When supportive therapy is not supportive

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Consider the idea of pseudo-contact: the patient who is using the relationship with the therapist as a defense.

The patient uses the supportive relationship with the therapist as a defense, allowing them to keep others at a distance because they are getting some pseudo-contact with the therapist. 

Vignette — portions of a de-identified actual therapy transcript:

Up until this part of the treatment, the therapist has inadvertently gratified the patient’s wish for contact without the patient actually having real contact, since the patient is not emotionally engaged. There is the semblance of contact, but no real contact.

The patient displays no striated signaling, and they appear passive, emotionally disengaged. 

Th: So why are you coming here?

Pt: Panic attacks, anxiety (flat tone). 

Th: Are you here to get to the bottom of that?

Pt: Sure we will go with that.

Th: That doesn’t sound convincing.

Pt: No I really want to (compliant tone, no emotional charge or engagement, no striated signaling).

Th: So without a reason to come here, you wouldn’t come.  That’s the admission ticket, we have to have a problem to work on. Is that what you are doing, coming up with something to work on so we can continue to see each other?  That is not helping you face your feelings. 

Pt: I know.

Th: You are coming here, I like you, we have some back and forth – so you are getting some positive regard from me that you would like to be getting from your family. 

Pt: That is true.

Th: Is it making it easier for you to live with this anxiety to come here? 

Pt: For the hour. 

Th: So you are coming here in a sense to soothe your symptoms rather than resolve your symptoms, that way you can avoid your feelings towards your family members, and not face the depths of the dysfunction with your family and your feelings about it. 

Pt: So I should not see you anymore?

Th: Only you can decide that. But coming here to help you live with these problems a little easier, rather than face and resolve these issues, isn’t going to help you that much, is it? You feel better for an hour, but you don’t actually get better. 

Pt: What should I do?

Th: Deferring to me isn’t going to help you. 

Pt: Yes, but I also just want your love and approval.

Th: Could coming here to get my love and approval be a way to try to sustain your maladaptive relationship with your mother – that you have someone who cares about you and listens to you, unlike her. So you can come here and get some of the things from me that you don’t get from her, and that enables you to tolerate her. Are you using our relationship as a defense, not to resolve your anxiety but to sooth your anxiety and avoid your feelings — by coming here for the sense of being cared about? 

Pt: I am, but what is wrong with that?

Th: Are there any indications that your life is actually improving?

Pt: No, not really.

Th:  Then I can’t support this, using me as a crutch for an hour a week. 

In closing:

The patient was getting from the therapist what they were not getting from their family, making it easier for them to avoid their internal conflicts and feelings towards their family members. Because the patient’s life was clearly not improving after a long time, the therapist had to take a stand and not support this maladaptive behavior. 

Author: Johannes Kieding

I have a passion for practicing ISTDP informed psychotherapy and I enjoy writing about it. For more information and what I do, visit my website: www.johanneskieding.com

About Johannes Kieding

I have a passion for practicing ISTDP informed psychotherapy and I enjoy writing about it. For more information and what I do, visit my website: www.johanneskieding.com