Neutrality? Does it have a role in ISTDP?

“I was just reading a book on transference-focused therapy and their description of “technical neutrality” and came to think how differently I would approach certain situations in therapy now that I´m trying to do ISTDP. Of course neutrality (as well as abstinence) is a debated concept within psychoanalysis and psychodynamic therapy but I believe I´ve read in several texts that it is not  relevant in ISTDP. We are NOT neutral in relation to the patient’s struggle with the punitive superego. At the same time there are aspects of neutrality that I think still apply in ISTDP – like not giving advice, being “supportive” in a general sense of the word or over-identifying with the patient. I wonder if you would consider reflecting on the concept of neutrality from an ISTDP-perspective?” Thanks Peter for this great question!

We can easily misunderstand the concept of neutrality as if the therapist is somehow “neutered”! God forbid! It would have to be a very dishonest or uncaring therapist who claims not to care whether a patient gets well or not. Otherwise, why do therapy? Just for intellectual interest?!

Obviously, we engage in this work so we can help patients face their feelings, face what makes them anxious, and let go of self-destructive defenses. That’s the therapeutic task that makes patients become healthier. And that task is really the same, no matter what kind of therapy people do. It’s nothing unique to ISTDP. Everybody is trying to help patients improve. Everybody is helping patients regulate their anxiety, let go of self-defeating patterns, and face feelings and truths they usually avoid. It’s just that different schools of therapy use different terms for these elements of the therapeutic task.

Anna Freud proposed an interesting way to look at neutrality. She said that the therapist must take an “equidistant” position: neither being only an advocate for the feelings, an advocate for avoiding what makes you anxious, nor only an advocate for the defenses. She said that we need to take stance where we encourage the patient to face feelings while acknowledging that those feelings arouse anxiety, and while acknowledging the temptation to use defenses. Leston Havens took this further by proposing that we offer “complex empathy”: empathy for the feelings, for the anxiety, and for the defense.

So is neutrality relevant in ISTDP? Absolutely, the question is how. Obviously, the ISTDP therapist is aligned with the patient’s wish to become well and aligned against the patient’s punitive superego. The therapist does take this stance. However, the therapist’s stance may have to shift because of the patient’s own stance regarding his conflict.

Let’s take Peter’s first example, advice. Why does the ISTDP therapist usually not offer advice?

Th: What is the feeling toward your boyfriend for throwing the glass of water in your face?

Pt: What do you think I should do doctor?  [defense]

Th: That still doesn’t say what the feeling is toward your boyfriend. What is the feeling toward him?

 

Almost always, the patient asks for advice to avoid a feeling or to adopt a one-down position with the therapist, a regressive transference resistance. We do not give advice in this example because we want to help her face rather than avoid her feeling, and we want to avoid reinforcing a regressive transference that she probably uses in the rest of her life.

This is often thought of in terms of “abstinence.” Here, the therapist responds optimally to the patient’s forward strivings but abstains from reinforcing her regressive defenses. This is why Paul Wachtel, in his book on psychoanalysis and behavior therapy, pointed out that psychoanalysis has its own forms of reinforcement. Behavior therapy’s brilliance lay in its clarity about what to reinforce and what not to reinforce. All therapy reinforces some things and not others. We might as well be clear about it. In ISTDP, we reinforce forward strivings by asking for feeling and we do not reinforce defenses, especially regressive ones.

Peter’s second point concerned “being supportive.” In fact, all therapy is supportive. Therapists constantly support certain activities and do not support others. Irwin Hoffman pointed out that analysis of sessions reveals both conscious and unconscious forms of support. Every time you explore one thing, you are not exploring something else. Every intervention reveals what you support and do not support. It is inherent in the very act of intervening. So, again, the question is not whether we support, but what do we support? In ISTDP we support the experience of feelings as deeply as possible. With fragile patients, we support them in this task by regulating their anxiety, and adjusting the dosage of feeling to work within their capacities.

“Being supportive” is only a problem when you are supporting defenses that cause the presenting problems. Then we unwittingly just support the pathology creation system. For example, a patient takes a helpless stance in therapy and the therapist supports the patient’s defense by agreeing there is nothing the patient can do but wait for his wife to change. A patient says he is not ready to face a conflict, and the therapist agrees that the patient should wait until he is ready, thereby supporting the patient’s passivity and denial that time and life are passing.

Peter’s third example concerns “over-identifying” with the patient. Freud recognized that our own desires for the patient’s growth can never be a substitute for the patient’s desire. We want the patient to have a better life, but, in the end, only the patient can give himself that life by facing his feelings and conflicts. We take a stand against the patient’s pathology, but we cannot take the patient’s stand against his own pathology. When we forget that basic fact, we try to fight the patient’s fight (losing neutrality), rather than help the patient see his fight and his task (maintaining neutrality). When we identify with the patient’s struggle but forget our own identity as a separate person, we fight the patient’s fight and lose. Only the patient can see and let go of his defenses. That is something you cannot do for him. In the transference resistance, the patient plays out a relationship where you (in the child role) are asked to take responsibility for the patient’s defenses (parent role). Since many of us did that as children, we fall into that trap temporarily.

That is why we need to confront the patient’s stance when he asks us to identify with his healthy strivings while he remains identified with his unhealthy defenses. Here, the concept of neutrality becomes clear. We hope the patient will choose health. However, the struggle between his yearnings for health and his unhealthy defenses is HIS struggle. Only he can turn against his defenses, not you. This is his fight, not yours. In that sense, you must regain your position as a neutral observer of a conflict in him, not in you. You empathize with his struggle, but you recognize as a neutral observer, that this is his struggle, his responsibility, and his task. You cannot fight his fight. You cannot take on a responsibility that is his alone. And you cannot do his job. This understanding, both emotionally and intellectually, constitutes the essence of a neutral stance when dealing with the transference resistance.

Of course we care when we see the patient suffer in a transference resistance. But we also have to recognize what our work is and what the patient’s work is. What his task is and what our task is. What he must do and what we can do. Where his responsibility begins and ours ends.

In ISTDP neutrality can be thought of as an outgrowth of an existential truth: overcoming the patient’s internal conflicts is the patient’s job and responsibility. The therapist can only point out those conflicts and the price the patient pays for handling his conflicts the way he does. The truth is powerful but we are not omnipotent. Only the patient has the power to face his truth and let go of his defenses. We are not neutral in terms of what we support. But we have to take a position of the neutral (if pained) observer when the patient hesitates to fight for himself and let go of his defenses. It is his life, his choice, and his responsibility, not yours.

The patient may accuse you of not caring, being detached, or uninvolved. But this is projection. The patient’s stance of self-neglect and helplessness reveals that he does not care for himself, detaches from himself, and is uninvolved in the fight for his own life. If he makes such a destructive choice, we have to accept his choice and part ways while he continues on his path toward self-destruction. For that is not a path we can take together in therapy.

For those of you who don’t have enough to readJ, the noted analyst Jay Greenberg wrote a nice article on the concept of neutrality, illustrating the problems of its definition:

 

http://www.wawhite.org/uploads/PDF/E1f_10%20Greenberg_J_Analytic_Neutrality.pdf

 

Enjoy!

 

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