Friday, September 14, 2007

Talking About The Right Things

So my post from a few days ago-- Are You My Patient? -- inspired a lot of thought-provoking ideas, and thanks to everyone for the comments. I wrote about patients who come to treatment, and then reject all suggestions, thereby leaving the doc feeling a bit helpless.
To be honest here, I've really only felt held-hostage by this situation a couple of times-- most people who don't like my ideas simply stop coming. And the very few times I've actually pointed out to a patient "Look, you're suffering and then you won't do anything I suggest, you won't even try the medications I recommend....yada yada yada..." Well, once I've confronted them, for the most part, they've made an effort.

Gerbil wrote in with a comment that really got me thinking. She said...

May I also point out Prochaska's stages of change model? It's a common misconception that people go directly from one stage to the next, from precontemplation through maintenance. More often, it's not linear at all--they flit back and forth among the stages. So it's entirely possible that someone would decide "hey, it's time to get help," but by they time they actually make it to the office, they're back in denial that they even need the help in the first place. And besides, isn't resistance the best therapy fodder there is?

So who's this Prochaska character and what Stages of Change?-- Follow the links, I looked it up and I was pleased that a reader made me learn something new.
But this is the thing: given that my post was about patient compliance, it really wasn't about compliance with Psychotherapy, it was more about compliance with medications and behavioral suggestions. Until Gerbil chimed in, I really wasn't thinking at all about compliance with psychotherapy or resistance.

There is an obvious way a patient can be non-compliant with psychotherapy: They can simply not show up. But let's push that one aside-- and let's just say the patient shows up on time. Is it possible, then, to be non-compliant with psychotherapy, in essence, to not talk about the rightt hings? I presented my Are You My Patient? post with an edge of frustration. Is it reasonable for the therapist to get frustrated with a patient because the patient doesn't talk about the right stuff?

In a traditional psychodynamic psychotherapy patients are urged to dig deeper, to talk without censoring, to explore and breakdown defenses, to travel down that royal road to the unconscience and resolve all those conflicts while unrepressing the long-ago repressed. The treatment of trauma-related disorders often calls for the patient to talk about difficult things that have happened in the past. Clearly, there are right and wrong things to talk about?

Maybe there are things that should or shouldn't be said in psychotherapy. I rambled last year about What Patients Talk About In Psychotherapy (-- at least check out the cartoon!) and I tried to make the point that people often talk about mundane things. I would contend that it's pretty hard for patients to talk about the Wrong things in psychotherapy. Patients generally come and talk about whatever is important to them, and they usually find this helpful, even if it's not anything terribly difficult, shameful, or all too deeply hidden in their psyches. Some patients talk in very introspective and insightful ways about pretty powerful things, and then say it's no big deal, it isn't particularly helpful, and while they seem to be doing great work, nothing changes. Other patients talk about things they could easily share with a friend-- nothing all that personal or earth-shattering, and relate that it's extremely helpful and they get a lot of relief. If a patient says there's something they don't want to talk about, well...I might push a little, but mostly I respect this-- it can be addressed later or not at all. Psychotherapy, even if difficult at times, should ultimately offer relief and shouldn't be about badgering or belittling the patient. Oh, and the other thing: the relationship itself is much of what helps, and this relationship happens (in good or bad ways) regardless of what is said.