Starting out, for the beginning therapist

I like to discuss with third year psychiatry residents starting their out-patient clinical year of psychotherapy what we hope do together with our patients.  We may strive to aid the patient in reconfiguring organized experience in order to free the patient enough to tolerate new ways of experiencing and understanding. Our job may be to provide a ‘good enough’ therapeutic space to allow the ineffable, the unremembered, or the as yet unformulated to come into being in the space co-created between therapist and patient. It goes without saying that we bring to the consulting room our respect for the other person and for their uniqueness as well as an analytic attitude which includes open inquiry. We guard as sacred the confidentiality of all that the patient entrusts to us. We provide a safe enough environment for the approximation toward an authentic self  by being open with the loving openness of the lover or parent who cannot wait to hear or see what comes next, open to the unknown, the unknowable, and to uncertainty.

Discussing with a patient what it is like to be in the room with the therapist and to be invited, even expected, to discuss feelings and fantasies, especially in the here and now moment, may be the first time the patient has ever experienced such deep, untruncated interest or experienced an opportunity to talk in such a way. The patient is assessing (unconsciously, non-consciously, and consciously) what may be addressed and what must be left unknown and unsaid, based, in part, upon the implied capacity of the therapist to tolerate, accept, and embrace the most untenable aspects of the patient’s (and therapist’s) self.

It is incumbent upon us to initiate negotiation between us and the patient about how we plan to work together. Some patients will come with the hope of realizing particular goals, some very specific: ‘I want to stop throwing things when I get angry’; some general: ‘I want to be happy.’ While you cannot guarantee an outcome, you can vow to attempt to explore (via attunement and open inquiry) and experience (through inevitable enactments) together what it is that troubles the patient.

Psychiatric therapists will struggle personally between their medical role as an authority and their responsibility to offer an authentic self to the experience. Both the struggle and the offering have therapeutic potential for therapist and patient alike and make for more meaningful and enriching use of the process.

I ask the psychiatry resident to consider: Do I have faith that earnest and authentic leaning to understand is salubrious in itself, even if I, as yet, fail to comprehend what is going on? Can I respect and empathize with this patient’s suffering, even if the problems include drug addiction, pedophilia, or some other behavior beyond my comprehension? How do I open myself to the sufferings of people with whom I have difficulty empathizing? Can I bear the patient telling her/his fears even when they intimate that I am untrustworthy or have failed to help the patient feel safe or more open? And we commiserate: it’s a tough job.