The Impatient Therapist
By Hans Welling
Abstract. The author argues that an eagerness in the therapist to help the patient and go deep into emotion can cause unnecessary resistance and a feeling of invalidation in the patient. Listening for the gifts that client give us may counter this attitude. The author gives examples of where these gifts may be found. In a clinical example an occurrence of impatience and its correction are illustrated.
As a therapist I am ambitious and impatient. Sometimes this is good because I work hard for my patients: They have 100% of my attention and my wanting to help them. But it can also get in the way when I want faster change, deeper emotion, more transformation, and I get frustrated. Worse than that is that the message transpires to clients that they are not doing good enough, which affects the safety of our relationship. It’s a trap I’ve fallen into several times, discovering over and over that I was “doing it again”. Especially with patients with intense suffering and with demanding patients I am easily triggered into wanting to go too fast.
Two things have helped me.
First, instead of focusing on where I want the patient to go, I focus on where the patient actually is. There may be defenses for sure, but I urge myself to focus on the wonderful deep and meaningful things the client is actually giving me. We receive without expecting: It’s an open hand and a warm heart ready to receive whatever the clients want to put in there. There is something about my being aware of these defenses that, without even mentioning this verbally, promotes both safety and awareness in the client and in turn leads to opening up and going beyond these defenses.
The second is the radical notion of AEDP that everything the client does is adaptive, however maladaptive it may seem (Fosha, 2000). So if the client stops the process, changes the topic, or blocks, we notice it and accept it. If the client goes just so deep, or doesn’t want to work on something, that is very okay. More than that, we must assume that the client has very good reasons for to doing so. We may just go with the client to the new direction he went, or we may make it explicit and welcome it by warmly inquiring, “Hey, I noticed the tears stopped, what happened?”
The Dialectical Process
Linehan has made a similar point that there is an “inherent tension between validating a response versus trying to change that response” (Linehan, 1997, p. 367). She thus describes therapy as a dialectical process of both empathically focusing on the client’s experience and focusing on change.
Of course, we would like our patients to change in ways that diminish their suffering and promote their growth and fulfillment in life; however, that effort is often at odds with the need to feel safe and validated in their suffering. If we encourage the client to go beyond resisting or avoiding, we are implicitly saying, that he should change; this is inherently invalidating of what the client is doing currently. So we try to walk the thin line between validation and change.
Some clients are more sensitive than others and may detect the slightest signal of invalidation. Other clients come in with a strong conscious readiness to change and may even elicit in the therapist to show ways he could or should change. But also here there is the risk that the therapist may unwittingly be colluding with the self-criticism of the client.
Many times I still “go for the affect,” (as Diana Fosha calls it in her workshops) trying to bypass the defenses, but more and more, work with patients has become focused on recognizing the gifts that clients are giving to me spontaneously. Here are some examples:
–Intense sadness announces the desire to change.
–Anger reveals protective resilience against pain.
–Unstoppable talking comes from the need to be understood.
–A question about my personal life may reveal a wish for closeness.
–The sharing simple facts and stories stems for the need to be heard and known.
–A subtle thank you at the end of the session is a huge relational gift to me and the tip of the iceberg of a client allowing himself to depend on me.
–A telephone call to a friend may show a big shift in relating to others.
–The “I don’t want to feel this pain again” is the first acknowledgement of that same pain.
–The vague smile that very shortly appears in the middle of a very sad story can be the beginning of shifting perspective and transformation.
–A patient reporting that “she wanted but couldn’t” is not a sign of failure but an opening for exploring anxiety and how this situation did not feel safe enough.
–A patient who apparently doesn’t want to talk about the pain of the father who abandoned him, is giving me a lot by telling me about his strength and the experience of how it was taking on life as a teenager without a father.
–The client who comes in with the huge defense,“I’m great, no bad feelings here,” is showing me right now something about a life of keeping suffering to himself. and having to show that he is happy.
However banal a story may seem I ask myself: “Why is the patient telling me this?” “What makes it important to her?” or “Why does he want me to know?” However defended a client may seem, if I am perceptive enough, I can find meaning, underlying emotion, attachment needs, resilience or adaptive effort, informing me where to go next. Rather then focussing on what the patient is not doing, I try to focus on and affirm what the patient is doing: the connection, the trust, the wish to change, the honesty and the courage.
My wanting a certain change to happen and having a fixed idea of where to go, may often be useful. And just as often, it can be an obstacle to really see what is happening with the client and where she really is.
This reminds me of Bion’s dictum of the proper attitude for starting a session as: “without memory or desire” (Bion, 1967). I adapted this slightly for my purpose into “with memory, without desire,” as I find that the memory of what I have seen before in patients and in my own life helps me to recognize the gifts, potential and meaning of that is implicit in what the patients are offering me.
Some of the work I did with Leonor taught me a lot about the importance of therapist patience. I think it illustrates the ongoing struggle I experience between my wish to help and how that gets me into trouble by losing sight of the patient’s experience.
Afonso, Leonor’s boyfriend , was killed instantly in a car crash. They had lived an exceptional love story lasting 12 years, starting when both were 14 years old. His life ended and her life collapsed. She returned to live with her parents, and had to stop working. She came to me one month after the accident and told me she needed help, that she could not do this alone.
Her main feeling in the beginning was that of horror and guilt, and of all the ways she should have acted to avoid his having to come home very late after work, when he was too tired to drive. She would obsessively try to find out details from of the accident, and replay the last telephone calls and the moment of the accident in her head. She would imagine how it must have been for him, what he must have felt and thought, trying to undo the fact that he had been alone in this last terrible moment. She kept as much of Afonso’s things intact as she could, and her room turned into a kind of mausoleum. She would visit Afonso daily in on the cemetery crying and having long conversations with him. After a few months, she tattooed Afonso’s face on her chest.
People around her worried about her and started to urge her to go back to her life and to think about the future, which would leave her furious, feeling misunderstood and alone. These reports were a warning for me not to make the same mistake. And although her reactions were extreme, I could relate to it as their love story was so truly beautiful and fully lived.
Being a psychologist herself, Leonor knew something about depression and at times would inquire if I thought she was depressed and if this mourning process was “normal.” I said that by the criteria people might find her depressed, but that I didn’t care if this was a normal process or not. I told her normal people don’t exist anyway. Her whole love story with Afonso had been exceptionally intense, and so I said to her that we could only expect that her mourning process would not be ordinary or normal. I would show her how she was progressing by integrating and confronting herself with and all the aspects of this loss. She felt very validated and said she wanted to live this mourning as completely as she had lived the relationship. I was happy that she felt supported, and she acknowledged the safety and the enormous support she got from our work together. It was intense and painful but it was very real.
But there were times I doubted if I was doing the right thing. I questioned whether I didn’t allow (!) her suffering too much. Wasn’t there supposed to be a balance between supporting patients in their suffering, but avoiding to reinforce their pathology? Wasn’t I too much on the supporting side? By the criteria, it was easy to label this as a pathological mourning (Welling, 2003). Wasn’t she avoiding experiencing his absence by keeping him so alive?
At those times I became impatient and I would, for instance, suggest letting more pleasure into her life, something she downright refused. Or I kind of hinted at the idea of saying goodbye to Afonso at which she reacted with shock. I felt we were getting in a struggle, that I was losing her and this was not the way to go.
I had to remind myself many times to really be with her in her experience at the place where she actually was and let go of my wish that she should be somewhere else. I wanted to be more attentive to the gifts she was giving me. There were all kind of subtle steps she was making; all I had to do was notice them and make them explicit.
Every week she would talk about a different aspect of missing him: the conversations, his advice, him being when arriving home, watching movies together, his body, the planned children. At first I thought that missing was a way of not accepting his loss, but I learned to see how this was actually a process of facing the loss. She was doing the mourning piece by piece! Then I could make this explicit.
She would tell how terribly lonely she felt and now I would say how brave she was to face that Afonso was not there anymore. When she would say she would remember his hugs, and I could say that I understood how hard it was to have to live without them. When she said she was disappointed in her friends, who didn’t understand her like Afonso did, I could see that she was actually trying to receive something from them, even if their efforts disappointed her. I would bring it to her attention when there were days when she would come in lighter, which would then fill her with shame and guilt to be alive. I would gently remind her whenever she had initiated some activity she had never done since he died, after which she would make sure to tell me that it was not the same thing without him.
A year into the process after the holidays I got impatient again. I felt her process was kind of stuck, and her musings over Afonso were repetitive and didn’t seem to go anywhere. I told here that she had done a lot of work, that she had suffered enough, and that she might try to focus on things other than Afonso. Over a couple of sessions I felt we were getting into a fight again. I knew I had to change course and that I had gotten impatient again. As I was writing this article, I tried my own recipe: I tried to go back to seeing were she actually was.
After telling me how hard her week had been, I asked her if she wasn’t fed up suffering. To my surprise she said, “No, I have a good reason to suffer.” But isn’t there anything else you want for your life? No. But it was not a depressed “no,” it was a determined no. I intuitively felt that this active renunciation of volition was important and I set up camp there. “Stay with that, what else can you tell me about this not wanting anything?” Somewhere in this session, she spontaneously told me this seemingly unrelated story: “The other day someone told me about the hole in the ozone layer getting bigger, and I thought I don’t care that the earth gets destroyed.” I heard the anger in the content of this story and saw that she got activated emotionally while telling me this. I recognized that here was my gift. “So I see you are very angry at life for what it did to you,” I reflected. “Yes, she said, it took away my love, my house, my job, and my dreams.” “And if this is what life is about, then you don’t want it, you refuse to dream again,” I conjectured. She agreed and we explored this anger and her rejection of life being so unacceptably unfair and cruelly random. I metaprocessed with her how it was to acknowledge this anger and refusal to live again here with me. She said it felt good and that she felt relieved. I felt this was pure, this is where she was and this is where we should be together and not try to be anywhere else. I felt free again of the urge to “do more” and we were on track again.
Soon after she proposed to be a day on her own in Lisbon, sleeping in a hotel like she used to do with Afonso to celebrate their relationship anniversary. Again, there was a gift here: She made a move towards autonomy. I just needed to make it explicit: “Wow, this is going to be the first time in a year and a half that you are going to spend a whole day alone with memories of Afonso. That requires courage!”
Now, three months after this article was written Leonor feels she deserves to enjoy the rest of her life and feels that she has her deceased boyfriend’s blessing to do so.
Bion, W. R. (1967). Notes on memory and desire. Psychoanalytic Forum, 2 (3) 271 – 280.
Fosha, D. (2000). The transforming power of affect: A model of accelerated change. New York, NY: Basic Books.
Linehan, M. M. (1997). Validation and psychotherapy. In A. Bohart & L. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 353-392). Washington, DC: APA Press.
Welling, H. (2003). An evolutionary function of the depressive reaction: the cognitive map hypothesis. New ideas in psychology , 21(2), 147-156.
I want to thank Netta Ofer and António Branco Vasco whose influence I sensed on several points in this article but are difficult to refer to specifically.[pdf-lite]