On Therapeutic Drift or: Coasting in the Counter-Transference

There are certain books which may meander for several hundred pages, but have a single, simple thesis easily summed up in a paragraph or less and easily remembered thereafter; and then there are complex books that use all of their many pages to advance multiple points or explore multiple sources and contain so much content that re-reading on several occasions is required to master it all. Irwin Hirsch's book Coasting in the Countertransference: Conflicts of Self Interest between Analyst and Patient (The Analytic Press/Routledge, 2008) is very much in the former category, and that is very much a virtue. 

Hirsch's book (xv+220pp) is of standard length but really does advance a simple point that merely recalling the title is enough to remind you of the force of his argument. And his argument, his point, is an absolutely crucial one still too little talked about in the clinical literature after a century and a quarter of psychoanalysis and psychotherapy: the avoidance by too many clinicians of raising, and maintaining sustained and necessary focus on, conflicted and unsettling topics in therapy because the clinician would rather "coast" than run risks of patients becoming (more) angry or leaving therapy entirely to avoid painful topics. 

He states his thesis with pellucid clarity and simplicity on p.2: the clinician "can be said to coast in the countertransference, choosing comfort or equilibrium over creating useful destabilization." A little later on he notes further that "the quest for personal comfort and equilibirum with each unique individual patient is always potent" (p.4) for one of several reasons: I can't bear their rage/sorrow/other uncomfortable emotion; I can't bear the loss of income; I can't bear the loss of company in my lonely life. 

Hirsch zeroes in on a point others have remarked on: avoidance of conflict is an understandable weakness of most people, but it is not so understandable, and certainly not so justifiable, in clinicians who know--and ought to know--that until and unless difficult emotions are grappled with in the therapy, the process of change is very likely to remain dormant, weak, and ineffective. In other words, the absence of useful destabilization means the absence of meaningful and lasting change. 

On this point, I am, in reading Hirsch, at once reminded of my first encountering Karen Maroda some time back and, before her, of the incomparable Nina Coltart. Both of these outstanding women, from whom I have been learning for many years now (as I noted here and here), and to whom I continue to repair regularly, remind us that we need to do a much better job harnessing our aggression in clinical work and using it in these difficult situations where the attractions of coasting peacefully and passively down the quiet canal, rather than venturing out onto stormier bodies of water, remain strong. 

Maroda first broached this topic, if I recall correctly, in her book Psychodynamic Techniques and then more recently in The Analyst's Vulnerability, which I wrote about here. The former book, I should note, is coming out next week with much fresh and updated material, and I am planning on reading it at once. 

But back to Hirsch. He notes that one of the most common refrains from clinicians justifying coasting is that "the patient is not yet ready." Oh I can confess I've dined out on that in two cases simultaneously for months! In one case, I did and do believe it was justified, and that the patient was too heavily defended against hearing directly and clearly about a very strong transference dynamic which showed up immediately upon intake and was a constant (a highly vexatious constant, I would add!) for many months. This was also, not surprisingly, the thing that had destroyed so many relationships across three decades and led to an acute sense of isolation and, on occasion, serious thoughts of suicide. His effect on me in session was so strong that I deliberately and I think justifiably avoided confrontation until I could be certain that my reactions to him were under careful control. (Winnicott's warnings against retaliation echoed in my mind constantly.) 

"Strike while the iron is cold" was very much my watchword here, and when I finally did start to unpack with him what he had been doing to me in the transference, and had been doing with friends and family for decades, we were able to have a much less defensive discussion and make faster and more straightforward progress than I ever thought possible. At the end of treatment, he thanked me for being the only therapist in decades of trying who was actually able to help him understand his actions and feelings and help him to change them. 

Another case at the very same time brought me up short. I had also been saying "She's not ready" about this patient, who one day confronted me about this very topic and my avoidance of it! She pointed out that I had not gone back to a very painful topic she had raised about 4 or 5 months earlier, and I readily agreed that I had not. She quietly asked why I had not, and I said that in my estimation it seemed that she was not yet ready and I did not want to press too soon or too hard into matters that, months ago, seemed very tender and almost unbearable. 

"But couldn't you have asked me if I was ready!?" Her question had a real scales-falling-from-eyes effect on me, and I realized at once that she was right and I was wrong: I had made an assumption--my confidence in which was about 75 or 80%--and that seemed sufficient to me that I didn't need to verify it with her: I was about 80% confident she was not ready and so I continued to allow us to drift quietly down the canal rather than risk choppier waters.

I apologized to her for my presumption, and sincerely thanked her for teaching me an important lesson about not underestimating a patient's strength or overestimating her reluctance to engage a topic without first using the simple expedient of asking her if she was ready!

The beauty of Hirsch's book is that he is able to point out our tendencies to drift and coast without at any point sounding like a hectoring or sanctimonious moralist. He illustrates the book with many examples of his own failings--but these, too, are told without any tone of that moral masochism Freud first recognized. So we can feel challenged and confronted, but gracefully, humbly, and clearly because of a heartfelt desire "to be more useful to patients" (p.51).

In the end, the problem with drift or coasting is not one that can be permanently eliminated in advance, and the elimination of it should not be a process of constant recrimination from our superegos. Instead, it requires regular work on all our part, session by session, to ensure we are not allowing this to happen, but being both gracious and realistic about it when we discover it is happening. And such vigilance is required because of the all-important awareness that "patients change less from theoretically biased insights and procedures than from new and unpredictable affective relational experience" with their clinician (p.113). The supreme gratification of this work, in the end, is in watching people change in long-sought and often difficult ways, and we should set our boats to sail vigorously in that direction rather than drifting about inhibiting the progress we all seek.