Who challenges the patient?

“I noticed your substitution of “invitation” for “pressure”, and I think that clarifies the purpose of the intervention: to encourage collaboration and deepening the emotional connection. Why did you substitute the term “confrontation” for “challenge” and “head-on collision” in the new book?” Thanks to Maury for this question.

It is easy to forget that the patient is never in conflict with you. It may FEEL that way. But that occurs when the patient forgets that his defenses are in conflict with himself, not with you. The patient’s defenses are always in conflict with his desires or with reality. For instance, a patient who sabotages his therapy is not in conflict with you. His self-sabotaging defenses are always in conflict with his healthy goals. If he wants a healthy relationship with his girl friend but dismisses her feelings, his defense, dismissal, is in conflict with the demands of reality.

The patient, unable to see his defenses, may mistakenly think you or other people cause his difficulties. So he will imagine he is in conflict with you or them. In fact, he is in conflict with himself. That is why we have to differentiate the patient from his resistance.

When we mistakenly think the patient is in conflict with us, we are caught up in the transference resistance. The patient is passive, for instance, and we become active. When active, we may mistakenly become more active to make a passive patient more active. Then what is really an intrapsychic conflict (between the patient and his resistance) becomes an interpersonal conflict (between you and the patient). When we are caught up in that enactment, we often think we need to “challenge” the patient and end up in a “head-on collision” with the patient’s resistance. And we fail.

The true purpose of our defense interventions initially is to help the patient confront reality, to see how his resistance (challenging reality) is doomed to fail. This facilitates a “head-on collision” between the patient and his resistance. He begins to see that he is not resisting you. He is resisting the inner reality of his feelings and the external reality of life, its demands, and limitations.

In this sense, we never challenge, confront, or “collide” with the patient. Reality does that. Reality is The Great Teacher.

Pt: “I’m not sure I’m ready to face this.”

Th: “That’s ok. You don’t have to face reality now. Reality is very patient. It will still be here whenever you decide to face it.”

We are simply the messengers from reality. Let the truth do its work and get out of the way. Often, therapists operate mistakenly from the belief that they have to “confront” the patient with reality, adding their anger and outrage over what the patient is doing. All too often, however, the patient ends up reacting to your anger and not to the truth. We need to get out of the way so the patient can experience the truth directly. Then he will experience how he resists the truth, how his defenses challenge reality, and how reality persists in spite of his resistance to it.

When we “challenge” or “collide” with the patient, we mistakenly identify with the patient’s projection. We act as if there is no healthy desire within the patient to be in contact with the truth. Then we enact the patient’s conflict: he embodies the resistance and you embody his healthy wish to become well. This can look dramatic and heroic, but this merely reinforces the interpersonal defense of the transference resistance. This is why I don’t use the term challenge or ‘head-on collision’: students often mistakenly believe they need to adopt an adversarial stance with the patient. This just enacts the transference resistance at best or leads to a misalliance at worst.

Our task is to help the patient see how he is engaging in an adversarial relationship with inner reality (his longings for love and freedom) and external reality (the demands and limitations of life). Once you let go of your conflict with the patient, he can begin to experience his inner conflict, the ‘collision’ between his longing for freedom and his resistance to it. Then he will challenge himself to fulfill his higher potential. Then he will confront reality and his defenses.

When we let go of this urge to have a conflict with the patient, we express our faith in his longing to become free of his defenses. When we no longer act as if we must “challenge” the patient, we express our faith that the patient can bear the experience of reality challenging his defenses. It really comes down to our faith in the patient’s unconscious therapeutic alliance, his inner wish to become reunited with the emotional Truth of this moment.






One response to “Who challenges the patient?”

  1. Florian Wschiansky Avatar
    Florian Wschiansky

    Dear Jon, thank you very much and bravo for this blog. For me it is a great one, very clear, very useful. a masterpiece… best, Florian

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