The Therapeutic Consultation:

Finding the Patient

MILTON VIEDERMAN, M.D.

The psychiatric consultation has not been adequately exploited as a therapeutic
device. Although, the original abstinent model for psychodynamic psychotherapy
has become more flexible, passive listening with interventions to elicit diagnostic
"data" remains the prevailing mode in psychiatric consultation. In this paper
I develop the idea of the consultation as an active process (Viederman, M.,
2002) that engages the patient emotionally for therapeutic effect.

THE NATURE OF ACTIVITY IN THE CONSULTATION PROCESS

The psychiatric consultation has not been adequately exploited as a
therapeutic device. Although, the original abstinent model that formed the
basis for psychodynamic psychotherapy has become more flexible, the idea
of passive listening with interventions to elicit anamnestic and diagnostic
"data" remains the prevailing mode in psychiatric consultation. I will
develop the idea of the consultation as an active process (Viederman,
2002a) designed to engage the patient emotionally and to have a thera-
peutic effect. Activity resides in imaginative, ongoing formulations in the
consultant's mind of the patient's presentation and experience and the
appropriate communication of such inferences to the patient.
To accomplish this end, the consultant must enter the patient's world;
develop a picture of him, of his experience with the people in his surround,
and to communicate appropriately this awareness to him in a language that
is familiar to him. In so doing, a climate develops in which the patient feels
recognized and understood. The consultant is reciprocally recognized and
becomes a "presence"'^"'^ (Viederman, 1991; Viederman, 1999) in the

Emeritus Professor of Psychiatry, Weill Medical College of Cornell University, Supervising and
Training Psychoanalyst, Columbia Psychoanalytic Center for Training and Research
Mailing address: 60 Sutton Place South, Suite 1-CN, New York, NY 10022 e-mail:
mvieder@med.cornell.edu
'^°"' Recently, I received a note from a 65-year-old woman, a former actress and now a teacher of
drama. I had seen her in a two-session consultation. "Thank you for getting me through a difficult time.
I appreciate your work so much. You have what we refer to in the theater as extraordinary 'presence'.
It was very liberating for me."
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patient's life. "Finding the patient" in this way decreases the isolation and
loneliness that often accompanies emotional conflict.
The consultation might be viewed as an experiment (Viederman &
Blumberg, 1993). Observations are made not only about symptoms, but
about personality, social class, use of language, gender, education, intel-
lectual capacity. Inferences are made about what the patient is saying and
these hypotheses are translated into communications to the patient, the
validity of which is determined by the patient's response. Those commu-
nications that do not strike a resonant note may be commented on by the
consultant, whether revealed directly by the patient or inferred from the
patient's response.
What is the climate of this engagement? The nature of the dialogue
is widely variable and is unique for each patient. The language and
mode of intervention, the "therapeutic stance", is constructed in
response to the requirements of the patient and the nature of the consul-
tation as it proceeds. More formal with some, more idiomatic and relaxed
with others; the consultant speaks with authority sometimes, in a more
tentative mode at other times. He may intervene with vigor and emotion-
ality or with restraint and some detachment (as in the case of the paranoid
patient for example). The choice of words should be consonant with the
patient's intelligence and cultural milieu. The range is limited only by the
available repertoire of responses possible for the consultant; this depend-
ing upon his personality, his freedom of expression, his emotionality, and
not least, by his experience, because the spontaneity of appropriate
responses, informed by experience and knowledge, will be constrained of
necessity in the novice. The response, even when constructed, must be
authentic.
The engagement with a patient is a type of conversation, asymmetrical
admittedly, but a conversation nonetheless. Yet, as the patient reveals
himself, the consultant develops a structure in his own mind of what
should be pursued and how to pursue it, as for example, in the case of the
thought disordered or cognitively impaired patient with whom greater
formal structure is required. Although the conversation may appear to be
seamless, it is subtly directed by the consultant in tactful guided transi-
tions. Humor, the degree of affective expression, closeness or distance are
all possible modes and are useful in different situations with different
people depending on the ongoing evaluation of the patient as the consul-
tation proceeds. The nuances of the variations in the consultant's behavior
are reflective of his evaluation of the evolving process (the therapeutic
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stance). This approach does not obviate the requirement that the consul-
tant obtain the necessary information to make a formal diagnosis.
The patient arrives with a familiar story, one that is on some level
comfortable for him. The aim of the consultation is to help him pursue to
a certain extent a new story of his life, to be surprised by what emerges, to
have a new and unexpected experience with a new person who recognizes
him and becomes real to him. This, for the most part, involves clarification
rather than interpretation of unconscious processes.
MEANING AS AN INTERVENING VARIABLE AND THE
PSYCHODYNAMIC LIFE NARRATIVE
There are two related concepts that have special importance in estab-
lishing contact with the patient and relieving distress. They define the
patient's emotional response as understandable and unique to him in the
context of his current experience.
Meaning as an intervening variable implies that between an external
stimulus and a dysphoric emotional response, there is a special meaning
unique to the patient that defines the response. A 48-year-old woman's
distress in the context of her treatment for pulmonary cancer lay not in a
pessimistic view of her future, pain, her fear of dependency, etc., but rather
in the fact that this prevented her from being a "mom" to her children. The
source of this particular meaning emerged in the context of the exploration
of a past in which she had experienced the absence of her mother when she
was a child. It was of critical importance to her to be an especially available
mother to her children.
The Psychodynamic Life Narrative (Viederman, M., 1983) is an exten-
sion of this concept. It is a construct developed and presented to the
patient in the context of a consultation in which the patient's painful
response to a current situation is demonstrated to be an inevitable and
logical response to early life experience that has special meaning to the
patient or may be a source of vulnerability. A 35-year-old diabetic woman
in the first trimester of her first pregnancy was terrified that she would have
a defective child. She called her obstetrician and gynecologist constantly to
be reassured but without relief. As the patient's story unfolded, the
following narrative was presented to her. "It seems clear why you are so
anxious about having a defective child. Your parents seem to have been
reasonable and attentive. Yet your mother's response to your having
developed diabetes at the age of six, was to tell you that it had to be
concealed for fear that you might not be invited for sleepovers and would
have trouble finding a boyfriend. In spite of this, you did extremely well,
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obtaining a professional degree, marrying, and developing a wide array of

friends. Underneath, however, you have always had a latent sense that you
were defective. Now in the context of this pregnancy, you are fearful that
this child, whom you see as an extension of yourself, will be defective in the
way you have felt yourself to be defective." The patient burst into tears,
composed herself, and wrote a letter a month later indicating that our talk
had been a turning point in her life. Her symptoms had disappeared and
she no longer felt the need to seek reassurance from her physicians. She
gave birth to a healthy baby without difficulty.
SPECinc TECHNIQUES
Among the specific techniques that may be used to facilitate the
emergence of a new experience are the following:
a) Echoing the implicit affect or content of the patient's experience as
it is revealed so as to let the patient know that he has been heard.
(Viederman, 2002b, 2002c)
b) Establishing meanings or connections between a dysphoric re-
sponse and the apparent stimulus (meaning as an intervening
variable). (Viederman, 2002b, 2002c)
c) Conveying to the patient the consultant's awareness of the climate of
the patient's troubling experience as the description evolves. A
statement to the patient "This is what I have heard you say" or "it
seems that" followed by a salient description of what the patient has
described, makes it clear to the patient that he has been heard. This
is how the patient knows that the so called "good listener" has really
listened.
d) Commenting on aspects of the patient's personality (sometimes
supportive of self-esteem), including his perception of the world.
This may involve his characterological inhibitions about expressing
emotion, revealing needs, etc. (Viederman 2002b, 2002c)
e) Use of the present to evoke associative thoughts to the past by
defining a particular trait (such as need for control or independence)
or a particular feeling state and asking for spontaneous associative
connections in the past. The consultant makes it clear that he is not
asking for explanations. This will encourage the revelation and
awareness of the dynamic living past that forms the current behavior
or experience. This approach permits the exploration of the pa-
tient's early life experience in a rich and vital way and is to be
contrasted with a formal fact-finding expedition. This does not
obviate the requirement that certain specific details of past and
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family history may be required. This may be formulated as a

"Psychodynamic Life Narrative". (Viederman, 1983)
f) Definition of the quality of the patient's behavior with the consultant
as a point of entry into the quality of object relations and active
pursuit of these elements in examination of their roots in the past
(transference). (Viederman, 1994)
g) Appropriate use of consultant's emotional reaction to the patient
and at times his behavior with the patient in order to pursue the
quality of relations with others (countertransference and enact-
ment). (Viederman, 1999)
h) Finally, direct interpretation of conflict close enough to patient's
potential awareness to be integrated and examined by him.
A brief comment on the therapeutic implications of the consultation is
in order. The therapeutic effect, whether it be symptomatic relief or some
significant change in the patient's perception of himself or the world, or
character change in the context of a long-term therapy, occurs in the
context of a new emotional experience. This involves some change in the
patient's perception of himself and perception of himself in the world.
Moreover, the search to find the omniscient, benevolent good parent often
is part of the patient's unconscious motivation to seek consultation (the
curative fantasy). (Ornstein & Ornstein, 1977; Viederman, 1991, 1994)
The consultant in his active engagement of the patient, in his recognition
and comprehension of the patient's state and his communication of this
awareness, constructs with the patient a new perception of his experience.
In so doing, he becomes an ideal object (Ornstein & Ornstein, 1977;
Viederman, 1991). It is to be emphasized that the degree of active
intervention will vary from patient to patient and to a certain extent will
depend upon the consultant's beginning formulation of the type of treat-
ment that is indicated. However, the initial engagement acts as a useful
substrate for the beginning of a long term treatment.
CLINICAL VIGNETTES
There are no simple algorithms to guide the consultation. Each con-
sultation requires an imaginative and creative response and the variations
are infinite. Three contrasting patient anecdotes will be used to show the
diversity of approaches and effects. Only pertinent highlights of the
consultation will be presented.
A 60-year-old professional writer presented with bi-weekly panic at-
tacks of some three-month duration. She was a psychologically-minded
woman in distress. The recent publication of a book necessitated many
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television appearances. It was when friends suggested a facelift in this

context that the panic attacks began. When I asked the patient how she
experienced the attacks she stated, "They were like the intrusion of an
unwanted mother". When asked what thoughts came to mind about the
image, she immediately spoke with both contempt and sadness of a
narcissistic mother, never nurturant, often indifferent and with a concern
about appearance and a vanity that had manifested itself in multiple
facelifts. The patient was taken aback by the connection. She spoke of her
efforts to be a different type of mother and of her difficulty with one of her
children. She expressed the wish to begin therapy. The panic attacks never
recurred.
A very different patient was a 65-year-old Nigerian woman interviewed
during an inpatient conference. She had been hospitalized on a psychiatric
service after an explosive outburst at a city shelter. The patient had a
marked thought disorder with circumstantiality, tangentiality and loose-
ness of associations. She was an isolated woman, whose only contact "was
with God". The interview consisted of a careful and patient construction
of her life story. Central was the fact that she had grown-up in a poor
family in Nigeria with 23 siblings and multiple parents. No significant
emotional contact had been made as I helped her to construct her life
story. However, I affirmatively stated that she needed a place of her own
to which she could retire, separate from the intrusion of others. The
patient responded at the end of our conversation by saying that I was a
messenger sent by God.
Another patient illustrates the value of resurrecting a dynamic past in
the present. The patient, a 53-year-old executive, was referred for evalu-
ation of insomnia. When asked about his ruminations in the middle of the
night, he spoke of an irrational fear of suddenly being discharged from his
job and finding himself vulnerable and helpless to support his family. The
association to this sense of vulnerability evoked a show of tears accompa-
nied by his recognition of the terror he had experienced when he lay in bed
as a child and overheard his mother fighting with his abusive, alcoholic
father. Later, in the interview, he spoke of a social phobia, panic in
speaking in front of groups that he connected, to his surprise, to a piano
recital when he was six. He had experienced a sudden unanticipated
panicky paralysis and had been shamed by his inability to play. Curiously,
he remembered his mother's presence but not that of his critical father.
The recent appearance of the symptoms had begun four years ago when he
made his first presentation for a big new job. The symptoms diminished
markedly after the consultation.
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CONCLUSION
The consultation process can be a gratifying experience for the con-
sultant. An imaginative and creative response to the challenge presented by
a new patient makes the work a perpetual source of fascination and
interest. One is confronted by the extreme diversity and uniqueness of
human experience. Every patient is different. To discover that one can
effect people rapidly adds immeasurably to the satisfaction. Attention only
to the external description of behavior misses the individual and idiosyn-
cratic core of human experience, what makes one human. My intent has
been to offer a perspective on the consultation process in order to broaden
it and to offer wider possibilities for patient and consultant alike.

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