impasse in psychotherapy...psychoanalytic definition of therapeutic impasse unproductive therapeutic...
TRANSCRIPT
Jennifer Stevens, Ph.D., ABPP
Impasse in Psychotherapy
Impasse:
A predicament affording no escape; deadlock
(Merriam Webster Dictionary)
Psychoanalytic Definition of Therapeutic Impasse
Unproductive therapeutic processes; deeply entrenched and mutually contributed to knots that bring lively work, development, and change to a halt.
Q: Who is responsible for an impasse in psychotherapy?
A: Both therapist and patient contribute to an impasse.
Most often these contributions are unconscious.
Definition of Psychotherapy:
“An encounter between a big mess and a bigger mess”
(E. Semrad)
Patients AND therapists bring into the
therapeutic situation:
early relational histories, internal objects & object relations
preferred forms of relatedness
unconscious conflicts & defensive styles
differing capacities to bear painful feelings
needs, wishes & fantasies for the treatment and the treatment
relationship
Therapists have:
Our preferred theories/ways of understanding our
patients and what we think they need from us
Limits of our knowledge and technical skill
Limited understanding of patients’ difficulties
Three conceptualizations of
therapeutic impasse
Defeating Processes
Negative Therapeutic
Reactions
Therapeutic Misalliances
Defeating Processes
Martin Cooperman, M.D. (1979)
Sudden change in emotional atmosphere of productive treatments
Relation between therapist & patient becomes conflictual (e.g. power struggles and accusations)
Transference:
Patient is angry, attacking, and symptomatic
Countertransference:
Therapist is hurt, frustrated, lost
Therapist’s competence is in question – by both patient and therapist
“Each patient… described feeling hurt, humiliated,
or badly used (narcissistically wounded), and
rendered helpless by a considered and concrete
act of mine which directly affected the
arrangement of the therapy …. With each, I had
arbitrarily forced into focus our separateness.”
(Cooperman, 1979)
Separation makes clear:
Limits on dependability, availability, and “being in it together”
Therapist and patient differences in wants, needs, and authority
The patient
Feels hurt, angry & humiliated for needing the therapist
Tries to regain sense of control through vengeful attack on
therapist & their work
Goes to great lengths to defeat own treatment and potential for
growth
It is the responsibility of the therapist to:
Be engaged in ongoing self-
reflection
To become alert to signs of impasse
To work to develop an understanding
of the impasse
To accept responsibility for
his contribution to an impasse
Negative Therapeutic Reaction (object relations view)
Is a paradoxical response to positive change
Marked by a radical change in course in a productive treatment
Includes a significant change in the nature of the treatment relationship
Internal Object
A mental/emotional representation of an important person
Often representations of care givers of early life
Related to internally
Influence of Internal Objects
How we feel about ourselves
What we can imagine for ourselves
What we expect from others
The quality of our relationships
Our Patients’ Bad Internal Objects
Do not recognize the separate, autonomous existence of the patient
Thwarting of the patient’s development
Persecutory; critical
Often related to patient’s psychiatric symptoms
Development requires separation from internal objects
Patients’ responses to separation from internal objects include:
Anxiety Guilt Loyalty conflicts
Concerns that differentiation will
destroy internal objects
Frightening feelings of emptiness
Changes in the Transference & Countertransference Patient begins to experience therapist as source of painful experience
Patient experiences therapist as dangerous
Patient threatens to leave treatment because unhelpful
Therapist tries to hold the patient in treatment
Both stuck in a repetitive cycle of holding on and trying to get away
Reflective Space Collapses
Move to action vs. representation of experience in language
Possibility of reflecting on process is eradicated
Patient’s and therapist’s words are used to act on the other (to coerce, to convince, or to control)
Therapeutic Misalliances(Langs, 1975)
Therapeutic alliance
A largely conscious agreement between patient and therapist
about the commitment to the task of psychotherapy.
Therapeutic misalliance
Unconscious joint commitment to an alternative task aimed at
the avoidance of difficult to bear affects and the gratification of
relational longings. A mutually agreed on misuse of the
therapeutic situation and relationship.
Patient’s Unconscious Participation in Misalliance
Interested in recreating and living out early relationships vs. understanding impact of early relationships
Engaged in a goal that runs counter to the explicit aims of psychotherapy
Presses toward action
Sources of Therapist’s Unconscious Participation in Misalliance
Unresolved intrapsychic conflicts stirred by particular patients
Inappropriate needs for sexual or aggressive expression
Struggles with the limits of the therapeutic frame
Longings for closeness
Efforts at feeling important and valued
Countertransference Indications of Misalliance
Therapist:
Notices lack of progress or depth in the treatment
Becomes aware of deviations in usual ways of intervening or behaving
Feels like something is not right
Begins to dislike or feel manipulated by patient
Therapist’s Response to Countertransference
Listen for possible commentary on therapist’s difficulty with the therapeutic alliance
Possible themes to listen for: manipulation, poor parental functioning, collusion
Engage patient in exploration of his experiences of therapistandperceived difficulties with the treatment alliance
Consultation, consultation, consultation …