The Dangers of Gratification: Clinical Considerations for the Advanced Intern

One of my favorite things about being an intern has been in the opportunity to come together as a group with other pre-licensed clinicians. It has been a tremendous place for learning and sharing in my experience.  Whether it's group supervision, group trainings, clinical case conference, or a consultation group - it's always been one of the best parts of the job for me.  I've benefited both from receiving support and giving it.  There is a shadow side, too.  You don't always get along with colleagues, group facilitators, etc. I've been a part of groups that totally didn't work for me for a number of reasons.  For the most part, I think these kind of groups tend to be really good.  Even in groups that haven't worked for me, I've learned something really valuable. I thoroughly enjoy connecting with therapists - but I'm also picky with who I keep the closest.

Among many things, there has been a thing of particular importance that I've noticed that pre-licensed (and many licensed) clinicians struggle with, myself included. Like many things, it is often times outside of their awareness.  It can be compounded by the customs and attitudes of agencies, implicit or explicit attitudes of supervisors, the clinician's own personal history, etc.  I imagine that many therapists can carry along this unconscious obstacle for months, years, or maybe even decades without realizing it... without the limitations of it being thrown into their faces. I use the word obstacle here very deliberately as it is the unconscious awareness of such a thing (like any), rather than the thing itself, that can lend itself to therapeutic barriers in treatment.

The therapist's desire to feel and be experienced as benevolent can creates barriers in the growth of the client and often leads to an over-gratifying therapist.  Many of us, though not all, get into this profession primarily to feel we are "helping" people.  We therefore derive a sense of satisfaction out of "positive" treatment outcomes/"meeting goals," positive feedback from the client, and idealization.  I have seen where this sense of satisfaction from being benevolent is so intoxicating that therapists begin to gratify the needs and wishes of the client (and what they project the client's needs to be) without adequate evaluation or exploration of the impact of such a wish on the client's life.  Moreover, we often we accept things at face value in this way and in acting-out of our own desire to be benevolent, we foreclose meaning, we stunt growth, and we rob clients of the developmental necessity of optimal frustration.

One way in which therapists can fall into this trap is to prematurely create treatment goals that are not actually based on client need.  Moreover, such treatment goals often provide a promise of certainty and premature knowing that is unfounded and unearned.  Initial goals are also often based on a sense of what client says they need which may or may not be what what is in their best interest.  Many clients who come in for therapy are coming in because they're stuck in one way or another.  They present with a primary interest in protecting themselves in a way that has caused them to suffer from their presenting problem in the first place.  It is our job to watch and determine how and to what extent their stated needs/wishes reflect resistance and how/to what extent they reflect movement towards affect integration and wholeness.  Nothing exists without a counterpoint, without ambivalence, without a shadow.  When you've agreed upon certain treatment goals, it's good to also examine the limitations of imparting said goals on a client -  the message that is sent implies that acting in-line with our goals is good but any deviation from said goal is attributable to less than optimal performance (or a bad internal object).  It may imply they are to be somewhere they are not.  We not only fall into our own need to feel good and effective as therapists who usher clients towards treatment goals, but we impose this split on our clients who feel they must perform to certain standards to be worthy of the therapeutic space. It provides motivation for a client to "perform" in alignment with treatment goals which may provide a space for superficial gratification and reinforcement of pathological means of relating to others.  If so inclined, the client can familiarize themselves with the mechanisms of how to obtain the therapist's praise in this way and perform or manipulate the therapy accordingly.  If the clinician is overly solicitous with positive reinforcement, this same dynamic is reinforced.  We are then no longer operating in a therapeutic way, but relating only to restricted part-objects in the client.

We feel good when we can say something nice to our client, we pat ourselves on the back for being kind and seeing someone's strengths while avoiding the impact that such reinforcement can have on clients.  In my experience, positive reinforcement may be powerfully healing for some but can just as easily be experienced as ego-dystonic, disconnecting, immediately gratifying but ultimately hallow and fleeting, infantilizing, it can feed defensive splitting of good/bad internal objects, etc.  In some instances, it may be met with positive receptivity from the client who is hiding the festering wound beneath.  This positive feedback from the client can reinforce defensive behaviors and resistance while simultaneously blinding therapist to his/her own intuition and ability to attune.  We, in turn, perform alongside them in a pesudo-therapeutic way.  People in general are skilled at  manipulating others into maintaining what feels familiar, repetitive, "safe".  I do not imply a malicious type of manipulation - I simply imply that the client is really good at living and operating and protecting themselves in the way they always have.  Our experience at intervening on their process pales in comparison to the years they've spent establishing it themselves.  It deserves respect, space, and thorough observation.  Reflections from the client that "this is working for me," or "this is really good," can make us want to keep doing the thing they're praising us for.  The clinician here may lose a sense of healthy skepticism and authority, becoming emotionally disconnected from a significant part of the client without even realizing it.  In this way, we maintain a sense of being idealized over a sense of making full emotional contact, over being experience-near, over being present and human.

Idealization is an inevitable encounter.  I have had Self-Psychology supervisors who tell me the goal here is to tolerate the idealization.  While I agree with this notion to an extent, it can be a very fine line between tolerating the idealization and subtly feeding it with our own need to be experienced as benevolent, skilled, or gratifying.

I believe that a key feature to what makes therapy work is the obsessive nature of the frame - the fifty minute hour, the couch, the regularity of the appointment time, the separation, the predictability and stability of the container creates a format for the hysterical nature of someone's internal chaos to run free (or so we hope).  Boundaries themselves are what creates the safety for us to play without getting seriously injured or hurt.  For some clients, the boundaries are experienced to some degree as restrictive, cold, withholding, inauthentic.  One may delight at the boundary being bent even so slightly for them.  One may hunger for specialness to ward of their profound sense of inadequacy, hunger for closeness they wont allow themselves to have without your dramatic display of proof and sacrifice.  To submit here is tempting - the stakes are high in this split.  We over-identify with the "good object," projection and the stakes are higher yet if we compound it with our own investment in preserving our own sense of benevolence. Our reluctance to let go of this idealization and allow ourselves the opportunity to become bad objects can make us too gentle in setting up boundaries, reinforcing limits, and introducing painful affect for fear we will become devalued and/or for fear we will destroy the client. We also send the message that we do not believe our client to be capable or strong enough to tolerate their own painful affect.  We dance around the pain in the transference - hoping we can short-cut to affect integration before we become devalued so that being devalued doesn't feel quite so threatening. We forget that hate and anger can be helpful, connecting, and beautiful.  I notice therapists cushioning the blow of reality with words that make us feel better about delivering the message of separation without paying mind to whether or not those words are developmentally appropriate for where the client is at.  An example of this is the young therapist who prefers the word "transition," to "termination," to make termination itself a less difficult thing to address and talk about.  Another example is the "depth" therapist who favors exploratory questions when setting a firmer boundary/limit or tighter container would be more appropriate - "What would that mean to you to have more time?" may be an appropriate question for some but for others, it may be more appropriate to say something like, "I think you want to feel special to me by asking for more time at the end and you're angry that that's not something I'm able to do. You feel I am withholding."

I have held tightly onto my sense that my primary reason for getting into this field was less about helping people and more about my own fascination with the human mind and the intellectual stimulation I derive from theory, application, and witnessing these ideas play out in the therapy room.  I am motivated to understand - not to heal. I am motivated to connect with something extraordinary, complex, and powerful that is the human spirit.  This certainly creates it own set of obstacles.  As I advance through these experiences, I'm learning that it is often more important to be experience-near than it is to be good, gentle, and gratifying.

I have fallen into these scenarios and pitfalls myself - I still do.  Sometimes I stumble, sometimes it feels like I've fallen out of a two-story window and landed face-down in a pile of mud. I walk away from some sessions saying to myself, "what the f*ck just happened!?"  The experience of becoming a therapist is intense and often filled with feelings of inadequacy, feeling uncertain and clumsy - it is understandably accompanied by a drive to feel competent, benevolent, and masterful.  We cheapen our experience in either direction: either by feeling we have nothing to offer and negating our own authority, or by creating blind-spots in our field of vision with hubris and unfounded certainty.  Many therapists, myself included, spend a great deal of time oscillating between these two extremes.  Overtime, I become more fleetingly connected with the center - I have something meaningful to offer, I am capable, I can learn, I fall down, I get up, I am weak, I am strong, I am human.

A final thought of mine came to me recently when I was sitting with a colleague in a coffee shop - I wondered how often we subtly and unconsciously rob our clients of a sense of empowerment by holding ourselves accountable for their positive growth and development.  Surely when there is therapeutic movement, we pride ourselves on having done good work, for being skilled therapists or for "going really deep," as I overheard one seasoned clinician boast.  Perhaps it is not such a thing to claim credit for - to do so undermines the patient of their own resiliency, their own capacity for growth and development.  Rather, it is the culmination of "good enough" therapy that allows clients themselves to access their own abilities that are inherent to them and belong to them.  It is not so glamorous or grandiose.  Good enough seems to be the therapist who strives to do very well, who pushes themselves to learn, who hungers for their own self-knowledge, who endures their own agony and vulnerabilities in efforts to grow - good enough is the therapist who does all of these things and who only just adequately performs.

I pour through psychoanalytic articles and readings on theory and technique as a way to self-contain in the chaos of performing this emotional work.  Sometimes I am aware of an "Us/Therapist" and "They/Client" language that is used when discussing the therapeutic space.  In all honesty, many of us therapists are clients as well - and I believe that's how it should be.  Jung (1954) wrote in his Psychology of the Transference,

"Consequently the higher psychotherapy is a most exacting business and sometimes it sets tasks which not only challenge our understanding or our sympathy, but the whole man. The doctor is inclined to demand this total effort from his patient, yet he must realize that this same demand only works if he is aware that it also applies to himself."