Psychotherapy: the therapist’s role, was originally published in Washington DC, psychologist, Dr. Lynn Friedman’s, Johns Hopkins blog in response to the following question.
During your Johns Hopkins graduate class, Psychodynamic Psychotherapy, you talked a lot about difficult psychotherapy situations. Specifically, you focused on establishing a therapeutic frame. You described the “psychotherapy patient’s job” and the “psychotherapist’s job” in creating a therapeutic frame for effective psychodynamic psychotherapy. Can you say more?
Author’s note: These notions come from Otto Kernberg and his colleagues.

The patient’s role in getting the most out of their psychotherapy

You thought that it was the psychotherapy patient’s job to make a commitment to treatment. That is, to show up, to try to say what comes to mind without censoring and to pay the fee. Most importantly, you thought that it was the patient’s job to try to step back and think about what he or she is doing. Also, you felt that we ought to ask our psychotherapy patients to think about what we are saying to them, to think about how we are working, together, and to talk to us about it.

In fact, you talked about talking to all new psychotherapy patients about these guidelines. You noted that it was critical to make this paradigm explicit to more primitively organized patients (i.e. for example, borderlines, people with narcissistic difficulties, acting-out behavior and other character pathology) and/or to any patients who were in an intensive psychoanalytic process where they were seen several times a week – and,  where they were regressed.

You were pretty adamant in your idea that it’s the therapist’s job to strictly adhere to the frame herself.  That is, you thought that it was vital that the therapist take responsibility for her own behavior.

Psychotherapy: The therapist’s role

That is, you felt that the therapist should establish regular appointments and should adhere to the agreed upon, once, twice or thrice weekly schedule or in the case of psychoanalysis, the four or five time a week schedule. You asserted that it was crucial for the psychotherapist to show up on time, to be emotionally available and to devote his or her full energies to helping the patient to deepen his understanding of himself. Beyond this, you felt that the psychodynamic psychotherapist should be forthright about the limits of his or her role. You noted that the psychodynamic psychotherapist is NOT a friend, or a paramour or a parent. That the psychotherapist is ONLY a “doctor” who is devoted to caring for his patients.

With all patients but in particular more primitively organized ones you felt that the psychotherapist needs to be, as you put it, “a steady Betty”.

To accomplish this you felt that no matter what their level of experience, you psychotherapists should regularly avail themselves to supervision or clinical consultation, particularly if they were working in an isolated setting such as private practice. Also, you felt that all psychotherapists, but especially those interested in working with more primitively organized psychotherapy patients should seek out their own psychoanalysis.

Why? Because in order to tune into our patient’s primitive, affects (emotions), we need to be in touch with our own. And, because all people tend to ward off painful feelings, at times.

As you know, I am new to private psychotherapy practice. I am evaluating lots of prospective psychotherapy patients. I find that some of them are not able to agree to these basic ground rules.

I have in mind here patients who schedule appointments and then, “no show” without so much as a call or “heads up”, or those who cancel without any reality based reason. I find myself feeling flummoxed and frustrated by these patients. I want to be a good psychotherapist but I find myself feeling very resentful when this happens, especially since sometimes I am traveling quite a distance to the office for one patient who stands me up. Please advise, before my own primitive affects get the better of me1

Dear A Student,

You raise many good questions and I have many thoughts.

First, these ideas about the psychotherapeutic frame are good ones. However, they are not attributable to me. Rather, there is quite an extensive literature about them. To learn more, I’d encourage you to read about them. For some clear reading, check out Nancy McWilliam’s book on Case Formulation. Also, she has several books on psychotherapy and diagnosis. I recommend them all to you.

Also, I recommend Otto Kernberg’s writings. Although he can be, at times, inaccessible I’d encourage you to forge ahead because he has very interesting things to say about the psychotherapeutic frame, especially with borderline patients and/or patients who are regressed. The book that I have linked to above, co-authored by Frank Yoemans and John Clarkin is very clear.

Difficult psychotherapy situations

You asked about patients who are not willing to agree to the therapeutic frame. And, I have many thoughts about that group. To begin with – the group is not a monolithic one. And, in fact, in my opinion every psychotherapy patient spends a little time in that group from time to time (even psychotherapists in their own psychotherapy or psychoanalysis).

First, a psychotherapy patient who can not make a commitment to attend the initial sessions is going to have a difficult time getting the optimal result.

That having been said, over the years, I have successfully worked with many of these patients. Moreover, I have found that with the proper support my supervisees have worked well with them, too. The two biggest ideas that I have about this are:

First, I find with supervisees as well as more experienced psychotherapists, one must have a healthy respect for oneself and for meeting ones own needs. The psychotherapist must figure out what she needs from the patient in order to do the work. About this, we all vary and there are no right or wrong needs. Rather, it is crucial to identify what ingredients are essential to your work as a psychotherapist and what are not essential. That is, you need to create a frame that works for you – and, that doesn’t leave you feeling resentful.

I’d advise you to know your limits and to make them explicit from the outset. Here, again, there is no consensual right or wrong. Rather, there IS a right and wrong for you.

As for cancellations, I know some psychotherapists who talk with prospective patients on the phone a bit about what they are seeking. As a part of that conversation, they indicate their fee and they explain that they charge for all missed sessions. So, they assert, it’s important to find a time that works for both of us.

During that same conversation they explain that they do not work for insurance and they explain their billing procedures. Often, they provide itemized bills so that their psychotherapy patients can attempt to recover what they can from insurance.

In conveying these policies, they do lose some patients. And, once and a while someone sets up an appointment and “no shows”. However, those patients are not likely to be a good fit for those psychotherapists.

I know other psychotherapists who accept that a possible “no show” for the first appointment is a reality of private practice and they have decided to live with it. Then, during the first session they establish ground rules. This stance has the benefit of allowing them to explore the patient’s feelings about the therapeutic frame.

There are many possibilities. The key here is to identify a way of handling these situations that is (a) therapeutic – and, leads to deeper self-understanding (b) allows you to feel comfortable and non-resentful.

Second: And, this is key. Whatever your stance, it’s critical to explore what it means to the patient. That is, you want to share your approach in a way that sends the message, “this is how I work, but it’s important to me to understand your feelings about it”.

Obviously, there is much more to be said about this.

I hope this helps.

Psychotherapists seeking psychotherapy supervision or psychotherapy from Dr. Lynn Friedman are welcome to call: 301.656.9650.

 

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