Sunday, December 18, 2011

Missed Opportunities?

Before I begin,  I wanted to let you know that ClinkShrink wrote a post called Can You Tame Wild Women? over on our Shrink Rap News blog this week. 
When we talk about psychotherapy, one aspect of what we look at is the process of what occurs in the therapeutic relationship.  This is an important part of psychodynamic-based psychotherapy, meaning psychotherapy that is derived from the theories put forth by Freud.  Psychoanalysis (the purest form of psychodynamic psychotherapy) includes an emphasis on events that occurred during childhood, and a focus on understanding what goes on in the relationship between the therapist and the patient, including the transference and counter-transference

In some of our posts, our friend Jesse has commented about how it's important to understand what transpires in the mind of the patient when certain things are said and done.  Let me tell you that Jesse is a wonderful psychiatrist, he is warm and caring and attentive and gentle, and he's had extensive training in the analytic method, he's on my list of who I go to when I need help, so while I want to discuss this concept, I don't want anyone, especially Jesse, to think I don't respect him.  With that disclaimer.....

On my tongue-in-cheek post on What to Get Your Psychiatrist for the Holidays, Jesse wrote: 

 When I say the Shrink should look at the context, even in small matters a gift might come with a subtext: "I just told you some terrible things about me and I want to be sure you still like me." It can be a bribe. It can be a seduction. It can simply be a gift given out of gratitude. The important concept is that we think about everything. Unlike a physical examination done by an internist, everything that occurs might be some window into how we can help the patient, and we do not want to lose that opportunity.

So wait, the patient comes to me because he symptoms of a mental disorder, often depression or anxiety, or problems controlling his behavior, or he's overwhelmed with stress and isn't coping well. Why is it so important that we understand every aspect of the sub-texted interactions?  How does this cure mental illness?  Why is it bad to accept (or not) a gift and move on?  Why do we have to think about everything?  And if it's really important, won't it come up again?  Is it really crucial that we not lose that opportunity?  Maybe I just want to take the cookies and say 'thank you' because
  •   A) I don't want to hurt my patient's feelings,
  •   B) it can be difficult to look at the meaning without upsetting the patient or putting the patient on the defensive and so the patient has to be fully on-board for this type of therapy and those patients generally don't bring gifts (ah, maybe we should be asking all analytic patients why they didn't bring gifts, now that might yield interesting information), and 
  •   C) I like cookies.
So the truth is that on these posts, the comments are always the most interesting part, so do write in and let me know what you think, not specifically about the cookie/holiday gift example, but about how important it is to understand the interactions that occur within the context of the psychotherapeutic relationship.  

Just so everyone knows that I am still Jesse's friend, I am posting the video he sent me of his late grand-chinchilla, Chinstrap.  And yes, Jesse had a grand-chinchilla.  He does assure me that Chinstrap was having a good time in this video, because I wondered. 

And I'd like to thank Steve over at Thought Broadcast for providing the graphic for today's post. 


Sarebear said...
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Anonymous said...

sarebear: huh? I Will have to use your cookie title on a post one day-- dinah

A Girl said...

If I were to give a gift to a therapist, then I'd pray and hope that they'd just accept it with a smile and a thanks.

I agree that there are many reasons for giving. But to me, it is always a childlike act: You made me happy, so now I want to make you happy. Your happiness will, in turn, make me feel good. To start analysing that, is to put a filter between you and I, and that would make me feel rejected.

Of course, I'll feel rejected at the slightest excuse. But a gift would leave me exceptionally vulnerable. The time and energy invested would be a testament to the importance of that therapist in my life. To analyse that ... perhaps some things are better left in the dark?

There are plenty of tools in therapy to maintain a distance - arrangement of seats, body language, payment, planning the next session, the fact that you can never just call up your therapist and invite them over for a cup of coffee.

Personally, I'd say, let a gift just be a gift.

humbug said...

"let me know what you think, not specifically about the cookie/holiday gift example, but about how important it is to understand the interactions that occur within the context of the psychotherapeutic relationship."

Pretty important, but not to the point that you have to question whether a holiday gift is a bribe or seduction ,unless it happens to be a Maserati or a lacy bra. Every communication or interaction occurs on more than one level. They can't all be the focus of attention; you would go nuts keeping up. It is like dealing with kids--pick your battles wisely. Not everything is a big enough deal to make into a big deal.
Patient:" I will be unable to make it in for my appointment next week because I am having root canal."

Shrink: "let's explore why you would rather have root canal than come in for your appointment."

Those are they types of questions that make me upset with shrinks who ask them. Seriously, there is something to be said for figuring out what is important and what is not. Dinah is right that if something is important it will come up again in some way or another.

hiphop junkie said...


Lisa said...

Or - accept with a thank you and a smile, and reflect on it in your own mind. Not everything needs to be overkill.

Anonymous said...

I sometimes would remark on unusual artifacts in my therapist's or psychiatrist's offices and be told the items were a gift from a client or patient. I honestly never detected a sense of pride or happiness in the accepted gifts. My psychiatrist had a huge bag of chocolates another patient gave her for the holidays last year. During the past summer, the bag was still on her desk. I guess she does not really like chocolate.
I am grateful to my treaters but I never gave them a gift. Just a "thank you" at the end of each session. I hope that is enough.

jesse said...
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Jane said...

About understanding the context of a relationship, sometimes the little things probably do need to be explored. I guess it would depend on how much the therapist senses that there is something else behind it.

And I swear I am not saying this to be controversial. This is just honestly what I thought when I saw Dinah's post. First she said Jesse had a grand chinchilla. Which I thought was cute. And then I saw the video. And Dancing Queen was playing. I laughed so hard I nearly spit up my tea. And I immediately thought, "Jesse is gay!" It's not funny that I think he's gay, it just looked really over the top in my mind. Like he's a gay guy who can't have kids, so he has a chinchilla and he listens to Dancing Queen. It was kinda flamin'. And I guess I find it funny because my brother is like that. He's gay and he and his partner have all of these pets to serve as their children. If I were Jesse's psychotherapist, maybe I would have analyzed this a little more. Or maybe not. Maybe I would have just thought it was a cute video and not explored it further.

If I were a psychotherapist, the person's sexuality might be important to know in therapy...Or maybe not. Guess it depends on what the goal of psychotherapy is. When I told a therapist I saw a long time ago that my brother is gay he said, "Well that would explain a lot." A long time ago, when my brother and I were both teens, we went to therapy with my Dad to see that therapist as a family. My brother was kinda hostile and super quite, refusing to answer even the most basic questions. Years later, in college, he started dating other men. I don't think my brother acts gay, and he was never gay before college, so I asked the therapist why he said that. He said, "It explains why he was so resistant to therapy. People talk about relationships in therapy." I think the therapist was reading way too much into that. I think my brother didn't want to be in therapy, cuz it's not his thing and it had nothing to do with him being a closeted homosexual. But maybe the little things need to be explored sometimes? Maybe the therapist was correct, my brother was paranoid about concealing his homosexuality, and therapy would have been easier on him if the issue was explored. Who knows.(shrugs)

I guess there is a fine balance between overanalyzing and not analyzing enough.

jesse said...

So much in this post! First, thank you Dinah for posting Chinstrap's maiden video, and I hope all enjoyed it. Chinchillas are the best.

There is a basic misconception in the post, which is that if a therapist is questioning, thoughtful, aware of the context of what transpires he then would respond in a stereotypical, pseudo-therapeutic cartoon-like way. Of course that would get patients upset and not lead to anything productive.

Perhaps it would be helpful to turn it around: is there any time in treating a psychiatric patient in which a good psychiatrist should not be perceptive? This has nothing whatsoever to do with psychoanalysis and everything to do with picking up the myriad clues a patient brings to the session that will let us help him or her resolve best the problems for which he is coming.

To give a few hopefully not too condescendingly-obvious examples: A man who has been losing weight tells of his family, and leaves out one of his children. A clue perhaps to his disappointment in this son, who has rejected his wishes to join the family business and instead is becoming a priest.

A woman is telling her male therapist about her problems with her husband, and starts wearing to the sessions short skirts and tight sweaters. She then brings as a Christmas present a gift certificate to a restaurant she herself enjoys.

A woman who has been quite inhibited gets angry with her therapist after he looked, she thought, disinterested in her in one session, and then calls at the last minute to cancel the next session.

Would not a good therapist and a perceptive physician see these as supplying information to be considered and to be responded to in a way that would help the patient?

When a patient comes to see us he is expecting us to note and pay attention to whatever would be of help, and to use that information in a sensitive manner.

When we go to a surgeon it may not help him one bit to observe what we wear, what we say, or in fact any of the multiple ways we indicate our feelings. That, however, is what in psychiatry can supply clues to help a patient talk about and resolve issues of which he is not even consciously aware.

jesse said...

@Jane, those associations you made are exactly what is useful in therapy. You had a thought about me after seeing the video and immediately associated it to your brother. So as you noted the therapist had thought that your brother's silence and hostility in therapy was due to his conflicted feelings about both wishing he could talk about being gay and his fear or anxiety about doing so. Whether or not that interpretation is correct is does indicate what goes on in therapy.

jesse said...

Dinah asked whether something that occurs would come up again, and so it may not be important that the therapist lost the opportunity that has presented itself. Yes, indeed that is true that issues reoccur (Freud wrote about the repetition compulsion). If, however, the therapist blindly accepts what the patient has brought (cookies are one thing, the gift certificate another) he may be creating difficulties from which he may not so easily extricate himself.

So let's imagine that the female patient brings a somewhat costly and personal gift (use your imagination, don't put it on me to tell you - cookies are easy) and then wants to know why the therapist is not wearing it at her next session. Or imagine that he is.

When you talk about cookies you are defining the question like this: "we all agree cookies are harmless, right, so there is nothing in it, right?" but avoid the question of where the border is between harmless, grateful cookies and something seductive with obvious meaning.

Obviously there are patients whose cookies would be gratefully accepted by any therapist, (so don't all get up in arms!), but have you not seen films in which an actress eating a piece of fruit has all the men in the theater panting?

So there may be certain gifts which carry an underlying meaning that then becomes difficult to explore, even when it reoccurs, precisely because the therapist has become compromised.

Dinah said...
This comment has been removed by the author.
Jane said...


That makes sense that he has a kid who owned the chinchilla. I thought maybe he owned a chinchilla and this was the offspring of that chinchilla. So he had a chinchilla child and then a chinchilla grandchild.

Dancing Queen is a gay anthem. Having lived in LA, where there is a very strong gay presence, I can attest to this. Wikipedia also lists it as a gay anthem from 1976. Regardless of date, there are gay men who were born in the 90s who consider it a gay anthem. Isn't ABBA as a group a gay icon? I thought it was right up there with Cher and Liza Minnelli and Dorothy singing Over the Rainbow?

And choice of song does mean something when attached to a video. Take this video for example. Would your perception change if the song were "Eye of the Tiger"?

Anonymous said...

I was around for ABBA. I was around for the shlock of Mamma Mia and whether ABBA was taken up by the gay community or not, it doesn't really change the fact that most of the audience was not gay.

Lisa said...

One other really key thing to keep in mind, that unfortunately therapists do not always keep in mind - their perception/interpretation may not be correct.

Kate said...

@Jane - I think you actually made the opposite point. Your response and associations with the video indicated your thought process. Mine was completely different. I have friends and relatives who are gay but when I watched the clip Jesse's sexuality (or lack thereof) did not cross my mind. Your association tells me something (correct or not) about what's going on in your mind, on some level -- sort of proving the point (which I don't buy into 100%, either) that everything is relevant -- (homo)sexuality from the chinchilla video?!

p.s. @Jesse - I had hamsters as a kid and used to torment my mother by calling her their grandmother. :)

Jane said...

It's not so much that I thought he was gay just from the was the combination of a pet as his grandchild and the song combined that made me think that. But I do need to take into account that I don't know where Jesse is from, and I don't know how old he is. If he lives in Los Angeles, is a 28 year old psychiatrist, listens to Dancing Queen, has a whole stack of ABBA, Cher, Streissand cds, had chinchilla children and grandchildren, and no girlfriend in sight...I might have to suspect something about his sexuality!

However, if Jesse is actually old enough to remember ABBA, then he might not think it's so gay. My Dad told me he had no clue Elton John was gay. I do not mean the Elton John of the 90s. The Elton John of my childhood, when I watched Lion King in amazement and listened to Can You Feel the Love Tonight. I mean the Elton John of the 70s. I have seen footage of Elton John in the 70s. He makes his 90s self look like John Wayne. But apparently you could be that sparkly in the 70s and not look gay...

For all I know, Jesse loos exactly like Brad Pitt, is married to a woman who looks exactly like Angelina Jolie, and he has a bunch of kids who love chinchillas.

Or he could be an attractive 28 year old, heterosexual single, psychiatrist! In which case he probably has ladies lining up to date him and they are learning all about ABBA, his favorite band, so they will have something to talk about over dinner.

dogdoc said...

A year ago I was a neophite to therapy having been seeing my shrink for just six months. It had been a very difficult time for me and I had no real idea what was going on in my sessions or if it would help! Christmas was just around the corner and I wanted to give Dr P something - so I thought a tiny box of hand made Swiss style chocolates the ideal choice.(I could always eat them if she rejected them).
When I gave them to her she definately hesitated but took them when I told her the contents. I was soo glad. In the past year I have been struggling still but more with understanding the process and what is "therapy". Your blog more than anything else is enlightening me. My Christmas card to her 'with a personal message' will include details of how to find Shrink Rap.

Dinah said...

Thank you dogdoc!

Since I know Jesse, I'm enjoying reading everyone's speculations about him.

Sarebear said...
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Cleanskin said...

I would love to give my psychiatrist a small gift but will not because of my concern that he read more into it than simply gratitude for his help.

Anonymous said...

lonestsJane wrote: "For all I know, Jesse loos exactly like Brad Pitt, is married to a woman who looks exactly like Angelina Jolie, and he has a bunch of kids who love chinchillas."
Well, I have know guys who were married,had kid and were, in fact, gay. I have known women who were married, had kids and were, in fact gay. Not bisexual. Gay. I guess that is a factor of my age since people of my generation were not as likely to come out as gay. So being married and having a family does not tell me much about people my age except that you cannot assume. And I am not terribly old.

Anonymous said...

Jesse, is it possible that the male psychiatrist believes the female patient is dressing up for him because that is what he wants to be the truth? And not because it is true? A bit of an ego boost for the psychiatrist/therapist?

When I took an ethics class in a therapy program it was interesting to watch the differences in interpretation of female behavior by male therapists in training. There were times that male students thought female clients in video taped sessions were behaving seductively when the female students did not see it that way at all.

jesse said...

@last Anon: absolutely that may be the truth. My example was given to say that it is important for the psychiatrist to be perceptive and to think about all possibilities. He then responds in a way to help the patient. In this example he certainly needs to consider that he may want the patient to become attracted to him, that he might have been subtly encouraging it, that it might be coincidence, and so on.

I tied that in with the patient giving him a gift of dinner in a restaurant that she had mentioned she enjoys. That in itself may not mean she was being seductive, but tied in with other things it might. And it might well be that the doctor went to the restaurant he knows his patient enjoys because he was hoping to see her there.

Being a good therapist is not formulaic. The point I was making is that frequently there are clues, that the patient gives, that are not part of a formal history. There is nothing that is automatically, always, irrelevant. Thinking of the total context is important.

@all of the posters who are wondering about sexuality, etc: Very frequently we read into a situation whatever is relevant to us. All of us do that, and that was one of the bases for Freud's discoveries, that his patients, encouraged to talk without censoring their thoughts, would create fantasies of which they became quite convinced. In analysis the patient learns about himself by paying attention to his own thoughts.

Jane had thought of her brother when she saw the video of Chinstrap. Her brother is gay and so she wondered if that were true of me, too. What is important here is not whether or not she is correct but to see, as she did, that her thought that I might be gay came from an association to her brother.

jesse said...

BTW, I totally appreciate all the comments on this post. This is such an interesting subject and the comments were (to me) totally thought provoking. And as you can tell little Chinstrap taught me that (some) rodents can be engaging and really lovable. Dinah and I have frequently gone back and forth about that!

Ed said...

As Jesse's 29-year-old, bisexual son, who was the caretaker of Chinstrap with my girlfriend, I found these comments quite intriguing.

Jane said...

"As Jesse's 29-year-old, bisexual son, who was the caretaker of Chinstrap with my girlfriend, I found these comments quite intriguing."

Aha! So YOU were the handsome 28 year old man I saw in my mind and mentioned in my comments. I thought it was your father. And I was only a year off :) Jesse must be very proud of how you turned out. The man I saw was sensitive, loves chinchillas, good looking, and he's very popular with the ladies. I thought I sensed something gay, but you are a bisexual. Pretty close!

Jane said...

P.S That's actually scary how close I was actually. I almost nailed your age. I think I threw out 28 because that's just old enough to have become a psychiatrist and just young enough to still be a youthful, good looking 20 something.

Ed said...

I have been reminded that I am, in fact, 28 and had subconsciously rounded up to 29.


jesse said...

@Jane: Ed is 28. He is warm, sensitive, very intelligent, and good looking. But he is not good at math.

Jane said...

Ed...if you didn't have a girlfriend, I think I would have to give you my number! Warm, sensitive, intelligent, and only a few years older than myself. You're the whole deal. And, guess what, I'm not good at math either.

Anonymous said...

Going with your cookie example first:

If I bring you cookies, chances are I think you hate me and feel that bringing you cookies will make you like me more. Then I will feel anxious because you probably know that I brought you cookies because I think you hate me, and now you know I think you hate me and you'll hate me for trying to make you like me more by bringing cookies instead of simply apologizing for being such a royal pain in the ass all the time, but you'll be pleasant about it because you feel obliged to do so. And then I'm going to leave the office and pick apart your every word, or your lack of words, and determine that I'm an even more awful person than I thought myself before. And you hate me.

Does he need to bring it up right then and there? No, not necessarily unless I seem to be making a habit of it. But, he would certainly be correct in asking himself what the gift represents. Accept it, but question it internally, and look for relationship to other actions and attitudes that will help guide him in understanding the meaning. If it turns out to be trivial, all good and well. If it turns out your client possibly thinks you hate them however...

...find another way to ask about the reason behind the cookies.

Dinah said...

Last anon:
Do you only bring cookies to people you think hate you? Do you ever bring cookies to people you like? Maybe if you brought me cookies, I'd think you liked me and that you knew I liked cookies and really, why would anyone want to over-analyze a cookie.

In my daughter's school, the principal used to keep a jar of cookies on his desk to encourage the kids to come see him. (It worked, teenagers like cookies, and the everyone liked the principal.) He left ---family reasons and he probably needed to be at a school where they paid him more because the cookies were bankrupting him). The new principal candidates were made well aware of the years of free cookies from the principal policy, and the one who was chosen ran focus groups to determine if fig newtons would do, or if they had to be oreos, and he concluded that, for the girls, it was only a cookie if chocolate was involved (no fig newtons). So I guess one can put a good deal of thought into cookies.

If I actually hated a patient (!), I would not eat the cookies, because the only way I could imagine hating a patient would be if they were evil and if they were evil they might spit in them or poison me. To date, I have eaten all that has been baked for me and I have eaten things baked by other peoples' patients.

Okay, all this talk of cookies, I have to go now, I'm getting hungry

Anonymous said...


Both. I like my therapist, but that's not why I'm bringing him cookies; I don't randomly gift people I like, even when it's based around a holiday, there's always motive behind the gift(s), and more often than not it's an apology and/or because I think they hate me, and always directly because I feel wholly inadequate as a person (and/or because I'm evil).

I also give gifts to people I hate where reciprocation or tension reduction is necessary. And those people definitely hate me as well.

In part, I feel like I have to put in more effort at gifting people who matter to me to keep their anger and hatred at bay, and on another side I hope that it will make them hate me less. Nobody hates receiving gifts, it makes them feel good, so if I make them feel good maybe they'll hate me less, *maybe* they'll see value in me.

I can't imagine why or how anybody would like me for me (and of all the people who *should* hate me it's my therapist!) so the only alternative I can offer is showering them with gifts that might make them hate me less, and to apologize for being such a pain in the backside which is no doubt part of the reason they hate me.

We could get into the extended family tension, where I've learned via my mother that you can keep family at bay by inundating them with gifts. It's better to be seen as the person who goes overboard than as the person who never puts in enough; so, while I vehemently dislike my aunt, she's going to get an expensive gift along with numerous other gifts because not doing so would result in her moaning to her daughter and husband about how uncaring we are, which after a good game of telephony I do end up hearing about. More gifts - Less tension.

Or, when you make a mistake you buy the person something as a way of apologizing, sometimes along with apologizing. Could be a coffee, could be baking cookies, flowers, new shirt... but there must be something, because my apologies are never enough, but if I give something with the apology or in place of the apology people always seem to take it better.

With regard to liking, even that's backwards in my little gift-giving world. Between my mother and I Christmas is a competition for who gives the greater number of gifts. Which, to compound issues, evolved after my mother admittedly began spoiling me in an attempt to make up for my being without a dad, which as I grew up made me feel inadequate because I could never give as much. Now I give, and give a lot, out of fear of feeling inadequate again instead of for love and care. This Christmas I completely deflated my savings account - $1000 - on buying Christmas gifts, only two of which were for somebody other than my mother. Money I was saving up to get a tooth crowned. And then after all that I think my mother hates me and feels I haven't done enough. I love my mother, but my rational side also knows that the gift-giving has little to do with love and more to do with trying to make myself feel good enough, both in her eyes and my own. Because, tada! I don't really think my mother loves me anymore, I think she just puts up with me because she feels she has to because she gave birth to me, but she'd never tell me this because she's too kind.

And you know, despite knowing this, knowing why I do it, and knowing that it never makes me feel better, just the fear of being hated or feeling inadequate sends me over the edge, and year after year, one occasion after another, I repeat these same actions.

So, if I give you a gift it's because I think you hate me, and I'm apologizing for the many reasons you have to hate me, and no matter what or how much I give you I'm still going to think you hate me. Only now there's an additional reason for you to hate me, because my gift was inadequate and I'm inadequate and you're just being polite in accepting it.

All of which I should actually bring up with my therapist. May just bring cookies to my next session.

Dinah said...

Last anon,
I'm sorry my holiday cookies have all been given away or eaten, otherwise I would mail you some. Not because I hate you, but because your life sounds like a lot of work and cookies make everything a little easier, and as Freud should have said "Sometimes a cookie is just a cookie."