“The patient’s unknown goal”

Recently, while doing some reading, I came across the phrase, “…the patient’s unknown goal…”

To me, that phrase is splendid for a number of reasons.  And it’s sent me reeling in my thinking across a variety of topics. 

Noah Grossenbbacher, Unsplash

In this post I’ll list a couple of those topics, and some of my thoughts about them. 

To me, “…the patient’s unknown goal…” brings to mind:

1. The patient’s goal is not known to the counselor, and must be revealed.
   • Thus, we as counselors must respect the fact that the patient’s goal is not known to us unless it is told to us.
2. The patient’s goal may be initially unknown even to themselves and may emerge later. 
   • It might come into their awareness as a product of their internal relationship with themselves (their own intra-subjective process between sessions).
   • Or it might emerge during counseling as a product of the shared effort (the inter-subjective process).  
   • Thus, we as counselors must respect the fact that they might not have a goal, or that their “real” goal might emerge, or change.

The full quotation brings the following to mind:

1. The pre-occupation of cognitive-behavioral therapy (CBT), motivational interviewing (MI), and other stock forms of so-called “evidence-based practice” with initial identification of “person-centered goals” is limited.
2. CBT would struggle if it had to function in a context that did not include a goal.
3. Harm Reduction (HR) would struggle if less harm was suddenly no longer good enough, and the patient wanted to be outside the HR model and get “better than well”.
4. Short-duration abstinence-oriented approaches would struggle if they took on a 5-year model of disease management and recovery management support for those with complex, chronic and severe SUDs.

Here’s the quote.  To me, it’s a wonderful read.  I wonder what it brings to mind for you?

The person on the couch has his own problems, and it is not for us to envisage any result out of the analysis in accordance with our particular sense of values and desirabilities.  I would here search the analyst’s conscience with regard to the use of the word ‘normal.’  Do we hope that our patient will be so analysed as to emerge a normal person, or do we hope that by analysing resistances to resolve anxiety the patient’s own potentialities may be realizable?  The first is to set one’s own goal in front of the patient; the second is to set oneself the patient’s unknown goal. Only as we can bear the unknown, only as we are not ‘hot for certainties,’ shall we be able to let the patient alone. 

Ella Freeman Sharpe (1930).  The Technique of Psychoanalysis:  Seven Lectures.. II.  The Analysand:  The analytical task, the procedure, errors avoidable by beginners.

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Suggested Reading

Bak W. (2015). Possible Selves: Implications for Psychotherapy. International Journal of Mental Health and Addiction. 13(5):650-658. https://link.springer.com/article/10.1007/s11469-015-9553-2

Coon, B. (2019). Planes, Car Repair Shops, and Dentists.

Coon, B. (2020). Older Model 2.0, Newer Model 3.0

Coon, B. (2022). Coast Guard Search and Rescue: Lessons and Inspiration.

Dunkel, C., Kelts, D. & Coon, B. (2006).  Possible Selves as Mechanisms of Change in Therapy, in C. Dunkel & J. Kerpelman (Eds.).  Possible Selves: Theory, Research and Application. (pp. 186-204).  Nova Publishers.

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Thanks to Chris Budnick and Jason Schwartz for their comments on this manuscript.