therapy relationship issues

therapy relationship issues Depressed students tend to make agreeable patients. True, those who have
borderline or narcissistic traits can be exceptions, like one tormenting female
student who taunted her therapist: “Probably I won’t kill myself but I won’t
guarantee it, because I want you to worry about me at night.” Generally,
though, therapists like working with depressed clients. What’s not to like about
bright and attractive young people who value themselves less than they deserve
and who are apt to treat us deferentially and compliantly, searching for our
approval? Th ese sympathetic suff erers make it easy to be empathic, accepting,
and encouraging—we root for them to get better. Fortunately, such positive feelings
on our part usually make for good treatment. Depressed students convert
their therapists’ empathy, acceptance, and encouragement into self-awareness,
self-acceptance, and reason for hope. Generalizing from the therapy relationship,
they become open to favorable experiences with other people. Th e healing
power of therapists’ genuine acceptance and empathy is, of course, the basis
of Alexander and French’s (1946) “corrective emotional experience,” Rogers’
(1951) client- or person-centered therapy, and Kohut’s (1977) self psychology,
and no doubt constitutes a signifi cant part of what all clinicians, regardless of
theoretical approach, have to off er their depressed patients.
Yet, there is a danger in coming across as too positive and approving: Some
self-loathing patients feel misunderstood and falsely reassured (McWilliams,1994, p. 244). What psychodynamic therapists interpret as a “harsh superego”
or what CBT therapists interpret as irrational self-blaming cognitions may
be viewed by patients as accurate self-appraisals to which their therapists are
blind. Alternatively, they may half want to believe their therapists’ more forgiving
viewpoint and half want confi rmation of their own sense of reality. To
respond to both sides of this ambivalence, therapists can gently put forward
their own perspective while also expressing empathy for the patient’s view: “I
don’t agree with your harsh view of yourself, but I’m starting to understand
why you might see yourself that way.”

What fi nally did reach and soothe Ralph was the therapist’s allowing room
for Ralph’s self-judgment, by saying, “I’m beginning to appreciate how in
your own eyes you could have done more for your father. Maybe in some ways
you did let him down—we’re all human.” Empathizing with Ralph’s sense of
wrongdoing, yet still accepting him in spite of it—not unlike a priest hearing
a confession—brought him comfort. If the therapist could permit Ralph his
guilt, then Ralph didn’t have to defend it so fi ercely, and he could turn his
attention to getting better.
Like excessive self-blame, depressed students’ hopelessness can also provoke a
therapeutic overreaction. Some patients stubbornly insist that they have no future,
treatment will fail, and nothing therapists do will help. On some level maybe they consequences of giving up their misery: “Being depressed,” one female student
said, “is all I know.” Such hopelessness can jolt therapists’ self-confi dence. If not
careful, we may fi nd ourselves going into overdrive to prove our value, pushing
helpful interventions on students who can’t or won’t be helped, feeling frustrated
and critical toward students who already feel quite frustrated and self-critical. At
such times, the answer is to take a deep breath, stop working so hard, and empathize
with the student’s despair. Talking openly about hopelessness may also put
it into perspective and sap its strength: “As you know, I believe that with time
and treatment you will feel better, but I also understand that this seems very hard
to accept right now. It’s hard to believe anything will ever change.” In a similar
vein, the therapist might ask, “What do you think it might take for you to begin
feeling a bit of hope?” With certain refl ective students, it also may help to bring
therapeutic overzealousness out into the open: “I wonder if you’re feeling pushed
by me to get better, and what that’s like for you.”
Unlike many depressed students who never expect to get better, anxious
students may demand to get better right away. Also unlike depressed students,
anxious students are oft en not so much interested in therapists’ approval as
they are intent on getting results—therapists exist as a means to an end. Th ese
are the patients who may linger aft er sessions are over and ask for extra sessions
because “I’m not better yet.” Th eir sense of urgency tends to be contagious—
anxiety begets anxiety. And so even though their “help me now”
posture may be nothing like depressed students’ passivity and resignation,
their eff ect can be similar, pressuring therapists to provide relief. We may catch
ourselves with anxious clients introducing one intervention aft er another,
prematurely scheduling a medication consultation, doling out advice. Since
feeling rushed and pressured is unpleasant, we may also notice ourselves getting
irritated. Let me do my job, one thinks. I’m helping as fast as I can. Th e
challenge for therapists here is twofold. Anxious students’ sense of urgency
is earned—acute anxiety does feel intolerable—and we should validate this:
“I can appreciate how awful these anxiety attacks feel and why you’d want to
make quick progress.” But for students’ sake and our own equanimity, we also
need to set realistic expectations. “Let’s see what we can do together. Th ese
problems generally require some patience to work through them. But we can
try right away to get moving in the right direction.”
Other relationship themes play out in work with depressed and anxious students.
Worrywart students may bore therapists, and on some level maybe they
want to bore them. Traumatized students’ stories may be diffi cult for therapists
to bear. Meanwhile, therapists’ own traits, insecurities, and unfulfi lled needs
also enter into the therapeutic relationship. As pychodynamic therapies teach
us, such transference and countertransference phenomena are inevitable and, if
introduced sensitively, can be used to therapeutic advantage, shedding light on
patients’ views of themselves and of other people and on how they impact others.And so, while heavy-handed transference interpretations are inadvisable with
college students, who will likely view excessive “how are you feeling about me?”
comments to be condescending or irrelevant, an occasional, tactful here-andnow
observation can vividly get across a point: “You say you’re afraid to speak up
with your family, and I wonder if that’s going on between us too. Are you keeping
your thoughts from me now, the way you do with your parents?”
An even more important reason to closely monitor transference and countertransference
phenomena is to preserve the working alliance. If we feel anxious,
irritated, or bored with a student, which can happen, we must recognize
and analyze the reaction so that it doesn’t compromise our professional stance.
If a student develops strong negative feelings toward us, we’d better repair the
problem before it’s too late. All of which is to say that we should always tend
to the health of the therapeutic relationship. Th e interventions that follow will
avail us little in the absence of a basically positive human connection.