1/ For starters, the therapist tries to persuade the patient, which is pretty much never helpful, and especially unhelpful in the heat of the moment when the patient is distraught. Presumably, he knows better. The fact that he gets caught up in this, and becomes so insistent on
2/ on setting her straight, suggests there is already unrecognized countertransference in the background. She's difficult and accusing—it's unlikely this is the first time. Possibly, the therapist is defending against recognizing there's a part of him that actually would like
3/ to be rid of her. This is pure speculation without the therapist weighing in and speaking for himself, but the defensive irritation suggests there is something more in the background. Trying to make an interpretation about her father, in the heat of the moment, is a further
4/ error. It's clear she's not going to hear it at that moment, and they have only 5 minutes left. It's a beginner's mistake. If he's not a beginner, it points again to countertransference.
A more helpful response might start with empathic acknowledgment of the patient's hurt,
A more helpful response might start with empathic acknowledgment of the patient's hurt,
5/ which does not mean agreeing with her interpretation of events. Her feelings of hurt and rejection are facts, even if she has misread his intention and misread the interaction. So they needs to be acknowledged.
Something along the lines of, "It felt awful when I looked up at
Something along the lines of, "It felt awful when I looked up at
6/ the clock just when you in the middle of telling me something so painful."
The immediate goal is to attend to the relational rupture & open some space in which it might become possible to think together—not correct her or interpret her experience. She's not going to hear an
The immediate goal is to attend to the relational rupture & open some space in which it might become possible to think together—not correct her or interpret her experience. She's not going to hear an
7/ interpretation in the heat of the moment. The general principle is, "Strike while the iron is cold."
Next, they have minutes left. This is not the time to introduce an emotionally & relationally complex topic. After acknowledging her hurt, she will likely say more about it
Next, they have minutes left. This is not the time to introduce an emotionally & relationally complex topic. After acknowledging her hurt, she will likely say more about it
8/ and he would do well to listen and try to understand better, not correct her. And he should end the session on time, perhaps saying something like, "I'm sorry we need to stop when you're feeling so badly and things are so tense between us. I'd like to revisit it next time," or
9/ words to that effect. If they've done their homework leading up to this to create a trustworthy alliance, she will return. That is the meaning of a therapeutic alliance. It doesn't mean the patient loves you. It means they can hate you, and come back to talk about it.
10/ In a subsequent session when emotions aren't running so high, it will be possible to do some work around reviving her capacity for mentalization.
E.g., "I know when I looked at the clock last time, you were certain it meant I wanted to be rid of you. I get how you came
E.g., "I know when I looked at the clock last time, you were certain it meant I wanted to be rid of you. I get how you came
11/ to that conclusion. I wonder if you can think of any other possible reasons why I might have looked at the clock at that moment."
This kind of comment is neither agreeing nor disagreeing with her interpretation. It's not trying to persuade her or convince her of anything.
This kind of comment is neither agreeing nor disagreeing with her interpretation. It's not trying to persuade her or convince her of anything.
12/ It is, rather, inviting her to use her mind in a different way. If she said something like, I could make up other reasons but I already know the real reason," I'd probably say something like, "Well, humor me. I'm interested in what else you might come up with."
13/ It's difficult work, because where there is transference, there is countertransference. The therapist would do well to reflect on & better understand his reaction... so he too can regain capacity to use his mind. There is where a trusted supervisor or consultant is invaluable
14/ Another thought: someone in comments suggested (tongue-in-cheek?) the therapist should have learned to check the clock without patient noticing. This brings us to something crucial to understand: *it would have changed absolutely nothing.*
Patients bring their relational
Patients bring their relational
15/ patterns with them into therapy and recreate them in the therapy relationship. This is called transference. It cannot be prevented nor would it be helpful to prevent it if we could.
In this case, the patient IS GOING to to see the therapist as "bad guy" no matter what. Just
In this case, the patient IS GOING to to see the therapist as "bad guy" no matter what. Just
16/ as she does with other people in her life. That's the transference. If it wasn't the clock, it would be something else. And it will keep coming up in therapy, just as it comes up in the patient's other relationships.
This is what is causing problems in the patient's life.
This is what is causing problems in the patient's life.
17/ This is why she needs psychotherapy.
The question is not how to avoid becoming the "bad guy," it's how to work with it skillfully in therapy—to help her recognize, understand & ultimately gain freedom from her painful/dysfunctional relationship patterns, so she is not
The question is not how to avoid becoming the "bad guy," it's how to work with it skillfully in therapy—to help her recognize, understand & ultimately gain freedom from her painful/dysfunctional relationship patterns, so she is not
18/ doomed to spend the rest of her life repeating them.
This is the essence of psychoanalytic (or psychodynamic) psychotherapy
This is the essence of psychoanalytic (or psychodynamic) psychotherapy
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