AWARD PAPER: BALINT AWARD PAPER
Year : 2019 | Volume
: 35 | Issue : 1 | Page : 19--23
Therapeutic relationship: Riding on a bumpy road and steering through to the destination
Drug De-addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Dr. Abhishek Ghosh
Drug De-addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Therapeutic relationship runs a dynamic course; it usually grows and intensifies with time, but there could be unforeseeable twists and disruptions. The course, to no small extent, is contributed by the therapist's dispositions and expertise on a particular theoretical orientation. Expertise is dependent on experience, level, and quality of training. Disruptions, although unwanted, give an opportunity to reflect upon the shortcomings and are an impetus for a course correction, which more often than not gives a desirable result. In this case discussion, I shall describe the highs and lows in a therapeutic relationship. After the initial euphoria, the therapist's inexperience, limited skills, and a wrong decision would contribute to significant disruption. However, the therapist's awareness of his/her limitations, a motivation to learn, and active help from mentors and colleagues would provide momentum in the second half of the therapy, which finally would see the daylight of success.
|How to cite this article:|
Ghosh A. Therapeutic relationship: Riding on a bumpy road and steering through to the destination.Indian J Soc Psychiatry 2019;35:19-23
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Ghosh A. Therapeutic relationship: Riding on a bumpy road and steering through to the destination. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Dec 9 ];35:19-23
Available from: http://www.indjsp.org/text.asp?2019/35/1/19/254986
Prologue: The initial encounter with the client
When I first met Mr. A, a gentleman in his mid-forties, I was a first-semester resident of addiction psychiatry. Mr. A was referred from the emergency, where he was admitted with a head injury, incurred during an episode of possible benzodiazepine withdrawal seizure. He appeared disheveled, and his raccoon eyes gave an impression that he was a man who had been through a lot of suffering of late. During our conversation, I found him extremely polite with good social communication skills. I learned that he earned his livelihood as an area manager of a pharmaceutical company. Mr. A said with a certain air of conviction that he would like to quit both benzodiazepines and alcohol. However, his visibly distressed (and disgruntled) wife, Mrs. N, was seemingly dismissive of his claim and pressed for his admission. Nevertheless, by that time, Mr. A was able to convince me of his “good” motivation. To “prove” my point, I, as a DM trainee of addiction psychiatry administered the Readiness to Change Questionnaire to quantify his level and stage of motivation. Not to my surprise, he was right there, in the action stage. I prescribed a few medications for the treatment of withdrawal symptoms, reassured his wife, and gave an appointment after a week. My first encounter with Mr. A was quite nondescript, except for his unusually courteous behavior.
I had a few more meetings with the couple over the next couple of months. Mr. A's motivation would remain in the action stage on pen and paper, but in real life, he would be using both alcohol and benzodiazepines. In addition, there would be discrepancies between the reports of Mr. A and Mrs. N regarding the amount and frequency of use. Mrs. N would always show her concern for Mr. A's excessive use of sleeping pills and resentment for his tendency to hide. She would break down in tears and request Mr. A, with folded hands, to “come clean.” I perceived Mrs. N as melodramatic and overinvolved. Mr. A revealed about his stress of meeting deadlines in the office and his struggle of dealing with his wife's skeptical attitude at home. During the same time, I was getting acquainted with the spirits and principles of motivational interviewing (MI) and was starting to pin my faith on the Rogerian psychology, erected on the pillars of empathy, unconditional positive regard, genuineness, and autonomy., Here, I think I owe my readers some explanation. Mr. A would attribute the continuous intake (and excessive, as per his wife) of substances to his job and family stress. Non-Rogerian therapists (especially those who have a predilection for psychoanalysis) would view Mr. A's attribution as rationalization, a neurotic and maladaptive defense which is likely to hinder the progress of the therapy. These therapies are based on a deficit model, and the evaluation is often focused on detecting the deficit to be corrected by the professional expertise. Therefore, a non-Rogerian therapist would try to instill knowledge, insight, and coping skills once they identify Mr. A's impaired problem-solving. However, a Rogerian therapist, following the spirits of the MI, would see it as an opportunity to explore and evoke the person's capabilities to deal with stress. The implicit message is, “you have what you need, and together we will find it.” Therefore, I was trying to elicit “change talks” and to develop a “change plan.” I would feel encouraged by the copious use of the Desire, Ability, Reason, Need, and Commitment to Change language by Mr. A. Nevertheless, Mrs. N would insist that her husband was insincere, irresponsible, and above all “manipulative.” I would rather focus on the harms of unwanted surveillance. I remember, once I also invoked George Orwell's 1984 to dwell on my point of unwarranted and unwanted surveillance and curtailment of freedom. I explained the concept of reactance, which talks about larger resistance in the presence of the larger threat to freedom. Mrs. N would be a reluctant listener of those conversations.
The rising action: The beginning of disappointments
After a few months, I realized that the treatment was not going anywhere about the abuse of sleeping pills (but his alcohol consumption had reduced to once in a fortnight). During this period, Mr. A had met with multiple minor roadside accidents, while allegedly driving under the influence of sleeping pills. He would doze off during the day and would appear “intoxicated,” reported his wife. Alprazolam and zolpidem strips were recovered from Mr. A's scooter, kitchen cabinet, shaving kit, and various other unusual places. The most “annoying” (to me) was, Mr. A would always appear nonchalant and dismissive about all these. I offered and persuaded for admission. To start with, Mr. A was unwilling for the admission and was discharged (on request) after 7 days. I increased the frequency of follow-ups but to no avail. The problem worsened; frequent altercations between Mr. A and Mrs. N ensued. There were instances of physical violence as well. I contacted Alcoholics Anonymous (AA) and Al-Anon, thinking that engagement to these self-help groups would help to disengage (and thus reduce violence) the couple for the time being. This too did not work. Mr. A would land up in the meetings in “intoxicated” state (with sleeping pills) and would report feeling uncomfortable disclosing personal details. He would also whine about the “standard” of the other AA participants. I found him “snobbish” but tried best to hide my feelings. However, Mrs. N was regular in Al-Anon.
The Chekov's gun: A half-hearted course correction
Witnessing not much progress (might be an understatement), I thought of changing my stance from “Rogerian” to something more active and directive. I borrowed the principles of problem-solving skill training for stress management. Mr. A was trained to identify problematic aspects of stressful events in the form of problem behavior, thoughts, and feelings; he would be encouraged to brainstorm and think about alternative strategies to deal with the situation, and finally would evaluate the alternatives and find the best possible solution. I also taught him the steps to manage craving and techniques of autogenic relaxation. Barring the crucial step of implementation of alternatives in real life, Mr. A would be able to do all the other steps (with some guidance from my side). During the same time, I had also discovered an indirect and critical communication pattern between Mr. A and Mrs. N. They would seldom appreciate and listen to each other; most of their conversations would end up in a verbal (or sometimes even physical) argument. I chose behavioral couple therapy to address these problems. However, I could not progress much beyond the recovery contract phase. One of the components of the recovery contract is daily trust discussion. In the absence of transparency from Mr. A's side, Mrs. N would find the trust discussion as unilateral and customary, lacking the required enthusiasm.
The climax: An orphanized client and hubris of the therapist
Once, Mr. A arrived at the clinic in a drowsy state. He started the conversation in a slurred and incoherent speech. When I inquired about sleeping pills, he blatantly denied. I lost my temper and criticized him for being dishonest and insincere to the “doctor.” Despite his apology, I transferred his case to my colleague. I explained, “I need some time to reconcile my feelings and changing the doctor could be the best possible bet at this time.” They agreed with a truckload of reluctance.
I was in constant touch with my colleague. I heard his condition had worsened further. He had an episode of blackout and lost his scooter keys during that time. The interpersonal relationship problem with the wife escalated to such an extent that other family members had to intervene. Because of poor work performance, he was summoned by his boss and given an ultimatum. He met with another roadside accident, and the police complained about “drunken driving.” He was admitted for the second time, for 1 month. However, it did not help much, other than putting a break in his drug use for some time.
The falling action: Good sense prevailed
A couple of months following discharge, Mr. A, and his wife approached me, and I took charge once again. By that time, I was an assistant professor. I resumed my nondirective Rogerian approach (from the directive cognitive-behavioral approach), and only this time, I would do more it diligently. To my surprise, I succeeded. Mr. A won't take any nonprescribed benzodiazepine. Subsequently, there was an improvement in the quality of the marital dyad as well. Mr. A would spend time with his wife and son and would make significant changes in his lifestyle and daily routine too. He would practice yoga in the mornings, take his son to school, take a stroll with his wife in the evening, and tutor his son at night. However, life was not very kind to him. He lost his 27-year long job during a mass layoff of at his pharmaceutical company. I thought of those famous lines by Charles Dickens, “It was the best of times, it was the worst of times, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair…” Surprisingly, Mr. A did not relapse; he would deal with a degree of “maturity.” He told me, although he was upset, he saw it as an opportunity to consolidate his relationship with the family, to regain their trust, and to recuperate from his “disease.” He started to rekindle his old network of friends and found a new job in the next couple of months. Lo and behold, there was not a single instance of benzodiazepine abuse. During the early part of this year, I could taper and stop the prescribed benzodiazepine completely. A few months ago, Mr. A celebrated his one year of abstinence from both sleeping pills and alcohol.
The Soliloquy: A Reflection on the Therapist's Techniques and Decisions
My initial attempt at MI technique could not break the ice, but the same Rogerian approach was helpful at the end. It was baffling to me at first, but now, I am almost sure about the reason. The initial MI lacked spirit; it was like a song with only lyrics, without melody; a body with flesh and blood, without the soul. I was young and inexperienced to figure out. I would be too busy to complete my assessments and gathering information. My reflective listening would have been a mere repetition of his statements; those were mechanical and perhaps lacked the earnestness. The affirmations would mostly sound like hyperbolic praise. I had also fallen in the “expert trap” because of my penchant for asking too many questions and collect more data. I might have focused prematurely on sensitive issues (e.g., interpersonal relationship) before satisfactory engagement. Overall, I would be more directive than what should have been. Although I emphasized the egalitarian nature of our partnership and respect for autonomy, I, in reality, was trying to dictate the terms and conditions (the content and the pace of the therapy). Ideally, the MI therapist should have “appropriate” investment in the client's outcome. He should be fully cognizant of the fact that the clients will sometime choose not to change. I, on the other hand, was highly invested in a positive outcome. I wanted to “prove myself” as a budding expert in addiction psychiatry and had turned Mr. A into a subject of my “wish fulfillment.” With all these faulty techniques and motives in abundance, resistance was an inevitable outcome.
My second blunder was altering the therapeutic approach in midway. I had “projected” my faults on to the Rogerian philosophy and changed my stance from a nondirective to a directive one. This had been detrimental as I inadvertently conveyed a dubious message. Up till then, the message was “you have everything you need, and my job is to help you in drawing those resources consisting your wisdom and experience.” However, with the change in stance, the implicit message was, “I have what you need, and I will give it to you.” The previous focus was on Mr. A's strengths and skills, but the later focus was on his lack of skills. In the MI, it was like an active collaboration between experts, whereas in the problem-solving or behavioral couple's therapy, I was an expert, instilling new skills in my passive client. This antithetic position of these two stances had confused Mr. A. Not surprisingly, his condition worsened. The “failure” was not acceptable to me, and I had to blame someone or something. Previously, I had already blamed the school of psychotherapy, and now it was Mr. A's turn to take my blame. First, I failed him, and then I deserted him.
Denouement: Actions behind the Scene
However, taking the much-needed time out had helped me indeed, to understand my mistakes, to reflect upon my faulty techniques, and to brush up my skills of MI. The time had also helped me to introspect, i.e., to reflect on my thoughts, feelings, and memories. I flipped through my written notes to have some insights about my attitudes. To my dismay, I discovered phrases like “he was caught red-handed,” “lying unashamedly,” and “abusing wife and son.” All these were a covert reflection of my negative and biased attitude toward Mr. A and were starkly in contrast to unconditional positive regard. These phrases would also suggest that I was immersed in annoyance and frustration, whereas MI requires me to be warm, friendly, and hopeful. Another quintessential component which I found missing was compassion. Our services are, in any case, for our client's welfare and not principally for our own. I had a significant self-interest, to prove my worth and to get approval and appreciation from my mentor. These narrow pursuits drove the initial treatment to a large extent. I realized that I acted like one skillful salesman rather than a therapist with a Rogerian slant.
Other than introspection, I sought suggestions from Dr. D, my mentor and “ego ideal;” I went to him with my introspection, in a state of desperation and dejection. Dr. D inspired me to read the novella, Jonathan Livingston Seagull by Richard Bach. Jonathan was frustrated with his limited seagull life; he wanted to fly high and perfect; he failed time and again but did not give up. A few lines are etched in my memory, “we can lift ourselves out of ignorance, we can find ourselves as creatures of excellence and intelligence and skill. We can be free. We can learn to fly.” This freedom, as I understood, was freedom from fear of disapproval and freedom from fear of failure. I also watched a couple of lectures by William Miller on YouTube. Miller said when he first started working with people with alcohol dependence, he knew nothing about alcoholism and what he did was to listen to them, their dreams, and hopes. He also said MI had a long winding story that did not happen by forethought but occurred in unexpected, serendipitous ways. I came to know, how the techniques and spirits of MI would be discovered as an afterthought while a group of young Norwegian psychologists would question Miller. It underscored the importance of spontaneous conversation, rather than a stilted mechanical therapy which I was trying so far. I also read the third edition of the “Motivational Interviewing: Helping People to Change,” cover to cover. I also consulted the website for the Motivational Interviewing Network Training (https://motivationalinterviewing.org/). This was a useful resource to learn, practice, and get feedback on MI skills. In addition, several videos are demonstrating specific skills of MI. However, the effort which was most useful of all was perhaps the feedbacks I received while presenting the case in the psychotherapy forum, attended by my supervisors and other fellow residents.
Hence, when I resumed the therapy later, I was aware of my previous limitations, equipped with new and improved skills, and infused with hope and enthusiasm. I did not think twice to take up my original stance, corrected my previous errors, and delivered a more accurate MI. I honored Mr. A's absolute worth and potential as a human being, recognized and nurtured his immutable autonomy to choose his way, sought through empathy to understand his perspective, and affirmed his efforts and strengths. I had developed a genuinely collaborative partnership and tried to evoke his skills and strengths to deal with the existing problems (drug related or others). I succeeded this time.
Progression: Underrecognized but Essential Caveats
I cannot emphasize more about the need for psychotherapy training and supervision for a mental health trainee. For a trainee in addiction psychiatry, learning, practicing, and maintaining the skills of MI are of utmost importance. Learning should be multipronged. Learning from the book should be supplemented by observing others doing MI. However, only study and observation will not get us anywhere, unless one practices it every day, in each encounter with clients. Practice should also be supervised, for immediate feedback on the performance. Feedback is fundamental to any form of learning. Attempt to learn without any feedback is like practicing archery in the dark! I consider myself fortunate that our curriculum has a psychotherapy supervision forum, where we would listen to the recorded sessions (either written or audiotaped). Although useful, this too has several limitations. Feedback is most valuable when given immediately. Psychotherapy forum typically happens weeks after the original sessions. For something like MI, taking notes during the session is not encouraged. Hence, the completeness of the written record is contingent upon the memory of the therapist. It is not surprising that many of the minor details could be omitted unintentionally. An important mode of communication during sessions is the nonverbal communication. Neither “audiotaped” nor written documentation is geared to gather information on it. There is a concept of coaching in MI, which has been floated by William Miller. Coaching is to be based on direct observation and immediate feedback. He has also prescribed simple strategies in listening to our own MI sessions. One could count the number of questions asked and the number of reflections (a lower ratio of the question to reflection would suggest fidelity of the MI); counting OARS (asking open-ended questions, affirmation, reflective listening, and summarizing) response, change, and sustained talks could also be done. One could also ascertain the styles which are incompatible with the MI.
Finally, the MI is almost diametrically opposite to the expert-based, authoritative therapist–patient relationship, practiced commonly. Therefore, it will need an extra effort and commitment to master the skills of MI. The amount of effort needed will depend on the therapist's disposition and allegiance. Initial failures, although overwhelming, should not deter a young therapist from learning and practicing one of the most utilitarian psychotherapies of our times, which has found its application in a wide range of medical and public health-related issues.
My journey with Mr. A has been an eventful one and has taught me some crucial aspects of the client–doctor relationship. I realized the centrality of the respect for client's autonomy, the nurturance of an accepting attitude, the need to establish a partnership (rather than an authoritative master–subordinate relationship) with the client, and the value of compassion. The journey has made me humble as now I am aware of my limitations. Nonetheless, it has also strengthened my morale as I know I have the capability to bounce back from a disparaging situation.
The author would like to acknowledge Debasish Basu for the support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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