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“How Old Are You?”: A Dilemma in Gratification for the Young Therapist

orange-is-in-by-christine-tmTimothy M. Scarella, MD

Introduction
Answering a patient’s direct questions about biographical information is a source of anxiety for novice psychotherapists and I inadvertently sparked a lively debate in a supervision group when I admitted that, when asked, I always answer my patients when they ask me how old I am. For trainees, the appearance of being young often prompts inquiries about age. Misperceptions surrounding the concept of therapeutic neutrality often lead trainees to not answer this (or any) question. However, despite the rich psychodynamic meanings behind the question that beg for exploration, respect for neutrality in the countertransference may favor answering rather than withholding an answer. Answering this question should not be equated with preventing exploration of its meaning, and may in fact directly benefit the treatment.

“You look too young to be a doctor” is a common observation from patients to trainees in all health-care specialties. Psychiatrists, psychologists, social workers, nurse practitioners and others who train in mental health endure equivalent sentiments. I actually do look young and thus my age is in the room whether the patient asks or not. I always considered my age as a potential part of the vetting process for a patient’s agreement to the intimate treatment relationship required in psychotherapy. At the very least I thought it a neutral and unthreatening piece of biographical information. I never thought twice about revealing it and I always paired my answer with appropriate exploration. Depending on the patient, exploration occurred before or after answering.

In the discussion group, I found few sympathizers to my position, though one study suggests that about a quarter of psychiatry residents may agree with me (Rutherford, 2007). Some of my colleagues worried that answering a question would stymie the development of fantasy. I believe that revelation of my age should not necessarily squash a fantasy; avoiding an answer is not an avoidance of being young, just as avoiding an answer to “Are you married?” doesn’t take the ring off of my finger. Exploration of the question should still allow for discussion of any fantasies.

They challenged me: “Do you have a good reason to answer that question?” In a human interaction the default is to answer a direct question and not to avoid answering it. Therefore, in psychotherapy, you don’t need a good reason to answer a question – you need a good reason to not answer. And no one had yet given me a good reason to not answer with my exact age.

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Some also argued, on my behalf, that the information was likely discoverable on the internet anyway, but I think that argument misses the point; my unconscious motivations for answering were questioned. Perhaps I, being self-conscious and anxious about being young and inexperienced, readily revealed my age as a counter-aggressive move: “I’m 26 – so what?” Others wondered if this was a moment to show off, to brag about having achieved my level of training at a relatively early age. I suppose the nature of the unconscious renders me unable to convincingly deny either of these and I will leave the question of my unconscious motivations to my therapist.

Misuse of the Concept of Therapeutic Neutrality
The stereotypical image of the silent, withholding psychotherapist is one that persists among psychiatry trainees beginning to learn psychodynamic psychotherapy. Luckily, many authors have excellently refuted the idea that ‘remaining neutral’ necessarily involves remaining quiet and avoiding all disclosure of feelings or biographic information (Greenberg, 1986; Hoffman, 1992; Mitchell, 1991; Renik, 1996). When Freud raised the concept of neutrality, he was referring to neutrality in the countertransference – the necessity of ensuring the actions of the therapist, including interpretations and disclosures, serve the needs of the patient and not the therapist (Freud, 1915). In this way, depending on the setting, both disclosure and withholding may be either in support of or in violation of therapeutic neutrality.

The distinction between ‘needs’ and ‘wishes’ was elaborated by Mitchell as a method for determining whether or not to gratify a patient’s requests in a given situation (Mitchell, 1991). He observed that conscious desires were traditionally thought to represent derivatives of instinctual wishes and that frustration of these desires in psychoanalysis brought unconscious conflicts to the forefront for analysis. Later, Winnicott and others pointed out that there was a second option – that a request could represent a true ego deficit, a lack of healthy cognitive function that, until corrected, would prevent benefit from the interpretative analytic process. (Cabiniss, 2011; McWilliams, 2011; Winnicott, 1955). In such a scenario, the patient does not wish to know, they need to know.

Mitchell goes on to state that the decision of whether or not to gratify rests on the evaluation of a request or question as representing a wish, in which case it is therapeutic to withhold gratification, or a need, in which case it is therapeutic to answer (Mitchell, 1991). My colleagues utilized this distinction with their inquiry – “What is the need for the patient to know”.

The Relationship of Gratification to Informed Consent in Psychotherapy
Indeed, why would a patient possibly need to know the therapist’s age? In psychotherapy, the personal characteristics of the therapist, consciously or unconsciously, influence the quality of the therapeutic relationship. This is not trivial, as the quality of the therapeutic relationship is a key predictor of a successful treatment (Horvath, 1991; Luborksy, 1985). Thus, an argument can be made that a patient may need to know a certain piece of information as part of informed consent for treatment.

Though a minimum standard of informed consent for psychiatric practice has been delineated (Rutherford, 2007), things are murky when it comes to answering questions that are not explicitly part of the informed consent process. Beahrs and Gutheil (2011) make the point that the information necessary for informed consent is specific to each patient. The implication is that the patient may select what his or her needs are.

As informed consent ideally occurs at the outset of treatment, when specific and reliable insights into the patient’s inner mind may be few, the therapist must make a reasonable decision about whether or not he or she agrees that the requested information is needed. Alternatively, the therapist may answer the question if there is no clear indication that gratification would be counter-therapeutic, or if withholding would be unethical (ie withholding one’s licensing credentials). If something is agreed upon as needed by a particular patient-therapist dyad, then it becomes part of informed consent.

Thinking dynamically, we can always explore why this patient needs this particular piece of information, as opposed to any other piece, for informed consent. I would advocate that circumventing appropriate exploration of these questions would generally be a missed opportunity. Nevertheless, the therapy’s need for exploration does not obviate the need of the patient’s ego to know the information.

Obligations of Therapist and Patient
Unlike the patient, the therapist carries a duty to be aware of the reasons for making certain demands of the dyad. The therapist may provide a hard-hitting interpretation despite predicting it will lead to uncomfortable feelings in the patient because of an awareness that the discomfort is in the service of the patient’s treatment. Simultaneously, the therapist is careful to avoid painful interpretations that serve only to satisfy the therapist’s sadistic impulses. A demand to withhold gratification, such as a refusal to reveal one’s age, requires similar justification. Some of my colleagues noted their personal discomfort at answering the question based on their own sense of boundaries. I am in no place to say if this was a ‘need’ or a ‘wish’ for them, but certainly the idea of revealing one’s age could represent a true conflict of needs for any given dyad.

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If the therapist consciously prefers that patients not know his or her age (or country of origin, marital status, ethnicity, sexual orientation, gender identity, religious affiliation, home address, favorite local bar), then when electing to withhold the information the therapist must determine that withholding involves more potential risk than potential benefit to the patient-therapist dyad. If this criterion is not met, then withholding would be in the service of the therapist’s wishes and in violation of the patient’s needs. In other words, the decision would be reflective of an intra-psychic compromise formation around the therapist’s unconscious conflicts, rather than in the service of examining the patient’s conflicts or strengthening the patient’s ego.

This would be a clear violation of the earliest formulation of neutrality, Freud’s “neutrality in the countertransference” (Freud,1915). If knowing the therapist’s age is a true ego need that the therapist cannot meet due to his own ego needs, and this need to know is important enough to the patient, then appropriate referral should be facilitated.

More than Avoidance of Risk
However, I think my general policy of revealing my age requires more than the assumption of low therapeutic risk. In fact, I believe that answering this question is beneficial in most cases. Though the exact nature and mechanism of therapeutic change in psychotherapy continues to be debated, it can be conceptualized that all psychodynamic therapies effect change by making patients more known to themselves. This is accomplished by the patient’s invitation to have the therapist know him or her, and the subsequent relational exchange of knowledge, of ‘knowing’. Resistance stems from the patient’s fear of knowing, and often, fear of asking.

At its core, the question “How old are you?” relates to the concepts of knowing and being known. In asking it, the patient manifestly says: “I would like to know about you”, a transformed version of “I would like to know about myself.” By answering, the therapist says: “It is alright to want to know, and it is alright to ask.” When exploring the question and its answer, the therapist is saying: “Whatever it is you find out, it will be OK; I will help you understand it.” Given the relative benignity of knowledge of the therapist’s age, the question is a golden opportunity to strengthen the therapeutic relationship without straying far from the frame.

I will offer two case examples to illustrate my point; non-essential details have been altered or omitted in order to preserve patient confidentiality.

Case 1: A woman in her early 50s is referred for psychotherapy complaining of a series of frustrating romantic relationships that have thwarted her strong desire to marry and start a family. Her internal objects lack complexity, and she has a striking lack of curiosity about her own internal world and that of others. There is almost no connection in the room, and little belief by the therapist that he is a stable presence in the patient’s mind outside of sessions. With time, she shows increasing curiosity about her mental process and seems to internalize more interpretations. One day, she abruptly asks me for my age, and she does not seem entitled but curious. Knowledge of the patient gleaned by the long-term relationship leads me to first explore her question, but later in that same session I answer it. The therapy continues to deepen, with substantial improvement in her self-efficacy, assertiveness, and insight.

Case 2: A man nearing retirement age requests treatment for anxiety. Upon entering the room in the initial consultation, before even sitting down, he gives me a concerned look. Fumbling over his words, he explains, “I don’t want to be rude but…I’m worried you may not be able to help me.” He asks for my age, and I answer the question immediately. His wariness about the therapist’s inexperience is validated, as I explicitly acknowledge the fear of my lack of life experience limiting my ability to understand his problems. A useful therapeutic relationship grows from this first meeting, which addresses long-standing issues that include an intractable intra-psychic emptiness and chronic interpersonal struggles between the patient and authority figures.

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These two cases represent different scenarios involving the question of my age. In the first, a neurotic patient engaged in a stable therapeutic relationship with a practitioner who possessed a reasonable working knowledge of her relative ego strengths and deficits showed a sudden interest in the therapist as a person. This is a sign that she finally feels safe to dip her toe in the waters of emotional closeness. Though gratification was delayed by first exploring the question, complete withholding may have reinforced the fantasy that seeking closeness would result in frustration and shame. This, for her, would have been a counter-therapeutic stance.

The second patient asked for the therapist’s age before even presenting his symptoms in an initial meeting. Even though the therapist detects a faint whiff of vulnerability beneath a shell of haughtiness, it is hard to find empiric evidence this early in a treatment on which to defend a decision to not reveal one’s age. The initial attitude of openness and empathy likely established a firm foundation on which the work was built.

The Goal of Therapy is Successful Treatment
Many patients have stated their worry that my young age creates a barrier to my understanding of their situation due to a perceived lack of life experience or lack of professional expertise resulting in an inability to empathize with their story. None (that I am aware of) have terminated treatment because of my age. I cannot say that this is due to my willingness to acknowledge and discuss my age directly rather than abstractly, but I don’t think it hurts.

I have not yet met a patient for whom, upon reflection, I could surmise a reason that knowing my precise age carries more risk than benefit in the treatment. As such, not disclosing my age on request would be a decision that was more about me than the patient and the disclosure is a way for me to hold up my end of the treatment bargain. It is a way to state clearly that the work is about them, not about me.

Tim Scarella is a recent graduate of the Harvard Longwood Psychiatry Residency Training program in Boston, Massachusetts. He earned his Bachelor’s Degree at Trinity College in Hartford, Connecticut in Chemistry and Neuroscience and his Medical Doctorate at the Northwestern University Feinberg School of Medicine in Chicago, Illinois. His clinical interests include health anxiety, somatization, conversion disorders, integration of psychiatric care into general medical settings and psychodynamic psychotherapy.   He can be contacted at: North Shore Medical Center, Department of Psychiatry, 55 Highland Avenue, Suite 201, Salem, MA 01970  Email: tscarella@partners.org

References

Beahrs, J.O., Gutheil, T.G. (2011) Informed Consent in Psychotherapy  American Journal of Psychiatry 158(1), pp. 4-10
Cabaniss, D.L., Cherry, S., Douglas, C.J., Schwartz, A.R. (2011) Psychodynamic Psychotherapy: A Clinical Manual pp 90-97 New Jersey:John Wiley and Sons,
Freud, S. (1915) Observations on Transference-Love (Further Recommendations on the Technique of Psycho-Analysis III) The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, pp157-171.
Greenberg, J.R. (1986) Theoretical Models and the Analyst’s Neutrality Contemporary Psychoanalysis, 22, pp. 87-106
Hoffman, I.Z. (1994) Dialectical Thinking and Therapeutic Action Psychoanalytic Process in Psychoanalytic Quarterly 63, pp187-218
Horvath, A.O., Symonds, B.D. (1991) Relation between working alliance and outcome in psychotherapy: A meta-analysis  Journal of Counseling Psychology 38(2), pp139-49
Luborsky, L., McLellan, T., Woody, G.E., O’Brien, C.P., Auerbach, A. (1985) Therapist Success and Its Determinants Archives in General Psychiatry, 42(6), pp602-11
McWilliams, N. (2011) Psychoanalytic Diagnosis, Second Edition: Understanding Personality Structure in the Clinical Process. 2nd ed. London: The Guilford Press pp 70-99.
Mitchell, S.A. (1991) Wishes, Needs, and Interpersonal Negotiations Psychoanalytic Inquiry 11, pp 147-170
Renik, O. (1996) The Perils of Neutrality Psychoanalytic Quarterly 65, pp495-517
Rutherford, B.R., Aizaga, K., Sneed, J., Roose, S.P. (2015) A survey of psychiatry residents’ informed consent practices  Journal of Clinical Psychiatry 68(4), pp558-65
Winnicott, D.W. (1955). Metapsychological and Clinical Aspects of Regression Within the Psycho-Analytical Set-Up International Journal of Psycho-Analysis 36, pp16-26

Image: Orange is In… by Christine tm