There is a strong positive relationship between a patient's perception of psychotherapy and its ultimate success. Some patients who appear to lack motivation for treatment may be capable of profiting from psychotherapy if they are taught what to expect--if they understand the "rules of the game." A clinical procedure for introducing such patients to psychotherapy is outlined by the authors, who also present excerpts from a hypothetical socialization interview.
PSYCHOTHERAPY WILL BE VIEWED here as a special form of social interaction.1 The transactions which take place in psychotherapy, like those of any other social enterprise, can run their normal course only if the participants are familiar with certain ground rules, including the purpose of the enterprise and the roles to be played by the participants. Only if this requirement is met can the psychiatrist judge his patient's aptness for treatment, capacity for insight, etc.; only then can the patient benefit from the opportunity offered him. A therapist whose patients do not have the requisite understanding of the assumptions underlying psychotherapy will encounter serious difficulties, especially if he is not fully aware of this deficit.
The purpose of this paper will be to argue that an important determinant of success and failure in psychotherapy is the degree to which the patient understands the rules of the game. Further, several techniques of training will be proposed which may facilitate psychotherapy in patients who may lack the necessary understanding, and evidence will be presented to show that one of these techniques has the desired effect.
The Enterprise of Psychotherapy
In this century, the writings of Freud and the dynamic psychologists who followed him have had such a major impact that the basic assumptions of depth psychology are widely available, although in an admittedly crude form. Psychotherapy is sought by a relatively high proportion of individuals in some social groups, so that virtually all members of the group have acquired considerable sophistication. It is not unlikely
This manuscript was originally prepared as part of a research proposal while the authors were with the Massachusetts Mental Health Center. The study was subsequently carried out by Hoehn-Saric, Frank, Imber, Nash, Stone, and Battle (7). The research upon which this paper is based was supported in part by Public Health Service grant MH-11028 from the National Institute of Mental Health, and by the Institute for Experimental Psychiatry.
1 The theoretical basis for this paper derives in large part from the senior author's work on hypnosis and the psychological experiment as social phenomena (in particular, see [12]).1202
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that a majority of those who enter psychotherapy have been personally acquainted with others undergoing a similar experience. In addition, the plethora of books, articles, movies, and plays about dynamic psychiatry serve as additional sources of information about the enterprise and its rules.
In describing the enterprise2 of psychotherapy here, we will confine ourselves to those formal aspects which are widely known among the lay public, and tend to hold regardless of the specific "school" of the therapist.3 It should be understood that such a general description can be neither complete nor specific. An analogy may help to make this clear. In reply to the question, "What characterizes a formal dinner?" certain abstract attributes could easily be enumerated. These attributes would not add up to a complete account of any particular dinner or even of important differences in styles of dining, but a knowledge of them would be of considerable help to an otherwise unsophisticated guest.
Characteristics of Psychotherapy
In essentially popular terms, the basic ground rules of psychotherapy include at least the following features:
1. The patient participates actively and verbally. Psychotherapy is the attempt to deal with the patient's difficulties by discussing them with the therapist. The patient's own activity is the principal instrument of treatment. He should try to report his thoughts and feelings honestly. The cardinal rule is that he must not consciously withhold information. Everyday restrictions on the communication of socially disapproved feelings do not apply. It is important for the patient to express negative feelings, including any that may concern the therapist.
2. The psychiatrist's task is to help the patient understand himself. The psychiatrist does not give advice or tell the patient what to do. Whenever possible, he refrains from judging past or present behavior. It is appropriate for him to inquire into very personal matters, but he does not play an active questioning role. As much as possible he listens without interfering.
3. The course of therapy will be stormy. The patient will experience intense feelings which may well be painful. He will go through a number of stages and should avoid making permanent decisions about his life at such times so that they will not be based on a transient set of feelings. At times he will have strong feelings about his doctor; he may "fall in love" with his doctor or "hate" his doctor. These feelings do not depend on the doctor's behavior but are related to the patient's own past experiences, and an important part of the treatment consists in dealing with them.
4. Causality is complex and unconscious. The individual is not aware of the true causal relationships between the symptoms for which he is seeking help and certain other feelings or past experiences. The symptoms themselves are manifestations of basic problems. A careful exploration of the patient's history, development, and present personal feelings will help to uncover the basic causes and relationships which the patient does not recognize at first. During this exploration the patient may remember events that previously escaped him, and these are important to the understanding which must be achieved. Recognition and clarification of the real links among experiences, feelings, and symptoms constitute insight, and will lead to an abatement of symptoms and a favorable alteration of behavior.
These assumptions are taken as axiomatic in psychotherapy, and an explicit discussion of them is rare. However, they are by no means the only possible ground rules for a doctor-patient relationship.4 To make thisclear, we will consider the very different
3 For a similar and independent analysis of the structure of psychotherapy based on verbatim protocols of therapy sessions, see Lennard and Bernstein(9). For a recent review of the experimental literature and a detailed related analysis, see Goldstein (4).
4 The assumptions have, of course, been discussed at least tangentially in many papers, e.g., especially Rosenzweig (13), Greenson (5), and most recently London (10).
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expectations underlying medical and surgical treatment. This example is particularly instructive because a patient who lacks the necessary understanding of psychotherapy may interpret the situation as if it were of the medical-surgical kind. As we shall see, this can lead to very serious misunderstandings.
Characteristics of Medical and Surgical Treatment
The underlying assumptions of normal medical or surgical treatment, as seen by the patient, include at least the following aspects:
1.The patient is relatively passive. His job is to allow the physician to proceed with the treatment. He is to provide the necessary information by explaining his symptoms and answering questions. Thereafter he is to follow instructions. Comments on his personal life, on his feelings toward the doctor, etc., are generally inappropriate.
2.The doctor's task is to make the patient well. He is an expert who obtains the necessary information, conducts whatever examinations and tests he believes to be appropriate, evaluates the data, and tells the patient what must be done. He may give a superficial explanation of his diagnosis or the reasons for his choice of treatment, to humor the patient or to elicit compliance, but he is not required to do so. The success of the treatment does not depend on the patient's understanding of it, and in fact the patient usually does not understand it.
3.Medical treatment is sometimes quickly effective and sometimes prolonged, but the patient's personal feelings have little to do with its results. Faith in the physician,rapport, and the like are seen as important but primarily because they make it likely that the patient will indeed follow the prescribed course of treatment. Only very secondarily is it possible that a positive attitude may have some curative effect. The length of treatment depends on the effectiveness of the available remedies. If recovery is slow, the commonest expectation is for gradual but steady improvement.
4.Causality is often simple and generally physical. The symptoms result from the presence of some specific disease, germ, organ malfunction, injury, or the like. Ideally, this basic cause is treated directly by medication, surgery, or specific prescribed activities. Neither the patient's nor the doctor's understanding of the cause has any beneficial effect in itself; it is only a preliminary to direct intervention.
It is clear that the ground rules of these two enterprises are very different and that they make very different demands on the patient. The medical patient must allow the physician to work on him with as little interference as possible and "follow doctor's orders." He is usually not expected to take any active part in the treatment process itself. In contrast, psychotherapy demands that the patient understand and actively participate. The doctor does not tell the patient what to do, but rather helps the patient find out what he wants to do. The curative factor itself is seen as the new understanding the patient derives about himself.
Anticipatory Socialization
As was pointed out earlier, the ground rules of psychotherapy are well known to most members of certain social groups. They have learned them through an informal process which serves, in effect, to teach them how to behave appropriately if and when they enter psychotherapy. It seems appropriate to borrow Merton's term from sociology and call this process "anticipatory socialization"( 11 ).
The term "socialization" refers to the process by which the individual who grows up in a particular culture learns what is expected of him in a variety of situations, and what he may legitimately expect of the individuals with whom he is interacting in these situations. Any individual must function in a variety of role relationships throughout his life. He may be an employee in relation to his employer, a supervisor in relation to people working for him, a husband in relation to his wife, a father in relation to his children, etc. A socialized individual has developed appropriate role expectations for each of these. In many cases the necessary learning occurs in the critical situation itself, as when a child's
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peers teach him what behavior is acceptable.
In other instances, socialization is carried out in preparation for future roles. A boy may learn how a man behaves by watching his father, or he may be taught in medical school how a doctor behaves. These are examples of "anticipatory socialization" because they anticipate specific social interactions ahead of time.
It is fair to say that the typical middleclass patient has had a good deal of anticipatory socialization before entering psychiatric treatment. This includes knowledge about the process, beliefs about its effectiveness, shared values about its importance, and very specific role expectancies which allow him to understand the psychiatrist's behavior and provide appropriate responses.5 Although this information has been widely disseminated, it is not equally shared by all groups in American society. Upper middle-class patients generally have had considerably more anticipatory socialization than members of less privileged classes. Ethnic, geographical, and religious factors undoubtedly interact to determine the degree of anticipatory socialization in any given subgroup.
The Effects of Inadequate Socialization
Consider the plight of the patient without this background information who comes to a psychiatric clinic for treatment.6 Perhaps he has been referred by a medical or surgical clinic, a social agency, or the courts. He does not know anyone who has ever been in psychotherapy and has had little exposure to psychological novels or casual "psychologizing." He has no concrete idea of what to expect and may well think that psychiatrists are dangerous and powerful people who deal with crazy folks. In the ensuing interaction there will be a clear lack of mutually complementary role expectations between himself and the psychiatrist. The result is easy to caricature, but it has a familiar ring.
The patient, relying on the only model in his experience which is appropriate, acts as if the psychiatrist were another medical doctor. Having briefly stated his presenting complaint, he expects to be asked further questions. The psychiatrist, on the other hand, wanting to get at the patient's feelings, makes little or no response and listens attentively. The patient waits expectantly to be asked questions while the therapist waits for the patient to say more. Both parties in the interaction become increasingly uncomfortable. When the level of anxiety becomes sufficiently high, the psychiatrist may ask some questions to elicit factual information or the patient may repeat the recital of his difficulties and his plea for help in different ways. At the end of the first hour, both parties are thoroughly dissatisfied.
The patient, who has come for help, advice, and treatment, wonders what the doctor really wants. He is confused and feels that somehow he has failed. His doubts about the availability of help from psychiatrists are reinforced, and his belief that his problem is really medical may be stronger. He usually feels worse than when he came and takes this to mean that treatment is not only ineffectual but actually harmful. He will return only because he feels he must, or perhaps because he has already been through several other medical clinics and this is the end of the line.
The psychiatrist, who is usually a resident, is equally dissatisfied. He may have some choice thoughts about why he has been assigned another untreatable patient with no capacity for insight or insufficient intelligence for treatment. He thinks: "Perhaps things will improve in further sessions, but I doubt it." But he has little choice except to go on seeing the patient.
In this manner, both patient and psychiatrist may continue unhappily for some time: the patient needing and wanting help, the psychiatrist willing to provide it, but both frustrated by a lack of communication. Eventually the predictions which have been
6 This problem is relatively rare among private patients since this type of individual will resist referral to a psychiatrist by his medical man and will usually find a medical practitioner who provides him with reassurance and support in the guise of administering medication.
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made privately by both parties come true, and the patient fails to keep his appointments. After perfunctory attempts to induce him to come, he is assigned to drug therapy or discontinued with a sigh of relief and an appropriate note on his chart indicating why he is unable to benefit from the treatment.
A patient who does not understand what is expected of him is almost certain to encounter difficulties. The psychiatrist's attentive listening, usually so helpful, leads to intense anxiety when the patient has no idea of an appropriate response. The hard-won ability of the therapist to refrain from giving advice may be interpreted as the hostile withholding of help. If, despite all odds, the patient is able to make some progress and derive a glimmering of insight, the resultant increase in anxiety may be interpreted by the patient as an indication that he is getting worse. Thus he may terminate the treatment--not because of an unwillingness to tolerate the anxiety, but on the basis of the commonsense conclusion that something that makes him feel worse does in fact make him worse.
Of equal importance is what may happen to the therapist. Despite the professional injunctions against premature judgment, all therapists have expectations about the course of treatment with particular patients. These expectations, based on the first interaction, are determined in large part by the extent to which the patient behaves appropriately to the psychotherapeutic setting. There is good reason to believe that they can affect the outcome of therapy. It has been pointed out by Gill, Newman, Redlich, and Sommers (3) how important the first interview is in determining the future course of treatment. This importance may, in part at least, be a function of the therapist's expectations. In general, such predictions become self-fulfilling (6). Once he comes to the conclusion (no matter how privately) that the patient is unsuitable for psychotherapy, it is highly probable that he will find the patient to be unsuitable.
Thus the mechanisms by which the lack of anticipatory socialization may interfere with therapy are not limited to the patient's lack of understanding of the procedures. The same circumstances also operate to convince the psychiatrist that the patient is a poor candidate for therapy. The patient's difficulties are thus compounded by countertransference problems, and the combination often creates an impasse which makes treatment impossible.
One may ask why these considerations have not been generally recognized. The chief reason seems to be the nature of the population from which psychotherapeutic patients are usually drawn. Working with educated upper-middle-class patients, it seems unnecessary for the therapist to explain the ground rules of treatment. Working with such a well-informed group, a therapist may develop techniques which work well with the overwhelming proportion of his patients. It is easy to see how a psychiatrist in private practice will come to believe that it is unnecessary to explain to a "good" patient what is expected of him, and that it is the patient's problem if he cannot work in treatment. To be sure, some patients with adequate anticipatory socialization still cannot make use of psychotherapy. But they should not be confused with those who simply do not know what to expect.
Explicit Socialization
Once the importance of anticipatory socialization has been realized, it is possible to consider ways of providing it for patients who might otherwise be unable to benefit from therapy. How can a patient be taught the ground rules of the psychiatric enterprise? A number of means suggest themselves immediately. We will focus here on one of them--the preliminary interview -- because an experimental study of its effectiveness is already available. But certain other techniques are also potentially useful and should be mentioned.
A particularly promising possibility is, the socialization of patients by their peers. This can be expected to take place in a hospital setting, where patients learn what to expect and how to behave by observing one another. This may well be the reason why inpatient therapy with psychologically unsophisticated groups is so much more effective than outpatient therapy. In the group therapy of alcoholic patients Brunner-Orne
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and Orne (1) have observed the great importance of fellow patients in the treatment process. It might be easily possible to maximize patient interaction even in an outpatient setting and thereby improve the effectiveness of therapy. Other instructional techniques--motion picture films and modified group therapy procedures--may also prove useful in time.
The method of anticipatory socialization with which we have most experience is perhaps the most obvious: the patient is told what he needs to know. The essential information is not communicated haphazardly during the course of treatment but explicitly during a preliminary socialization interview. This interview may be conducted by the therapist himself, as has been the case in the senior author's practice, or by another trained individual, as in the study by Hoehn-Saric, Frank, Imber, Nash, Stone, and Battle (7); at present it is not known which of these two procedures is more effective. The interview may be as short as half an hour or may comprise several sessions.
In such an interview, the therapist (if he is conducting the interview himself) must depart from his usual neutral role and assume the part of a teacher. His object is not to say everything there is to say about psychotherapy, however, or even everything about the psychotherapeutic enterprise as outlined earlier. The three major purposes of the interview are: 1) to provide some rational basis for the patient to accept psychotherapy as a means of helping him deal with his problem, recognizing that talking is not seen by most patients as a medical modality; 2) to clarify the role of patient and therapist in the course of treatment; and 3) to provide a general outline of the course of therapy and its vicissitudes, with particular emphasis on the clarification of negative transference.
Although the manner in which this material is presented must vary in individual cases to suit the needs of the patient and his readiness to understand, the general outline may be useful. In practice, the order in which the points are taken up, the directiveness with which it is approached, and the length of time devoted to it will vary widely. Obviously the therapist's task is not merely to make the points but to make certain that the patient understands and, hopefully, accepts them.
1. Establishing rapport. The therapist should begin by taking a very brief history. The success of socialization depends on the formation of a relationship in which the patient can recognize the competence of the therapist and accept the usefulness of information given. A history and description of the presenting symptoms are obviously relevant from the patient's point of view as well as essential for the therapist. In the process of taking a history it is helpful to indicate by appropriate responses a sympathetic understanding of the patient's predicament.Some simple comments which would seem highly insightful to the patient are also useful here. These will be the rather easy generalizations, readily acceptable to the patient, which can be made on the basis of the patient's complaints. Comments of this kind are not interpretations in the usual psychiatric sense. They are designed to be immediately helpful, reassuring, and supporting. Their purpose is to provide the basis for the acceptance of the therapist's subsequent comments. This aspect of the procedure usually takes a short time. It fits readily into the model of the doctor-patient relationship that is already familiar to the patient.
2. An explanation of psychotherapy. In the context of the interview, it matters little what rationale is given to help the patient understand psychotherapy. It is important, however, that some rationale be given. The main points are that therapy is a learning process; its goal is to effect permanent, enduring change rather than immediate, transient improvement. In addition, there should be some statement of goals and an approximation of the length of time required. It should be emphasized that progress cannot be evaluated for several months. A discussion of unconscious motivation (particularly if an obvious and nonthreatening example is available from the patient's history) may be appropriate. These questions lead naturally into an account of the therapeutic process in concrete terms and of the respective roles of the patient and the therapist.
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3. The roles of the participants. In this context, it is clarified that the patient's role is to be active; that the therapist's job is to help but not to advise; that decisions will always be made by the patient rather than the psychiatrist; that the patient is to discuss whatever comes to his mind even if it would be painful, very private, or perhaps embarrassing to the therapist. Usually it is advisable to warn the patient that the therapist will say relatively little; that there may be long periods of silence which may occasionally be uncomfortable but will ultimately tend to be productive. The therapist's role in helping the patient become aware of the facts which he has been keeping out of mind is emphasized. Some clarification of the difference between the activity of the psychiatrist and that of a medical man may be helpful; psychotherapy is not done to a patient but with a patient.
4. Anticipating the patient's resistances. It is of particular importance to discuss those aspects of treatment which might terminate it prematurely during the early sessions. Thus, a patient is warned that he may develop very strong feelings about his doctor, thinking very highly of him at one stage and finding him stupid or incompetent at another. It is pointed out that both types of feelings are characteristic of the treatment process and neither is necessarily due to the doctor. It is emphasized that almost all patients go through a period where they feel hopeless and negativistic, that apparently good, cogent reasons will appear which make it "impossible to come to a particular session" but that at these times it is particularly vital to continue. In this connection it is emphasized that negative feelings are very difficult to discuss with the doctor but that they will have to be brought out; otherwise they would impede and perhaps interrupt treatment.
In this context, it is explained that progress is not in a steady fashion but that there will be ups and downs--that it is common to go through different periods or stages in treatment where irrational and transient feelings may exist toward others and for this reason permanent decisions ought not to be made without discussing them with the therapist. It is emphasized that many decisions which seem totally unrelated to what is going on during treatment may, in fact, be determined by it.
In medicine, it is good practice to tell a patient with early measles that his fever will increase on the following day and he will feel worse but that shortly thereafter it will begin to diminish and he will feel a lot better. The patient is reassured by such a statement and when on the following day the fever does, in fact, increase, his feeling is not one of panic but rather of relief because the prediction made by the physician is borne out and it is assumed that, if he were able to predict correctly a worsening of the condition, he will also be correct in his prediction of subsequent improvement. Janis (8) has demonstrated that this type of procedure is exceedingly ego-supporting for patients facing surgery.
Thus resistances and negative transference reactions are taken up initially. If they subsequently occur, they may then be seen as a predictable part of treatment and even interpreted as a sign of improvement. If the patient is not warned in advance and interpretation is made during the period of negative transference, the patient may well discount and deny the interpretation, whereas if he can be reminded of an earlier discussion of this phenomenon, it can be dealt with a great deal more readily. Some sophisticated patients may describe their progress in insight therapy by saying, "I can't stand my doctor and I hate going to sessions now. I guess I am improving."
This aspect of the interview has proven very helpful during initial interviews where the patient's parents or spouse have been involved. Frequently situations are encountered where either parent or spouse may provide the impetus for treatment but would tend to sabotage it when results begin to emerge. Such a course of events can readily be anticipated and in such instances prediction at the very beginning of treatment (with or without the patient's presence) may prevent premature termination.
The Effects of Anticipatory Socialization
This kind of socialization interview can have a dramatic effect on the course of future therapy. Patients who have resisted
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treatment in several contexts and with several therapists often begin to benefit from treatment once they have understood what it is all about. Although many individual cases in the senior author's own practice substantiate this point, a clear experimental demonstration is also available.
In a study designed to test the effect of the anticipatory socialization interview, Hoehn-Saric and associates (7) confirmed the prediction that an anticipatory socialization interview would maximize the results of subsequent treatment. Four therapists who did not know the nature of the intervention were assigned ten patients each, of whom five were given an abbreviated version of the interview and the other five did not have this pretreatment. Significant differences in rate of improvement between the experimental and the control groups could be demonstrated after four months of treatment.
This study validates earlier clinical impressions about the effectiveness of the interview. To be sure, it leaves many questions open. Is anticipatory socialization best done by the therapist or (as in the study) by someone else? If the therapist himself undertakes it, a considerable change in his behavior is required in shifting from the period of anticipatory socialization to long-term treatment. Certainly the need for such a change is avoided by having a different psychiatrist undertake anticipatory socialization. On the other hand, the rapport created in the initial interview may be of considerable value.
However it may be conducted, anticipatory socialization is a device which improves the patient's chances of benefiting from therapy. It should not be seen as a manipulation of the patient, or as a prescription for his future behavior. In other medical situations he is manipulated or given prescriptions, but in psychotherapy such procedures are avoided, and a patient who fails to realize this is at a grave disadvantage. By making the necessary information available to him, we remove this disadvantage, and give the unsophisticated patient an opportunity equal to that with which most middle-class patients begin.
Acknowledgment
The authors wish to thank Dr. Ulric Neisser for his help in the revision of the original manuscript, and also Drs. Frederick J. Evans, Jerome D. Frank, Milton Greenblatt, Lester Havens, Rudolf Hoehn-Saric, Philip S. Holzman, Stanley D. Imber, Richard Jung, Joan Koss, Donald N. O'Connell, Emily C. Orne, Sydney Pulver, Anthony R. Stone, and Albert J. Stunkard for their comments and suggestions.
Appendix
We have included here two excerpts 7 from a hypothetical anticipatory socialization
interview where treatment will be carried out by different therapists.
Although it appears as a monologue on the part of the psychiatrist, in actual
practice it is interrupted by questions, amplified to clarify particular points,
and varied to suit the particular case. An interview of this kind must be tailored
to the specific therapist, patient, and the situation. The major issues relevant
to socialization for treatment are taken up. In some instances it may be possible
to cover these in a single interview but, more commonly, two or more sessions
are needed. The first excerpt illustrates how the patient's role and the process
of treatment are described.
... Now, what is therapy about? What is going on? Well, for one thing, I have been talking a great deal; in treatment your doctor won't talk very much. The reason I am talking now is that I want to explain these things to you. There is an equally good reason that the doctor in treatment does not say much. Everyone expects to tell the psychiatrist about his problem and then have him give advice which will solve everything just like that. This isn't true; it just doesn't work like that. Advice is cheap; there is no reason for paying for it. Before you came here you got advice from all kinds of people: your wife, your parents, your friends, your family doctor, your minister,
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and so on. Many of these people know you quite well; some of them know you very well; and if it were just a question of getting advice there is no reason to think that your doctor would be that much better at it than all of the people who have always told you what to do. Actually we find that most people have a pretty good idea of what is wrong and while we can give advice to someone else with a problem similar to our own, it just doesn't help them. Unfortunately, when people give advice, they usually provide solutions which will work for themselves but not for the person who has the problem. If all of the advice you have received had helped, odds are that you wouldn't be here. Your doctor wants to help you to figure out what you really want to do--what the best solution is for you. It's his job not to give advice but to help you find out for yourself how you are going to solve your problems.
What does this mean? Well, if your doctor sees you getting into some kind of trouble, he may warn you about it, but here again the final decision as to what to do will have to be made by you. The great advantage you will have with your doctor is that he has no ax to grind. He doesn't think he knows what is best for you, but he is going to help you try to find out. He doesn't think that he knows the answers. He just wants to understand, with you, why you do things.
Now, what goes on in treatment itself? What is it that you talk about? What is it that you do? How does it work? Well, for one thing, you will talk about your wishes, both now and in the past. Why should this help? Why is it important? Well, there are many reasons. We don't talk about lots of things because they are too personal, or because they would hurt other people's feelings, or for some other similar reasons. You will find that with your doctor you will be able to talk about anything that comes to your mind. He won't have any preconceived notions about what is right or what is wrong for you or what the best solution would be. Talking is very important because he wants to help you get at what you really want. The problem most people have in making decisions is not that they don't know enough, but that they never have had the opportunity of talking things over with someone who doesn't try to make their decisions for them. The doctor's job is to help you make the decision.
Another reason is that most of us are not honest with ourselves. We try to kid ourselves, and it's your doctor's job to make you aware of when you are kidding yourself. He is not going to try to tell you what he thinks but he will point out to you how two things you are saying just don't fit together. You know, feelings have to add up, kind of like two and two are four, but we like to kid ourselves sometimes that they are five. It's your doctor's job to remind you when you are doing this. For example, let's take your ambivalence toward your wife. You have told me a lot of things you dislike about your wife--how annoyed you are with her, how you would sometimes like to throttle her. But there are also reasons for continuing to live with her. There must be, because this is just what you are doing. The job of your doctor is to help you keep in mind all of the important facts and feelings so that you can come to a solution that takes all of the facts into account. It's hard because sometimes these feelings conflict; then again, if it were not hard you would not be here, you would not have the problems you do.
You have probably heard that psychiatrists are interested in the subconscious. What is really meant by that? The subconscious isn't such a mysterious thing when one looks at it. For example, you must have met people who seem to get your goat and get you really angry with them, but you can't put your finger on anything they have done to account for your feelings. It may be that this person reminds you of someone but you don't realize it. The person whom he reminds you of is someone with whom you are angry, so you find yourself taking it out on the person at hand. Unless you can remember whom you really are angry at, it's pretty hard to get over the feeling of annoyance. In this case, becoming aware of what is unconscious would be no more than remembering and recognizing the difference between these two people. Sometimes, though, that is an awful lot of work.
When we are not aware of the reason for a strong feeling like this, a psychiatrist would then say this is unconscious. By becoming aware of the reasons for our anger with someone, we can treat him on a more realistic basis. It is easily possible that a very nice individual happens to resemble somebody whom we have good reason to dislike, and so we deprive ourselves of knowing somebody whom we would like because we are not aware of the resemblance. It is the psychiatrist's job to help you recognize when the feelings you have toward
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someone seem to be inappropriate and then learn to understand the real causes....
A particularly important aspect of the interview relates to the discussion of negative transference and warning the patient of its consequences, thereby minimizing its potential for disrupting treatment.
... By the way, if you go ahead in treatment, you will find that ----------------- , who is all for your getting some help now, may come to feel that it isn't helping you any. This is often an indication that you are changing, and these very changes are puzzling and troublesome to someone close to you. You should know that almost always in treatment some of the people around the patient will be convinced that he is getting worse--often just at the time when he is really improving. And the patient himself also sometimes feels worse and discouraged at some stages of treatment. You know, you'll feel you're not getting anywhere, your doctor is a fool, and there's no point in this, and so on. These very feelings are often good indications that you are working and that it's uncomfortable. It is very important that you don't give in to these temporary feelings when they come up.
You know, it's very funny--what will happen, as you talk about more difficult things, is that you'll find you have trouble keeping your appointments. You won't be able to get away from work, there will suddenly be necessary overtime just at the time of the appointment, your car will break down or run out of gas, your wife will need your help at home for something, and so on. All of these things will seem quite unrelated to treatment. The funny part is that they'll be happening just at the time when things are getting rough for you in therapy. What this means, of course, is that you are getting down to something difficult and important, and that these are the most important times to bring yourself to your therapy meetings. This is what psychiatrists call "resistance." This is something that always happens sooner or later. The only way to protect yourself is not to allow yourself to judge how important any given meeting will be, but instead to decide beforehand that you are going to be there, come hell or high water. In other words, if you make an appointment, you will keep the appointment regularly. This doesn't mean that you can't postpone a session for good reason, if you discuss it with your doctor beforehand. For example, if you know three or four weeks in advance that you've got a business trip, and you know it's something you have to do, it won't, as a rule, interfere with treatment if you miss an appointment. It's the sudden emergencies which are almost always unconsciously planned--things that come up unexpectedly.
Another thing--in treatment you will often find yourself uncomfortable. For one thing, your doctor won't say a great deal and you will find yourself trying to make decisions about what to say. We do this all the time. If we didn't, we would get ourselves into a lot of trouble. If you think your boss is an idiot and an S.O.B., and you told him this, you might well lose your job. In general, we have to make a distinction between what we think and what we say. In treatment this is not so. You want to say whatever comes to your mind, even if you think it is trivial or unimportant. It doesn't matter. It is still important to say it. And if you think it is going to bother your doctor, that doesn't matter either; you still say it. In contrast to your boss, if you think that your doctor is an idiot or an S.O.B., you jolly well tell him about it. You will find this is very hard to do and yet it is one of the most important things to learn in treatment--to talk about whatever comes to your mind. Often what you think is trivial and unimportant is really the key to something very important.
For example, you might suddenly become aware that the room is hot or that the doctor's necktie is funny or that he needs a haircut, or something like that which seems both trivial and even perhaps a little rude to bring up. Yet, in treatment, if you think of it, you say it. Many times I have seen things like this turn out to be extremely important. So, just like the appointments, we make an absolute rule not to think ahead about what you'll say and therefore protect yourself from facing important things. Say whatever is on the top of your mind, no matter what. If you are really talking about stuff that isn't important, your doctor will let you know. But remember, that's his job, not yours, to decide.
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1212 ANTICIPATORY SOCIALIZATION FOR PSYCHOTHERAPY
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