He sat down before his laptop, extending a finger to the screen like he was adjusting controls, a pilot making final preparations ahead of the flight. He adjusted his seat, making it higher, or at least higher such that he could aim his gaze downwardly at me. A requirement, I figured. “Good morning,” he said chirpily. I returned a tense greeting, feeling a bit like I did the last time I was in a dentist chair. Where are those torturous needles, I wondered? I always imagine that when I go there, my hygienist will start off lightly, performing a gentle prodding here and there with puffy, soft fingers. The only pressure I’d feel would be in my gums as they harden, showing off their sturdy endurance. Hmm…looks good, you’re doing well, I expect to hear.
“So, what’s your problem with my approach?”, my colleague asked. My colleague? Are we intertwined, at odds, collaborative in any way. I don’t know else to call him. My interlocutor seemed best in the moment.
“Right, straight in, I see”. With the needles, I added inwardly. “Well, let’s see. Where to begin”. He chuckled, thinking this a friendly exercise. He opened his mouth, readying a statement. I think the question was a ruse. He didn’t really want me to start. He wanted to appear inviting, but actually spear in with his driving oratory, his oral assault. I opened up, bore my gums, my weakened incisors, and intoned, “I basically think that mental health treatment is a morally neutral exercise, as psychoanalysis prescribes, or has prescribed. And…”
“I guess that’s where we disagree”, he interrupted. He was still smiling. This was still a friendly exercise, though I knew what was coming next. “I mean, I understand that old school approach, taking a neutral position, but I think that has falsely justified a lot of neglect, especially of victims, over time”.
There were already balls in the air, forcing choices upon what to juggle. Old school? I mused. A pejorative term, I think, signifying a kind of philistine ageism: what’s old is out, or should be. What’s new is necessarily that and ought to be ushered in asap.
“We might, though you’ve stepped in before I’ve even named the alternative to neutrality. Should I yield and just…let you?”
“No, go ahead”
“By the way, are we recording?”
“Yes”. He was now terse: impatient to move on, or offended that I’d questioned his piloting skills.
“I think your approach is essentially moralistic. Dominantly so, actually. And I know what you might say, what you have said: that psychotherapy, or analysis, is an ethical framework. It is set up as an ethical entity, representing, if you will, moral values. However, it isn’t meant to be moralistic, I and many others think. It’s—”
“But what’s moralistic in my approach? I mean, I tell people it’s their choice, their decisions on what approach to take. I’m not forcing anything on anyone”
“For the moment, that’s besides the point I’m not yet making, because this part of the discussion isn’t about authority, as you’re suggesting. By moralistic, I mean offering the patient an idea, a lesson essentially, that is intended to leverage a change by appealing to their moral reasoning”
“Right”. More impatience, inflected with wary distrust.
I continued: “You, say such and such a behavior is wrong. You say it hurts others. You add that it hurts others in ways they haven’t noticed, either they didn’t know or didn’t want to know, and that distinction gets short shrift because the nature of their resistance is to be dismissed—”
“They’re narcissistic”
“—by assessment/partially diagnostic labels that are a shorthand for an explanation of why someone is acting in a certain way”
“Hold on, you don’t think that problem behaviors, the ones we typically speak of, are a result of narcissism?”
“I’m not saying that. I’m saying that labels like that are not motivational. If a person is stirred to an action that’s adaptive or not, they don’t go ‘well, I’m narcissistic’ as their half-conscious understanding of their desire in any given moment”
“Wouldn’t you agree that they’re not thinking of other people, specifically their loved ones, in such a moment?”
“We don’t know that, and I think you’re assuming that if they did think of loved ones, it would deter problem behaviors because that’s what thinking of loved ones does”
“Not necessarily. I know that people have mixed feelings towards loved ones, that they feel ambivalent. I get that”
“Well, I don’t hear that represented in your approach. As far as I can tell, it’s all about drawing attention to the negative effects of problem behavior with the expectation that your listener will then feel inspired to stop doing the problem behavior, thus healing can proceed. It’s like one of those TV ads that show half-starved, shivering animals laying in a shelter, looking miserable. You’re meant to feel sorry, get off your ass and either adopt one or make a donation. The ads not saying, what are your mixed feelings towards the neglected that might lead you to NOT act”
“Well, sure, you want people to act appropriately. What’s wrong with taking steps to elicit appropriate guilt?”
I stuttered, half-incredulously. Where to begin. “See, there’s the crux of your method: appropriate guilt. You think because you’ve called it that, and because your patient will consciously agree, as in agreeably if dolefully nod their head, that they will change their ways. What’s wrong with that? We don’t need therapists or analysts to play that role, is what’s wrong with that? That’s what preachers and social justice warriors are for, to persuade rather than explore thoughts, seeking to understand conflicting thoughts and feelings, not to vanquish them. You’re a mental health professional, and now I’ll be directive if not directly moralistic: it shouldn’t be that difficult to persuade you that persuasion as a tactic is at best limited as an intervention; at worst, it’s counter-effective. People resist being told what to do or manipulated in how to feel”
“That’s not what I do”
“I think it is what you do”
“It’s not. How can I persuade you?”
I paused. “Do you do case conferences with your colleagues, your team, as you put it?”
“Of course, we meet regularly, discuss cases, prepare a plan of action, discussion interventions”
“Do you each read transcripts from sessions, verbatim or near-verbatim notes, or make recordings, as we’re doing?”
“No”, he said tiredly.
“Then how do you really know how each of you is responding to patients’ process? How do you know how you’re persuading patients to experience appropriate guilt, as you put, or else being interested in their ambivalent feelings. And how, if you don’t hear instances of patient responses to your statements, how do you know if they’re really thinking about what you’re saying versus merely complying with your pronouncements? And why, for example, if they glean from the outset that you think they should feel guilty about their actions, would they even tell you about their mixed thoughts and feelings”
“Wait, aren’t you presuming that people will only share their feelings if they expect validation? I’d suggest that when people come to me, they already feel some guilt. I’ve not imposed that upon them, as you’re implying. They expect to hear push back. Secretly, I think—here’s an in-depth interpretation for you—they’ve longed for someone to take a hold of them and tell them what to do, persuade them that what they’re doing is against their values”
“That’s the authority piece, and you may have a point that people are looking for a version of parenting via the therapeutic relationship”
“Well then?”
Now I chuckled. “Interesting. You say that as if you think the matter resolved”
“Well, you seem like you’re affirming that a parent-like, values-validating approach is indicated, which would be healing. What’s next?”
“Indeed”
Graeme Daniels Psychewriter 