Frank Weil lectures; #3 (Reel 2)

The first parallel first thing in coming to mention is that the relation is a voluntary one. A few of you may be here because your teachers are here also and you think that you want to be seen by them. I can add that I'm quite sure knowing the present generation of students that some individual stayed away because teachers put pressure on them to come and the students felt that their independence would be lessened if they came. Also a few wives or husbands may be here because the other of the pair wanted to come. And in the therapeutic relation there are times when the beginning of the relation is on a somewhat unwilling basis which can lead to certain difficulties. But by and large psychotherapy is based on the fact that the individual comes voluntarily because of his feeling that it has something to give him. He surely must hesitate at times just as you may hesitate to come to another damn lecture and especially to come to one which does not have the are a being given by a distant fire. Another point is that you came to the first of these lectures that if you came to the first of these lectures and the second time then coming the third time again is voluntary a startling and there must be some

feeling that as in the therapeutic relation that coming a number of times might be worth doing. Still another point in the relation between you and me is that you may have sensed that I am strongly and sincerely interested in having you get something out of these lectures. I worked on this material with TLC tender loving care partly out of my own interest but also because I wanted it to be clear and effective for those who came. But also you know that I am not so unrealistically dedicated to the cause of your development. To be willing to spend many hours in strenuous preparation and the work of giving these lectures without having something more in return. The fact is that I have received a great deal such as a generous fee plus what I've learned during the preparation of these lectures plus the fact that the challenge of speaking before a receptive group has made me see some new things even what I have been giving the lectures plus the fact that the lectures will be public.

I make the point of expressing what I get out of this situation and do so realistically and not as an empty polite comment because it's true as a similar process is true in a therapeutic relation. The psychiatrist should be paid appropriately for the time spent with a patient paid either by the patient or by the clinic by the center in addition to his own body of knowledge and skill is enhanced during the period of the treatment. The essence of this comment is that in the relation between you and me there is a tremendous concentration on your needs but not merely an empty plight are touristic fashion. Since it is combined at the same moment with an adequate recognition of my need use it is not a one way street. And this pattern appears in the therapeutic relation. Also although there is a tremendous concentration on the needs of the patient the needs of the psychiatrist cannot ignore. And this proud. Of the attention to the needs of both

issues are of high importance in general. Alliance is about creating about the ass in the therapeutic relation the fact of the two way street helps the patient to accept the fact that another individual is concentrated on my attempt to help their own. It becomes realistic and workable when the patient can see the professional aspect of the relation and which the other is not trying to be a self-sacrificing or giving parent focused only or overwhelmingly on the Empress of the shire or of an adult with another point. But the two way street aspect the partnership an essential aspect of our growth and our life and see is crucial I think in using it as a paradigm for the future in the development of a much more complex variety of ethics which may be called for which may be necessary. Now another point characteristic of the relation between you and me is that it is obvious that

I will not permit the temptations of Satan or of the Canaanites nor of the Homeric figures to interfere with my primary job. You know that I have enough self-awareness to recognize the temptation to be the wise elder statesman and enough guts to renounce where that me is that I will not try to impose my ideas on you out of any great wisdom but I will not talk down to you although I can't satisfy all of the groups who come. That I will not use the jargon of a special profession to show that I know something you don't know. Also you know that I am capable of looking inside myself at times and recognize that in any lecture there is a temptation to be exhibitionistic and you know that I will subordinate and exhibitionistic impulses I might have been to the kind of sublimation that makes a lecturer perhaps more enjoyable to the art of interning. I know that in spite of your temptation at times to fall asleep

you respond in part with a process similar to mine. I've reciprocating to some degree by giving serious consideration to the facts I give and the inferences I made still further. Tempted to elaborate must be a little stiffer there you know that in a real sense I regard this situation as one in which you and I are equal or you know that I met it in the early part of the first lecture when I talked about the fact that as far as I know most everyone in the room is capable of being a very good member of a very good team of the type that I have been and to be a very productive if he wants to be and if he works hard enough and long enough. But you know and I know that I would not be standing on this podium if it were totally worth it for all relations because of my work and the way in which I have worked and because of the work of others who I know and read because of the fact that your

interests have been primarily in either direction. I do have something to say which you want to hear and so you came to hear me in this way the relation has a quality of inequality. Comparably in the therapeutic relationship there is a combination of unequal equal relation with the degree of inequality based on the training or experience or objectivity of the therapist. The psychiatrist must recognize the fact that through his training through his own individual work experience he can be a leader in the situation to some degree and that he has something to give him the pay should basically have an equal equal relation but also the psychiatrist must be able with quiet confidence to say the equivalent of a brother I'm not trying to dominate I'm not trying to say on better or stronger I'm saying that out of my experience there are some things I have to say about certain ways in which you're blocking yourself or others and have certain mistaken ideas or misdirected feelings. I'm not trying to punish you

for an idea or a feeling or to shame you but I am saying that a person myself who wants what's best for you and for the others around you urges you strongly to take another look and still another look at this or that part of your thinking or your personality. Comparably and this relation with you by the way that rather long quotes something that I hope I would not do in that form. That rather long quote I want to have here and to emphasize because I think that it is an urgent aspect of the ethics about which we are going to be talking and ethics which inevitably as in the conflict between the generations inevitably carries the combined quality of the in the end the euro they are being both equal or. And our big inequality is inequality is both ways. But the ambiguity of the quality and inequality is first to be seen or else when taken by surprise. But it's not only a negative a difficulty

it's also one of the most creative aspects or possibilities in a generation gap in the attempt to overcome it comparably in my relation with you. I don't have the right or the class to tell you what to think or what to say. There is obviously an equal equal relation between us. The inequality between us a century is based on the fact that I have spent a very long time being with people or hearing residents in training talk about people who really tell me or the residents a great deal about our research including their ethical problems as a way of lessening their pain or suffering. Another point in a previous lecture I mention the fact that I am willing to violate it to boo about talking about unacceptable things if it's necessary in our joint search for the truth that is comparable to what happens in the therapeutic relation and which is necessary at times to have a discussion of matter is ordinarily taboo. But I said also that I paid attention to your needs in this situation. I would not

use the four letter words since I knew that some of the audience would find them unacceptable and using them was not necessary in our joint search for the truth. There is a part how to this and the therapeutic relation and that the psychiatrist is sensitive to the needs of the patient and will not do something merely for the heck of it. Another point in your relation with me is that these lectures are in the setting of a specific tradition. There are some rituals and traditions which are come to be associated with the hour lectures. One is that the lectures are read rather than given extemporaneously. I would not have planned it that way but I have come to recognize certain values in working intensively on the material in advance means that the lecture is given a great deal of change some of his ideas discarded some material which might be distracting. In fact I've come to feel this way of doing things is a good one even though it has never been my first choice. The parallel point of the setting of a tradition.

Parallel point in a therapeutic relation is that both the patient and the psychiatrist recognize that certain cultural patterns are involved in the relation itself as well and as in some of the material to be disguise. Usually this is a matter of practicality is the psychiatrist as a number of other up the gay chanson so he and the patient come to an agreement. But the appointment starts at a particular time and is over at a particular time. If it did not his schedule would be as chaotic as occasionally it is in the offices of some doctors who do not use an appointment system. But at the end of the appointment time even though the psychiatrist or the patient would not want to stop the discussion they do stop except under most unusual circumstances. Otherwise other patients will be short changed in some back. And this is a kind of limit setting. That is part of the therapeutic alliance. You know enough for the similarities between the therapeutic alliance and the relation between you and

me. Now for the essential difference. And these will be important to our So in our attempt to think of the therapeutic alliance as one of the paradigm big mapping. For the future of the US in the therapeutic relation the patient comes because he has pain or suffering or an awareness of there being something wrong or individuals whom he regards as honest and trustworthy I've indicated to him that there is something wrong or he has a feeling of lack of fulfillment of his own potential. Or because a competent physician has told him that there are factors of some importance in producing psychological factors of some importance in producing a pet reading some physical disorder. It's clear then that the motivation for coming to therapy has a profound difference from the motive for coming to lectures like this. And the second point of difference is that it's understood in advance of the therapeutic relations the patient will do his best to talk freely to tell as much about himself as he can and. Will be

willing to say whatever is part of his thinking or feeling. This does not mean that he will act as I would any of his suppressed or repressed desires nor believe that anything good. Rather he knows that an understanding of the complex web of the interplay of forces within a human being calls for self observation by the patient of his thoughts and feelings and for the observation of them by the psychiatrist and for a discussion of their observations. There is no dirty talk for the sake of dirty. The method does not recommend that the patient or the therapist lose their tempers. In fact does not recommend any type of putting other impulses into action. It is the discussion of the patients thoughts and feelings which is one of the unique characteristics of the therapeutic alliance. Since this provides the road to understanding this description leads to my underlining one point which may be of high importance in the development of a contemporary ethics it is that the traffic light. The

stop light in the human being need not be placed at the point in which an unconscious impulse becomes a conscious thought. Human beings need not tell Satan to get thee behind me. I need no one to keep their temptations he had been in the darkness of the unconscious rather the stop light can be placed at the point in which the impulse of the conscious thought might be put into action and to behavior overt behavior. That is the point at which the individual should stop block unless some means that he can have time to give some real consideration to the issue. In certain instances here is good the director of this traffic may say that since he is no longer a child a previously forbidden behavior may not be permitted by himself but also he or his ego at that stoplight may say that the previously forbidden behavior such as driving 100 miles an hour in traffic or out of traffic. Still it is forbidden. One of the basic

issues in the therapeutic alliance is that in discussion of the patient's thoughts and feelings a clear difference is made between the two categories imposed thought or ideas one category. In contrast with action or behavior to consider this further as a more general issue of ethics one might safely say that most human beings that they can give permission to themselves to have in mind punctually in mind practically any impulse are thought of by or idea. As long as they can laugh at many of them or can recognize that some of them are an awful waste of time even as thoughts or ideas then they can take a second look after the stop sign flashes they can take a second look of a clearer look. Back to the issue of action and behavior and see that some bits of action of behavior which once were now up are ProMED but others which once were ProMED such as a primary

self-centeredness which is permitted in childhood now is not to be permitted. If one wants to have the greater value and the greater fun of the development of a good kind of partnership or of a team in human relations. So the essence of the change in the location and the taste of the stop light in human activity is of in the therapeutic relation there is a more permissive attitude try to having impulses thoughts or ideas then the patient usually thought it was possible but also in the therapeutic relation there is the pattern of urging the patient to have a profoundly skeptical attitude about the advisability of putting many of his impulses right ideas into action or behavior unless they clearly have a favorable of fact and surely not if they have a clear unfavorable fact. And of course in some instances there must be a strong and clear limit setting attitude about putting specific impulses into overt behavior. Now the

therapeutic alliance then becomes an experience of partnership. As is true in many of the others that we should talk about could talk about them. Have any examples. The patient develops a workable degree of trust and confidence trust and confidence not blind trust nor blind missed trust and in the setting of the growing trust between the patient the therapist there develops several patterns been Portman's one is called the transference which simply means the patient begins to develop certain feelings of anxiety or liking or dislike hostility or jealousy etc. toward the psychiatrist who seems in some fashion to be like one or more of the important figures in the past life of the patient. The goal then is to discuss such feelings openly and see the way in which old patterns have been transferred to the therapist. This provides an immediate source of information about some of the important feelings of the past the profound hope is that in the setting of a good partnership the good

relation such feelings can be seen for what they are and lead to further understanding of him self or the patient. But now since we want to use the therapeutic alliance as a paradigm for other varieties of ethical creative alliances we must mention that the patient is not the only one of the two who may have some illogical inappropriate response in the course of the alliance. The psychiatrist also may have responses comparable to transference responses which the psychiatrist then are called counter-transference. This means that the psychiatrist must learn to look frequently at his own response. This is not merely the result of the injunction of the great philosopher to know thy self. It is a specific work acquirement of day to day work in the field of psychiatry has come to see that unless she watches him sour his work may suffer.

And I am eager I am eager to transmit to you some feeling of the way in which a therapeutic alliance can be less effective because of personal feelings on the part of one of the other. The car is in general good human relations alliance or one of the most important most productive varieties of ethical behavior and that therefore it is imperative that we look at some of the difficulties in having a good alliance a good alliance of the use of art and the ways in which the difficulties can be overcome mastered coped with by past. A typical example a typical example is this one of our excellent presidents in training and psychiatry was treating a bright young college student. The student had severe and unnecessary guilt over having a greater education and that his father ever had or could have. The student's guilt is not the rest of the students treat the student's guilt

slowed him down and his colleagues at work and he became an under achiever. I can mention that the psychiatry restaurant is about 6 or 7 years older than the college student that both are intelligent and gifted and both are eager to have a good career. Both are somewhat competitive and both a counterforce in each of them. I want to be sure that their competitive feelings did not hurt either. But the residents problem was mild r.m.r while the student's conflict was severe as was indicated by the difference in their careers so far. But a psychiatrist the one in training and psychiatry must not ignore his own patterns even if they are minimal. Now in our program we have continuous case seminars in which the progress of a patient in the work of a resident with that patient is reviewed every two weeks years and in several seminars it had been

clear that the resident treating the college student had a very good perception of what was going on with a student his patient and between the two of them. But he the resident perhaps had an unusual ability to see the students urge to compete with his father and his guilt over that him hours and hours so to see the unfortunate resolution of the conflict in the student with the student unconsciously trying to get new grades and the Higher than a C or a D. But the student flourished during several months of treatment where the rest didn't. And his colleagues work improved staff a day but then came a plateau in the treatment in which no further improvement was taking place. At first in the discussion it seemed that this might be related to the fact that the students farther out had a period of the illness and the student had some fantasy that he had cars so much worry in his far there that he

might be responsible for the father's own ass. But this formulation of the student not making further progress somehow did not hold water in the further discussion and then the resident was treating the patient and several of the residents colleagues and I who make up the membership of the seminar. Turned our attention to the feelings of the resident himself. And it was not difficult to discover that as the student was making excellent progress then in his college work he the student had begun to talk to talk of going to graduate school or perhaps especially to medical school and he even said that he might then want to consider training in psychiatry. With this as the student was doing so well in talking going into SCAD grade the resident had some feeling which I give in an exaggerated form to make my point. It's as if the resident were saying to him something like Hey what's this business of

making younger people stronger. Our one does is to help these brave youngsters to be able to compete more successfully with people of my age. The resident had been frankly aware of his response to the patient's growing confidence. Of course he had not said a single word that would have been competitive toward the student or a single word which would have given the student which would have made the student hesitate to go further in his own development. But it seem now to the resident himself and to the rest of us in the small group that the resident may well have been slightly poker faced during the interviews in which the student talked of his great progress. And when the student received an A on two successive semester papers the resident may have been a trace less friend. They may have revealed a bit of his feelings in his facial expression. It was the understanding of all of us in the summer NAR that the resident may have been tempted frankly to express some of his competition but only in facial expression or

in tone of voice. I must add that the story is of some years ago and it's hatter. It had a happy ending and to preserve confidentiality I can say that the resident now is a professor of psychiatry and the university student now is a resident in the field of surgery. This is enough to last page. Thank you. This is enough of a stash of the therapeutic alliance which in a way focuses a number of points of our thinking about ethics. I want only to add that quick to lay another comment about the alliance. It is that it is not easy to develop or to sustain as none of the areas a solution of the conflict between the generations is not easy to come by or sustain the therapeutic alliance in spite of the difficulties has been achieved successfully. Time after time

and as I see it two points explain its success. One is that it is a partnership. I have two people working together on the parts of the personality of one of them which boasts one to change. The second point that makes it work the first way is the partnership in a common job. The second point that may make it work is that an honest self scrutiny is a built in part of the process. The skyjackers to the patient not only must look frankly at the patient's emotional problems which interfere with his life. The psychiatrist knows also that he must look inside himself at the ways in which even a minor or minimal problem can interfere at times with his own good functioning. So there are on both sides a degree of ability in self-scrutiny that combination of partnership and built in sub scrutiny

which may give us one of the most important leads of combinations for the future of a creative sort of that takes. So. These two points now partnership and self scrutiny seem vital in an ongoing consideration of ethics. They will be crucial in the discussion and in the remaining lectures. When we consider the conflict between the generations the creative types of ethics and then the sudden appearance of a number of doors opening to the development of the technology. Ask us next time. We will turn first to anthropology to an extraordinary contribution to I thinking which arises from a study of the West African cultures. You have just heard Dr. Murray Slovene professor I'm director of the Department of Psychiatry at the University of Cincinnati College of Medicine speaking on the therapeutic alliance one of a series of lectures on

psychiatry and ethics. These lectures were given at the Franco Wilde Institute at the Hebrew Union College Jewish Institute of Religion in Cincinnati. The topic of Dr. Levine's next lecture is the conflict between the generations. These programs were produced out the University of Cincinnati station WAGA U.S. and are distributed by the National Education or radio network.