The ‘Rules’ of Psychotherapy
Couch is a series about psychotherapy.
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 confidence
s 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.
Some details were altered to protect the patient’s privacy.
Robin Weiss is a psychiatrist in Baltimore.
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