An important question from Louise:
“I have a question about how to know if my psychiatrist is right for me. He appears very knowledgeable and generous, but he is never warm and never says anything positive. After a year of weekly psychodynamic psychotherapy, I feel like I am a worthless person (I did not feel like this when I started). I feel traumatized by each session and spend the following days crying. I really believe he is trying to help and I feel guilty about going to someone else.”
Answering this question is a little scary for me. Who am I to criticize another therapist knowing that I am far from perfect, myself. Then there is the danger of not knowing Louise or her therapy from direct observation, but only from her brief description. So I’ll talk in general, recognizing that the reality may be different, and that ultimately Louise will have to make her own decisions.
Let’s look at how so many well meaning and ethical therapists, by withholding feeling and feedback, end up frustrating their patients and often, in my view, reducing the effectiveness of their work by trying to follow the principle of “neutrality.”
In the dawning days of talk therapy, Freud’s idea was that gratification would kill desire. As a good 19th century scientist, he equated all the “drives” with thirst, hunger and sex. He pictured a hydraulic system where pressure builds up till we satisfy the need, then there is a release and the pressure of desire drops.
Applied to therapy, the model predicts that if the therapist withholds emotion, information, support, etc., it will increase desire and motivate the patient to reveal more and make more progress. Unfortunately the model is too simple.
Before we take a look at the complexity, we must consider the effect of shame. New therapists are taught about “neutrality.” They learn that it is not good to reveal too much or show too much feeling. Maybe the explanation is actually more rounded and complex but, when you are just beginning, what comes through is “Thou shalt not…” Students identify with the simple and powerful prohibition, even more because it is unnatural and hard to do. A senior colleague who retired and had to refer his patients, confided that the hardest part was that his colleagues would learn the shameful truth that he had been friendly and giving. In my view, this was one of his best characteristics. You can see that neutrality has cast a huge and dark shadow on the profession of psychotherapy.
So what about the real complexity? First, as I said in the post on Attachment to Your Therapist, the most powerful source of energy and drive to move therapy along is the need for connection. We want to feel closeness. We want to be special. We want to share a common understanding. These needs are powerful and inborn, coming from our evolutionary roots as social beings. They make us willing to reveal things to ourselves and our therapist that are hard to admit and carry painful feelings, just so we can be understood and feel close. What creates a tipping point is hope. When we have hope of getting close, we desire it more and work harder for it. When we lose hope, we give up and turn elsewhere. This is why too much deprivation turns our hope and desire off, while just enough energizes our efforts to get close.
For each individual, the tipping point between hope and discouragement is different. Perhaps Louise was traumatized in her early attachment experiences. Perhaps this is why a high degree of withholding from her therapist is actually re-traumatizing. Whatever the reason, when we lose hope of connection we lose our enthusiasm and energy. We become defensive or depressed. We lose our willingness to take risks and try new things. Think of the difference between children who feel safe and secure, versus ones who are frightened. The ones who are not afraid are full of energy. They jump and point and talk about what they see. Kids who are not feeling safe are low keyed, vigilant and quiet, or perhaps desperately active in a stereotyped and non-creative way. This is not the atmosphere you want in your therapy.
Is there a phenomenon of satiety? Does giving turn off motivation? If a therapist is more passionate and genuine, can this turn-off of desire? Moments of closeness bring a peak of good feeling, then a something of a letdown, but soon the need for closeness again asserts itself and we find ourselves driven to seek some new way to connect. There is, however, one important dynamic that can look like gratification leading to loss of motivation.
As mentioned in the post on Attachment to the Therapist, a second motivation that drives therapy is a childhood agenda of changing the therapist, motivating him or her to solve unfinished business from childhood. As therapy progresses, these “young” feelings and desires become more insistent, more explicit, and as a result, more obviously childlike. Freud learned very early in his work that there is always shame in expressing these wishes verbally and a preference for acting them out silently. This is what often makes patients want things rather than understanding. We want extra time, or special attention to our material needs. Medication is perfect for this, especially the benzodiazepines that make you feel warm and fuzzy and taken care of. These do not lead to growth. What helps people grow is the hard process of becoming aware of the long ago pain and going through the feelings in a context of safety and understanding.
Again, there is a tipping point that is unique for every individual. Too much encouragement of acting out of wishes as opposed to insisting on conscious awareness of them is sending a bad message to the patient. That therapist is, in effect, implying that he or she can fix the unfinished business from the past, which is not true. Extra time or medication can never repair the pain of an early experience of deprivation. Marvin J. Ashton said, “You can never get enough of the things you don’t need, because the things you don’t need can never satisfy.” This really applies to the things that substitute for love. So when this happens, the therapist is sacrificing real hope of growth in favor of short-term good feeling. A devil’s pact is formed where both patient and therapist are taking the easy way out, and progress stops. This can look like Freud’s hydraulic model. It can seem as if too much gratification caused a loss of motivation. What really happened was that both patient and therapist have given up.
But there is a tipping pint. Zero willingness to give may be so discouraging that it stops progress. Early in my career, a young woman whose father had died during childhood came to session and confessed that she had forgotten to bring money for the bus fare home. Being young and trying to do the right thing, I tried to explore the possible underlying wish to have me take care of her as a father would have. In the end, she had another way home and I didn’t lend her the small amount of money she needed. In the following weeks, the therapy lost its momentum and eventually she stopped coming. I should just have given her the bus fare.
Decisions of when and how much to be helpful are not really so hard. Parents make them every day. When a child asks to have his shoes tied even when he knows how, there are times, like after a big day, when you should tie them for him and other times when it is right to say, “You can do it.”
So, Louise, I don’t think it is good for your therapy that you feel so bad after each session. What I would strongly recommend is that you make this issue the central primary subject of your therapy. Talk about it, and see if the two of you can resolve it. He should be very willing to look at the matter, and, I hope, willing to look critically at his role in it. It is possible, even likely, that tackling it out in the open will actually help you learn about yourself and perhaps open his eyes to things about himself.
