Moving In and Out

June 2, 2009
Jerry M. Lewis, MD
Volume 26, Issue 6

Then he fell silent and moments passed. I knew, of course, about his father’s recent death and their stormy relationship. I was moved by his sadness-could feel it within. I found myself thinking about my own father’s death. The silence between us continued, and finally I said, “It is so sad.” His crying intensified; he did not look at me. I felt a teary mist in my eyes and thought, “Now what?” Should I try to stay inside where he was and reflect again on his sadness, or should I back away by offering him a more cognitive level of dialogue? This question-whether to move in or out or, perhaps more accurately, to offer him the choice of where he feels most safe-is at the heart of some forms of psychotherapy. However, as we shall see, this is not the case in all forms.

Head down, he cried softly, “I can’t believe I’ll never see him again, never have the chance to talk with him about us, never try to resolve all the pain in our relationship.”

Then he fell silent and moments passed. I knew, of course, about his father’s recent death and their stormy relationship. I was moved by his sadness-could feel it within. I found myself thinking about my own father’s death. The silence between us continued, and finally I said, “It is so sad.” His crying intensified; he did not look at me. I felt a teary mist in my eyes and thought, “Now what?” Should I try to stay inside where he was and reflect again on his sadness, or should I back away by offering him a more cognitive level of dialogue? This question-whether to move in or out or, perhaps more accurately, to offer him the choice of where he feels most safe-is at the heart of some forms of psychotherapy. However, as we shall see, this is not the case in all forms.

Some of the factors that influence the psychotherapist’s ability to move back and forth between intimacy and detachment will be explored in this essay. My focus will be on only 3 of these factors: the psychotherapist’s theoretical orientation, some aspects of his or her personality, and whether residency training (or other educational pursuits) encourages the development of this ability.

Although under ideal circumstances a psychotherapist might be able to use different theoretical stances according to what seems best suited to the patient and his dilemma, that has, in my experience, rarely been the case. Even in my genera­-tion, with its psychotherapeutic emphasis, residency training was almost entirely psychoanalytic in its orientation. One was taught only psychoanalytic psychotherapy. Somewhat later, Havens,1 more than anyone else, wrote about the different schools of psychiatry (objective-descriptive, psychoanalytic, interpersonal, and existential) and the psychotherapeutic interventions that flowed from each theory.

The movement in the psychotherapist’s mind from detachment to empathy and back to detachment is central to my understanding of psychoanalytic psychotherapy. Other forms of current psychotherapies take different stances. Existential therapies usually call for a radical empathic stance (“being and staying”), and detachment is considered an interruption or defeat of the psychotherapeutic process. At the other extreme are those therapies in which detachment is the therapist’s optimal mental state. In cognitive therapies, for example, the therapist examines with the patient the nature of the patient’s cognitions. There is no central theoretical mandate for empathic relatedness, although the therapist may be a deeply empathic person. However simplified these brief descriptions of existential and cognitive therapies are, the lesson is that the movement back and forth between detachment and empathy is much more a central feature of some psychotherapeutic orientations than it is of others.

There is, however, a serious qualification to this line of thinking. Most psychotherapists are not purists in the sense that their work with patients flows seamlessly from a single theory of the mind. Rather, they patch together a quilt of premises from different theories that is congenial with their personality makeup. It may or may not emphasize the importance of both detachment and empathy.

When it comes to the therapist’s personality and its influence on the oscillation of detachment and empathy, it has been my experience that most doctoral-level psychotherapists (seen in supervision, in consultation, or as participants in psychotherapy seminars) have at least modestly compulsive features in their personality structure. These may, in fact, be necessary to succeed in the long and arduous educational process that leads to their advanced degrees. Although there is much individual variation, compulsive persons on the whole tend to be more comfortable with detachment. Predictability, structure, and control are more characteristic than uncertainty, diffuseness, and spontaneity. Ideas often take precedence over feelings, particularly if the latter are intense. I am not describing obsessive-compulsive disorders but rather personality traits or propensities. What this suggests is that for many, if not most, of us it is the ability to leave the detached state and to move into empathic connections that requires more work.

Again, Havens’ writing on finding or creating a safe place in psycho­therapy is relevant.2 What I wish to emphasize is that the therapist must also come to feel relatively safe in his efforts to enter into the patient’s deepest affects and to follow wherever they lead. For many, the position of detached, careful observer is much safer, and although that may be more so for those of us with moderate compulsive characteristics, it is a fundamental human dilemma. The existential contradiction is that of separate- ness and connectedness. In order to feel safe, must I keep you at some distance? And will that distance lead to a painful aloneness? This dilemma can be of particular significance for the therapist, although there is much about the psychotherapeutic contract that lessens the risk.

And then there is the issue of how we teach residents and graduate students to be therapists. In these recent decades of descriptive psychiatry, the issue is not whether we use what has come to be known about the complex processes of psychotherapy but rather do we attend it all? Some programs pay scant attention, and my experiences in leading psychotherapy seminars for senior residents and advanced graduate students have some­times led to that conclusion.

Many years ago I had the remarkable opportunity to establish a new residency program and its curriculum. The decision was made that the faculty would devise experiential learning modules that focused on the psychotherapeutic skills of both detachment and empathy.3,4 We began with audiotaped and videotaped “patient statements” (made by nonpatient volunteers) and asked beginning residents: “What did you hear?” “What did you see?” “How might you respond in an early session?” “How do you think the patient might respond to your response?” These beginning exercises were replaced by more complex learning modules, including role-playing and each resident interviewing the same actor-patient.

The beginning psychotherapy sem­inar was 2 hours each week and, of course, attendees were filled with anxiety. The residents were being asked to participate in an interview process that was very different from what they already knew-history taking. Furthermore, their faltering efforts to be­gin to master a different way of being with another person were seen and heard by the seminar leader and the other resident-participants. There was, in short, a good deal of bleeding, and the leader had to try hard to convey the idea that all psychotherapists make errors in every session with every patient. What was important was to recognize, whenever possible, the error and, if possible, correct it in the here-and-now.

Now 25 years later, I do not know how much impact that seminar had on its participants. Many of them are now admired senior psychotherapists. Some went on to psychoanalytic training. A few today do mostly psychopharmacology. More than several have told me it was a frightening but valuable experience, but it is difficult to know what to make of such comments so many years later.

As I review what is written in this essay, there is part of me that suspects I sound like an old psychotherapist who is lamenting the disappearance of yesterday. Another piece of me, however, says it isn’t all rant; there remains something essential about the psychotherapist’s capacity both to enter the patient’s experiential world and to observe from some distance all that is idiosyncratic about the ways in which the patient behaves. Moving in and out, I think, may capture this essence.