By David Batuner
Often, when dealing with a case, we are presented with a certain way of thinking about things and conducting ourselves. Specialists in fields that are currently popular may have a certain protocol or philosophy in the way they approach a patient and try to understand a case. But oftentimes, this can lead to frustration, a dead-end in treatment, because the factors at play in the case seem to elude our particular philosophy. I have encountered just such a scenario in my time as a behavioral therapist, which ended abruptly and unsuccessfully; but perhaps there was another way to consider the case, one that might have had a better result.
When we open ourselves up to the main principles of psychoanalysis, we gain access to a trove of ideas and insights that may not have been visible previously. We can use this additional information to aid in resolving what seems like a hopeless case, or at least learn more about the case in order to aid in future cases.
The case that comes to mind involves a pre-teen and his family at home. While the initial task was to teach the child to behave and conduct daily tasks, which were hindered by developmental abilities, one of the biggest obstacles I encountered was a dynamic within the family that seemed to enable the patient’s tantrums, rage and violent outbursts. One of the principles of modern psychoanalytic treatment is to treat not just the patient, but their family as though they are your patients. Without this, I found, I was thwarted in any efforts to interact with the child in the prescribed way by either the parents or siblings intruding and enacting familiar patterns of dysfunction. This is not to say that the patient’s behavior was the fault of the parents, but it was obvious that the values and priorities of parent and child were poorly matched, they would often clash and get angry at each other; the child would then react with extreme rage and violence and any productive part of the session would come to an end.
While we treat the parents and siblings as colleagues or partners in a case, it is helpful also to remember that they have their own sets of issues that we need to understand. In any family, it stands to reason that there are many strong emotions and dynamics that have been established long before the therapist has arrived; to then treat the parent or sibling as an impartial party means that one fails to perceive and act on these dynamics. That principle would have been particularly useful in this case, since whenever I would explain why talking to the child in a certain way would have a negative effect, the parent would view this as a personal attack. In psychoanalysis, this fact would not be surprising at all. People often cannot handle a direct ego-oriented statement or question. They will see it as a direct assault and put up resistance: anger in words or in actions. In fact, the parent would agree with my suggestions in person and then complain in writing that I was condescending, though I made my statements in accordance with procedure and made every attempt to be as gentle with them as I could. Psychoanalysis would have provided a different route: a more gradual indirect approach that takes into account this resistance and the transference of emotions.
Transference could serve to explain this impasse. It would be quite beneficial to be aware of the fact that a patient or a parent transfers their emotions onto the therapist, the figure that is providing treatment and therefore serving as either a frustrating figure or one that they want to please or prove themselves to. Knowing this, it would not come as a surprise that the parents negative feelings would be attributed to me. Moreover, a pattern emerged where the parent would be very pleased when I would join their frustration at the situation and agree that the situation was bad, and become irate when I would suggest something that seemed to them to invalidate their view of things. In a way, I was performing the procedure in psychoanalysis known as joining, mirroring and reflecting; but being unaware of this, I was of course doing this haphazardly and unsystematically, creating a rift rather than building a productive patient-therapist relationship. Learning the process of joining with the patient’s feelings, then mirroring these feelings as a separate entity, then reflecting feelings in order to shift the patient’s emotional state takes sensitivity, awareness and experience, but it is essential if one hopes to grapple with the often fragile egos that often accompany a difficult case. In dealing with these subconscious elements of a person’s psyche, actions and words that could seem random or erratic gain a new significance.
All of this helps to achieve the goal of any therapy: to go from unproductive or unacceptable action or aggressive action-talk, to more open and productive communication of feelings and desires, opening up the path to a resolution that is good for both the patient and the people in their lives. In this case, this goal was not achieved, because if one is unaware of these principles and factors, it is impossible to act accordingly. There was clearly a lot more going on behind the scenes between patient, sibling and parent than the stated problem of the child’s outbursts and learning difficulties. Simply focusing on the child and their behavior does not allow for a more complete view of the situation, so it is unsurprising that the case was terminated without a positive outcome.
So while psychoanalysis as a practice might wax and wane in favor in certain parts of the world in different eras, it provides insight and information that would otherwise not be there, and with that understanding, a chance for different outcomes.
David Batuner graduated from Boston University and worked as a Behavioral Therapist. He is now enrolled in the mental health counseling program at BGSP.