In a message dated 97-09-24 15:55:53 EDT, Ross Skelton wrote:

<<Do psychiatrists have the right to use the Christian name of their
patients?>>

Ross,

I'm not sure why you would restrict this question to psychiatrists, unless
you put it that way generically to refer to psychotherapists in general.  My
own practice (I'm a psychologist) is to use Mr., Mrs. Ms., Dr. etc. and to
refer to myself as Dr., because I view this as an aspect of the frame--as a
structural element which reminds my patients and I about the professional
nature of the therapy relationship and which helps to set it apart from
ordinary social relationships.  Therefore, besides being a matter of
professionalism, it helps to educate the patient from the start about the
nature of therapy, and it may serve a "holding" function for those patients
who fear that certain of their wishes may be acted upon in the therapy,
rather than analyzed
(a ubiquitous concern of patients, in my experience).  In other words, that
patients and I would like to be more "cozy" with each other at times is a
matter for examination in the work.  I have never forbidden a patient from
using my first name, although I could conceive of doing that with certain
patients, whose wishes to breach the boundaries of the therapy (and whose
actions toward that end) may be  particularly strong. (Harold Searles cites
the case of a man with whom he worked on the inpatient ward for a long period
of time--a patient who tirelessly and angrily demanded that Searles take him
home with him.  At some point, and obviously frustrated by the patient's
demands, Searles insisted aloud that he would NEVER take the patient home
with him, even if it meant that the patient would remain in the hospital for
the rest of his life!  An interesting and complex intervention indeed!)

If a patient called me by my first name (which is not a rare occurrence,
especially for those patients who have worries about the professional nature
of the relationship and who worry about what they may come to know about
themselves if the dyad stuck to the main task), I would continue to refer to
myself as Dr. (when phoning the patient for example), and I would try to
understand what is going on in the patient and in the therapy as reflected in
this shift and in the patient's associations surrounding it.

Tact is an important related matter here. I recall an adult patient of mine
who repeatedly extended his hand to me when the session ended.  I granted him
(and myself) this gratification for a time, until his associations revealed
the central meaning of this:  His wish for me (=his father, who died when the
patient was but 5 years old) to "give him a hand", to guide him in his
efforts to feel like a man.  Once I interpreted this to him, it helped him
begin the work of mourning for his father, and he no longer felt the need to
extend his hand to me after each hour.  Getting back with the names issue, I
guess my point with this is that on occasion indulgence is in order until it
can be better understood and/or interpreted.

When I work with young children, I do use their first names, as this is more
customary here in the US, and abroad as well I imagine.  It gets trickier for
me when working with older adolescents, some of whom may feel infantalized by
the use of first names (particularly if I continue referring to myself as Dr.
in that context), and others who may feel too alienated by a more formal
approach;  in either instance, there can be a risk of undermining the working
alliance, by playing into the teenager's suspicions.  In one instance when an
18-year-old male patient and I started calling each other by first names, it
seemed to have the effect of strengthening the alliance.  In another case
with of a 17-year-old male patient, I was concerned that my referring to
myself as David might heighten his rampant homosexual fears, but that calling
myself Dr. M. might in turn distance myself from him.

When one is confronted with this concern of names in a particular case, it
would seem to be a loaded issue with many potential meanings attached to it,
the exploration of which could yield valuable insights on the case.  I
recognize that many therapists use first names even with their adult
patients.  It seems to me the most important thing is to attend to the
possible meanings in the use of names, regardless of how one works this out.

I'm curious to hear the ideas of others on this interesting issue.

Regards,

David Mittelman