Harnessing--And Using!--Your Aggression in Psychotherapy: A Catena of Clinicians

Preface: 

There's a great bunch of psychotherapists on Twitter from whom I continue to learn much. The discussion over the past few days has been about clinicians who comfort but do not challenge; who soothe but never summon up the guts to push patients to change. This has made me go back and revisit some thoughts on here written over the past few years.

My love for and debts to D.W. Winnicott should surprise nobody who reads anything I write. Using his thrilling 1947 paper, "Hate in the Counter-Transference" with students ignited some of the best discussions I've had with students in a quarter-century of teaching. All credit should go to him for advancing the discussion of counter-transference (then still undertheorized) in general, and in particular for his blunt acknowledgement that parents hate their children just as therapists hate their patients sometimes, and both are not only normal but sometimes even justified.

But I'm increasingly coming to question aspects of his paper that might--however inadvertently--reinforce the notion that psychotherapy and psychoanalysis are never about direct challenges to the patient but consist largely in soothing and comforting. This is a point Jonathan Shedler has often made on Twitter, and I am very grateful that he keeps making it.

My rethinking of Winnicott is inspired directly and recently by reading Karen Maroda's new book, which I discussed in some detail here. The most memorable line in the entire book comes quite late: "we need a statute of limitations on this holding and nurturing behavior" (p.197) among psychotherapists who do not sufficiently challenge their patients nor engage in healthful, careful conflict with them en route to their actually changing, getting better, and eventually going away.

Maroda says that we need, as psychotherapists, to learn how to engage in "constructive conflict" with our patients (p.106) and what she later calls "creative rage" (113). As she will caution in a later chapter on enactments, "there is no simple answer to this question" of "how do we harness negative countertransference emotions in the interests of furthering the treatment?" (p.129). 

I took Maroda's challenge in that book as something of a rebuke to misreadings (or, perhaps better, misapplications) of Winnicott. For all his courageous and welcome bringing out of hatred from the closet, Winnicott's treatment of hatred in that essay no sooner brought it out before domesticating and stuffing it back in the cupboard again: E.g., early on he says that "hate that is justified in the present setting has to be sorted out and kept in storage for eventual interpretation." 

I do not find much in the essay to indicate that hatred became a present, this-day object of discussion with his patients: it is either always locked away for future interpretation or else, when it appears on the scene, is described as something in the past, safely overcome and no threat to patient or therapist right now: E.g., he writes that "It was indeed a wonderful day for me (much later on) when I could actually tell the patient that I and his friends had felt repelled by him, but that he had been too ill for us to let him know."

Winnicott goes on to give a rather nervous list of five reasons how and why analysts will of course keep their hatred on a very short leash in "ordinary analytic work"--in contrast to that with psychotic and anti-social disorders, which is his primary focus here. Most of the time, he rather blithely says, analysts will see that their hatred is "easily kept latent." 

But then all of a sudden he immediately shifts into saying that patients need "objective" hate and need to be able to access it in the therapist. I regard this sentence as the pivot of the article and indeed its most important claim:

If the patient seeks objective or justified hate he must be able to reach it, else he cannot feel he can reach objective love.

He must be able to reach it! Just when readers like me are starting to wonder about hatred and aggression being too domesticated, Winnicott brings us up short with this reminder: your hatred might be safely stored away for future use, or as a relic of past feeling, but in fact you need to have it in the therapy with your patient who needs it now. You might, in other words, have been amply supplying a lot of soothing, comforting "love" of some sort, but without feeling and accessing hatred, how much of that love you think you are offering is really being received and used well? (Indeed, that "love" you are offering might itself be fueling deeper hatred, or at least fear and anxiety, in your patient! Certainly there seems to be some evidence of this being true with psychotic patients.) 

Winnicott in this essay does not really offer specifics about handling hatred and aggression, but his final sentence is a severe warning that avoiding the use of hatred and aggression may well lead to treatment collapse: "Only in this way can there be any hope of the avoidance of therapy that is adapted to the needs of the therapist

rather than to the needs of the patient."

So let us say--as all good clinical practice demands--that the patient's needs are paramount, and yet one of those needs is to be challenged to change and grow, not merely to be soothed and comforted. They might hate you (at least right now) for your challenge to them to change and grow, and their hatred in turn might spurn your own hatred in the counter-transference. Without having had in-depth therapy of your own, can you handle this as a clinician? Can you be courageous enough to challenge and to hold the line when the patient resents or hates you for it? Or will you--as research suggests--revert to the familiar and familial role of comforter which many therapists learned to play as children with psychologically damaged parents?

I know I am not very good at this, but am constantly trying to learn to be better at it. But instead of just trying, as Winnicott suggests, to contain that hatred for future use, can you canalize, capture, or harness some of it for sound and careful clinical use in the here and now? 

Winnicott seems to imply that you can without showing how. So here is where I turn once again to Nina Coltart, that most independent-minded and bluntly outspoken of all the British analysts of the post-war period. With characteristic brevity and boldness, Coltart says a therapist should "harness our aggression skillfully in the service of clinical work" and that so doing is a "strongly positive factor" which patients will welcome. But such skillful use requires work in and by the therapist on him/herself so that it is done without fear or anxiety. (Famously or perhaps infamously Coltart gives an example of her using her own hatred in a very spectacular way with one patient who was, she said, utterly sabotaging treatment. Her outburst with him turned things around.) 

The other person who has done even more work than Coltart on this topic is Michael Karson (whose book is discussed in more detail here) Do not, he says, be that doctor who enlarged his practice by only pleasing, and never challenging or curing, his patients! You're going for patient improvement, not patient satisfaction. 

Karson says you do this by getting in touch with your aggression. One way you can do this, he suggests, is skillful use of interruption: "Good therapists are constantly disrupting their patients' master narratives" (6) and as a result are not in the business of merely supplying a comfortable environment to vent. The problem with merely being a person to whom I can comfortably complain is that "comfort seeking impedes growth" (7).

Rather than merely providing comfort, your job is to challenge patients and their faulty narratives. You do this by something that Karson later calls virtuous aggression (29). He gives such examples as challenging bad ideas, collecting the fee, and ending sessions on time. "These things all injure patients, as they should."  There is no point pretending otherwise. 

I admit I found that last bit very refreshing and straightforward. To drive the point home further, Karson says: consider the surgeon. He or she would not deny that cutting someone open and removing and replacing an organ is not injuring them in service of a cure. Would he or she flinch from saying: I have this slot on the surgical theatre's schedule, and these many minutes, for the procedure, and at the end of it, I am getting paid? 

Later in the book Karson says  too many therapists tiptoe around and try to avoid conflict. Bluntly he insists that "the overarching lesson about conflict in therapy is that it is better to approach conflict than to avoid it" (90). In fact, you cannot avoid it for "rupture and repair" always happens in therapy. If you are distinctly unc0mfortable with such things, and if you aren't comfortable making mistakes and then examining them, you have no business being a therapist. 

Some--perhaps much--of this is not necessarily sophisticated. Some of the conflicts that should not be avoided are around age-old things like the frame and the fee. Karson stays that to start and end on time regardless of joy or sorrow says that all is welcome here to be treated equally. It also refuses to infantilize the patient, and says that you have hope and confidence in them to be able to handle themselves and move on with their day. As Karson says, "patients need therapists to be not only loving but also strong, and time management denotes strength" (124). So whether in laughter or tears, the session ends on time.

This all still sounds a touch too abstract and theoretical. I am, as noted above, far from an expert on these matters, but as someone who has had to learn, and is still learning, to observe that statute of limitations on all this comforting business, and to become more comfortable challenging patients to change, I will continue to read on and think about these things. 

In the meantime, I can report the following have been helpful to me when tempted to collude with patients seeking comfort over change. This is far from a rigorous and tested list! It merely represents some very modest gleanings from that "constant feedback loop" which Shedler talks about in psychotherapy: I have tried these things and found them useful. My samples are very small and not verified by anybody other than my supervisor, and I do not suggest these are the only, or even best, practices: merely what has worked for me in particular sessions. 

With delusional and histrionic patients: Indirect challenges seem to bear more fruit. Frontally challenging deeply held ideas, in my experience, results in easy deflection and dismissal of the challenge. Looking for underlying components, and assessing their relative strength and importance to the patient, may direct you towards the proverbial Achille's heel which, when pressed upon, may yield in the direction of conceding something to be untrue and thereby moving closer to reality. 

With deeply sexually traumatized patients: I have had blunt discussions with such patients about the idea of a frame and how that--far from being a sign of my lack of care when I do not extend sessions, or have sessions with them over coffee in a shop of their choosing--is a protection to them, and a reminder to us both that we are here to do work and not merely commiserate. 

With psychotic and borderline patients: One thing I have learned from both mentalization and metacognition approaches to therapy (for the latter, see the MERIT approach in this book, which I have read but not written about yet) is that providing an environment encouraging unstructured and completely free association may be counterproductive. Rather, ask them early in the session what they want to work on that day, and then keep challenging them to return to that. (Stated differently, I have learned from my own psychoanalytic therapy that free association can itself be a defense mechanism! I ran out the clock on one session with almost sadistic glee wildly and knowingly associating all over the place to a rather unremarkable dream I had in order to avoid talking about something difficult from the previous session!)

With enmeshed and abused adolescents and adults: I've learned to challenge their near-constant deferring to the dominant authority figures in their life even though this makes them acutely uncomfortable. I could have colluded in keeping them comfortable but instead I would gently but repeatedly press, "But what do you want to do?" until I got a first-person answer that seemed genuine. (This requires careful handling, of course, so that they do not merely shift their submissive instincts from parents to you in a fairly obvious transference.) They were awkward and uncomfortable finding their voice, but once they had voiced their own views and desires, the relief and sense of increased autonomy was palpable.  

This approach reminds me that I have found the use of questions, rather than statements, and these delivered in a gentle tone with as much curiosity as possible, will almost always go farther with the patient in inviting open reflection than declarative statements. (I wish I could do this as well as my own analyst, who has this incredible capacity to deliver a simple question--"I wonder why that is?"--absolutely saturated with curiosity.)

With just about everybody: Thanks to Adam Phillips and--as we saw above--Michael Karson, I find myself routinely challenging master narratives. If you listen carefully (that third ear!) you will hear patients switch registers or voices, and give you material that is clearly a "received notion" (from family, typically). I regularly ask "Whose phrase is that" or even more bluntly "Says who?" if they give me something like "I know I am a real pain" or "this is such a stupid thing to bring up." 

I especially do this with patients who come in pre-loaded with diagnostic terminology: "I'm very OCDish" or "my mother says I'm bipolar." I always invite a deeper discussion here about what that label means to them, or might mean, and about the larger meaning of a diagnosis as such. Some find it welcome relief after a period of uncertainty; others find it a prison and stigma to bear. 

A few other thoughts: if I can feel (as my grandmother would say) when my dander is up in a session, I find myself returning to Winnicott to ask: does this aggression need to be held for another time? Or (with Coltart et al): Can I safely draw on a bit of it now in a productive way? If I feel I cannot--if I feel I might lose control and say more than would be helpful--I keep silent and process it in supervision. This does two things: it allows someone I respect hugely, who has had a wide and varied practice of 40 years, a chance to weigh in; and it also gives me a cooling-off period. Then when I go into the next session, I can, more coolly and with greater precision and control (and thus comfort!), talk about the previous session and open with the challenge. I try to do this right at the outset of the next session (as I also try to do if I feel there has been a rupture or I've made a mistake) so that I do not lose courage and dither!