A thorough understanding of resistance and the core conflictual relationship Keywords: Psychoanalytic perspective, resistance, psychotherapy, psychodynamic, counseling A psychodynamic therapist assists the patient in achieving a sense of In general, for medical and psychological research, an effect size of is. Keywords: Psychodynamic Psychotherapy, Therapeutic Boundaries . The outer boundary for all treatment and treatment relationships is, of course, the fiduciary The therapist tried to explore fully the patient's perspective and experience. .. The effort to study the meaning and qualities of mutual experience in these. Therapy is a relationship, and patients bring their templates and patterns into From a psychodynamic perspective, it is irrelevant whether Caroline's therapist is .
The clinical conversation about the meaning and construction of therapeutic boundaries in each treatment dyad is an important vehicle for deepening the therapeutic work and relationship. Within an ethical framework, each clinician must decide what treatment boundaries suit her or his personal and clinical style. Patients may be harmed by clinical postures and interventions that are too distant from the relational context as well as ones that are too close to it.
Sometimes when clinicians consider therapeutic intent of a particular intervention, they construct therapeutic boundaries that seem excessively close or out of place for a professional relationship. Consider the following clinical vignettes where therapists constructed creative boundaries that abandon the treatment frame or stretch it too far.
At the end of treatment, a family therapy team accepts a patient's offer to celebrate the end of a successful treatment with cake and a bottle of champagne. The supervising therapist frames this intervention as empowering the mother and affirming her therapeutic gains. This is a troubling clinical intervention. The use of alcohol with patients is ethically questionable and contraindicated.
Consider the following vignette. An analytic patient who went through a successful analysis at long last plans a marriage. The patient invites the analyst to the wedding but wishes her to attend accompanied by her significant other and to dance at the wedding. The analyst formulates the multiple requests from a relational perspective and chooses to honor all of her patient's requests. Therapists must never keep clinical secrets about their practice. When formulating the psychodynamic meaning of boundaries and useful interventions, therapists must be comfortable revealing the details of the process, formulation, and intervention to a trusted peer or consultant.
A wish to keep an intervention secret may signal a need for consultation or supervision. Ongoing consultations with a trusted colleague or senior clinician are vital to protect the process and the participants. Consultants who possess the courage and experience to respectfully question the therapist's approach are most valuable.
Probing self-scrutiny is required for analysts to fully understand their own interest in and influence on the clinical process. I will present several case vignettes depicting common boundary dilemmas and illustrate a dynamic, relational framework for understanding and intervening. The case vignettes illustrate the internal, interpersonal, and therapeutic process that the therapist and patient move through to elucidate meaning, develop formulations, and arrive at a clinically useful intervention.
Despite an eating disorder, bouts of severe depression, social isolation, and dangerous, sadomasochistic sexual relationships, Sam conveyed that he was interested in treatment to ameliorate his depressive symptoms. He made it clear he was terrified of another destructive treatment relationship and was skeptical about the therapist's capacity to be of help to him and about his own capacity to change. After many years of treatment, Sam announced his wish to attend and to eventually join the church down the street as a vehicle to expand social connections.
The therapist felt his own anxiety rising because he was a member of this church. The therapist informed his patient that he also belonged to this church.
Sam was interested but did not view this as a problem. In some ways, Sam's decision to join a church was a step forward and a decision to be celebrated.
However, the therapist was intrigued. Now that Sam understood that his therapist belonged to this particular church, why didn't he choose another congregation for himself?
Although the therapist supported Sam's wish to expand his community involvement, he felt privately that his patient's membership in the same church that he and his family attended was untenable for the psychotherapy.
The therapist assumed a negotiating stance with Sam, directly discussing his feelings and concerns but stopping short of setting a limit while he tried to ascertain the meaning of the proposed step to his patient and discover what were the issues and affects being negotiated here. The therapist tried to explore fully the patient's perspective and experience. Sam was aware of wanting a relationship with a spiritual community and had chosen this church based on its community reputation.
He was out of touch with any feelings, wishes, or conflicts symbolically expressed by his desire to join his therapist's church. The therapist wondered if Sam would like to be closer to the therapist and wished to know more about him but had been unable to ask.
Perhaps it had been difficult to allow himself to be curious about the therapist, personally and professionally?
Examining the Therapeutic Relationship and Confronting Resistances in Psychodynamic Psychotherapy
The therapist felt anxious and ineffective. Would they be able to negotiate this relationship crisis without a rupture in relatedness? Sam might be worried too. The therapist realized Sam might recast him in a negative light and leave treatment.
Alternatively, the therapist wondered whether Sam's therapeutic achievements were more than he could bear in terms of affective tolerance and shifts in positive self-image. Belonging to the same small congregation would significantly alter, perhaps in an untoward manner, the quality and nature of the therapeutic relationship.
Was Sam destroying the treatment relationship to regain a familiar, albeit compromised, sense of self and internal affective climate? Perhaps Sam wondered what his therapist privately felt about him or if he was like the therapist.
Was Sam worthy of being in the same community as his therapist? Would the therapist allow or invite him to belong to his church? Was Sam capable of affecting his therapist in a deeply personal manner?
Perhaps he was longing for an authentic, personal response. Sam's predominant experiences with relationships involved exploitation, betrayal, and abandonment. Was this request a reenactment of Sam's earlier abusive relationships, with Sam turning passive into active and assuming the role of abuser? The therapist, feeling angry, wondered how much of this feeling was Sam's projected anger and how much was his own reaction to feeling intruded upon.
Perhaps this was a test of the therapist's capacity to protect the treatment from Sam's self-sabotaging impulses and ultimately a test of containment and caring. I know it doesn't feel this way to you but I am trying to protect the psychotherapy and our work together. One of the components that has worked well in this relationship is clarity about the limits and boundaries of our relationship and work together.
Why would we want to alter a system that has enabled you to move closer to a sense of self and life that you desire and, I believe, deserve? The therapist wondered whether Sam doubted he deserved his successes and was trying to undo his gains out of guilt or loyalty to old relationships. The next Sunday the therapist, sitting in the front pews of the sanctuary with his wife and three children, heard a man wailing in tears behind him.
He turned and saw his patient sobbing. The therapist felt intruded upon in a previously safe space. Although he did not fully understand his patient's motivation, it was clear to the therapist that the two of them belonging to the same church would not work therapeutically, at least for this therapist. He wondered how his patient could begin in church a new chapter of relatedness with his painful history when it was contained in his therapist who was sitting before him.
Sam, on the other hand, reported that the reason he was weeping in church was because he felt moved by the lovely organ music. Although the therapist understood that Sam viewed this differently, he felt sharing the same church would be disruptive to the psychotherapy. Sam angrily and steadfastly maintained he could handle these issues and feelings: It is part of who I am and how I work therapeutically. In order to be fully present and available to the treatment relationship and to respect your psychotherapy, I need to attend to my personal needs for privacy.
After much careful thought about the experience and its effect on the patient, the therapist, and the psychotherapy, the therapist informed his patient that he felt they could not be co-congregants and continue the therapeutic work. I understand you feel it is possible for you.
I may be wrong, but I also don't believe it will be useful for your psychotherapy. I know you see this differently. Perhaps some therapists could see their way clear to do this. I can't do it. We may have to agree to disagree about this matter. If he decided to attend the church, the therapist would terminate the psychotherapy and, if he wished, refer him elsewhere for treatment.
Sam responded with a sense of betrayal and rage that threatened to destroy all he had achieved as well as the therapeutic relationship. Although angry and feeling betrayed, he decided to remain in treatment to understand his feelings and experience because he felt this relationship had been of great value to him and their work was not finished.
Holding firm to the boundaries allowed Sam to relive, not merely remember, the problematic past in relationship with the therapist. The therapist understood that the conversation was as important as any decision about where to set the boundary. Power was mutually shared through the process of each participant deciding what he felt he could and could not do.
The therapist offered Sam a new relational experience by acknowledging and owning his personal feelings, including what Sam might experience as limitations. Sam did have a choice here. As the boundaries were renegotiated, the therapist could see more of what his patient needed from him. Convinced that his therapist had reached an unambivalent decision, Sam was more open and willing to engage in the exploration of his deep sense of injury and rage.
The therapist offered himself as an authentic presence who was committed to understanding Sam's dilemmas and willing to tolerate his aggression in the service of protecting his treatment and his development. Sam needed to experience his therapist as failing him and betraying him. His therapist was able to tolerate the frustration, anger, and devaluing involved in assisting this man to differentiate his past relationships from his present ones and to have a different affective experience and outcome.
Sam's acceptance of his rage and sadism toward himself and others were crucial to his psychotherapy.
Although disagreeing with his therapist's decision, Sam acknowledged the value of being enraged at an important other without the destruction or denigration of either participant. Negotiating the intense affect and sense of betrayal while remaining in connection was a positive experience for Sam. This vignette is not intended as a prohibition against therapists and patients attending the same church. Often, particularly in rural communities, therapists discover that their professional and personal lives overlap with those of their patients.
Such overlap may be handled in and out of the consulting room in a range of clinically useful ways. The case of Sam illustrates the process of engaging patients in a sustained interpersonal and intrapsychic inquiry that leads to construction of affect, meaning, and deeper understandings.
Such conversations and eventual understandings allow therapists to determine where to set boundaries in any particular treatment. Emma, an attractive woman in her late thirties, began weekly psychotherapy almost against her better judgment. In a state of chronic depression, rage, and anxiety, she worried about how little she understood about the effect she had on others and how greatly that blind spot affected her relationships.
Furthermore, she struggled to control her anger, with very mixed results, and deeply worried that she was or would become the raging women her mother was. She reported a childhood history of severe emotional neglect and abuse with a rageful mother who always knew best. She developed a close friendship, by uncanny coincidence, with a woman in a similar profession who was a group psychotherapy patient of her therapist.
Emma began playing with thoughts of what she could ask for from her therapist. She initiated the conversation by bringing up information from her colleague's treatment relationship with the therapist. Emma wanted to be treated the same. The therapist felt Emma's determination to get her fair share at last. Emma was unable to identify or express her personal wishes.
She was not interested in discussing her experience of her therapist's particular manner of caring for her or how the therapist experienced or felt about her. She wanted treatment identical to her friend's. Emma expressed sadness, frustration, and impotent rage at her inability to control her therapist or her colleague.
The therapist commented that although Emma longed to be first, she wanted to punish someone for all the times she felt denigrated, marginalized, and not chosen. Someone should make up for her heartache. Emma was committed to the feeling that she would be second best. Across the years of Emma's treatment, she had never asked her therapist about her personal vacation plans and had never been told.
Now, Emma was curious and wanted the same treatment as her colleague. The therapist inquired about Emma's request, her feelings, and the meaning of knowing this information.
Examining the Therapeutic Relationship and Confronting Resistances in Psychodynamic Psychotherapy
Emma was unable to identify her curiosity, longing, or sense of loss about her therapist and the vacation. Emma was vacillating between recasting and inducting the therapist in the role of the abusive mother and assuming that role herself by bullying her therapist.
Although knowing Emma was anguished, the therapist felt predominantly bullied and mistreated and unsure of how to proceed. Informing patients about her vacation plans was not unusual when it had a relational and therapeutic purpose. However, in Emma's case the feelings of being coerced made her disinclined to share this information. She and Emma seemed deadlocked and unable to move beyond feelings of insult and anger.
Emma remained fixed on her angry, competitive feelings with her colleague and on her right to know. The therapist fantasized about Emma's unexpressed envy and jealous feelings toward her that were expressed through the colleague.
- Psychodynamic Perspective on Therapeutic Boundaries
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This is about me. Emma, however, seemed unable to understand the dilemma dyadically. Emma pulled out all the stops before the therapist's vacation, demanding to know where the therapist was going on vacation and accusing the therapist of behaving in a patronizing manner.
The therapist felt trapped in a no-win situation. She had no particular interest in withholding this information from Emma. Yet she felt strongly about not disclosing data under duress or if it did not make contextual, clinical sense. The therapist wondered if Emma might be experientially communicating just how she felt as a child, trapped in a no-win situation despite her best efforts to remedy it.
The therapist commented on Emma's anger and grief. I feel confused and hurt. Although she understood some of the significance of the meaning of the request, she was most captured by Emma's angry and threatening posture. Emma did not share her sadness and her hurt, even though the therapist sensed they were there. The tone and packaging of the request made the therapist very uncomfortable with sharing any information. It is not my intent. In general, for medical and psychological research, an effect size of 0.
Interestingly, when effect size was re-measured nine months or more after treatment ended, the effect size increased to 1. H described in more detail the allegations of mishandling a client's financial records and how this was affecting her. She became angry after learning that the accuser of this alleged wrong doing, Ms.
H's direct supervisor, had already contacted the regional manager of the company. She vehemently tried to convince the management that she had not knowingly mishandled the documents in question. The manager was receptive to Ms. H and a compromise was proposed, wherein Ms. H would have to pick up additional clients and would not be considered for a pay increase for the current fiscal year; if she agreed to these stipulations, her occupational record would remain unaffected by the alleged incident.
Though this prevented Ms. H from losing her job in the immediate future, she still felt betrayed and taken advantage of by now having to take on extra clients, which had not been contracted earlier. H also had nearly daily contact with her supervisor, and this relationship remained tense and uncomfortable subsequent to the meeting, which created emotional upheaval for her on nearly a daily basis.
She felt uncomfortable, and described feeling very transparent and exposed when she sensed others could see her distress.
Her anxiety localized to her gastrointestinal system, and she experienced diarrhea, nausea, vomiting, and abdominal cramps. She progressively became less interactive, less talkative, and more withdrawn at work. Her friends started to become concerned about her withdrawal from work-related social activities and inquired about the apparent increase in her workload.
H's psychotherapy began, she was struggling with a long-distance relationship with a boyfriend living in another city. She reported ruminating on thoughts that he was cheating on her, though no concrete evidence existed for such a suspicion to be justified.
She strongly disliked being yelled at, reprimanded, or treated poorly, but noticed a common pattern of being attracted to and involved with men who commonly did all of these things i.
A main focus of Ms. H's complaints pertained to the intricacies of her previous long-distance relationships and her fear of their inevitable demise. She reported that nearly all of the men she had dated had married soon after the termination of their relationship with her. H's childhood and her relationship with her parents had been a subject matter very difficult for her to address in psychotherapy.
She had only briefly touched on this aspect of her life, and remembered her mother saying when she was young that Ms. She recalled feeling obligated to take on an authority role as a young child. H's father was allegedly physically abusive toward her mother and left the household when Ms. H was a child. Early on she described being full of anger, and utilized her anger as an avenue to deal with her emotions that were constantly in flux.
Emergence of resistance During her initial sessions, Ms. H conducted herself in a hostile manner, demanding that the psychiatrist bestow insight from which she could benefit. She would bring in typed notes of her dialogue with men and read them aloud hoping for a magical interpretation from the psychiatrist, which she could then take back to the relationship and utilize.
When her expectations went unmet or when inquiry was made as to her developmental upbringing, she became angry, degraded the psychiatrist, and then subsequently showed up late for sessions or did not come at all.
Managing the Resistance Once the patient is engaged in the psychotherapy, the psychiatrist facilitates an increase in awareness of ineffective coping strategies. These strategies may have served a purpose during developmental years but are no longer relevant. For example, in the case of Ms. H, she would often deem herself unworthy of care or affection and, therefore, would unconsciously create situations that would prevent her from becoming vulnerable or intimate. This would come in the form of denigrating others to elevate her and bolster her own defenses.
By pointing out this aggression, the patient may gradually learn that he or she is masking underlying fears of inadequacy. In this case, over time, Ms. H learned to tolerate her own limitations, and she no longer generalized her world to fit her exaggerated projections. Slowly her pattern of resistances diminished and she became progressively less anxious.
The psychiatrist's initial temptation may be to fall back or retreat when the patient seems unable to tolerate the distress of affectively charged relationship issues. When working with a patient who is apprehensive about relationships, the psychiatrist may over-identify with this apprehension.
However, if apprehension is then modeled by the psychiatrist, the patient may become more apprehensive rather than less so. It is a safe assumption to expect that the patient will seek comfort measures, such as withdrawal or even anger, when he or she is challenged to bear emotionally laden content.
It is necessary for the psychiatrist to increase the patient's awareness of his or her defenses against this by commenting on it when the time is right. This may then pique the curiosity of the patient to work further. Case Presentation, Continued It was brought to Ms. H's attention that seeking treatment in the midst of a significant acute stressor superimposed on long-standing anxiety was to be commended, albeit an extremely challenging undertaking. You seem uneasy coming here and discussing your personal matters.
How would you feel? You don't get how hard this is for me right now. I was really getting settled in at work and then this happened. I really feel like my future is over before it even started.
Nothing good ever goes my way. These types of things always happen to me. I've been coming here weekly and I'm not getting anything out of this. You're supposed to be making me feel better.
You have many expectations coming here, and it sounds like you want to get the most out of this experience. You're placing a great deal of pressure on yourself to succeed, and it sounds like you're in a great deal of emotional pain. I imagine this is a struggle for you, and I give you credit for seeking treatment at this time.
In addition, the therapeutic alliance was strengthened and facilitated by acknowledging the intensity of the anxiety during exploration of these issues. With tact, it was also articulated by the psychiatrist that this was collaborative work that was ultimately deemed by the patient to be supportive. I've noticed when you start discussing the problems that led you to psychotherapy and how they make you feel, you sometimes change the topic or become silent.
That's interesting because my ex use to tell me he knew nothing about me because every time I'd begin to talk about details of my upbringing I'd get angry for no apparent reason or simply stop communicating.
Tell me more about that. Maybe it's an effort to protect myself? What do you feel you may be protecting yourself from? Perhaps the pain related to some of things that happened in the past. Tell me more about what that pain is like for you. It makes me feel scared inside. I start to get butterflies, and my stomach gets queasy. My heart races and I sometimes feel like I can't catch my breath. It sounds frightening and I can tell you've really been struggling.
I now have a better appreciation for how debilitating this has been for you. You sharing these intimate details about who you are and how you feel will help us work toward our goals here in the room. Over time, the patient learned to respect the consistency, safety, and nature of the working relationship.
The goal is to improve interpersonal functioning with less distinct focus on making the unconscious conscious. He devised CCRT as a system to guide the clinical judgment of the psychiatrist regarding the patient's central relationship patterns. Menninger's Triad The concept of a central theme is also emphasized in Menninger's Triad, in which the central theme is attended to in three spheres: When this pattern is then repeated within the therapeutic relationship, a concrete example is available for the patient and psychiatrist to dissect and improve.