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In This Chapter:
Judgment vs. Rules
Checks and Balances in Various Therapies
Problems in Active Therapy
Conclusion
Chapter 12: Checks and Balances
Protecting the Therapy: Judgment vs. Rules
Traditionally, psychoanalysis and many other therapies have relied on rules to prevent trouble. Woven throughout previous chapters is the theme of using judgment instead of rules to prevent irreparable damage. In this chapter I will discuss observations and ideas that are relevant to preventing damage to the therapy. Note that issues pertaining to the safety of the patient are outside the scope of this course, being matters of professional judgment and training rather than of therapeutic technique.
Let us sample some systems of psychotherapy from the point of view of checks and balances. The metaphor of cooking is a good one in which all therapies rely on the same principles of cooking but use different systems to heat the ingredients. In all therapies, emotional activation under the right circumstances leads to cathartic healing and internalization. However, each therapy uses different methods to destabilize defenses and activate emotions. Each has its advantages and liabilities.
Psychoanalysis: Multiple visits per week and the use of the couch create a highly charged crucible aimed at maximizing transference phenomena, regression and the emergence of fantasy. The patient's fundamental rule is to free associate. The therapist's rules of neutrality, abstinence, and anonymity work to encourage talk and discourage acting out within the therapy. On the other hand, acting out outside the therapy is a problem that psychoanalysis is not very well equipped to handle. Consequently, the tradition is to evaluate whether the patient is suitable to the therapy. Those with strong, stable ego structure are less likely to act out, and are, therefore, better candidates for this form of treatment. Thus, the rules create checks and balances to contain the intensity of the treatment.
Cognitive Therapy : The therapy imposes restrictions on the content of sessions. Discussion is restricted to the uncovering of cognitive distortions. It is assumed that behavior is a result of thought, and therefore that unhealthy behavior is a result of unhealthy thinking. As thinking is corrected, behavior will automatically change. The rational atmosphere acts powerfully to discourage fantasy, acting out, and other manifestations of regression. These expectations shield the therapy from just the kind of thoughts and impulses that are encouraged in psychoanalysis.
A 21st Century Active Therapy: The patient is encouraged to seek greater health in emotions, attitudes and behaviors. The therapy is open to any technique that will help modify dysfunctional patterns, including: examining distorted attitudes and ideas, understanding their origins, encouraging healthy behavior change, learning about unconscious wishes and plans through spontaneous associations, dreams, etc., observing transference resistances and working with them through examination of their contents. The therapist can be active and engaged, even passionate about helping the patient to progress in a mutually agreed upon direction. What are the problems that can arise, and how can we prevent them?
Things That Can Go Wrong
Negative Cost/Benefit Ratio: Sometimes patients want to change in ways that are at the limit of what they can do with the resources available. In such cases, the perceived benefit needs to be very clear and the patient's support system very strong. The therapist is usually a significant part of the available support system. The fact that you like and care about the patient is an extremely important part of the equation. Taking all these factors into account, if the cost/benefit ratio is still negative, then the therapy has a structural flaw. Going back to the chapter on structure, it is the therapist's job to bring the treatment contract into question. Before doing that, there are a few things you may be able to do to improve the situation:
1. If there are things you do not like about the patient, these will make the work harder. Rather than suppressing your negative feeling, it is better to make those characteristics part of the therapy. By bringing them into the therapy, you will probably find that you no longer have a negative feeling. You will respect the patient's willingness to work on those aspects of him or herself. Beyond that, you may be dealing with your countertransference. If you are unable to resolve your negative feeling, the likelihood of success is much diminished.
2. Put the patient in charge of determining the rate of change, and acknowledge that the job is going to take whatever time it takes. Patients can feel pushed by expectancy that is beyond "optimal." A look at the "Grow Graph" shows that progress that is too rapid will result in excessive stress, and will tip the cost/benefit ratio the wrong way.
3. Be vigilant about compromises that will eventually undermine the therapy. For example, the patient may want you to accept an addictive behavior because the comfort it gives is necessary to achieve the desired growth. If you agree, then when the time comes for the patient to give up the addictive behavior, you may have colluded in supporting it, and implied a promise that the patient can keep it. Your change of mind may not be forgivable.
Transference Resistance : Experience with therapy and supervision strongly suggests that the most common reason for the failure of psychotherapy is the failure to identify transference resistance. This kind of resistance seems completely real to the patient, and often to the therapist as well. It might be a philosophical difference or an outside circumstance or a characteristic of the therapist that seems to stand in the way of progress. You might find yourself struggling to resolve the philosophical dispute or help the patient see that the outside problem is not the crucial one. As the struggle becomes an impasse, it is time to wonder how it represents a transference re-enactment. How can you make this easier to work with?
Working to identify the patient's "classic" transference paradigm right from the beginning will give you a head start when this happens. The more you and the patient have developed an understanding of his or her characteristic transference distortions, the easier it will be to show (metacommunication) how the same issue is behind the seeming impasse in the therapy.
Stepping Into the Transference: At the beginning of treatment as an active therapist, you may do things without fully understanding their meaning in the context of the patient's transference wishes and plans. In promoting health, you may take an action that reinforces the patient's transferential view of you. The fact that you are following an agreed upon plan will go a long way to make it possible for you to do the three step dance, retreat into your observer role, and examine what has happened.
For example, a patient presented with difficulty following a diet that was important to his health. Early in treatment the therapist took this as a goal without knowing the source of the patient's resistance. Soon it became apparent that the therapist had entered into a transference paradigm in which he, the "parent," was experienced as wanting to attack the patient's core individuality. Identification of the patient's perception that the therapist was attacking the patient's self led to new awareness that the patient might be able to follow the diet without sacrificing his identity.
Therapist Inconsistency : The concept of "optimal" expectancy means that your level of expectation can vary. As your expectations of the patient vary, it is appropriate that the level of your support should vary as well. If the patient is floundering with a real-life problem, it may be appropriate for you to offer suggestions or advice. As the patient makes progress, the same level of helpfulness might be infantilizing. You will need to adjust. This requires judgment. Fortunately, parents are expected to exercise the same judgment without infantilizing their children, and most are able to do so. It is my belief that therapists can easily establish that their helpfulness is attuned to the patient's real need, and will be available according to the therapist's ability and the patient's need. If you adhere consistently to what you believe to be "optimal" expectancy and optimal helpfulness, then the patient will not have trouble with changes in what you are willing to offer.
Therapist Error : Patients will often forgive an error or even a weakness when you have demonstrated consistently your caring and your allegiance to what you believe is in the patient's best interest. Since you have been retained to conduct the therapy, then your concern with your livelihood and safety are part of your job. Beyond those considerations, the errors that patients will not forgive are those that come from placing your own needs ahead of the patient's. When this is true, it may not be forgivable. On the other hand, the patient's perception of you as pursuing your needs at his or her expense may be a reflection of transference rather than reality. Remember that in examining transference, the key factor is the patient's perception of your motivations. Again if you are well prepared to make a transference interpretation, you may save the day for both of you.
Nothing to Lose: If you are about to lose a patient, you are actually presented with an extraordinarily valuable situation. Here is where the best you can do is to follow your intuition about what will work to save the therapy. It is a time to take risks you would usually avoid. Especially if you succeed in saving the therapy, you will learn a great deal about your patient and yourself.
Conclusion
A supervisor once said, "Mix it up with the patient." This advice has grown on me over the years. Active participation in the therapy brings up a different set of problems, but when judgment is equally active, they are soluble. In addition, the concern that activity will make the transference disappear or be inaccessible to exploration, is simply not true.