We give a lot of thought to what causes the therapist-patient relationship to bog down. A reader of our blog identified as “Anonymous” replied to an entry we posted on the “Doctor-Patient” relationship, inspiring us to share some thoughts about therapeutic relationships that seem to come to an impasse. We’d like to hear from readers who have had such experiences and what you did about it.

“Frank examination of one's own limitations is difficult, but worthwhile. Getting candid feedback from others can be even more challenging, though indispensable”Grant

Anonymous writes:

I agree with your comments about how irrelationship can affect the relationship between a doctor (or other provider) and patient in therapy. Our reimbursement system sometimes encourages treatment choices that relieve the practitioner’s financial anxiety but may not be best for the patient.

After all, therapists need to keep a certain number of patients in treatment to maintain a professional standard of living. Undoubtedly some practitioners extend therapy needlessly or maintain patients in a comfortable equilibrium that avoids disruptive issues.

After a while, this is bound to make the patient suspicious and cause the whole relationship to sink into irrelationship. Both the caregiver and the patient — the audience — are compromised. In our society, irrelationship would be attractive for a lot of workplace situations because it drags out the process of finding solutions to problems, and could extend the workload indefinitely.

This reader gives us a lot to think about.  

The therapist and patient invested in irrelationship derail the therapeutic process since growth of intimacy is necessary for making progress. Going further, brainlock makes the song-and-dance routine of irrelationship harder to identify, thus solidifying the mechanisms that keep a (therapeutic) couple at arm’s length. This leads to what is referred to as a “therapeutic impasse,” (Alexander, 1950; Whittaker et al., 1950) or as an “interlock” (Wolstein, 1959).

Therapists’ training provides tools and insight (often acquired by going through therapy or analysis themselves) for avoiding pitfalls that may put the therapeutic process at risk. The ability to identify unconscious obstacles in themselves and patients promotes patient self-knowledge needed to improve functioning, decision-making, and resilience in adverse situations (Bromberg, 2013). Not unreasonably, patients expect their therapists to be competent at managing their own feelings and issues, but idealizing the therapist may put the therapeutic process at risk.

“The psychotherapeutic relationship — like any other — can go off the rails. Therapy itself, then, can provide a perfect opportunity to explore the process of interactive repair.”Mark

Research by Pletzer et al. (2015) supports the belief that therapists are better at regulating their emotions than non-therapists, but many of us know stories of therapy going off the rails. The authors readily admit to instances in which their own blind spots disrupted the therapeutic connection with a patient. Awareness of such issues improves the likelihood of preventing or repairing damage they can cause. Sometimes patients will point out lapses in empathy, faulty interpretations or other problems, prompting patient and practitioner to examine the issue together. This process, called interactive repair, is a learning and growth opportunity for both, and is essential to the irrelationship recovery process.

Some patients are uncomfortable with this kind of candor if they expect their therapist to be “perfect,” but contemporary perspectives generally view such interactions as enhancing therapy. Some experts even believe this type of frankness to be necessary for therapy to be complete and effective.

The authors have identified several indicators that a therapeutic relationship may be affected by irrelationship. We’ve grouped them into two categories, although overlap is evident in some cases: A) The therapist resists validating certain types of feelings or feedback from the patient; and B) The therapist violates therapeutic boundaries either explicitly or subtly, even to the point of creating role confusion in the relationship.

Resistance to validating patient’s feelings or feedback:

  1. The therapist seems unaware that therapy is bogged down, or is evasive if the patient mentions it.
  2. The therapist insists on bringing up issues the patient has clearly signified an unwillingness to discuss.
  3. The patient believes the therapist’s analysis of an issue is erroneous, but the therapist resists such feedback; or the idea of countering the therapist’s interpretation makes the patient fear upsetting the therapist.

Violation of boundaries:

  1. The patient feels called on to meet the therapist’s needs by listening to his personal stories, unrelated to therapy, or in other ways.
  2. The therapist makes frequent phone calls to the patient between sessions; suggests a relationship outside the professional connection; or makes sexual or other inappropriately personal comments.
  3. The therapist over-identifies with the patient’s issues or insistently over-directs the patient’s behavior.
  4. You or your therapist (or both) have strong emotional reactions to one another that you do not discuss.
  5. If you suggest stopping therapy, your therapist has a strong negative emotional reaction and tries to manipulate you into staying.
  6. If you bring up any such boundary issues, your therapist becomes defensive or dismissive.

One other type of issue needs to be singled out because of its sensitivity in our culture: money-related issues. Money-related issues may cause the patient to cancel frequently, to discontinue, and to have confused feelings about being in therapy. For example, if the patient feels the fee is too low, he may be unwilling to “take advantage” of the therapist. On the other hand, the patient may be unable to discuss honestly his inability to pay the therapist’s fee, leading to debt and negative feelings about therapy.

“Let’s face it: therapy is intimate, and can get scary the same way any intimate relationship gets scary.”Daniel

Psychotherapy can easily trigger (re)enactment of unresolved irrelationship dynamics, especially compulsive care-giving routines in which one party feels that she or she does all the giving or all the receiving. But psychotherapy can also be an ideal forum for affected individuals to work jointly at creating a safe environment in which:

  • Patients can learn both to accept the care offered by their therapist and to feel valued because the work they do gratifies the therapist.
  • Therapists can provide valuable services while accepting the patient’s trust and hard work as well as payment for services.
  • Therapists learn valuable lessons that can make them better therapists.

To sum up, though the therapeutic relationship can be a scene of irrelationship wreckage, it can — when that circumstance is addresses and worked through — be an opportunity for healthy interactive repair and caregiving for both parties.

Our readers are invited to share any experiences and feelings about therapy, but especially particularly disturbing episodes.

References

Alexander, F. (1950). Analysis of the therapeutic factors in psychoanalytic treatment. Psychoanal Q., 19:482-500.

Bromberg, P. M. (2013). Hidden in plain sight: Thoughts on imagination and the lived unconscious. Psychoanalytic Dialogues, 23, 1-14.

Pletzer, J. L. Sanchez, X., & Scheibe, S. (2015). Practicing psychotherapists are more skilled at downregulating negative emotions than other professionals. Psychotherapy, no pagination specified.
Wolstein, B. (1959). Countertransference. New York: Grune & Stratton.

Whitaker, Carl A.; Warkentin, John; Johnson, Nan (1950). The Therapeutic ImpasseAmerican Journal of Orthopsychiatry, Vol. 20(3), July, 641-647.

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Unlucky Louie
Unlucky Louie

My most recent therapist, who I left after 6 months, avoided giving any attention to my expressions of anger, particularly towards my deceased mom. After this happened a few times, I asked her about it and she revealed that it made her uneasy to consider what my opinion of her and all other women might be in light of my hatred of my mom (who was an enthusiastic Mommy Dearest). Hell if I was going to go to therapy and add my therapist’s personal doubts to the list of things I had to worry about, so I ended the relationship.… Read more »

Grant Brenner

Thanks for relating your experience, Louie. It sounds like that was an emotional challenge for that therapist, from what you describe, one perhaps she was willing to address but at the same time one which was too much of an issue for you to want to deal with in therapy on top of everything else. At least she was able to share her side of things to some extent, though the billing issue muddies the water further – an issue we discuss in our piece. What would have been a good response from her, at that point? Or was it… Read more »

Louie
Louie

She’d said she was overwhelmed, and I’d mentioned her avoidance issue on three or four occasions, so at that point, the best thing she could have said is that she’d help me find another therapist, or at least she couldn’t help me. That kind of honesty would have reinforced my own instincts and, in a round about way, been more therapeutic than our very frustrating six months.

Louie
Louie

I asked her about the mother-anger issue several times, and never got a response that satisfied me, so the best response would have been for her to say we were not a good fit and fare thee well. I can’t work with someone, in any sphere, not just in therapy, who can’t address such a big issue.

marcelle mazzetti
marcelle mazzetti

I’m glad you responded to my comment made on your blog entry, “Doctor-Patient…” . (Did a little editing, did ya, haha).
I think your response was forthright and honest. It goes to the point that no relationship
is immune.

(Presently reading your book..)

Mark Borg
Mark Borg

Reading it? WOW! We’d love to hear your thoughts (yes, as is clear from the “little editing,” we always appreciate your perspective). We’d also love it if you’d be so kind as to “review” it on amazon.com http://www.amazon.com/dp/1942094000/ref=rdr_ext_tmb Thanks, and sending…best regards,–Mark