Assessment or Consultation?

As with all therapeutic encounters, the approach of the therapist plays a central role. Key to this is the therapist’s perception of the task and their role. The term ‘assessment for psychodynamic psychotherapy’ is commonly used to describe the interview. There is some risk that this sets up the meeting on the basis of some form of test that may be passed or failed. The patient is allocated a rather passive role, deemed as suitable or unsuitable for this form of therapy. The therapist could then be seen as holding all the expertise and agency, and as making decisions on the patient’s behalf.

The term consultation seems to better capture a process that involves two participants working actively together to better understand the patient’s situation. In reality, both parties will to an extent be assessing each other, both at conscious and unconscious levels. Transference and countertransference responses exert pressures on any interaction between two people and these are likely to be intensified by the specific nature of this meeting. The discussions that have led to the referral, completion of the self-report questionnaire and the wait will amplify the anticipation of an emotionally meaningful experience. The patient’s transference responses become activated and the therapist is likely to have already become a significant figure. Attending to these processes, how they shape the encounter, how they can be glimpsed and understood is a fundamental component of the consultation.

The consultation is experiential, without the use of psychological measures or data. It concerns the process in the room. A detailed and particular focus upon unconscious aspects of the patient’s mental life offers an opportunity to consider the difficulties more deeply. The task is therefore broader than an assessment for a specific treatment and may lead to new ways to understand the presentation, in a way that is helpful to both the patient and the referrer.

The style and approach will vary considerably between different therapists and services. There is considerable debate about the extent to which the therapist should put the patient at ease. A stance of strict analytic neutrality, which resists any pressure to relieve the patient’s distress, may enable the assessor to rapidly access the deeper layers of anxiety and more primitive fears in the patient’s internal world. Some therapists may see this as unacceptably intrusive or potentially harmful in a consultation and may offer some relief from anxiety during the meeting; this may be more easily acceptable to the patient but may avoid making direct contact with their disturbance.

As Keats described in the opening quote, unless one has direct contact with an experience it can feel unreal or detached. The same is true for a psychoanalytic consultation, in which the patient’s main emotional difficulties may be described rather than actually experienced. The nature of the disturbance can only be felt in reality if it can be brought to life in the room. It is likely to require a degree of anxiety and emotional tension for the disturbance to become manifest, with an avoidance of any unconscious pressure to reassure or collude with the patient’s habitual defences against this happening. An example of this type of collusion may be an overly intellectual discussion of their difficulties, or the therapist adopting an explanatory approach as if to nullify rather than explore an emerging discomfort, frustration or negative transference. Unless there is some challenge, it remains unknown how the patient’s defensive organisation will respond to stress.

At the same time it is important to take into account the particular patient and their ability to tolerate anxiety and manage a degree of scrutiny. The capacity to reflect about thoughts and feelings requires an ability to think symbolically; if anxiety levels become unbearably high the capacity for symbolic functioning may collapse and concrete or paranoid function can take over. The therapist will need to make a judgement about how much to intervene to steady things should the patient become more distressed or disturbed during the meeting. Many of us who conduct psychoanalytic consultations will have experiences of patients who may have left the meeting prematurely in a vulnerable or disturbed state, perhaps even making accusations or complaints. Although it can be tempting to attribute this outcome to ‘unsuitability’ on the patient’s part, it may be the case that the therapist has not made a sufficiently sensitive assessment of the patient’s fragility. The example of the surgeon whose technique was described as perfect but the patient died can also be applied to the psychodynamic consultation; a premature or overly challenging interpretation can also lead to a patient lost in terms of the opportunity to understand something more clearly. If a patient becomes unduly distressed it also raises the question as to what has been gained from the consultation, other than contributing to a painful, humiliating or traumatic experience of an already vulnerable patient. While there is some evidence that increased anxiety allows paranoid-schizoid functioning to be observed more clearly, there is little to substantiate this as increasing the predictive power of the consultation [3].

In this example, although there may have been some accuracy in Dr D’s interpretation, it seems it had been made without sufficient recognition of the intense fear and the fragility behind Mr M’s bravado and interrogative style. In supervision Dr D recognised how he had felt defensive in the countertransference and his interpretation had been premature.

The balance to strike between the need to mobilise a degree of anxiety sufficient to allow contact with the disturbance while also establishing a containing frame for the task can be illustrated by the possible difference in outcomes this may achieve.

Possible responses and risks:

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   1. Dr G takes primarily a reassuring approach, asking questions about the history and taking up how much Ms F has conveyed her efforts to improve relationships within her family to no avail. Ms F agrees, leaves the consultation saying she has never felt so well understood. The risk however is that she has rapidly formed an idealised transference to Dr G, her defensive organisation in which disturbance is projected into others has been supported and the underlying paranoia and pressure to ‘take sides’ has not been addressed. It remains unknown how Ms F will respond if these defensive structures are challenged. Furthermore, Ms F has not had sufficient experience of a psychodynamic approach from the consultation to make an informed decision about treatment

   
   
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   2. Dr G does not respond to Ms F’s request for support but sits quietly. After a while she says it seems that Ms F feels all her family interactions have become toxic, and how much Ms F wants her to see it like this as well. Ms F nodded and seemed to agree with this. Based upon this response to the initial mild challenge, Dr G continues by saying that the problem with this is that it does not allow Dr G to help Ms F with the underlying feelings about herself, which perhaps is what Ms F is also wanting help with. In response Ms F become very tearful, openly sobbing and saying she feels like there is ‘toxic waste’ inside her and no one loves her as result. It became possible then to think together about this toxic part of her, which falls out with people, and how frightened she is of addressing it

Broadly speaking, a consultation can be described as a psychoanalytically informed conversation towards trying to arrive at some shared understanding of the issues behind the symptoms and difficulties the patient presents. This includes considering how experiences earlier in life may continue, through unconscious processes, to exert their influence in the present – including how they relate to the therapist in the consultation. This means that defences do need to be challenged to allow some direct engagement with the disturbed parts of themselves during the consultation. The patient’s perceptions and responses to the therapist’s presence and interventions when in a more disturbed and vulnerable state means they are better able to make an informed decision about how to proceed, based on a realistic experience of what ongoing therapy may entail.

Psychodynamic Psychotherapy Consultation: The Physical Setting

As with ongoing therapy, the physical frame provides the containing space within which consultation takes place. The features of this should include:

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  Appointment offered clearly as a consultation to explore the difficulties and what form of psychological therapy may be helpful

  
  
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  Private, uninterrupted room

  
  
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  Up to 90 minutes for the initial meeting, some therapists prefer longer

  
  
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  Option of a follow-up appointment

  
  
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  Parameters of the meeting clearly explained at the outset