Supplying the Necessities: Psychotherapy as Provision

Provision, that is, making available to one's patients certain experiences that were traditionally considered forbidden within the analytic relationship, makes sense to me on two levels. One is conceptual, while the other is pragmatic and clinical. In the abstract, the idea of provision has taken on a somewhat sinful cast. Schooled as I was in the view that gratifying patients' wishes is a misstep akin to spoiling them, at the back of my mind has been the belief that giving too much to a patient is really just giving in. Yet adhering to the principle of abstinence, as some have called it, never came naturally to me. I was often tempted to do something immoderate, such as agreeing to a patient's request for an audio tape of my voice to listen to between sessions. Or attending an art opening. Or reading a favorite book. Or answering a personal question directly. I felt unkind and evasive when I responded to a patient's request with a question-- "Why is it that you think you need this?"--rather than with empathy and further discussion. As time passed and norms changed, I've become more comfortable with doing what feels instinctive.

A bi-product of the move towards provision is a turning away from a more skeptical view of wishing and wanting, and instead, seeing these as expressions of authentic, unmet needs on the part of the patient. As we all know, the manifestation of such desires takes many forms, some of them undetectable, some more easily identified. I believe the role of provider is to comprehend, to collaborate with the patient in grasping origins and implications, and to mutually determine what can actively be made available to the patient and what cannot. Even when both agree that some unmet longings will be understood but not provided for, patient and analyst are engaged in the practice of provision, an experience which is in itself healing.

Kohut's idea of optimal frustration bridged the transition from frustration to provision by acknowledging the therapeutic benefits of an occasional experience of deprivation, such as when a therapist's vacation creates a void that the patient is forced to fill for him or her self. It would be interesting to put Kohut's notion in the context of provision rather than of frustration. Perhaps having the latitude to decide the form in which provision takes place means that what was once thought of as frustation can now be called something like "providing the space for the patient to access more of his or her own inner resources."

In the more recent move towards optimal responsiveness, a concept advanced by Bacal (1998), therapeutic growth occurs as a result of the therapist and patient together addressing the patient's needs as they arise, placing the patient more firmly at the center of the therapeutic work. Owing a debt of gratitude to infant research and to attachment theory, this approach emphasizes providing the requisite response to a patient's unfolding needs. The assumptions underpinning optimal responsiveness are radically different from those that preceded them. There is a shift in theory, but also a thoroughgoing shift in mindset.

The shift in mindset is what interests me most. For example, supplying something necessary for the well-being of those with whom we work implies emotional generosity. Approaching people generously involves changing our attitude towards them. When we regard our patients with parsimony and misgiving, we adopt a posture of wariness, creating an interpersonal distance, which is likely to prevent deeper, more open explorations of the patient's needs and our responses to them. When we regard our patients with generosity, they see or sense that we are more receptive to them, and are consequently much more likely to reveal themselves to us.

Our patients entrust us with themselves, and as therapists interested in provision, we also entrust ourselves to our patients. Let me offer an illustration from my personal life. I was keeping an eye on a four-year-old child who, overtired, had begun to yell and misbehave in a public place. I tried to help him compose himself by speaking calmly and distracting his attention with a toy. I looked at him intently. When it suddenly occurred to me that he might escalate his behavior rather than moderate it, I felt a tinge of fear. As he eyed me, I noted a quick flicker of recognition, a signal that he read my worry. He then relaxed, and engaged with me in play. I believe he saw my distress and chose to respond to it. We were in this together. Had we not had a prior history, and had I not spoken calmly and with respect, he might have reacted differently.

As we provide, rather than keeping our patients at arm's length, we allow them a measure of our own vulnerability. This does not guarantee, however, that in every instance they will respond in a way that feels warm and fuzzy to us. Sometimes a patient will react to a therapist's willingness to provide by demanding too much, disrespecting boundaries, or speaking in a hurtful or abusive manner. Of course there are some forms of provision, including those in the sexual realm, which are out of bounds.

While adhering to a rule of abstinence reduces the number of possible choices, and thus uncertainty and the risk of error, with provision comes complexity and a need to question meticulously. What will be useful to this particular person? Am I going too far? Am I not setting enough limits? Are my own issues interfering with what I'm choosing to do here? If I decide to do or not do this, what impact will it have? Is this too much to ask of myself? At the heart of these, and many other question, are the particular affective themes predominating in the work with each patient. What will be helpful with one patient will not succeed with another, and what once worked with a patient may at a later stage not prove to be effective. Provision, after all, is not just the act of supplying something. A provision is also a specification that calls for the meeting of certain conditions. As such, it often requires a level of careful attention, analogous to the function of empathy, in order to discern what is necessary for the patient.

For some therapists more than others, provision is intuitive. They possess an instinctive awareness of how to respond to another's needs. Whether the therapist leans more heavily upon an intellectual or an intuitive approach is dependent upon the therapist's disposition, and also upon the fit between therapist and patient. Deciding on the how and why of provision will seem relatively easy with one patient, but may require much more conscientious thought with another. What one therapist provides for a patient, another therapist may not be willing or able to provide. There is no one right therapeutic procedure, only a relationship, developed over time, that works for both participants.

References

Bacal, H. (1998). Optimal responsiveness: How therapists heal their patients. Northvale, NJ: Aronson.

Nancy Hicks, Psy.D., M.Div., is an instructor and supervisor at the Training and Research Institute for Self Psychology in New York City. She is in private practice in Metuchen, New Jersey and New York City.