Priorities in Treatment

Priorities in Treatment

Modern Psychoanalysts have adopted one of their most important guidelines from the Hippocratic Oath - “First, do no harm.”

A first step to help insure that they “do no harm” is for the analyst to rely on the contact functioning of the patient’s own ego.

Do the patient’s statements or questions indicate that the patient aware of the analyst as an individual? Is the patient content to lie on the couch and talk until hell freezes over? Does the patient prefer to be silent? etc.., etc..

In any of these cases the analyst will respond (or not respond) based on what the patient’s contacts say about the individual s/he is dealing with. Rather than imposing interpretations or unsolicited ideas on vulnerable patients; modern analysts base interventions or responses, if any, on the contacts they receive from those patients.

Additionally, as long as the patient is talking and engaging in progressive communication, the analyst is usually not intervening much at all.

When resistances become operative, there a type of hierarchy involved in dealing with them. One could say that resistances are dealt with according to a system of priorities - depending upon what kind of resistance is being manifested at the time. The priorities in treatment can be conceptualized as follows:

1. Treatment Destructive Resistance – The treatment destructive resistance (or “TDR’) is first in priority and foremost in every good analyst’s mind. It refers to anything which will destroy the treatment if left unchecked. Therefore, the first question most analysts ask when confronted with new behavior or dialogue is “Is this a potential TDR?” i.e., “can this wait, or do I need to deal with this right now?”

Patient’s questions which might be totally innocent in a more social setting, such as “How is the parking near your office?”; or patient’s statements such as “I didn’t have an easy time parking here;” would each need to be carefully investigated and considered as potential treatment destructive resistances in the modern analytic setting.

When attempting to deal with a TDR, “all bets are off;” i.e., the analyst may use a variety of clinical techniques which might not otherwise be used - to try to save the treatment. The premise is that if the patient is not coming to talk s/he will not otherwise be helped.

2. Status Quo Resistance – At this stage the patient has settled in to treatment and clings to old patterns; the patient may wish to conceal any “bad feelings” and/or concentrate on proving that s/he is a good patient.

3. Resistance to Analytic Progress – In this stage, which may be difficult to distinguish from the last, patients may experience anxiety over investigating anything new or adding anything new to the treatment. Thus, the patient may have largely abandoned the idea of clinging to the old “status quo,” but may also be fearful of the new material or of “being pushed” towards new realizations.

4. Resistance to Cooperation – Here, patients may try to concentrate exclusively on themselves; to the exclusion of their analyst. In a group environment this could be called “resistance to teamwork.” At this stage, patients may be aware of their therapists as “real people,” but may not realize the importance of working together, or may not want to give their therapists the satisfaction of doing so.

5. Resistance to Termination – This stage can involve the patient’s falling back on old habits in an effort to keep the old relationship with the analyst. In this regard, some modern analysts believe that there should be a natural end to most treatments at a certain point, whereas others do not believe treatment needs to end as long as both parties want to work together. In either case, it is usually thought that the feelings surrounding the ideas of termination (i.e., separation) should be worked through.

Spotnitz, 1985, pp.175-183, Spotnitz, 1976a, pp. 86-88 and Spotnitz, 1976b, pp. 183-191.

In actual treatment, the above stages of resistance often overlap or are blurred together. Patients can display behavior reflective of several different stages in a single session or can slip back and forth between stages over a period of time.

Also, while treatment destructive resistances are generally far more common at the beginning of treatment, they can also arise when moving from one stage of resistance to another, or at any other time.

Resistances or defenses are not always obvious or easy to detect; its a good bet that many patients even do their best to conceal them. Therefore, the best modern analysts know that they need to be constantly sensitive to their own feelings as a guide to bringing their patients successfully through every stage of treatment.

References

Spotnitz, H. (1976a). Psychotherapy of Preoedipal Conditions, N.Y., Jason Aronson.
Spotnitz, H. and Meadow, P. (1976b). Treatment of the Narcissistic Neuroses, NY, Man. Center For Advanced Psychoanalytic Studies.
Spotnitz, H. (1985). Modern Psychoanalysis of the Schizophrenic Patient: Theory of the Technique, Second Edition, NY, Human Sciences Press.

© 2007, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail:
njanalyst@hotmail.com
http://modernpsychoanalysis.org/