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Passion vs. restraint

Protecting the Transference

Empathy and Expectancy

Preventing Problems

Chapter 8: Therapeutic Stance

"Full Throttle" Therapy

In the early days of psychoanalysis, the principles of neutrality, abstinence and anonymity were developed to enhance and protect the transference. Huge battles have been fought over these principles as subsequent generations of analysts have sensed that the humanness of the analyst was somehow an essential ingredient in the treatment. Glen Gabard, in his recent textbook, Long Term Psychodynamic Therapy states, "An attitude of restraint is probably the current-day derivative of this psychoanalytic tradition." The problem lies in the "one stance fits all" approach when there are two distinct and different modes of change. The assumption that the therapeutic relationship must be the same at all times leads to blandness and caution. A single prescription can only be a middle-of-the-road compromise.

There is a more effective answer. Supportiveness, warmth, and closeness are optimal for the cathartic healing of trauma, but these same attitudes are ineffective and even harmful in other situations such as working with impulse disorders. Matching the stance to the current therapeutic process requires judgment but allows one to be passionate and strong. This is what I call "full throttle" therapy. The following discussion will examine therapeutic processes and the factors determining optimal therapeutic stance. Of course a shifting stance has the potential to create problems, but the danger is less serious than that of excessive caution.

Protecting the Transference

The original reasons for adopting neutrality, abstinence and anonymity was to protect the transference. In the 19th century positivist tradition, it was assumed that the transference was purely the patient's misperception, and that the therapist could be completely objective. If the therapist were a blank screen, then what remained would be a pure reflection of the patient. Of course there is wide recognition that this was not true. For example, withholding is as powerful an intervention as any giving. It is impossible for the reality of the therapist not to affect the playing out of the transference.

There are several factors that help in discerning which aspects of the transference belong to the patient. First, the distortions that the patient brings to the relationship tend to be repetitive. The same issue will come up over and over. This helps in identifying the patient's contribution. Second, the patient's issues are often quite different from those that the therapist brings. Notwithstanding, transference and countertransference do inevitably become entangled to some degree. This is where the therapist needs to be familiar with his or her own countertransference tendencies. Personal analysis or therapy helps, and so does experience. An open minded, self-examining attitude and a scientific spirit are also crucial to unraveling the tangle that happens when they do mesh.

Finally, the most important clarifying factor is that transference wishes don't go away, they get stronger. We can look at transference in a traditional way, as the desire to act out unfinished business from childhood, or we can look at it in the way I have suggested, as the carrying out of a five-year-old's life plan. Either way, even if we give some of what the patient desires, the desires do not disappear. They become stronger and more literal. The patient's hunger for fulfillment feeds on close contact and soon the wishes exceed what any therapist can do. This leads to a break through to consciousness and the process of letting go and healing begins. More on this later.

Therefore, with or without neutrality, abstinence or anonymity, it is ultimately possible to sort out and isolate the parts of the transference drama that belong to the patient. In fact, support and a giving stance only fuel the fire. The danger to be guarded against is not extinguishing the transference, but implying promises that cannot be kept.

Catharsis and Empathy

Trauma therapists know that a stance that is anything less than affirming will be less effective. The treatment will be slower and may remain stalled with unresolved trust problems. Remembering that cathartic healing is built on the base of the "empathic attunement" that becomes available at about 9 months of age, it is clear that a close connection enhances the healing and distance impedes it. When working with painful experiences, the threat is that the patient will be overwhelmed with too much feeling. Cathartic healing allows new neural connections to bring down the level of feeling in a lasting way. Similarly, in other kinds of therapy, when the level of affect needs to be reduced and modulated, empathic closeness is the appropriate stance. Is this stance always helpful? It is well known that "being nice" can be counterproductive. How can we understand the issue more precisely?

Enabling

Experience in the substance abuse field shows that the willingness to let go of a relationship is one of the most powerful tools in fostering recovery. Conversely, well-meaning helpers who are afraid to alienate an addict often make the situation worse. The important factor is closeness and distance. An unconditionally supportive therapist gives the self-destructive person a sense of safety and confidence, preventing the patient from appreciating the potential harm. This is easy enough to understand. Paradoxically, however, stern admonishment and even nagging have the same enabling effect. The common denominator is that both positive and negative attention give a sense of closeness. It is the closeness that supports self-destructive behavior and defenses. On the other hand, a more aloof stance causes the patient to feel the potential loss of connection with the therapist and tends to pull him or her back from self-destructiveness and denial.

This is the key mechanism through which too much "niceness" or gratification of wishes can interfere with progress in therapy. At times when the work to be done is cathartic healing, closeness is not only helpful but essential in order to soften overwhelming affects. Much of the time, however, affects need to be brought to the surface, not softened. When the work involves bringing out affects by undermining cherished defenses or replacing old internalized values and attitudes with new ones, the fear of loss of connection is a source of motivation. A slight degree of aloofness and independence of mind on the part of the therapist is the effective stance where internalization is the desired change process.

When patients are being encouraged to give up defenses or to make frightening changes in behavior, then some combination of empathy and "expectancy" is appropriate.

Thus, the instinctive sense that one should avoid gratification of patient's wishes has a clinical basis, but not the traditional one of suppression of transference. A more accurate reason is to avoid a false closeness that enables destructive defenses and supports the status quo. Depending on the change process that is operative at the moment, a somewhat different therapeutic emphasis is warranted.

Maximum Empathy and Optimal Expectancy

The key variable in determining the right emphasis is the level of affective activation. A single formula can characterize the optimal stance for both situations, too much affect and not enough. The therapist who is able to maintain maximum empathy and optimal expectancy will provide the right distance for each situation.

Maximum empathy simply means working to help the patient let you in on his or her experience to the point where empathy happens and you are in "his or her shoes." Strong empathy is compatible with any degree of closeness or distance. Empathy is a function of the accuracy of your understanding. Closeness is the degree to which the patient perceives his mind and yours to be aligned.

Expectancy is my word to describe an attitude of expectation that the patient will pursue health even though it means feeling things that are uncomfortable. Optimal expectancy means a degree of aloofness and independence of mind such that the threat of aloneness is potential rather than real. In the midst of cathartic healing of trauma, there is more than enough aloneness and fear, so that any added hint of aloofness would leave the patient feeling a real aloneness. On the other hand, When resistance is high and defenses are operative, the patient's level of emotional activation is low. The perception that he or she could lose the connection with the therapist is a key motivator. Optimum expectancy tells us to stand our ground and not follow the patient into his or her world of denial and avoidance. The increased distance motivates the patient to move back towards health. On the other hand, too much distance would make the patient feel abandoned and hopeless and would be counterproductive.

For example, when the patient rationalizes some self-destructive behavior, we don't argue, but disengage. "I'm not telling you what to do, but I am not sure that behavior will help you." When the patient moves into primitive cognitions such as paranoid thinking, the therapist stays put,"I don't know about people wanting to cause you pain, but you do seem to see yourself as extremely important to them." These distancing interventions will help the patient return to a healthier position, whereas exploring the pathological material or arguing with the patient will create unhealthy closeness and enable the defenses.

The amount of distance that is optimal ranges from very little when the therapy is in a springtime phase, to just enough in fall and winter. Too much distance will lead to hopelessness, discouragement and disengagement on the part of the patient.

Implications

Note that the stance of maximum empathy and optimal expectancy leaves room to be very active, engaged, passionate, helpful and above all, supportive. This is why I do not believe in differentiating between "supportive" and "uncovering" therapies. There is a right balance of closeness and distance for any moment with any patient. At the same time, empathy, in the sense of accurate emotional understanding of the patient's world has no negative effects and no degree that is too much.

Avoiding Problems

Abandoning the safety of a blanket policy of restraint requires experience and care. Remember that you must still not make or imply promises that you cannot keep. If your level of support in any given area is going to vary, then the patient has to understand the reason behind the variation. For example, sometimes, you may feel that the patient has worked hard enough, and it time at this point in the session to stop tearing away at defenses. The patient will probably understand instinctively that your expectancy is in proportion to his or her state of readiness to move forward. On the other hand, support and helping may be misinterpreted as something that you will do every time, and therefore as a promise.

In practice, managing such expectations is challenging but possible. Early interactions in the therapy are important in establishing what the patient should expect. Absolute consistency is indeed reassuring to patients, but relative consistency, if it varies reliably according to the situation, may be reassuring as well. On the other hand, lack of either kind of consistency is problematic. When you fail to adhere to your own pattern, the patient will experience shock and pain and will rightly hold you responsible.

Another key area to protect is your prerogative to shift back and forth from participant to observer. If you allow yourself to stay in the participant role even after you become aware of it, you may be compromising your ability to regain your position as observer. The longer you linger as participant, the harder time you will have explaining why you allowed the patient to persist in believing you would perform a rescue, rather than helping the patient change. Once again, don't make or imply promises you cannot keep.