Working in the Here-and-Now of the Therapeutic Relationship

Earn CE Credit

• Nick: A Case Study
• Ruptures
• The Past as Present
• An Ending or a New Beginning
• Working with Disjunctions and Derailments

When clients arrive at our office, they’re hoping we can help them feel better. Often they assume it’s their outer conditions they need to change: “if only my husband would…” or,  “once I find a new job...” or, “I don’t know why I’m feeling bad because I have a great life, but…” It’s not that we don’t listen to their concerns, but these are all situations that exist outside our consulting room.
 
In order to help clients change, we have to allow ourselves to be changed by what we, in the therapeutic relationship, do together. Working in the present, in the room directly with what is happening, demands that the therapist emotionally connect with the client and not just sit back, hidden by our professional role of “helper” or “expert.” It requires emotional involvement, reflection, vulnerability, transparency, and risk.
 
Research repeatedly tells us the therapeutic relationship is the curative factor over and above all theoretical orientations. A figure commonly cited in the literature is that up to 50% of clients drop out of therapy after the first session. These figures are established regardless of finances: in private practices, agencies, and free clinics. Researchers attribute these high numbers to two things: lack of emotional engagement and failure to deal with ruptures.¹            
 
If the therapist and client only talk about relationships that exist outside the consulting room, they miss many opportunities to deepen their work together. As therapists, we need not make generalizations or assumptions about what the presenting problems of our clients mean or how they came to be. These scenarios are acted out and worked with in the transference and counter-transference of the therapeutic relationship.
 
We also risk losing our clients through impasses and unattended derailments.

The first phone call can be a deal breaker before things even get started, because clients’ relational patterns begin to be reenacted from the minute they make contact with us. If we let these moments go by and don’t address them at an appropriate time, we sacrifice the teachable moment as it’s happening between us.
 
The mutual engagement in the here-and-now of the therapeutic relationship is a deep, internal conduit for change, and it entails our clients experiencing the impact they have on us. It empowers them in personal ways we can seldom predict that speak to the uniqueness of who they are. It’s different from a prescriptive, goal-oriented, solution-focused model where we therapists are the all-knowing ones with advice and answers. It is instead dealing in the moment with things as they are, in the client, in the therapist, and the space between the two.
 

Nick: A Case Study

We can see how this way of working played out with Nick, a 48-year-old divorced man who came to treatment complaining of “loneliness and relationship problems.”² He wanted to know why he always ended up alone and what he did in relationships that made women leave. He was also confounded by his rejection of women before things even got going. An additional problem that came up later in our treatment was his compulsive overeating. I wondered why it had taken several months for his concern about his weight to come up between us. Later I learned he had tremendous shame around his body, had been cruelly taunted as a kid about being fat, and became inured to his body as if he was destined to carry this “dead weight” around.
 
In our first session, Nick appeared overweight, with little attention given to grooming: a rumpled denim shirt, an unpressed pair of chinos, and well-worn tennis shoes. His hair was combed but hadn’t seen a pair of scissors for a while. He sat near the door, in the chair furthest from mine. As he settled, his movement seemed labored and uncomfortable, squirming in his seat, as though his body was a rough place to inhabit. It’s bound to be painful in there, I thought as I observed him.
 
“I don’t seem able to sustain intimate relationships,” he said softly, gazing down at his shoes, puzzled by his own incapacity. When I asked why he thought this was the case, he replied, looking everywhere but at me, that he didn’t know, but then mentioned he was too picky when it came to women. He realized he was a perfectionist—not that he thought he was perfect, but he always found something about the women that became objectionable.
 
“They don’t have a decent job, or we have little in common, or they’re not smart enough, they have no sense of humor, they talk incessantly about themselves…” He said this staring out the window, as if talking to the trees. I didn’t feel like I was in the room with him. His list was endless, and I wondered if it was the tip of the iceberg, saying more about him than the women he was rejecting.           
 
During one session after we’d been working together for a year, he shook his head and proclaimed, “Relationships are too much work.” Much of our conversation took place while he fidgeted with his clothes, his hands, or the couch. Inquiring into these nonverbal motions in the past had yielded little information and alerted us to the likely disconnect he had with his body. He acknowledged however, he thought the nonverbal gestures were about his “discomfort with intimacy.” I had seen him through two short romantic skirmishes, only to find him alone yet again.
 
“I must be afraid to get close to people, so I’m always discovering excuses to find something wrong with them.”
 
I nodded, suspecting he was on to something. “Sounds like a good insight.” Then, almost wondering aloud, “How is it trying to get close to me?”
 
He thought as his leg started kicking back and forth. “Well, it seems easier compared to others.”
 
“How so?”
 
“You’re not judging me, you accept what I’m saying, don’t need anything from me.”
 
I confess I was pleased to hear this, but suspected there was more to the story.
 
“Do you feel close to me?” I literally felt my body heating up, as if we were moving closer to something important happening between us in the room.
 
“I guess,” he said, looking out the window, fidgeting in his seat.
 
“You’re not sure?” I asked, trying to keep him present and accounted for.
 
“Well, I know we’ve talked about coming twice a week and I think I’m afraid to do that.”

The last several weeks we had been discussing his aversion to adding a session, making it a twice-a-week treatment, an opportunity for us to become more intimate. I could see him bristle at my suggestion when he mentioned “not enough time” at the end of the last few sessions. I suspected this was one version of how his fears of intimacy got re-enacted between us. “And what scares you about being together twice a week?” I asked.
 
“That you will discover something really wrong with me,” he said softly, picking at his buttons.
 
“And what would I see that’s wrong with you?”
 
He thought. “I don’t know––that I’m missing a gene that’s required for intimacy and a healthy relationship,” he said. “Maybe I have some incapacity, or I’m damaged goods, unable to be resurrected for a real marriage.” He said this with a big sigh, hanging his head, shaking it back and forth.           
 
We explored what he meant by “damaged goods.” This was a painful process with long silences and quiet tears running down his face.
 
“Once you see that, you’d give up on me, feel I’m unable to change.” He said this under his breath, choking down the tears, almost as if his words are stuck in his throat. “Maybe you’d think I’m a hopeless case, give up on me and want to get rid of me.”
 
He was barely audible. Were these new thoughts for him? My heart ached for him. Now we were getting to how fear of intimacy played out between us.
 
“Is that what you think? Are you the one who thinks you’re a hopeless case?” I asked. He was afraid I’d reject him. Perhaps this was why he rejected some women so quickly so they didn’t have a chance to reject him first.
 
The conversation segued into his first marriage failing. For the nine years they were together, it had been harder and harder to extend the intimacy, both sexually and interpersonally. Here in the room, elbows on his knees, head in his hands, he was unable to say why he had withdrawn from his wife. I also wondered about the pain he had been holding regarding his failed marriage. He didn’t understand why he felt so bad about himself; he just did. He always remembered feeling this way: not wanted, made fun of for being heavy, not feeling worthwhile or responded to. I imagined his weight, which had been with him his entire life, was an insulator for many of these feelings.
 

Ruptures

A few weeks later, Nick came rushing in late—highly unusual for him—and stormed across the doorway to my office. He appeared excited, invigorated, as he waved his arms around and stumbled hard onto the couch.
 
“I don’t know what’s going on,” he said breathlessly, “but recently I’m feeling angry—angry all the time.” My eyebrows rose as I nodded, suspecting this was a good thing.
 
He settled himself, took a breath and added, “Truthfully, I think it’s just I’m aware I’m angry.” Normally, Nick struggled to connect with his feelings and suffered with a blunted affect that resulted in a lot of fatigue and apathy. I suspected the overeating fueled the fatigue and depression and served to numb out painful feelings. “Since our work together,” he continued, “I see how there’s always been this under current of anger, but now see I’m allowing it to register. Not the usual denial of how I feel, and so I’m seeing how pervasive it is.” I can see how the food allows me to bury my frustration. He appeared animated and incredulous.
 
“Sounds like a good insight,” I said. I waited. Silence.  “Are you feeling angry now?”            
 
He considered this. “I…I don’t know. I guess I am,” he said surprisingly, almost as if to himself. I waited.
 
“Is there something you’re angry with me about?” I asked, not having anything in mind, but thinking about his being late and coming in angry.
 
“Well, no,” he pondered, “that seems like a stretch. Why would you ask?”
 
“You’ve come late today, which is uncharacteristic of you; in fact I can’t recall you ever being late, and you’re talking about being angry right now. We’re the only two here, so I thought it might have something to do with us.”
 
“I’m thinking it’s more about the spat my boss and I had this morning. I’m feeling stirred up by that,” he said, repositioning himself. After a minute, he stilled himself, focused and continued, “You know, now that I think about it, I did leave here kind of ticked off last week.”
 
He talked about his disappointment with me because I hadn’t had a chance to read an article he had written. I had told him I’d be happy to read it, but hadn’t done so between our two appointments. I certainly understood his disenchantment with me; had I been honest, I would have told him I couldn’t read the article for a couple weeks. I now realized my counter-transference had prevented me from saying anything, not wanting to disappoint him—an old habit of avoiding and pleasing people so they’ll like me.
 
As he said this, I remembered the look of disappointment and surprise on his face at the end of our last session, after asking me for my feedback on the article. I had since forgotten this moment, his facial expression being so subtle and fleeting. The moment had slipped by me; it was possible I didn’t want to see or feel his anger coming at me, a feeling that’s difficult for me.
 
“I felt unimportant and dismissed by you, not valued,” he said somewhat sheepishly, as if I were going to explain myself or make him wrong.
 
In this situation it was necessary to feel my own frustration and guilt for not reading the article, watch how this impacted my client and not collude (by evading his anger), retaliate, or defend myself. I stayed with what was happening between us to further explore his anger and frustration with me.
 
Here was a rupture between us, and if I hadn’t made a point of contacting what was happening in the room, this incident would have gone underground. I suspect our relationship would have hit an unconscious impasse, creating a lack of trust and distance between us. As we talked about his anger and hurt with me, he saw he could acknowledge it, feel it, express it, and that I could hear it, and we could still stay connected despite the difficulty.
 
Tracking Nick’s feelings in the context of the intersubjective field showed us how my need to please and avoid anger and Nick’s unspoken hurt and disappointment manifested unconsciously between us. Coming in late and angry, despite neither of us knowing why, acted out Nick’s feelings. I represented the “Bad Mother,” as Melanie Klein calls it, by not attending to reading his article. This re-enacted the parental relationship he had growing up. In Nick’s formative years he hadn’t had responsive parents as a mirror to reflect what his own thoughts and feelings were. This left him feeling devalued and ignored, as well as cut off from his own sense of self—a feeling that had a long and painful history and showed up in his depression, isolation and eating habits.
 
As we can see in this re-enactment, it was not just Nick’s feelings being acted out, but mine as well. In my attempt not to disappoint him, I had done just that. The disjuncture was something we’d created together, a common experience within the therapeutic relationship. As therapists, we’re going to make mistakes. The important part is how we bring the current experience to good account. This is the working through of therapy in the relationship, in the moment, in the room—the unpacking of what just happened.
 
As therapists, it’s important to carefully monitor what gets stimulated, not only in the client, but in ourselves as well. We allow ourselves to be moved, provoked, bewildered and, above all, impacted by our clients. What emerges in a session is a result of our unconscious subjective world colliding with theirs. We notice our personal reactions and distinguish them from our clients’ in order to help our clients with theirs. Each session is a mutual discovery. This creates a present aliveness, illuminating the issues lurking in both of us, often occurring under our radar of knowing.
 

The Past as Present

A few months later, after Nick’s hours were reduced at work, he requested to see me every other week. He said he was feeling on shaky ground with finances and didn’t want to risk spending more money at this time. Money had never been discussed between us, other than the initial payment, and I was curious what his financial situation was. He reported that his house was paid for, no alimony, and he had investments, but felt it wasn’t a “good time” to be spending additional money.
 
I understood his concerns and wondered with him if there might be any other additional reasons for wanting to cut back sessions. To ask for additional reasons beyond the cost of therapy can be a rich window into emotional issues obscured between the therapist and client.
 
“No, it’s really just a monetary thing,” he said with a shrug.
 
During the transition to therapy every other week, I mistakenly charged him for an extra session, perhaps a result of my own anxiety about money or disappointment about the reduction in sessions. Since Nick didn’t mention my mistake, I brought it up towards the end of our next session and asked him if he had noticed it.
 
“I did, but figured you were the therapist and knew best so I wasn’t going to say anything about it.”
 
I told Nick that I felt bad about my error, let it go, and imagined we had handled it.
 
But here was a reenactment. He was going to ignore his own need and accommodate to mine, a painful, reoccurring pattern established early in his life.
 
At every moment in therapy, there are multiple levels to which the therapist can respond, including the content, process, body language, affect, or relational field.  Looking back, this moment with Nick was a missed opportunity to explore our relationship. Nick had a hard time speaking up for himself and was often oblivious to his emotional needs, looking to accommodate and please others before knowing or asking for what he wanted.  We had discovered together over the months how overeating often took the place of his ability to be aware, feel and speak up about his own needs. But one missed opportunity is no reason for despair; core issues undoubtedly find a way to come around again, especially when they aren’t handled.
 
A couple months went by and Nick neglected to pay for the month’s sessions. When I billed him for them, he objected, saying he remembered writing me a check. After several phone conversations, which I found stressful, afraid I hadn’t calculated correctly, he came to see he had indeed missed the payment. The check he wrote had been buried on his desk and was never delivered.
 
The following session he came in with a check, sat quietly and finally said, “I feel the therapy is moving along too slowly and not making enough of a difference. I’m not sure I should keep coming,” he said flatly, without affect.
 
Not feeling he’s getting his money’s worth, I thought. Aloud I said, “I’m surprised to hear this since you’ve repeatedly remarked how much therapy is helping you change by speaking up for yourself, feeling more (mostly anger,) and reaching out to people.”
 
“I said those things because I figured you wanted to hear them,” he said as his face reddened.
 
“What makes you say that?” I wondered out loud.
 
“Well, I like to keep people happy… it’s automatic pilot for me and easier than figuring out what I want or think.” He’s trying to give me what he thinks I want, while dismissing how he feels.
 
Again, I suspected this had something to do with how he learned to adapt to his early caregivers. I realized I had missed the transference and might lose him–– and was not feeling good about that.
 
His anger and disappointment with me were being acted out through his non-payment. His affect and compliance had been well hidden from me. As uncomfortable as it is for me to be the object of anyone’s anger, I knew it was necessary to endure. This was another window into working with Nick’s anger that had prevented anyone from getting close to him, myself included. He’d make a decision, not always conscious, to withdraw from relationships so he wouldn’t have to deal with his own aggression, and to soothe a hurt, scared self.
 
At times the unpredictability of the here-and-now encounter in the therapeutic relationship forces us to emotionally confront ourselves in a way that no amount of training fully prepares us for. If I had not allowed and distinguished my own internal responses from Nick’s in this moment, we would have been more prone to an unconscious enactment. In these scenarios, one of the likeliest impediments in the treatment is therapists’ fear of their own feelings, which could potentially steer the therapy in the wrong direction.³
 

An Ending or a New Beginning

Not long after that, Nick left me a voicemail saying he was dropping out of therapy. I called him back encouraging him to come in for at least one last session to wrap things up.  He did come in, and much to his credit, he was finally able to say what was on his mind, allowing us to complete the final chapter in the therapy. This was a tremendous achievement on Nick’s part, being willing to stay connected, even if only to terminate and tell me what was going on. He felt I didn’t have any answers for him and that he couldn’t get comfortable being the only one doing the revealing. We eventually came to understand how his acting out was an unarticulated way of telling me how angry he was with me for not giving him more direction. Nick felt I was too concealing and he wasn’t happy with the relationship being “so one-sided.”
 
The vulnerability had become intolerable for him (like in his marriage?) despite the knowledge that intimacy was something he longed for. It had become too uncomfortable emotionally; he felt exposed and at risk (i.e. with money). I wondered if it was easier for him to find fault with me, as he did with other women in his life, than to take a chance being vulnerable with me. Better he reject me first than be rejected by me.
 
“How do you think this reluctance to jump into ‘risky waters’ helps you?” I asked.
 
“It keeps me safe. I can stay home in my cave, play computer games, and eat junk food rather than come here, face you and feel how screwed up I am.”
 
“I can see how courageous you are to come in and admit all of this to me,” I said, knowing how true this was. I was touched by his admission.
 
As we talked, Nick began to see how his reluctance to engage with people let him off the hook; he could retreat to his comfortable, numb solitude by reducing sessions. He would distract himself with Sudoku, crossword puzzles, computer games, etc., and saw now how this contributed to his shutting down and isolation.
 
As we continued to discuss times he had been uncomfortable with me, for instance ending a session on time even if he was in the middle of something, or initially not being able to address his food issues, Nick came to see how he erected a “demilitarized zone” around himself so he wouldn’t be hurt and judged by me (and others). He saw how the distance “helped” him not to have to live with uncomfortable feelings, the meaning it had, and how he was the only one who could change it. He came to see his loneliness was located inside himself—self-imposed in an attempt not to be hurt anymore.
 
As Nick became aware of his loneliness, rather than making others responsible—particularly his ex-wife, imperfect girlfriends, or even me—he saw how the pattern was an unconscious state of mind and body that protected him. Once we linked his thinking and behavior to his history, and the template of habits it created, he recognized how it had been a successful strategy for survival growing up. This unconscious strategy had helped him live through the emotional neglect of his childhood, and protected him from the constant hurts of unresponsive, dismissive parents. He realized the distance he felt earlier with his ex-wife, and now with me, was an outworn way of taking care of himself so he wouldn’t be hurt again. Staying isolated allowed him to avoid the grief, shame and anger that got stimulated in close relationships; food became his biggest comfort and companion.
 
By linking what was happening in our relationship with his history, Nick’s behavior made sense to him. This changed his relationship to himself, replacing his anger and internal saboteur with compassion. Instead of hating himself, eating to dull the pain and withdrawing from relationships, he came to see how hard he was struggling, not only to connect with others, but to himself as well. By working with the relationship in the present, we saw how his past was alive today in the present.
 
Nick also saw how his protection of extra weight helped him adapt to the deprivations of his early life. What was once a strategy of soothing and protection now became a lifetime of habits, using food, withdrawal and emotional numbing in an unconscious attempt to avoid being  hurt. We had worked for two years without any success with his weight, however, this realization was the beginning of a life-long effort and success at slow weight loss. He no longer needed the extra padding to defend himself and terminated therapy shortly after he lost 40 pounds. It wasn’t that all his issues had been resolved, particularly the relational ones; but he felt he could manage things going forward. I felt good about the work we had done together, and he successfully terminated.
 

Working with Disjunctions and Derailments

Tracking the derailments in the therapeutic relationship is a way to bring the life of the transference and counter-transference right into the here-and-now of the inter-subjective field. The disjunctions between the therapist and client have to happen so we can understand how they’ve developed. We therapists stand in for the internal object through which the client’s conflicts are experienced. And then we get to repair what’s happened between us.  Nick wasn’t used to anyone wanting to know about his needs, so he tried to stop having them. When this became impossible, he simply walked away, a pattern that left him painfully lonely.
 
The disjunctions that occur in sessions usually have a long history attached to them; making the pattern explicit, in the present moment of the therapeutic relationship, helps the client identify the pattern. Just as a mother must hold, contain and partially work through the experience her child cannot hold and work through by himself, so must a therapist help digest and metabolize experiences for the client. While the relationship creates moments of disruption, we can use our mutual attentiveness to help the client own formerly disavowed feelings.⁴
 
For me the challenge comes when I get caught in my own complexes, my own feelings of inadequacy, anger, helplessness, of not knowing what to do, or of wanting progress to look a certain way. I have to set my agendas aside of wanting to help, heal, or have a specific outcome. I keep my meditation practice active so I can concentrate on the here-and-now, notice my own feelings and not let them intrude on my client’s, continue with my own growth and development and utilize consultation/supervision when I suspect my own material is interfering.
 
Noting what gets acted out in the therapeutic relationship, and helping the client to articulate what this might mean, is the working through that reveals these old patterns and frees the client to make healthier choices. Staying present in the relationship helps clients release long stored up affect, integrate the disowned parts of themselves, and inhibit the reactive patterns that spoil the natural joy of being. As clients learn to tolerate and digest their internal world, their connections with themselves and their world transform. More creative aliveness becomes available. As a result of sharing and participating in the joys and suffering together, discovering what’s unknown, unfelt and unpredictable, I feel humbled, privileged, and enlivened by our encounter. We are changed by each other.

Footnotes
¹ Barrett, S., Wee-Jhong, C.,  Crits-Cristoph, P., & Gibbons, M.B. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training,45(2), 247—267. 

² I have constructed Nick as a compilation of people, events and situations to protect confidentiality.

³ Russell, P. (1998). The role of paradox in the repetition compulsion. In J.G. Teicholz & D. Kriegman (Eds.), Trauma, repetition, and affect regulation: The work of Paul Russell(pp. 1-22). New York: Other Press.

⁴ Riesenberg-Malcolm, R., ed. Bott Spillius, E., (1999) On Bearing Unbearable States of Mind, London: Routledge.

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