Therapy Gems: On Delivering the Right Intervention – Limit-Setting Versus Interpretation with the Troubling Client

ON DELIVERING THE TRANSFORMATIVE INTERVENTION
RIght Intervention1
Jill Terminates Her Therapist
The client often threatened to fire her psychotherapist. She said she would find someone else to work with. A few times, she would say, “You’re not available enough. You’re too busy. I’m going to find someone else. You took a week off. Are you saying I need to find another therapist? You’re NEVER HERE!” Other times, she went for an assessment elsewhere, then she returned for her therapy appointment complaining about the limitations of the other psychotherapists she had consulted.

A 45 year-old woman, Jill, has Bipolar Disorder, Rapid Cycling, sometimes with psychotic features, and an underlying Borderline Personality Disorder. She grew up experiencing profound sexual abuse. She also suffers from chronic pain.

The therapist initially felt depreciated and he defended himself. “At least half the time, I answer the phone when you call and the rest of the time I call you back. I only go on one-week vacations so my clients don’t have a long wait between appointments.” But the client was coming from a place of limbic arousal, i.e., emotional reasoning. That is, she experienced a felt-sense of the truth of her statement; therefore, it was true for her. An appeal to these facts failed to touch her global generalizations. If she felt a lapse in empathy from the therapist, she experienced him as entirely distant and abandoning. Furthermore, the therapist’s response was a mild rebuke which further underscored the client’s sense of feeling rejected. To her, the therapist’s self-defense focused upon himself; that was a further failure in the crucial empathic attunement she needed at that moment. No wonder she was enraged.

This all-too-common scenario presents a dilemma. I joked with the therapist, “Yes, I too have sometimes thought of taking a client up on pulling away, you know, that feeling like let her move on? She threatens to quit, so sometimes the thought is ‘Let her quit. It will be easier for me.’ Correct?”

He replied, “I really want to take her up on it. Let her go find someone else.”

“So you identify with her abandonment feelings. Now you feel hurt and rejected. Then you want to reject her back. Is that about right?”

“Oops! Projective identification.”Right intervention2

“Exactly. It’s a relational connection around her unhealthy defense, and you are caught up in it. So it’s really tempting to identify with her rejection and do it to her, to let such a challenging client go. But that reinforces her defense of injuring others when she feels hurt, then she confirms her negative self-worth and hopelessness, and her negative introject – ‘I am not wanted or lovable and I’m as bad as my mother showed I was.’”

The therapist replied, “Yes, but if you think about it the right way, ask yourself ‘What could this behavior mean? What dynamic could cause her to reject someone she needs, her therapist?’”

“Exactly. We can do something practical or expedient. Like letting her find someone else. We could assist her to try to locate someone to refer to. But that confirms some of her worse pathological beliefs and reactions. Or we could do the right thing. Make the right Right intervention3intervention. So once you think to do the right thing for your client, then you move away from the hurt or rejection – the identification – and go to your highest thinking, from limbic to cerebral control. If you can use your higher abilities, perhaps she can learn to do that too.”

The discussion led to a hypothesis from which two interventions were developed. Their accuracy was confirmed by the progress Jill made in subsequent weeks. The accusations and rejecting behavior stopped. She even maintained that she relied upon the therapist to help her learn to live a more satisfying life, but she had previously been afraid ever to feel that way. The therapist wrote out these interventions in a letter in which he gave examples for each of the elements.

1. “Jill, when you feel even the slightest sense that I am not entirely attuned to you, instead of telling me you have gone all the way to feeling abandoned by me, like you have been by your mother, and that some painful memories have come up for you, you rejected me back. You’ve told me about other relationships in which you rejected someone back. You want the person, even me, to hurt like you do. Then you don’t feel so hurt and alone like when you were alone and expecting your mother to beat you.”

2. “Jill, it seems that when you blow up most of the time it’s when you feel I’m not attuned to you.” After listening to her stream of responses, we could add, “But there is a real downside to that. It makes you believe something untrue, that in this world no one can stick by you and you aren’t worth it. The other person gets defensive and that feels like he’s not really there for you. So whenever you get so angry, the result is you are worse off. You and your world seem worse and worse.”

Some weeks later, Jill said “You know, I keep that letter on my night stand and I re-read it. It keeps me grounded.” This statement hints at a double-reparative function to the letter. On the one hand, Jill had the content of the letter with its description of her emotional states and her patterns. The content implied a prescription, namely, do not reject others or hurt them, but rather, talk about the emotions, stay connected, and the therapist will stay, also. On the other hand, Jill had the process of the intervention, the act of giving her an experience of empathic attunement, reflective self-observation, and self-regulation, a kind of loving maternal gift which has the same kind of organizing effect at age 45 that the same class of actions would have for a child.

Paradoxically, delivering the right intervention led to improvements over time in the therapeutic alliance and ultimately in the client’s mood and behavior. In these episodes, client anger towards the therapist can be a manifestation of ruptures in the therapeutic alliance or, if the client is referred out or terminates, we call it a negative therapeutic reaction. I’ve also seen the term acting in, meaning expressing an emotional conflict in behavior in the therapy, rather than in words. By doing the right thing, the therapist repaired the alliance and initiated a positive therapeutic frame in which the client’s attachment wounds and world view could be examined. Doing the right thing was transformative.

Gemina’s Father Crosses the Line
Let’s look at another example of a conflict between the strong temptations to give a practical or limit-setting intervention versus a more interpretive, exploratory, empathic intervention.

A nine year-old client, Gemina T____, lives with her mother, who had previously alienated the fathers of two older children. However, Gemina’s father was pushing for visitation. The child was refusing to meet with him. Therefore, the mother had filed motions in Family Court to block visitation on the basis of allegations of abuse by father. We do not know what mother has said to Gemina about the child’s father or whether abuse actually occurred.

The father was not his best advocate. He called mother and pushed her to relent, that is, to permit visitation. She procured a restraining order. The Guardian ad Litem recommended, and the Family Court judge ordered, that child visitation with father occur within the context of therapy sessions.

Note: therapists do not want to be put in this position. It often prevents the sessions from being therapeutic, and it puts the therapist in the position of an agent of the court who must report on the parent’s behavior. So the therapist lost some of Gemina’s trust – she was an agent of father and against mother and Gemina – and the father was angry with the therapist for being unable to assist his goal of getting regular visits.

In this case, the Court’s decision distorted the therapeutic situation. Father called and pushed the therapist to facilitate these meetings in spite of Gemina’s desire to avoid the meetings.

Ideally, we would not condone a child controlling visitation. In this case, the awkward situation created by the Court’s plan created circumstances in which the child distrusted the therapist because the latter was talking with father.

Frustrated at what he believed to be the therapist’s hesitance to force these meetings, Gemina’s father called the therapist three to six times every day. During these calls, when the therapist said she would not demand the child attend the meetings or when the therapist otherwise conveyed she could not meet father’s demands, father swore at her, threatened to complain to her employer, and depreciated her performance in the case. She felt anxious and upset by these calls. She pointed out to me that she did not feel physically endangered, but she was glad she lived very far away from Mr. T____.

The therapist was ambivalent about discharging Mr. T____ . She merely wanted to limit his calls. Equally interesting is the observation that, in the group supervision session in which this case was presented, members of the supervisory team also recommend assertive, limit-setting interventions. It seems that practical and limit-setting interventions come easily to us. But with a little more thought, we can do better.

That is when she consulted with me. What should she do? What should she do first? How? We’ll discuss that shortly.

Right Intervention4First I suggest the Gemina case situation is similar to a class of cases in which the client or a family member is behaving in therapy and towards the therapist in a way which causes high levels of clinician anxiety. Let’s talk about some of the sub-types of these cases.

I will not use term “manipulation.” Many of these clients can be called “manipulators.” I never liked this term. It is like a Buzz Word. That is, it obscures more than it illuminates! It also leads to a therapeutic dead end. “You are manipulative” is an unhelpful intervention. So, in this discussion we will look underneath the behavior to its roots.

The intervention must get at the root of the behavior. That is the level at which we can effectively intervene. We pump medication into the ground so the roots of a diseased tree can take up the chemical and bring it up to the branches and leaves. We treat strep throat systemically. Analogously, our psychotherapeutic interventions need to get at the underlying dynamics of the behavior rather than at the surface.

Note: Yes, of course there are clients for whom limit-setting interventions are indeed required. I have commented that these situations in which the client’s aggressive reactions make the therapist uncomfortable elicit punitive, practical, expedient, or limit-setting interventions. Surely, there are times the behavior crosses a line into a territory in which the therapist believes she is truly unsafe. Then of course a serious limit-setting intervention or a termination may indeed be necessary. The client could cause harm to property in the clinic or make a direct threat or take intimidation to a frightening level. But short of that, when the client inhibits overly dangerous actions, the therapist’s discomfort is more unpleasant than dangerous.

TWO SUB-TYPES
Gemina’s father is in the subtype we can call INTIMIDATORS. Remember he had a lot at stake. From his point of view, he had lost a year of time parenting his daughter. He missed her. Despite the therapist’s efforts to empathize with this man, he viewed her as aligned against him. He felt a sense of loss. His behavior and character had been labeled by the mother in a way which made him feel helpless. Accustomed to defending against such vulnerable and hurt feelings by pushing people to the limit in order to accomplish his aims, and expressing fear through rage, he increased the intensity of these reactions.

Furthermore, in this case, the therapist was his only connection to his daughter. So his emotional reactions towards her were unusually intense. His defenses led to verbally Right intervention5abusive behavior towards her in an effort to get her to achieve his aims.
Another subtype, which we can label ABANDONMENT SENSITIVES, includes those who are tuned in to any cues which presage abandonment and whose behavior may express anger at the therapist when the client feels abandoned. The provocations for such feelings may be very small demonstrations of pulling away or failing to empathize. One function of these angry outbursts may be to unconsciously elicit supportive behavior in which the therapist undoes the felt-abandonment. Another function is to hurt the therapist as the client hurts.

These clients often call in order to know the therapist is still there – they cannot hold onto a felt sense of positive relatedness to the therapist. Most therapists have had clients with high anxiety or Borderline Personality Disorder who make frequent calls. These calls are often as distressing to therapists in their way as are those of Gemina’s father in our example. As we do not call either group manipulators, we could – but will not – call the second group needy. Again, this is a Buzz Word and a surface intervention, as in “You are needy.” It is blaming and ineffective.

Now let’s come back to what therapists may do with these challenging clients.

LIMIT SETTING INTERVENTIONS
Let’s return with this new understanding to the case of Gemina’s father. The most typical response to such clients is usually in a category I will label “Limit Setting.” For example, “Mr. T…, you are calling too much. You may only call once per week or we will no longer be able to work with you.” “Jill, you cannot holler at me or call after hours.” “Ms. V…, you are hanging around the office when it is not your appointment time. That is stalking. We are terminating your services.”

To cite another example, a previous therapist of one of our new clients had told her, “You are not safe. The next time you do any self-injury or self-cutting, I will not work with you anymore.” The client did self-cut and the therapist terminated the relationship. Then the client cut more.

A therapist who worked for us often used to use the following language in response to clients’ extra-session calls: “That is not how I work. My way of working is to see you during our sessions. I do not accept phone calls after hours.” She made a similar speech over a number of client requests or behaviors: “That is not how I work.” I viewed this as potentially a rejecting response using limit-setting rather getting into the depths of the client’s dynamics or the dynamics of the client’s requests. She could have first inquired, “Let’s talk about what you need or are looking for when you make calls to me outside of our sessions.”

In this vein, an analyst once told me that therapists are taught not to accept gifts of value from clients. A plate of Christmas cookies or a paperback may be all right, but therapists are taught that anything of a value of $10 or more is not. Therapists often return items of value with a simple statement, “I don’t accept gifts.” He pointed out that this kind of limit-setting wastes an opportunity to understand the client and is rejecting. He suggested that before giving back the item, the therapist would be wise to ask, “Let’s talk about what you were thinking and feeling that led you to give this gift.” The deeper meaning could be around any number of dynamics, such as, the client’s difficulty expressing appreciation or the client’s effort to repair the relationship or the client’s effort to ingratiate the therapist in order to prevent disapproval. Limit-setting interventions fail to get to a relational understanding.

So, often, these clients are told to stop or to limit a behavior which makes the therapist uncomfortable. Yes, these clients often push the boundaries of the relationship. But is limit-setting the way to produce change?

CLIENT DYNAMICS
By understanding these clients, we are more likely to produce meaningful changes. Let’s look at some of the meaning of these behaviors. These categories overlap considerably, but discussing them separately is instructive. There may be other dynamics. These are the ones I have seen most commonly.

1. For some of these clients, their expectation for therapy is not based upon the classic Therapeutic Alliance. That is, the process of effective treatment occurs within an alliance between the client and therapist to use the therapist’s methods in order to meet negotiated goals, in a relationship of rapport and empathy. The purpose of the relationship and the treatment methods, including setting goals upon which the two agree, is to change the client’s dysfunctional behavior, conflicts, reactions to painful memories, and relationships.

Rather, these clients form a Narcissistic Mis-alliance. That means their goals are driven by emotions, needs, and the urge to gratify those needs rather than to resolve dysfunctional needs. They have not developed a therapeutic split in which they can ally with the therapist in order to observe and change dysfunctional patterns. These clients may form a therapeutic alliance of highly variable strength from session to session; but when their fear or anxiety is activated, they place acting upon their needs ahead of insight or change.

So let’s come back to Gemina’s father. As we discussed before, he had many reasons to be worried and upset. Commonly, he might get a message such as, “Mr. T___, you can’t call me anymore except once per week. If you are not polite, I will hang up.”

Would a better intervention be something more like this? “Mr T___, when you are frustrated you seem to feel thwarted, like you will not accomplish your goal, and then you escalate to more demanding and even frankly abusive language to get what you want and need. Like feeling behind the eight-ball and even helpless is such a defeat that you turn it around and put that on others, like me.” To that could subsequently be added, “When you behave in such an aggressive fashion, you make people want to reject you or ward you off. So does that work for you, really?”

2. Abandonment Anxiety accounts for the underlying theme in another group of clients who often make therapists anxious and uncomfortable. A typical response by therapists to clients who want the therapist to be there for them always and on cue is to tell the client she cannot have that. But this could be read as further rejection. More effective is the response we discussed for Jill and, similarly, for Marie, who is described below. When the client receives a message which shows attunement, she is likely to have reduced fear; then she is likely to reduce her angry behavior.

Marie Depreciates Her Therapist
Marie, a 40 year-old client, for example, who was diagnosed with Borderline Personality, began calling the therapist even before the first interview. Rather than set a limit on the client, who might then have canceled the assessment, the therapist said, “You have had therapists before and have been disappointed. Perhaps you are trying to find out what kind of person I will turn out to be and whether I can be there for you.” The client appeared to be calmer after that. She did not call again in the days before the assessment. She did come and she did initiate treatment.

After a few months of treatment, she was panicked when the therapist was late arriving for a session. As soon as he opened the office door, she slammed the door and left, shouting very loudly at the dismayed and embarrassed therapist, in the hallway to the office building, “You’re no good. You haven’t helped me at all. I hate you.” Another time when a session did not leave her with hope and positive feelings, but rather left her re-experiencing painful memories, she left a message on voice mail in which she said, “You are a terrible therapist. I am not better than I was before. You have not helped at all.” This message was shouted into the phone so loudly that it was barely intelligible. She said the same thing when she called the therapist, but the therapist was unable to answer. She always called within a couple of hours of such outbursts to apologize for her statements and to ask to be able to continue therapy. She believed her contrition was sufficient to repair the relationship. All the therapist had to do was accept her apology.

In all the examples in this paper, the typical response of most therapists would be to think about limit-setting. They might tell her she cannot act in any of these ways, that she has violated boundaries, and/or that she cannot return. When she virtually humiliated the therapist by shouting in the hallway where other tenants could overhear, the therapist naturally could have been stimulated to set limits or to discharge Marie.

But the therapist held back. Thinking over the situation, he realized Marie was not a “spoiled brat” or too needy or too manipulative – although any of these adjectives might have applied. Rather, when she shouted at or about the therapist or fired the therapist, she had been in a panic that she was unwanted, abandoned, of little priority, or not worth the therapist’s time. The therapist had inadvertently activated memories of her mother abusing her and failing to protect her. So the therapist reasoned that the right thing to do was not to reject Marie, but to deliver the correct intervention, such as, “Marie, you must have been worked up into a panic over the anxiety that by being late, I might not think you are important or even that I might not show up, so you’d feel abandoned. As soon as you imagined that could be, you felt abandoned already. It’s because of those terrible feelings that you act so strongly – to let me know how awful YOU feel.” She never shouted at him after that.

3. Psychological Defenses are implicated in these episodes. A common defense is Turning Passive to Active. The wounded client gains a sense of strength, thus overcoming powerlessness, by taking an injury which was experienced and inflicting an injury in turn.Right Intervention6 Projective Identification is a related defense in which the client behaves in a way which engages the therapist to identify with her feelings. Identification with the Aggressor is the carrying out of actions towards others which are similar to those acted upon the client. Acting Out is the expression through actions of emotional reactions and impulses the client is unable to express in words. This list is not meant to be exhaustive, but to illustrate some means by which the client’s underlying dynamic can manifest in ways which make the therapist uncomfortable.

4. Identification is perhaps the least complicated of these dynamics. As all of us do, the client is acting in the way in which he or she saw a parent or other important figure act. Many of the kinds of clients we are discussing have grown up in unprotective environments or witnessed a parent acting in an aggressive way. Often the client had been the target. So the client has identified with what he or she experienced.

SUMMARY

So then, with respect to clinical intervention, it seems that such limit-setting interventions are frequently like taking the easy way out. The client is actually showing self-control and reasoning by carrying out these behaviors in a way which is not truly dangerous and is meant for an effect rather than to inflict physical harm. So then it would seem the preferred intervention is to avoid rejecting the client and to do the therapeutically correct thing.

Point out some of these factors:

• the client’s pattern around such behavior
• the client’s perception and cognitions which generate the behaviorRight intervention7
• the associated emotions
• the purpose of the defenses involved
• the unresolved emotional experiences behind the behavior
• and the consequences for his or her relationships and world view

Such interventions demonstrate meaningfully that the therapist is attuned, empathic, understanding, and connecting. Then watch the results to see if the outcome is to reduce the client’s tendency to such behaviors. The therapist’s greatest gift is the right intervention delivered sensitively at the right moment.

Do the right thing.

© Don Rosenberg, 2013

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