Uncertainty, Transference and Other Reasons Therapists Might Fail

Frosty-breath hangs in the cool, fall air. It obscures my view of the forested hillside, but atop the slope I can see the cabin.

A diesel engine roars to life behind me, and rumbles over the crunchy grass to the edge of the woods. It’s time to start carving a roadway to the cabin. The path twists, turns, traverses, and BAM! The bulldozer is halted in its tracks: a boulder is lodged deep into the soil and there’s no way around it.

I must have circled this boulder dozens of times with crowbar and shovel trying to dig it out: figuring out how it is shaped beneath the dirt, learning every crack and crevasse. Until finally, with a heave-ho of the crowbar, it begins to shift in its place. Another push. And another.

And finally, the boulder rolls free from the ground, off the path, leaving behind a scar in the earth; a pit to be filled in over time. For now, I can continue building my path to the cabin, but who knows what other boulders or barriers there are yet to face.

No Simple Highway

These are the points in life when people most often turn to psychotherapy. They have tried everything and, to varying degrees, may have a fantasy that psychotherapists have some top-secret piece of advice.

Especially therapists-in-training who are excited about helping, anxious to prove their competence, and unfamiliar with the uncertainty of the therapeutic process. Therapists like these might find themselves colluding with this client’s wish for a magic solution in order to reduce both parties’ uncertainty.

But usually we fare better to recognize our own narcissism — the urge to protect our professional self-esteem — and avoid playing along with the fantasy that we can provide a quick fix.

We must keep in mind “there is a road, no simple highway,” and along this road there are boulders neither we nor our clients can foresee. Even more powerful than the solution is that we can go along for the ride, sharing in the uncertainty of the voyage.

Uncertainty

A focus of this series has been therapists misinterpreting uncertainty as incompetence, potentially threatening professional self-esteem. However, I believe uncertainty is a fundamental human anxiety. Our drive for knowledge and scientific advancement may be fueled by our discomfort with uncertainty. Religion, be it truth or tale, offers billions of people a sense of comfort in the certainty it provides.

Existentialists are interested in our uncertainty in the process of “becoming” or self-actualization, finding meaning, living in conformity with our values, and death. Psychoanalysts may be interested in the analysands’ uncertainty of their ability to fulfill drives (biological and relatedness needs) within the confines of their perception of the world.

The Psychodynamic Diagnostic Manual demonstrates variations in treatment across diagnoses depending on how the client orients him or herself to the world in regards to Blatt’s polarities: relatedness versus self-definition.

I believe it might be helpful to explore the experience of uncertainty in these polarities in terms of two common cognitive distortions: dichotomization and catastrophization. For example, a client who presents with a dichotomous hope of being comfortably enmeshed while catastrophizing about abandonment is struggling with anxious uncertainty in relationships. Conversely, a perfectionistic client who presents with a dichotomous drive to fulfill immense expectations while catastrophizing about all the things that could lead to failure is struggling with anxious uncertainty in self-definition.

Gestalt therapists recognize an uncertainty-laden future orientation as a core source of anxiety; staying in the moment is a key focus of Gestalt therapy. One might say we are well when we feel we can handle the future’s uncertainty, anxious when we fear we cannot handle that uncertainty, and depressed when we are certain we cannot handle what the future may bring.

Transference

The first article in this series discussed the therapist’s uncertainties, imperfections and sense of competence. This article has focused more on the client’s uncertainty both in facing life’s challenges and the process of therapy. The second article in this series presents a case that demonstrates my personal uncertainties and imperfections as the therapist interacting with the client’s uncertainty in relationships. How do we know whose stuff we are dealing with in any moment in therapy?

Simply, we can’t. It’s usually some of both.

However, we can remain reflective with one eye turned inwards toward our emotions (the other eye attending to the client). This will allow us to be aware of our emotions so that we can begin to wonder if they are from our past or a reaction to the client.

The client’s past being played out in therapy is often called transference, and at times we might be pulled into playing along (in a complementary role), while our past being played out in therapy is often called countertransference.

Some approaches to therapy have historically sought to eradicate countertransference via psychotherapy for therapists-in-training. The more common belief is that, while therapy is good for everyone, countertransference and “enacting” past interpersonal relationships is inevitable; we must remain aware and reflective of where emotions are originating in order to determine the best approach to take with our clients, and to have the emotional space within ourselves to hold our clients uncertainty.

The Therapist’s Approach

Does the therapist aim to reduce anxiety, or to encourage the client toward anxiety-provoking material to gain new ways of experiencing?

Many theoretical orientations offer both anxiolytic and anxiety-provoking interventions, which can affect the client’s sense of uncertainty. Problem-focused orientations often refer to anxiety-reducing interventions as symptom-management, while exposure epitomizes facing anxiety. In depth psychology orientations, supportive psychotherapy reduces anxiety while expressive (interpretive) interventions increase the client’s experiencing of emotional material.

Existential Analyst, Frankl, describes relieving the existential anxiety (meaninglessness) of a woman on her deathbed by elucidating the meaningful things she had done that will never cease to exist. Conversely, Mann’s Time-Limited Dynamic Therapy highlights weekly that the client’s time in therapy is running out – a microcosm of our time running out on earth from the day of our birth. Perls, a leader in Gestalt Therapy, described himself as an excellent frustrator.

Many dynamic therapists see themselves as a frustrator. Not only can the therapist be a frustrator when encouraging the client toward experiencing anxiety-provoking material, but increasingly throughout therapy as the client’s transference develops: the client begins to see the therapist like the parental frustrator who inhibited childhood impulses.

Similarly, Davanloo calls himself a relentless healer. Therapists like Davanloo and Kernberg, amongst other interventions, point out (interpret) the client’s transference from the first session.

Conversely, supportive interventions decrease anxiety. Fonagy, an attachment theorist, helps clients with mentalization, similar to self-reflectiveness in mindfulness-based therapies like ACT and DBT, to self-regulate affect.

Developmentalists might be interested in a corrective emotional experience; rather than interpreting client transference, reacting differently toward the client than the client’s parents did during childhood. Kohut might empathize with a client’s hostility, “I’m realizing I came off as equally uncaring as your father when I reacted that way. I’m sorry. That must have been difficult considering your friends have also been distant lately.”

How to approach the client depends on more client and therapist personality factors than can be covered here: severity of illness, type of illness and characteristic defense mechanisms, introversion versus extroversion, relatedness versus self-definition, and degree of emotional distress, to name a few.

Arousal-Performance Curve

Performance, whether in therapy or sports, is associated with level of arousal.

Emotional arousal can determine the client’s motivation in therapy. High levels of distress lead to inhibiting anxiety; a client will shut down and may experience panic (over 7 out of 10). Too little emotional arousal results in loss of motivation and disengagement (below 4 out of 10).

Either too much or too little emotion can result in a client leaving therapy. Anxiety-provoking approaches to therapy can give clients motivation as well as new, meaningful experiences, that can in-turn be processed more reflectively during periods of lower emotional arousal later in the session.

Conversely, clients who come into therapy with marked emotional dysregulation might benefit from anxiety-reducing interventions that prepare them for deeper levels of emotional processing later in therapy. Clients with more severe illness or PTSD may have a narrower “therapeutic window” (a more peaked curve: both quickly distressed and easily bored). This can help determine whether to encourage the client to experience the uncertainty during therapy, or to reduce anxiety by reducing uncertainty.

Thank you for reading the third and final article of my three-part series on therapist imperfections.

The series has focused on the fact that therapists are perfectly imperfect humans, and thereby vulnerable to the uncertainty innate to the human condition, but uncertainty is far from equal to incompetence. In fact, it is our ability to stay with another human being who is in distress and share in a time of uncertainty that speaks most loudly to our competence.

More so than any skill or solution, we can guide the client through the unpredictable experiences that might arise in psychotherapy.

This article was originally published on January 25, 2016. 

Missed the first two articles in this series?

Attention Psychotherapists…You’re Going to Fail. [Part I]

How I Failed my Client in Psychotherapy and Grew From it [Part II]