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The psychotherapy process
requires the deliberate joining of two human beings, mainly orchestrated by
one, and requiring heartfelt collaboration by both. Breaches in the
relationship are plumbed for the information they provide, the two continually
surprised and inspired as they move to new, uncharted views about what the patient
needs and how to get there. Indeed there are rules, procedures, and boundaries,
but knowing when these guidelines contaminate the therapy's authenticity and
sap its power is one of the therapist's most subtle challenges.
Therapists constantly work to
identify how their craft differs from the commonsensical stuff of everyday
relationships. They are not supposed to hug their patients, attend their
weddings, or even have the smallest need for their patients' approval. The therapy
process is not to be corrupted by patient and therapist embracing too much of
their real relationship, as if the technical, less personal aspects of therapy
are the most authentically therapeutic.
As therapists, we do not talk
much about wanting the patient to respond to the personal influence we may
bring to bear in creating desirable change. Struggling, even suffering, in the
service of establishing and maintaining an ever more profound connection to the
human being otherwise known as "the patient," may be labeled
overinvolvement.
Yet, the pull toward connection,
uncomplicated human connection, pervades the therapy experience. Much is known
about the ways in which this therapeutic connection can be distorted internally
via transference, countertransference; projective identification, and
developmental distortions and lags. These complicating developments in therapy
represent one source of the impasses I call therapeutic disjunctions (Frankel,
2000), in this case intrapsychically generated. Gender differences, cultural
background and real life influences on mood are a few examples of the other
category of disjunctions based upon mismatches between people, deriving from their
personalities and their actual life circumstances. When any of these disjunctive
factors is at work the disconnect between therapist and patient can be
profound, without necessarily being obvious from the surface appearances both
parties maintain. Their words may be right, as if they agree on key issues, but
they may be infected by silent skepticism or tarnished by the tone in which
they are uttered. Many of our theories of technique are directed at understanding
and healing these interpersonal rifts.
Underrepresented in our theory
making, however, are the ways in which therapist and patient actively breathe
life into each other, collaboratively facilitating the other's healing when
required and encouraging ongoing personal and therapeutic development. These
creative forces are as present as the divisive ones, making therapy a
remarkably complex set of activities that encompasses multiple pulls at every moment.
In order to distinguish it from other kinds of therapeutic joinings, I call
this coming together between therapeutic partners the conjunctive process. In
this book much space will be devoted to delineating and illustrating the
driving force in therapy I call conjunctive, as well as addressing why
therapists tend to be uncomfortable about actively encouraging this kind of
connection with their patients. I use the term conjunctive sequence to refer to
a series of linked interpersonal steps involved in therapeutic unification.
Finally, at the heart of the matter, conjunctions are points of joining here
the two therapy partners clearly influence each other toward depth of
understanding, and are aware that the conditions change are being engaged.
But the actual uniting, that
which convinces the patient to comprehend in a deep way what he and the
therapist have been struggling for, is actually closer to magic than anything I
will be able to describe. This magic consists of a special conglomeration
words, intuitions, feelings, emphases, and pauses. The order which pain and
disappointment, and elation take place is all-important to the final result.
The moment at which comprehension occurs, however, is often surprising, and is
not so easily linked to the quest to find psychological meaning.
Even contemporary, relationally
informed psychodynamic therapies tend to accord the therapist prerogatives in
orchestrating and leading the therapy that give him or her an edge on knowing.
In this chapter I begin to develop a point of view that, while recognizing the
therapist's responsibility to make sure the therapy progresses, argues
forcefully for therapist and patient sharing authority and taking full
advantage of each other's wisdom. These conditions are required for the two to
move effectively toward bilateral change in the direction of the patient's
therapeutic goals, the interpersonal and therapeutic development I call conjunction.
How Equal in Influence are
Therapist and Patient?
The notion of therapeutic
symmetry pervades this book. The underlying principle is that the therapist and
patient are both human beings. They make judgments, cooperate when they feel
doing so is reasonable, and yield to each other's influence when they are convinced
that the other makes sense, deep interpersonal sense. This picture of
interpersonal symmetry does not contradict the notion that, indeed, there is an
inherent asymmetry in the therapy situation, with the therapist being
responsible for guarding its outcome. Other asymmetries are based on the wisdom
that each partner brings to the table at any point. Yet, understanding the
conjunctive driving force behind the therapy requires a focus on the sharing
and collaboration that constantly occurs between the two therapy partners.
Shifts in psychodynamic thinking
acknowledge the individual and shared subjectivity of the therapy situation, as
well as the mutative influence therapist and patient may have on each other and
provide a contemporary theoretical backdrop for establishing conjunction as a
major activity of therapy. In these views, the balance between therapist's and
patient's authority to know and lead in the therapy is shifted toward parity,
each having moments of greater knowing. My understanding is that this
reciprocity, or sharing of influence, occurs whether it is acknowledged
formally or not. The undercurrents coloring the therapy experience are always
there, with therapist and patient sending a complex array of signals to each
other, embellishing the formal work of therapy. In this picture, the therapist
is a human being, as fallible and as open to constructive influence as the
patient. This statement captures the essence of my own position, emphasizing
the equivalence of the two partners, each with his or her role in making the
therapy work, each willing to be the authority when needed, each changing
through the other's influence. Therapy is a human experience, the two people
involved willing to be interested in knowing the other as fully as is necessary
for the patient to discover and achieve
his or her most personal goals.
About Steven Frankel:
Steven Frankel M.D. is a psychiatrist.
A graduate of Yale University Medical School, he is certified by the American
Board of Psychiatry and Neurology in both general and child psychiatry as well
as by the American Psychoanalytic Association. He is an Associate Clinical
Professor at the University of California Medical School. He is the founder and
director of The Center for Collaborative Psychology and Psychiatry in
Kentfield, CA.
Dr. Frankel is a Distinguished
Fellow of the American Psychiatric Association, and has been voted to Best
Doctors in America by his peers each year since 1987. He has practiced in the
San Francisco Bay Area for over thirty years. His ideas are developed in his
many professional papers and three books, Intricate Engagements, Hidden Faults,
and his latest work: Making Psychotherapy Work: Collaborating Effectively with
Your Patient. Learn more about Dr.
Frankel and collaborative psychology in
http://www.collaborativepsychology.com/
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