In Part 3 of this series, I presented, in some detail, what more or less happens during an initial consultation with a clinical psychologist. It was pointed out that typically toward the end of this consultation, certain suggestions or recommendations may be made by the psychologist regarding the patient's treatment, including possibly coming back for a course of psychotherapy. And, as we noted, sometimes the patient will choose to return, and sometimes not. There are no doubt numerous and complex factors contributing to the initial consultation becoming the only and last meeting between patient and therapist. On the patient's part, these include feeling fearful of therapy, being unable or unwilling to pay for it, or feeling too hopeless, depressed, unmotivated, distrusting or apathetic to invest fully in the process. But there can also be other reasons for not returning.
First and foremost to be considered is the possibility that something went wrong with the way the initial consultation was conducted. Perhaps the psychologist failed to adequately foster what we refer to as a "therapeutic alliance" with the patient, due to lack of empathy, excessive formality, misattunement to the person's mood or emotions, etc. Or might it have been a "bad fit" between patient and therapist? As anyone who has experienced the "dating game" knows, sometimes there is just not the right "chemistry" between two people to motivate a second date. Finding the "right" therapist is a little like dating in this way (but definitely not in other ways), and may require several initial consultations with different practitioners before finding someone with whom one feels comfortable working. Factors such as personality type, age, gender, race, experience, cultural background, theoretical and sexual orientation, professional persona, and therapeutic style can all play a part in determining whether the patient decides to enter treatment with the psychologist or not.
Timing is yet another decisive element: Is the patient really ready for the intensive introspection, self-exploration, and modification of problematic patterns of behavior required by therapy? This question brings to mind the old joke: "How many psychologists does it take to change a light bulb? Only one, but the light bulb has to really want to change!" If, for whatever reason, the patient is not prepared to proceed on this sometimes daunting and difficult journey, he or she will likely choose not to do so at this time. This reluctance can take many forms, as, for instance, in the aforementioned phenomenon known traditionally as "flight to health," wherein the patient suddenly and prematurely terminates treatment, citing a seemingly miraculous cessation or resolution of the troubling symptoms or problems for which he or she first sought consultation.
It may also be possible that, in some cases, it is the clinician, not the patient, who is unready or unwilling to proceed, due to his or her own lack of experience, anxiety, bias or other uncomfortable feelings evoked during the initial consultation. Or because the psychologist is having a "bad day," or is currently struggling with his or her own personal issues which may, sometimes synchronistically, be mirrored and stimulated by those of the patient. Psychotherapists call such feelings evoked in themselves "countertransference." Countertransference reactions can range from feelings of disgust or repulsion to feelings of sexual attraction or romantic love; from insecurity, fear and anxiety to annoyance, anger or even hatred. If any of these feelings arise in the clinician during the initial consultation, as can occasionally happen, they may prevent the relationship from moving forward, depending upon how they are (or are not) dealt with. Much the same may be said of what Sigmund Freud referred to as "transference" feelings on the part of the patient, positive or negative, which, like countertransference, can also occur during (and, to some extent, prior to) the initial consultation.
But can the so-called flight to health following (or, as in some cases, resulting in the pre-emptive cancellation of) an initial consultation ever be a real and legitimate phenomenon rather than merely a manifestation of "resistance" to treatment? I believe so. Not every person seeking a consultation with a clinical psychologist or other mental health professional necessarily needs ongoing psychotherapy. And, for some, especially in this day and age of video or telephonic consultation, it may be impossible or impractical to meet with the consultant more than once, due to geographic, financial, logistical and other limitations. In some cases, patients may feel significantly better following the first consultation, convinced that they have found or received what they were looking for, and that for them, this is sufficient. At least, for now. Clearly, this depends in part on the nature and severity of the presenting symptoms or problems, the timing of the consultation relative to outer circumstances, and the quality of interaction between patient and doctor. For some patients, the experience of being taken seriously, truly listened to, heard, acknowledged, understood, supported, encouraged, cared for, and empathically mirrored during the initial consultation can indeed be profoundly therapeutic.
Consider, for example, a case reported by Swiss psychiatrist Carl Jung, referred to him during the early days of psychoanalysis, excerpted from a book called C.G. Jung Speaking: Interviews and Encounters (1977, pp. 417-419):
....The doctor of a small town in Canton Solothurn had sent me a young patient who suffered from incurable insomnia. She was pining away from lack of sleep and narcotics. He could think of no way to help her except hypnotism or this new psychoanalysis that they were beginning to talk about.
But she came to me. She was a teacher, twenty-five years old, of a very simple family, who had successfully completed her studies, but who lived in constant fear of making a mistake, of not being worthy of her position. She had gotten into an unbearable state of spasmodic tension. Clearly, what she needed was psychic relaxation. But we did not know much about all those ideas then. There was no one in the locality where she lived who could handle her case, and she could not come to Zurich for treatment. I had to do, as best I could, whatever was possible in an hour. I tried to explain to her that relaxation was necessary, that I, for example, found relaxation by sailing on the lake, by letting myself go with the wind; that this was good for one, necessary for everybody. But I could see by her eyes that she didn’t understand. She got it intellectually, that’s as far as it went, though. Reason had no effect. Then, as I talked of sailing and of the wind, I heard the voice of my mother singing a lullaby to my little sister as she used to do when I was eight or nine, a story of a little girl in a little boat, on the Rhine, with little fishes. And I began, almost without doing it on purpose, to hum what I was telling her about the wind, the waves, the sailing, and relaxation, to the tune of the little lullaby. I hummed those sensations, and I could see that she was “enchanted.”
But the hour came to an end, and I had to send her away brusquely. I knew nothing more about her. I had forgotten her name and that of her physician. But it was a story that haunted me. Years later, at a congress, a stranger introduced himself to me as the doctor from Solothurn and reminded me of the story of the young girl. “Certainly I remember the case,” I said. “I should have liked so much to know what became of her.” “But,” he replied in surprise, “she came back cured, as you know, and I was the one who always wanted to know what you had done. Because all she could tell me was some story about sailing and wind, and I never could get her to tell me what you really did. I think she doesn’t remember. Of course, I know it’s impossible that you only hummed her a story about a boat.”
How was I to explain to him that I had simply listened to something within myself? I had been quite at sea. How was I to tell him that I had sung her a lullaby with my mother’s voice? Enchantment like that is the oldest form of medicine. But it all happened outside of my reason: it was not until later that I thought about it rationally and tried to arrive at the laws behind it. She was cured by the grace of God....
Though we might prefer to conceptualize or explain what happened during this admittedly anecdotal initial consultation by Jung in different ways, the reported outcome remains the same: the patient's symptoms, in this case chronic tension, anxiety and "incurable" insomnia apparently related to low self-esteem, insecurity, compensatory and perhaps compulsive perfectionism and, in all likelihood in my view, an underlying low-grade depression, were evidently alleviated. Medications available at that time (probably around the 1920s) had been ineffective. Yet, she apparently received something very valuable from Jung during this single yet transformative session that she desperately needed and found helpful. What was it?
First of all, it is important to note that Jung knew in advance that in this particular case, he would have only one consultation with this patient, which engendered in him (and no doubt in the patient as well) a certain sense of urgency. (This is a vital lesson for all clinicians: There is never a guarantee we will have the opportunity to see the patient beyond the initial consultation, an existential fact which, therapeutically speaking, stresses the need to always make the most of that first--and of each and every--session, never knowing whether it may be the last.) Hence, he may have conducted this initial consultation, which evidently lasted only one hour, somewhat differently than usual, meaning possibly deliberately devoting less time to history-taking, evaluation, diagnosis, etc., and placing more emphasis on therapeutic intervention. Be that as it may, while Jung here, ever the mystic, attributes the "cure" in hindsight to his having "sung her a lullaby with my mother's voice" and to "the grace of God," I suspect there was more to it, though I do not doubt these played some part.
To me, it seems more probable that something in Jung's own demeanor, presentation, style and personality got through to this patient on some deep and unconscious or irrational level, communicating a kind of comforting paternal and maternal acceptance she had always sought but perhaps never received from her own parents. Moreover, Jung spoke to her and her problem pragmatically and personally, strongly concluding and recommending during their initial consultation that more relaxation was necessary, more of just doing nothing, just being rather than being productive, aimlessly drifting with the wind and the waves (something Jung came to associate with what he called the "feminine" mode of being in the world). (See my prior post.) So he appears to have related to her primarily from this feminine or maternal part of himself (which he would later name the anima), and conveyed to her, both cognitively and, more importantly, experientially, that an appreciation of this side of existence--passivity, purposelessness, playfulness, instinctuality, musicality, poetry, beauty, emotionality, and nature--is not only acceptable, but valuable and absolutely necessary for maintaining mental health. My guess is that this liberating message was received by Jung's patient both consciously and unconsciously, and that she took it to heart, presumably allowing and integrating more relaxation, non-doing, and the pleasure of pure being into her rigidly one-sided life style. There could, of course, have been other intervening variables affecting the patient post-consultation that we can never know, as is always so. Nonetheless, her referring physician clearly drew a direct correlation between Jung's consultation with this young woman and her seemingly miraculous recovery.
This, then, can be understood as having been C.G. Jung's explicit and implicit clinical (and psycho-educational) prescription to the sleepless patient who, following the initial consultation and presumably some consideration and assimilation, apparently practically applied it to her imbalanced situation with seeming success. Though obviously more intuitive and improvisational than intentional in this instance, Jung's prescriptive recommendation--and others like it made by contemporary clinicians everyday, such as getting regular exercise, sufficient sleep, practicing mindfulness or meditation for stress management, for instance--can be viewed as representing the kind of conveyance of "clinical wisdom" which makes for highly therapeutic initial consultations in certain cases. Unfortunately, such powerfully therapeutic and transformative initial consultations tend to be the exception rather than the rule. In reality, most people's problems presented during initial consultations are complex, multi-determined, deeply rooted, and resistant to change, requiring a course of psychotherapy (brief or longer) often combined today with pharmacotherapy. But, in any case, as I have tried to demonstrate in this series of postings, the initial consultation can be crucial in helping patients move, eventually if not immediately, toward a therapeutic resolution or transcendence of their presenting problems.
McGuire, W. & Hull, R.F.C. (Eds.). (1977). C.G. Jung Speaking: Interviews and Encounters. Princeton, NJ: Princeton University Press.