Ego Psychology and the Problem
of Adaptation the field opened for theoretical advances later known as ego
developmental psychology. This field of study has developed quickly. We now
understand the real interaction between therapist and patient involves a
sophisticated integration process at all levels of the patient’s functioning. As
each new theoretical advance is integrated into our therapeutic approaches,
the dynamic forces of the therapeutic encounter grow more impressive.
One of the recent additions to our understanding involves the
intersubjective perspective developed by Robert D. Stolorow and George E.
Atwood. See Orange, Donna M. George E. Atwood and Robert D. Stolorow
(1997) for their work on the context of the therapeutic connection. The
flexibility and openness to change, that the dynamic interaction with the
patient teaches, applies to our own developing professional identity.
Continuing inquiry is at the core of the dynamic psychotherapist and
rules out a rigid adherence to one theoretical position to fit all patients and
clinical encounters. The century ahead will have a faster pace of development
in theory and practice of psychotherapeutic approaches to human behavior.
The integration of new biological findings, especially the unfolding studies of
the brain and genetics, requires an ability to add to our humane and
comprehensive approach to clinical practice and research. The patient-focused
inquiry remains in place amidst our scientific advances.
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The patient’s degree of structuralization with the accompanying needs,
requirements and wishes will be the major determinate of how much is
absorbed and integrated in treatment efforts. There are (and will be) limits to
what the ‘good enough’ therapist can do, limits generally determined by the
developmental level of the patient. The capacity of the patient to extract from
the therapeutic interaction will be a major variable in determining outcome.
The patient has to be able to use the treatment situation to assist their
development. In turn, the therapist has to ensure that he or she does not
intrude on that important work by the patient. In 1919 Freud pays homage to
the patient’s ego fusing “into one all the instinctual trends which had been split
off and barred away from it. The psycho-synthesis is thus achieved during
analytic treatment without our intervention, automatically and inevitably.”
By extending ourselves we help the patient to do their own healing, to
resume their own development. We try not to interrupt a natural activity once
the patient has understood the resistances. Paralyzing disorganization is
handled step-by-step. Anxiety and depression are used as an adjunct for
development, providing a psychological “barometer” of the internal environment
suggesting more work is necessary. When the conditions for further growth
and development are established we have to step back and allow the patient to
handle their own treatment.
Attunement emerges as a key factor in the interaction. The patient must
reveal issues and the therapist must hear, see and feel those issues of the
patient, if there is to be a shared experience. Like the affective attunement of a
good enough mother linking with the infant and child, the therapist’s ability to
participate in the world of the patient allows the patient to sense he or she is
heard, perceived as a real person, confirming there is validity to what they have
experienced. This requires an availability of the therapist. We feel good after a
session when this kind of attunement occurs. We question why it does not
occur at other points.
To be attuned, the therapist must work to leave bias, preconception and
intellectual knowledge behind, to inquire rather than judge in the
communication of the patient’s raw material. We balance our affective
attunement and intellectual skills to help the patient see things in a different
way; to ask questions when we do not know the answers; and to maintain the
“holding environment” while the patient is reframing experiences and
redirecting their energies.
In the patient-focused interaction, communication becomes the
important vehicle for therapeutic change. As the neutral outsider, becoming
the stimulus for the therapeutic interaction, the therapist becomes a new
object for the patient, a consistent and predictable object. The reliable, steady
and real qualities of the patient-therapist encounter allow the patient to shape
what is needed for further growth and development.
Perhaps the most important value of our “school of thought” is the
potential for improved communications. Jerome Frank (1973), quoted in
Strupp and Binder (1984) states:
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“While the contents of schemes and the procedures differ among
therapies, they have common morale-building functions. They combat
the patient’s demoralization by providing an explanation, acceptable to
both patient and therapist, for hitherto inexplicable feelings and
behaviors. This process serves to remove the mystery from the patient’s
suffering and eventually to supplant it with hope.”
One critical element of a professional approach to the distressed
patient is staying in focus. The problem definition in our developing
understanding of the patient’s patterns allows us to maintain a central
focus, to bring together diverse productions of the patient and link the
here-and-now with the past then-and-there experience of the patient.
The therapeutic interaction is the meeting place for all parts of the self,
with the therapist attentive to helping the patient clarify their direction.
“How does this apply to getting you where you want to go?” can be a
question returning the patient to the therapeutic focus.
As the therapist stabilizes and supports the patient, we assist movement
toward a flexible, moderate and tolerant position on matters. Rather than the
black and white, all or none style that characterizes many distressed patients,
the therapist listens respectfully and raises questions that suggest
compromise, negotiation and middle ground on life choice during transitions,
decisions in line with internal values and goals. In the process therapists hear
of almost unendurable sadness our patients can experience. We marvel at the
resiliency left after major trauma. Greenacre (1975) says: “It is the relation
between analyst and analysand that makes the nearly absolute truth tolerable
and in some ways acts as a catalyst for healing to take place.”
Since Freud’s early writings we have known the forces of resistance and
the enactments of transference-countertransference must be understood by the
patient and therapist. Interpretation has been the defining characteristic of
psychoanalysis for decades. We learn to understand interpretation leading to
insight is not always enough to produce change however. Pulver (1992), an
advocate of insight being “crucial to psychoanalytic change” notes: “The search
for a single mechanism of psychic change is doomed to frustration.” Insight
without changed behavior has heuristic value but will not be enough to sustain
a therapeutic relationship. The therapist’s understanding of the patient, no
matter how brilliant the insights may be, does not create change if not
integrated into new strategies put in play by the patient. Schwaber reminds us
of the discovery process, inviting the patient to seek answers rather than giving
outside directives. “Interpretation is a shared act” (Schwaber, 1990b). The
therapeutic focus shared by patient and therapist is woven into the fabric of
change.
BEYOND THE CONSULTATION ROOM
One of my valued learning experiences was in 1966 at the Medical Center
of the University of Illinois in Chicago with a group of twelve international
educators studying research in medical education. The first book I read in the
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program was Self-Renewal: The Individual And The Innovative Society by John
Gardner. My clinical experiences in psychiatric training at the Institute of
Living in Hartford, Connecticut and my developing vision of educational
innovations merged as I read, “The ultimate goal of the educational system is to
shift to the individual the burden of pursuing his own education.” Though I
had known the burden first-hand, there was a sudden insight about this
burden at the core of self-development, the stimulation of inquiry fueling
growth and development and what is called scholarship in later years.
When my work shifted in 1967 to the new medical school in New Mexico,
the people, setting and challenges in the “Land of Enchantment” became the
fabric of life, a merger, fit, and commitment. Over the past 47 years, working
within our culturally diverse communities, my clinical and social concerns lead
me to new strategies on broad societal challenges.
When socioeconomic factors, instability of the family, geographic moves,
migration, competition with older and stronger siblings, the inability of a
parent to provide psychological closeness, sickness and social withdrawal
create a gap in early growth and development, children can arrive at the prekindergarten level already scarred by deprivation though still hungry for the
experience of a loving and available teacher. The interaction with a responsive
adult can revive a child’s instinctual drive to reach out and interact, to get
what is needed, to gain strength and gratify instinctual needs. Memories of a
warm and loving teacher or mentor remain with us for a lifetime.
And when continuing difficulties rule out positive corrective experiences,
childhood loss and gaps in self-development leave an imprint on each
successive day. The burden of pursuing education may seem out of reach.
By working with colleagues in different fields, integrating the shared
experiences and resources of concerned individuals and organizations in New
Mexico, I see opportunity to change our situation. I need to join the thousands
of concerned citizens and hundreds of organizations working for a better place
for our vulnerable individuals, families and neighborhoods. I intend to focus
on individualized attention for children within vulnerable populations,
energizing youth, and renewing the community-based supports to sustain
change. My commitments include:



develop a one –to-one mentoring and tutoring program available to
every child at risk in New Mexico
fuel the community reinvestment of bright and inspiring college
student mentors as our future leaders
and integrate fragmented community efforts into a shared
responsibility for the New Mexico educational experience crucial to
improved quality of life for all.
The current report of the Annie Casey Foundation presenting state by
state evidence combining education, employment, income, health, poverty and
youth risk factors placed New Mexico in 49th place in 2012, and in 2013 we
have moved to 50th place. There is only one direction to go now.
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If we do not grow creativity, resilience and trust, fuel confidence and
scholarship, the failing individual and family may not be able to identify or
express the need for help, despair giving way to social withdrawal and lost
opportunity for renewal of positive life force. When unrecognized or not
reversed, the path to failure becomes a pattern of negative adjustment. A prior
option for those below proficiency used to be “well at least there’s the army.”
No longer! The American military reports 75% of applicants cannot enlist
because they have not graduated high school, have criminal records or are
physically unfit.
Costs of social disruption in the classroom, the increasing budget for
youth in the criminal justice system, the lowered income of the individual
failing in the system and the loss of vital and creative people in society seem
incalculable. Though the future of America rides on present and successive
generations of our children, we continue to lose ground with an erosion of
values and fragmented thrusts to fix the educational system.
WHEN YOU RETURN TO WORK
Clinical experience and professional development form a fabric of change
for the continually evolving psychotherapist. You cannot be a spiritualist who
never gets lost because you do not know where you going. Being grounded is
at the core of your developing professional competencies. And it starts with
your theoretical positions, routines and competencies.
Best wishes to you.
Respectfully,
John R. Graham, MD
abqparadox@comcast.net
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