It’s wonderful when treatments lead to major success and character change, but I will go out on a limb and assume that no one always succeeds and that no one never makes mistakes. I want to contribute to a culture where those who teach and supervise also discuss their mistakes and showcase work that isn’t going so well.
In this blogpost I will share a de-identified transcript—containing both nonverbal information and commentary—that highlights a way of attempting to address the omnipotent transference resistance. So far, 6 sessions in, this is not a very successful course of treatment. I believe there is much to learn from this case, and if nothing else I hope that my trainees will see how I can make the very same mistakes that I sometimes point out in their work.
My rationale in this session—which in hindsight I can see is misguided—was to try to go for higher mobilization of the patient’s psychodynamics to try to tap into some UTA, but I believe I end up feeding into the omnipotence and fortifying the transference resistance. Having said that, my best courses of treatment have always involved taking occasional wrong turns and finding my back. I remain hopeful about the ultimate outcome with the “Make Me Feel Better!” case.
Before I get to the transcript—a few words on the omnipotent transference resistance and an extremely truncated literature review:
The omnipotent transference resistance seeks to override the reality that the longings arising from unmet childhood needs will never be gratified, and this form of resistance seeks to obscure the adult division of responsibilities. The omnipotent transference resistance can be seen as highly transferential and regressive in nature because the patient distorts the reality of both the patient-self and the figure of the therapist by seeing the patient-self as less capable and seeing the figure of the therapist as more capable—indeed omnipotent, as the name suggests.
From Sigmund Freud’s structural model of the psyche, this form of resistance can be understood as originating in the ‘Id’ where the pleasure principle is subsumed by resistance. In Beyond the Pleasure Principle (1922), Freud asserts, “There is no doubt that the resistance… sub serves the pleasure-principle; it is trying to avoid the ‘pain’ that would be released by the repressed material, and our efforts are directed to effecting an entry for such painful feeling by an appeal to the reality-principle” (p. 23).
In An autobiographical study of inhibitions, symptoms and anxiety: the question of lay analysis and other works (1926) Freud writes, “The fourth variety [of resistance], arising from the id, is the resistance which… necessitates ‘working-through” (p. 160).
Further elucidating this phenomenon, Ralph R. Greenson (1967), in The technique and practice of psychoanalysis: volume 1, writes, “The patient’s transference love always becomes a source of resistance. It may oppose the work of analysis by the patient’s urgent demands and longings for immediate satisfaction. The analytic hour then becomes an opportunity for gratifying the patient’s desire for proximity and closeness and the patient loses interest in insight and understanding” (p. 227).
In Davanloo’s Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD (2000), Davanloo writes:
“Many patients have a strong tendency to transfer to the therapist the role of someone from the past. The aim is to emphasize and bring the patient back into the reality of the task and to avoid getting involved in the patient’s transference.
As the therapist’s major task is to mobilize the unconscious therapeutic alliance against the resistance, he must at all costs avoid getting into the position of implying that the purpose of the interview is for him to change the patient [my italics],
rather than for the patient to change himself. The therapist’s task is to avoid getting into the position of being omnipotent and a figure of the past.Throughout the head-on collision, the therapist repeatedly emphasizes the patient’s responsibility, “refusing the transference role” that the patient is trying to impose on him” (p. 238).
These citations point to this thorny form of resistance that all too commonly derails treatments. The Davanloo citation is one of the few places in his writings that I have found where Davanloo is explicit about the importance of not pushing your own agenda onto the patient and of not stepping into old shoes, though I understand this is something he would discuss more often in his oral teaching.
The things I did well in this session only had a minimal impact due to the fact that I tended to relate to the patient as if her will was fully on line when in fact it was not. The patient and I have not managed to make any substantive inroads into her symptomatology.
Some of the useful interventions in this transcript involve encouraging the patient to reposition the posture of her hands to reverse self-directed aggression, clarifying how the question of how she experiences her anger is not about the patient propositionally describing her conscious experience, but instead this pressure to the experience of feeling is to help the patient have the feelings, not talk about or describe them.
Consistent with this understanding, the transcript demonstrates how I discourage the patient from offering “weather reports” on how she experiences her anger.
The “Make Me Feel Better!” Patient
The patient is in her late 50s and presented with chief complaints of major depression and procrastination. In the first 5 sessions there were inquiries into the nature of her symptoms, relationship history, helping her see her triangle of conflict, breakthroughs to anger and sadness, some capacity building, and work on restructuring regressive and self-attacking defenses. One pattern that emerged involved the patient reporting significant symptom relief towards the end of the sessions, but the gains did not generalize, and she was as depressed as ever every week.
The transcript that follows is from the 6th session, and it illustrates how the barrier to greater progress appears to have its source in a well camouflaged ‘resistance of the id,’ where the patient had convinced me that she was fully behind trying to resolve her depression, when it fact it was other longings that she wanted to satiate (consistent with Greenson’s earlier citation). The patient is very skilled at acting the part of a “good patient,” which she appears to do because she believes this to be her admission ticket to be able to see me. The patient can intellectually see how her omnipotent expectations on me to work a miracle are not consistent with reality, though this insight does not appear to translate into the letting go of these hopes.
What complicates the matter is that some of the breakthroughs of feeling and concomitant symptom-relief, albeit temporary, appears to at least in part have been genuine. In the final analysis the patient picture appears to be one where the presentation consists of a portion of ego-syntonic compliance and engagement in the service of an enacting the relationship with her father, and on the other hand, at least partial genuine will and engagement.
The patient typically displays higher order defenses and can isolate affect with some striated muscular signaling, but with a somewhat low threshold to a more regressive self-attack sometimes characterized by mild weepiness, internalized aggression in the form of somatic pain, major withdrawal, self-critical thoughts, and minor explosive discharge when the ‘screws are turned’ through the phase of heavy pressure and challenge. Character defenses consist of passivity and intellectualization, which were the hallmarks of how she maintained a semblance of a relationship to her intellectual father. In relationships she has tended to take a used and abused position and override important boundaries. Strengths include psychological mindedness and intelligence. The patient appears somewhat right of center on the psychoneurotic spectrum, with a moderately masochistic organization.
As I suggested earlier, in this session I opted to try to get a higher mobilization of the patient’s psychodynamics through pressure and challenge in the hopes of getting more of the UTA going, but looking back, I believe this may have reinforced an element of compliance and I would have served the patient better by remaining in tier-1 and inverted forms of pressure.
The patient started the session silent, passive, yet I could see that she was glad to see me. At this point I had a faint sense that I might be in the father’s shoes—had I intellectualized too much with her? Acted too paternal? When asked why she was passive, the patient had reported a ‘gloom and doom’ depressive mood with collapsed motivation. We drop in 9-minutes into the session:
Therapist: Look at it: on the one side, we have the hopelessness, the dreariness, you know, passive silence, depression, collapsed motivation. That’s one side of it. But if that was all there was, surely you would cancel our therapy appointments and just say, you know, ‘this is not for me anymore.’
Commentary: Here I am simply looking to clarify and bring into bold relief the situation at hand while drawing the patient’s attention to the most obvious conflict, which is that she shows up for psychotherapy but remains emotionally disengaged.
Patient (with more energy in her voice): Well, the depression is what’s not for me anymore. Feeling this way is what’s not for me anymore. I’m just… Yeah. I just don’t want to feel this way. I just don’t want this heaviness, this having to force myself to… To do things that I shouldn’t even have to think about doing. Just that kind of… I don’t want that in my life and I don’t want to be like this. I don’t want to feel like this.
Therapist: So, there is this spark within you that really wants to get better. [00:09:00]
Patient (some shifting around in her chair, still energy in the voice): Yeah. I just want this to work. I want it to go away. I don’t want to be like this. It’s depressing feeling like this. It’s oppressive.
Patient: And it’s coming from inside me. I mean, I can look at all these other things and say, you know, well, it’s my sister or it’s my son or it’s this or it’s that. Um. But it’s from within.
Commentary: the patient is saying all the things any therapist would want to hear. Though there are slight signs of striated muscle activation, it’s only slight. My countertransference tells me that though there may be some genuine will on line, it also feels a bit compliant.
Therapist: From within. Mhm. But when you’re in this cloud of depression we see that you go very passive and silent. Yeah? (Pt nods) Okay. Do you realize that no one gets close to you then? I can’t get close to you. No one gets close to you.
Commentary: Here I wish to shore up insight and agreement around the primary thing that the patient is doing that is impeding progress—keeping a distance through the depressive position—while clarifying how this functions to keep her emotionally out of reach.
Therapist: You’re out of reach, emotionally speaking. [00:10:00]
Patient (small sigh, conviction in voice): yes, I do.
Therapist: Uh huh. And so, we have to see what we can do about that, right? Because the only way this is a good use of your time is if we’re connected to each other so we can access your most intimate thoughts and feelings. You see what I mean?
Patient (energy in voice): Yeah.
Therapist: So, is there a barrier of depression between us right now?
Commentary: Again, this is in reference to the fact that she began the session passive and silent, reporting collapsed motivation. I asked again because it was not clear to me that the patient truly agreed with the formulation, that she had “owned” it, so to speak.
Patient: I don’t know. Maybe I’ve just… Internally feel… just kind of wiped out.
Commentary: The patient’s response is noncommittal, which is at odds with the fact that only a minute prior she agreed that she was emotionally distant. In hindsight I would have wanted to bring this discrepancy to her attention and commented on that she appears to have changed her position and is now equivocating.
Patient: And I did a lot of energetic things today.
Therapist: Mhm. But you know, you just said though that you can always point to external things, but we know it’s coming from within. Hmm?
Therapist: So we don’t want to blame it all on the externals, there’s something within you that we haven’t fully resolved.
Commentary: Could I do this session over; at this juncture I would have said: “Do you see how you now seem to be doing what you said you were prone to do—blame externals and then you equivocate on whether or not you are distant? And maybe you aren’t sure you want to give this up.”
Patient (small sigh): Yeah. It’s [00:11:00] like a dead place. It’s like a… It’s just like… It’s just like everything closing in on me and me wanting to just… read, read, read, do something to distract myself from who I am. Read a book.
Therapist: So that part of you that wants to distract yourself from who you are, that part of you must have some feelings here with me because I represent the opposite.
Patient: Mhm. Yeah, you do!
Therapist: So what are your feelings here with me?
Commentary: Though I do represent change for the patient, I believe this focus may distract her from her own will to change.
Patient: Right now I feel [00:12:00] about the same as I felt before we started. Feel relaxed. Actually, I don’t feel… Pressure. I don’t feel negative about this. I just wish I… I wish I could, like, reach in and get rid of this feeling.
Therapist: Right. But do you see that we’re having great difficulty seeing what your emotions towards me are? Because, you know, “I don’t feel negative. I feel calm. I feel the same,” that that doesn’t tell us anything about the emotions towards with me.
Patient: But I feel sad. I feel depressed. Sad.
Therapist: Still we don’t know the feelings towards me.
Patient: That’s right, this is all just inside of me, But for you… I’m. I’m glad I’m here. I feel good to be here. I feel like I’m doing something to try and get better.
Commentary: It had been obvious to me at the very start of the session that she was glad to see me, but a kind of glad that did not necessarily indicate that she was gearing up to work hard.
Therapist: Yeah, there’s positive feelings here, but then there’s the part of you that wants to distract yourself and wants to [00:13:00] read a book.
Therapist: But we don’t know how that part of you feels towards me because I represent the opposite of that.
Therapist: “Yeah” still doesn’t say how you feel. I mean, surely there would be feelings there. Surely it’s not a neutral situation. You know what I mean?
Commentary: Looking back I would have liked to reflect back to her that she still appeared passive. In hindsight I believe I was compensating a bit too much for her passivity, which made it more difficult for me to see it.
Patient: Yeah, I do. I do.
Therapist: So let’s see if you can get in touch with your feelings towards me. The part of you that wants to distract yourself. Mhm?
Patient (small sigh): A part of me that wants to move forward toward you. And there’s a part of me that wants to pick up a magazine.
Therapist: So, in a sense, very mixed feelings here. But both positive and negative. But let’s see if you can get a little more clarity. I mean, the part of you that wants to pick up a magazine [00:14:00] is feeling what, towards me?
Patient: The part of me that wants to pick up a magazine. Where I truly lose myself in reading.
Therapist: Yeah, but how you feel towards me right now?
Patient: A little bit angry.
Therapist: How do you experience that anger?
Patient (tearful, raised voice): Anger. Frustration. I thought I’d feel better. And I put the responsibility on you to make me feel better. And it didn’t happen. I’m disappointed. Kind of angry. Frustrated. How? What am I going to do? How am I going to get help? [00:15:00] Like, putting the responsibility on you?
Therapist: Sure. Yeah. Part of you had those longings that I could swoop in and just help you feel better.
Therapist: And that’s understandable. That would be really nice if that was possible.
Patient: It really would!
Therapist: So it is understandable that you’re angry towards me. But the issue is, can we face that more fully or do you want to just skim the surface of it?
Patient: Well, let’s go more forward. I mean… It’s I mean, I don’t feel like I’m angry. But I am angry if that makes sense. But I mean that it’s like that feeling… I mean, maybe that’s what depression is. It’s like repressed anger. I don’t know.
Commentary: The absence of a sigh should have alerted me to the fact that her will was not sufficiently on line.
Therapist: Yeah, but right now, we have to see what you’re going to do about the ruminating, [00:16:00] right? Because you could ruminate about this all day long, and we won’t get anywhere. You know what I mean?
Patient: Yeah. I don’t want to.
Therapist: Right. Yeah. If you don’t ruminate right now, if you don’t waffle between anger and not anger and all this rumination. Let’s see how you experience the anger towards me right now.
Patient: Well… I… well, I want you to magically do something that’s going to lift my depression.
Commentary: It is clear to me that the patient intellectually understands that I am not a magician, and so with reality testing intact, I believed I could keep pressing. What I am missing is that even though her reality testing is intact, it does not mean her will is fully on line.
Therapist: But that doesn’t say how you feel the anger towards me.
Patient (raised voice, slightly teary): I’m angry that you’re not doing it.
Therapist: Yeah but how do you experience the anger. I mean, we know you’re angry. We know why. And that’s good. But it’s not enough, is it?
Patient: Just experience it by withdrawing.
Therapist: Yeah, but that’s a crippling force, you know, a crippling paralyzing force. That furthers your depression. So [00:17:00] right now, you’re seeing the anger and the withdrawing are mushed together. You can’t feel the difference between them.
Patient: I do feel I do. I just feel that anger is energy, right? I feel some energy with that, right? I mean, I couldn’t say I was angry, but I feel energy about it. I mean that because it does feel different.
Therapist: But let’s see how you experienced this angry energy right now.
Commentary: The patient may have simply corrected me or may have taken an argumentative position. It wasn’t clear which one and I believed I could press through.
Patient: Just kind of more twitchy, nervous, tense.
Therapist: But apart from this nervous tension, apart from it, how do you experience the anger underneath towards me for not making you feel better? Mhm. Because now you go silent, which isn’t going to help us. So let’s see how you’re going to overcome this [00:18:00] silence. You know, the stonewalling. Mhm.
Patient: No I don’t feel like I’m stonewalling. I feel like I don’t have anything to say but I know I do. I just. Just like, I just clamped down on it.
Therapist: Yeah, but let’s see what you’re going to do about this need to ruminate about the process, huh? Let’s see how you feel your anger towards me if we don’t ruminate and analyze? Mm.
Patient: I feel it as tightness… Kind of a slow burn.
Therapist: But tightness seems like anxiety, right? I mean, let’s just see if you can actually experience the anger right now more fully, huh? You don’t have to give me weather reports about what you’re aware of. Let’s just see now, what are you going to do to actually experience this anger? Hmm?
Patient: Mhm. [00:19:00]
Patient (raised voice, a bit teary): I am really feeling anger. I’m feeling upset that you don’t have some magic bullet, that you aren’t… You’re not saying something that’s going to make me feel better! And I know that’s silly, but I still feel it. And I don’t want to be angry. Yeah, I don’t want to feel upset.
Commentary: The patient is clearly expressing that she is conflicted and not fully decided on facing her feelings. I treated this indecision as tactical and not rooted in a major resistance, which is why I opt for trying to press through. This seems to be a mistake.
Therapist: Well, let’s not call it upset. Let’s call it what it is, which is anger. How do you more fully experience this anger towards me now? This is the moment of truth. Let’s see if you can go further.
Therapist: More… how are you fully experience the rage, Huh? Fully.
Patient (raised voice, teary): Well, you’re not helping me right now feel better. And I feel horrible. And… And I think that’s what you’re [00:20:00] supposed to do it! Just do something that makes me feel better! That makes me feel more alive. That makes me feel…
Therapist: If we don’t explain things… you’re explaining. How do you feel? The rage without the explanations.
Patient (almost shouting, fingers pointed towards herself in claw-like fashion): I just want to scream. Do something! Okay, so now help me, right? Fucking help me!
Commentary: The patient’s anger is still filtered through the omnipotent transference resistance/resistance of the id, as well as self-attack, with slight repressive weepiness and discharge. “Fucking” may suggest sexual undertones, but then again a cigar can be just a cigar, as this is a culturally normal expression of anger in the US. But the more fundamental issue here is that I am engaging heavy pressure and challenge in the absence of her will being sufficiently onboard.
Therapist: Turn your fingers outward. Turn your fingers out. Because they’re going on you. So turn the rage on me. Not on you. On me. And now imagine the rage coming pouring out onto me. Not you. Me.
Commentary: This intervention is again meant to reverse the directionality of the impulse.
Patient: Okay, then you should help me. You should want to help me. And you should have something to do that will help me feel better.
Commentary: The omnipotent transference resistance and the resistance of the id are in operation, blunting her feelings towards me.
Therapist: Right. And how do you want me to feel right now? How do you want me to feel right now when you’re furious with me?
Commentary: The desired outcome with the question of “how do you want me to feel” is to establish a cognitive awareness of the sadistic impulse, as this awareness often creates a protective wedge against the internalization of the impulse. The intervention mitigates against self-attack and can help the sadistic impulse change directionality.
Patient: I [00:21:00] want you to feel like you’ve missed something. I want you to feel like, ‘Hey, I really screwed up here and I need to find a way to help her’, Right?
Therapist: So would that make me feel good or bad?
Patient Well, it felt good to say that. I mean, usually just thinking that would make me feel horrible, but it didn’t make me fee horrible, it felt very good to say that.
Therapist: Right. So you’re now you’re making progress. Okay. When you’re angry, you want to be hurtful, right? It’s part of being human, isn’t it? Okay. But we saw your fingers were going like this (gesturing fingers pointed inward), so all the negativity was channeled against you, right? And when you put your fingers like this (gesturing fingers pointed outward) and you could experience the part of you that wanted to be hurtful towards me. It feels much better, doesn’t it?
Patient: Much better. Much better!
Therapist: So much better. Isn’t it.
Patient: I just never [00:22:00] do that. I mean, I never experienced that. Except with you, I guess.
Therapist: But now let’s have a good think about this. This is very important to examine now, okay? Because we’re learning that you’ve had a longing to be rescued by me. That I’ll swoop in and make you feel better. And it’s a very understandable longing. I imagine you haven’t nearly had enough comfort like that growing up. You know, where the parent just embraces you and all is well and you know that everything is going to be okay. And you haven’t had enough of that. So of course you have a longing for it.
Patient: Mhm. Yes (emphatically said).
Therapist: But your childhood is over, so it’s no longer possible to be rescued. It’s only possible when we’re children.
Patient: That’s true.
Therapist: Okay. Yes, but still you have the longing nevertheless.
Patient: Nevertheless, I do, right? I do. [00:23:00] Yeah.
Therapist: So again, it’s understandable. And so therefore, you’re enraged with me as you realize that I can’t rescue you.
Patient (small sigh): Right? That’s right. Absolutely right.
Therapist: Yeah. So far, so good. It’s all very logical. But then sometimes, instead of feeling the rage, you become very passive and silent.
Patient: All right. Okay.
Therapist: Or you get tearful and weepy and you feel bad about yourself, right? Okay. But it feels much better when you can just feel the rage towards me.
Patient (beaming and said with conviction and energy): So amazingly better!
Patient: Right. Yeah. It’s like if you told me this. I’d never believe it, but it does. It is true.
Commentary: My intention here is to celebrate a small win and drive home cognitive insight into the link between allowing herself to feel the sadistic impulse towards me and improved mood and reduced tension.
Therapist: So my question to you is this. Would it be worth it to you to continue to work on tearing down [00:24:00] these walls and facing the truth of your feelings? Not in the service of trying to get me to comfort and rescue you, but in the service of you yourself getting to the bottom of your depression.
Patient (small sigh): I just want to get rid of it. I want to get to the bottom of it. It’s. It’s getting… It’s… It’s worse than it has ever been. And it’s, you know, it’s like going down a dark tunnel and truly never seen any light. Right. And I’m sick of it. I’m sick of feeling this way.
Commentary: I would have liked to see a bigger sigh. Around here I am beginning to rethink my approach of heavy standard pressure and challenge.
Therapist: So but to have a good think about this, okay? Because, I’m wondering if at some level we’ve been working at cross purposes where even though you’ve told me in your own words that we were here to get to the bottom of [00:25:00] things, but in your heart of hearts, you were longing to be rescued by me, longing for me to comfort you.
Patient: That is true. That is true. Okay.
Therapist: And so that’s obviously a disaster for our work if we’re working at cross purposes. And that would also explain why your progress seems so short lived.
Therapist: I mean, you feel much better after some of our sessions. You’re so relieved. But then it doesn’t generalize to the rest of your life, does it?
Therapist: And so right now our job is to be unflinchingly honest about what’s really happening and what it is you really want. Because if you find yourself longing again to be rescued, we have to talk about it. We have to look at [00:26:00] it. You know what I mean?
Patient: I do. I know I am. I’m the only person that can rescue myself. Intellectually. I know this. I’ve known it my whole life. But I still want to be rescued. Taken care of.
Commentary: I sense she is being more honest, and that if we are to have any hopes of overcoming this hurdle it will be through full exposure of this part of the patient.
Therapist: And I appreciative how honest you are about it. It’s very encouraging to me that you can be so open about that. It must be profoundly disappointing and maybe angry-making when you realize that what you never got as a kid you’ll never get. That ship has sailed.
Patient: It has. I haven’t gotten it as an adult. And and I’m not going to get it. I know that intellectually, I do know that. And I know I am the only one that can rescue [00:27:00] myself and take care of myself. I do know that in life, it’s just painful to think about it.
Therapist: Right. Right.
Commentary: The patient slows down a bit and appears less spontaneous, more passive. I believe this part of her resistance is coming into bold relief because I discontinued the heavy pressure and challenge, which hid her passivity. I am silent for about 10-seconds:
Therapist: It’s still there, isn’t it? Just because you intellectually see all of this doesn’t mean it’s gone, is it?
Commentary: I believe this is where I finally stopped compensating for her lack of sufficient will and adopted a more appropriate stance.
Patient (small sigh): It’s there. I don’t want it to be there. It’s ridiculous. But it’s there.
Therapist: Because we see you have a tendency to go passive and wait for me to drive the session. Waiting to be rescued. And then you’re cut off from your own spontaneity and your own drive.
Patient: Yes. I am looking for permission and a roadmap. Permission…
Commentary: the patient is conscious of her defensive, one-down posture.
Therapist: Which is, of course, you know, is the [00:29:00] position of a child that need permission from a parent. So we can see how pervasive and ubiquitous this really is. This is really deeply ingrained. You see?
Patient (small sigh): I was looking for my mother to do it. Looking for my… Both of my husbands to do it. Friends to do it. And it just it never happened. Not even for a little bit. And it’s never going to happen. But it’s still this… Kind of a desperate feeling. Mm hm.
Therapist: Say more about the desperate feeling.
Commentary: I am looking to draw her out, understand potential nuances of her desperation, and approach her conflict without covering it through my own over-functioning.
Patient: It’s just those that. You know, all those years waiting for my mother to [00:30:00] care about me. To love me. To know me. Just, you know… And my first husband said. And then, um. My husband was a X. I really thought.. I felt so safe, you know, because I was in X. So I really thought he would know me. And he didn’t. You want to know? Waiting for… Hoping that… Against all odds… (small sigh) I guess I’d never really thought of it like this before.
Therapist: I mean, I can see pain in your face.
Patient (sigh): All those years waiting for people. Trying to.. Mm. It just never happened. And I know it’s not going to any new with my mother. And I knew with both of my husbands and I knew some of my friends that that is never going to happen. And still it just wish the whole kind of desperation. So, you know, I don’t know it just… I’ve done a whole lot of fantasy I guess.
Commentary: My change in approach appear to yield more sighs and bring her in closer to her intrapsychic conflict.
Therapist: But how do you feel about the idea of instead of looking for something that you can never get, that we just face the truth of your emotions about the fact that you never got it and you didn’t get it from the people who were supposed to give it to you?
Patient: Right. I mean, I feel fine about that. I mean, I accept it. (some silence). If I really accepted it, I probably would not keep looking for it.
Commentary: the patient here appears to become more honest with herself and with me.
Therapist: How do you experience me right now?
Patient (tearful): I experience you being helpful.
Therapist: And the tears now in your eyes. What are they? Angry tears? Sad tears? Anxious tears? What are those tears?
Patient: Oh, I really live for people. Um. And hopes that they would… be nice to me. Take care of me. So. And [00:35:00] it just never happened.
Therapist: So. Finding me helpful right now. Is that the adult part of you that that is feeling movement towards your goals in therapy? Or is it the younger part of you that is feeling like some of the needs to be rescued and taken care of and comforted are getting met?
Patient: No, I don’t feel comforted. I don’t feel rescued.
Therapist: So [00:36:00] this is really the adult part of you that finds that we’re having progress in therapy.
Patient: It is. Like me being present. Mhm. I don’t want to face it.. but let’s say I want to face that. It’s like… So what is it?
Commentary: The patient is clearly ambivalent still.
Therapist: Are there more feelings towards me right now then?
Commentary: This intervention of asking about feelings towards me does not address the main thing going on, which is that she is still ambivalent. Could I do it over I would have brought her ambivalence to her attention.
Patient: There is some gratitude. I was feeling dead. I feel alive now. Yes. What I to feel is that I am grateful to be alive [00:37:00]
Therapist: So there is gratitude and there’s positive feelings here. But is that the only way you feel? Are there any negative feelings at all right now?
Patient: No. This is a weird thing to say… it feels.. I am still relieved.
Commentary: The patient indeed is beaming, her face relaxed.
Therapist: So it isn’t catastrophic to begin to face the truth of your life.
Patient: Oh, it’s catastrophic to block myself off from just being alive.
Commentary: The patient appears more alive indeed, and yet I sense that her tendency to say just the thing any therapist would want to hear is still in operation. Looking back I believe this is what has created some confusion for me with this case—what appears to be such genuine symptom relief seems to have made it more difficult for me to address her compliance and ambivalence with more perseverance. Even though there appeared to be more movement when I reduced my activity and standard pressure and challenge, I went back to the approach of trying to get a higher rise to see if some UTA may assist in the process. I decide to assess to what extent she can experience her feelings towards her parents. I ask her who should have been there for her but was not. She reports her mother.
Therapist: But who should have really been there for you?
Patient: My mother.
Therapist: So what do you feel towards your mother?
Patient: Some bitterness.
Therapist: But I’m not clear on your emotion towards your mom. I mean, what is the emotion actually?
Patient: Oh, very, very mixed. Just. Anger. [00:41:00] Sadness.
Therapist: Uh huh. But how much of that anger are you actually experiencing towards your mom?
Patient: Not very much. Not very much. Except longing. To have her love. And it’s just… I don’t understand why at my age… she’s been dead for years. Why am I still thinking ‘I want my mother.’ Why can’t she… I want her to take care of me.
Therapist: But I mean, let’s look at this now, because there seems to be two things that are blocking your experience of the anger. One is that you become hyper focused on the longing. And second, you begin to ruminate. (patient nods). And [00:42:00] is that how you want to spend the rest of our session, the rest of your life?
Commentary: I am not focused on the primary issue, which is that her will is not sufficiently on line.
Patient: No. I don’t want to spend another minute, not another second. I have then spent my whole life longing. And it’s just such a waste of time.
Commentary: I am again aware of only minimal striated signals, and that she is saying the things any therapist would want to hear. Combined with the pattern of having symptom relief that do not generalize, I am skeptical, but decide to see how she responds to more standard pressure and challenge to the UTA.
Therapist: So then let’s see what you do about it. So what are you going to do about it? Let’s see how you feel. The anger towards your mom.
Patient: It’s like, how could you be so distant. Be so… I mean, it was like.…I’m almost feeling like I have become her. Because she was depressed. She was just… she wasn’t there. She didn’t express joy, ever.
Therapist: But let’s not ruminate on her. [00:43:00] Let’s let’s see how you experience the anger towards her.
Patient: It seems like heartbreak.
Therapist: I mean, we can get to the heartbreak, but you still seem to be avoiding your feelings towards her.
Patient: Yeah, I am.
Therapist: So we have to see how you’re going to get past that. Mhm.
Patient: How could you do this? How could you ignore me? How could you be so absent in our home when you were there? It’s like you weren’t there. And I kept looking for you to be there. And I kept looking for something. Some affection, some personality, [00:44:00] something. And it just wasn’t ever there.
Therapist: And the feeling towards her?
Patient (elevated voice): Rage. So tense and just rage. I just want to shake her. What is wrong with you!? Why couldn’t you love us? What.. what.. what happened to you? That you’re like this, right?
Therapist: If you don’t try to understand or change her though.
Patient: You destroyed your family. You just… You didn’t do anything for us. You didn’t do anything for me. You just ignored all of us. And everything you did was like such a struggle. [00:45:00] Just. Just to do one simple thing for anyone. What was wrong!?
Therapist: And physically, if you just keep it physical, what do you do physically experience without words? Without words.
Patient (tearful): You were never there for me.
Therapist: So let’s take a step back and review, because you have a rage towards her. But it’s getting diluted [00:46:00] through tears and focusing on getting her to be the way you want her to be rather than the way she is. See what I mean?
Patient: Right. Right.
Therapist: You’re focusing on the mother you always needed, someone who could acknowledge you, acknowledge her mistakes. And of course, that’s what you should have had. I wish you had had a mother like that. But do you realize that as we try to approach your rage towards your mom it is getting filtered through this lens of of trying to get your mom to be different?
Therapist: By focusing on that, you don’t let yourself process the rage, and then you have depression with endless rumination and longings.
Patient: That’s right. Because I feel like it’s not right to be so angry with my own mother. To feel this kind of a hatred.
Therapist: Could it be that the judging of yourself for it could be hurting you further?
Patient: Yes. You’re not supposed to feel that way about your mother.
Therapist: You police yourself. But we have to stop the session in a minute. How are you feeling about our session today?
Patient: Well, it’s pretty amazing because I was like, so shut down at the beginning… And now I’m alive.
Commentary: Her dramatic symptom relief seems to throw me off a bit where I lose sight of the defensive elements in the patient’s presentation that are making the gains so short-lived.
Therapist: You’re alive, and you’re courageously beginning to face the truth of things, including emotions. But we’re also learning where you are stuck and what your role is in that stuckness. We are learning that you focus on the mom that you wish you had, but that isn’t the reality of who she is. All right. That’s one of the primary ways. Again, we’re talking about trying to get these needs met that were never met.
Therapist: It’s how how you are blocking your feelings right now. Okay.
The session ends
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