I have received a number of comments and emails about Paul, of In Treatment, accompanying April to her first chemotherapy session. Most of the questions and comments seemed concerned with whether or not this constituted a breaking of the rules of therapy.
Many years ago when I first started in analysis, my analyst used to tell me that there were no rules. Now I was absolutely certain there were rules and further I wanted to know them so that I could follow them or at least know when I was breaking them. We went round and round on this because I could not then wrap my mind around what he meant.
Jung, in a letter to J.H. van der Hoop, wrote:
I can only hope and wish that no one becomes "Jungian." I stand for no doctrine, bt describe facts and put forth certain views which I hold worthy of discussion. I criticize Freudian psychology for a certain rigid, sectarian spirit of intolerance and fanaticism. I proclaim a cut-and-dried doctrine and I abhor "blind adherents." I leave everyone free to deal with the fact in his own way, since I also claim this freedom for myself. (Jung, CW, Vol. 1, p. 405)
This does not mean that rules should be abandoned or that they have no value, only that they must not become what analysis is all about. In the Freudian world over the years there has been concern about "wild analysis", that is analysis which deviates from Freud's methods and theory and done by those who were not trained as analysts. But Freud himself did not always adhere to the technique we regard as Freudian -- i.e. on the couch with analyst behind the patient. Indeed with one of his first patients, Freud conducted the analysis while he and his patient were on long walks through the city of Vienna!
Carotenuto says,
On occasion, when reading clinical reports, I have the distinct impression that I am reading lies, because expounding rather than describing what has actually been done is in fact stating what should have been done. (Carotenuto, The Difficult Art,p. 25)
Earlier in the discussion about note taking, I noted how risk management evolves to become the standard of care. Here again we have an example of a rule becoming not a guideline or point of measurement but a rigid structure. Having a fixed frame, meaning that the setting, fee and time remain constant, means having that structure available in order to have something to measure deviations against. And any such deviations need to be considered in light of what is best for the patient, though of course, that too can be a tricky area. However, if we accept that Paul has the April's best interests in mind, both generally and in terms of the therapy, then it begins to make sense that he chooses to take her to that first treatment.
In the very strictest sense of the frame, in the world of rigid rules, then what he did was a violation. But in the world he is operating in, with a patient with a life-threatening illness, then taking her becomes a reasonable action. It does open the risk of a complaint against him for acting outside the realm of the usual -- if April becomes unhappy with him and the therapy for some reason, for example -- but sometimes that is a risk worth taking. If one practices always with risk management in mind, then one certainly is far less likely to be sued or have complaints made, but that does not mean that such therapists are necessarily taking into account the best interests of the patient, unless they assume that those interests are coincident with their own.
It's tricky. It's a judgment call. And one that will require be willing to talk about it with the patient and work through whatever comes up because of this deviation. Fortunately, we are very very seldom faced with a dilemma like that Paul has with April.
There are certain behaviors which must be fenced off and rules out no matter what -- like illegal conduct of any kind and sexual acting out. There isn't a way to make either in the best interests of the patient, not really. So those issues go behind a wall that cannot be breached. And the rest of the rules? Well, it falls to the therapist and the patient to deal with them together, talk about them, wrestle with them, become conscious of underlying issues. In other words, make them a part of the therapy.