Addressing Challenging Moments in Psychotherapy

Clinical Wisdom for Working with Individuals, Groups and Couples

Jerome S. Gans

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000450576
• Edition: 1
• Topic: Psicología
• Subtopic: Asesoramiento psicoterapéutico

This practical and helpful volume details how clinicians can work through various common challenges in individual, couple, or group psychotherapy.

Chapters draw upon clinical wisdom gleaned from the author's 48 years as a practicing psychiatrist to address topics such as using countertransference for therapeutic purposes; resistance, especially when it needs to be the focus of the therapy; and a prioritization of exploration over explanation. Along with theory and clinical observations, Dr. Gans offers a series of "Clinical Pearls, " pithy comments that highlight different interventions to a wide range of clinical challenges. These include patient hostility, the abrupt and unilateral termination of therapy, the therapist's loss of compassionate neutrality when treating a couple, and many more. Many of the "Clinical Pearls" prioritize working in the here-and-now. In addition to offering advice and strategies for therapists, the book also addresses concerns like the matter of fees in private practice and the virtue of moral courage on the part of the therapist.

Written with clarity, heart, and an abundance of clinical wisdom, Addressing Challenging Moments in Psychotherapy is essential reading for all clinicians, teachers, and supervisors of psychotherapy.

Part I
Introduction

Introduction

DOI: 10.4324/9781003174608-2

In my 48 years as a practicing psychiatrist, I have listened to approximately 80,000 hours of patients’ stories and supervised approximately 90 psychotherapists. I have worked in a variety of settings. These include working as a liaison psychiatrist in both a cardiac care unit and in an acute physical rehabilitation hospital. I have worked as a staff psychiatrist in a mental hospital and run T-groups (training groups) for two major psychiatric residency programs. Over that period of time, I had either a part-time or full-time private psychotherapy practice treating individuals, couples, and running psychotherapy groups.

This book is a collection of clinical observations and aphorisms that I have culled from my experience treating patients and supervising therapists. The book gives examples of the wonderful variety of challenging moments in psychotherapy. Here are a few.

• A patient introduces himself by telling you in an intimidating manner that the magazines in your waiting room are out of date—and that he wants current ones when he returns next week.
• You realize to your dismay that you’ve been exploiting the diplomatic nature of one of your group members to calm group conflict.
• You wonder how you will be able gradually to nudge a chronic complainer into self-reflection.
• You find yourself consistently very sleepy three-quarters of the way through a session when you were wide awake at the beginning of the session.
• You notice that your patient’s excessive vagueness is turning your brain into cotton candy.
• You look at your appointment book and realize you are dreading the next therapy hour because it is with Marvin.
• An unhappily married woman convincingly explains to you in individual therapy that her husband was “never like that” before she married him.
• Your group patient tells you that your answering her question with a question feels disrespectful and causes her to shut down.
• You feel anxious when with 5 minutes left in the session your patient mentions that she is feeling suicidal.
• Your decision not to look at your patient and instead “talk to the room” is advancing the therapy.
• Your supervisee asks for your help in dealing with a question her patient just asked her, “What do you think of me?”
• Your long-term patient who has done very well in a 5-year therapy invites you and your spouse to her wedding.

The first part of this book highlights clinical observations I’ve made about human nature taken from the various settings in which I have worked as a psychiatrist. These observations serve as background and inform my responses to challenging moments in psychotherapy that I discuss in the second part of the book. Over the years I have learned that in most instances people are doing the best they can; meaningful therapeutic work takes place at the boundaries; there is much that we can learn about ourselves from our patients; and many natural reactions are not helpful and many helpful reactions do not come naturally. I welcome these challenges as an expected part of the ongoing psychotherapeutic work.

In the second part of the book, I put these challenging moments in long-term psychotherapy under a magnifying glass. I describe my interventions to these challenging moments and refer to them as Clinical Pearls. The term refers to pithy comments I have made to my patients and my supervisees in the service of advancing the therapy. The Clinical Pearls confront complexity and make it appear deceptively simple. I then unpack these Clinical Pearls by explaining the thinking that went into their construction, articulation, and goals. The Clinical Pearls condense what I have learned in the course of working with two major groups of individuals: my patients and my supervisees.

A few years ago, I decided to make a list of these Clinical Pearls after many of my patients and supervisees said that I have a of way of concisely sharing clinical insights that they have found helpful both professionally and personally. For example, neophyte therapists who were my supervisees felt understood—given their financial struggles—when I suggested that the best supervisor is a mortgage. (If I had 1200 words to say about that remark, I would have made it a Clinical Pearl.) At the time I didn’t have the energy or the time to expand on the thinking that went into these aphorisms. Now, largely confined to my home during the pandemic, I have time to spare and, with my retirement over a year ago, renewed energy. While writing about the Clinical Pearls, I have been mindful of a medical school teaching about clinical pearls: they are the same size as rabbit turds. You, my readers, will make that determination as you read on.

I would characterize my general approach to patients as indirect. Drawing on my undergraduate experience as a major in English literature, I employ in my interventions with clients a wide number of literary devices such as irony, paradox, exaggeration, indirection, surprise, and humor. The Clinical Pearls attempt to achieve a variety of goals. In the various clinical examples provided, they secure attention, promote safety, respect choice, and foster a sense of agency. By conveying empathy, they serve to deepen affect, welcome transference, and replace grim antagonism with playful curiosity. They prioritize exploration over explanation and embrace complexity. They employ countertransference for therapeutic purposes. Cognitively, the Clinical Pearls help clarify communication and promote consolidation and integration of discoveries.

The Clinical Pearls address many clinical topics. They educate patients about basic rules of psychotherapy, monitor the therapeutic alliance, and offer guidance in dealing with patients’ questions. In addressing character pathology, they strive to make the ego-syntonic dystonic. In processing transference and countertransference, they deepen affect, especially negative feelings. They assist the therapist in treating the suicidal patient and other self-destructive conditions. They encourage and give value and appeal to imagination, authenticity, creativity, and spontaneity.

I have disguised case material taken from my private practice and from my supervisees’ practices. My patients have come from across all sectors of the socioeconomic spectrum. The patients range from their early 20s to their late 80s. Early in my career, I treated psychotic patients as well as the neurotic, character-disordered, depressed, anxious, and bereaved patients who comprised my patient roster as time went on. While I have treated many patients with adjustment disorders, I have not included examples from this population in the book. The reason for this omission is that the book deals more with patients’ internal worlds and persistent conflicts than with temporary external problems.

The material in this book, for the most part, has resisted neat categorization. Some of the clinical examples can be grouped under the headings of individual, group, and couple therapy. Over half of the Clinical Pearls deal with the patient–therapist relationship primarily in the here-and-now. The many clinical examples discuss the use of countertransference for therapeutic purposes. The Clinical Pearls seek to advance the therapy by promoting self-reflection, strengthening the therapeutic alliance, favoring exploration over explanation, and fostering curiosity and stimulating imagination. The first 11 chapters contain insights about human nature that I have encountered in the therapy hour. The next ten chapters each contain two Clinical Pearls except for the chapter on using countertransference for clinical purposes that contains four Clinical Pearls and the miscellaneous chapter that contains three Clinical Pearls.

One more comment about the last ten chapters. In earlier drafts, each of the 22 Clinical Pearls was one chapter. For smoother reading, I condensed the 22 chapters into 10. This was a complicated task because each Clinical Pearl mentions and illustrates a number of psychotherapy-related topics. My task in forming each of these ten chapters was to select two Clinical Pearls (and four in the chapter on countertransference) appropriate to each chapter heading—even though the Clinical Pearls originally were not written with those chapter headings in mind. Again, you the reader, will decide the success of these pairings. The perfect is the enemy of the good.

I want to offer a cautionary note especially to younger readers about the use of Clinical Pearls that comes from my early clinical training. During my psychiatric residency, I had the privilege of observing the work of Dr Elvin Semrad, a wonderful teacher of psychotherapy at the Massachusetts Mental Health Center in Boston. At case conferences he would interview patients we had been working with for months. He had an uncanny way of relating to very sick patients by using simple language to address profound suffering. For example, he would say to the patient, “Tell me, what is breaking your heart?” and, before we knew it, the patient was divulging material that we hadn’t unearthed in months of sitting with the patient. We residents were so impressed with Dr Semrad’s seemingly magical ability to have patients reveal their innermost thoughts and feelings that we immediately left the case conference and asked our next patient, “So tell me, what is breaking your heart?” Of course, in our hands, that approach fell flat. And how could it not have, since that intervention did not come from our authentic experience and sense of self. So, consider the Clinical Pearls as only one approach to a challenging moment in psychotherapy. Find your way to approach such a challenging moment that fits you and your way of doing therapy with a particular patient. Find the uniqueness of every patient and select from all the approaches those that have the greatest chance of improving the treatment. If my thinking discussed in the formulation and use of the Clinical Pearl contributes to your therapeutic personhood, I will be more than pleased. Continue evolving your distinctive therapeutic presence.

Who is the audience for this book? This book will interest therapists who treat patients in long-term individual, group, or couples psychotherapy. Both clinical practitioners and educators/trainers will find the book useful because it deals with clinical situations that both neophyte and seasoned clinicians struggle with. It will appeal to those who welcome the dark sides of human nature into their offices. The book will engage therapists who use their countertransference for therapeutic purposes, especially those attentive to the possibility that they might be impeding the very therapeutic enterprise they are trying to promote. The Clinical Pearls will provide interesting clinical material for those who wish to expand their use of innovative therapeutic techniques that involve spontaneity, playfulness, and creativity. Several chapters address moments in therapy especially challenging for neophyte therapists. Older clinicians—I am now 80—will resonate with the emphasis on compassion, kindness, and respect for the patient. Therapists in the middle years of their careers might find approaches to complement or possibly challenge their current practice. The clinical observations and Clinical Pearls may provide additional tools to supervisors of psychotherapy. Also, for those considering entering into psychotherapy training, the book might serve as an additional inducement to explore their concerns. Because I evolved some of the ideas in this book while working as a liaison psychiatrist in both a cardiac unit and an acute physical rehabilitation hospital, the book may prove useful to mental health professionals who work with physical therapists, occupational therapists, speech therapists, and nurses—and, perhaps, physicians interested in the psychological aspects of patient care.

For as long as I can remember, I have taken delight in the diversity of human nature. It is no wonder then that as a psychotherapist I have embraced a pluralistic approach to the work. I have tried in my career to put into practice the statement of the Roman playwright and poet Terrence, who said “Homo sum; humani nil a me alienum puto,” “I am a man (person); I think nothing human is alien (foreign) to me.” I hope that readers find that this book enhances the treatment of their patients and brings new life to their clinical practices.

Part II
Clinical observations

Chapter 1
There are no completely objective data in interpersonal relations. The way I am with you partly determines the way you are with me.

DOI: 10.4324/9781003174608-4

It is impressive how many years it took the field of psychotherapy/psychoanalysis to appreciate that the classic definition of transference was limited. The original idea of transference was that if the analyst was interested, reliable, curious, impassive, and non-judgmental, over time the patient would begin to experience the analyst as an important person from the patient’s past with whom the patient experienced unresolved conflict. The patient would begin to relate to the analyst as if he or she were that important person from the patient’s past. Only this time, because the analyst was not in reality that person and because the analyst was devoted to helping the patient resolve these conflicts, the patient’s transference could be analyzed and the patient freed up from his/her neurotic repetitions from the past. The patient’s transference was conceived of as an objective fact.

Notice how this formulation assumes that if the patient were in analysis with any one of ten well-trained, competent analysts, the patient’s transference would be the same. It took many decades before analysts began to challenge this formulation. In retrospect it seems obvious that the gender, physical appearance, age, manner of speaking, office décor, missed session policy, skin color, accent, and degree of interactivity of the analyst would have some effect on the patient’s transference. In addition to all these factors, the therapist’s countertransference would likely have the greatest effect on the patient’s transference, as later examples in this chapter will illustrate.

The field of psychotherapy has come a long way. In one of the seismic shifts in psychological theory, today’s zeitgeist of intersubjectivity posits that what transpires during the therapy hour is co-constructed by the therapist and patient. Ten different therapists treating the same patient would inevitably produce ten somewhat different outcomes—maybe a little different or a lot different depending on the particular therapist. The classical idea maintained that countertransference could and should be kept out of the therapy, but if it wasn’t, the therapist’s feelings had a deleterious effect on the therapy. The therapist was to get supervision or possibly even therapy. Notice how this formulation doesn’t allow for the possibility that the therapist’s feelings or personal experiences could have a positive effect on the therapy. The modern notion of countertransference understands that it will inevitably find its way into the therapy but that this is not bad. What can be harmful is when the therapist is either not aware of the intrusion of countertransference or not receptive to working with it when it is pointed out. Put positively, countertransference can be employed for therapeutic purposes.

Let’s consider one example. Assume that the patient and therapist have worked hard and productively over a 5-year period and the patient has resolved a career-limiting problem with authority and harsh self-criticism. The patient begins noting her frequent thoughts about terminating her therapy in its fifth year. Patient and therapist agree to devote the next 3 months to exploring this wish to ensure that what is decided is in the best interest of the patient. Let’s also assume that the patient is ready to terminate.

It turns out that the patient’s therapist, also a woman, happens to have unresolved issues with being left. She is unaware of this blind spot. Instead of being able to acknowledge and hopefully even celebrate the patient’s impressive work in therapy, the therapist acts as if she is being abandoned. Her reactions to the patient’s progress are stilted. Her mild but persistent skepticism about her patient’s wish to terminate create sporadic moments of self-doubt in her patient. Even so, her patient’s confidence about her own judgment prevails and she decides to terminate. The sense of trust and safety that she has felt with her therapist feels slightly tarnished as she terminates her therapy. She is uncertain if she would return to this therapist should the need arise.

Now consider another therapist who treats this same patient. As in the first therapy, the patient and therapist work effectively for 5 years and the patient resolves her issues with authority and harsh self-criticism. After 5 years of therapy, the patient feels ready to terminate and they agree to give the termination process 3 months. This therapist happens to have three daughters, two of whom have already left home and are in college. Letting go emotionally has been difficult but now with the third daughter ready to leave for college, the therapist—and his wife—feel ready. They truly celebrate their youngest daughter’s achievements and feel ready to embrace whatever the empty nest has in store for them. This male therapist’s response to his patient’s well-earned desire to terminate is colored by his experience with his youngest daughter. H...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Foreword
• Acknowledgments
• Part I Introduction
• Part II Clinical observations
• Part III Clinical Pearls
• Index