The standardized techniques with their operational manuals are getting more and more popular in this age of cost saving. But at what cost? First these simply started as research protocols, but now they have dramatically moved into the mainstream of general clinical operations. How can psychotherapy be practiced by a manual and reduced to explicit formulations? Louis Fierman expressed great doubts about such reductionism: “We could never describe or formulate one single sentence as the therapeutically desirable response of the therapist to a given behavior of a given patient because no formulation can guarantee that when the therapist makes this response under given circumstances to the given patient, that it would be therapeutically spontaneous and genuine expression of the therapist’s mind.” Communication between patient and therapist is never linear, as J. Lacan emphasizes ― it is cumulatively spiral, mediated by both directions. If there are manualizable aspects of the psychotherapy, they cannot be at the level of interpersonal relationships.
The therapist’s actual interactions and verbalizations vis-à-vis any patient are really a series of improvisations. It is the quality and spontaneity of these creative interventions that differentiate clinicians from one another. The issue of improvisation reminds me of a call I received from a colleague. He said that he has been treating a middle-aged man who recently complained of mild but recurrent chest pain. Inquiry into his current life circumstances revealed that the patient’s business partner was trying to ease him out and take over. To make matters worse, the partner was also having an affair with the patient’s wife. Yet the patient could not acknowledge emotional reactions to either home and work situations, or actively deal with the stress that he was under. As might be expected, he was totally unable to make a connection between these distressing events and what was physically happening to him. In fact, he was indignant that his medical doctors could not find anything physiologically wrong.
Under the circumstances, it was not too surprising that the referring therapist found the patient to be uncooperative and unreceptive to treatment. The patient denied to the therapist having any psychological problems, was unable to express or verbalize his feelings, and showed a complete lack of ability and motivation for self-examination. He revealed only an impoverished use of language, could not free associate, had no fantasy life, and insisted that he didn’t dream. If he had had any dreams, he could not remember them, even if he tried. In consultation with the psychotherapist, and for a few sessions that followed, the patient had been aloof, detached, testy, irritable, demanding, and contentious.
What was the upshot of these unsatisfactory sessions? The therapist said he would like to refer this patient to me! And when I asked, “Why me?” he replied that he could not get Otto Kernberg on the phone!! I made an appointment to see the man. He was worse than I expected; the only thing he was concerned with was whether it would be difficult to find a taxi in my neighborhood.
What could I do with such a person? To my own surprise, I found myself asking whether he could tell me a joke. It is the first time I have ever done this (I guess, out of desperation). In immediate reply, he sternly informed me that he did not know any jokes, in fact that he dislikes jokes and hates joke tellers. Then he remained totally silent. Well, so much for my improvisation! However, he did show up to the following session ― with three joke books in full view. He promptly put them on my desk, and superciliously said, “If you are so interested in jokes, here they are; you can read them yourself.” When I asked whether he himself had read them, he replied that he “just glanced” at them. After some more proddings about the ones he had read, the patient proceeded to tell me the following joke:
“There was this businessman who one day lost all his money in the stock market. He came home, to where he lived on the 28th floor of an apartment building. He opened the window wide, turned around, and announced to his wife that they had lost every penny they had. The wife suddenly ran across the room and jumped out of the window. Thereupon the man calmly leaned over the ledge, looked down, and said, ‘Thank you, Paine Webber.’”
Of course, this opened up the whole area of his passive wishes for his wife’s death as well as the suppressed rage he had been trying to contain ― and much more. The point here is: How can such an interaction be anticipated and manualized? The learning process has to allow for the as-yet unknown, and even the unknowable. A manual may be useful only insofar as it is just a simple foundation, a primitive beginning (even if it were a wrong start), only to be corrected and revised, evolving step by step as a mutually learning experience. It is never static. [“We can only learn if we also always unlearn at the same time,” says M. Heidegger.]
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T. Byram Karasu, M.D. is the author of The Psychotherapist as Healer