יום רביעי, 27 ביוני 2012

Client Relational Psychotherapy

Yesterday, interviewing for a possible internship, I had to excuse my zeal for results in psychotherapy. I did so apologetically,  and later I  discovered it was also unnecessary, as the interviewer just wanted to see that I am on the normal side of things. But here is  my apology as I phrased it:

First I explained the personal motives I have for pursuing such materialistically reductive method. I said that when I was a youth instructor , working with at-risk teenagers, I was very frustrated at team meetings. We would discuss a case, come to some psychodynamic insight about the teenager in question, and then ask what to do about what we understand. For example, if one of the girls woke up late for school, we would probably understand it either as fear of facing  a threatening world, or as enjoyment of a feeling of safety with the staff.   Both ways of understanding the behavior in by the emotions and perceptions behind it, would lead us to the following question: so what to do about it? Obviously one could go both ways in the first way of understanding the behavior - the staff could promote exposure to threats, demanding the teenager to cope with challenges,  enforcing the rules in order to promote a sense of  achievement over  avoidance.  The other way to react educationally was to talk about feelings, understand the threat in getting up for school, by that forgiving  punishment, helping the teenager untangle its defences  and providing support, facilitation, and mediating the challenge, to promote a feeling of safety and acceptance as the basis of future coping.
The other way of understanding the behavior, as a sense of safety with the staff, also leads to the same question - do we challenge safety or do we facilitate it?

The problem with these question is not that they are not solvable, they are very solvable. But it seems they are transparent in the psychodynamic discussion.  Anyone who ever discussed a case among colleagues knows that there are many approaches. Should we love the patient, or should we frustrate him? When to be Kohutian , when Lacanian?   Well in the team meetings I described these questions would be solved by staff policy (all girls must go to school or be punished) , the personal  taste of the director (Behaviorism) , and technical circumstances ( punishment bank is not yet depleted) .

Well one day I will write a post about abuse of therapeutic power, regarding that very institution,  but the point is, that these are peripheral considerations.  They have to do with  who's in charge, what are the resources and a lot of other factors that are not specific to the patient. The dynamic interpretation of the behavior is specific, although only hypothized. But it does not give a specific intervention for the patient.

My idea  was that the intervention should be adapted to the ego  strength of the teenager in question. As Winnicott puts it, when explaining the need for holding, "challange strengthens the strong ego, and weakens  the weak ego". And so I thought that one should evaluate the teenager's ego  strength , and facilitate/challenge by this rule. I think this is a key to comparative psychotherapy interventions and should be a leading factor in determining which intervention when and for whom.

However, the problem is that to offer my solution I should have been in power to call the shots. It would have been my personal Winnicottian taste.   Maybe I would have been right, maybe I would have been wrong,  who knows? As I would prefer to avoid abuse than to be right, I think there should be a way to say who is right. 

If abuse is misuse of power,   for  any other means than to help the patient, then   we should be very much concerned with what helps the patient. The patient should be listened to. The experience of the patient in therapy becomes an ethical matter.  Yes, there are technical considerations, such as negative transference, where the patient better go through negative emotions toward therapy itself in order to have a corrective experience, not as bad as the damaging experience.  There are stuff the patient is no conscious of . But it is the patient that gives licence to  any negative experiences during therapy such as these.

This idea goes in line with research of the therapeutic alliance, and   the patient's early positive perception of the relationship with the therapist as a main predictor of therapy effect  in the view of the therapist and  the patient in later stages. Meaning, it is a technical consideration, not just a goal.

Research dealing with the threapeutic alliance calls the patient a client. As the relationship changes from that which a person has with a medical authority to that which is common to have with a  service provider, e.g.: "This is not what I'm paying you for, let's stop talking about my infancy and focus on my current anxiety attacks". 

Let's face it briefly and get it over with: globalization, onlinization and other stuff that made many customer services  available , replaceable and  sometimes   marginal. Many customer services now focus less  on the   stuff they do or give to the customer, and more on how they make the customer feels about it. Customer becomes user in this world, not obligating to a provider, not needing anything really, just using and enjoying.  Businesses care less about the technical back office and how stuff works, even benefits to the client are secondary, what matters is what is experienced as desirable by the  client, now user. It is an age of user experience over all. Nobody cares how it works, as long as it pleases me, touches the things that are important to my identity, makes me feel good about myself and what I do.

I drifted some.  But I nearly explained the reason for the post title. Anyway, the interviewer asked me why I focus on results. I said that results  make sure that we focus on the patient experience (thinking to myself UX).  "How does it fit with relational psycholoty, saying that we have many many ways to relate to the patient, as he has may many ways to relate to us?" I was then asked. And that is where I get to my point. 

I believe in psychodynamic understanding of people. Yes, theorists of many approaches appeal to 
me with their insights on humanity. Some are easier for me to apply on myself and others, some I should learn more about to be able to use their methods effectively. I am a pscyhodynamic fan.  Exactly  because of  the richness in the ways I could understand myself and others, I find a great need for  measuring what is needed, what is right, and what works.

I think psychoanalytics , a results based data mining approach to psychotherapy, is in the way of a client centric psychology, that deals with what is important to the patient .  Our theories better be broad and rich as ever, we should try, using them as maps for exploration. But we should also work hard on measures for therapeutic experience, on what feels better, on what helps, improves.

With more and more peritherapeutic approaches emerging, such as coaching, mindfulness, yogatherapy and what not, psychologist become the philosophers and methodologists of psychotherapy . It is their job to understand the mind, to understand well being. To define goals for any  experimental approach. 

Talking therapy would have its tradition, its great thinkers, and an advantage in some circumstances. But it would not be the face of psychotherapy. 

Once we have established a way to measure results, we can experiment, be creative, find new metaphors, go by our fancy, and then see if it works. It doesn't matter what you do , as long as you  track results and improve your practices accordingly. A more humanistic, subjective way to go about it is necessary still, to avoid technocracy, disformations by concretization etc. Of course psychoanalytics is a tool to  be used in ethical hands.  But it is unethical not to use it.

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