The Therapeutic Process

During the initial stages, the productivity of the patient and his over-all willingness to get involved in treatment depend on the urgency of symptoms and on his ability to trust his feelings with a stranger. Most of these Filipino patients, especially those who have reacted with surprise to the psychiatric referral, manifested sonic shyness, embarrassment, shame, fear, or distrust in the initial part of the hour and had to be reassured and helped to facilitate their verbalizations. In general, however, they are able to master their anxiety and actually enjoy the interview. This is not to say that they then proceed to jump into a discussion of their emotional problems. But they are able to handle their discomfort, becoming less guarded and more responsive. The frequent complaint of Western colleagues about Oriental patients in therapy that the patients are extremely reluctant to talk and sometimes impossible to communicate with does not seem to apply with this group of Filipino patients. Perhaps, the fact that the therapist belongs to the same nationality is a crucial factor with Filipino patients.

There are three features of the initial therapy experience which contribute significantly to a favorable response from the patient. Perhaps they are interrelated.

1. The feeling of acceptance by the therapist, usually communicated in non-verbal ways. The gesture which may simply consist of a warm or pleasant greeting, a friendly countenance, a little question of whether he is comfortable goes a long way, provided the gesture is neither studied, calculated or perfunctorily done. The stiff, rigid approach of the technician-businessman type of doctor will hardly do. Thus, the psychiatrist who during the first interview, informs the patient, without the latter’s inquiring, what his fees are, has indirectly rejected the patient by manifesting greater interest in what he can pay. Later on, the therapist will be tested in other ways by the patient so as to find out whether he is being accepted or not.

2. The permissiveness of the hour which enables him to “get things off his chest” is often something he has long been looking for. The generally repressive and suppressive climate with the family, relatives, friends, and other people makes ventilation difficult. Of course, all psychiatrists hear each patient say, “This is the first time I have ever said this to anyone.” In this group of patients, however, subjects which are not all untoward to discuss with spouse or parent are kept to one’s self. A young man would like to change his college course but cannot tell his father; a young girl, unmarried, cannot tell her mother that she is pregnant, even if they feel quite close to each other; a married woman admits she seriously doubts her feelings for her husband; a businessman has never old his wife the heartaches and bellyaches of his work, etc. Although the patient is told to share these problems with loved ones, because “that’s what a parent (or wife or husband) is for” both patient and therapist know that this inability of the patient to share his problems is precisely why a psychiatrist came into the picture.

3. The benevolent authority image of the therapist appears to be particularly encouraging to patients. The “authority” aspect has many shades of being “parental,” but differs in that it evokes an image of one who is capable, has unusual skills, possessing a unique set of powers. In this respect one must note that in the general culture, a doctor of medicine is a figure often endowed unrealistically with much awe and great esteem, almost as if he were next to God Himself. Very often, patients continue to feel excessively grateful to their doctors. Many times have I heard the remark after the illness: “First I thank God for my recovery; next my doctor for saving my life.” The patient’s own powers and resources to return to health are hardly given credit. To many Filipinos, the two God-like people are priests and doctors. In them are embodied “the benevolent authority” with powers to heal, not hurt. More than one patient referred by a priest commented that his or her problem must be pretty serious because God’s grace did not seem to suffice. Without doubt, the childlike fantasy of being helped by magical powers contributes to the great expectations from putting oneself in this authority’s hands.

The above three features are affectively and perceptually experienced by the patient during the first sessions. With them, he is able to set the emotional tone of the relationship. With these three important elements, he can do no wrong by going ahead. Any shame or fears about going to a psychiatrist are assuaged; any misgivings about whether this figure is to be trusted or not are dispelled. The patient quickly anticipates the doctor’s fulfillment of his role. He will be kind. He will not hurt. He will respect confidences. He will be a magical giver of things.

Application, in a hard and fast fashion, of some of the basic rules in the conduct of psychoanalytic psychotherapy immediately encounters resistance because they go against the assumptions which the patient has already made about the therapist and the therapeutic process. For example, keeping a strict schedule is difficult. Filipino patients are not generally as time-bound as Americans. Quite common occurrences are patients who come late or outside of their appointment hours, or who cancel appointments without notice. -The therapist tries hard to keep a reasonably well-ordered schedule and generally succeeds, but hardly a day passes without a patient’s changing his mind.

To ask the Filipino patient to postpone major decisions until after they are discussed in therapy is practically asking for trouble. In psychoanalytic method, this is suggested and even imposed on the patient as part of treatment to avoid his acting on impulse any unconscious concealment of plans and in general to encourage reflective logical and realistic decision-making. The Filipino patient will interpret this rule differently. He will take this to mean that the therapist will now assume responsibility for making decisions. By not acting and nor discussing them, the patient relinquishes his responsibility. A young man waiting for the therapist to ask him about the opening of school, did not bring up the subject. He practically disqualified himself from enrollment because he failed to take the required entrance examinations. Another patient, a woman, who was told not to leave her husband until it would be discussed in therapy interpreted the suggestion to mean that the therapist was against it—I thought you were stalling and delayed discussing my plan because you were against it.”

The majority of patients find it difficult to conceptualize treatment without drugs. But because drugs are particularly prone to be endowed with magical value, I make a definite stand to the patient about its use. What happens many times is that the patient surreptitiously takes pills, anyway, so that it is often better to control its use or devaluate its power rather than categorically ask the patient to refrain from taking any at all.

‘The early part of the relationship is usually marked by many trivial questions sometimes by phone, to which the patient wants a quick answer. These are asked by way of extracting specific instructions from the doctor. “Should I wash my hair?” “How many cups of coffee may I take a day?” “When I go to the office, may I take one tranquilizer? How about half a tranquilizer?” “Do you think watching TV might upset me?” “Is golf all right?” These questions do not mean that the patient is now involved in an intensely dependent relationship with the therapist so that even the most trivial decision must have the latter’s blessing. This is still part of the preliminary testing period during which he wants to feel sure the doctor is simply there. Many times I have found out that both question and reply were completely meaningless. What was important was that an overture was made and a response received. What it was all about was of no importance. The patient was behaving like a patient. The doctor was expected to react like a doctor and give his expert opinion, even if the question sounded silly or the patient sounded childish in asking it. As one patient put it — “Well, no one really knows when and how this nervous illness comes. I just want to be careful.” It would be a mistake to interpret such behavior on deeper, “dynamic” levels.

Since the patient is likely to bring, during the first sessions, some interpersonal problem, or a complaint about his work or office, he will expect the therapist to take a stand, for or against his side. The therapist need not spell this out in a declarative sentence but should convey clearly in his remarks or line of questioning how he is reacting to the patient. Indeed, this is the expected stance in the culture when somebody walks up to you and voices a complaint. You do not fake a neutral stand which is likely to be interpreted as being against him. Even the equivocal Siyanga (“Is that so?”) will be interpreted one way or the other depending on the tone of voice in which it is said.

It is very important for the Filipino patient, and from what one observes, for every Filipino, as well, that he knows whether he is right or wrong. He cannot quite emphasize the there are two sides to every issue theory, especially where he is involved. He may try to adopt that kind of posture, more as an intellectual pretension, but since he tends to react more by feeling, he finds himself eventually drawn to one side or the other.

Implied in all this, of course, is the issue of blame. The patient is most anxious to know at whose door blame should be laid and he is interested in clearing himself first. In fact, he is most anxious to be told that he is in the right. Automatically, this stance puts him in the position of aggrieved party, deserving of pity and sympathy. The benevolent authority, namely the therapist, whose task is to help the patient and whose word is taken as decisive, now finds himself walking on a tightrope. The therapist is either for or against him.

The neutrality of the therapist, the cornerstone of the search for truth, which is the essence of the psychotherapeutics venture, is thus threatened quite early in the encounter. If he is a “true” Filipino, sensitive to cultural cues, and aware of expectations of his role, the therapist may discover too late that he has forfeited his neutral position without his conscious wish to do so. It will entail greater effort to retreat into a neutral position.

Obviously, the trick is to walk on this tightrope successfully without rejecting, and prematurely losing, the patient. There is actually no safer alternative than this, because no matter how truculently a patient denounces his so called antagonist, no matter how loudly he protests the situation he is in, the chances are that the true state of his mind and heart is one of ambivalence. In short, as the problem is worked through slowly and gradually, and the ambivalence is diminished or overcome, he is not only “reconciled” to take the very opposite of his originally announced goals, but he may also be quite relieved in doing so.

The therapist who early in the game identifies himself with the forces on one side of the patient’s ambivalent mind, against the other, side, finds himself out in the cold. Sometimes, even if he never committed himself in the beginning, his failure to come right out as “for” or “against” is perceived by the patient one way or the other. Examples: (1) A woman patient said she had planned to leave her husband because of his many faults. She had gone as far as packing her bags and letting her sister know she would move in with her. Aside from discussing in therapy the consequences, the pros and cons of such a move, the therapist neither pushed nor stopped her. The patient, however, perceived this as pushing her. Many developments later, including the husband’s retaliation, family intervention, etc., all of which had been anticipated and discussed, the patient gave up her original plan. She then expressed the belief that the therapist had encouraged her to move out; after all, she was not stopped from doing so. The therapist’s reiteration of her role and function (to merely clarify the situation and open the patient’s eyes to all possibilities but not to make decisions for her) just went over the patients’ head who now exclaimed, “Aha! you were testing me, then, to see how far I would go” (2) A man, much depressed, blamed his illness on his work and expressed a desire to transfer to another job. He said in no uncertain terms that his work .was responsible for all his symptoms and the mere though of going to the office caused him to have stomach cramps. As usual, the therapist pursued the task of weighing all motives, advantages of staying put, moving out, including a third alternative, postponing final decision until he felt better. After several discussions of this nature, the patient said that he has decided to go against the therapist’s suggestion and was staying put, instead. Asked how he came to think the therapist wanted him to leave, the patient replied: “Well, you asked me what other jobs I had thought about. I told you that I had thought of several others. But I never considered them as seriously as you did.”

The first weeks following the initial interviews appear to be critical in terms of the patient’s decision to involve himself further in psychotherapy. The amount of activity during this time, manifested in productiveness during interviews; calling the therapist over the phone, impromptu appointments, and in the interest and concern expressed by the family, may be deceptive. A patient may discontinue after a relatively few contacts, numbering less than eight or ten. Such a decision may be made for any number of reasons, impossible to track down and analyze unless he sees another psychiatrist to whom he may communicate the reason. Even so, not all psychiatrists in Manila are able to transmit mutual, helpful communication. From bits of information and retrospective analysis, one may speculate anything—from flight into health out of fear of going deeper into one’s mind to an actual relief of symptoms— which was all that the patient wanted. A negative ‘first impression” of the therapist, or some particular inability to feel rapport with a particular doctor is likely to cause the patient to stop much earlier, usually after the first or second session. Should he end up in another psychiatrist’s office later, the patient explains that though he on she had felt initially improved, the recurrence of symptoms must mean that the first psychiatrist had not done a good job. Sometimes, the patient returns to the same psychiatrist, in which case there is ground gained in showing the patient that no instant recovery is to be trusted. The second psychiatrist, unless he takes advantage of the situation to emphasize this point, will again be endowed by the patient with magical expectations.