Tuesday, November 12, 2013

Responding to Patients

There is no formula for what to say or when to say it. Rather, in a moment to moment appreciation of the effect our words have had on a patient, we will perpetually fumble and tweak our utterances. Attention to detail in communication will guide us as we attempt to proceed in a meaningful way. After we speak, patients may say nothing; they may quietly consider our words; they may sigh in relief or exasperation; they may weep silently; they may appear as if slapped in the face. We strive to be attuned to minute changes— in face, posture, breath, tone, prosody, and so on, as well as in narrative—for the effect we may have had. We do well to be able to admit when we have made a mistake. Often, a response from the patient with confirmatory material, or new material, means we have said something of meaning to the patient.

We ask ourselves: When do I feel compelled to speak up? Am I aware of at least some of my motivations to speak? Do they include the wish to know more, or only to correct or inform the patient? Can I apply an experience-near, emotional, and cognitive context to my remarks? Am I more or less attuned or empathically immersed in this moment? Am I involved or distracted? Is something in my own physical state or personal life having an effect on my level of attunement? Is something in my visceral or fantasy experience in the moment intimating unspoken information about the patient’s experience? What might it being trying to tell us?Does something about the patient’s demeanor, affect, voice, or the content of the material lead me to dissociate from it? What do I find so disturbing, and why? Do I want to invite the patient to help me in exploring answers to these questions?

Buirski and Haglund, from a Self psychology perspective, move us into the area of how we respond to or what we say to patients. They note interpretations that provide new cognitive knowledge when made with empathic attunement –resonating both cognitively and affectively—serve the selfobject function of promoting self cohesion through self understanding.  They go so far as to say that “for  verbal interpretations to generate meaningful cognitive and emotional understanding, they must be given within the context of a primary selfobject relationship” [italics mine]. An interpretation, constructed from the experience of both patient and analyst, is meant to help organize the patient’s experience. While their paper is about how verbal interpretation can serve as a selfobject function, they nevertheless recognize the function of procedural and perceptual communication in making meaning. Haim, while from a more traditional perspective, nonetheless asks, “When the analyst talks, is he working to regulate the patient’s tension level, or her or his own?” Haim is forthright about her uncertainties of when to respond and what to say.  She decides that “the best time to make an intervention is when the patients asks for one” [Spotnitz’s ‘contact functioning’]. Both authors seem aware of the relational and intersubjective component of experience between patient and analyst.

Buirski, P., Haglund, P. (1999). Chapter 3 The Selfobject Function of Interpretation. Progress in Self Psychology, 15:31-49.

Haim, R.J. (1990). The Timing of Interventions: A Countertransference Dilemma, when to Talk and When Not to Talk. Mod. Psychoanal., 15:79-87.

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