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- Category: A Study Of Psychopathology
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When I was undergoing residency training in psychiatry with supervision in psychotherapy in the late 50’s in the United States, the criterion for a good therapist was that he be able to keep his patient coming for a long time. It was a testimony to one’s ability to “relate” to patients and to keep them “motivated.” The experiences of my first year of practice with Filipino patients brought puzzlement and some dismay and serious doubt about the applicability of a Western method to another culture. These reactions came ‘in the face of the observation that the majority of patients after being relieved of their acute distress were not interested in finding out more about themselves. Minor disparities in cultural styles and communication between the Filipino patient and his Western counterpart were easy enough to understand and work into the method. The massive repressive barriers which stood in the application of the method had made me and some of my colleagues ponder over the question of applicability.
Since then, a much broader understanding of the culture and an increased flexibility in the applications of the method have both been cause and consequence of modified attitudes. The body of psychoanalytic theory may be utilized with Filipino patients as a frame of reference, but the actual or direct application of the techniques derived from psychoanalysis may in many instances be neither wise nor possible.
In the United States modifications in and departures from psychoanalytic theory and technique have been started decades ago, sparked by the birth of the Neo-Freudian movements. More recently, impetus for change has arisen from the investigations of behavioral scientists of varied cultures as well as from the demands of community psychiatry, whose goals militate against a long, drawn-out laborious method, which is possible with only a few.
The book Short Term Psychotherapy (1965), edited by Lewis Wolberg, has a compilation of opinions on the subject of people with vast psychiatric and psychotherapeutic experience. They answer many questions that I and my colleagues had raised when they were first faced with modifying the application of the method. The questions have to do with methodological differences between short-term and long-term methods, role of transference in short- term treatment, use of psychotropic drugs, seeing family members, etc.
Jules H. Masserman in Short-Term Psychotherapy (1965) asks the succinct question: “Are there any special kinds of symptoms or syndromes that respond better to short-term than to long- term methods?” Dr. Masserman replies:
Briefly, the true measure of therapy is not its length, but its effectiveness, and the question is rendered even more oblate by the fact that we classify “syndromes” in large part by their supposed amenability to treatment. In effect, I treat all cases that come to me, never consider any two-word diagnoses worth even a file card, and treat everyone as effectively—and therefore, as briefly as possible.
Question: What supportive approaches are helpful in short-term therapy?
Dr. Masserman: Well, I have a couch and a chair, with a good solid floor beneath to support the patient. And I pay tent on all of them. But support that remains useful outside the office occurs when the therapist has been a bridge to a physical and social reality in which the patient can continue to live.
Question: At what point does one part ways with his patient in short-term psychotherapy?
Dr. Masserman: Exactly the same sort of point at which an internist parts with his patient or a surgeon thinks the patient is ready for discharge from the hospital: when I believe the patient is equipped sufficiently with broader understanding, restored skills and with adequate techniques to function well enough in his society so that he no longer needs my particular guidance. This may occur after one interview and may not occur after two or three years.
Paul H. Hoch (1965), in the same book, states his position. Noteworthy is his point, shared by all, that the psychiatrist using short-term therapy has to be highly skilled, to be effective in the limited time that he has.
There are skeptics in the field of psychotherapy. Some psychotherapists will tell you that practically no patient can be treated on a short- term basis. Some will say that certain types of patients can and that others cannot be managed briefly. I classify myself in the second group.
A good deal of sophistication is required for short-term therapy. The therapist must be keenly aware of what he is doing since he does not have quantities of time available for experiment. For this reason untrained people are not able to employ the method. Furthermore, a short form of treatment must be mote active than the prolonged form. For instance, it is impossible to utilize some techniques employed in orthodox psychoanalysis where the therapist remains passive and allows the patient to work on his own problems leisurely.
Sandro Rado (1965), from the same source, tackles the problem of families:
Question: Should one handle another member of the family other than the patient?
Dr. Redo: Talking to a husband, wife, parent or child, whoever is available and halfway rational, may help avoid impending breakdowns. There are many completely legitimate methods of psychotherapy that somehow are held suspect. To an extent this is due to the setting of rules of orthodox treatment. What the therapist needs is sound judgment, not knowledge of a rule book, because none exists. Freud never dreamed of making all these rules that are attributed to him. In the very beginning, when people thought that he must be a charlatan because he was only “talking” to patients, be was happy if he did not see a relative of a patient. Today, when you cannot pick up a newspaper without reference to psychoanalysis, it is inexcusable for the therapist not to get all of the outside information he can possibly accumulate. When I talk to the husband or wife of a patient, I surely know that I will get a biased picture, but I do find out many things about a patient which I can utilize in my treatment. Not to do this is in my opinion a violation of elementary medical responsibility. Fifteen or twenty years ago, I listened to a speaker who said that he who invites relatives to appear in the doctor’s office is not a psychoanalyst. This just doesn’t make sense.
Franz Alexander (1965), an early proponent of short-term psychoanalytic psychotherapy, describes what happens in effective brief psychotherapy:
In general, there are two main trends: (1) Emphasis on cognitive insight as a means of breaking up neurotic patterns. The patient understands it; he knows that it belongs to the past; he sees what he is doing. (2) The other places emphasis about the emotional experience the patient undergoes during treatment. These are, of course, not mutually exclusive principles— insight and experience, yet roost controversies center around emphasis on one or the other: Cognitive versus experimental.
The traditional belief is, however, that the longer the analysis lasts, the greater is the probability of recovery. Experienced analysis more and more came to doubt the validity of this generalization. If anything, this is the exception. Very long treatments lasting over many years do not seem to he the most successful ones. On the other hand, many so-called “transference cures” after very brief contact have been observed to be lasting. A clear correlation between duration of treatment and its results has not been established. There are no reliable criteria for the proper time of termination according to my experiences.
During treatment the patient unlearns the old patterns and lean new ones; that is, if the therapy is successful. This complex process e relearning follows the same principles as the more simple relearning process hitherto studied by experimental psychologists. It contains cognitive elements as well as learning from actual interpersonal experiences which occurs during the therapeutic interaction. These two components are intricate! interwoven. They have been described in psychoanalytic literature with the undefined, rather vague term ‘emotional insight.” This is a magic word. The word “emotional” refers to the interpersonal experiences; the word “insight’ refers to the cognitive element. The expression does not mean more that the recognition of the presence of both components.
Lewis R. Wolberg in “Short-Term Resolution of an Emotional Problem” (1965) gives the stages: (Italics by Wolberg)
A number of stages may roughly be observed in the shorter mastery of an emotional difficulty.
I. The patient becomes reassured that he is not hopeless and that there is nothing so drastically wrong with him to prevent a resolution of his suffering.
2. He develops some understanding of reasons for his emotional break-down and he becomes aware of the fact that be has had problems within himself that have sensitized him to his current upset.’
3. On the basis of his understanding, he recognized that there are things be can do about his current environmental situation, as well as about his attitudes toward people and toward himself.
4. He accepts the fact that there are and probably there always will be limitations in his environment and in himself which he may be unable to change.
5. He fulfills himself as completely as possible in spite of handicaps in his environment and in himself, at the sgme time that he promotes himself to as great degrees of maturity and responsibility as are within his potential.
Of the 419 patients, there were eighteen patients who stopped after one to five sessions. Of these5 seven were men, two adolescent boys, and nine women. Whether one can classify them as having had therapy is equivocal.
One of the men came from a cardiologist for acute anxiety and severe panic reaction. He had just been discharged from the hospital where his restlessness and agitation could not be managed. The wife, when interviewed, said that the patient had been so demanding and threatening that she was ashamed to hospitalize him again. Yet, she was afraid to bring him home because she does not have enough male help available should anything happen. I mentioned the psychiatric ward of a private general hospital where the nurses were psychiatrically trained. She accompanied him there. After less than an hour in the ward, the patient saw other patients, heavily tranquilized and obviously more sick than he was, and fell to Laughing at himself. He said he was not that sick, and went home. I received a phone call later from the wife explaining everything and remarking that he was much like his old self.
A similar incident was that of a woman who came with a depression because of the sadistic treatment she received from her husband. She was managing a small restaurant which was their principal means of livelihood after the husband had crippled a leg in an accident. He was now bedevilling her with accusations of infidelity and she was on the verge of giving up the business when she decided to come to a psychiatrist. Upon her suggestion, the husband came to be interviewed. He seemed quite disturbed indeed over her growing independence from him. I referred him to a colleague and after some time I received a phone call from the highly amused couple. The wife said that after coming from the sessions, they both suddenly felt very silly, like children who did not know how to behave, and have decided to help themselves.
The two adolescent boys after one or two sessions said they could not talk to a woman. The mother of each one called up to tell me that the boy prefers going to a priest. Whether the exploration and discussion in that short time were of any help cannot be determined.
One woman after one session went back to the referring neurologist, indignant that I had called her immature and childish. The line of questioning had most likely opened her eyes to the self- diagnosis.
Two women after about five sessions transferred to a male therapist. From information gathered, a feeling of unconscious competitiveness and threat from a female figure appeared to be a significant factor in the transfer.
One woman after two sessions of exploring and discussing her difficulties with her husband called up to say she could no longer come. She had told her husband what had transpired in the sessions despite my suggestion to the contrary. When she mentioned that her dreams had been discussed, he concluded that the therapist must be a “spiritualist” and forbade her to continue.
The rest of the eighteen were not heard from and it is difficult to speculate on whether they benefited at all from the brief contacts.
Over two-thirds of the rest of the patients stayed for short- term psychotherapy varying from two to eight months; the remaining few came for a year or more. In my opinion, two major factors favor the abbreviation of treatment: (1) Availability of external support from family and friends and (2) abundant emotional outlets.
Other factors, of varying importance in each case, may be:
1. Residence in the province, where the distance from Manila made regular visits to the city impossible.
2. A few patients travelled often out of the country; interruptions in treatment were often ill-timed.
3. As the patient improved, use of money for other things with more immediate satisfaction made further visits to psychiatrists unattractive.
Should the patient decide to persevere, there usually follows a comparative decline in his verbal activity as well as in impulses to contact the doctor. He now accustoms himself to coming at regular intervals. At this stage the beginnings of a working relationship are starting to emerge and the process begins to look like what obtains in psychoanalytic training centers in the United States. A closer scrutiny however will still reveal a few differences.
The patient who has been talking a good deal of the hour at each previous session now has difficulty summoning words. Frequently, the remark is heard from the patient: “I think I have told you everything” or “I’ve done all the talking so far. I think it’s your turn now.” It is not completely true that the therapist had been “silent” prior to this point; what happens is that whatever the therapist had been saying was not really listened to nor assimilated, The patient had been responding more in an affective way, orienting himself to the doctor, deciding whether there was mutual acceptance. This time, when he asks the therapist to have the floor, he expects some kind of a lecture, a sermon, specific advice, and concrete instructions.
In this “resistance” in the psychoanalytic sense? In a sense, it is. By definition, any psychological force in the patient which impedes his verbalization and discussion of thoughts on his mind constitutes resistance. The permissiveness which he enjoyed at the start now begins to make him feel uncomfortable. After some relief from the depression or anxiety, there may be some recurrence in a milder degree. He pressures the therapist to do something—”Perhaps you should see my wife (or husband or parent)” or “Please recommend me to another cardiologist.” This flurry of requests, like the numerous questions in the initial phase, is not to be taken for their content value. It is a form of resistance to further, deeper exploration and is a way of pressuring the therapist to pursue a different tack.
Since resistance is also ego-defense, it may do well to examine it as such. Because the permissiveness of the therapist exerts no controls over him, he now begins to try to impose them on himself. He tries to redefine his role as patient and that of the therapist as a doctor. Psychotherapy with the American patient starts with the protagonists as strangers for some time and, as the process continues, the patient begins to want to know the therapist as a person and with caution begins to express fantasies about the doctor’s personal life. These fantasies place him in a specific type of relationship with the therapist, be it son to father, wife to husband, sibling-to-sibling, etc. With the Filipino patient there is minimal curiosity about the therapist’s personal life, most of the basic data (where else he works, his civil status, children, where he lives) being usually already known to the patient. After the initial period during which the rapport has led to a feeling of acceptance and of faith and trust in the therapist, the patient takes distance not so much to orient himself in relation to the therapist, but to place the therapist within the framework and network of his (the patient’s) relationships.
He does this because there is now confusion in his mind as to just what kind of a relationship it is. A Filipino likes to describe relationship in terms of similarity to that of his childhood. Thus, in referring to their relationships, one frequently hears remarks such as: “She is like a second mother”; “He is like an older brother”; “We are just like sisters”; “She is like a daughter to me”; “She is the baby’ in our gang.” Even at work, this tendency prevails. All other relationships are treated as effectively meaningless, unless it happens to be the opposite one with negative feelings. The general feeling towards the therapist being positive, such considerations do not obtain. But since the therapist behaves like neither fish nor fowl, the patient slows down in order to allow the therapist to show his hand.
At this point, two things begin to appear in the psychotherapy, either simultaneously or in succession:
1. More obviously, transference phenomena increase, varying in course; form, and intensity from one patient to another;
2. The therapist’s assessment of the patient’s capacity for cognitive restructuring of his behavior and on this basis a decision as to whether therapy is to be mainly “a corrective emotional experience,” or directed towards deeper insight.
As a consequence of the therapist’s decision, now reflected in subsequent questioning or interpreting, the patient reacts accordingly. He may find the therapist’s line of action too challenging or too inactive and will decide to interrupt treatment; or he may find it suited to his psychological needs and stay on longer.
These two events, as well as the patient’s coming to a decision himself, take place over a period of time. As any therapist knows, each is a complicated process, influenced by many factors not only within the therapeutic relationship but by external, environmental forces as well. Notable among these factors are: (1) the basic personality structure of the patient with ability to utilize insights, (2) counter-transference phenomena, and (3) in Filipino patients, perhaps more than in their American counterpart, events or attitudes in the family.
Each of these complex processes will be discussed separately. Generalizations will even be more difficult to make, as each patient begins to show his true, unique psychological colors. At this point I will be drawing exclusively on my own experiences and some informal remarks by colleagues (since there has been no formal writing done by Filipino psychiatrists about their practice of psychotherapy).