A healthy life

Therapeutic help

Scenes from life

Imagine a psychotherapist working in the public health system who is conducting an initial interview with a patient. The patient has been referred to the therapist because of an eating disorder. She is clearly anorexic and has become so dangerously underweight that she is somewhat at risk both of extreme physical collapse and possibly of harming herself in other ways.

During the course of the interview, which is very much aimed at gathering information that might be helpful in understanding the person and finding a useful way forward for her, the therapist uncovers a very complex home situation. The woman, who is in her thirties, has two young children and is obviously very unhappy with the relationship she has with her husband. It emerges that much of this unhappiness stems from the way in which he keeps a large part of his life a secret from her. However, during the previous year or so she has learned that when he goes out at night, as he does frequently, it is to engage in various criminal activities. She had no idea of this earlier in the marriage.

As the interview progresses further, so the patient reveals a great deal of information to the therapist. This includes the fact that although she has repeatedly told her husband how she deplores what he is doing, even though it is swelling their income, he shows no sign of stopping. In fact, she points out to the therapist, her husband has planned a robbery for later in the week. She even knows and mentions the name of the person who is to be robbed.

At the end of this first session, the therapist has collected a great deal of information that might be useful in subsequent therapeutic sessions with the patient. She has even begun to make a formulation of the case; this being one of the initial tasks that she would normally do as early as practicable when seeing a new patient. However, the therapist is also faced u

with a very difficult moral issue. She knows that a crime is to be committed, or, at least, she believes that her patient is sure that a crime is to be committed. The therapist/patient relationship is usually regarded as sacrosanct, but in this instance, should it remain sacrosanct?

Malcolm is 42 years old. He is single and has had a sequence of unsatisfactory relationships. He seems to be able to start a new relationship easily enough, but it soon begins to go wrong and it is always the other person that ends the relationship, rather than him. The latest break-up has been particularly unpleasant from his perspective and he has become both anxious and depressed, so much so that he has sought therapeutic help. He is in a good job and so can afford the relatively expensive hourly rate of therapists in private practice. Asking around, he finds two names that come strongly recommended. He has no way to decide between them and so decides to go to see each of them for one session and then make his mind up which of them he will continue with.

The first is a very gentle man in his late fifties who seems to be extremely friendly and accepting of Malcolm and his problems. The session seems almost like sitting and having a chat with a sympathetic friend. The therapist quietly explores all manner of things with Malcolm, from the details of his most recent relationship right back to the type of relationship he had with his parents, particularly his mother. He also asks him a little about his dreams, how often he has them, what they tend to be about, whether or not they wake him up and so on. He also asks Malcolm a number of questions about how he is feeling in the therapeutic situation - how he is feeling here and now. And he probes Malcolm's answers quite deeply, not letting him get away with statements such as 'Oh, I feel alright'. He pushes for more and keeps returning to how Malcolm is feeling when he talks about particular events and circumstances.

The second therapist, whom Malcolm sees a few days later, is a woman in her forties. She is quite sharply dressed and has an air of rather brisk efficiency and competence. There is nothing vague about her; she seems confidently to know what she is doing. Her questions to Malcolm are much more business-like than those of the first therapist. She explores in some detail what went wrong in Malcolm's recent break-up and keeps bringing him back to what he did and what his partner did and how what they each did impinged on the other.

She asks Malcolm nothing about his dreams or his previous relationships or his early life, but is more interested in finding out from him exactly what he would like to achieve for himself in coming to see her. When he tells her that he has been feeling anxious and depressed, she wants him to spell out exactly how that has affected what he does and what precisely he has been thinking about it all.

Towards the end of the first session, the therapist begins to suggest to Malcolm other ways in which he might begin to think about what has happened to him. She even describes to him one or two techniques for making his anxiety reduce and ways in which he might try to behave differently from usual when he begins to think depressing thoughts.

After the two sessions, Malcolm is no nearer to making up his mind who to continue with than he was before. Each seemed to have something to offer. He liked the style of the first man and felt in sense 'better' after seeing him but he liked the practicality of the woman that he saw secondly. He felt that he had come away from that second session armed with something helpful to do in his day-to-day life.

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