Surviving Attacks in Psychotherapy - An Occupational Hazard By Toby Ingham on 12/5/18 - 12:53 PM

The sound of gravel being ripped from my drive is that of an angry 25-year-old man leaving his session with me. He is furious, and though he sat through the final minutes of the session with his emotions firmly in check, they spilled out as soon as he left.

He is angry with me because I have tried to find out why he walked out of therapy with me three months ago with no warning, and why he wants to come back now. He is here because it is a requirement of his psychoanalytic training, and though he gets some satisfaction from working with me, I don’t think he would be here if he wasn’t required to be. He is frustrated by my asking about the premature break earlier in the year.

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We are caught in a difficult transference. His acting out, his anger with me, his resistance and refusal to want to find out more about what’s going on make things difficult. But it’s not going away. By coming back now he has drawn further attention to it. He could have stayed away, and then no questions would have been asked. Not by me! But he’s come back because he must for his training.

I find my practice can run very smoothly (a superstitious side of me prevents me from saying more), but every so often an issue will flare up and the atmosphere is changed. Often clients who are in training prove the most difficult, particularly when they are ambivalent about being in therapy. I think of these experiences as attacks on psychotherapy. Evidence that an attack has been launched is demonstrated by particular behaviors, and frequently these are behaviors that manifest themselves in terms of boundary or therapeutic frame issues.

In this example, someone breaks off therapy and then expects to come back with no reference being made to their previous actions. The challenge then is how to find a way of working and thinking these things through with the client without becoming caught up in the attacking behavior. And without, as D.W. Winnicott put it, the psychotherapist retaliating and attacking back.

When these kind of aggressive and attacking experiences are enacted in psychotherapy, the psychotherapist is tested. The psychotherapist must find a way to keep working with the experience. And as they try to, the client finds more ways of provoking the therapist to retaliate. But retaliation might be fatal to the therapy. It might prove that the client is as unlovable as they already think themselves to be. It might lead to the end of the work. It might prove very hard on the psychotherapist’s sense of their own professional identity.

So, in the sessions that follow I have to find ways, despite the provocations, of developing the therapeutic relationship, trying to develop the relationship so that the client may come to lower their defenses so that in time, the client may become interested in the complicated dynamics that are at work. If this can happen, and the therapy can survive the attack, then the client may develop the sense that this therapeutic relationship is not like other murky, unfair and repressive relationships that they have or had, perhaps with their father. They may come to see that in their therapeutic work with me, they are outside of that original destructive parental paradigm. The negative paternal transference might be resolved. This could then be the beginning of profound change.

The attack, however it comes, could be a gateway to change. A gateway out of the stuck world of unhappy relating that the client has lived in. This may be what the client has come to therapy to resolve, although they probably don’t know that yet. The only problem is that the attack is real and happening right now. And the client’s way of finding opportunities to provoke the therapist into an uncharacteristic act of rejection are very hard to predict and can be very hard to work with and survive.

In the case of this particular client, it took some time for his anxiety and his aggressive and attacking behaviours and defenses to be contained within the therapy so that we could think about them together. This seemed to coincide with a more measured approach to his driving.

I have gained from my experiences of surviving these kinds of attacks without retaliating- they are always very hard work. They are an occupational hazard.   

File under: The Art of Psychotherapy