Modern Psychoanalysis

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Thursday, January 17, 2008

Clinical Techniques: #2 - Commands

Clinical Techniques: #2 - Commands
Dr. Hyman Spotnitz (1985, p.255) says that “(t)he preferred intervention when the treatment gets under way is the command.” In spite of this, the use of the command as part of our clinical armamentarium could be said to be even more frequently “overlooked” than the use of our first-mentioned clinical technique, silence.

Why is this?

First, ideally modern psychoanalysis is a patient-centered, patient-driven approach to therapy. (See e.g., Fennessy, 2008). This infers that the therapist does not attempt to direct the patient in the same way as s/he might in other therapies.

Beyond that, it must be mentioned that many of the applicants for candidacy in modern analytic programs start out with personalities that aren’t easily adapted to the idea of giving patients direct orders or commands; quite the contrary. The ability to use or develop divergent clinical techniques (such as commands) may, therefore, depend on the quality of training received in the psychoanalytic institute.

Luckily for some analysts, however, in modern psychoanalysis
“… (c)ommands are not issued to secure obedience;” instead:

“(t)he therapist’s intent … is to find out whether the patient wants to obey or defy and to help him communicate why he wants to do so – in other words, to mobilize resistance and, eventually, to resolve it.” (Spotnitz, 1985, p. 255).
According to Spotnitz, commands may be as simple as ordering the patient to “(l)ie on the couch and talk,” or they may be effectively “formulated in terms of the patient’s resistive attitude…,” for example:
“The patient may say… that he is not going to talk any more. A reminder that he is supposed to talk tends to intensify the resistance of a negatively suggestible person, but if he is told, ‘You’ve talked too much. Keep quiet for the rest of the session,’ he may reply, ‘I will not’ – and continue talking.” (1985, p. 255).
Notice that when we use the term “resistance” in modern psychoanalysis we are normally referring to “anything that interferes with talking.”

Robert J. Marshall refers to commands, such as those used in the last example, as

“… prescribing the resistance in that the therapist literally orders the patient to exercise resistance. Prescribing the resistance may be best used with negatively suggestible persons. These are persons whose characterologic mode of response is ‘No.’” (1982, p. 69).
Marshall (1982, pp. 69-70) then gives the following case involving his patient, Sam, a 10-year old boy:

“He began a series of resistances after announcing that he wasn’t going to say anything more about his life. When he reiterated his unwillingness to talk, I said (in essence), ‘Sam, you’ve really told me a tremendous amount about yourself in a short period of time. I think you deserve a vacation in talking about yourself. So now tell me what kinds of things you can do in order to avoid talking about your life.’ I also indicated to him that I thought he was an ‘expert’ in thinking up ways of avoiding talk. I enjoined him to tell me any conceivable ways of avoiding talk so that I might recognize those ways with other children. He readily revealed all of his ploys… At this point I suggested to him that there probably were good reasons for his not wanting to talk, that he should really talk if he wanted to be helped, but that it was okay if he didn’t talk. Sam then ventured some complaints and feelings about his parents about which he felt guilty.”
This excellent example shows that commands may thus be used as part of joining the patient’s resistance. (“Joining” as a clinical technique will be separately discussed in a later article).

Marshall also used “requests” similar to commands to great effect with a 13-year old boy named Bill, who appeared to be the polar opposite of Sam – Bill was extremely anxious to please his therapist. Over a period of weeks, Marshall confronted Bill “…with a series of unreasonable requests such as bringing me a ham and cheese sandwich for lunch,” until Bill was finally able to object and later “became more comfortable in revealing his rage…” towards his dictatorial therapist. (1982, p. 65).

Spotnitz indicates that commands may be used to help certain patients restore control, to help teach patients to assert themselves, or for patients who cannot tolerate or respond to questions. (1985, pp. 256-57). Likewise,

“Countercommands may be issued. When ordered to do something by a patient, the therapist may say, ‘You do it.’ A patient who commands the therapist to ‘Keep quiet,’ may be told, ‘You keep quiet too.’ ‘Tell me,’ ‘Say it,’ and other brief statements in the imperative mood are often made.” (Spotnitz, 1985, pp. 256).
As with all of our modern psychoanalytic techniques, these interventions are never used haphazardly, but only as part of the treatment plan. Though the technique is simple, the implementation of it is not – it takes a skilled modern analyst to use these techniques in furtherance of “the talking cure.”
References

Fennessy, J. (2008). Narcissism and the Contact Function, in PRACTICE MATTERS, A Journal of Modern Psychoanalytic Treatment Technique (Vol. 2), Philadelphia, PSP.

Marshall, R. (1982). Resistant Interactions: Child, Family, and Psychotherapist, NY, Human Sciences Press.

Spotnitz, H. (1985). Modern Psychoanalysis of the Schizophrenic Patient: Theory of the Technique, Second Edition, NY, Human Sciences Press.


© 2008, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail: njanalyst@hotmail.com
http://modernpsychoanalysis.org

Psychoanalysis

5 comments:

kris said...

Commands do seem to go against my grain, as does another technique mentioned in your blog: the treatment plan. I am quite interested in what a "treatment plan" looks like in the modern psychoanalytic tradition.

I am familiar with the cognitive-behavioral types of treatment plans favored for insurance reimbursement. For example, a typical intervention for a depressed person might be "client will learn to identify negative self-talk" followed by "client will replace negative talk with positive affirmations". These plans came with timelines for each goal, so the client could evaluate whether he/she was succesful or not.

The plan is supposed to be created in collaboration with the client. To assure this "collaboration" both parties sign, affirming this to be the truth despite any and all facts to the contrary.


So back to the treatment plan in the modern psychoanalytic tradition. If I get it right, the big picture is that the client talks, and the analyst(therapist) facilitates the talking. This suggests that a treatment plan might identify 1) those areas that a client may be loath to discuss, 2)the typical ways the client resists & defends against talking about the forbidden subject(s) and 3)strategies and or techniques that might promote a willingness, comfort or safety in broaching the censored material.

Close?

Jim said...

Very close.

Though you’d have a great deal of difficulty seeing what one of my "treatment plans" looks like since I never write them down. :)

I consider at least the first two areas you mentioned; and a few others, such as the patient’s need to be safe, the patient’s emotional maturity level, what the patient might need from me, what I feel in the room, and whether the patient is engaging in progressive communication.

I’m not generally interested in “promoting a willingness, comfort or safety in broaching (any particular) censored material,” and there are no “timelines” in the traditional sense.

I’m most interested in promoting the patient’s ability to talk about whatever s/he wants to talk about.

kris said...

I have been mulling over your response. Some of it makes sense to me.

This includes the parts about figuring out the patient's maturity level and need for safety.

I also like and understand the parts about being alert to what you may "feel" in the room at any particular point.

I view timelines as counter therapeutic. They place a set of roles on each participant that invades and diminishes the therapeutic relationship. It injects issues of control, evaluation, performance and value into the hour.

But while I eschew the controlling nature of timelines, I embrace the proposition that the therapist is to promote CHANGE and to assist the patient toward those goals. Yet you note that the only goal is to help the patient talk about what he or she wants to talk about.

I have a hard time believing that talking, by itself could be a curative factor. A little story to illustrate.

While in college, I took the city bus from my place to my classes. "Hilda", was always there and who could sit down and start a sad narrative of her life that seemed never ending. By the end of my college years, Hilda's issues did not seem to change in the least bit.

Surely there is a magic outside of just "talking". What is it?

Jim said...

I’m not sure that the “only goal” is to help the patient talk about whatever s/he wants to talk about - though it may sometimes seem that way! :)

Your story is an excellent illustration of a typical pattern that one might see in treatment.

This is why the modern analyst needs to consider whether s/he is helping the patient engage in progressive communication, even though there are no “timelines” in the traditional sense.

What do you think the magic outside of just “talking” is?

kris said...

Ahhh! the magic of treatment...
Isn't that worth a library or two of dissertations?

I believe that the magic comes from two different sources. The first comes from the professional who is the repository of decades of declarative, logical, verbally passed knowledge and skills. But the professional must have an equal repository of empathic, deeply respectful, open, creative, tentative naievete.

But that's just one part of the equation. Then there is the person who is able to undertake the potentially promising yet terrifying journey.

And I think the real magic is the four way dance between the promise and terror, the skill and respectful ignorance.