Gender and ISTDP?

“Is there a gender difference for how male and female therapists experience ISTDP towards their male and female clients? Personally, this more ‘confrontative’ style works better for me with a male client than with a female client. Between women one should ‘listen and understand’ more, which I do not like anyway in private encounters, this expectation on me and on interaction between women. This is probably something to learn for the therapy room (but in private life, I am happy as I am with my encounters). Is this something that you have noticed in your work with teaching psychotherapy?”

What a fascinating question! First of all, let’s be clear that we never confront a patient until the patient can observe a defense he uses, can see its price and function, and can see that the defense is not him but a way of dealing with feeling. Only at that point, will it be possible for the patient to see that we are confronting a behavior rather than criticizing him as a person. Thus, confrontation only occurs with certain patients under certain conditions.

But our questioner raises another point, how comfortable are we when confronting a patient with his self-destructive behavior? Sometimes not too comfortable. Why? Sometimes confrontation makes us feel anxious because we are afraid of our own aggression and capacity for power. Sometimes we fear confronting others because this evokes anxiety we had in the past over people who confronted us or people whom we wanted to confront but couldn’t due to the dangerous consequences of doing so. As a result, our ways of addressing patients may become constricted by our own defenses of avoidance and reaction formation. Rather than confront patients’ defenses, we may start to intellectualize or justify their defenses. We start to tiptoe around the patient’s defenses which start to dominate the therapy.

On the other hand, another way we can deal with our anxiety is through a counter-phobic reaction: becoming more aggressive. When our feelings and anxiety rise, we may start to confront the patient prematurely, leading to a misalliance. We may rely excessively on confrontation rather than help the patient see his defense and its price. And we may project that the patient is more resistant than he really is, leading to an excessively confrontational stance.

In other words, confronting a patient’s defenses requires the therapist to take a strong stance that can arouse the therapist’s anxiety, arousing defenses of reaction formation or counter-phobic responses. Thus, examining countertransference is essential when therapists either avoid or excessively rely upon confrontation as a technique. These are universal problems shared by male and female therapists.

However, as our questioner alluded to, the socialization of gender roles can lead to different styles in therapy by male and female therapists. Stereotypically, males feel more comfortable confronting patients than females. However, I have found both male and female therapists who engage in premature confrontation. Stereotypically, females tend to avoid confronting patients. However, I have found both male and female therapists who relied upon reaction formation as a defense against confronting destructive defenses in the patient.

We should always “listen and understand” as our questioner described above. But we must take care that “listen and understand” does not mean “agree with me 100%!”

Pt: I thought you understood me.

Th: I do understand your point of view. I don’t agree with it. I think slapping your girlfriend was incredibly destructive to the relationship. You are having to decide whether you want to remain with a girlfriend who loves you or a defense that sabotages you.

Pt: If you understood me, you would agree with me.

Th: No, if you understood how slapping her destroys your relationships, you would no longer agree with your defense of slapping.

Pt: I want you to listen to me.

Th: No, you want me to agree with your self-destructiveness. You want me to lie to you.

This would take some strength to say, wouldn’t it? It takes strength whether you are a man or a woman. And it would take strength in any culture I have encountered. It takes strength to say the truth to a patient who threatens to dislike you, abandon you, or criticize you if you do not agree with his destructiveness. But if you collude with his destructiveness, you abandon him. He loses a therapist. But when you confront his destructiveness, he realizes you regard him as strong enough to bear the truth. I remember a patient who once said he could trust that I cared for him because at one point when he was verbally abusive in the session I had told him I couldn’t stand his guts when he did that. When I was honest about his darkest qualities, he could trust my honesty about his best qualities.

It is said that Plato regarded truth as the food of the soul. It takes emotional courage for us to share this truth, especially when we might be punished in session for doing so. Yet it is a test we are asked to pass daily. Sometimes we will have more trouble being honest with a male or a female patient. Sometimes it is due to our socialization. Sometimes it is due to our own transference. Sometimes it is because we fear the patient’s reaction. Sometimes it is because we are afraid to confront something within ourselves. No matter the cause, our task is the same: facing the truth of others and ourselves, and then speaking from the truth.

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