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Seven Questions for Glen O. Gabbard

A psychoanalytic psychiatrist explains the therapeutic process.

Today's responses come from Glen O. Gabbard, M.D., a psychoanalytic psychiatrist who wrote the book on psychotherapy. Literally. But non-shrinks may know him best as the guy who analyzed Tony Soprano.

The project continues to expand. So far we've heard from the founder of CBT, the APA president and the best-selling relationship author of all time. I must say it's a pretty nice ensemble, considering no one's getting paid. Each therapist contributes a unique voice to the Seven Questions, illuminating a distinctive personality and theoretical orientation. Now it's time to hear from a psychoanalyst.

Today we talk with Dr. Gabbard, Chair of Psychoanalysis and Professor of Psychiatry at Baylor College of Medicine in Houston, Texas. He's the prolific author of over 290 papers and 23 books, mainly professional writing on the treatment of psychiatric disorders. But he also has an interest in the screens, big and small.

With books like Psychoanalysis and Film and Psychiatry and the Cinema, Dr. Gabbard has earned his position as an authority on the subject. In fact, he's one of a select few psychoanalysts with his own listing! His Psychology of the Sopranos feeds the zealous fans of the late, great series. In Dr. Gabbard's analysis of over 400 on-screen depictions of therapists, he found only a handful to be credible. Among them was Dr. Melfi from the Sopranos

I referenced Dr. Gabbard in my post on Therapist Burnout. His writings on boundaries and the therapeutic frame were an essential part of my education, teaching crucial lessons that still contribute to my peace of mind and career longevity. It's been a pleasure to correspond with him and receive his considerate, psychoanalytically-informed responses to the Seven Questions. His comments about remaining "present" in session (Q5) and his pearl of wisdom for clients (Q7) really speak to me. I hope you benefit as well.

Seven Questions for Glen O. Gabbard:

1. How would you respond to a new client who asks, "What should I talk about?"

I would say to the patient that he is free to talk about whatever is currently distressing him the most. I would also call attention to the use of "should" in his question. I would emphasize that psychotherapy is not coercive in any way, and that he should feel free to focus on his concerns and not worry so much about what I think he should talk about.

2. What do clients find most difficult about the therapeutic process?

Most patients find that the most difficult thing about the therapeutic process is going where they need to go to truly understand themselves. Intensive psychotherapy takes you to the darkest corners of the psyche where you really don't want to go. Hence patients tend to fight off the help of the therapist because they feel a tremendous sense of vulnerability involved with unmasking their self-deception and carefully crafted defenses to look at who they really are.

3. What mistakes do therapists make that hinder the therapeutic process?

Most therapists prematurely jump to conclusions about what's going on with the patient. Most of these conclusions derive from preformed theoretical and conceptual models that may or may not fit the patient. Therapists should be generating hypotheses without verbalizing them while marshalling evidence to support the hypotheses before formulating an explanation of the patient's fantasies, symptoms, or behavior.

4. In your opinion, what is the ultimate goal of therapy?

The ultimate goal of therapy cannot be answered in any generic way. The goals in therapy are a collaborative effort in which therapist and patient together identify what is distressing to the patient, what the patient would like to change, and what is realistically possible to change in the course of psychotherapy. Certainly the search for the truth about oneself is an overarching goal in most dynamic psychotherapy, but it may have lesser or greater importance depending on the patient's expectations of the process.

5. What is the toughest part of being a therapist?

The toughest part of being a therapist is being truly "present" with the patient. The demands placed on a therapist in a typical day of psychotherapy are truly extraordinary. The therapist must be present in a way that allows the patient to feel heard, validated, and understood. The therapist struggles every moment of every therapy hour with conflicting wishes involving himself that may be at odds with what the patient's needs are. The therapist's attention will wander out of the room and into his own realm of fantasy in such a way that may or may not be useful for the process, but the overarching goal of being useful and helpful to the patient must trump the therapist's own emotional and intellectual whim of the moment.

6. What is the most enjoyable or rewarding part of being a therapist?

Therapists are paid to talk to interesting people all day. In this regard, we are in a privileged profession. The pleasures are many: connecting with someone at a profound level of intimacy that is rare in other situations, learning about other cultural and psychological perspectives on matters of great importance to the human condition, and helping others enrich their lives and make changes for the better.

7. What is one pearl of wisdom you would offer clients about therapy?

Do not conceal your reservations or negative feelings about the therapy from your therapist. If you feel you are being misunderstood, if you feel the therapist talks too much or not enough, if you feel the therapist's concerns are placed above your own, if you feel that the therapist imposes theoretical models on you that do not fit with your own subjective experience, or if you feel the therapist is distracted and bored, bring up these concerns and expect to have them taken seriously. Any therapist who dismisses them is not someone you want to continue seeing.

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