June 15th, 2011

The games therapists play

Tug-of-war is a silly game – all of that straining in order to move a rope a few yards. If you’ve ever played, the whole thing seems pointless, yet it is so easily and regularly played in our daily social lives. Husbands with wives, parents with children, co-workers and confidantes – no one, not even the experienced therapist, is above such game playing. One person feels an unmet need and pulls at an important other to meet it. The other misreads or rejects the person’s pulling and gives a yank themselves. Whether you call it a “power struggle” or a “transference-counter transference pattern,” it is universal in clinical work.

Take any client with whom “difficult” interactions in session occur and ask yourself: Of what am I absolutely certain about this client? What are the thoughts you grip tightly about this person that pass the “nod” test – that if you heard a colleague say this about your client, you would nod emphatically in agreement without really thinking about it? Chances are, you’re like me and you’ve written statements in progress notes such as “unmotivated for change,” or “help-rejecting,” “boundary-violating consistent with Axis II diagnosis” or “oppositional or noncompliant to interventions.” We must ask ourselves what will be the likely ripple effects of gripping these thoughts with such certainty. Are we allowing for our inevitable influence on the therapy relationship?

After decades of laboratory and longitudinal study of relationships, psychologist John Gottman describes the process of derailed connection. Gottman’s lab examined the interactions of hundreds of couples and was able to predict relationship failure (with approximately 90 percent accuracy) based on how well or how poorly individuals made “bids” to connect with one another. Those who “turn toward” the other person making a bid were much more likely to stay together, while those who “turn against” or “turn away” from one another were much more likely to see their relationships falter. According to Gottman, “bids can be hard to decipher when the bidder doesn’t acknowledge his or her own needs for connection.”

Conflict and negative feelings are natural to relationships. It is what is done with those feelings that predict outcomes. Gottman informed the field about marital relationships, but what about the therapy relationship?

Neuroscience has identified the role of “mirror neurons” in the brain during any human interaction. These brain cells, according to neuroscientists such as Daniel Glasser at University College London, prime our systems for similar reactions, a tendency to mimic the observed person’s emotions and behavior. These specialized brain cells may be the biological seat of empathy, of the skills of attunement which are the stock and trade of psychotherapists.

In therapy, what happens in the moment between therapists and clients – the tit-for-tat of emotional and behavioral reactions, is important in the eventual trajectory of the work. Work from parallel fields (such as Gottman’s study of couples, and Glasser’s examination of mirror neurons) suggests the benefits of therapist attention to the process of their in-session interactions with clients.

Despite our professional intentions, the pain carved across a client’s face sparks emotion and behavior in us as observers. Anxiety pulls for anxiety. Look anyone in the eyes and try not to communicate anything… While our training may have us hold our inner experience in check, our brains have a mind of their own. We communicate glimpses of our inner landscape to clients regardless of our efforts. Instead of avoiding this neuroscientific fact, we might benefit from embracing it and learning to harness skills for authentic exchange to move clients toward lasting change in the context of a healing connection.

Research from dozens of studies has consistently shown “therapeutic alliance” to be a robust predictor of outcome in therapy. Studies have also shown that “ruptures” in the alliance – breaks in the therapeutic bond as a result of errors and (to use Gottman’s term) missed “bidding” between therapist and client, are predictive of poor treatment outcomes. When therapists push their change agendas without the consent and agreement of clients and when they fail to attend to clients’ experience, rupture occurs and tug-of-war interactions become more likely.

Therapists who give up games and learn to “dance” in attunement with clients are more likely to generate progress in treatment. This may be especially true of therapy with “difficult” clients – those whose behavior hits clinicians’ buttons – those who are violent and abusive, substance users, clients suffering from significant mood disturbance, trauma victims and those diagnosed with personality disorders or with highly maladaptive social behavior – these clients seem to slap therapists with the rope. These people pull for negative reactions. And as soon as therapists get caught in assuming intent on the part of clients for their rope-pulling, a-tugging they both will go.

What is needed is proactive recognition of the patterns of interaction. Most importantly, resolution of difficult client-clinician patterns requires a moving toward the pattern in some way. What are the scripts I’ve learned about how to experience and express emotion that may be interfering with my work with a particular client? What thoughts might stand a loosening of grip? How might I mindfully allow my inevitable experience of negatively-toned thought and emotion during sessions instead of shoving such reactions away? How might I communicate engagement and commitment to the agreed upon goals of treatment despite the client’s behavior and my negative reactions? When might be the best juncture for proactive intervention – a process intervention? An authentic acknowledgement of error perhaps? Maybe a limit that needs to be set, or a strategic bit of self-disclosure, or bit of shared humor (remember mirror neurons and the development of alliance through shared affect)? Might there be a role for any of these in your efforts to drop the rope with difficult clients?

Human action becomes vital and vehement when what is basic to us, the “stuff” we experience as core to our survival (whether literally true or not), is threatened. Our brains seem to know little difference between fear bred from bullets or ill-timed therapist “interpretations.” If we miss the cues, fail to attend to clients’ “bids” for connection, and if we react instead of responding, we will tug-of-war needlessly with our clients. Let’s make a pledge to strike terms such as “oppositional,” “manipulative,” or “unmotivated” from our session notes. Let’s instead look to the mutuality of clinical work. It’s where the action of change is at.

Mitch Abblett, Ph.D. is the Clinical Director of the Manville School at Judge Baker Children’s Center. In addition to his work with children with emotional and behavioral difficulties, he conducts trainings nationally for clinicians regarding the relational aspects of work with “difficult” clients.

By Mitch Abblett Ph.D.

One Response to The games therapists play

  • September 1st, 2013 at 10:55 am Bella O'Dell posted:

    What often seems missing in discussions of “difficult clients,” is that client viewpoint is utterly absent. Clients will see therapists as domineering, delusional, misdirected or simply unhelpful. Or the therapist represents himself with powers he really doesn’t possess. Or therapy is oversold, creating the fantasy that it can create impossible transformation. Client feedback is ridiculed and deflected. First do no harm? I’d say, first establish basic human respect. disequilibrium1.wordpress.com/

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