I Hate You--Don't Leave Me - Jerold J. Kreisman [72]
Just as the doctor evaluates the patient during the initial assessment interviews, so should the patient evaluate the doctor to determine if they can work together effectively.
First, the patient should consider whether he is comfortable with the therapist’s personality and style. Will he be able to talk with him openly and candidly? Is he too intimidating, too pushy, too wimpy, too seductive?
Secondly, do the therapist’s assessment and goals coincide with the patient’s? Treatment should be a collaboration in which both parties share the same view and use the same language. What should therapy hope to achieve? How will you know when you get there? About how long should it take?
Finally, are the recommended methods acceptable to the patient? There should be agreement on the type of psychotherapy advocated and the suggested frequency of meetings. Will the doctor and patient meet individually or together with others? Will there be a combination of approaches, which might include, say, individual therapy on a weekly basis, along with intermittent conjoint meetings with the spouse? Will therapy be more exploratory or more supportive? Will medications or hospitalization likely be employed? What kinds of medicines and which hospitals?
This initial assessment period usually requires at least one interview, often more. Both the patient and the doctor should be evaluating their ability and willingness to work with the other. Such an evaluation should be recognized as a kind of “no-fault” interchange: it is irrelevant and probably impossible to blame the therapist or the patient for the inability to establish rapport. It is necessary only to determine whether a therapeutic alliance is possible. However, if a patient continues to find every psychotherapist he interviews unacceptable, his commitment to treatment should be questioned. Perhaps he is searching for the “perfect” doctor who will take care of him or whom he can manipulate. Or he should consider the possibility that he is merely avoiding therapy and should perhaps choose an admittedly imperfect doctor and get on with the task of getting better.
Obtaining a Second Opinion
Once therapy is under way, it is not unusual for treatment to stop and start, or for the form of therapy to change over time. Adjustments may be necessary because the borderline may require changes in his treatment as he progresses.
Sometimes, however, it is difficult to distinguish when therapy is stuck from when it is working through painful issues; it is sometimes difficult to separate dependency and fear of moving on from the agonizing realization of unfinished business. At such times there will arise a question of whether to proceed along the same lines or to take a step back and regroup. Should treatment begin to involve family members? Should group therapy be considered? Should therapist and patient reevaluate medications? At this point a consultation with another doctor may be indicated. Often the treating therapist will suggest this, but sometimes the patient must consider this option on his own.
Although the patient may fear that a doctor is offended by a request for a second opinion, a competent and confident therapist would not object to, or be defensive about, such a request. It is, however, an area for exploration in the therapy itself, in order to assess whether the patient’s wish for a second evaluation might constitute a running away from difficult issues or represent an unconscious angry rebuke. A second opinion may be helpful for both the patient and the doctor in providing a fresh outlook on the progress of treatment.
Getting the Most from Therapy
Appreciating treatment as a collaborative alliance is the most important step in maximizing therapy. The borderline frequently loses sight of this primary principle. Instead, she sometimes approaches treatment as if the purpose were to please the doctor or to fight with him, to