Some years ago, as a result of my personal vulnerability from “less than ‘good-enough’ therapy,” I began to offer a service to patients and therapists: acting as an interventionist to the therapeutic alliance. If there is a powerful impasse in a “treatment” or some kind of stoppage to the therapy’s progress, I’m called in.
At times, a patient may rage at a therapist for something quite human – such as when the therapist can’t understand, won’t listen, is tense, or interrupts the patient’s flow of speech. If the therapist is not vulnerable enough – personally within his or herself – to handle the patient’s “onslaught” – his or her anger, lengthy silence, hostility, manipulative or sullen behavior, and the like – then there can be a rupture in the work. The therapist blames the patient, and the patient blames the therapist. All work stops – it’s a stalemate!
Patients must be able to emotionally use therapists just as a child uses his or her caretaker; patients may also try to control the therapist/caretaker similar to when a youngster constantly demands attention from a ‘Mom.’ The young child behaviorally frustrates the parent – sometimes crying for hours or sullen in crib – other times refusing to eat or take a bottle, throwing food and small objects out of a crib or high chair. The therapist must survive this “onslaught” – this indirect and direct destruction – much like how a mother (or caregiver) needs to be able to tolerate the child’s neediness, rage, envy, fears, and hostility.
Some therapists – like some ‘Moms’ – are not personally able to tolerate a patient’s reactions. In other words, personal and emotional capacities (of ‘Mom’ and ‘therapist’) need to be ‘good enough’ to handle the needs and deprivations that “‘good enough’ parenting” and “‘good enough’ therapeutic work” engenders. If a patient tries to seduce a therapist and the therapist buys into the seduction, then their therapeutic alliance is finished and effective therapeutic work is no longer possible. As an extreme example (with names kept under pseudonyms for confidentiality):
Meg called me for help. Richard is her current therapist and has been for roughly two years. She says that Richard “can’t handle,” her, “talks over” her, and doesn’t understand that sometimes she “needs [her] space.” Meg also tells me that Richard doesn’t “like it or [her]” when she gets mad. He, in Meg’s words, “wants Meg to understand.” Meg tells me that she has been “thrown out” of two prior therapies for “raging.” Meg explains in her way: “When injured by [my] therapist, imagined or real, I lash out. I have much anger and rage and it’s directed AT the therapist.” She continues, “I have made tiny, tiny progress, but it seems like ‘it’ is not enough. I need someone strong and experienced enough – personally and professionally – to help me in this area [‘lashing out’].”
This time, Meg once again tests ‘a therapist.’ She rages at Richard: she calls him names, she becomes silent for half of her sessions, and Richard interrupts her silences. Meg gets angrier. She starts to miss sessions and actually persuades Richard to do some “phone therapy” since, in her words, “I get too scared to go to sessions. I either get afraid of Richard or guilty of my lashing out.” Richard colludes with Meg, and agrees to have telephone sessions when Meg wants them.
Richard had not been trained to handle such “onslaughts.” He cannot handle or begin to understand Meg’s enacted behavior. He cannot feel Meg’s intent to torture and rage at him. He fails to understand Meg’s behavior is a smokescreen for her unfelt fears, terrors, and other early developmental issues. Perhaps he has not been a parent? Perhaps he wasn’t at one time permitted to be a young child? Perhaps he has not been trained with a “‘good enough’ personal therapy?” Richard’s defenses do not work and without an emotional awareness of his own vulnerabilities. Therefore, he fails in his heart to understand Meg. According to Richard, he is only “trying to help.” Meg doesn’t care – much like an infant who wants unconditional soothing, love, and attention.
I worked with Meg for two sessions and before inviting Richard to call me. Meg has been hurt and is very angry with Richard for not tolerating her demands. Meg can’t let up. Richard shares with me his desire to have Meg “cooperate.” He tells me he cannot “tolerate” this kind of behavior – rage, silences, and “neediness.” He’s right: he can’t. He doesn’t understand. He can’t feel it within himself. He tells me he has tried all sorts of “therapeutic adjustments.” He’s shifted his focus, he’s offered stress-reduction exercises, and now he thinks that Meg may not be “treatable.” He has colluded with Meg’s attempted destruction of Richard – of the “onslaught,” and of the “therapy.” Even though Richard might intellectually see how Meg wants his undivided attention and is testing him to not throw her out, he fails to grasp the emotional depth of Meg’s unfulfilled needs. He tells me he may not be able to work with Meg. Meg almost gets her wish – to get thrown out of a third therapy!
With Meg’s permission, I talked with Richard about my observations and try to help him shift his reflective space. In doing so, I hoped that he might begin to understand emotionally the dynamics of this stalemate.
Having intervened, I began working with Meg. I soothe her in my style and listen to her tantrums, highly empathically. I stay with her, all of her fire and brimstone. I can be with her as I can emotionally be with myself. I understand terror and vulnerability from inside of myself.
Meg gets a little relief. We set some timetables and, eventually, Meg is forced to exit her treatment with Richard. Why? I learn that Richard is ending therapy with Meg and in fact told her he “could no longer work with her.” He doesn’t want Meg as a patient. I continue to work with Meg until she finds a suitable and “strong” enough, adequately trained and experienced therapist, one who also has “good enough” self-awareness of his or her own personal vulnerability – one who can help her.
Why didn’t I continue to work with Meg? I would have wanted to. However, I am emotionally “separate enough” to have my patients and children leave. I helped Meg begin to trust. I tolerated her rage and hostility. I listened to her with empathy. I interpreted only what she was ready to emotionally hear. Meg and I live and work in different states and Meg wanted to “face her therapist” in person. She wanted to be in the same room with a “strong and experienced enough – personally and professionally – therapist” and challenge herself.
The above is extreme. Oftentimes I help a patient return to a therapist. Sometimes, he or she can understand his or her part in the stalemate – but sometimes not. In some instances, it will be clearly the latter. In addition to becoming an ally to the “patient,” I attempt – where feasible – to become an ally to the “therapist.” In this way the therapist may accept a different reflective space and understand the dynamics of the stalemate. This may or may not be possible. Optimally, my empathic link to each can create a bridge, one which will enable the therapy to continue such that the patient’s experience of betrayal, envy, abandonment, or rage, can be integrated into the therapeutic relationship.