TIFT #36 "It's The Love"

“It’s the love,” that is what a good friend and experienced therapist dared to say some years ago. Let me take a break from the series of posts about therapist objectives to discuss recent comments about healing an intense attachment to one’s therapist.

A reader wrote:

“I guess my hope is that, as someone who teaches therapists, you will nuance your claims about how childhood needs can’t be fulfilled. I think therapists often use this reasoning against clients in ways that are really damaging. And, perhaps more importantly, this reasoning causes people like me to settle for of continued pain when that is not necessary.”

I am writing this post knowing that nuance implies a greater level of ambiguity and subtlety. Please read this post as relatively impressionistic. My aim is to give ideas, not to be definitive. So I hope my readers will not take it too literally or seek rigid rules. Every client is different and every client-therapist relationship is unique. I wish all the best.

Do therapists get attached?

Yes, for the most part. As with human nature in general, it is totally natural and healthy for therapists to care and feel connection with clients when they know enough for empathy to develop. Responding this way is an essential part of our nature as a species whose survival has always depended on social relations. Can it be suppressed? Yes, there are people for whom empathy is blocked or the capacity is missing. Those people should probably not be therapists. So, in general, the answer is that we therapists can’t help getting attached to clients. It’s a kind of love, but also a love that comes with clarity that there are boundaries.

Many therapists have been taught that sharing this information with clients is a bad thing to do. I think this attitude has its roots in the Victorian era. That outlook was still prevalent when Bowlby studied British orphanages of the 1940s and came to the then surprising conclusion that withholding warmth or affection was actually damaging. Also the 40s, the psychoanalytic community was still convinced that the therapist’s emotions should be withheld for the ostensible reason that it might damage the transference and spoil objectivity. I think that was a similar vestige of the Victorian emphasis on control of "base" instincts. In my experience, transference is a robust phenomenon that easily overcomes whatever bit of humanity might peek through the curtain.

Relationship is such a powerful force that it affects therapists in training. Bathed in a professional community where covering up feelings is highly valued, it is not surprising that practitioners should remain anxious about showing their human responses. Besides fitting in with the community a truly valid reason might be that the therapist is uncertain or vulnerable about boundaries, in which case it would be better for that therapist not to take on the client or to obtain serious help. Not every therapist has been so self-aware.

Beyond the latter serious therapist limitations, I don’t see good reasons for voluntarily hiding one’s feelings. Letting the curtain drop may cause anxiety for the therapist. It means letting go of the comfort of privilege and power. And yes, being human is delicate. There are ways to express feelings that can easily be misconstrued. Here is a good description of how to do it from the point of view of the blog reader quoted above:

“However, some of my experiences with my current therapist have been really different. Unlike my previous therapists, she actually tries to meet my young parts needs. I’ve been surprised at how flexible and creative she’s been in doing this. And I’ve found that, while imperfect, these attempts have been largely successful.”

Some clients are better able to tolerate a degree of distance and an impersonal relationship with their therapist. Perhaps they have less early life damage or perhaps their self-protection is stronger because they have had even more hurt and are simply better at defending themselves. Even if they can tolerate such a therapeutic context, it does not mean that treatment will be more effective or shorter. Because psychotherapy does, and should, go deep into the personality, I think that therapy conducted at an emotional distance will generally be slowed down or limited to the extent that a genuine emotional relationship is denied.

In answer to the reader at the start of this post, It is true that 24/7 primal love is impossible to duplicate in adult life, but it is also true that the very best part of primal love is empathy, being accurately tuned in, which is abundantly possible within the therapeutic context. Overall, then, I have to agree with the reader that showing humanity, while remaining sensitive to how our verbal and nonverbal communications are received, should be seen as the standard for good therapy. Now let’s look at how abuse and deprivation at different stages of development may affect the client's quest to heal.

The deepest, earliest, level of attachment damage

When clients (I’m still reeling from a scathing comment on my use of “patient”) get very attached to their therapist it is usually because of a shortfall in primal love from long ago. The deepest level of damage is failure to internalize “basic trust,” probably similar to a reliable sense that things will somehow turn out OK or a feeling that one still exists even when the therapist is not physically present, as with object constancy. One reader wrote this:  

“This might sound odd, but after every therapy session, it’s as if I’ve died to my therapist. By that I mean, for no logical reason, I think that the only time my therapist ever thinks about me is when I’m in her rooms having a therapy session.”

Here she shows just such a failure to internalize a basic sense of being connected. Along with it, we can also expect damage to the ability to trust. Both can be sources of difficulty taking in therapist caring even when it is available. Clients will naturally experience a great deal of mistrust and will withdraw instantly at a sign that the therapist is not completely genuine. Paradoxically, these may also be people who, out of intense need, have trusted, or overridden their mistrust, when they should not have.

This situation obviously poses problems for the therapy. Even a relatively trustworthy therapist may not be trusted or may go through a long period of scrutiny. Often, the things that finally convey trustworthiness are the slips and uncontrolled moments that reveal a therapist’s genuine humanness. Reassurances, while appreciated, are likely to be taken with a degree of doubt or a “wait and see” attitude. Such encouraging words may not lead to enduring change but express the therapist's good will and can help to sustain the relationship while waiting for trust to emerge.

As trust is established, internalization of a positive relationship seems to happen very gradually, even over years. As I have stated elsewhere, I believe the triggers for each increment of internalization are moments of attachment anxiety, as in saying good-bye and in necessary separations.

Damage from (slightly) later in development

This discussion is informal and not necessarily precise or complete. In my mind, consequences from a bit later in development are different. I think of age two as the age of power struggles and three as the time when the conscience comes on line with it's powerful ability to generate shame. Basic trust may already have been solidly internalized so that trauma is now manifested differently. Many caregivers, even those with significant impairment, may have been able to nurture during the earliest years but hit their limits later. New issues such as power struggles and rivalries may not be handled well and personality mismatches can appear. Also, losses, abuse, violence, and other traumas can follow relatively intact earlier years. When trauma and deprivation happen at this slightly later period I see the “inner child” metaphor as a more true way to capture the intense purposefulness with which the client may seek connectedness.

When damage is built on a relatively more intact foundation, I think some additional emotions come into the picture. Anger at the caregiver’s failure is more of a factor. That entails more issues. There may be fear of expressing anger, which can result in self-directed aggression or identification with the aggressor, such that an attitude of self-criticism is adopted. Alternative soothing and sensations may be discovered as substitutes for love,  becoming compulsions later.

Perhaps most significantly, with greater cognitive development, the child may become sensitized to the threat of hopelessness or helplessness. As children in troubled circumstances become aware or believe that they bear sole responsibility for their own and siblings survival, they also react to the possibility of not having the resources to succeed. Even unconsciously, this equates to loss of hope and may be warded off at great cost. What if my primary caregiver is not capable? Fear of the experience of hopelessness can be held off by denial or bravado. "I can handle anything." When such denials last into adulthood they can contaminate conscious thinking and become a block to adult acceptance. Acceptance of what can't be fixed (and is therefore hopeless), is painful beyond present reality. This is one reason why clients who have experienced childhood deprivation and abuse may have great trouble accepting that they have survived childhood and that they now have the necessary equipment to navigate their world. To them, it feels like childhood must be repeated and repaired rather than left behind. 

Lack of internalized connection vs. not accepting what wasn’t?

At this point, it may be hard to tell whether the need to be convinced of the therapist's caring comes from missing internalizations in the earliest years or the intolerability of facing and accepting a past associated with fear of ultimate hopelessness. To me, experiences like the reader’s of not existing in the therapist’s mind are among likely indicators of early internalizations that never happened or that were not very solid and have been disrupted under stress. At the very least, it is worth asking how much we are dealing with failure to internalize love vs. seeking to undo early pain and the dread of hopelessness.

What conditions promote internalization and healing?

Genuine caring on the part of the therapist seems to be a necessary but perhaps not sufficient requirement for trust to be built. Without trust, it is hard to expect the client to embark on the emotional risk taking involved in accepting connection and internalizing it. Furthermore, without a genuine connection, there is nothing to internalize. The conditions for acceptance are not very different. Acceptance also involves a significant emotional risk. Emerging from denial of the experience of hopelessness is no less frightening than a child with limited understanding having to face death or annihilation. The client must be ready to face hopelessness and loss of what was experienced as necessary for life, even when those fears have been held out of consciousness. There needs to be a place safe enough and emotionally supportive enough to undertake the painful process of accepting aspects of primal love that can not be replaced and losses that must be written off.

Perhaps a way to summarize is that, in my current view, holding back on genuine connection and caring does little to help, and tends to limit progress in the areas discussed, involving early developmental problems. On the other hand, as the reader says, “how flexible and creative she’s been in doing this.” There are many ways that real feeling and connection can be communicated without losing sight of potential harm.

Jeffery Smith MD

 Photo by Lucas Sankey on Unsplash.