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IN THE METROPOLITAN PRACTICE OF PSYCHOANALYTIC psychotherapy, we are on a familiar stage. The neurotic patient enters our setting, (when properly referred) more or less ready to consult with us, then to leave and carry on his life outside. We may think of the situation as primarily one between two individual actors, giving secondary attention to the group life of either.
When I went from training and practice in San Francisco, to practice with the Indian Health Service in Montana in 1971, I took with me this individual-patient-to-individual-therapist view of my work. My new role was principally one of consultant to mental health field staff who were located at small hospitals and clinics on the Montana and Wyoming reservations. I also had a small practice of Indian patients whom I could see once or twice a week.
What I could not ignore, after hearing scores of cases in consultation, was that most of the Indian patients came only once or twice. My own practice went better, but the relationships were tenuous. One common result could be said in several ways: Not much hope came from these meetings. The therapist was not idealized. The pairing bond between the patient and therapist tended to be very weak.
Actually, the clinical problems presented were not so different from urban practice as one might expect: anxiety over performance, depression after loss, loss of self-esteem from failure, and so forth. But whereas an empathic understanding of the therapist would draw forth increased gratitude and commitment from the patient in these settings I previously knew, this did not often happen here. While the patients, as individuals, often seemed to present the familiar patterns of neurosis and narcissistic personality disorder, and individual therapists seemed to behave like understanding