The Therapeutic Relationship, part 4 - What do we actually mean by "Therapeutic Relationship"?

The Therapeutic Relationship, part 4 - What do we actually mean with "Therapeutic Relationship" with Dr. Aleksandar Dimitrijevic.

Show Notes

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We've made a couple of videos about the. Therapeutic relationship, the relationship between the therapist and the patient. And actually this time, I would like to try to give an overview of what it is that we mean when we say therapeutic relationship, what does it include itself? And there are several, so to say layers to it, beginning on the one hand with a real relationship.

And then going all the way to transference and counter transference, which can be very irrational at moments. So the things I will try to present briefly are the real relationship, therapeutic lines, resistance, transference, and counter transference. And each of these deserve more elaboration and many, many books were written about them.

And some of them we've already covered with a couple of videos. So it's possible to follow, uh, more detailed discussions on, on this channel. So to begin with real relationship, it is a part of mostly social relationship that exists. And it also is inevitable in psychotherapeutic relationships, things happen on certain dates.

in certain rooms, there are reality constraints included the length of a session, the payment at the end of the month, certain things are inevitable, natural laws, social laws that we should all meet at a certain building in a certain apartment at a certain time and so on. And so on. there usually isn't much to discuss about this, usually, especially in adult psychotherapy, these are things that are easily negotiated at the beginning of the treatment.

I'll return to this because there are specific moments when this can become challenging. Now the second level, and it's the second because. It does not include that much. Irrational is the level of therapeutic Alliance. Therapeutic Alliance is an agreement somewhat explicit, but to a large extent, implicit the two persons or in case of group psychotherapy, many sense are going to work on a certain problem, trying to overcome.

A certain source of discomfort, pain, misery, and happiness, or whatever in a certain way. So having individual group sessions with certain frequency, with certain duration during which the therapist will be doing this will be doing that. And so on and so on. And this is defined sometimes in the world of psychoanalysis.

as an attempt by the analyst to collaborate with the rational part of the patient's ego. So that is the force or the structure in the patient's personality that will agree to the rules and all of the rules come regularly. Come in time. Talk about things that maybe at the first moment don't seem to be relevant.

Free associate talk about dreams and then follow the rules when it comes to the life outside of therapy, if they're necessary, therapeutic Alliance is per definition, not exciting, and it should be the frame within which exciting things are going to happen. but therapeutic lines in empirical psychotherapy research turns out to be the decisive factor that can predict the quality, the outcome of one psychotherapy.

It is not the education or the therapeutic school or the frequency of sessions or the duration of the treatment. As much as the quality of the therapeutic lines, just by the way, the second most important thing about this is the personality of the analyst. Again, not his or her education, school of choice, favorite author IQ, or whatever.

So the therapist needs at the very beginning to be completely focused on establishing. The therapeutic clients as best as possible so that the work will start. And once the work starts, the better the therapeutic clients, the deeper, the work is going to be the more the patient can trust. This is a reliable person.

This is a predictable space, is a predictable time. The more relaxed and trustful the patient is going to be to. Dig deep into the problems, possible solutions, trauma or whatever. This is not easy in the beginning and it is not easy later on. And one of the reasons it is not easy is that especially there's an apt German word for this lightens stroke.

The motivation for psychotherapy comes from the pressure. That the pain is exerting on the person. The more I'm suffering at this moment, the more I'm going to be motivated to work on my problems. And now when pain is very high, very intense to keep all the information, keep all the boundary is in your mind is not easy.

Sometimes you want things to change very quickly. Sometimes you want your analyst to do something special to help you and so on. And so on the second, or I'm sorry. The third level that we need to discuss is the level of resistance here. Again, the relationship between the patient and the therapist may seem to be in the focus of everything.

and through this relationship, someone unconscious that we call them forces will be expressed. These parts of patient's personality that don't want things to change. That would prefer everything to remain the same, the, that feel too anxious about what does this life without pain? What does this life without constraint look like?

This now it's not good, but I'm used to it. Maybe things in future will be better, but I have no idea how to imagine them. I have no experience of what they look like. So they may be frightening for that reason. Most of this is inside every one of us, but it will be recognized in the relationship. Uh, The therapist will say something.

And in the next session, it'll turn out the patient didn't even hear it. Or the moment the patient left the room, he or she forgot about everything that was discussed. So it will be obvious in the relationship, although in a certain way, coming from inside the patients in touch now, where is the problem?

And, and, and, and this is, this is still only the third layer. The problem is that the first three, the real relationship therapeutic clients and resistance very often are impossible to distinguish from one another that they are OVN or influence one another, or want to destroy one another and so on. So because of the resistance, the patient can try.

To destroy the therapeutic lines. So everything that was agreed in the beginning now will be challenged. I won't be coming on time. I won't be talking about dreams. I will forget to pay. I will be disrespectful of this or that rule. I will insist that I cannot take sessions if I cannot smoke in the office or, or that, and then real relationship can also be used.

For the, uh, for the transference to express itself, uh, I don't want to come to this part of the city. I don't want to collaborate with the person of that age and so on and so on. So very often when the therapist is listening to one's simple sentence that the patient says all of these registers could be present or some of them, or one can be masked.

Under the other and so on. If we have initially agreed that the patient will have three sessions per week, and now there is a request to change this to four or to two, the real relationship level would be let me open my agenda. Don't see whether I have available appointments, but therapeutic Alliance and resistance and transference and counter transference.

Require that we first explore the unconscious dimension of all of this.

There are indeed situations when therapeutic alliances almost destroyed or indeed destroyed by the powerful forces of the resistance. It is very well documented, especially in the case of borderline personality disorder patients. the dropout levels are extremely high. And although these persons require a lot of very careful treatment, most of them leave it very early for various reasons that that, unfortunately I cannot talk about at this moment, these so-called attacks on setting attacks on therapeutic Alliance.

Sometimes are that strong that patients leave sometimes are that strong, that analysts don't work carefully enough on them or consciously or unconsciously can hardly wait for the patient to leave so that they can get some relief from these attacks. So these different registers have to be taken to consideration.

As much as humanly possible at every moment. Now, things become really complicated when we include the level of transference and countertransference into this and these two levels to repeat this briefly, because we've already recorded several video on, on, on these topics. Transference means partial, temporary.

limited loss of capacity to really distinguish between past and presence between the actual person, their present and someone else who is important in my present or in my past to mix these figures, experiences, emotions, to such an extent that their moments in therapy sessions are in between therapy sessions.

when the figure of the therapist, a professional person who really listens carefully to me becomes so extremely important for the positive or for the negative reasons that therapeutic sessions at moment may become the center of my life. So that basically the rest of my day is waiting for the next session to begin.

and when these emotions are so intense, they can so to say, shake the structure of the therapeutic work to, to a large extent, because the therapist becomes not, not almost not to parental figure, but actually in my emotional life, a parental figure for me. I could forget about the therapeutic lines in the agreement we made at the beginning and forget that actually, I may even know that this person has a family and lives there and is of this or that age or whatever, and wish for everything to change so that my transference wish it is will somehow be, uh, met and fulfilled.

So because of these reasons, I may want sessions to last incomparably longer than we have initially agreed. And then more or less everyone knows how long they last. I may want to be allowed not to pay for sessions so that I will have the feeling that I'm the favorite patient. and so on and so on. So a strong transference can shake the therapeutic Alliance even more profoundly than resistance and transference at moments can also be a form of resistance, which is a further complication.

So now we have four different layers, four different registers. And when you try to think about them, then every sentence can mean so many different things. Every gesture can mean so different things, so many different things. Have we yesterday at the end of the session, shaken hands or not the, if we usually do what we haven't yesterday, what layers of meanings can that have?

If the patient usually pays regularly and now hasn't paid for three weeks. Is this just, uh, my salary is late or is this some sort of an unconscious message that is full of emotions

now? Counter transference means. At the first moment, I would say a simple thing. And that is the analysts. No matter how well trained, analyzed, and supervised have the unconscious as well, that it is impossible to analyze anyone to that level, that the unconscious will stop speaking independently of what we would like to happen.

So analyst in sessions have all sorts of reactions. Thoughts in our minds, feelings, wishes, distractions, arousals, uh, memories, traumas, and so on and so on. And all of these get connected and to a certain extent, provoked. by the reactions of the patient. So our counter transference reacts to the patient's transference, but our counter transference also reacts to patient's resistance.

If the patient comes late, uh, analyst can get annoyed or bored or have many different. So ORs of reactions, some of them more on the conscious level, some of them more on the unconscious level. So again, Several layers of possible reactions. And this is another level, another force that influences that shakes everything, and that we have to do our best to have to, to, to take into account at every moment.

Some people say that whenever there is. such a resistance in the therapy that the patient, that the treatment is an impase, the patient feels stuck and the treatment seems to be stuck. Many people believe it is the resistance in the analyst that has to be taken into consideration. And once that is overcome, the treatment will continue with progress.

So that is another way. And I cannot tell which one should be preferred to look at this. That one person has several layers of conscious and unconscious reactions in the relationship. And then the other one has, and they're all to a certain extent connected and to a certain extent, different or, or, or, or disconnected and therapeutic relationship actually means.

for the analyst in the first place, a constant effort to both allow yourself to experience most of these. So to feel that you're angry when you're angry to feel that you're interested when you're interested and so on and so on. And at the same time to have this self reflective capacity that you should follow, that you should monitor.

I, I, I probably should even say. different layers of patients, communication and different layers of what is going on in you and what you're communicating. And then to try to figure out what actually is going on in there, which is at moments challenging intellectually and emotionally, but which makes this, this job unique and extremely inspiring and probably unlike.

Any, any other profession.