PsychotherapyMost Family Physicians have neither the time nor the inclination to become involved in Psychotherapy. For those who do, either on a regular or intermittent basis, it can be a very rewarding experience. Dr. Michael Paré is a family physician who limits his practice to Psychotherapy. The following are some of his reflections on the subject, and as such represent Level 5 Evidence. - Editor Psychotherapy is at heart a mysterious process. Although Psychotherapy is informed by science, by expert opinion, by tradition, by professional regulation, by social sanction and more recently - perhaps unfortunately - by economic constraint and control, Psychotherapy is at base and at heart a phenomenon and a practice that is both ancient and ultimately mysterious. The practice of psychotherapy or a similar type of intimate healing human relationship is as ancient as civilization. Psychotherapy can be traced back - at least in a modified form - to shamanism in ancient civilizations (Torrey, 1986). Although there are differences between the practice of shamanism and psychotherapy there are many similarities. The key similarity is that both relationships (shamanism and psychotherapy) are based on a healing relationship between a culturally sanctioned healer and a client (or patient*). One of the difficulties of talking about psychotherapy and giving an overview of how - to put it in rather raw terms - "psychotherapy is done" is that it is such a huge, multifaceted field. It has a very rich (read: conflicted, complex and self-contradictory) history and the entire field of psychotherapy (and my own practice of it) is continually evolving even today. Therefore to write about the field of psychotherapy and how it is done in a short paper is a very difficult task. It is necessary and inevitable that gross simplifications must be made and many of the more elusive elements of psychotherapy will leave un-mentioned. Another difficulty of describing psychotherapy is the problem of finding the right words to do so. Again psychotherapy is (in part) a very immediate experience of emotions and cognition's and connections between psychotherapist and the patient and many of these are - of necessity - brief, elusive, and subjective to some extent. The processes and elements that constitute psychotherapy defy clear-cut analysis, control, and categorization and are in essence fleeting and are difficult to pin down in any clear-cut systematic way. It is partly this reason that science and research although contributing substantially to the progress of psychotherapy can never entirely encroach on the actual practice of psychotherapy, which could never be a science - but must be an art. Even the word "Art" may not be the right word and there may not be a right word to describe the essence of psychotherapy. Put differently the right word may simply be: "psychotherapy". Other words that could be used to clarify what therapy is (but again do not describe the full flavour of the phenomenon of psychotherapy) are "craft" and "calling" and "vocation". Alternatively psychotherapy could be described as "healing relationship: between patient and therapist. In medical psychotherapy it may be best to clarify that it is a basic medical method of emotional healing for medically defined (and diagnosed) mental (or emotional) problems or disorders. If providing psychotherapy simply becomes a "job" or "task", then it has certainly lost an essential defining element and will probably not be effective and perhaps should be given up. It has been said that the first requirement of psychotherapy is to make it a safe place; a place safe enough for a human relationship(s) to take place. Leston Havens (1989), in his special way of explaining things about therapy, says the first requirement is that the parties involved should not frighten each other away. The group needs to be safe enough for the patients to feel that they can open up and self disclose vulnerable aspects of themselves. They need time to expose their vulnerability slowly but progressively in a place where they will not be excessively criticized, judged, categorized, pathologicalized, observed as specimens, or seen "objectively" as simply cases of pathological human misery (or cases of, for example, pathological "anxiety", of "deranged personality", etc). Nevertheless although it is a caring, supportive human relationship that is at the core of the psychotherapy process is not a simple relationship by any measure - as if any human relationship is simple! The relationship in psychotherapy is an unusual, ambiguous, and limited relationship in many ways. It has been said by Hans Strupp that the psychotherapeutic relationship: "is a highly personal relationship within a highly impersonal framework". The prevailing view of the majority of therapists now is that the therapists' chief role within the therapist-patient relationship must be to be foremost a human being who is in relation to a fellow human being in a relationship designed to help the patient. Aspects of other social roles that the therapist may have may contribute to their ability to provide therapy - such as being a scientist, or being a researcher, or a professional, and a psychological theorist as well as being a teacher, or "coach", or a "confessor". These roles and attitudes need to be held in abeyance to some extent and not allowed to interfere excessively with a warm, genuine, and real fellow human being who is in connection with the patient. This has been called an "I-thou" connection by Martin Buber. Buber maintained that when the therapist truly, genuinely connects with "the other" in therapy with an "I-thou" relationship, rather than a less personal: "I-you" relationship (or an even worse the impersonal: an "I-it" relationship), that something very special occurs. When the therapist relates to the patient as a person. The patient is sometimes profoundly changed by this real connection. The patient experiences new aspects of themselves and starts to open up to themselves more and therefore also to other people more. This experience of benign intimacy is carried out of the therapy experience into the wider interpersonal world of the patient. Some forms of therapy, i.e. behavioural therapy, emanate directly from psychological theory and have at times considered themselves as an offshoot of science. This was also true of psychoanalytic psychotherapy originally. Freud originally defined psychoanalytic psychotherapy as the "objective" study of the human mind. He even compared it favourably to surgery. It has progressively been made more clear by several waves of practitioners and theorists in psychotherapy that a simplistic objective stance in regard to the patient is not a viable attitude for therapy to proceed. There is a necessary subjective element to all therapy, which is central to the process. In order for the therapist to connect sufficiently in an empathic way the therapist must subjectively resonate with feelings and moods and responses that are - in part - provoked by the patient's self-disclosure and - in part - by the therapist's own ability to experience similar types of emotions related to their own emotional life. Therefore surgery is a very poor analogy for psychotherapy - in that - in surgery the patient is unconscious and the chief active participant (the surgeon) is overwhelmingly objective and rather emotional uninvolved with the patient as a person. In addition the analogy is also inappropriate since in surgery - at least once the cutting has begun - the physician has all the power. In therapy both the patient and the therapist share power. It is a complex situation with the therapist having more control and power over the frame of therapy (i.e. when, how, who) while the patient has more control and power over the content and direction of therapy (i.e. the material discussed). A reasonable analogy would be the therapist as a taxi driver (in control of the vehicle and to some extra the detailed navigation), while the patient is the patron (directing the driver to their ultimate destination). In psychotherapy the hope and goal is that the therapist can view the patient (and visa-versa: that the patient can view the therapist) with a subjective stance at times and an objective stance at other times. It is optimal that the therapist (and the patient) be able to at times to a switch out of potentially excessively subjective stance of identification. This ability to switch out of the subjective will help the patient (or visa-versa the therapist) see things objectively enough so as to help themselves distance themselves and not to over identify with this stress, pain, and problems of the patient (or the limitations of the therapist). One characteristic of an effective therapist is the ability to move in and out of both a subjective and an objective stance in regard to the patient and help the patient at times with their tendency to become stuck in their excessively subjective or objective stances. Nevertheless this is only possible because of their ability to subjectively merge to some extent with the patient at other times in therapy. Jerome Frank (1973) and Carol Rogers said there are a few key attitudinal requirements of a benign and competent therapist. The therapist's attitude should be consistently reflecting an interested respect and a desire to be benevolent and caring towards the patient. The therapist must suspend their moral judgment and be genuinely accepting and tolerant of a wide range of thoughts, feelings, and behaviours. They need a genuine concern and commitment to help another person within the confines and limitations of their role as the patient's therapist. Another of the paradoxes of therapy is that the most powerful aspect of the therapeutic relationship may be the therapistŐs relative inactivity by just sitting and being with the patients. This inactivity has to be a positive, benevolent, accepting inactivity as Winnicott has recommended to mothers as a way to be with their children. Winnicott suggested that mothers (and fathers is a lesser extent) let their young child be alone with them. To be alone with them is not to for either person to be really alone. The child will feel the hovering presence of the parent and will occasionally look up briefly for a visional connection. The child will often also physically approach the parent - as if for emotional fuel delivered with a simply touch and then will be off again exploring, learning and experiencing. Parents and by extension therapists are "good enough" if they don't intrude too much on the child's (or the patients) emerging selfhood. In psychotherapy it is necessary to balance this quiet non-naive acceptance with at least some diagnosis, feedback, analysis, and intervention but it is likely that a balance that is geared more towards a rather quiet, empathic, sympathetic acceptance is the more effective method in therapy. Put another way - an over abundance of analysis, of objectivity, of explanation, of theory, of diagnosis, of specific interventions will spoil the quiet, gentle, humanistic connection between the therapist and the patient that makes psychotherapy - in its still mysterious way - a powerful therapeutic endeavour. Thanks to Dr. Aruna Gottamukkala, Staff Psychiatrist at St. Martha's Regional Hospital in Antigonish, Nova Scotia for reviewing the draft copy of this article. References:
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