Since 2005 when my blog began, by far the most popular topic has been attachment to your therapist. The many poignant comments to those posts show how wrenching the experience can be. They also show how challenging it can be for therapists. Today’s post is for therapists confronted with the powerful needs and longings of their patients.
As described in the last post on Attachment and the Inner Child, the most accurate and helpful way to understand intense attachment to the therapist is to view it as the reaction of a child who has been waiting for many years for someone to fulfill needs that have remained frozen since they were originally blocked. These are not ordinary wishes, but emotional necessities that, at the time, equated to survival. The critical nature of these needs is reflected in the intensity of their expression in therapy.
Perhaps the most difficult problem for therapists is that this emotional intensity is being experienced by a patient who possesses all the tools and powers of an adult. While some patients can see that their reactions do not reflect their more mature selves, others find reasons to justify their feelings and desires. The immense power behind such wishes can be daunting for the therapist as well as upsetting and even frightening for the patient.
It is easy for a therapist to be thrown off when learning how strongly a patient has become attached. The most troublesome accounts in the blog are about therapists who react to their patient’s neediness in a rejecting way. Others have made or implied well meaning promises and then been unable to fulfill the expectations they have created. A third group have told their patients that this kind of attachment is not supposed to be part of therapy and have tried to suppress or discourage their patient’s feelings. None of these reactions is therapeutic and all are unhelpful or frankly damaging. The thoughts that follow are aimed at helping therapists deal with intense attachment in a way that leads to therapeutic benefit.
The first perimeter of safety for patient and therapist is good boundaries. Ideally this means the therapist has been giving clear signals about what he or she can and cannot do from the beginning. At some point in the therapy, the patient may begin to be conscious of wishes that go beyond those boundaries. At that point, the therapist will hopefully be in a position to give understandable and caring reasons for limits that have been consistently maintained. Training, experience, and supervision are the main ways therapists come to be comfortable with their own style of boundary maintenance.
Problems happen when the therapist has been inconsistent or has allowed expectations that cannot be met. The patient will understandably be very very upset when wishes that appeared to the patient to be acceptable are suddenly refused or not met. How can a therapist deal with such a problem? The effective way to preserve the therapy and the relationship is an honest and frank conversation about what happened. When therapists try to cover up their mistakes with unsatisfying explanations or by attacking the patient, they cannot succeed. At best, the patient will quit therapy and find another therapist. At worst, the patient may stay but no longer trust the therapist’s integrity and honesty. It happens too often that the outcome is a literal repetition of the failed early experience that led to the need or wish being frozen in the first place.
A therapist who has acted with good intentions and who offers a genuine explanation recognizing the patient’s hurt is likely to be successful in preserving the relationship. Even more important, by preserving the relationship, it is then possible to turn a relationship problem to therapeutic benefit. First, processing the patient’s understandable anger will accomplish some of the work of healing the original disappointment as well as leading to the therapist being forgiven. In my view, the work won’t really be completed until the patient can differentiate between anger at the therapist and anger related to the original disappointment. The working through of such feelings of betrayal is intense for both patient and therapist. The feelings are real because the mismatch of expectations is real. The needed healing requires that the full strength of emotion must be allowed in the room and treated with respect. There is no place here for the therapist to dampen the interaction by insisting on a role or professional persona. When the feelings are in full bloom then neural circuits can be reconfigured and those strong feelings put in their place. As the temperature goes down, it will be possible to make connections between the past and the present experience.
Where to Set the Boundaries
Parents wonder how tough to be with their children. The answer is that it’s not how tough they are, but how the restrictions or demands are presented. Families with many children must, of necessity, impose significant hardship on their children, but the children often come out with excellent emotional intelligence and resilience. On the other hand, when the hardship comes from a parent trying arbitrarily to impose pain from their own childhood, the result is generally destructive. The situation for therapists is quite similar.
Therapists debate endlessly about how depriving to be with their patients. What really counts is whether the deprivation comes from genuine caring for patients and their success or from the inner needs of the therapist. Withholding for its own sake, even if sanctioned by some principle of technique will be understood by the patient as serving the therapist’s needs at the expense of the patient. It is well to remember that the original “neutrality” and “abstinence” of psychoanalytic technique came from the same Victorian enthusiasm for deprivation and self-control that produced the sterile orphanages that Bowlby showed to be deeply harmful to children. In general, patients with a level of deprivation that makes them become intensely attached do best with a warm and relatively generous therapeutic relationship.
A better way to decide what to give and how much is to evaluate actions towards the patient on a basis similar to that used by the Federal Drug Administration to evaluate medications. Their judgments are based on weighing costs and risks versus benefits. First let’s look at the highest quality, the gold standard of what therapists give to their patients. That would be something that is highly beneficial, has no dosage limit or side effects and is free. While no medication meets those stringent criteria, the most fundamental elements of psychotherapy do. Every day, we give our patients something that is highly curative, has no dosage limit and bears no cost other than our time, which the patient has already agreed to buy.
This amazing medicine is the understanding or “accurate empathy” that we offer every day. All that is required is a willingness on the therapist’s part to connect and engage on a genuinely emotional basis. Accurate empathy, truly felt, is what allows the patient’s emotions to heal. What makes this a gold standard is that accurate empathy has no dosage limit, no ill effects and no cost. It is the fundamental stuff of healing yet, at the end of the day, giving it leaves the therapist energized rather than depleted.
Even those therapists who insist on not showing emotion, if they are effective, must engage in a feeling way. In spite of their surface withholding, their engagement or lack of it is immediately perceptible to the patient and makes the difference between a technician with poor results and a true healer.
Equally important, along with empathy, is the therapist’s calm perspective on the situation. This is what signals to the inner child that the world is not ending and that life will go on. Note that this doesn’t mean therapists should stand by when patients threaten destructive acting out. It does mean that the dual elements of empathy and perspective are basic to all effective therapeutic relationships. These gifts don’t require boundaries, because one can’t overdose on empathy and perspective.
Now let’s look at the other extreme, the bottom of the quality scale. The inner child wants to be loved, and any token of love can become currency in the dance. The tokens given and received in this way are often ones of very low quality. What I mean is that they give little and carry high costs. Sedative medication is often given and received as a token of love, but it blocks progress by covering up the feelings that need to be exposed for healing. Furthermore, it leads to physical dependency and becomes less helpful over time as the patient requires higher doses for the same effect. Disability status can be another very costly “token of love.” It gives relief, but can make recovery of functioning much harder to reclaim. Excessive therapist time outside of sessions is another kind of token that can easily slide into excess and create resentment on the part of the therapist. At that point, what started out as a gift becomes a burden on the relationship. These are low quality tokens of love, to be given only with care and full awareness of the liabilities.
Having looked at the extremes of high quality and low quality, we can now examine the middle ground. This includes such things as advice, limited touch, expression of human feelings beyond the therapeutic contract, extra time and any other “gift” that feels good, but brings with it potential misunderstandings, disappointment, resentment, and other negative side effects.
Schema therapy has a useful concept to cover this middle ground. They speak of “partial reparenting” to describe their approach to this question. They note that it is natural to fulfill some of patient’s wishes and possible to do so without awakening unrealistic expectations or causing too much disappointment. A certain amount of generosity on the part of the therapist is energizing to the therapy. Furthermore, stinginess, even if it is sanctioned by theory or technique, can still come across as motivated by something other than the patient’s true best interest.
For these middle ground areas, the key to gifts having a positive effect is being aware of the inner child. Think of the days of lace-up shoes, when parents had to decide when to tie their children’s shoes and when to insist that the child do the job. When the child was not ready to learn to do it by him or herself, it was obviously right for the parents to do so. When the child was ready to learn, then the right thing was to expect the child to do it. But there is also the situation where the child might be tired from some effort or outing, and ready for a break. There, an understanding parent might give some relief by tying the shoes without discouraging the child’s growth. Such decisions in parenting and in therapy are matters of judgment and it is impossible to get it exactly right every time. Furthermore, as in child rearing, an action that is appropriate at one point in therapy might be infantilizing at another point or with a different patient.
Even though the adult patient may understand what is and is not appropriate, the inner child may have other ideas and react quite differently. By being aware of the child within, we are in the best position to gauge what actions will be helpful and which ones will undermine the ultimate job of therapy, that is, facing difficult feelings and realities in a way that is positive and leads to growth. With experience, we will be able to anticipate possible side effects and dangers of our middle ground interventions. As we practice we will learn to deal with our mistakes and become more confident and consistent in containing and healing strong emotions. Over time we acquire greater skill in maintaining the kind of flexible boundaries needed for middle ground expressions of support and giving.
Technician vs Healer
In looking at the experiences of patients who have commented on the attachment to your therapist thread, it seems that some therapists are more comfortable in a technician role. In view of the previous discussion of the complexity of flexible boundaries, this is very understandable. It can be difficult stepping into the role of empathically engaged healer, especially when feelings are intense.
When empathic engagement is threatening for the therapist, working with patients’ strong feelings is hard. The good news is that understanding what is going on can give clarity and clarity can give confidence. Perhaps the most unnecessary and problematic attitude for the therapist is thinking that we are not allowed to be human. Patients are far more ready to forgive human fragility and failures than to forgive a therapist who insists on being right. Too much of the time, in early life, the child has been faced with the same kind of refusal to acknowledge weakness by parents or caregivers. Both parents and therapists are human and fallible, but need to be ready to acknowledge their limits. Our readiness to do so when needed can help the patient understand and accept his or her own limitations. This may be a time when a therapist needs support, too. Seeking help from supervisors, peers, or through consultation can be very soothing for the therapist and indirectly for the patient as well.
When we know that we are dealing with an inner child who feels and reacts like a child and has a child’s limitations, it is easier to feel compassion and to know that our honesty as well as our understanding and warmth are what give our patient a chance at a corrective emotional experience.
Therapists, please feel free to follow this blog and in particular the posts marked “For Therapists.” You are welcome to contact me directly as this helps me to know what issues are on therapists’ radar. The Bookstore has items by myself and other authors. My upcoming book for professionals, Psychotherapy: A Practical Guide (Springer) will be out in March, 2017.