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Psychotherapy Casebook


Dean Schuyler, MD

Published: April 12, 2018


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Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is a psychiatrist and a member of the palliative care team at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina

Prim Care Companion CNS Disord 2018;20(2):18f02290

To cite: Schuyler D. Relationship. Prim Care Companion CNS Disord. 2018;20(2):18f02290.

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Published online: April 12, 2018.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (

Funding/support: None.

Potential conflicts of interest: None.

I am a cognitive therapist. Psychotherapy, according to the cognitive model, is about changing attitudes and beliefs. When attitudes change, the behaviors that patients complain about also change. The patient has to do the work, but when he or she does, change often doesn’ t take long. At the Veterans Affairs (VA) hospital, I apply the cognitive model to my palliative care patients, both inpatient and outpatient. Change, when it occurs, is attributed to change in attitude.

How do you understand friendship? A relationship develops between friends that permits, even at times encourages, change to take place. How does a relationship affect psychotherapeutic change? I would maintain that unless a relationship is present, change will not occur. But, when the basis for an interaction is relationship alone and no attitude change is attempted, what happens then? Surely, no therapeutic relationship can be effectively defined in the absence of attitude change.

I have been working at the VA hospital for 8 years. I have made a significant number of friends. Some of them have also been my patients. Some patients have said that it is "great" to talk with me. It is not at all clear that their attitudes have changed over time. A better way of understanding the interactions is that a relationship has been created. Many years ago, Truax and colleagues1 wrote a seminal article detailing the relationship factors in successful psychotherapy. To my mind, these factors—warmth, acceptance, genuineness, and empathy—must be present for change to occur in psychotherapy. What if those factors are present, but the factors related to attitude change are absent?

I have thought about the patients that I treat. One person has been a resident in the nursing home unit at the VA hospital for a long time. I have continued to see him for many years. I am not sure that any attitude change has resulted. I tell myself that I meet with him nearly weekly for me as much as for him. We have become friends. I am concerned about his worries. I don’ t want him to be worrying, and he has a lot of time to himself for which worry is a real possibility. We meet and talk about worrying, but we cover many other topics, both for me and for him.

Another patient who I see regularly has a serious illness. We do not speak often about his illness. Rather, we speak about so many things that we believe in common. We have lengthy conversations, agreeing much of the time. The reason he keeps outpatient appointments has been attributed to "relationship." We are friends. I care about him and enjoy meeting and talking with him. We disagree about his illness, and we seem to scrupulously avoid talking about it.

This aspect of successful psychotherapy came to mind recently when I met with a married couple. The wife had called me at home to discuss her husband’s medical situation, and I agreed to meet with them. When I did, I completed my usual intake interview. I asked about his family, childhood, education, military service, marriages, and work before I broached the topic of his medical health. Only then did I ask about his concerns surrounding his medical problems and their treatment.

I was surprised when they each said how valuable this meeting had been for them. For the first time, they felt like they were treated well by a physician. I expressed my interest in the husband’s well-being and suggested that he see a "competent internist." Two days later, I called and spoke to the wife, asking what had taken place since our meeting. She had called her husband’s primary care doctor, who had scheduled a number of blood tests prior to a visit scheduled for that week. Clearly, the husband’s medical treatment had been less than acceptable before, and our visit had been a highlight for both of them.

The more I think about it, I spend a great deal of time establishing a relationship with everyone I treat. And, for some people, the relationship is the major service that I offer; it is vital to their well-being. Change is also a critical element in psychotherapy. It seems clear that change is not always present and not even desirable at times. Some people just want a friend to meet and talk with. That seems like a perfectly acceptable rationale for some therapeutic relationships.


1. Truax CB, Wargo DB, Frank JD, et al. The therapist’s contribution to accurate empathy non-possessive warmth, and genuineness in psychotherapy. J Clin Psychol. 1966;22(3):331-334. PubMed CrossRef

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