Insight and Opinions about Therapy
This is a compilation of my responses to some questions that have come up in different professional forums that I participate in; feel free to comment and to share your thoughts. (I reference a number of psychodynamic concepts, so feel free to ask if you need clarification about any of them.)
Topics:
1. Male vs. Female Therapist Preference
2. What do therapists mean when they talk about “splitting”
3. When a client “likes” therapy but doesn’t “need” it
4. The client wants to terminate but the therapist thinks this is “resistance”
5. Thoughts about “projective identification”?
6. Some thoughts on the “Social Biofeedback Theory of Parental Affect Mirroring”
7. Therapist Self-Disclosure
8. Can Pathological Liars be Treated?
9. If someone functioned well for many years by avoiding talking about a trauma that happened, and now they are in therapy and want to know whether they should open up about the trauma, what should the therapist advise?
Question: If someone has a strong preference for a male vs. female therapist, should this be respected or challenged?
I think this taps into a more general controversy about whether we support our clients’ defenses or challenge them. I think the case can be made either way, depending on the client and the timing. Someone who has issues with men may need a female therapist at first in order to do productive work without too much “noise” from negative transference reactions towards men. At a later time, that same person may benefit from a male therapist to work through the negative transference issues. I think at times it might even be best to encourage someone to start out with the situation they are averse to, as long as the therapist is extremely competent and the client has good ego strength to be able to separate out that even though there are negative reactions by nature of the therapist’s gender, this doesn’t necessarily correspond to the reality of the situation. I think at times a person’s trauma responses may also mean that they can never see the same-gender person without having a reaction that makes it hard to work/think. For me, this taps into the issue of where the person’s window of tolerance is, and under what conditions they can maintain enough ability to think/regulate affect to be able to work constructively on issues that are activated.
Question: When therapists say that clients are “splitting”, what do they mean?
Splitting can at times be referring to state dependent memory, in which representations (memories/schemas) of the object (good or bad) are selectively available depending on the mood or state that the person is. So, for the person with Borderline Personality Disorder, when a “good self/satisfying object” representation is activated, it can be hard to access memories or representations of the “bad” aspects of the relationship, and vice versa. This is not to say that the actual memories belonging to the opposite state can’t be accessed cognitively, but rather that they cannot be used emotionally at the moment to help the person temper the current emotional experience. This is similar to when a depressed person has trouble remembering happy memories or using happy memories to feel happier.
There are different opinions (for example, the Kohut vs Kernberg debates) about whether splitting is a defense against intolerable affects or narcissistic wounds vs. whether it is a normal development experience that some people don’t grow out of due to excessive aggression or a predominance of bad experiences with others that leads to a need to protect the memory of whatever little good there is, without contaminating it. The theory will guide the treatment. For example, transference-focused psychotherapy is a process in which the therapist helps the client become cognitively aware of the opposite state that is inaccessible in the moment, and regularly interprets the opposite states that are both present even though the patient can’t experience/access them simultaneously. A self-psychological treatment would involve helping the client with affect regulation and the internalization of a soothing and good object so that the need for splitting dissipates.
It is also important to note that the ability to split is in fact a developmental achievement (lacking in psychotic patients, for example). We all need to learn to differentiate into “good and bad” before we can integrate the good with the bad. Some clients actually need help to be able to split, and I would even say that there are cases in which we would facilitate splitting by having more than one treatment provider in order to help dilute a traumatic or malignantly negative transference. This can only work if the treatment providers can effectively manage their own relationship in a way that doesn’t polarize the treatment or confuse the patient.
Fairbairn talks about an internal split, in which we have a relationship with parts of ourselves that we split. For example, a person may split between their longing for an abusive attachment figure vs. their anger at this disappointing or abusive person. They may split between a part of the self that wants a relationship vs. a part of the self that feels this need for the other is bad and should be attacked (i.e the need is the source of pain when the object is unavailable, so the person attacks their need/longing). In fact, most episodes of “falling in love” involve some form of splitting as in “love is blind”; I once read some neuroscience research about how love and attachment inhibits the part of the brain involved in negative social judgments and negative memories. So when we are “in love” (or an abused person in the honeymoon phase of a relationship) we may in fact not be able to easily access negative appraisals or memories of the same relationship, on a brain level.
In dissociative states, splitting can become cognitive as well when there is actual amnesia between different states rather than just an inability to access emotions across self states.
I think that splitting is also a very prominent dynamic in eating disorders (desire vs. deprivation, for example) and sexual compulsions, and there are many other types of splitting we can speak of as well. The love/lust split seems to be common in marriages in which affairs take place. For example, when a man can’t pull together two split representations of a woman: as a romantic object/wife vs. a mother/homemaker. The passion and romance are split off into an outside relationship and the sanitized non-sexual mother figure is preserved in the marriage. In the mentalization literature, we find talk of the split between reality and fantasy (or internal and external reality) and how some people act as if they can live in their imaginations without having to respond to the demands of reality, and others focus only on concrete reality (i.e. what they should “do” about a situation or the practical aspects of it) and psychological-mindedness seems split off. There are many other examples of splitting in clinical work, but these are some of the main ones that are talked about.
Question: If a client “likes” therapy but doesn’t need it, should the therapist tell them that they need to stop therapy?
Unless there is a malignant regression in which the client stops functioning in daily life due to a preoccupation with the therapy, I view it as the client’s choice to pay money and spend time to have attachment needs met and hopefully this can help the client also access others who will meet those needs as well. I think that pathologizing an ongoing need for support/handholding is often a stance based on a dismissive attachment style mindset. I often say to dismissively attached clients, “what’s wrong with choosing to talk to a therapist just because you feel like it even if you don’t need to?”
That being said, I see nothing wrong with helping a client to explore the pros and cons of leaving the therapy at any given point, and I still think it’s good to have a general diagnostic sense of the client’s needs and mental health status and to state a professional opinion about the nature of the problem and suggested treatment as the therapist sees it.
Issue: The client wants to terminate but the therapist thinks this is “resistance”
(This discussion was a response to the article Ghosting on Freud: why breaking up with a therapist is so tricky | Life and style | The Guardian )
My personal feeling has always been that the client doesn’t owe the therapist any kind of explanation or process when they want to terminate. In terms of it being helpful to the client to ask them to discuss their wish to terminate with us in person (and process it together), I think it’s always a good idea in initial sessions to discuss any previous therapies the client has been in, how those ended, and to try to socialize the client a little to the idea that sometimes there may be a wish to leave treatment for defensive reasons and that it can be good to try to talk about that if it’s happening, especially if there seems to be a pattern of leaving prematurely. I try to let the client know that if they feel angry towards me or critical, I would be open to their feedback if they wish to share it.
At the same time, I’ve seen firsthand situations where people have tried to leave therapists who were abusive, manipulative, narcissistically vulnerable, or intrusive/boundaryless, and the idea that the client was “supposed” to come in person to discuss the termination led to guilt, fear, or reluctance to leave when it made sense to do so. It’s hard to know which therapists will listen and respond to the client’s concerns, versus those who will just manipulate the client into second-guessing themselves or feeling bad to leave (for the therapist’s own narcissistic reasons). Not every therapist is healthy and clients don’t always know how to judge whether the therapist is someone that it would make sense to talk things through with or not.
So, I always like to err on what I consider to be the side of caution, and let clients know that they are free to leave if they so choose, without explanation to me, at any time- although I’d appreciate it if they could give me feedback or talk it through with me, and that this may even be helpful to them. I have also helped clients to extricate themselves from unhealthy therapy situations with the suggestion that they have the right to stop the therapy without justifying it or processing it with the therapist (obviously people should cancel any scheduled appts. and pay any balances).
Some thoughts about “Projective Identification”?
One thing to keep in mind is that there are actually two different types of processes that can be referred to with the term “projective identification”. One is an internal process which does not require the participation of another person. In this case, the projective identification is a process by which a person interacts with his “internal objects”. The person will project his own disowned experiences into the other in his imagination and will then identify with, control, or attack it in the other within his own mind when he is interacting with the other person. The other does not need to participate in any way. For example, a husband might project a sense of jealousy onto his wife in his mind and then treat her as if she is the jealous or suspicious one, regardless of her actual behavior. This is more of a one person psychology approach.
The other definition is more akin to what the relational analysts call “enactment”, in which the process involves a behavioral response from the other which confirms the patient’s sense of the accuracy of their projection.
I sometimes like to say that a person can do 3 things with his internalized object relations schemas in relationships: find relationships that objectively match up to his expectations of how relationships go; perceive the other in distorted ways based on his internal expectations; or create a self fulfilling prophecy of evoking responses in the other that get them to match up to internal expectations.
The literature on “mentalization” and the “social biofeedback model of affect regulation development” also speaks to a process in which a parent might project something onto the child that doesn’t match up with the child’s internal experience, and will respond to the child as if this alien introject belongs to the child. For example, an angry parent will treat the child as if the child is angry when the child isn’t. Essentially the child is on the receiving end of projective identification and can’t come to know himself properly. This can lead to a pattern of using projective identification as a communication style in general and using others to project back out the “alien self”.
Bion was the one who elaborated the theory of projective identification to refer to a normal communication process between mother and infant that leads to containment and development of a mind to process emotional experiences. Analysts since Bion have continued to develop these ideas, and projective identification between therapist and patient is now viewed as a process that can either be pathological or healthy. There are different types of projective identification processes and relationships between the one projecting out and the one taking in: evacuative (the patient wants to “get rid of”
unbearable experience); communicative (the patient wants to communicate something that he can’t say in words or to give the therapist an emotional experience similar to his), etc. When the patient wants to evacuate, if we “return” the projection, it can be injurious as well as feel like blame or throwing something bad right back at the patient. When the goal is to communicate, the patient can respond to the analyst’s efforts to put what’s going on into words and make it conscious; he can make use of the analyst’s metabolization to “take it back into the self”. When we understand the function of the projective identification process for the patient, we can figure out the best way to respond.
Some thoughts on the “Social Biofeedback Theory of Parental Affect Mirroring”
Essentially, this theory states that a caregiver serves as a type of biofeedback machine regarding an infant’s/child’s emotions, and that in the same way that a regular biofeedback machine allows one increased awareness and regulation of physiological states, the emotional mirroring/feedback offered by the caregiver leads to a child developing increased awareness of his emotions as well as ability to regulate them (how this is thought to come about is rather complicated so I’ll save that for another time).
In any case, the punchline seems to be that it is a specific type of feedback (i.e. “marked contingent mirroring”) that is most helpful to the child- feedback that is: “mirroring” (i.e. it shows the child a picture or mirror image of his emotional state), contingent on the child’s cues (meaning that the child’s display of emotion or affect is what causes the response and the response needs to be relatively free of the parent’s distortion or projection), and “marked” (meaning that there is something in the tone or display that makes the reflection not feel too “literal” to the child- for example, a mother who cries in fear as her child cries in fear, which would be a response that is too similar to the child’s (unmarked) would increase the child’s fear rather than regulate it.
I think that much of what we offer our clients in therapy is an experience of responsiveness that is simultaneously same and different; that if we don’t identify enough or empathize enough with the client’s experience (or, as in complementary countertransference, with the role that we are being invited to assume…i.e. with the client’s “script”), then there isn’t enough of a “match” or “click” for the client to become engaged emotionally, or to activate a relationship experience or script (or other sort of automatic procedural schema) that needs to be worked with in the therapy.
On the other hand, if we identify too much or mirror too closely, we lose the opportunity to offer the client a different perspective- or at least a model of resolution that includes something a bit “other” than whatever script has come to be repeated in a ritualized sort of a way- so that new learning can be made use of without simply assimilating it seamlessly into what we already “know”. In more plain terms, a helpful response to a frightened child is one that acknowledges his emotion but that also projects the parent’s sense of being in control (security) and conviction that the experience can be either mastered or at least coped with.
I think sometimes the most powerful experiences happen when something gets repeated or identified with- and it feels like there is an exact match between a past experience and present one (or between the therapist’s feelings and the client’s, in another example), only to then tease out ways in which there are differences as well. For example, feeling criticized by one’s therapist can feel like a repeat of a traumatic experience with one’s critical father in childhood- until the differences in the present can be noted in a way that renders the current experience non-traumatic. Moving in and out from identification and counter-identifcation seems to be a flexible position that allows for old schemas to be pulled up while also accommodating to new contexts.
I think we could also say that parents or therapists who reflect too closely and are too attuned to their children or clients, are not as helpful as those who are attuned most of the time but also mis-attuned at times- so long as the rhythm of repair of mis-attunements is within a manageable window of tolerance. Social relationships require a certain rhythm of sameness and difference in order for there to be a “flow” and a balance between subjective autonomy vs. accommodation to the other/environment; a connection but also disconnect between internal and external. So, if we empathize too much, it’s a problem. And, if we empathize too little, it’s a problem. But perhaps most of all, it is helpful when we empathize and don’t empathize at the very same time- or we empathize in a way that is inexact and then find words to pull this apart.
For children whose responses in childhood are responded to haphazardly- for example, if a depressed mother sometimes shows an emotional response on her face in response to her child’s behaviors, but at other times, is completely blank in response to those same behaviors…or if an emotionally dysregulated mother is so caught up with her own emotions that she cannot separate them from her child’s- there are sometimes provocative or coercive behaviors on the part of the child in an attempt to find some relationship between a behavior initiated by them and predictable response from the other, even if the response is negative (children crave predictable contingencies). So, in the example of the child who tries to annoy others, we can speculate about many possible motivations- as well as whether a given child will change more readily in a therapy in which the annoyance is effectively elicited or in a therapy in which it isn’t- we might also add the possibility that this child learned that he can get a pretty reliable, predictable response of annoyance in response to certain provocations on his/her part, and that this sense of effectiveness and contingency match-up may have been crucial to a sense of survival-
Some thoughts on Therapist Self-Disclosure:
For some patients, self-disclosure from their therapists can be critical. It validates their perceptions. It gives them a sense of the other person’s aliveness (especially for those who grew up with a sense of “absence” of the object, due to a caregiver’s depression/self-absorption, as in Andre Green’s “dead mother” for example). And, it “evens the playing field” a little bit when the asymmetry inherent in the therapy relationship feels intolerable to the patient- either because the patient needs to feel “special” in order to avoid feeling completely devalued, or has had difficult experiences with power in the past. Self-disclosure can also relieve a patient from trying to read into/understand ambiguous cues from the therapist (for those with trust issues/hypervigilance in relationships, negativity biases, this can lead to a relaxation of the need to control).
However, I think caution about self-disclosure is also in order.
Depending on how psychopathic the person is, they can either be treated or not. I think that when we say “pathological lying”, we are referring to our own experience of being lied to, or tricked about external reality. However, the patient’s intention or the motive for what they’re saying is not necessarily obvious to us. So I think there are different psychic mechanisms operating behind different “liars’ lies”.
For me, the question lies between the following possiblities: the person is actively trying to deceive the therapist (for power, for example); the person is trying to “get something” or “get away with something” (avoid responsibility, get drugs, etc); the person does not realize they are lying but actually uses their mind to change reality when it’s convenient or for defensive purposes (to avoid shame, for example); or the person simply dissociates and doesn’t have full awareness of what they say or do at times.
For example, if a person has unpaid bills and debtors are going after him, the person might just tear up the bills and once they’re “out of sight/out of mind”, act as if the problem no longer exists. He would then be totally confused when bills keep coming or debtors keep calling, since he has erased the problem using his own mind. (This idea was explained in a talk I heard by Mary Target).
The other thing to realize is that intentional lying is a developmental achievement, from a mentalization perspective, because it presumes an understanding of the difference between how one person subjectively experiences external reality and how another does, and a theory of mind is needed to “get” that another person is capable of being tricked by what one says or does.
In other cases, a person may use others as “objects” to play games or to actualize fantasies, and there may be less hope prognostically that this can be treated psychotherapeutically. (This is more sociopathic in nature and presumes an empathy and conscience deficit).
In terms of treatment, it is often imperative to start where the client is at. For the “pathological liar”, we may disagree with their version of reality but we have to be able to observe how they are perceiving and relating to reality in a way that increases the client’s ability to observe rather than forecloses it. It can be important to remind ourselves that the important thing initially is not whose reality is right, but how the client is experiencing and relating to his subjective relationships and external reality. The empathic connection is often our best place to begin.
Should a therapist ask a client to talk about trauma after years of avoiding it?
This is a hard question to answer without knowing the specifics of the case. However, one thought to keep in mind is that sometimes it is possible to vaguely touch on trauma issues as part of the narrative of what someone is presenting with, without going into detail or bringing the person in touch with the associated affects. (The article “DID 101: A Hands-on Clinical Guide to the Stabilization Phase of Dissociative Identity Disorder Treatment” by Richard Loewenstein gives a great example of this).