It might help some readers of Dr. Riolo’s website to learn more about the context in which I wrote this piece for the Times. This was not a case I had been brooding about for ten years, as might be inferred from one of the readers comments. Some months ago, I had been approached by another metropolitan newspaper to be a semi-regular contributor to their Clinical Cases column. At that time, I began to reflect on the patients and case histories that had been most meaningful to me, over the years. One of the six or seven cases that stood out involved the patient described in the Times piece. My recollection of this patient was not colored by terrible doubts, though some readers may feel I should have been more skeptical of my own motives. Rather, I recalled the patient, and my treatment of her, with a certain warmth and affection.
The issue of when to interpret a patient’s gift, in my view, cannot be viewed in isolation, or solely as a matter of psychotherapeutic theory. It must be viewed in the total context of what is most likely to benefit the particular patient/client, who is undergoing a particular type of psychotherapy. Something that might warrant interpretation as part of a patient’s psychoanalysis might well not be interpreted in other forms of psychotherapy; e.g., in supportive or cognitive-behavioral therapy. Let me hasten to add that, while I am not a psychoanalyst, my residency training at S.U.N.Y Upstate Medical University in Syracuse was strongly psychodynamic in orientation. I have great respect for the psychoanalytic tradition, while remaining a skeptic regarding empirical evidence for the efficacy of psychoanalysis per se, versus other types of psychotherapy.
My own orientation is more toward cognitive-behavioral forms of treatment, such as those developed by Albert Ellis PhD and Aaron Beck MD. So, this is my bias, if that is the right term. The particular patient described in my case was, as I indicated, in a supportive form of therapy. The goals of supportive therapy (versus other approaches) are described in some detail in my book, A Consumer’s Guide to Choosing the Right Psychotherapist (Jason Aronson, 1997). It is difficult to describe these in a brief, non-technical column, such as the one in the New York Times. Essentially, the goals of supportive psychotherapy are (1) to strengthen the patient’s coping skills; (2) to encourage mature ego defenses (such as use of humor) as against more primitive defenses (such as splitting, denial, projection, etc.); and (3) to help the patient sort out his or her options in a reflective way.Interpretations aimed at revealing a patient’s unconscious motivation would not be a routine part of supportive psychotherapy, but might be appropriate under certain circumstances. Let me give you an example, based on the case at hand. If my patient had been repeatedly sending me expensive gifts in the mail, or compulsively bringing them to me in my office, a clarification, interpretation, or confrontation (all of these have slightly different meanings in the technical literature) would have been in order. Alternatively, if her cookie-giving behavior seemed to be part of a broader pattern of psychopathology say, one linked to inappropriately submissive behavior toward her husband or parents interpretation might also have been appropriate. If, in short, the behavior in question appeared to be an unconsciously-driven stumbling block to the patient’s progress or recovery, it might well have merited interpretation. In my best professional judgment at the time, none of these factors applied to this particular patient. Of course, I may have been mistaken. But based on my usual standards for judging improvement in therapy the patient’s subjective assessment; my own global assessment; and use of standardized scales, such as the Beck Depression Inventory I believe that this patient did improve substantially by the time we concluded treatment.
Might she have improved more, had I interpreted her need to give me cookies? Maybe maybe not. In my field, you do the best you can, based on your training, experience, intuition, knowledge of the research literature, and, yes common sense!
Sincerely, Ronald Pies MD, Clinical Professor of Psychiatry, Tufts University School of Medicine
Ronald Pies, MD, is Clinical Professor of Psychiatry at Tufts University and Lecturer on Psychiatry at Harvard Medical School. He is the author of A Consumer's Guide to Choosing the Right Psychotherapist (Jason Aronson, 1997) and Handbook of Essential Psychopharmacology (American Psychiatric Press, 1998). Pies is also author of Ethics of the Sages, forthcoming from Jason Aronson
