Article: Clients that Didn't Get Better

I mean, sure. But... I think there's something missing here. The psychodynamic therapy is really about using the relationship as a means of healing (if I understand correctly).

Not everyone can do that. Even if they're showing up, trying, and working hard. That's one of the reasons that people end up in therapy, because they're not able to really connect with others, for example.

I was talking about my experiences in therapy years ago, and a friend pointed out that most people get "into" the relationship with their therapist quickly and easy, and move on to the hard work of whatever they're working on. But, for me, the "work" might actually be establishing that relationship. Learning to trust enough to be myself and experience emotions with my therapist. Being able to connect. All that stuff... Her perception was, "Maybe for you that might be 90% of the effort/time in therapy... maybe THAT'S what you need to do, then the rest will go much more smoothly and quickly."

In that case, it can look like I'm not really doing the work. I look resistant and like I hide things from my T. But it's not because I'm not TRYING. It's because I'm not at a point where I feel like the relationship is real, or sturdy enough to lean on it. I don't HAVE the connection yet. And, in my case, I KNOW that getting into "my stuff" is extremely destabilizing to my life - I've done it before, and it was a huge mess. It would be incredibly stupid of me to try to jump in to the deep end before I know that T is capable of throwing me a life jacket or something.

Cinnamon_Roll - Thanks for the extra explanation! That makes sense. And, sounds incredibly difficult and crazy to deal with. I can't imagine a T expecting me to schedule my vacations around their time off . I hope there aren't too many of those types left.

re: Feeling your emotions in T... ugh! I mean, that's great that you're working on it, but I struggle with this too. I just don't feel like I *experience* emotions while in T (other than lots of fear!). And, I keep coming back to it not feeling quite safe enough for me, though I'm not sure what else I need. Hmm... yeah, even just thinking about it, I get a pretty strong "nope!" feeling inside!

Here Today ("if a person lacks the motivation to do the homework -- that seems more to me like something going on in the motivational system of the client that neither the therapy nor their existing coping skills are addressing") - YES. I agree wholeheartedly with this.

I don't think it's the therapist's job to "fix" someone, I don't think a therapist CAN "fix" us - they have to help us fix ourselves. BUT... if therapy isn't working, I DO think it's the therapist's job to acknowledge that, try to figure out why, and help the client address it.

If a client isn't motivated to do the homework - why? Is there an unconscious fear of change (for example, are they afraid that by changing themselves, their spouse might not love them anymore?) Do they have issues with authority and feel like the therapist is stepping on their independence by assigning homework? Is the homework too hard for where they're at and overwhelming? Or too easy, and seen as ridiculously stupid? Is the point of the homework not clear? Do they not trust the therapist enough to try the homework to see what they get from it? Are they overwhelmed by other things in their life, and can't find the time to do homework and meet their basic needs for sleep, food, and a shower?

There's lots of reasons. And the reasons are important... they can help find a way "in" - a way to actually identify what's really going on beneath the surface. (And THAT'S what I think/hope/expect that Ts with psychoanalytic training shine at!)

Thanks!

Wow! Really?! How can a therapist “objectively” tell a client that the client isn’t experiencing what the client says they are experiencing?!
Personally, I would ditch that therapist!

With regard to only showing the therapist one side of yourself (the good side), I think it would be helpful to let the therapist know that is what is happening, but you find it difficult to reveal more. But, then it’s the therapist’s job to find a way to elicit your “hidden” side.

In the cases mentioned in the research, where the therapists felt like only “half the person” was with them, in therapy, surely they needed to address that with their clients directly, and try to get to the bottom of why that was? Only then would they be able to find a way to assist their clients to open up about what they were hiding, and actually get to the root of their clients’ problems.

I think this is a very accurate summary of the situation and problems. I'm officially in psychoanalysis but it is not the "analysis" we are doing really, precisely because I'm one of those people who cannot use the relationship. So the whole work is about trying to find ways to create this relationship, to find the connection, to sustain it even a tiny bit. I might never get to the "real psychoanalysis" but I don't think matters - neither to me nor my T - what matters is where I am currently and what I need right now and how we can work on that.

I also wanted to comment a bit more on psychoanalysis/psychoanalytic approach.

Although it is typically defined in terms of a frame (e.g. blank slate, using the couch, frequent sessions, expecting to schedule vacations etc) and the frame is an important part, I don't think this is a defining feature. There is something else that is much more important, so that if you take this something else away and only the frame remains then there is really nothing analytic left. I think public view of the definition in terms of the frame exists because these are the visible parts - this other something is not really visible, but if I would have to define it then perhaps right now I would say that this expresses itself in few things.

1) Being very patient. Here a also mean the suspension of the eagerness to go along with the more active and attractive part of the patient (the presenting part in the half-patient in the current context). The T's task is to create a representation in his mind about the whole patient, including also those parts that are missing from the treatment and that present themselves precisely through the lack of being present.

2) The ability to tolerate and "digest" difficult and intolerable feeling states, with non-judgement, curiosity and perhaps benevolence (I don't want to use the word "friendliness" because that already assumes some polarity and blocks the way for the patient feely freely unfriendly or even hostile when needed), without the need to throw these feelings back to the patient too quickly, prematurely.

If those things (and maybe something else that I cannot articulate right now) are present then all these frame components will have their natural role and they don't define the treatment.

For instance, I find it very dangerous when a T, who is not trained analytically but who likes this approach, tries to mimic the blank slate technique. I don't really know how this technique was used by US analysts in 50s or 60s and I only have experience in analysts trained in Europe (basically contemporary British school), but the blank slate and use of silence are not things in themselves but techniques to use when appropriate and not to use when inappropriate. This requires the ability to make an informed judgment by the T if and when it is appropriate (i.e. it helps to further the treatment for the patient). If the patient does not tolerate it (i.e. tends to regress too much) then it is not appropriate and should not be used.

Btw, my T announces his vacations in the beginning of the year and although he does not expect me to take my vacations at the same time, he does expect me to pay when I decide to go on holiday on any other time. So in that sense he is "old-school". But really, I don't perceive it as any problem because this is just one part of the frame and not the defining feature of our work. Besides, I think this vacation thingy came originally from middle Europe anyway where people, at least those who can choose, all tend to take their vacation in July or August. In my country, majority of people have vacation in July, thus it is really a no-brainer to synchronise our vacations. I would understand that it would be weird if my T would decide to take his vacation let's say in February and work in July and would expect me to do the same.

This is something that I finde so intriguing about this article. The blatant contradiction between the fact that the clients didn't get better, and that their core problems quite often weren't even touched. And yet they (the therapists) so strongly believed in their narratives, that therapy (ie themselves) was useful for the client.

Somehow they seemed to need this legend in order to hold on to their image of themselves as a 'competent' therapist.

But in fact, this self-image (or rather their adherance to it) seems to be part of the problem since the therapist don't seem to be able to question their approach and their conceptualisations of the case...

Thanks for your comments on psychoanalysis in general, feileacan. Found them very useful. I think that is the really important bit. But: It's not just the "public view". I met serveral psychoanalysts for interviews who were so caught up in their method/approach that they seemed unable to focus on the relationship part. For them the approach or structure has become more important than the content, I suppose. Which is really sad. Also, those type of analysts are probably the ones who fail to 'notice' that their client (who is only half there) is simply not at the point to enter into the therapeutic relationship in way that the actual 'work' might begin. Or the other way round, they fail to realize, that helping the client to stay present in this relationship is part of the work...

When I met those analysts for interviews *all* of them were incredibly keen to take me on as patient. Without exception. Because all of them focused on this highly functioning part of mine, were intrigued by my intellectual and introspective abilities and were totally and utterly convinced that they would be able to help me (despite by now 7+ years of therapy with some improvement but no significant results regarding the 'core problems').

I met a few of them for a second session, and when I told them that I found it difficult to "hold" the connection to them during the session, they said that they hadn't been aware of that... Which speaks volumes.

I've surprised myself that I started working with a psychoanalytic T now. Those interview experiences over the years were so disillusioning that I never really considered this approach for myself. This new T is very unorthodox in her approach. In fact, with her, I felt right from the start, that she 'sees' me and adapts her approach accordingly. Which is how it should be really. We briefly discussed the 'framework' in the beginning (no. of sessions per week, couch /sitting up etc.) and she made it so clear, that this is 'my' therapy therefore it's about what I need in any given moment. And her job is to help me find out what I need, but not to use coercion to bring me into an 'ideal' psychoanalytic frame. It might help that she's also got extensive training in trauma therapy. Which I find a very good combination. And which makes her approach so refreshingly "un-analytical", whilst she is deeply aware of the emotional dynamics in the room. Which works for me so far (and I'm hoping this will continue...)