Department of Developmental Psychiatry, Queen's Medical Centre, Nottingham NG7 2UH, UK
In his editorial on the interpersonal domain, Hobson (2003) asserts that the analysis of intersubjective engagement in the therapeutic dyad is essential to the understanding of subjective meanings and their role in the manifestation of psychiatric disorder. In the same issue of the Journal, Lanman et al (2003) describe their attempts to determine a measure of fit between individuals in a couple system.
Both these papers acknowledge a fundamental fact concerning all human relationships; that they are, in their totality, the interaction between one personality and another. What is striking, however, both in these papers and in other recent literature concerning, in particular, personality disorders (Tyrer et al, 2002), is the lack of any discussion concerning the specific role the therapist's/clinician's personality plays in shaping the therapeutic relationship.
Hobson's use of Donne's metaphor (No man is an Island, entire of it self) captures what I believe to be the sine qua non of personality disorder; namely, that personality disorders can only be understood in the context of interactions between personalities; that the construct of personality disorder cannot exist in isolation. This notion is akin to the distinction made between primary and secondary qualities by the philosopher John Locke. In a psychiatric context one might consider schizophrenia to be a primary phenomenon, an integral part of the individual, whereas personality disorder, being contingent on an interaction with another, is secondary.
If one can accept the notion of personality disorder as a consequence of the interaction between two personalities, then surely it behoves members of the psychiatric profession to consider how their personalities influence the therapeutic relationships that lie at the heart of the discipline. That this appears, historically, not to have been the case is revealed by Lewis & Appleby's (1988) seminal paper. While amply demonstrating psychiatrists' negative attitude towards individuals with personality disorder, the authors failed to address the possibility that this might be a function, in part, of the psychiatrists' personalities.
If we are to be scientific about studying interpersonal functioning, then perhaps the first step might be to consider a systematic evaluation of both personalities involved in the therapeutic dyad. One possible method might employ a dimensional assessment of personality that would, in turn, help define how different personalities fit together. For example it might be reasonable to expect a clinician, scoring highly on the openness dimension of the NEOPIR (Costa & McCrae, 1992) to fit well with a patient scoring much lower on the same scale.
If this were shown to be the case, it could have important ramifications for resource allocation, both in psychotherapy and in the wider psychiatric field, allowing individual personalities to be fitted together in order to better facilitate the therapeutic relationship. An appreciation of the role their own personalities play in the construct known as personality disorder, might also diminish psychiatrists' negative attitudes to the disorder they appear to dislike.
REFERENCES
Costa, P. T. & McCrae, R. R. (1992) Revised NEO Personality Inventory (NEOPIR) and NEO Five-Factor Inventory (NEOFFI) Professional Manual. Odessa, FL: Psychological Assessment Resources.
Hobson, R. P. (2003) Between ourselves:
psychodynamics and the interpersonal domain. British Journal of
Psychiatry, 182, 193
-195.
Lanman, M., Grier, F. & Evans, C. (2003)
Objectivity in psychoanalytic assessment of couple relationships.
British Journal of Psychiatry,
182, 255
-260.
Lewis, G. & Appleby, L. (1988) Personality disorder: the patients psychiatrists dislike. British Journal of Psychiatry, 153, 44 -49.[Abstract]
Tyrer, P., Duggan, C. & Coid, J. (2002) Ramifications of personality disorder in clinical practice. British Journal of Psychiatry, 182 (suppl. 44), s1-s2.
Tavistock Mental Studies Institute, The Tavistock Centre, 120 Belsize Lane, London NW3 5BA, UK
We are grateful for the opportunity to respond to Dr Calton. He challenges claims for objectivity in the diagnosis of any disorder that has an interpersonal component, taking as his example some research into the diagnosis of personality disorder. He queries why we do not consider the role of the therapist's personality in our paper, Objectivity in psychoanalytic assessment of couple relationships' (Lanman et al, 2003). In that paper, where we show evidence of a good degree of objectivity (based on interrater reliability) for the diagnoses we discuss, we specifically refer to the fact that those making the judgements need to have had a psychoanalytically based training in order to develop their ability to make use of their emotional reactions to the patient.
Our paper deals with psychotherapeutic diagnoses, rather than with psychiatric ones, but on the basis of our work we would like to comment on Dr Calton's position. First, there are likely to be very significant differences in what is judged to be a helpful fit between therapist and patient, between the two different domains of general psychiatry and psychoanalytic psychotherapy. In the former, a friendly and sympathetic stance may be the crucial therapeutic vehicle for providing medication and other treatments. But in the domain of psychotherapy it is not necessarily a good thing to match therapist to patient, if by this one means attempting to avoid prejudices or sensitive areas, because this is likely to lead to a serious evasion of the darker areas of interaction, conscious and unconscious, where the significant problems will tend to lie. If the study of the interaction in the room, between therapist and patient, is itself the treatment, then the therapist's best equipment for this is self-knowledge, including knowledge of the darker areas of his or her own personality and knowledge of how to recognise and use the ways in which these affect him or her.
While personal psychotherapy together with detailed supervision by no means guarantee the development of such knowledge - and there will be practitioners who are unable to respond, as well as therapies which do not go far enough - these remain the best available means of acquiring the skills necessary to work with unconscious processes, enabling a therapist to understand a patient's personality difficulties of and the way these interact with their own. Outside this particular field, it may not be widely recognised that one of the principal tools of contemporary psychoanalytic therapy is the constant monitoring by practitioners of their own emotional responses to patients, not simply in order to suppress or redirect them, but in order to gain information that the therapist will then be able to employ in clinical diagnosis and engagement with patients. This is not to be confused with the self-disclosure advocated by some therapies. In our view there is no substitute for a rigorous psychotherapeutic training in this area, which includes selection of trainees, personal psychotherapy and detailed supervision.
REFERENCES
Lanman, M., Grier, F. & Evans, C. (2003)
Objectivity in psychoanalytic assessment of couple relationships.
British Journal of Psychiatry,
182, 255
-260.
HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |