The therapist may decide to focus treatment either on the patient’s inner life (especially fantasies of the past) or on his outer life (especially realities of the present) and cast the treatment into a certain course. Obviously, these don’t have to be mutually exclusive. The choice depends on many variables, including both the nature of the early intrapsychic conflicts and the actual current events through which they are played out. The therapist makes this choice through inductive as well as deductive reasoning. The first aim is to find a small number of pervasive issues that appear now in relation to the therapist, but which run through his or her personal history. Next is to explain how the patient’s attempts to resolve these central conflicts have been not only maladaptive (that is, producing symptoms and character pathology), but adaptive (that is, characterizing his or her general style of pleasure, productivity, and personal relationships).
The therapist must recast these overriding issues into the therapeutic mold. If the central conflicts are oedipal in nature (i.e., originating in the triadic developmental stage), the material needs to be recast to reflect the inner life of the patient. Then the patient is helped to take a certain distance from the issue and try to reconcile his wishes, fears, and defenses as they are expressed or repressed within himself. On the other hand, if the central conflicts are preoedipal in nature (i.e., originating in the dyadic developmental stage), then the material should be recast to pertain to the external life of the patient. Here attention is directed to the interpersonal (rather than intrapsychic) role in the origins or perpetuation of the damaged or deficient patient. D. Terman warns us, however, that attributing a self-injurious attitude to the patient’s inner life ― no matter how true it may be ― only recreates the original injury.
People do not value anything except what they made themselves, says E. Semrad. That is why S. Roth advises allowing therapy to set in motion an organic and self-directing process. Calling psychotherapy “the art of wooing nature,” he proposes that it is the patient who inevitably is in charge ― despite active “wooing” on the part of the therapist. He suggests that, although the clinician is the one to oversee the treatment, comment on it, and try to influence its momentum, for the most part the patient does what he wants. He offers Kutuzov’s story in Tolstoy’s War and Peace to illustrate his point: The Russian commander-in-chief was asked how he manages so masterfully to maneuver thousands of soldiers in his army. To this he replied, “it is rather simple. I look to see in what direction the army is moving, and then I give the order to go in that direction.” As long as the patient has an embryonic sense of self, he’ll only need some clearing of the path from the therapist. This is because given the optimal circumstances, the psyche self-regulates.
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T. Byram Karasu, M.D. is the author of The Psychotherapist as Healer
