Int J Psychol Psychoanal

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International Journal of Psychology and Psychoanalysis

Department of Psychiatry, University of Illinois at Chicago, United States of America

Abstract

Therapeutic ingredients form the backbone of psychological intervention. The breadth and method for learning skills, quality of teaching and the recipient i.e., therapist in training's ability to capture the knowledge combined with skills is a fluid, intense and time-limited induction process. This may encapsulate attachment theory, self-psychology, psychodynamic insight oriented psychotherapy, tools of cognitive behavior therapy, problem solving and crisis management therapy and psychodrama, and systemic, structural and strategic models of family therapy. But no single method seems sufficient in the toolbox of a therapist. The veracity of agile integration of many methods of treatment on demand, an understanding of biological advances and the key elements of goodness such as- kindness, respect and non-patronizing stance- may offer the best chance of therapeutic alliance towards psychological shift.

Through the transformation from being a trainee in General and Child Psychiatry into a lifetime's career as clinician-teacher and researcher, we integrate several psychological theories that shape the clinical practice. This paper is a reflection on such transformative integration, elevating the platform to consolidate the gains in nuanced therapeutic intervention. An interesting encounter with a patient of mine has, precipitated my ever crowding thoughts about what are the essential ingredients in human interaction that help people the most, be it a child or an adult. A laconic teenager with Korean background adopted in infancy by a caring caucasian family was just discharged from an intensive care inpatient unit after being admitted with rage and suicidal ideation. He is a 17-year-old; suffering from major depressive episode complicated by irritability and impulsivity, with an established diagnosis of bipolar disorder type II. He is receiving lamotrigine for mood stabilization and a serotonin reuptake inhibitor for depression. He is anxious and avoidant in terms of attachment with his adopted parents. The parents are more invested in predictable social order such as grades and exacting school career like their other biological children who are driven. The Korean son is fighting the norms and the perceives or experiences lack of sensitivity. He appears to resist intimacy within the family with trust issues eroding at any attempts of emotional connection from the rest. He conveyed to me that it is not the medication or therapy that helped him during the recent admission to the inpatient unit, but the people. He also added an astute sentence, "It is not the personality or skills of the therapist, or how much they talked or listened that helped, but the people themselves". He could trust them based on who they are as people, and with time. That powerful statement by him set off my thinking process, which I recount below, concluding with the reconciliation with the teenager towards a promising therapeutic alliance.

In any context, there are sets of therapists with multiple levels of education and expertise that are available to recruit. It is common knowledge that training in various methods are again influenced by the quality of training and reliability in the delivery to the end user, financial resources aside. Therapeutic failure and lack of alliance can often be pure lack of skills or it could be a more complicated issue of some therapists not being able to tune in with sensitivity due to their own life encumbrances. I had to reflect back and draw from the time of my own psychotherapeutic training in General Psychiatry Residency and fellowship in Child and Adolescent Psychiatry. The concepts and supervision sessions involved Lacanian methods [1] involving literally mathematical equations from an Argentinian psychoanalyst; Gestalt theory based on psychodrama from Fritz Pearls' [2] descendent from South Africa, a prototypic Freudian psychoanalyst [3] and a cognitive behavioral therapist [4]. Then, there were also the therapists that loved Rogerian theory [5] to support and solve problems with finding congruence, empathy and unconditional positive regard. The self-psychology specialists taught us the 'self object transferences' of mirroring and idealization where mirroring is meant to heal the low self- esteem, based on magnificent work by Kohut [6]. The solution to long drawn psychoanalysis was the insight oriented brief psychodynamic psychotherapy that is meant to incite personal shift and growth through making links or interpretations in patterns of behavior [7]. This could be a progress from the long drawn Freudian or Lacanian analysis that is expensive in terms of time and money above all other factors, and to fit into residency training period. I reconciled with the fact that no model is a perfect fit given the pros and cons of any model. I liked the kindness of Rogerian therapy in supporting, and holding the patient while solving, but it lacked the ability to sustain change through sharing insight. I liked the cognitive behavior therapy except it might not meet the needs of the patient that came with crisis on hand, wanting active help in solving the crisis. Reframing thinking often met with dazed look from patients when they cannot even concentrate and absorb anything that entailed cognitive prowess under acute stress. Psychodrama was excellent and quick demonstration on a day that your patient is in the mood to role-play, especially in lieu of explaining to parents or children a desirable interaction under challenging circumstances. That aside, the actual reenacting can be dramatic and not everyone wants to relive and act out in therapy towards healing, especially in the re-corrective psychodrama in case of trauma victims. As I debated and tried to piece together meaning from each set of supervision classes in my residency in Melbourne, may I add, psychoanalytic capital of Australia, I was branded as "the biological psychiatrist". Indeed, I started to ponder if therapy in the wrong hands and at the wrong time might create patients out of normal people through "pathologizing" what could even be normality. I believed that people should call spade a spade and not indulge in interpreting. I felt the silent Freudian therapists were punitive in remaining silent or rarely talking. This was especially the case of a child who is failing in school with learning disorders and was frustrated. Parents were complaining that I was not helping them to learn how to solve it at home as I was trying one of those brief insight oriented therapies. I also distinctly recall my supervisor asking me why I was late to the session with that patient. I was confronted if- my real excuse of drawing blood from a previous patient that inadvertently took more time than expected, and has encroached the time of therapy session- been infact an intentional avoidance on my part. May be this is a wrong example involving wrong tool with wrong patient in the hands of a novice like me, a few decades ago. That said, I could relate to Anna Freud's defense mechanisms [8], a creative adjustment for me to understand the dynamics in intra-psychic and inter-psychic thought processes in bite size pieces. The list of primitive and mature defenses offers sex planatory power for the neurotic psychopathology.

So, in the spirit of the Winnicott's 'good enough' theory [9], I was about to settle on finding an optimal good enough solution to my pursuit of optimal therapy, and developing equanimity between true and false self. Not everything had to be peeled off in interpretation to revert to being a vulnerable true self [10]. I believe that it is possible to integrate the elements of treatment, if it helps the patient. Even the self-psychology model that looked attractive and based on building a sense of self through empathy sometimes appeared to fall short of generating tangible solutions of real issues in crisis. So embracing Otto Kernberg's theory of nurturing narcissim [11,12] via Kohut's mirroring [6], and finding sustainable methods to reflect and regain positive thinking through CBT tools, solving practical problems through Rogerian methods of finding common ground solutions to resolve immediate conflict could potentially work together. Making sure that parents are validated by the therapist in parallel, so that they will build on their own empathy and sensitivity towards the child to strengthen the attachment made sense to me. Observations by Bowlby and Ainsworth [13] inspired me to involve parents in parallel so that they could nurture the attachment towards their children to melt the insecurity or avoidance out of disappointments from their children. Furthermore, in tuning into the cultural nuances, I pay attention to the remark by Bowlby, "If a community values its children it must cherish their parents" [14]. This could apply to minority population with the potential to be marginalized in the society or to the cross-cultural communication within an individual family. I must cherish his mother, and help her develop insight in nurturing her sensitivity towards her son beyond the language of her culturally driven social order that he is resisting.

Furthermore, as in the adolescent's context that I introduced at the outset here, there is a family that surrounds the youngster. No matter how much therapy I offer him, there are going to be the dynamics within the family with back and forth interactions that could be potentially inflammatory, no matter how or who incited conflict or emotional distance. We have choices between structural [14,15], strategic [16] and systemic [17] family therapy methods to address these family dynamics. The questions that arose were if the boundaries are too loose or too rigid to interfere with the business of parenting and communication; or are it the quality of affective involvement and ability to solve the problems without conflict; or it is pathological microsystems disrupting the transactions within the family? My answer is apparent in the question that is laid out here. Just as elements are potentially integrated from various psychotherapies, I see that elements of family therapy can also be used effectively in addressing the dynamics within the family. In fact it is the integrated individual and family focus that offers the full value of any therapeutic intervention. I often trust the nonspecific factors of therapy to allow me to offer insights as suggestions arrived through Socratic questioning [18].

Modern psychiatry opened the doors of the brain function and we know way more than ever before about the cognitive problems that may be impeding the psychological processing of information. We are equipped with the knowledge of how cognitive systems are intricately connected to emotional systems in the brain networks [19]. The more we are learning to understand the issues with executive dysfunction, inattention, and working memory and verbal memory problems [20], the more guilty one would feel as a therapist to just focus on insights and conflict resolution without catering to the frustration due to the inherent cognitive problems directly linked to emotional disturbance. This interface between cognitive and emotional brain networks may or may not be dysfunctional in any given patient, but this is more common in developing child with psychiatric issues than we believed in the past. This is often the case where there is no hint of intellectual disability in a youngster. Therefore, therapists are encouraged to open their minds to look at the whole self of a being.

Fast-forward 25 years; I treasure my knowledge in psychotherapy including psychoanalysis despite my nascent dissonance with my supervisors. I now admit with humility that I needed many years of percolation. More than using the techniques 'as-is' the theories have provided strong foundational understanding of the dynamics that I would otherwise have missed. The teachings from the grand masters immersed me and countless others in laying a quick path to understanding what is at play in psychological terms. I recognize the value of Freudian sentence from his letter to the existentialist psychiatrist Ludwig Binswanger that "psychoanalysis is a cure through love".

New knowledge is assimilated onto what we now are discovering. As I arrived in the USA, I took upon the task of designing the child and family focused cognitive behavior therapy (CFF-CBT) that integrated CBT tools with self psychology model, taking into account Rogerian problem solving, validating parents as they nurture their children with sensitivity fostered by Bowlby and Ainsworth [13] and teaching parents to use strategies to cope as a family [21]. Additionally, it is a brief therapy involving 12 sessions. This was empirically tested in randomized trial in a specific set of emotionally dysregulated youth with bipolar diathesis that proved to be fruitful and subsequently a user manual was prepared for dissemination [22].

In 'finding the person' you are treating in therapy, the final deal closer in recovery is, therefore, the key ingredients in the making of a therapist. They are the encompassing scaffold to any therapeutic intervention. I wondered what the inner goodness of the therapists was that attracted my teenage patient. We had to come up with mutually agreed elements that touched him. I tried to be in his shoes; especially as he sought empathy, connection, and to find himself through others' treatment of him, in pursuit of wanting to belong. I plan to integrate competence to help the aloof and distant Korean teen in a Caucasian family, with kindness as an act that go beyond the compassionate stance, respect without judging, and non-patronizing dignity in approaching him as an individual [23].

In summary, I would underscore to the future generations of residents and colleagues to reflect on the goodness defined by kindness and respect, with non- patronizing persona, glued together with competence while integrating the skills drawn from the theories of the Grand Masters that are likely to meet the needs of the patient. This is the closest I came to disassembling the ingredients in the making of the 'goodness' in the person as a therapist for my adopted teen patient with Korean descent. Rest of the elements will fall into place with any evidence-based medicine that would embrace these elements of ultimate goodness.

References

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