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- Category: A Study Of Psychopathology
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The family is still the very important unit of Philippine society, in spite of rumblings to the effect that its much vaunted closeness and solidarity is either slowly dissipating or was largely a myth, in the first place. Nowhere do you see family action rallied as effectively as when one member is taken ill mentally, emotionally, or physically. No matter what the motivation—whether it be from fear, fright, guilt, shame, loyalty, concern or simply a wish to be of help—family and immediate relatives are nearby. Usually the one who feels most responsible for, or obliged to, the patient, and possibly the most guilty, hovers the closest and has to be reckoned with in the management of the patient. Less frequently, a guilty-feeling relative may conspicuously stay away.
The preceding chapters in this study, exploring the psychoparhogenesis in these patients, are replete with evidence that family relationships are a rich source of emotional conflict. It is no paradox that the same family also continues to be the patient’s main source of solace in illness and strength towards recovery. Until he discovers other possible founts of strength, hopefully within himself, the security of the family is still his best bet. Even men, who are more autonomous than women and who seem to take their families for granted, often seeking their “ordo amoris” elsewhere outside the home, seek the bosom of their family when illness strikes them.
Psychoanalytic psychotherapy helps the Filipino patient discover himself or herself primarily as an individual but still within the context of the family. An American colleague of mine has repeatedly remarked that “psychoanalysis is the treatment, par excellence for adjustment of neurotic problems in developing countries.” By its emphasis on the individual and its concept of a mature person as one who is achievement-oriented, unencumbered by family obligations and dependency needs, the patient is helped to stand alone. At the present time, Filipino patients may be helped to “self-actualize” and see themselves more as individuals, yet they still must learn to reconcile their individualism with family values. Ideally, they are able to develop an inner sense of freedom so that they no longer feel oppressed by the limits set by family and society.
In this study, it happened rather frequently that one or more members of the family were present when the patient came for the first time. It may be a parent, the spouse, an older sibling, an aunt, or some other relative. The more distressed the patient, the greater is the possibility that he or she would come with a companion. When not in acute distress, a patient may come alone or still bring a relative along. A female patient may choose to come with a friend simply because she never likes being alone. A young girl in her teens may come with her parents the first time and on subsequent visits, with a housemaid upon the mother’s insistence. Most male patients come alone, except the depressed or acutely anxious ones. In such instances, the wife is likely to be near. It impresses me that several male adolescents insisted on coming alone, over parental objections. They resent being accompanied, and at most will agree to being picked up by the parents after the session. They may consent to the parents coming once or- twice, but after that, they resent parental participation. With the majority of adolescents, however, the parents participated actively in the treatment process.
A parent, spouse, sibling, or interested relative may want to be there with the patient and during the interview may wish to actively participate in data-giving. Once in a while, a patient may refuse to be interviewed alone and insist that the relative stay in the room. In both instances, the anxiety is shared between patient and family about what the doctor will do and what the verdict will be. I have found it less awkward and ultimately rewarding to go along with their wishes for a while. To insist on excluding the family member would be interpreted as coldness, rudeness or cruelty no matter how tactfully it may be done. On occasions when I have requested the relative to wait outside, the relative (usually the mother) repeated instructions to the patient, as one would to a child: “Now, you be sure to tell the doctor everything. Don’t be ashamed. Don’t be afraid.” Of course the opposite effects were often achieved.
Where the patient’s and the family’s wishes conflict and the patient makes a conscious move to assert himself or herself, I allot most of the time to the patient and later talk with the family, in the patient’s presence. As will happen occasionally, a relative will maneuver to have a minute alone with the therapist and whisper some added information.
It often happens with married women patients that sometime in the middle of therapy she will ask that her husband be seen also. The converse happens only quite seldom. The woman feels that she cannot seem to communicate effectively with her husband or else that he needs to be told (but not by her) of his role in bringing about her recovery. Moves to refer the spouse to another therapist, after initial interviews, are generally unsuccessful. Conversations with colleagues reveal similar experiences.
Why do they not wish the spouse to see another psychiatrist? The reasons given are many and varied. They have already built up their faith and confidence in the original therapist and find it difficult to trust another. Or they say they do not wish another stranger to know all about their troubles. In the few instances where they did give separate therapists a try, they could not help comparing notes, whereupon each insisted on seeing the other’s therapist. Or seeing separate doctors meant two sick people instead of one; the spouse who was not originally in treatment may interpret the suggestion as a blame for the other’s illness. He might cooperate superficially at first, but his participation soon petered out. There were many cases -where I felt separate therapy for each one of the couple would have been greatly beneficial. An attempt to arrange for separate therapy was made in each case. As a rule, resistances led to failure. They insisted on seeing the same doctor. The reason seemed to he that they thought of themselves as a unit. What frequently happened was that it failed just the same, because one was bound to think his treatment less important. Occasionally, an arrangement with separate therapists worked out well. This was a rare exception. My colleagues and I have remarked on the greater ease with which American patients accept separate therapists for husband and wife.
Also a rare exception among Filipino couples, although it does happen, is the man or woman who voluntarily seeks a separate therapist, other than the spouse’s. When this happens, there is usually a personal reason. “I don’t like your doctor. He (she) said something which I did not like.” In one case, there was evident competition about who had a better or more interesting therapist. As the patient explained it: “My wife thinks you are on my side, so she went to someone else.” Obviously, as with couples who insist on one therapist, this situation does not have one simple reason to explain the couple’s actuation.
With American patients, psychiatrists do not experience the same or even a remotely comparative kind or degree of intervention from relatives. Jurgen Ruesch (1961), who reminds the American psychiatrist not to neglect the patient’s interaction with the family, calls the latter “the silent partners in the therapeutic situation.” In the Philippine situation they are far from silent. The Filipino psychiatrist who trained in the United States and who likes to aim for the well-regulated, scheduled activity of the fifty-minute hour will not want to have the patient’s family and relatives intruding into his time, technique, and equanimity. Should he, in his compulsive approach, wish to track down all of the patient’s psychopathology to its roots, he may end up handling the whole family. On the other hand, if he rejects the family, he may be rejecting the patient as well. A recognition of the Filipino’s relationship with his family and of his needs as they clash or dovetail with theirs, requires less rigidity and more tolerance on the part of the therapist. To compound the therapist’s problem, in the face of this family network, he has to exert greater effort not to lose sight of the patient and his problems as the central focus of therapeutic concern.