What if I can’t get a conscious alliance?

“What do you do when a patient does not form a conscious alliance in therapy? Sometimes I see videos where therapists think there is a conscious alliance but I sense they just have compliance in response to psychoeducation, bargaining, or premature challenge.”

Every patient wants our help to overcome their suffering. At the same time, based on their history of suffering, they fear that closeness with us will cause more pain. Unconsciously, every patient experiences a rise of feelings when we try to form a healing relationship. The question becomes this: how does the patient deal with these complex feelings that arise?

Fragile patients have trouble tolerating their mixed feelings toward the therapist. Thus, they may project their anger upon the therapist, imagining you to be critical. Or the patient may project his loving feelings upon you: “I’m afraid of the questions you want to ask.” “I feel like all eyes are upon me.” “I feel like there is something you are looking for.” The patient forgets her wish to form a healing connection. So she projects. She forgets that she has questions about herself and her life for which she wants answers. She forgets that her eyes want to look inside and see her. She forgets her wish to look inside. When she projects her will, she will fear you. We need to deactivate her projection of will, so she can own her will. Then you will have a conscious alliance with the fragile patient.

Depressed and somatizing patients usually form a good conscious alliance, but they become depressed or somatize as their mixed feelings rise.

Patients with high resistance with isolation of affect experience mixed feelings toward the therapist. But rather than become overwhelmed with anxiety or depression, they detach from the therapist to detach from the feelings they have toward you. The therapist who does not see the patient’s wall of detachment mistakenly may try to overcome the resistance through psycho-education, bargaining, or premature challenge. In response, the patient may appear to agree to engage in therapy. But some important clues tell you that they are complying rather than collaborating.

Complying with a therapist is a defense against declaring one’s own will to become intimately involved in therapy. Since compliance is a defense, we will see no signaling of unconscious anxiety or defense.

Imagine the highly resistant patient saying, “Sure I’d like to take a look at my feelings.” When this is compliance, we will see no sighing. Why? Because it is the defense of compliance, no feelings rise. If the patient genuinely wanted to become closer, this would trigger complex mixed feelings, anxiety, and a sigh or tension. If the patient declares a wish to be close, we will see a sigh and a defense. But if the patient complies, we will see no sigh and no defense. Why no defense? Because compliance itself is a defense. So no defense is necessary to ward off a defense.

If the patient appears to have a conscious therapeutic alliance, but we see no sighing or defenses when he agrees to look at his feelings, his response is compliance. This is one of the most common mistakes therapists make with highly resistant patients with isolation of affect. They think they have a conscious therapeutic alliance, but there is no evidence of unconscious signaling or defense to verify that hypothesis.

About 25% of patients exhibit little or no conscious therapeutic alliance initially in therapy. They say “yes” but act “no.” If we pay attention to what they say but ignore what they do, we fail to see and address the resistance. For this group, we will see little if any conscious therapeutic alliance until after a breakthrough to feelings.

So we have to listen to the unconscious therapeutic alliance to guide us when a conscious therapeutic alliance is not forthcoming. Even if the patient claims he has no problem, no will to look at his problem, and no conflicts, we will ignore his words and pay attention to the wordless music of truth: his sighs and other forms of unconscious anxiety, his defenses, and phrases that point to his unconscious wishes and desires (the unconscious therapeutic alliance). We have to listen to his essence hidden underneath the resistance. The resistance speaks through words. His unconscious essence communicates through his body and defenses. We listen to both, but privilege his unconscious essence.

In this small group, highly resistant with isolation of affect, in the absence of a conscious therapeutic alliance, we have to listen to the unconscious therapeutic alliance to guide us. Ignoring the unconscious therapeutic alliance, we end up listening to the resistance (the false “yes”), and trying to educate and convince the resistance. Meanwhile, the essence of the patient remains in prison, ever more despairing that we will listen to the cries from the unconscious.

If the patient’s conscious agreement to look inside himself does not trigger anxiety or defense, it is a defense. It is compliance. The words must match the unconscious music of anxiety and defenses. Otherwise, the words are just that: words.









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