I had a lot to learn before I could figure out how much I had to learn.
—A SUCCESSFUL CLIENT
ONE OF THE MOST DIFFICULT aspects of being a new therapist is learning how to deal with client resistance. Most of us make the mistake of thinking that resistance is like a rain delay—something to wait through before we can get started. Nothing could be further from the truth. Working with and working through resistance are key therapeutic skills. Many of the answers to a client’s difficulties are woven into the resistance he or she brings into the therapy relationship. With time, we gradually learn to decipher the important information embedded within resistance.
Beginning therapists often first identify resistance in the content of what a client says. Content resistance is reflected in emotional difficulties around certain topics. Strong emotions or gaps in the discussion are often the first indications that “something is going on in there.” A client may always look sad when he mentions his sister, another may talk a great deal about her father but never mention her mother. Sometimes a client will say, “I don’t want to talk about that,” and go on to another topic. These are all examples of content resistance.
With increased experience, therapists begin to recognize what is called process resistance. Process resistance is embedded in personality, coping styles, and defenses formed during development. Our brains are shaped through adaptation to experiences and, in turn, organize our adult perceptions in line with what has come before. In this way the past becomes the present and future, or, put another way, we create what we expect to find. A prime example of this is the transference relationship, through which the client experiences the therapist as a significant person (or persons) from the past.
New therapists often get their first view of process resistance in situations of setting and collecting fees, missed appointments, and early termination. These are arenas in which a client will “act out” his or her resistance. It is up to the therapist to understand and name the acting out, as well as discover the underlying emotional processes motivating the behaviors. It is particularly difficult for beginners to confront these situations, and it takes time to gain the confidence needed to overcome the discomfort of making process interpretations. It is easier to avoid discussing missed sessions or bad checks than to have frank discussions about the thoughts and feelings motivating them.
It is scary to go to therapy, and ambivalence is the norm. Just making the decision to go can be nerve-wracking, let alone making the appointment and sitting in the waiting room anticipating the therapist’s arrival. Wild and unfettered enthusiasm is often a well-practiced form of resistance. By the time I walked into my first session, I was a giddy mess. The voices in my head kept telling me things like “the therapist will think I’m crazy,” or “he’ll think my parents did a bad job,” or, worst of all, “he’ll tell me I’m too screwed up to be a therapist.” Remembering these experiences helps me to be more empathic with new clients.
In light of all of these concerns and fears, it is important to do what you can to make clients more comfortable. Begin by complimenting them on their decision to seek help, then guide them though the early sessions. If they have difficulty beginning, start off with some general and nonthreatening questions, such as asking about their education, interests, and hobbies. Get a sense of your clients as people and don’t start out with both feet in your abnormal psychology textbook.
Not only is it scary to go to therapy, but it can also be scary to confront clients on their defenses and resistances. Given our standard roles as peacekeepers in our families, many therapists do anything they can to avoid conflict. This may be especially true for women, given the expectation in most cultures that the role of a woman is to take care of others and make them feel better. Countless female students, clients, and friends have told me that if they say or do anything that upsets anyone they feel like they are being a “bitch.” It is certainly important to be able to distinguish between being a bitch and making a valid interpretation.
Many therapists were not allowed to express anger in their childhoods. The dynamics of their families and the needs of others required them to be the good girl or boy. The problem with not being allowed to be angry during development is that it does not get integrated into daily life and normal interactions. Because of this, when anger is expressed, it is explosive, frightening, and serves as further evidence that it needs to be suppressed. Unfortunately, when anger is deleted from conscious experience, power and appropriate assertiveness usually get lost as well.
Although certainly not the goal of therapy, conflict is sometimes important for growth. We need to be able to face our clients’ anger and absorb negative transference despite our discomfort with being the target of these feelings. Remember that below many a positive transference lurks negative transference; resistance implies a defense against something that is provoking anxiety. Whereas some people hide their anger with a smile, others keep their vulnerability hidden behind a shield of rage.
A therapist’s fear of confrontation may be indicated by some of the following untherapeutic behaviors:
• Not discussing multiple time changes for appointments
• Avoiding discussion of missed sessions or lateness for sessions
• Avoiding discussion concerning the collection of fees
• Setting fees too low
• Not bringing up difficult topics
• Not making interpretations or making too many interpretations
• Cutting sessions short or running overtime
• Missing sessions
Make a point of exploring your relationship to anger, assertiveness, and power in your personal therapy, and pay special attention to the therapeutic issues just described.
At first it is confusing: A client comes to therapy, often at great emotional and financial expense, only to ward off your assistance, suggestions, and interpretations. Resistance is the basic paradox of psychotherapy, but only on the psychic surface. As you become familiar with a client’s history, family, and the emotional challenges faced during development, his or her form of resistance will make more and more sense. Resistance is a form of implicit memory, an adaptation to the past that reverberates in the present. As you gain experience, you will learn to spot it during the first few minutes of interacting with a new client.
Clients’ core issues are embedded within their resistances. I have had a number of clients who were severely abused by their fathers when they were young boys. Jason, a 29-year-old baseball player, spent the first session with his arms defiantly folded across his chest, daring me to make him feel anything. Doug, a middle-aged business consultant, brought me gifts nearly every session. Tony, a teenager three times my size, pushed his chair back into the corner of my office and looked as if he expected me to attack him. Each of these men had made many unconscious adaptations to their early abuse and were demonstrating them to me in the transference relationship. Although all three clearly remembered being abused, none was aware how his adaptation had become interwoven into his personality, defenses, and interpersonal behaviors.
Sometimes, symptoms work to provide us with something we need that we are unable to ask for directly. A husband who can’t get his needs met may be taken care of when he is sick, or an overworked mother who develops panic attacks and agoraphobia discovers that her family begins to share some of her burden. An adolescent, nervous about leaving his depressed mother, finds that his increasing symptoms of anxiety are an acceptable reason to postpone leaving for college. Rewards, or negative things that get to be avoided because of symptoms, are called secondary gains. These benefits serve to reinforce and maintain symptoms, making clients more resistant to change.
The key to dealing with secondary gains is to help clients attain the things they need directly. Assisting clients in identifying needs and being more assertive about attaining them is almost always helpful. In other cases, such as with the adolescent with the depressed mother, getting his mother the help she needs takes him off the hook, allowing him to stay on a healthier developmental course. When people have their needs met directly, they are less likely to hold on to the self-damaging symptoms they use to get them.
What we call “resistance” is a necessary form of communication from client to therapist and a central component of the therapeutic process. Although the word resistance is commonly used in psychotherapy, it is still uncertain whether the term is appropriate. What we are discussing may be better described as implicit and procedural memories from early relationships or traumatic experiences. Although outside of conscious awareness, these memories heavily influence how people experience the world and the ways in which they respond to it.
Although clients are often aware that they are engaging in repetitive patterns, few understand their origin in unconscious memory. One key role of the therapist is to identify, understand, and communicate these patterns to the client. We try to educate clients about how their past reverberates in the present and shapes the future. Describing it as a form of memory helps to avoid blaming clients or establishing an adversarial relationship. It is far better to think in terms of a collaboration, where there is a mutual exploration of how the client’s brain has learned to adapt and survive.
Aikido is a style of marital arts based on principles of balance and energy. The core philosophy of Aikido is that if someone is attacking you, he must be mentally unbalanced. In this context, the role of the Aikidoist is to protect the attacker from his bad judgment until his balance can be restored. Therefore, the power of the attacker is not confronted head-on with oppositional power but avoided with a skillful side-step. The energy of the attack is then channeled into a circular movement that evolves into a nondestructive hold. When a move is executed correctly, neither the attacked nor the attacker are injured.
The way of Aikido is a wonderful metaphor for confronting resistance in psychotherapy. The biggest risk for a new therapist is to take the client’s resistance personally and meet it with his or her own ego-driven energy. As in Aikido, resistance is an indication that the client needs assistance in attaining psychic balance and integration. Although it is entirely natural to have an emotional reaction to your clients’ resistance, remaining centered and mindful of your therapeutic role is essential. Retaliation, although often tempting, is almost certainly the wrong thing to do. Resistance needs to be acknowledged, understood, and appreciated if it is to be successfully converted into an acceptance of new ways of thinking, feeling, and being. Acceptance of the client’s resistance as a necessary defense in light of past challenges is a central aspect of therapeutic success.
Over the course of your career, you will be faced with a hundred forms of resistance; the question is how you deal with them. The first rule, which may be the most difficult to follow, is: Don’t be defensive. Remember that the resistance is probably about the client and not about you. Second, listen carefully to the client’s concerns. There may, in fact, be realistic aspects to their concerns about your skills or knowledge that should be thought through and discussed before proceeding. For example, a client may realize that he is difficult and in need of an experienced therapist rather than a beginning one. Some clients may have issues that are too embarrassing to discuss with a therapist of the opposite sex. After listening to a client’s concerns, ask yourself: How might the client be right? A client’s questions give you another opportunity to not know; after all, none of us can guarantee that we can help every client we see.
Think about the following questions:
• Do I have the skills to treat this client?
• Are we a good match?
• Might this client benefit more from working with another therapist?
• Do I feel that I can help this client?
• Am I having a strong countertransference reaction that may compromise my ability to help this particular client?
These are difficult and complicated questions to answer. It takes years to gain the necessary experience to come to good decisions, so rely on your supervisor’s help while you can.
If you have seriously considered a client’s objections and engaged in your own self-reflection and it still seems more like resistance than a legitimate concern, move on to the next step: Try to make sense of why your client needs his or her resistance. Explore the client’s relationship history and the quality and degree of support he or she has received from others. As discussed in the last chapter, it may be that the client has been betrayed or misled by those he or she depended upon most. The resistance may be based on previous experiences with doctors or other mental health practitioners. I have had several clients who have been victims of therapist malpractice; the first phase of treatment was entirely focused on issues of my own competence and trustworthiness. On a more benign level, it may be that you remind a client of a car salesman who once sold them a lemon. The point is, resistance has been learned from experience for the purpose of survival in some other context. It needs to be accepted, discovered, and explored and not taken personally.
Although the underlying motivation for resistance is usually not about the therapist, it is often framed in the context of therapist attributes, behaviors, or shortcomings. Have you been told by clients that you are too young or old, too white or black, too gay or straight to understand or be of any help? Clients may look at you suspiciously and ask, “How many cases have you had?” or “How many years have you been a therapist?” or even “Did you at least go to an accredited school?” Of course, the less experience you have or the less impressive your credentials, the more impact these thinly disguised attacks may have on your ego and equilibrium.
When your personal attributes, credentials, or abilities are questioned, it is natural to become defensive and angry. Of course, these negative emotions are detrimental to both the client’s view of you and the therapeutic relationship. The best strategy is to be prepared to have your skills and abilities questioned so you can respond in a confident and nondefensive manner. Try responses such as “I’m just beginning my training as a therapist. I chose to work at this clinic because of the reputation of the supervision. As you know, I am under the supervision of a licensed therapist and we review each session together.”
It is the client’s right to know about your training and experience, and having them questioned or even challenged is not necessarily an indication of resistance. However, pay attention to how clients ask you about your qualifications. If their questions are asked in the emotional context of sarcasm, condescension, or anger, they may represent important information about the client’s expectations, past experiences, or defenses. If this is the case, you may want to follow a direct answer about the quality of your training with a question such as “Are you hopeful about being helped by therapy?” or “How do you feel it will be to work together?” Questions such as these may get directly to their fears and concerns about entering therapy.
I have had clients tell me that I have no right to treat someone with schizophrenia because I’ve never experienced it, or that I don’t know what depression is because I have a “perfect life.” I’ve also been told that I couldn’t possibly understand an adolescent growing up today because I grew up in a time before peer pressure and drugs. Simple phrases like “teach me” or “you’re right, I don’t understand what you are going through but I would like to learn,” can disarm initial resistance and help establish a healthy therapeutic relationship.
What a client is usually asking through criticisms, challenges, and attacks is “Can you help me?” or “Can I trust you?” This is where I try to guide the discussion when I’m challenged. In conversations about my age, gender, race, or training, my underlying message is “I don’t know if I can help you, but I’d like to try.” Do I need to be of the same religion, experience the same prejudices, or have the same illness as clients in order to help them? Can they teach me about what their world is like and help me to help them? Would they be better off with a gay, black, or Jewish therapist? Perhaps they would, but in the course of these discussions, we usually establish a relationship that evolves into psychotherapy.
Keep some of these principles in mind when you encounter resistance:
• Don’t take it personally and never retaliate.
• Don’t punish your clients for their resistance (e.g., “So you think I’m a lousy therapist; well, you’re a pretty shitty client!”).
• Accept it, validate it, and give your clients credit for using their defenses when they were necessary (e.g., “You were absolutely right to not show your weaknesses to your parents because they did use them against you.”).
• Explore it as you would any other unconscious memory.
• Give clients words for their resistance so they can come to recognize and understand it (e.g., “It seems that you become quiet and withdrawn whenever you feel criticized. Next time you are withdrawing, see if you can notice it and even try to tell me when it is happening.”).
• Contextualize it. Discuss when it was necessary in the past and distinguish the past from the present.
• Set up situations where the client can experiment with not resisting (e.g., “Instead of canceling your appointment when you are feeling frightened, why not call, tell me you are frightened, and come to your appointment with your fear.”).
• Most important: Be patient. Today’s resistance contains tomorrow’s insights.
Therapists commonly react to cancellations with feelings of annoyance, anger, fear, or rejection. When clients call to cancel, it is easy to feel devalued and marginalized; we may feel we are not important enough to them to be a priority. These relatively common situations can evoke our own feelings of rejection, abandonment, and shame. We may also worry about what our supervisors will think or, later, in private practice, we can be angry about the negative financial impact of cancellations.
I have had many beginning therapists report that when a client cancels, their first assumption is that the client has decided they are incompetent. The cancellation activates their shame and they secretly feel the client has made the right choice in abandoning them. In cases like this, it is easy to see how difficult it is to do therapy when our own shame is so easily triggered; the cancellation becomes about us and not the client’s defenses.
I had a client named Joseph who called to cancel nearly every appointment days, hours, or minutes before the session. At first, my primary experience was annoyance; I set up my day to see clients at certain times and these constant cancellations felt disrespectful and almost abusive. I felt that Joseph devalued me, the therapy, and my time. As my attunement to Joseph’s internal world deepened, I learned that his cancellations served a variety of needs. They provided him a lifeline to me between sessions, a way to act out how painful his life felt, and an opportunity to exercise his power and feel a sense of control-although he had chosen to come to therapy, he still felt I controlled him.
This same pattern played out on a regular basis in his personal relationships; he would withdraw from others at the slightest possibility of failure or rejection. As I continued to translate his cancellations into his needs for contact and control, he was more and more able to come in and discuss his needs rather than acting them out. During this process, the number of canceled sessions decreased and I invited Joseph to leave me a message whenever he felt he needed contact.
A client calling to cancel an appointment can mean anything. People do get flat tires, find themselves stuck in traffic, and run overtime in business meetings. But more often than not, cancellations are a client’s way of telling you something. Based on what you have learned about the client, try to translate cancellations into their emotional meaning. Ask yourself what the client gains or avoids by canceling. How does it fit into his or her defenses, history, and presenting problems?
Many clients are afraid of becoming dependent on you or having you see that they are in pain and need help. In an effort to avoid being dependent, they might cancel because they feel too safe and comfortable. The fact that you are doing a good job and providing them with a trusting and caring relationship may lead them to cancel sessions and resist treatment. If a client has repeatedly experienced feeling hope at the beginning of relationships only to be let down or abandoned later, feelings of hope in therapy may trigger anxiety because of the expectation of the rejection to follow. Some of us learn to do unto others before they do unto us.
Consider these ideas when trying to understand why a client might cancel an appointment:
• Were any uncomfortable (or potentially uncomfortable) topics discussed during the previous session?
• Does the client seem to be getting less comfortable in therapy?
• Does the client seem to be getting more comfortable in therapy?
• Is the client becoming dependent on you?
• What was your frame of mind during the last session? Were you as present as usual or were you distracted, upset, or having any feelings that may have affected your work?
• How has the client left relationships in the past? Could this missed session be a prelude to termination?
Premature termination is a common problem in psychotherapy. Clients discontinue for a variety of reasons. If a client isn’t ready for therapy he or she will not stay, and no amount of skill will keep him or her in treatment. Some clients come in, take a look, and never come back. Rather than thinking in terms of preventing all premature terminations, learn to retain clients who are ready for therapy.
Clients who have been in therapy for just a few months rarely come in and say, “You know, I’ve been thinking of terminating and want to discuss these feelings with you.” More commonly, they will leave a message informing you of their decision to terminate, having already made up their minds. If a client is terminating because the therapy is upsetting his or her psychic equilibrium, discussing the situation in an open manner may be difficult; the client may have to stick to the decision to maintain a sense of control. The very success of therapy will unsettle some clients and make them retreat to the safety of familiar defenses.
Because this is a common occurrence, during early sessions I ask clients about their relationship history and how they have left relationships in the past. Understanding what a client thinks and feels before leaving a relationship—and how he or she actually does it-reveals the person’s defenses, coping strategies, and attachment patterns. It also provides you with a general idea of whether the client will terminate prematurely and how it may happen. The best strategy is to make clients aware of these patterns and have them alert you when they become activated.
Tom was an attractive 35-year-old executive who came to therapy complaining of anxiety and loneliness. In one of our first sessions I inquired about his past relationships-how they began, their course over time, and how they ended. As he described them, his relationships sounded somewhat superficial, based more on physical attraction and the roles he and his mates played in each others’ lives than on emotional intimacy. He reported that in both of his significant relationships he gradually felt misunderstood, used, and unappreciated. He also said that there was no use in talking about it because his partners weren’t capable of understanding him or taking care of his needs.
In both relationships, Tom moved out while his partner was away on business. They returned home to find that Tom and all his belongings were gone. Confused, each of the women contacted him in an attempt to understand what had happened. Tom reported that, in each instance, he was surprised that they were so surprised he was gone. He mused, “Couldn’t they see that I was withdrawing from them over the last few weeks?”
My prediction was that during the course of treatment, my mistakes or empathic failures would be experienced but not named. He would accumulate a set of bad feelings, make decisions about my inadequacies, and then simply disappear. I brought up this idea and discussed it at some length during our third session. He thought it was an interesting hypothesis but couldn’t imagine that I was correct. Tom assured me that because this was a therapeutic relationship and I was so attuned to him, he could never imagine terminating before he was done with therapy. Besides, he had many good reasons to leave his past relationships because of his partners’ problems and I was nothing like those two women.
After 2 months of weekly sessions, Tom reported that something had changed; he started having stomach aches and bad dreams. He was certain that I was disappointed in his progress in therapy. I assured him that I wasn’t having these feelings and that his physical symptoms and nightmares might be connected to feelings being evoked in our relationship. His father had been killed when he was a young child, and I felt that his feelings of closeness to me were activating emotional memories of his grief and loss. The bond developing between us may have triggered his withdrawal from caring for the fear that I might be someone he would lose.
Tom came in during the ninth week of treatment and shared with me his decision to terminate. When I suggested that we take some time to process these thoughts and feelings in case they were related to his pattern of abandonment, he sat quietly and stared at me. When I asked him what he was thinking, he responded with anger, “I get to choose my therapist!” He repeated this phrase a number of times as if he found it soothing to hear his own voice. Any attempt at discussion was experienced as manipulation and accompanied by anger. Tom had become rapidly overwhelmed; he felt he had to flee in order to protect himself from caring too much or getting too close. In this case, ours was just another failed relationship.
Fortunately, identifying patterns of relationship termination can help clients gain insight and avoid repeating them. What might have happened if Tom had shared his feelings of being misunderstood? We could have then tied his current reactions to therapy to the loss of his father and he could have become conscious of the transference of these feelings into our relationship. In the absence of an understanding of these processes, Tom was convinced that his feelings were a reaction to our relationship as opposed to a repetition of a painful drama from his past.
When thinking about a client’s relationship history, pay attention to these basic points:
• Clarify and delineate the steps of the emotional and behavioral drama (describe the sequence of thoughts, feelings, and actions).
• Make the sequence of feelings and behaviors explicit.
• Remain vigilant for early signs of the withdrawal/termination process.
• Discuss the evidence with the client and (tentatively) predict what may happen next.
• Offer alternative strategies to acting out past patterns.
• Try to evoke memories of similar emotions in previous situations.
The therapeutic process can help break down repetitive patterns into stages of step-by-step thoughts and feelings. By becoming conscious of the various steps in these internal processes, the client increases his or her ability to notice and interrupt repetitive sequences. With clients who are ready, examining relationship patterns and predicting their activation can be useful tools for increasing insight and decreasing premature termination. It may take years and many repetitions of the pattern for clients to gain the perspective and maturity required to weather this kind of emotional storm.
It is not unusual for a therapist to fantasize about or find a way to “fire” a client. These urges take the form of forgetting important details about the client’s life, hoping that he or she will call and cancel, or daydreams about referring him or her to another therapist. When this occurs, it makes sense to consider whether the client should be referred. Perhaps a particular client has problems that you are not trained to work with, your countertransference reaction is too strong, or you find that there is simply a personality conflict.
A strong countertransference reaction to a client could be a good reason to refer. Some clients remind us of problematic figures in our own lives or have symptoms that stir up a great deal of emotion within us. With good therapy and supervision, we can often turn countertransference reactions into personal growth and positive therapeutic experiences for our clients. At other times, strong countertransference reactions, especially at the beginning of treatment, may lead to a wise decision to refer.
There are many other reasons for referring a client to another therapist that are unrelated to countertransference. Some examples include:
• The client’s psychological difficulties are beyond your level of training or supervision.
• The client suffers with symptoms that would be best helped by an expert in a specific therapy (e.g., a cognitive behaviorist who specializes in phobias or posttraumatic stress disorder).
• You discover some conflict of interest or dual relationship that could impede therapy (e.g., discovering that your client is married to your husband’s boss).
• You and your supervisor come to genuinely believe that you are unable to help a particular client.
Clients who are ambivalent about or afraid of therapy may try to get you to fire them. They may be fearful that you will abandon them and try to gain power over this fear by forcing your hand. Clients may miss sessions, come early or late, bounce checks, come in drunk, or just sit for weeks and remain uninvolved in treatment. In these and countless other ways, they will try to precipitate the abandonment they so fear. Creating their own abandonment is a way to gain control over what they experience as a painful inevitability.
Clients who are aggressive, critical, yell at you, or spray you with sarcasm may seem to be begging to be referred or terminated. Their aggression may also be motivated by the expectation of aggression toward them. A client may have the unconscious strategy that a good offense is the best defense. Unfortunately, for many of these clients, this is a self-fulfilling prophesy that leaves them alone again and again. At a deeper level, they may be trying to make you feel their abandonment anxiety.
When a client seems to be begging to be terminated by treating you badly, ask yourself why. Why come to therapy for a fight? What is the significance of fighting for this client? Is it a form of contact, the only way he or she feels able to reach out to you and connect? This is often true for clients who have grown up feeling neglected, misunderstood, or abused. Anger may be the client’s only bridge to people in his or her life.
A client’s anger is often a reaction to a real need to depend on you and the fear that you will disappoint him or her. The very feeling generated in you—your anger and wanting to fire him or her—is the feeling the client needs you to withstand. It is a test of your centeredness, maturity, and availability. When you tolerate your feelings and identify the anger as a desire to connect, trust, and be loved, the anger is often converted to just that.
One of my college friends often said, “Money is funny.” At first, I thought this was just a silly rhyme, repeated in lieu of eloquence. It turns out he was right; money is funny. Though it is basic for our survival, we are supposed to act as if money isn’t important. We are not supposed to talk about it or flaunt our wealth or success. We don’t tell other people how much we earn and it is considered crude to mention what things cost. Disagreements about money can break up marriages, destroy friendships, and start wars. So, naturally, it is a difficult topic to confront in therapy.
Many clients come into therapy with the unconscious wish to be told that they will be seen for free. It seems so unfair to have to suffer at the hands of other people and then to have to pay to be cured. For some, paying for therapy actually adds insult to injury. On more than one occasoin, I have heard clients say, “My parents screwed me up, let them pay for it!” In many families, money and love are intertwined.
This is especially true in families where one or both parents are too preoccupied to spend time with their children and give them money and gifts instead of attention. For these children, money becomes a powerful symbol of love, personal value, and self-esteem. The attempt to avoid paying for therapy may be a way to manipulate the therapist into providing the love and affection the client lacks.
Therapists are often as ambivalent about collecting fees as clients are in paying them. We may come from families with money conflicts or have other issues concerning money, love, and self-worth. I’ve heard many training therapists say, “I became a therapist to help people and I feel embarrassed getting paid for it.” Add to this the fact that we may be unsure of our own worth, and collecting fees becomes a significant therapeutic challenge.
One of my first private practice clients had a very difficult time paying for therapy and I had an equally difficult time confronting him about the money he owed me. He would go months at a time without being able to pay, bounce checks, and assure me that things were just about to turn around. He wasn’t interested in a fee reduction, telling me I was a wonderful therapist and should be paid accordingly. He wasn’t interested in going to a clinic with a sliding fee because he felt it was “beneath him.” Not only was I embarrassed about bringing it up, but I also soaked up his praise like a sponge, all the while allowing him to accumulate thousands of dollars in unpaid bills. Years after he stopped coming to therapy, I received a notice that he had declared bankruptcy and that the law had forgiven his debt to me.
In retrospect, and with many more years of experience, I can clearly see how I failed this client in not discussing issues around money. His large bills, grandiose plans of future success, and praise for me were all aspects of his narcissistic defenses. I swallowed his fantasies hook, line, and sinker. If I could do it over again, I would address the issue of fees from the start. We would probably have discussed his injured self-esteem and how he needed to look realistically at the treatment he could afford.
This discussion about fees could have provided a window to the deeper issues with which he was struggling. Instead, my own embarrassment and lack of experience led to the reestablishment of a relationship that did my client little good. Ironically, he paid exactly what his therapy was worth. Over the years I have learned to be less fearful about discussing money during fee setting and reminding clients at the end of sessions about paying before they leave. When clients tell me that they can’t afford my fee, I may suggest that they bring in their tax return so we can discuss the issue of finances in more detail. After an initial surprise on their part, they often tell me about their finances in great detail. It seems to be a relief just to talk openly about such a taboo subject.
It is probably a good idea to have a standard policy of how long you will go without payment to help you address these issues in a timely manner. Perhaps a one-month limit on missed payments should be standard before you postpone or discontinue treatment. Of course, every situation is different and you can’t abandon a client of limited means. A standard policy should apply especially to clients whom you feel are not paying due to issues of resistance that need to be confronted in order for successful treatment to occur.
Successful therapy is a “safe emergency” that depends on a continual balance of support and challenge. With one hand we hold onto our clients to give encouragement and strength; with the other, we sword fight with their defenses. The use of interpretations is one of our most valuable sword-fighting techniques.
When we hear people telling a half-truth or fooling themselves with false beliefs in general conversation, we smile, utter some cliches, and move on to the next topic. Interpretations, like silence, are a violation of social norms. You are guaranteed to stop a conversation dead in its tracks when you say, “You are just saying that because you can’t handle the truth.” The vast majority of social conversation functions on the implicit agreement that “I won’t call you on your act if you don’t call me on mine.”
Making an interpretation is essentially calling someone on their act. Interpretations attempt to make the unconscious conscious by challenging beliefs, naming resistance and defenses and adding new and challenging information to the client’s conscious awareness. Because interpretations are difficult to assimilate, their dosage and timing are important. Consider these strategies when making interpretations:
• Don’t make an interpretation the first time it occurs to you. Be patient, think it over, listen thoughtfully, and gather evidence.
• When making an interpretation, try to incorporate the client’s own words, images, and metaphors.
• Be prepared for your interpretation to be rejected.
• Don’t push a rejected interpretation.
• If your interpretation is rejected, put it in the back of your mind for later.
• If your understanding is right, there will soon be another opportunity to offer it again in another way.
• Don’t forget that you may be wrong.
After an interpretation hits home, remember that your client will need time to assimilate it. Accurate interpretations are a challenge to psychic equilibrium and those that are not deflected by the client’s defenses result in a release of emotions. When an interpretation makes a defense conscious, it is rendered less effective, and the feelings it was inhibiting are released. That is why when an interpretation hits home, you may notice your client’s facial expression changing; he or she may appear to become deflated, sad, or tearful. When this occurs, talk less and shift to a supportive stance. These moments are key in maintaining the vital balance of challenge and support.
Stan came to therapy because he was concerned about his relationship with his children. Neither his adult son nor his daughter would speak to him and he couldn’t understand why. All he knew was that they told him that he made them feel badly about themselves and they no longer wanted him to “contaminate” their lives with his negativity. “Can you imagine that!” shouted Stan. “I bring them into the world, raise them, put them through college, and now they don’t want any part of me!” He repeated this refrain for the first 2 months of treatment and rarely let me interrupt him.
Near the beginning of the third month, Stan came in and opened the session by sarcastically asking me how I earned my money. “I do all the talking, you just sit there, and then I give you a check. What a racket you have here.” My reflexive response was to tell him that he never gave me a chance to get a word in edgewise, but I soon realized that his transference had become activated. He was now doing to me what he probably did to his children. Here was my chance to earn my check. “I’m glad you mentioned this, Stan,” I said. “You’ve talked a great deal about your wife and children but I wanted to know about your childhood and your relationship with your parents.”
Stan had grown up as one of five children in lower Manhattan with two parents who worked in the garment business. Life was tough, money was tight, and his parents spent most of their time taking care of the family business. Unfortunately, his parents took their tough business personas home and dealt with their children as if they were competitors. Stan toughened himself up, became a successful businessman, and carried on the tradition of family communication through blunt confrontations and attacking the weaknesses of others. He was able to remember how he longed for tenderness from his parents despite the many times he was shamed by them for failing at sports or getting a B on an exam. He told me of how he and his brothers had subsequently experienced difficulties in relationships, substance abuse, anxiety, and depression.
To test his ability to tolerate an interpretation, I suggested that his asking me at the beginning of the session how I earn my money was how his parents would confront him. He smiled faintly and said, “That was nothing.” I then tentatively asked if he sometimes treated his children the way he treated me and perhaps the way his parents treated him. From the expression on Stan’s face, I could tell that he was making the connection between his childhood and his children’s experience of him. The realization that he had recreated his own childhood pain within his children was devastating. He quietly stared at the floor, his eyes welling up with tears. No more interpretations were warranted and it was time to be as supportive as possible.
We later talked of how, with the best of intentions, parents often pass the pain from their own childhood to their children. I assured him that by working together, we could change some of his behaviors and attempt to heal some of the damage in his relationship with his children and grandchildren. Thus, in this brief period of time, I had shifted from a stance of challenge to one of compassionate support. If I had reacted to Stan’s initial confrontation with defensiveness, he would have labeled me an incompetent wimp. By understanding and interpreting the transference, I was able to link his children’s emotional experience to his own. This created the possibility for Stan to replace a critical style with an empathic one with people he cared about.
Remember, defenses gain strength when attacked. The key is to absorb the transference, not get defensive, and interpret what you consider to be the emotional process taking place. Care and patience always trump strength and aggression. Also, be patient with yourself; you will gradually improve at making interpretations. Simply said, it is an extremely complex and delicate process that requires lots of practice.