Karen Maroda on the Therapeutic Relationship
I've previously read some of Karen Maroda's work and found it helpful. I've just had a chance now to finish her 2012 book Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship and found parts of it very helpful and insightful. Herewith some notes on it:
Figuring out Fit:
She begins in a way that puts me in mind of the great Nina Coltart, whose Slouching Towards Bethlehem talks about how to figure out whether you and a new patient are a good match, and how to figure out when to refer to someone else. Thus Maroda writes of what to look for: "Ideally a good match includes compatible styles of relating--just enough shared early emotional experience to make for a connection, but not so much as to blur the distinctions between therapist and client" (p.7). This might still seem a bit abstract so she has some even more practical counsel: Watch how you feel when the prospective patient walks in. What does your gut say? If you have an instant and strong negative reaction that does not abate, that is a strong sign not to be ignored.
Do not, she goes on to say, tough it out and assume initial dislike will go away or be surmounted in an heroic burst of empathy: this almost always fails. Remember, she continues, that "it is not a good idea to engage in therapy, even short-term work, with someone you are either not interested in or dislike" (p.8). If therapists attempt to engage in such work anyway with people "who do not elicit their curiosity and whom they do not like [they] are doing an injustice to the clients as well as to themselves" (ibid).
What, then, to do? Refer, of course, and do not be reluctant or neurotic about it. She says that while you might feel uncomfortable broaching the topic of a referral elsewhere, you should "keep in mind that if you know this person is not a good match with you, at some level the client knows it too" (p.11).
Mining the Intake's Several Veins:
Maroda reviews the data we are all familiar with, showing that drop-out rates are high, and this often occurs after a handful of sessions. Why? One reason she highlights is a rupture in the alliance, which never really had a chance to get off the ground, and this may be due in significant measure to how you conduct your intakes: do not, she says, put people off by taking notes, a principle I first learned from Coltart who is adamant about never taking notes with a patient in the room, which practice I also abhor.
Maroda further says that you need, in that crucial first interview, to avoid asking rote questions, dealing extensively with insurance, etc. Your job is to help them get comfortable ASAP to start talking about themselves. To put it crudely--which she does not, but which I have heard others say--the point of the first session is to have a second session.
As you are further considering fit, and whether this prospective relationship has any chance of success, Maroda recommends that you ask about the patient's existing and past relationships: the patient without any, especially sustained over the long-term, is a very poor prospect for successful therapy.
Don't be so high-minded during the first session to overlook the more mundane factors revealing much about the person and the prospects and direction of therapy. Here she says that much is revealed in the first session by such things as how they first greet you--she comments on the quality of handshakes, which apparently used to happen back in those pre-Covid days we can all scarcely remember now--and how and where they sit, whether they make eye contact, etc.
Once you agree to begin treatment, do not leap in too far and too soon and so overlook the importance of educating new patients on therapeutic process: let them know that "what they defend against feeling is exactly what they need to feel to get better....Paraphrasing Winnicott, I say that we always fear most what has happened to us already" (p.20).
Don't Overdo the Empathy:
Maroda makes an almost off-hand comment that reminds me of much of what I have been reading recently about working with psychotic and schizophrenic patients: there's such a thing as too much affirmation and empathy. She says that if you have people who have difficulty accepting empathy, she advises that "the fewer words the better, and the less dramatic the better" (p.20).
Confrontations:
I really liked Maroda a lot for calling us out on how poorly most of us do with confrontation. I know this is a weakness I have to watch out for and am working on. Once again she puts me in mind of Coltart, who writes about the one and only time she "bawled out" a patient for what she said was a sustained and lethal attack on the treatment and relationship. This startling and singular action turned out to be the pivotal moment needed to prevent outright treatment collapse.
Maroda notes that most therapists never learned how to do confrontation well. She illustrates this nicely with a story about how she confronted a man with herpes who slept around and put a lot of people at risk. In confronting him over this she diverged from what she says is the problem whereby "too many therapists masochistically submit rather than risk real emotional vulnerability" (p.191) which confrontation, done well, invites.
Dealing with Anger:
In this part of the book, she makes an obvious point that nonetheless needs stressing: Don't become a martyr by sacrificing yourself unduly as it only breeds fierce and seething resentment. I've learned that the hard way!
We must respond to angry outbursts and not just suck it up in silence for, she insists, "no therapy is taking place when the therapist pacifies or silently withdraws from an angry client" so don't just sit there and let them rant at you! Instead, you "should struggle hard...to get out of the position of masochistic submission". A failure to respond will usually make the patient either contemptuous or feel hurt and abandoned. Find your own voice and style to respond, but respond. These can be moments of deep change because deep emotions are engaged (p.193).
Hatred in the Counter-Transference:
I have often quoted D.W. Winnicott's 1947 paper "Hatred in the Counter-Transference" but Maroda is right to remind us that "we have given short shrift to the benefits of acknowledging anger and hatred in the countertransference when a stable, positive attachment between therapist and patient exists." As she goes on to note, DWW's classic paper is cited here, but rarely developed, discussed, or implemented.
If you are going to do this, and the relationship is stable and positive overall, try, before expressing anger, to verify whether the patient has any sadomasochistic relationships in the past or any personality tendencies in either direction. If they have pronounced masochistic tendencies, your getting angry may be an unwittingly gratifying thing they are seeking. Finally, ask yourself if you are feeling the need to punish the patient before you say or do anything.
Overall she offers the following concrete guidelines:
- be reasonably in control while manifesting emotion
- direct, honest, and non-defensive anger is what you are aiming for
- admit if you did something to make the patient angry
- don't get snarky or passive aggressive. Say something like "I'm getting tired of your insults and anger and I won't tolerate them any more. What I want is for you to talk about what lies behind those angry insults."
The Importance of Gratification:
Finally, Maroda has some very welcome words that bring out the importance of gratification and stress that it is not something therapists should be ashamed or embarrassed about. She notes that some gratification is not bad but in fact necessary to keep the relationship moving forward. As with the ideas developed at the outset about determining fit, you need to work with patients who interest you and whom you find it gratifying to help.
This is, of course, as she says a "delicate balance" because you can never be totally gratified: that must always be denied to both patient and therapist alike--even as you pursue the limited gratification appropriate to your respective roles (p. 211). She refers to Searles here who freely admitted that he felt at least a little bit in love with every patient at some moment, but he never mentioned this to them or acted on it: here, Maroda observes, is someone who had good affect management, which we should aim for as well.