The Balance Between Involvement and Professional Distance In Therapy. By Dr Linda Berman.

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The Tea Table – Mabel Frances Layng. Wikioo.

“The professional must learn to be moved and touched emotionally, yet at the same time stand back objectively: I’ve seen a lot of damage done by tea and sympathy.”

Anthony Storr

Psychotherapy is a moving, dynamic process, in which we constantly shift between thinking and feeling. It involves considerable sensitivity and empathy on the part of the therapist, but also the ability to ‘stand back objectively,’ as Storr says.

‘Tea and sympathy’ have no place in the therapy room. What does this phrase mean?

Well, if we were to provide tea and sympathy, we would be offering a friendly, non-professional listening ear, comfort, solace, kindness and hospitality.

Perhaps we might offer a chunk of home-made cake, a warm hug, reassurance, a smattering (or more) of advice,  and all this might be interwoven with anecdotal titbits about our own or others’ similar experiences.

Whilst tea and sympathy may sometimes be necessary in a relationship outside the therapy room, whether with family or friends, it is certainly not therapy.

If therapy begins to spill over into this kind of interaction, it becomes unhelpful, and, as Storr says, potentially damaging.

The therapist is not a friend, (any more than a friend can be your therapist) and attempts to become so would be unethical and would need very close attention in supervision.

The therapy relationship is actually ‘asymmetrical,’ one in which we are equal but different. Trying to blur the lines and boundaries of the therapy will result in confusion and a lack of safety and containment for the patient.

An understanding of what the patient needs will gradually come to us out of their own individual story, both verbal and non-verbal.

Building the therapeutic alliance will involve establishing trust and confidence in the relationship between therapist and patient.

From the beginning, the therapist will sense what is needed in terms of closeness and distance in relation to the patient.

This is not about power, but about empathy and sensitivity, gauging the patient’s needs and maintaining appropriate boundaries.

If the therapist is experienced as very active and overpowering, the patient will most likely feel intruded upon and overwhelmed.

On the other hand, if there is too much distance emotionally, the patient may well feel rejected and disliked.

Both these situations can be experienced as a replication of past experiences for people in therapy.

Sometimes, the patient might project parental distance or over-closeness onto the therapist. This negative transference needs to be picked up and interpreted early, as, if unexplored, it could result in the patient not returning.

Hopefully, the patient might be encouraged to verbalise their experience of the therapy relationship. If so, then the negative transference could very much provide valuable grist to the mill of therapy.

Through an enabling and facilitative interaction, with appropriate management of closeness and distance, the patient can begin to learn what real and authentic connection between two people is all about.

Research has indicated that an effective therapeutic alliance is the most important aspect of therapy, in terms of a good outcome, so the therapist’s interpersonal skills are paramount.

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Bert Pot. Close Distance. Flickr.

“Therapists have a dual role: they must both observe and participate in the lives of their patients. As observer, one must be sufficiently objective to provide necessary rudimentary guidance to the patient. As participant, one enters into the life of the patient and is affected and sometimes changed by the encounter.”

Irvin D. Yalom

This dual role of which Yalom speaks forms a crucial part in the maintenance of a difficult balance. As therapists, we need acute and sensitive self-awareness in order not to become overly-attached or coldly detached in relation to the patient.

Like the painter (see below), the therapist has to be able to be both together with and apart from the patient, simultaneously near enough to be involved and far away enough to be an observer.

  • Balance: Multi-Tasking: Keeping Several Balls In the Air At One Time.

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“Balance”, Paul du Toit, 2001. Wikimedia Commons.

“Life consists of two sides … light and dark. Joy and sorrow. Without a balance, one cannot fully experience a full and well-rounded life.”

JoAnn Ross

The quotation above refers to the fact that life is about balancing opposites, managing the inconsistencies and changes that constantly make our lives interesting and colourful…. and, at times, difficult. It is highly relevant to the process of psychotherapy.

The effective psychotherapist’s tasks are manifold:               

“In his clinical practice, the psychotherapist is  kind of hybrid….: a quasi-scientist, quasi-artist.”

(Dr Robert Hobson: Forms Of Feeling: The Heart Of Psychotherapy)

Amongst many other tasks, the therapist must have a sound understanding of theory and concepts, an up-to-date knowledge of research in their field, the ability to connect and link theory and practice, and an understanding of symbol and metaphor.

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Self-Portrait Being Duplicated into Three – Salvador Dali. Wikioo.

“Psychotherapy is an art enlightened by wisdom, theory and research.”

Barbara Temaner Brodley.

There is a need to develop the skills to acutely listen to another’s language and to hear what is expressed in the ‘music behind the words’ and non-verbal communications. 

“Dreams, puns, elisions, plays on words and similar tricks that we ordinarily think of as frivolous, all play a surprising and somewhat disconcerting role in the communication of important and serious feelings.”

Milton H. Erickson

In addition, it is crucial that therapists have one or more experiences of personal psychotherapy, in order to develop self-awareness and empathy.

It is also vital that they can maintain a confidential, accepting, open and non-judgemental stance, and have the ability to wait, with patience, trusting their own intuition and insight……

  • Some Models Of Distance And Closeness in Psychotherapy
  1. Freud’s blank screen: Aloofness and Distance.

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Freud considered that the therapist should be a blank screen onto which the patient could project whatever they wish, which would, in time, form the basis for transference interpretations.

He saw his role as that of the doctor diagnosing and treating the patient. Freud believed in ‘drive theory,’ seeing the infant as only wanting contact with others to satisfy their libidinal instincts.

It is important that the therapist does have some degree of neutrality, anonymity and detachment:

“The ability to observe without evaluating is the highest form of intelligence.”

Jiddu Krishnamurti

However, it is impossible, and certainly undesirable, to present such a limited view of the therapist’s self as a blank screen.

Again, there may be echoes of this blankness in the patient’s past, with unresponsive and unavailable caregivers.

The repetition of this in therapy could be detrimental and psychologically incapacitating for the patient.

2. Way beyond the blank screen: the psychoanalytic theory of object relations.

In 1917, Sandor Ferenczi was beginning to emphasise the importance of empathy, mutuality and reciprocity in therapy. He was a colleague of Freud, but his ideas differed in that he did not believe that the therapist should be a neutral figure with no apparent feelings.

He recognised the importance of relationships, of the child, and the patient in therapy, needing a sense of relatedness and care, in order to discover aspects such as trust, identity and love.

In the 30’s, 40’s and 50’s, therapists like Sullivan, Guntrip, Fairbairn, Klein and Winnicott developed objects relations theory further.

The theory of object relations puts strong emphasis on the importance of relationships with primary caregivers in infancy in terms of the child’s development.

It suggests that our early experiences of those who look after us are paramount in terms of future growth, relationships and mental health.

The term ‘object’ is a little misleading, as it actually refers to a person. For example, a parent is usually a ‘primary object.’ The perceptions we have of these early relationships and their internal representations, will colour and shape our future lives and relationships.

Ways of thinking about ourselves are seen as developing from these early experiences with our primary caregivers.

The responsiveness of the other person to the child, the way in which the child’s image is mirrored and reflected in the parent’s eyes, crucially influence the child’s self image.

A significant other who is not empathic, who cannot attune to the child’s needs, will not be able to help that child develop a sense of self that is cohesive and sustaining.

The way the parent thinks about their child will form and affect the manner in which the child thinks about themselves.

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Mother and Child Smiling at Each Other. (Mary Stevenson Cassatt) Wikioo.

‘The mother gazes at the baby in her arms, and the baby gazes at his mother’s face and finds himself therein… provided that the mother is really looking at the unique, small, helpless being and not projecting her own expectations, fears, and plans for the child. In that case, the child would find not himself in his mother’s face, but rather the mother’s own projections. This child would remain without a mirror, and for the rest of his life would be seeking this mirror in vain.’

D.W. Winnicott

All this has significantly influenced the way therapists relate to their patients in the therapy room.

Carl Rogers, in the 50’s, further developed the theory of the necessity of empathy and relatedness in therapy, along with authenticity and congruence.

This approach models effective ways of relating and encourages the patient to develop similar qualities.

We must be aware of the patient’s need for what Bowlby termed the ‘secure base.’

Once this is established, movement around this secure base in psychotherapy becomes more flexible, so that the patient will be able to cope better with the dynamics of closeness and distance within the boundaries of the therapy space.

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  • Seeing The Whole Picture: Both Close And Distant.

“The only people who see the whole picture are the ones who step outside the frame.”

Salman Rushdie

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Ola Billgren – Summer [1969] Gandalf’s Gallery. Flickr.

“You must look within for value, but must look beyond for perspective.”

Denis Waitley

In order to see more of a whole picture of our patients and their lives, we must look, observe, think and feel about them from several different viewpoints. 

In many ways, we have two heads, two simultaneous perspectives. This is, indeed, a difficult balance.

imageTwo Heads – Alfred Henry Maurer. Wikioo.

The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.’

F. Scott Fitzgerald

The therapist has to contend with many dualities, and to manage these.

For example, there are duality issues related to understanding and responding to both therapist’s and patient’s inner and outer worlds, blending theory and practice, awareness of conscious and unconscious, caring and charging a fee/ending each session, hate and love, transference and counter-transference, and many others.

Keeping two opposite views in mind, or managing contradictory feelings, are difficult tasks; however, if we are able to do this, the rewards are manifold.  

Such thinking is surely situated at the heart of creativity.

“People who accomplish a great many things are people who have freed themselves from biases. These are the creative people.”

Milton H. Erickson

So often, people opt for one side or another, choosing to ignore the fact that the world, truth and life in general, are just not that simple.

Seeing the whole picture- and recognising the full story- brings us the satisfaction of clarity, inclusivity and increased awareness.

imageEugène Jansson. Sunrise Over the Rooftops. Motif from Stockholm (1903) Wikimedia Commons.

“You end up exhausted and spent, but later, in retrospect, you realize what it all was for. The parts fall into place, and you can see the whole picture and finally understand the role each individual part plays. The dawn comes, the sky grows light, and the colors and shapes of the roofs of houses, which you could only glimpse vaguely before, come into focus.”

Haruki Murakami

© Linda Berman.

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