TIFT #117: Therapeutic Triangle

Writing a book is not just putting down what one knows, it’s a journey of discovery. Chapter 2 of the upcoming How Psychotherapy Works: Navigating the Therapeutic Space with Confidence is about coming to appreciate and even love the inner selves we encounter in our work. The clarity I want to share here is about how we relate simultaneously to our conscious client and to a nonconscious, inner self. Understanding this complex knot of relationships is central to what we do. Making sense of it in terms that are both scientific and humanistic should be an important part of training. It is what our clients need.

Inner selves

The first part of the chapter opens with three visions of the inner self, and each turns out to be a different way of looking at the same thing. Freud’s unconscious (which later became id and superego) is really the same inner self as cognitive science’s “System 1” or “Thinking fast.” And those two are the same as the inner selves of Internal Family Systems therapy. In my practice, I use different names, depending on which one fits best. It could be your “inner self” or “the little kid inside” or “the nonconscious problem solver.” What all those names try to capture is that our clients possesses an autonomous, survival-oriented, nonconscious self holding and fiercely guarding the Entrenched Maladaptive Patterns (EMPs) that are the targets of our therapeutic efforts.

In helping new therapists relate to a self they can’t see, we begin with something familiar and easy to visualize. Let’s start with Fido, whose social responses are products of a brain closely analogous to our own inner one. Fido is a great communicator. When he trusts us and our intentions, he lets us know. When we get too close to his bowl while he is eating, he growls and we understand instantly what he means. His brain sizes up the situation and immediately issues a response that sets things right.

Babies’ responses arise from the same, pure inner self, without words and without the inhibitory influences that appear later with consciousness and language. To put this phase in perspective, think of how proud we were, after a few years, of being able to look at our skinned knee and not cry. Consciousness and words begin to exert influence that makes raw emotions increasingly manageable. These images are intended to dramatize the difference between the nonconscious inner mind, the one that “thinks fast,” and the conscious mind that “thinks slow” and uses reasoning to filter out the irrational. They are very different.

Under good conditions, the two minds partner together, with the more creative ideas coming from the inner mind then filtered and evaluated by the conscious one. However, not infrequently, the inner mind becomes “frozen in time.” It does so in response to a major threat, something we experience as being of existential significance. Of course a life-and-death threat to a toddler is far different from one experienced by an older child or adult. “Frozen in time” means time stops for the inner mind while some part of it remains vigilant and ready to launch a response if ever we encounter those same conditions. This is what Entrenched Maladaptive Patterns, EMPs are made of, identification of conditions associated with a threat and a tightly held pattern of response kept at the ready.

That tense readiness and rigidity are what create a split between the inner self and our conscious client. Without the presence of an EMP, the inner mind remains in a close and harmonious partnership with the outer one. System 1 and System 2 work together. EMPs cause the inner mind to become stuck at the developmental slice of time when the EMP was invented and to hold onto vigilance and readiness so as not ever to be caught by surprise again. The inner self falls behind or is left behind, focused on protecting the whole self no matter what.

The EMP is a complex of protection, held by an inner self and dating back to anywhere from far back in evolution to childhood struggles to trauma in adulthood. In each case, people come to therapy because their rigidly held response has become outdated, causing pain, and needing to be replaced with a better one. While the origin story is the same for every EMP, how they look in life and in therapy is incredibly varied. The best way I know to understand that variety is to look at the five kinds of information output the brain/mind uses to ensure safety.

Neurons can cause actions to happen both directly and indirectly. Directly, they transmit signals to glands, internal organs, muscles and other bodily regulatory systems. These are rapid and are what cause “affects” such as tears or crying out. In humans, the mind has the additional ability to influence our voluntary decisions by projecting information into consciousness in the form of thoughts, feelings, and impulses to do or not to do. These are so remarkably effective in influencing our behavior that it is plausible to think they evolved for that purpose. Here are the five information products that influence outward behavior, both involuntary and voluntary: 

• Direct: Body and brain regulation, i.e. affects, attention, etc.
• Direct: Involuntary actions, i.e. letting out a cry.
• Indirect: Projecting thoughts into consciousness to influence actions
• Indirect: Projecting feelings into consciousness to influence actions
• Indirect:  Projecting impulses to do or not to do into consciousness

In writing the chapter, the next section raised a question I had not thought of before, how to describe the complex interaction between the therapist and both conscious and nonconscious clients. How do we relate in order to do our job of delivering new information and experiences to the inner self. Not only do we have to bring new information, but we need to take into account her bracing, mistrust, and fear of change. The metaphor that comes closest to describing these relationships is step-parenting. However, let me first talk about the pros and cons of using such a comparison.

Why the parenting metaphor is useful

The first and most compelling reason is that our earliest and most powerful experiences of  being changed, guided, and influenced by another is from parenting. Psychotherapy is more like that than other helping relationships. Your surgeon’s empathy is nice, but not fundamental to the success of the operation. Furthermore, my position is that an active therapist is more effective than a passive one as long as infantilization is avoided and boundaries are managed properly. And, like parents, therapists need to be ready to adjust their stance as the client heals, grows and takes on more initiative over time.

How the parenting metaphor is not correct.

Both therapy and parenting have provided cover for abuse. Therapists have used their power and position for criminal abuse and have gone so far as to use the metaphor of “reparenting” to take over client’s lives. That’s not what I mean by parenting. Therapists are different in that they are responsible for practicing ethically, but not for the other person’s entire life the way parents are. Furthermore, they are different in that, except in emergencies, they can make suggestions but don't have authority over clients. 

A triangular therapeutic relationship

When we recognize the presence of an autonomous inner self, the picture becomes quite a bit more complex. In working with dissociative identity clients, this is necessary and unavoidable, but increasingly I’m seeing it as more broadly applicable. But, if clients can have inner selves, why not therapists? That would make it a foursome? This absolutely does happen and it is called countertransference, when the therapist's inner self, separated from consciousness, gets involved with an inappropriate agenda. This is a serious cause of therapeutic disasters and damage. A major principle is that in healthy functioning, there is harmony between consciousness and inner selves. They operate as one. When that is not the case, we call it countertransference and it is a manifestation of the therapist's EMP. While countertransference is a very important topic, we have limited space in this post and will put it aside for now. What remains is a triangle with the adult client, the client’s inner self, and the therapist, who is hopefully functioning as one mind.

Therapeutic communication

Looking at two integrative authors’ writing about communication with clients, explicitly talking about two client selves is not mentioned. Paul Wachtel’s Therapeutic Communication and Clara Hill’s Helping Skills each suggest talking occasionally to clients about “a part of you…” That’s when “the client” is aware of ambivalence. In both cases the “you” they are referring to is the conscious client, seen as a single, unitary being. This is quite awkward and restricting when the inner self can so easily be at odds with the conscious one. It is remarkably freeing to realize that, at least when it comes to EMPs, humans are not unitary. We have one or more inner selves with specific goals and plans exerting powerful influences on the “you” who is ostensibly our client. In the end, both are truly our clients and both deserve respect and attention.

The therapeutic step-parent

While the reality may vary, step-parents are different from parents in ways similar to therapists, especially in relation to inner selves. Step-parents do not have full authority and they must earn the right to have influence. They must have a positive alliance with the biological parent, while the relationship with the child is not to be taken for granted. Within similar limitations, our job is to ally ourselves with the adult client, helping build understanding and clarity, while modeling healthy relationships with both the adult and the inner child, according to their respective developmental levels. In doing this, it helps enormously to be able to talk openly about both clients. 

Inner selves are not all the same

Because inner selves vary in experience and level of development, I refer to them differently according to what fits best. Some are younger and show it in the way they solve problems, while others may be more sophisticated, for example, five-year-olds generally have a firmer grasp on the concept of time future.

More than one inner self

To be complete, as Internal Family Systems therapy affirms, there are often two or more inner selves. For many EMPs, the dread that lead to their formation is related to some form of fear. In a second and distinct type of EMP what is dreaded is shame. Here the EMP consists of internalizing values that use shame as a deterrent to behaviors the mind considers dangerous. These EMPs can be sources of merciless inner shaming and criticism. Two inner selves can also represent opposite attitudes, for example positive self-esteem in opposition to self-hate. Their contradictory positions are held internally without dissonance except when they come to consciousness. As IFS documents, there are “managers” who quietly support survival, along with “firefighters” who come to life when an emergency alarm sounds. And finally, resistance to change in therapy is a common EMP, an artifact of our plans to remove EMPs on which the inner self believes life depends.

The triangular therapeutic relationship

The books referenced earlier discuss how to shape one’s sentences but verbal communication is what we do most automatically and often very well. It’s where our reading of social cues naturally shapes how we say things. Rather than attempt to teach how to form correct communications, I would rather look at the task to be accomplished and rely on a lifetime of social experience for the details. To identify appropriate prompts for therapeutic communication I think first of describing the work to be done. It can usually be boiled down to moving either or both of the client's selves from point A, to point B and, along the way, dealing with resistance ®:

 A ————®————>B

Going from point A to point B through a resistance is, in fact, the definition of work. Together these three elements give a clearer sense of what to say and ask. As step-parents we may discuss strategy with the "parent," the adult client, who has final responsibility and authority, meaning the final right to determine behavior. But the one whom we want ultimately to be the recipient of new ways of responding is the inner self. There, we partner with the adult client to help the younger part accept and try out different ways of responding. In doing this, we are partly talking to the inner self and partly modeling good parenting to the adult client. We work with the adult client to earn the trust of the inner self and to have influence together. The tone and vocabulary depend on having a clear picture of who we are addressing, the work to be done, and the state of resistance. Using a different metaphor, imagine being a coach helping a young person and her parent make a first jump from the diving board. It could be simple and easy, or it might require time, sensitivity and strategy. In doing this, we remember our role. We are ultimately outsiders in a very personal drama.

Degrees of certainty

Another major and constant factor in therapeutic communication is the degree of certainty. That can range from a hunch to a strong conviction based on a working hypothesis, repeatedly proven accurate. Like the weatherman, building the degree of certainty into the language helps us limit unrealistic expectations. We avoid surprises, but keep an eye out for our words being taken differently from the way we mean them.

Clinical Vignette:

A high achieving retired businessman is at the end of being able to sustain one more multi-day binge of drinking. He drinks when his shame and guilt about harm to his family become overwhelming. And beneath those bad feelings is a dread of something else having to do with his early experience of severe verbal abuse by his step-father and sexual abuse at 8 by a priest. Metaphorically we picture a cave he cannot enter because his young self feels so threatened and ashamed of what is there.

Therapist: "We know that nothing that happened was your fault and that your bad behavior later was from trying to cope, but your inner 8 year old doesn’t know that. We need to show him that this is all forgivable."

Client:  "I know, but it doesn’t penetrate. I know that’s true, but I can’t feel it."

At the next session, the client has found a pathway to forgiveness. A revered person, looked up to as a shining example of life well lived. The client finds personal documents showing that this person did bad things in his youth and felt genuine remorse, but was able let go of his past and turn his life around. Together with the adult client, we acknowledge that experiencing forgiveness is indeed possible following the pathway laid down in this powerful and personal story.

In a third session, we go into the cave. He tells me a modest amount about his abuse, but includes the fact that he, as a young boy desperate for love, had welcomed the priest’s warmth and support. It was confusing but didn’t hurt when that turned to overt sexual abuse. He didn’t have to say more. We both understand that his childlike mind had equated his welcoming the priest’s attention to having responsibility for shameful participation. The context over those sessions is enough to carry the nonverbal message that there is no need for shame. At that moment, his shame is transformed and the dread lifted. In the session that follows, adult client and inner self are no longer at odds. They are finally at peace with one another and with his past.

Now the cave is empty and the dread it had held is gone. There are some habit patterns to clean up, but the seemingly impossible work has been done.

Conclusion

Inner selves are real. They think differently from rational adults and when they become frozen in time, they retain goals and plans laid down at times of existential threat. Those can remain forceful in the person’s life and cause tremendous suffering, not only for the client. Our role is to understand the emotional work that is to be done and to relate both to the “parent” the adult client, and to the “inner self,” helping them work together to overcome barriers to change and return to harmony with each other. The best way to support this process verbally is to keep in mind the participants, the work to be done, and the degree of confidence we have in what we say.

 Thank you, dear readers, for helping work out what will go into the next draft of Chapter 2.

Jeffery Smith MD

Photo Credit:  James-x, Unlplash