The Therapeutic Consultation Finding the Patient

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The Therapeutic Consultation:Finding the Patient

MILTON VIEDERMAN, M.D.The psychiatric consultation has not been adequately exploited as a therapeuticdevice. Although, the original abstinent model for psychodynam ic psychotherapyhas become more flexible, passive listening with interventions to elicit diagnostic"data" remains the prevailing m ode in psychiatric consultation. In this paperI develop the idea of the consultation as an active process (Viederman, M.,2002) that engages the patient emotionally for therapeutic effect.

THE NATURE OF ACTIVITY IN THE CONSULTATION PROCESSThe psychiatric consultation has not been adequately exploited as a

therapeutic device. Although, the original abstinent model that formed thebasis for psychodynam ic psycho therapy has beco me more flexible, the ideaof passive listening with interventions to elicit anamnestic and diagnostic"data" remains the prevailing mode in psychiatric consultation. I willdevelop the idea of the consultation as an active process (Viederman,2002a) designed to engage the patient emotionally and to have a thera-peutic effect. Activity resides in imaginative, ongoing formulations in theconsultant's mind of the patient's presentation and experience and theappropriate communication of such inferences to the patient.

To accomplish this end, the consultant must enter the patient's world;develop a pictu re of him, of his experience with the people in his surrou nd,and to communicate appropriately this awareness to him in a language thatis familiar to him . In so doing, a climate develops in which the patien t feelsrecognized and understood. The consultant is reciprocally recognized andbecom es a "presence"'^"'^ (Viederman, 1991; Viede rman , 1999) in the

Emeritus Professor of Psychiatry, Weill Medical College of Cornell University, Supervising andTraining Psychoanalyst, Columbia Psychoanalytic Center for Training and ResearchMailing address: 60 Sutton Place South, Suite 1-CN, New York, NY 10022 e-mail:[email protected]


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The Therapeutic Consultationstance). This approach does not obviate the requirement that the consul-tant obtain the necessary information to make a formal diagnosis.The patient arrives with a familiar story, one that is on some levelcomfortable for him. The aim of the consultation is to help him pursue toa certain extent a new story of his life, to be surprised by what emerges, tohave a new and unex pected experience with a new person w ho recognizeshim and becomes real to him. This, for the most part, involves clarificationrather than interpretation of unconscious processes.ME ANING AS AN INTERVE NING VARIABLE AN D TH EPSYCHODYNAMIC LIFE NARRATIVE

There are two related concepts that have special importance in estab-lishing contact with the patient and relieving distress. They define thepatient's emotional response as understandable and unique to him in thecontext of his current experience.Meaning as an intervening variable implies that between an externalstimulus and a dysphoric emotional response, there is a special meaningunique to the patient that defines the response. A 48-year-old woman's

distress in the context of her treatment for pulmonary cancer lay not in apessimistic view of her future, pain, her fear of dependency, etc., but ratherin the fact that this prevented her from being a "mom " to her children. Th esource of this particular m eaning em erged in the context of the explorationof a past in which she had expe rienced the absence of her mo ther when shewas a child. It was of critical importance to her to be an especially availablemother to her children.The Psychodynamic Life Narrative (Viederman, M., 1983) is an exten-

sion of this concept. It is a construct developed and presented to thepatient in the context of a consultation in which the patient's painfulresponse to a current situation is demonstrated to be an inevitable andlogical response to early life experience that has special meaning to thepatient or may be a source of vulnerability. A 35-year-old diabetic w omanin the first trimester of her first pregnan cy was terrified that she would havea defective child. She called her obstetrician and gynecologist constantly tobe reassured but without relief. As the patient's story unfolded, thefollowing narrative was presented to her. "It seems clear why you are soanxious about having a defective child. Your parents seem to have been


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AMERICAN J O U R N A L O F P S Y C H O T H E R A P Y

obtaining a professional degree, marrying, and developing a wide array offriends. Un dern eath , how ever, you have always had a latent sense that youwere defective. Now in the context of this pregnancy, you are fearful thatthis child, whom you see as an extension of yourself, will be defective in theway you have felt yourself to be defective." The patient burst into tears,composed herself, and wrote a letter a month later indicating that our talkhad been a turning point in her life. Her symptoms had disappeared andshe no longer felt the need to seek reassurance from her physicians. Shegave birth to a healthy baby withou t difficulty.SPECinc TECHNIQUES

Among the specific techniques that may be used to facilitate theemergence of a new experience are the following:a) Echoing the implicit affect or content of the patient's experience asit is revealed so as to let the patient know that he has been heard.(Viederman, 2002b, 2002c)b) Establishing meanings or connections between a dysphoric re-sponse and the apparent stimulus (meaning as an interveningvariable). (Viederman, 2002b, 2002c)c) Conveying to the patient the consu ltant's awareness of the climate ofthe patient's troubling experience as the description evolves. Astatement to the patient "This is what I have heard you say" or "itseems that" followed by a salient description of wh at the pa tient hasdescribed, makes it clear to the patient that he has been heard. Thisis how the patient knows that the so called "good listener" has reallylistened.d) Commenting on aspects of the patient's personality (sometimessupportive of self-esteem), including his perception of the world.This may involve his characterological inhibitions about expressingemotion, revealing needs, etc. (Viederman 2002b, 2002c)e) Use of the present to evoke associative thoughts to the past bydefining a particular trait (such as need for control or independen ce)or a particular feeling state and asking for spontaneous associativeconnections in the past. The consultant makes it clear that he is not

asking for explanations. This will encourage the revelation andawareness of the dynam ic living past that forms the current behav ior


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The Therapeutic Consultationfamily history may be required. This may be formulated as a"Psychodynamic Life Narrative". (Viederman, 1983)

f) Definition of the quality of the patient's behavior with the consu ltantas a point of entry into the quality of object relations and activepursuit of these elements in examination of their roots in the past(transference). (Viederman, 1994)g) Appropriate use of consultant's emotional reaction to the patientand at times his behavior with the patient in order to pursue thequality of relations with others (countertransference and enact-ment). (Viederman, 1999)h) Finally, direct interpretation of conflict close enough to patient'spotential awareness to be integrated and examined by him.A brief comment on the therapeutic implications of the consultation isin order. The therapeutic effect, whether it be symptomatic relief or somesignificant change in the patient's perception of himself or the world, orcharacter change in the context of a long-term therapy, occurs in thecontext of a new emotional experience. This involves some change in thepatient's perception of himself and perception of himself in the world.

M oreover, the search to find the om niscient, benev olent good p aren t oftenis part of the patient's unconscious motivation to seek consultation (thecurative fantasy). (O rnstein & Ornstein , 1977; Viederm an, 1991, 1994)The consultant in his active engagement of the patient, in his recognitionand comprehension of the patient's state and his communication of thisawareness, constructs with the patient a new perception of his experience.In so doing, he becomes an ideal object (Ornstein & Ornstein, 1977;Viederman, 1991). It is to be emphasized that the degree of activeintervention will vary from patient to patient and to a certain extent willdepend upon the consultant's beginning formulation of the type of treat-ment that is indicated. However, the initial engagement acts as a usefulsubstrate for the beginning of a long term treatment.CLINICAL VIGNETTES

There are no simple algorithms to guide the consultation. Each con-sultation requires an imaginative and creative response and the variationsare infinite. Three contrasting patient anecdotes will be used to show thediversity of approaches and effects. Only pertinent highlights of the


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television appearances. It was when friends suggested a facelift in thiscontext that the panic attacks began. When I asked the patient how sheexperienced the attacks she stated, "They were like the intrusion of anunwanted mother". When asked what thoughts came to mind about theimage, she immediately spoke with both contempt and sadness of anarcissistic mother, never nurturant, often indifferent and with a concernabout appearance and a vanity that had manifested itself in multiplefacelifts. T he pa tient was taken aback by the connection. She spoke of herefforts to be a different type of m oth er and of her difficulty with one of herchildren. She expressed the wish to begin therapy. The panic attacks neverrecurred.A very different patient was a 65-year-old Nigerian woman interviewedduring an inpatient conference. She had been hospitalized on a psychiatricservice after an explosive outburst at a city shelter. The patient had amarked thought disorder with circumstantiality, tangentiality and loose-ness of associations. She was an isolated w om an, whose only contact "waswith God". The interview consisted of a careful and patient constructionof her life story. Central was the fact that she had grown-up in a poor

family in Nigeria with 23 siblings and multiple parents. No significantemotional contact had been made as I helped her to construct her lifestory. However, I affirmatively stated that she needed a place of her ownto which she could retire, separate from the intrusion of others. Thepatient responded at the end of our conversation by saying that I was amessenger sent by God.Another patient illustrates the value of resurrecting a dynamic past inthe present. The patient, a 53-year-old executive, was referred for evalu-

ation of insomnia. When asked about his ruminations in the middle of thenight, he spoke of an irrational fear of suddenly being discharged from hisjob and finding himself vulnerable and helpless to support his family. Theassociation to this sense of vulnerability evoked a show of tears accompa-nied by his recognition of the terror he had ex perienced when he lay in bedas a child and overheard his mother fighting with his abusive, alcoholicfather. Later, in the interview, he spoke of a social phobia, panic inspeaking in front of groups that he connected, to his surprise, to a pianorecital when he was six. He had experienced a sudden unanticipatedpanicky paralysis and had been shamed by his inability to play. Curiously,


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The Therapeutic Consultation

CONCLUSIONThe consultation process can be a gratifying experience for the con-

sultant. An imaginative and creative response to the challenge prese nted bya new patient makes the work a perpetual source of fascination andinterest. One is confronted by the extreme diversity and uniqueness ofhuman experience. Every patient is different. To discover that one caneffect people rapidly adds immeasurably to the satisfaction. Attention onlyto the external description of behavior misses the individual and idiosyn-cratic core of human experience, what makes one human. My intent hasbeen to offer a perspective on the consultation process in order to b road enit and to offer wider possibilities for patient and consultant alike.REFERENCESOrnstein, P. & Omstein, A. (1977). On the continuing evolution of psychoanalytic psychotherapy.Annual of Psychoanalysis, 5, 329-370 .Viederman, M. (1983). The psychodynamic life narrative: A psychotherapeutic intervention useful incrisis situations. Psychiatry 46, 236-246.Viede rman , M. (1991). Th e impact of the real person of the analyst on the psychoanalytic cure. Journal

of the American Psychoanalytic Association 39, 459-489.Viederman, M. (1994). The uses of the past and the actualization of a family romance. Journal of theAmerican Psychoanalytic Association 42, 469-189.Viederman, M. (1999). Presence and enactment as a vehicle of psychotherapeutic change. Journal ofPsychotherapy - Practice and Research. 8, 274-2 83.Viederman, M., & Blumberg, H. (1993). Anatomy of a consultation: A teaching method. GeneralHospital Psychiatry 15, 183-199.Viederman, M. (2002a). Active engagement in the consultation process. General Hospital Psychiatry24(2), 93-100.Viede rman. M. (2002b ). Life Passage in the Face of Death (Vol. I): A Brief Psychotherapy. [Videotapewith accompanying text] American Psychiatric Puhlishing: Arlington, VA.Viederman, M. (2002c). Life Passage in the Face of Death (Vol. II): Psychological Engagement of thePhysically 111 Patient. [Videotape with accompanying text] American Psychiatric Puhlishing:Arlington, VA.


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The Therapeutic Consultation Finding the Patient

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