Clinical Values

Emotions That Guide Psychoanalytic Treatment

Sandra Buechler

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135061005
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

In this refreshingly honest and open book, Sandra Buechler looks at therapeutic process issues from the standpoint of the human qualities and human resourcefulness that the therapist brings to each clinical encounter. Her concern is with the clinical values that shape the psychoanalytically oriented treatment experience. How, she asks, can one person evoke a range of values--curiosity, hope, kindness, courage, sense of purpose, emotional balance, the ability to bear loss, and integrity--in another person and thereby promote psychological change? For Buechler, these core values, and the emotions that infuse them, are at the heart of the clinical process.They permeate the texture and tone, and shape the content of what therapists say.They provide the framework for formulating and working toward treatment goals and keep the therapist emotionally alive in the face of the often draining vicissitudes of the treatment process.

Clinical Values: Emotions That Guide Psychoanalytic Treatment is addressed to therapists young and old. By focusing successively on different emotion-laden values, Buechler shows how one value or another can center the therapist within the session.Taken together, these values function as a clinical compass that provides the therapist with a sense of direction and militates against the all too frequent sense of "flying by the seat of one's pants."Buechler makes clear that the values that guide treatment derive from the full range of the clinician's human experiences, and she is candid in relating the personal experiences--from inside and outside the consulting room--that inform her own matrix of clinical values and her own clinical approach. A compelling record of one gifted therapist's pathway to clinical maturity, Clinical Values has a more general import: It exemplifies the variegated ways in which productive clinical work of any type ultimately revolves around the therapist's ability to make the most of being "all too human."

1 Evoking Curiosity

I want to beg you, as much as I can, dear sir, to be patient toward all that is unsolved in your heart and to try to love the questions themselves like locked rooms and like books that are written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is to live everything. Live the questions now.

• • •

For if we think of this existence of the individual as a larger or smaller room, it appears evident that most people learn to know only a corner of their room, a place by the window, a strip of floor on which they walk up and down. Thus they have a certain security.

—Rainer Maria Rilke, Letters to a Young Poet

These lines were written by Rilke to a young man who asked for the poet's advice as to whether he should become a writer. The young man, Franz Xaver Kappus, is impatient and wants "The Answer," now! The 10 letters Rilke wrote to help guide the anxious fledgling have been published as the Letters to a Young Poet.

Rilke responds to the youth's urgency with wise and gentle advice. In these letters, written from 1902 to 1908, Rilke recommends patience. He advises Kappus to maintain an open mind and not to succumb to easy, ready answers simply to have an illusion of clarity.

Rilke's (1934) humility about being able to help Kappus can serve as a warning to clinicians: "For at bottom, and just in the deepest and most important things, we are unutterably alone, and for one person to be able to advise or even help another, a lot must happen, a lot must go well, a whole constellation of things must come right in order once to succeed" (pp. 23-24).

How does the clinician encourage the patient to "live the questions now"? How do we elicit openness to new experience, willingness to experiment, tolerance of uncertainty and ambiguity? How do we sustain our own open minds and alive curiosity?

Instinctive Curiosity

In this chapter I reflect on what interferes with curiosity and what elicits it, in treatment and elsewhere in life. I believe there is a continuum, from curious open-mindedness to paranoid closed-mindedness. Curiosity and paranoia are opposites, in their response to the unfamiliar (for a discussion of the absence of curiosity see D. B. Stern, 1983). To stimulate the patient's curiosity in treatment, we have to address paranoia's pervasive pull, in ourselves and in the patient.

If we watch an infant eagerly exploring, we may be puzzled by this issue. Isn't curiosity an inborn proclivity? William McDougall (1908, cited in Izard, 1977, p. 197) defines curiosity as an instinct and highlights novelty as its instigator: "The native excitant of the instinct would seem to be any object similar to, yet perceptibly different from, familiar objects habitually noticed." McDougall suggests that lesser degrees of strangeness elicit curiosity, whereas greater degrees activate fear.

Almost a full century separates us from William McDougall, yet I believe this to be a timely insight for us as individuals, and as a society. Are we intrigued by the stranger, or do we become defensively closed off? Our ability to remain open to the strange and unfamiliar (nonfamily) has great political and psychological significance in our post-September 11, 2001, world. Our society as a whole needs to learn how to find enough that is familiar in the strange(r) to evoke more curiosity than fearful defensiveness. But we also need to find enough that is unfamiliar so as to elicit sufficient active curiosity.

Writing of interest and curiosity, Izard (1977) captures its importance to society, as well as to the individual:

In a very general sense the psychological significance of this emotion is to engage the person in what is possible, in investigation, exploration, and constructive activity. If people lived in a world that was stable and unchanging forever, then perhaps there would be no need for the emotion of interest. But the fact is that we are in an ever-changing world and have the capacity for the emotion of interest, and our interest will not permit the change and flux to go unnoticed. Our interest makes us want to turn things around, upside down, over, and about. This is because we see some possibility in the object or person or condition that is not immediately manifest to the senses

[p. 225].

Interest and curiosity motivate a good deal of our active effort, in treatment and the rest of life. Interest guides as well as motivates us through selective focusing. Any session presents both participants with myriad possibilities for focusing on some material, noting other material peripherally, and failing to notice some material at all.

Thus, for example, a patient comes to a session feeling hurt. In the previous session, she had waited for me to notice her new haircut and, perhaps, to comment. I had said nothing, not because I thought commenting inappropriate or because (as the patient supposed) I didn't like the haircut and was being polite, but because I didn't notice the haircut at all (I frequently overlook changes of this kind). My lack of interest focused me away from the haircut, which the patient (mis)interpreted.

Curiosity selects focus for both patient and analyst. This would appear to make their roles similar, and yet, I suggest, they differ in their responsibility for exciting curiosity. The analyst is called on to sustain her own curiosity and evoke it sufficiently in the patient to support ongoing treatment.

To further specify the analyst's task, I briefly describe six functions of the analyst's curiosity, and then consider how she can evoke the patient's ongoing curious self-exploration.

Curiosity as a Clinical Resource

The analyst's curiosity provides some protection from burnout. Maintaining our curiosity can help us balance the pain our work often evokes (see chapters 6 and 9). Like long-distance runners, analysts need sustained momentum. Curiosity motivates us to take understanding further.

More specifically, I believe curiosity is essential to

1. Focus selectively, preventing both participants from becoming overwhelmed by the material.
2. Create a context where other important interchanges can occur (D. B. Stern, 2002, p. 519).
3. Promote the integration of self-states in each treatment participant.
4. Notice what has not previously registered.
5. Expand the material or, in Sullivan's terms (1953, 1954, 1956) conduct the detailed inquiry.
6. Reflect on the countertransference.

After brief consideration of these uses of the analyst's curiosity, I address the process of promoting the patient's self-discovery. Successfully launching this journey makes the difference between a stunted treatment and a much richer, ongoing process. The development of the patient's "analytic attitude" (Schafer, 1983) toward himself is key to the results of the work (see chapter 9 for a discussion of the analyst's analytic attitude as a model for the patient's functioning).

Focus

Looking back, then, over this review we see that mind is at every stage a theatre of simultaneous possibilities. Consciousness consists in the comparison of these with each other, the selection of some, and the suppression of the rest by the reinforcing and inhibiting agency of attention

[James, 1890, p. 288, in Izard, 1977, p. 134].

I can think of no better description of sessions with patients than "a theatre of simultaneous possibilities." Curiosity heightens the spotlight on some issues, relegating others to the background.

A patient rushes into her session late, unsmiling, speaking rapidly. She is worried about her job and the uncertain economy, exasperated by her boyfriend's psychological obtuseness, and overwhelmed by her mother's chronic anxiety. Barely pausing for breath she recounts the latest episodes in these arenas. None of this is new to us. I feel as though what she is saying is both too much and too little: too much to focus on, yet too little room for meaningful reflection.

I begin to think about her ambivalence about her boyfriend. Should she marry him and try to create a shared life? She presents myriad instances of his inattunement, self-involvement, personal failures, unrealistic demands, and physical unattractiveness. Settling down with him would indeed be settling, in her mind.

Yet I also know she faults herself for her own hypercritical tendencies and inability to compromise. I begin to think about "settling" and "compromising." Are they different? What gives each its personal meaning to her, to me, to human beings in general?

Before I began to think about the question I already knew that, like Rilke's young poet, my patient wanted The Answer that would rid her of each of her problems immediately. Once again I felt the clash between the patient's hopes and my own (Mitchell, 1993; Buechler, 1995b, 1999). I knew I couldn't give her what she wanted, and that, if I tried, I would share her overwhelmed state.

Once I began to think about the difference between compromise and settling, the session took a shape, for me. Some stories seemed more relevant than others. Words acquired new meaning. I listened differently, and heard references to this issue in the patient's choice of words. When she spoke I felt less adrift. I was looking for something, not just looking. Some might say this was a loss. I had stronger "memory" and "desire," despite Bion's (1977) often quoted injunction that the analyst should have neither.

And yet, I could function, form thoughts, connect to my countertransference. I could hypothesize as to why her boyfriend might sometimes tune her out, using my own countertransference experience as information.

My thoughts had greater coherence, allowing me to associate to them. My patient's human dilemma evoked some personal reflections on my own life. I could also bring my experience as a reader of poetry, fiction, psychoanalytic theory, and emotion theory to the session. I could wonder what my own analyst would say about "settling" and "compromising."

I believe curiosity and focus are really aspects of each other, fundamentally inseparable. Each makes the other possible. They allow us to bring more to the session, shaping thought enough to give it meaning and, at least potentially, make it communicable.

Therapeutic Context

Curiosity, the desire to use words to understand—the desire that psychoanalysts of all orientations are glad to embrace as their own—is an orienting motive. It sets in motion the kind of interaction within which other things, at least equally important, can take place. You need a task around which to organize the relationship with a patient, because you are not a parent and not a friend; even a parent or a friend interacts with children or friends around some kind of mutual interest. Analyst and patient need to have reason to be together. . . .

Our curiosity is not a mere excuse for other kinds of relatedness. It must be authentic. We must really want to get to know the patient and ourselves, consciously and otherwise. And we must believe that learning these things will help. But in coming together to be curious, we also set up a situation in which other events are possible

[D. B. Stern, 2002, p. 519].

Curiosity moves us to wonder "why now?" Why does this patient come for help now, not a year ago, not next year? My training, largely Sullivanian, taught me what Levenson (1991) might call an algorithm of treatment. Clarify the "presenting problem" first and then work on setting the frame and getting a careful history. All the while, attend to fluctuations in the patient's level of anxiety, as expressed nonverbally (through gesture, tone, facial expression) as well as verbally.

Of course no treatment proceeds in such a linear, stepwise fashion. The "frame," which, as Levenson suggests (1991) includes the participants' expectations for the work, is negotiated throughout treatment. The "history" is continuously compiled and amended. Regardless of one's model of treatment and regardless of how much one believes the history is "uncovered" or "cocreated" (Spence, 1982; D. B. Stern, 1997), it is clear to me that it is, at least partially, an exercise in curiosity.

When I meet new patients, I usually want to know how he or she heard of me, and why they chose to see me. I am interested in why they seek treatment now, whether something feels different, or worse, or more urgent. I want to know how long each problem has bothered them. I ask about what I call "the situation" they were born into, because I believe each of us enters life in a cultural milieu, period of human history, socioeconomic context, familial configuration, and neighborhood that shape our experience of being human.

As the patient and I explore his or her history, I am forming, testing, and discarding hypotheses. I am also looking for connections, repetitive patterns, and difficulties that take different shapes as one grows older. For example, I come to understand a woman was severely depressed as a young adult. Might the depression actually go back far enough to help us understand her elementary school isolation?

For the moment I am concentrating on the clinician's curiosity, but I will focus on the patient's shortly. The elaboration of the patient's history and reasons for seeking treatment now are clearly fueled by curiosity. A patient tells me about a beloved relative's death, which occurred when she was well into her teens. I ask if she went to the funeral. She did not. I ask why. She is silent. She does not recall ever questioning this. Many other unanswered questions suddenly become salient. The clinician's curiosity, early in treatment, helps create a climate that makes the rest of the work viable.

Making the Strange Familiar

Many years ago I took a course on the metaphor, hoping to better myself as a poet. I don't think it furthered this goal, but it has helped me as an analyst. The basic exercise in the course was to use words to "make the strange familiar, and the familiar strange." I find this a useful w...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface and Acknowledgments
• Introduction: Manifesting Clinical Ideals
• 1 Evoking Curiosity
• 2 Inspiring Hope
• 3 Kindness in Treatment
• 4 Promoting Courage
• 5 Manifesting a Sense of Purpose
• 6 Creating Emotional Balance
• 7 Bearing Loss
• 8 Developing Integrity
• 9 Emotional Uses of Theory
• References
• Index