The Therapist's Answer Book

Solutions to 101 Tricky Problems in Psychotherapy

Jerome S. Blackman

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136209147
• Edition: 1
• Topic: Psychologie
• Subtopic: Addiction en psychologie

Therapists inevitably feel more gratified in their work when their cases have better treatment outcomes. This book is designed to help them achieve that by providing practical solutions to problems that arise in psychotherapy, such as: Do depressed people need an antidepressant, or psychotherapy alone? How do you handle people who want to be your "friend, " who touch you, who won't leave your office, or who break boundaries? How do you prevent people from quitting treatment prematurely? Suppose you don't like the person who consults you? What if people you treat with CBT don't do their homework? When do you explain defense mechanisms, and when do you use supportive approaches? Award-winning professor, Jerome Blackman, answers these and many other tricky problems for psychotherapists. Dr. Blackman punctuates his lively text with tips and snippets of various theories that apply to psychotherapy. He shares his advice and illustrates his successes and failures in diagnosis, treatment, and supervision. He highlights fundamental, fascinating, and perplexing problems he has encountered over decades of practicing and supervising therapy.

SECTION D

Techniques With Acting In and Acting Out

GENERAL COMMENTS ABOUT BOUNDARIES

Although we indicate the frame and the working alliance to people we treat, they do not always follow our rules. When they do something that breaks the alliance in the session, we call it “acting in.” If they misbehave outside of therapy, we usually call it “acting out.”

Acting out originally meant that a behavior outside the session symbolically reflected conflicts people felt too embarrassed or guilty to think of in relation to their therapists. Today, we use the term to describe people who engage in maladaptive behavior (possibly using poor judgment) that is symbolic of various wishes, emotions, and defense mechanisms.

There are, no doubt, an inflnite number of ways people can break rules inside and outside of treatment. My examples only reflect the tip of a large iceberg.

Problem 31

What About Boundaries?

The idea that there is a “boundary” between the therapist and people in treatment is an abstract concept but sometimes becomes concrete and immediate.

The concept of a boundary developed over many decades; practitioners in the early 1900s had little sense of this boundary.¹ The idea began to take shape when Freud (in delineating his own technical errors in the “Dora” case) figured out that most of the feelings people in treatment develop toward their therapists are based on feelings from childhood that have been unknowingly shifted onto the therapist. These shifts, or transfers of feelings from people in the past, were named transference.

Once you realize that only a fraction of what people in treatment feel about you is really about you, it is easy to spot transferences. You can then understand and discuss those feelings while people are in your office.

Transferences threaten the “therapeutic barrier ”² or the “frame”³ in treatment. This “barrier” prevents action between you and the person you are treating. Talking is allowed and encouraged, but there should be no hugging, touching, kissing, and certainly no sexual activity. The “frame” refers to the person (and you) being on time, stopping on time, and not engaging in any activity aside from talking in your office. Bringing a non-silenced cellphone, a drink, or anything else to a session can be considered “acting in” —a break in the frame—and the meanings understood .⁴ “Boundary violations,” sometimes sexual, are the most serious and dangerous of all boundary crossings.

The following problems include several variations of boundary problems, how I have understood them, and some thoughts about how to handle them.

____________

1 Makari (2008).

2 Tarachow (1963).

3 Langs (1973).

4 Malawista, Adelman, and Anderson (2011).

Problem 32

“Let’s Make a Deal” and Gifts—Boundary Crossings

There are differences in severity among the types of boundary crossings. In Example 1, below, I refused to engage in an unethical business venture with Jeff (I did not cross the therapeutic barrier—although he had read my first book)⁵

In Example 2, I accepted the boundary crossing of reading an article from Angela, because it did not involve unethical behavior. My reading her article seemed to contribute to her development of closeness; it helped her analyze negative transferences from her mother; and it did not become sexualized.

I do not usually consider it a boundary crossing if people I am treating call me after hours with a problem. I cover my own practice 24/7 when not on vacation (then a colleague covers me), and encourage people to contact me if they become suicidal. Occasionally, someone I treat gets into a crisis, and after talking to them on the phone, I decide on an emergency appointment for that person in my office. Usually, I have found that people do not take advantage of this policy, and this approach has allowed me to treat people who can become suicidal. They know I am available if they become overwhelmed by depressive affect (transient breakdown in affect tolerance).

I have treated some people who left a message threatening suicide several times a day. I had to have them committed to a mental hospital. A few women have attempted to engage me in nontherapeutic activity—“erotized” transference (Problem 33)—a severe boundary violation that posed serious technical headaches.⁶

Boundary crossings include behaviors of people in treatment who dislike the therapeutic barrier. They invade your life or tempt you in mild, seemingly harmless ways to step out of your therapeutic role. Keep in mind that their invitations are inimical to their own interests. Moreover, their (mis)behavior gives you useful material to understand.

SHORT ANSWER

If you have the data, explain the meanings of people’s attempts to cross the therapeutic barrier. If you have little data to explain it, explore the meanings: Express interest in the boundary crossing and ask people their thoughts about it (like a dream).⁷ With certain people, at certain times, you may decide that a boundary crossing is acceptable—but be forewarned: Boundary crossings always have meanings, whether you can figure them out or not.

LONG ANSWER

Some people attempt to cross the therapeutic barrier by suggesting that you engage in activity that is unethical or improper (“boundary violation”): money-making schemes, hostility, or sexual conduct. If people attempt to engage you in any behavior other than verbal communication, you need to show them the meanings (if you know them), explore the meanings (if you don’t), or stop the behavior if it is inappropriate.

Mild boundary crossings include therapists suggesting a book to a person in treatment “to help,” for example. Alternatively, some therapists will accept books or articles from schizoid people who have had problems feeling warmth and closeness with other people. In supportive psychotherapy (with borderline and psychotic people), such activities may be useful at times, but these activities have other meanings and can be counterproductive

EXAMPLE 1

Jeff, a 50-year-old tax attorney, had marital problems and anxiety. At work, he was known as “the fixer.” He spent so much time solving others’ problems at work, as well as his mother’s problems, that his wife was threatening to move out.

After obtaining some of his traumatic childhood history, I showed him that he became overly independent and caring (pseudoindependence and pathological altruism) to guard against fears of being humiliated.⁸

In his second session, Jeff reported he had told his wife he had been distant from her because of embarrassment stemming from painful adolescent trauma. She responded favorably, they spent more time with each other, and for the first time in months they had sexual intercourse.

He revealed he had found my first book, 101 Defenses, online and downloaded it onto his hand-held reader. He read me about pseudoindependence, which he thought fit his problems. I agreed.

He said he had a “great idea”: I should put together a kit for married people who were too independent from each other. He would get this advertised as a self-help book and provide business and tax input. My response to this suggested boundary crossing (his offer to start a business with me) was first to acknowledge that he felt better and wanted to do something for me in return. His offer also seemed to be part of the “fixer” pattern, however (pathological altruism). Helping others through a book and helping me with income seemed to parallel behavior that had caused him to help others to the detriment of his relationship with his wife.

He saw this. I further explained how he positioned himself not to face his “need” for my help (just make a kit), similar to how he had avoided depending on unreliable people during his formative years. He concluded he needed to spend more time with his wife and less time on extra projects for others.

On follow-up a week later, Jeff reported that he and his wife planned a church ceremony to renew their marital vows. They would then take a second honeymoon for a month. We agreed that he had, as was his way, “fixed” the problem. When they returned, if he needed anything from me, he’d call.

If he calls, I may find out whether “fixing” his problems in a hurry relieved shame over relying on me further.

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EXAMPLE 2

Angela, a 62-year-old married woman, suffered from depression and some deficits in self-image. She could not maintain friendships or closeness with her husband (a characteristic of borderline personality). She voiced suicidal thoughts but no plans. She avoided asking much about me; she was more comfortable knowing me as “just my doctor, with no life.” Her reality testing was good enough to know that I had a life; she had heard of some of my activities in the community.

After 2 years of twice-a-week psychotherapy, she brought me a short story she had just had accepted for publication. Since she had been keeping distance from me for so long, I thought this indicated a (sublimated, although symbolic) gesture of closeness. I therefore accepted it without exploring any meanings of her act of giving it to me. I thought that Angela fell into a category of people who, when I attempted to explore the meaning of a gift (including inexpensive Christmas gifts or cards), had concretely experienced me as “spoiling” their meaningful gesture of emotional closeness. Rejected, they did not buy any explanations of transference.

I later read Angela’s story, which I enjoyed, and told Angela so. She then recalled how her mother was never interested in anything she did. She now realized that her anger at her husband not only distanced her from him but was displaced from her mother. The symbolism in the story pertained to her conflicts.

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Some analysts prefer to refuse and then try to understand the motives for any gift .⁹ They try to understand why people might be upset if the therapist refuses it. The problem is that for some people, like Angela, a reality rejection would have been more difficult to understand as transference. Her pain would have occurred due to a reality where deprivation seemed unnecessary.

Adatto¹⁰ commented ironically that accepting gifts caused problems for the therapist. What should we do with them? Put them on the refrigerator, frame them in the office, throw them out? And then what do we tell people we did?

____________

5 Stein (1988).

6 Gabbard (1994a).

7 Lewin (1955).

8 A. Freud (1936).

9 Volkan (2011).

10 Dr. Adatto mentioned this conundrum during a class on dyna at LSU medical school in 1974, when I was in training there.

Problem 33

Boundary Violations, Erotic and Erotized Transferences

Boundary violations are the most serious types of boundary crossings. You commonly see them in psychotic or psychopathic (“antisocial”) people and/or therapists. “Lovesick” therapists are especially liable to sexual transgressions.¹¹

I found in my limited experience consulting with (or about) therapists who engaged in sexual misconduct with people they treated that the therapists were defending against the concept of boundaries (rebellion against “authoritarian rules”) or were grandiose and had no conscience.

SHORT ANSWER

If people you are treating “come on” to you—that is, make sexual overtures—first try to figure out what this means. They may be using sexualization (a common defense) to guard again...