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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by pegasus on October 7, 2007, at 21:49:47
I have this friend who is a T. Yesterday my friend asked me to consult on a case. I'm not really sure what I'd advise, and I'm hoping maybe some babblers will have some good advice. I have to keep things pretty confidential, but this is what I can say:
I'm going to call them T and client here. So, T and client have discussed client's love for T a lot in therapy recently. So far so good. T has been supportive of these conversations, and yet also made it clear to client that there is no chance that they would ever have a romantic relationship (and, in fact, is *not* at all attracted to this client in a romantic sense, although T would never tell client that).
A while back client revealed to T that client feels angry at T's spouse and young child, because they "stand in the way" of the two of them having a romantic relationship. T had a really strong negative reaction to this statement, and told the client that it was not ok to say that. T reiterated that they would not ever have a romantic relationships, because of their therapeutic relationship. T is very angry about this statement, and feels that it crosses a line of what a T has to put up with, but tries to leave the anger out of sessions.
Personally, I don't quite get the anger. I mean, sure it would suck to have anyone angry at my husband and daughter. And I'd feel a bit uncomfortable having someone going around with a fantasy that they stood in the way of a romantic relationships that I was personally not even interested in. But that's certainly within the universe of things that I'd expect to come up in therapy. It seems to me that it's all grist for the mill, and a symptom of the problems that the client is struggling with.
More recently, client has been focusing in sessions on trying to tell T about erotic fantasies involving the two of them. T is internally very angry and turned off by this. In sessions, T tells client that the content of the fantasies is not important, but that what they can work on together is how to manage these fantasies. After a few sessions where they weren't getting much done except wrestling over this, T is thinking of terminating the client (transfering client to another T).
I am appalled by this. They've worked together for over two years. I think T needs to deal with the negative countertransference, and work hard to get back to therapeutic sessions. Or at the very least, warn client that continuing in this manner is not therapeutic, and that client is risking being transfered to another T by insisting on bringing up these erotic fantasies.
What do you guys think?
peg
Posted by Phillipa on October 7, 2007, at 22:38:45
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
Did this just come up after two years? My first thought was it was a new client, therpist relationship. My feeling is be upfront tell the client that it is not in the best interests of either to continue to relationship unless it gets back to being theraputic. My gut says that the Therapist needs to transfer the patient to maybe one of the same sex? Phillipa ps now I'm no expert for sure on theraphy
Posted by muffled on October 7, 2007, at 22:58:26
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
Well Peg, i'm not so sure about how to deal with the transferrance, but the part about "the hubby and KID standing in the way".....well, that TOTALLY set off ALL my mamma alarm bells...
So what I can add is 1. WHY does client even KNOW T got a kid?
2. What type of T is she (CBT, etc)? 3.When it comes to your own children.....well, its a WHOLE NEW BALL GAME. When the client said bout KID standing in the way.....the mothers instinct in your avg mother can be VERY VERY strong. I sometimes wonder if its even stronger in a mom who had difficulties in their own childhood. I wonder if thats the crux of the prob?....
I wonder if there have been other loose boundaries....
That book "In Session" is mostly bout long term T and transferrance, has your friend read it? Its so-so, but there ARE some VERY good points in it. I would HIGHLY recommend it if she does much long term T.I think it has some excellent points on how to handle these situations. I think its no longer in print but you can buy it used.
Hope this is of any use...
M
Posted by happyflower on October 7, 2007, at 23:04:32
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
Well I think this T needs to get into some kind of supervision with this client. I have heard a lot of times on babble on how clients get jelous of children or spouse of the T for various of reasons. So a client saying this isn't all that odd to me, it is understandable acutally. They crave something that they have never got in their life whether it is maternal or sexual. And knowing that T's immediate family recieves this from him, would make her feel envious. This is why many T's don't have personal photos around of their families.
I think he is letting his counter transference get in the way, if he can't deal with this especially after he seeks some guidence, than it is best to terminate because he won't be very effective, but this would be the last resort.
But if he can see and perhaps understand why the client feels the way they do, and he can control his own feelings to the matter, then he should continue to work with this client. It has been 2 years, so part of that could be the bond the client is feeling, and sometimes the closeness of the therapy relationship feels a lot like love to the client.
Maybe this is the first time this T has had to deal with errotic transference, if he doesn't want to seek his own conceling in this, there are a TON of books written on this subject.I don't think the client should be threatened with termination for expressing her feelings for the therapist (even if it makes the T uncomfortable). She isn't doing anything wrong. But the T's response to this needs some attention. This should be worked out, and the T needs to keep his cool on this. (it won't be the only time this will happen to them) This is somehow triggering something in the T, and makes him angry, he needs to find out why he feels that way because this will no doubt happen again in the future with another client.
That is just what I think, but I am no expert.
Posted by Maria01 on October 7, 2007, at 23:32:43
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
What type of framework does this T use(psychoanalytic, etc)? Aside from that, the T should really get some direct supervision/consultation regarding this client. I don't think some of us are qualified to answer such a difficult question.
Just curious...are you a T as well? It might be better to bounce this off of a fellow T face-to face. While it's nice to seek out opinions, nothing substitutes for consulting with another therapist or supervisor that works within the same framework. Not to raise hackles or anything, but if my T were to ask laypeople for an opinion regarding my progress, etc., I would be upset. The internet is a public space, and there is no way of telling if the client in question has access to the internet, including Babble. Best to preserve their dignity and to bounce this off another practitioner face-to-face. Just my 2 cents' worth...
Posted by Dory on October 8, 2007, at 0:19:29
In reply to Re: another bad termination, posted by happyflower on October 7, 2007, at 23:04:32
just interesting, but there is no mention of the gender of the T or the client.
Posted by gardenergirl on October 8, 2007, at 0:22:03
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
> A while back client revealed to T that client feels angry at T's spouse and young child, because they "stand in the way" of the two of them having a romantic relationship. T had a really strong negative reaction to this statement, and told the client that it was not ok to say that.I'm not sure I can picture myself telling a client it's "not okay to say" something, but then again, it sounds like the T was setting or enforcing a boundary. At any rate, I do think that given the T's strong reaction and the client's focus and behavior, it's necessary to make sure boundaries are very clear.
As to the anger, I think I can relate to that somewhat. A T is trained and paid (ha! usually) to be "in the line of fire", so to speak. His or her family is not. And by saying they "stand in the way" of what the client wants, even if it's metaphorical, the client placed them "in the line of fire". I think I would find that unacceptable. And scary. Even if I didn't believe the client posed a significant risk, the "vision" of my family being more vulnerable would likely feel more threatening. And given the client's continued focus on her erotic feelings and fantasies, which is nothing wrong or shameful imo, the idea that the spouse and child represent "obstacles" whose elimination could be seen as positive by the client, might be a constant sense of threat, at least in the background. That's a huge thing to work through, and I think that a consultant might be warranted.
I guess I think that all T's have their personal "line in the sand", and it sounds like this client stumbled right into the T's. And I think that where the line is drawn will vary a great deal. In this case, if keeping his family "safe" to the extent he defines safety is his line, I think he has the right to enforce it. I think that things are going to be difficult for the client no matter which way it goes--staying with this T or transferring to another. And sadly, I suspect this relationship is unlikely to be repaired enough to facilitate the work it sounds like this client could benefit from.
So many things that maybe can be anticipated but can't be "disclosed in advance" away.... It's hard work on both ends.
What a tough scenario!
gg
Posted by twinleaf on October 8, 2007, at 0:33:36
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
The client is doing what she is supposed to do- expressing her thoughts and feelings about her therapist honestly. The therapist really needs to have good supervision to handle this right- without being rejecting (terminating), or being seductive (it doesn't sound like he's been that, but those are the two ways therapists can react, unless they can handle their feelings in a good and steady way). Often, having loving and positive feelings about a therapist is a first, important step in having more whole, loving feelings towards someone in real life. It's so important for the present and future wellbeing of the client that the therapist handle it well. It's a sacred trust, really. Think of how Daisy's therapist reacted- I believe he said it was an honour and a privilege that she had loving feelings for him. A number of other babblers have described similiar situations, which eventually had happy outcomes outside of therapy- can't think of who they are right now (and some names may have changed), but they are in the archives.
Posted by RealMe on October 8, 2007, at 2:09:42
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
I agree with you completely. When I was doing therapy, I had a patient who used to rage at me week after week. She did this with her previous therapist and the one before as well. What would happen was that the previous therapist was idealized and the current therapist was just no good. Well, one day she said to me that she had this fantasy to chop me up in little pieces, boil me in a pot, eat me, and then vomit me up. Rather appalling to most people, but it did not freak me out. She was struggling with wanting to be an infant who would be cared for like a baby, and when this did not happen with a therapist, she would become enraged. She did some very intrusive things in terms of my personal life that we had to address as well.
I certainly would have handled the comments about wishing the family were eliminated so she could have T all to herself. What is to get angry about. The patient was honest. How many patients wish this but never speak it outloud? I would hazzard there are more than a few. I would have just said something to the effect that nothing was going to happen in that regard, and then I would begin to address what it is that is driving this patient to literally become obsessed with the notion of a romantic relationship. What is the patient avoiding with this, and what is real life link, past and present.
RealMe
Posted by happyflower on October 8, 2007, at 7:02:21
In reply to Re: another bad termination » happyflower, posted by Dory on October 8, 2007, at 0:19:29
You are right she didn't mention the gender of either, I just wrote my take on it using gender for ease of writing. It was very late for me and I just wanted to say something about what I thought to help. What I said would work for either gender as far as I am concerned.
Posted by JoniS on October 8, 2007, at 9:12:45
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
I agree with those who believe the T needs to work on their own countertransference issues. Isn't therapy ALL ABOUT TALIKING ABOUT OUR FEELINGS?? Duh! If a T can't handle this then I have to ask myself, why are they Therapists? Talking about feelings is not acting on them.
The first time my T ever (and I don't ever expect he will) tells me a discussion or a feeling or thought is wrong or we shouldn't talk about it I will know to end that "therapy".
I am jealous of my T's wife. I am only human. It doesn't mean I will ever cross any boundary and interject myself into her life. To be able to talk about my feelings in a safe place that helps me understand myself - well that is one of the greatest gifts therapy has to offer.
I hope the client's best interests are served.
Thanks for asking for our input. That makes me feel good.
Joni
Posted by pegasus on October 8, 2007, at 10:39:07
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
Thanks so much everyone for your thoughts. I know it's a bit risky posting about this here, but I figured that it was a common enough situation that it wouldn't be identifying. Believe me, I considered it carefully, but I'm open to hearing feedback on that aspect of it as well.
To add a bit more information, the T in this situation is receiving supervision, and the supervisors are advising termination. I disagree that that is appropriate, but that's possibly related to my own issues. Which is why I wanted to see what you all thought. This is long term therapy, and not CBT.
It's been helpful to hear your varying perspectives. I'm trying to work out my own thoughts about this, for my own future reference. It's good to know what others here think. Don't underestimate the amount of wisdom people on babble hold.
peg
Posted by raisinb on October 8, 2007, at 14:07:18
In reply to Re: another bad termination » pegasus, posted by pegasus on October 8, 2007, at 10:39:07
Wow. What a terrible bind to be in.
Without knowing much about the situation, I can say that if I were the client in that situation, I would *much* rather be terminated than be shut down or subtly rejected in sessions--by words, actions, or all those nonverbal communications that are usually more important than what is actually said.
If the T feels such strong anger and/or repulsion, then the T should try and manage it--but if that can't be done (and it sounds like this T has been trying, but failing), then the client can't help but feel that anger--and how can that be helpful? How can the client learn that his/her most destructive or "icky" feelings can be acceptable after all? How can the client learn to be fully honest? To trust that others can handle her?
Termination after 2 years is going to be damaging, but months or years of more difficulty because of the T's feelings getting in the way of the process might be worse. Not being able to talk about one's fantasties in psychodynamic therapy is like not doing homework in CBT--like taking the meat out of the sandwich, you know?
As sad as it's going to be, I think the T is going in the right direction. Ultimately only the T knows what's manageable for him/her, and s/he should act on that knowledge.
Posted by DAisym on October 8, 2007, at 15:18:09
In reply to Re: another bad termination » pegasus, posted by pegasus on October 8, 2007, at 10:39:07
Hi Peg,
I'm late to this thread and haven't read all the responses but I wondered how much potential the client has for a psychotic break? As a mother, this would frighten me, particularly if I was aware how easily information can be found on the internet. We can't hear whether the client is wishing that there were no barriers or if there is an implied threat. And I don't know the therapist's history with threatening situations, so this might be too big of a button to be pushed for her.
I'd even go so far as to think about what termination might trigger in an unstable client and think through how honest about it you'd want to be. Again - I don't know the client. I think about myself and how I have thoughts about my therapist's wife - but they aren't in the "I want to harm you" category. But sometimes they are "I wish you didn't exist" category. But I don't think I'm scary, so termination around this wish wouldn't be necessary. But we've had clients at my agency that are too intense and need someone who can tolerate their affect. And what if the therapist was feeling an inappropriate response to a client's feelings - such as a reciprocal attraction? I know - the gold standard is "no tears and no erections" - to quote "In Session" but how realistic is that? A good therapist includes those that know when to transfer.
And more than most people think, many therapist believe that strong sexual transference is a reason to transfer, mostly to protect the therapist from a variety of potential scenarios, including getting sued. It is a reality of the world we live in.
The ultimate question becomes whether the therapist feels they can continue to work effectively with this client and if the answer is no, a sensitive transfer, with the therapist owning their "stuff" is really the most ethical thing to do. And I'm not completely suggesting that the therapist own their stuff out loud with the client. Honesty versus damage to the client must be wrestled with.
We might all wish that therapists can handle anything we throw at them. But since they are human, the next best thing is that they know what they can't handle and what to do about it.
I feel for both the therapist and the client here.
Posted by gardenergirl on October 8, 2007, at 19:16:56
In reply to Re: another bad termination, posted by raisinb on October 8, 2007, at 14:07:18
> Not being able to talk about one's fantasties in psychodynamic therapy is like not doing homework in CBT--like taking the meat out of the sandwich, you know?
What a great way to put it!
gg
Posted by RealMe on October 8, 2007, at 22:00:46
In reply to Re: another bad termination » pegasus, posted by pegasus on October 8, 2007, at 10:39:07
Alternatively, if the T can't resolve her anger, then it might be best for the patient to see someone else who is less inclined to react to what patients say.
RealMe
Posted by pegasus on October 10, 2007, at 10:01:41
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
Thanks so much everyone for your thoughts on this. I hear that this is the situation now:
The T got supervision from a number of experienced Ts. They unanimously recommended transfering the client to another (same sex) T. So, in the next session, the T plans to explain to client that they seem to be stuck in a place where they are not doing anything therapeutic or helpful for the client (this has been explained to the client before). Dwelling on these erotic fantasies is only feeding them. If they cannot move the sessions into more therapeutic territory, and stop trying to talk about erotic material that is not therapeutic, T will need to transfer client. The expectation is that the client will then continue to try to bring the conversation back to erotic material, and will consequently be terminated (transferred).
This is psychodynamic therapy, and the supervisors are experienced in that orientation. From what I gather, the concept here is that erotic fantasies centering on the T, especially when presented as attempts to seduce the T rather than as attempts to understand the underlying psychological issues, are different than other types of fantasies. Discussing them in sessions generally feeds them, resulting in less and less therapeutic value to the client. Intuitively I get this. Talking about sex with the object of one's desires is a lot like having sex with them.
Where I get stuck is in why it's ok to transfer a client who is stuck on erotic fantasies, but not a client who is having, say, persistent fantasies of the T as a perfect mother. I've heard of a number of therapeutic conversations where clients and Ts talk about that one. And it seems to be helpful. In an intuitive way I understand how fantasies with T as sex partner are qualitatively different than fantasies with T as mother. And it does seem intuitively that discussing the mother fantasies would be more helpful. But exactly why is that? Is it just that the desire to be mothered is so energetically different than the desire to have sex?
Peg
Posted by raisinb on October 10, 2007, at 10:29:25
In reply to The plan, and my confusion **possible sex trigger*, posted by pegasus on October 10, 2007, at 10:01:41
You know, I don't think that erotic fantasies and fantasies of perfect parenting are that different. Isn't it conventional wisdom that adult sexual needs have their roots in infantile needs to be held, fed, etc.?
What I thought when I read about the situation is that the T and the client are stuck in a place where they are just going over and over the fantasies (thus gratifying them, in a way), instead of a place where they can *analyze* the fantasies for the underlying needs. I guess it's kind of like entering fully into a book, wallowing in it, and losing yourself in the fantasy, rather than analyzing themes, character patterns, and tensions.
It seems like that could happen with any kind of fantasy?
Posted by Phillipa on October 10, 2007, at 19:14:15
In reply to The plan, and my confusion **possible sex trigger*, posted by pegasus on October 10, 2007, at 10:01:41
If you received no mothering in your life as I didn't than it would feel good to know someone cares enough to listen to you. Just my take. Phillipa
Posted by RealMe on October 10, 2007, at 23:29:38
In reply to The plan, and my confusion **possible sex trigger*, posted by pegasus on October 10, 2007, at 10:01:41
Has T tried to get the patient to look at what is behind the erotic fantasies. Having a same sex therapist might help, but then that might result in what I had with the one patient who then ended up raging at me all the time. In the case of my patient back then, my supervisor and I decided to have a review conference, and the decision was made that when I left, she would not be seeing an individual therapist anymore--just be in her group. So, sometimes it is true that thinks are not working, but I sort of got the sense, and I could be wrong, that the underlying stuff was never addressed due to T being so freaked.
RealMe
Posted by pegasus on October 19, 2007, at 8:58:26
In reply to another bad termination, posted by pegasus on October 7, 2007, at 21:49:47
For those of you who were following the story of my friend, who is a T, wanting to terminate a client with romantic transference . . . it has a happy ending. The T decided to talk about needing to transfer before actually doing it (the original plan), and explain that if they can't find a way to do work that is therapeutic, as opposed to fighting over whether to talk about the details of the clients' fantasies about the T, then the T will have to transfer the client to another T.
The client got it, and they talked about how the client has been resisting real therapeutic work, etc. And the client understands that if those fantasies take over the sessions again, that they should talk about why they come up, what purpose they serve, etc. Otherwise, they'll talk about transfering.
So, it's all on the table, and they're back to doing good work together.
Yay!
peg
Posted by Dinah on October 19, 2007, at 9:16:04
In reply to Bad termination: happy ending, posted by pegasus on October 19, 2007, at 8:58:26
This is the end of the thread.
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