Intimacy is the epiphany of the hard work at living by both parties. It grows with crises and adversities. In psychotherapy, most of this hard work must be carried out by the therapist, especially during the crises of the relationship with the patient.
E. Glover divided the crises in therapeutic encounter into two categories: The first treatment crisis is characterized by the patient provoking an argument because of the nonjudgmental attitude of the therapist, which generates guilt, just as some lovers cannot tolerate the pleasure of being loved and thus provoke fights. The second crisis is characterized by the patient wanting to flee because the therapist gets incorporated into the patient’s fantasies. On the latter occasion, the therapist can be perceived as a punitive judge, strict task master, or high-and-mighty parent. And in either state of crisis, if the therapist becomes defensive, the patient would feel misunderstood and become even more vituperative or prone to act out. Of course, the therapist in return should be warned against himself being on the defensive (or on the offensive, for that matter) or worse, also acting out.
It isn’t that the treatment relationship always stays stable, or that the mutual discourse between therapist and patient should be obliged to remain harmonious at all times. This would be unrealistic, and probably countertherapeutic as well. R. Chessick has depicted intrapsychic realignment by noting that if you plot a graph of any activity, the result shows peaks and valleys as well as long plateaus. Comparably, adaptation (or maladaptation) to therapeutic crises, chronic or otherwise, with highs and lows and reciprocal readjustments, are part-and-parcel of the essentials of treatment.
In actuality, the psychotherapy process is a state of permanent mild crisis, and the therapist must constantly remain on alert. These chronic crises are primarily related to the subtleties of the therapeutic relationship. First and foremost is the establishment and maintenance of trust, which will be tested in every stage of psychotherapy. The patient always needs validation, though the request manifests in constantly changing defensive patterns. The therapist does not meet the patient’s shifting demands by deliberately aiming at the center of the patient’s pathology.
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T. Byram Karasu, M.D. is the author of Life Witness: Evolution of the Psychotherapist