Disclaimer: this blog post is over the top and vulgar. It is meant to be.
Patients give consent to engage in psychotherapy; we discuss a variety of topics with our patients including confidentiality (and limits of), privacy, access to records, among other things. What we don't ask for is consent to fuck with their minds.
In psychodynamic psychotherapy (and other theoretical orientations), we ask our patients to have as much freedom of thought as possible, and we do our best to facilitate safety so our patients can speak freely. We may even make a call for associations to ask the patient to speak what is on their mind, however embarrassing or shameful it may be.
But what do most of us do after our patient talks? We talk. "Tell me more...," "what comes to mind..., "how do you make sense of..." Our curiosity is piqued and we want to know more. If you're following these blogs, you may have found that I love talking about Winnicott. I think his ideas of a transitional space apply here, too.
When a child is playing with a transitional object, we mustn't ask the child whether that object is real or fantasy. It is really important for the transitional object to be whatever the child wants it to be: real, not real, or somewhere in between. We may ask the child what his Teddy bear's name is and how he feels holding the teddy bear, but we would never ask the child if Teddy is real.
As a human, and also as a therapist, I value freedom of thought. Therapy is a place to explore different ideas and thoughts in an un-impinging environment. The patient can put on many different hats, talk about sexual or sadistic fantasies, challenge the therapist in various ways, all within a safe environment where there are very few limits (of course, our personal boundaries and boundaries of the "therapeutic frame" matter too).
Psychotherapy and all of its intellectualism, can turn into a mind-fuck really fast. I'm not just talking about the therapist's sapiosexuality, though I may write on this topic at a later time. Psychotherapy involves the penetration of ideas and thoughts, mostly by the therapist; however, the patient can also be a participant (active or passive) in this act. Do we ever ask our patients if it's okay to penetrate their minds? If not, why? Are we not playing around with their fantasies and desires, the most vulnerable parts of their psyche?
As therapists, we have to exercise caution with our patients. Our patients come to us at their most vulnerable moments, many with histories of abuse, sexual trauma, coercion, or oppression. We are in a position of authority no matter how many times we engage in collaboration and discussions around power. Power is inevitable. If we facilitate freedom of thought with our patients, we must also ask for consent to fuck with their minds. This could be as simple as, "Is this okay to talk about?" or "How is this feeling?" I may even tell a patient that I hope she feels comfortable telling me if something gets too uncomfortable; this doesn't necessarily mean we stop talking about it, but it allows the patient to have some agency in saying "that's enough for now." By no means am I saying that we mustn't talk about uncomfortable things. What I am saying is that we have to be conscious of own curious desires.
Furthermore, we have to be open to our patients' thoughts, fantasies, and desires being neither real nor fantasy, but something in between. By asking our patients questions and fucking with their minds, we are impinging on their creativity and freedom of thought. I am still learning when to intervene and when to be silent; oftentimes, I don't know until I experience the response from my patient or when I reflect on the session later in the day. It is most certainly a dance, and the patient has to be an active, consenting participant in this dance.
- cg