Harold Searles on the pitfalls of being “the dedicated physician”

“Unconsciously, the therapist is bent on maintaining the patient in an infantilized state, and is opposing that very individuation and maturation to which, at a conscious level, he is genuinely dedicated. I, for one, tend dedicatedly to remain immersed in a rescue-effort toward the ‘fragile’ patient, in order to avoid seeing him or her as being stronger, or potentially stronger, than myself.

“For example, one hebephrenic woman…would evidence, from time to time over the years of our work, remarkable forward surges in her ego-functioning, and unfailingly I would find that my rejoicing in this development was outweighed by an upsurge of my feeling inadequate. I had been feeling despair at how grievously ill she was; but now I would find her manifesting an appearance of blooming physical health that made me feel old and jaded, and I would be reminded, ruefully, too, that she was physically taller than I. In the same process, she would reveal a kind of effortless savoir faire, in matters both interpersonal and cultural, traceable to an upbringing far richer in social and cultural ‘advantages’ than my own.

“In short, I would feel her to be an all-around hopelessly larger person than myself. Then, as if quickly detecting that I still couldn’t take it, she would soon be, again, her deeply fragmented, ‘hopelessly ill’ hebephrenic self, and I was once more in my comfortable role of the long-suffering Christ trying to heal this wounded bird.”

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“The more deeply one examines the psychodynamics of the dedicated-physician therapist who is unconsciously devoted to preserving the status quo, one finds that he holds, at an unconscious level, split images, one an idealized image and the other a diabolized image, of himself and of the patient as well, and that he is dedicated, unconsciously but tenaciously, to preserving these split images and preventing their coalescence, with the leaven of reality, into realistic images of himself and of the patient as two fellow human beings, each possessing both strengths and limitations on his strengths, each capable of hating and loving.

“I want to emphasize that it is no pernicious thing consciously to regard the patient as supremely important and meaningful to oneself. For us consciously so to relate to him can only enhance his self-esteem and help him to become whole. The pernicious thing is that we repress both our idealized image and our diabolized image of him, hide both from ourselves and at the same time act out both these toward him, by inappropriately employing, in psychotherapy and psychoanalysis, the traditional dedicated-physician-treating-his-patient approach that, however conventionally accepted in the practice of medicine generally, congeals and reinforces the wall between patient and doctor when we employ it in this field.”

— excerpted from Searles, H. F. (2017). The “dedicated physician” in the field of psychotherapy and psychoanalysis (1967/1979). In D. B. Stern & I. Hirsch (Eds.), The interpersonal perspective in psychoanalysis, 1960s–1990s (pp. 32–44). https://doi.org/10.4324/9781315471976-3