[The earlier posts in this series can be found at Part I, Part II, Part III, and Part IV.]
As I pointed out in my first posts in this series, when Doctors are turned into providers, they are reduced to technicians. At the same time, when patients are turned into clients, or the more execrable "consumers", their relationship to their Doctors shifts into a potential, and all too often real, adversarial relationship. Furthermore, by neglecting or denying the fact that people in pain tend to regress, the change denies the treating professionals the single most powerful weapon in their armamentarium.
All psychotherapy is built upon Sigmund Freud's recognition that the contents of the mind are predominantly unavailable to the conscious mind, and the unconscious is the source of most of our psychological difficulties. The idea that our unconscious mind should be so powerful and determinative of our behavior is now being confirmed by the Neuroscientists but is always a disquieting observation. Everyone wants to believe their behavior is based on rationality, yet the existence of a dynamic unconscious underscores how little we really understand about our own inner workings.
Those Psychiatrists, Psychologists, Social Workers, among others, who study and train in the practice of Psychotherapy learn that the most effective agent of change in their patients is through the transference; when early relationships that have been problematic for the person are re-evoked and repeated within the therapy, the patient is given a second chance to work through the conflicts that began in the past and continue to cause problems in the present.
Not every problem requires the most intensive work, but all problems addressed in therapy will rest upon some usage and understanding of the state of the transference relationship to the therapist.
The change in therapy of patients into clients and Doctors into providers began for noble reasons.
When the War on Poverty began with great fanfare during the administration of Lyndon Baines Johnson, the goal of abolishing poverty by empowering and supporting the poor brought some new terminology into common parlance. Empowerment became all the rage. "Power to the People" was the mantra of the 60's protesters. As with all slogans, what was left unspoken was what kind of power would be engendered in the recipients of society's largess. Over the course of several decades, empowerment more and more came to mean helping patients demand their deserved entitlements from the "uncaring and withholding system." First the Social Workers adopted this philosophy, and it then spread to the Psychologists and Psychiatrists. This led to an unconscious splitting of the transference that continues to be problematic.
Dr. Bliss at Maggie's Farm has helpfully (though unawares) done some of my work for me. In her post on Transference and Politics, she wrote:
One of the key basic concepts is Transference. At the risk of annoying readers who hate fashionable words like "template," I have to use "template". To keep it simple, a transference is a relationship template, usually molded during youth, and mostly unconscious - by which we mean that we aren't aware that it is acting on us.
Transferences distort our relationships as our brains attempt to apply the template of prior relationships, or, more often, our distorted versions of prior relationships, onto current ones.
Most common are paternal and maternal transferences, but sibling transferences, grandparent, friend and avuncular transferences are common too. (What's the female version of avuncular? Avauntuler?)
Because our transferences tend to be beneath our awareness, they are usually only evident to analysts when observing behaviors or feelings which do not seem to fit the real current-life situation. Thus the less transference-driven our relationships are, the more mature and in reality they tend to be.
As psychoanalytic concepts have been integrated into everyday thinking over the past 100 years, there has been a degradation of the technical terms. Thus we can talk about a "maternal transference" towards government, for example, when someone experiences their government as "need-fulfulling", or a "paternal transference" towards government when it is experienced as "opportunity-providing, demanding, and challenging."
[Emphasis mine-SW]
Those who saw (and see) their job as empowering their clients to extract needed sustenance from a withholding parental transference object (especially a governmental body) are consigning their patients to a permanent infantile role in relation to reality. The alternative, requiring the patient to discover what within them interferes with their ability to seek and find gratifications in the world of reality through their own agency, is much more difficult. (Which better describes what is occuring in France right now?)
The first therapist will spend his time agreeing with the patient that their ___________ (fill in the blank with Mother, Father, Medicaid, Welfare, etc) was cold and ungiving or was emotionally abusive and demanding. The patient will remain a client who blames others for his current troubles.
The second therapist will acknowledge that they experienced their ____________ (fill in the blank as above) as cold and ungiving, or emotionally abusive and demanding, but will additionally wish to understand how such experiences continue to prevent their getting a job, or finding a loving relationship, or any of a host of other problems they are having.
The first therapist endeavors to be seen as a loving Maternal object, taking advantage of the positive transference aspects of the maternal transference and allowing both the therapist and patient to ignore (disavow, project) the negative transference which has been split off and attached to others.
The second therapist risks the patient's anger and rage by insisting that there is no all-giving Maternal object (the object that is at the core of most Utopian philosophies) and that the patient must do his part to come to terms with current reality. This is by far the more difficult job, not least because no therapist wants to have his patients angry at him, but once a working relationship is established and the recognition that going back to a fantasied past is impossible, both can get to work on understanding the inner workings of the person's mind which have led him into trouble.
Consciously, therapists changed their usage of patient to "client" and "consumer" in order to level the playing field between Therapist and patient and dispense with the hierarchical relationship between the two. In so doing, the Therapists (in league with the Insurance companies and the legal profession) have consigned their clients to dependency. Paradoxically, by using the transference to fuel insight in therapy, we can be much more successful at freeing our patients from their inner constrictions and enable them to achieve much greater autonomy.
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