Therapist to the Therapy

As a result of my personal vulnerability in "less than 'good-enough' therapy," I began some years ago to offer a service to patients and therapists as an interventionist to "the therapy." If there is a powerful impasse in a "treatment" and there is a work stoppage, I'm called in. At times, a patient may rage at a therapist for something quite human (e.g., the therapist can't understand, won't listen, is tense and/or interrupts the patient's flow of speech, etc.). If the therapist is not vulnerable enough (personally and inside of him/herself) to take the patient's "onslaught" (e.g., anger, lengthy silence, hostility, manipulative or sullen behavior, etc.) 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 as a child uses his/her caretaker, and patients also try to destroy the therapist/caretaker similar to a youngster demanding 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 a mother (or caregiver) needs to be able to tolerate the child's neediness, rage, envy, fears, hostility, etc. Some therapists -- like some "Moms" are not personally able to tolerate patients' reactions. In other words, personal and emotional capacities (of "Mom" and "therapist") need to be "good enough" to handle need and deprivation 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, therapist and patient are finished. Good therapeutic work is no longer possible. As an extreme example:

Meg calls me for help. Richard has been her current therapist for two years. She says Richard can't handle her. Meg says Richard talks "over her," he doesn't understand that sometimes she "needs her space." She also tells me that Richard doesn't "like it/her" when she gets "mad." He, in Meg's words "wants Meg to understand." Meg tells me she has been "thrown out" of two prior therapies for "raging." Meg explains in her way: "When injured by [m]y therapist, imagined or real, I lash out. I have much anger and rage and it is directed AT the therapist." She continues, "I have made tiny, tiny progress, but it seems 'it' is not enough. I need someone strong and experienced enough personally and professionally to help me in this area ('lashing out') as a starting place." 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" as in her words, "I get too scared to go to session." "I get either afraid of Richard or guilty of my lashing out." Richard colludes with Meg. He agrees to have telephone sessions when Meg wants them. Richard has not been trained to handle "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/terror 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 he is out of 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, attention, etc.

I work with Meg for two sessions and then invite 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 is right; he can't. He doesn't understand. He can't FEEL it within himself. He tells me he has tried all kinds of "therapeutic adjustments." He shifted his focus, he offered stress reduction exercises, and now he thinks 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 intellectually sees how Meg wants his undivided attention and is testing him to not throw her out, he fails to grasp the depth of Meg's unfulfilled emotional 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 talk with Richard about my observations and try to help him shift his reflective space and understand emotionally the dynamics of the stalemate. Richard cannot understand.

I have intervened and begin to work with Meg. I soothe her in my style and listen to her tantrums. I am highly empathic. I stay with her and 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/her own personal vulnerability -- 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/children leave. I helped Meg begin to trust. I tolerated her rage and hostility. I listened with much 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/she can understand his/her part in the stalemate, but sometimes not. In some instances, it will be clearer later. 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 that will enable the therapy to continue and the patient's experience of betrayal, envy, abandonment, rage, etc. can be integrated into the therapeutic relationship.

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