Shirah Vollmer MD

The Musings of Dr. Vollmer

To Understand Or To Ameliorate?

Posted by Dr. Vollmer on February 3, 2016

How does the mind work? More specifically, how does your mind work? That is what I am curious about. Does that mean I do not care about my patients and that I am only on a journey of understanding? Of course not. This struggle between the therapeutic basis of the relationship versus the need to understand unconscious motivations seems to be a weak fight in that they are complimentary. The central question is what is the agent of change. Is it the bond the patient forms with his therapist or is it the patient  “learning” the secrets and lies which underlie his “analytic surface”?  How about, both are true? Or, why do we care as long as the patient gets better? We care because we aim to help people and we aim to teach new therapists how to help people. If the relationship heals then the content of the therapy is not relevant. On the other hand, if the understanding is key, then maybe we won’t wish the patient a happy birthday. I find this discussion tiresome and yet my job tonight is to review these ideas with bright and eager students. I will take the unpopular stance and say that we do not know the agent of change, ever. In fact, it is a surprise when patients get better, not because we don’t have a lot of training or experience, but because the one thing that seems certain is that patient, no matter how much they consciously express a desire to change their way of being in the world, the pull towards sameness is very strong. Hence, when a person grows and sees himself as a third person in order to understand his own struggles, the work is both rewarding and astonishing. What distinguishes psychoanalytically trained therapists from cognitively oriented therapists is that we accept that change is not going to come easily, if at all. Through this understanding we have joined the patient in his rigidity and we propose an opportunity to loosen up the joints in that box the patient has put himself into. Like Houdini’s work, the escape is crafty and creative, and not linear or easy to see. Knowing the dark halls of interior mental life, we tread slowly and gently, with great respect for what is around the next corner. We take time and patience as we are wary of what we will uncover with even gentle probing. We imagine the challenges their life presented to them and this helps the patient feel less alone, but it may not help the patient cope with his circumstances. Coping skills developed over many years. Adding new coping skills and/or getting rid of old ones is not a linear process. So, what is the technique? I imagine a student will ask. To which I will respond, you imagine the life of your patient, both past and present, and from there, the narrative begins.

2 Responses to “To Understand Or To Ameliorate?”

  1. Shelly said

    When the therapist does her analytic work, how much of her own history and biases enter into the equation (not you, of course!)? Does the therapist simply offer up solutions to the issues, or only help the patient see where the patient “gets stuck,” so to speak? If the therapist imagines the life of his patient, won’t the therapist be limited by their own imaginations?

    • The goal of psychoanalytic therapy is for the therapist to be aware of both conscious and unconscious biases which the therapist brings to the table. The more the therapist has an understanding of his issues, the more able he is to decide what is an appropriate comment. Advice can be helpful, but typically, the most valuable work is in helping the patient get “unstuck” as you say, by helping him see how his attitudes and expectations, based on past experience, are interfering with his ability to flourish in his world. The imagination of the therapist is critical to the success of the treatment. So, yes, the therapist is limited by his own imagination, but hopefully his imagination is a fertile place. Thanks.

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