During psychiatry training, residents are assigned “psychotherapy supervisors”. The resident sees a psychotherapy patient and then meets with his supervisor to review the session. Sometimes this means the resident will dump onto paper everything he can remember about the session: “She said A, that made me think about B, so I said C, and then she replied with D”. Sometimes, with the patient’s permission, the resident records the session on audio- or videotape. Together, supervisor and resident later review this data. The supervisor provides feedback and suggestions to teach the resident about psychotherapy and how to proceed with treatment.
During my last year of residency, one of my supervisors was a psychoanalyst. Every week, I went to her private office for supervision. A plush psychotherapy couch was near the window. She sat in the chair behind the head of the couch. I sat in the chair across from her.
About four months prior to my graduation, my patient—a man who had been single for several years—started dating a woman who worked in health care. I thought this was a positive development: Maybe he had learned that others did not share the opinion he had of himself. Maybe he learned to view himself with more compassion. Maybe he had developed more confidence when interacting with women.
When I shared this information with my supervisor, she looked at me with disbelief. She insisted that this was his reaction to termination.
“It’s a flight into health,” she said. “He’s found this woman now because you’re leaving.”
What is a “flight into health”? Malan says:
[It is] a concept which at first sight may seem to contain an inherent paradox. The paradox can be resolved by making it clear that the flight is into apparent health—the patient believes he has recovered but the clinician believes that unsolved underlying conflicts will give rise to more or less serious difficulty in the future…. [A flight into health may be] a way of avoiding either further painful conflicts or anxiety-laden feelings about [the] therapist. (p. 219)
“She works in health care, you work in health care. You are an important person in his life; he wants this new person to be an important person in his life. Don’t you think it’s interesting that he found this relationship right when you are about to leave?”
It was my turn to look at her with disbelief.
“How do you know this is all about me? How can you be so sure?”
My supervisor and I often revisited this topic in the remainder of our meetings. In fact, she wondered if my opposition to her suggestion was significant in our termination, the end of our educational relationship. (And, as psychiatrists are trained to do, we talked about it. Neither one of us changed our opinions.)
Though I disagreed with her assertion about my patient, I was more vexed with her unshakable confidence in her hypothesis. How could she know that she was absolutely correct?
Malan summarizes my sentiments about this issue:
… the therapist sees all the problems that his brief therapy has not resolved, and—in ignorance of systematic follow-up evidence—has no faith in the patient’s ability to mature further. (p. 218, emphasis mine)
Frick also argues that the concept of “flight into health” is cynical.
Neither my supervisor nor I pursued follow-up with this man. Only time would tell if his relationship signified recovery or avoidance.
To be clear, “flights into health” can happen. Some people find it much easier to believe that their conditions have improved, rather than acknowledge and endure “the pain and anxiety of further exploration and self-disclosure” (Frick).
Whether related to termination or not, what we say or think about someone often reveals more about us than about the person in question.
Maria Yang, MD 