The Psychotherapeutic Relationship

The therapeutic process is not only about what is intrapsychic (the content of the mind, and the unconscious); it is also an interactive, bidirectional, and co-created engagement between therapist and patient. Regardless of any particular theories one utilizes, fostering from the very outset a mutually respectful relationship with the patient is paramount. Understanding diagnoses will not be helpful if the patient does not come back. To that end, the patient must, from the beginning, implicitly understand that you are trustworthy, respectful, and caring. Sometimes it is helpful to acknowledge with open inquiry the interpersonal experience. Collusion with patients’ illusions, without inquiry, may serve to increase the patient’s anxiety, hopelessness, and self-alienation.

Hoffman (1983) and Aron (1991) recognize that, while the relationship is mutual (both make contributions and affect one another), it is also asymmetrical. Relationships, including those between therapist and patient, are constituted by mutual regulation. We affect and are affected by each other, and, when this is not the case, one or both can feel ineffectual, unrecognized, even helpless. We aspire to mutual recognition. While we want the patient to journey her or his own path, we do not aspire to foster an autonomy that threatens the patient with isolation. When we do not demand pathological accommodation, or when we offer being alone in the presence of the other, it may be the patient’s first, or a rare, experience of autonomy without risk of loss of connection.

In seeking to connect with us, patients may probe beneath our professional façade. Do not mistake striving to know the therapist as [only] hostile or as [only] resistance. Consider the wish for connection and a longing to have an authentic effect on others. Sometimes patient silence is hostile as when the patient is too furious to speak or is withholding. Sometimes an experience or memory has no words. But sometimes it reflects a wish to be accepted as one is, without having to perform or produce. It is okay to admit that you do not know what the silence is about but would like to know, and likewise, it is okay to sit in silence, intimating your willingness to wait. I remember Hermann Hesse’s Siddhartha: I can think, I can wait, I can fast. Sometimes the therapist must be so willing, too.

Aron, L. (1991). The Patient's Experience of the Analyst's Subjectivity. Psychoanal. Dial., 1:29-51
Hoffman, I.Z. (1983). The Patient as Interpreter of the Analyst's Experience. Contemp. Psychoanal., 19:389-422.