“A colleague said, ‘No wonder the patient gets angry at you. Your constant pressure for feeling can come across as irritating!” How would you respond?
My own inclination (based on your book and Allan Abbass’ book) is to say that: 1) pressure to feeling and defense work are key to healing; 2) if we do not persist we will never reach through the resistance which defeats both us and the patient; and 3) the patient’s unconscious communication (e.g., negation ‘I’m not angry.”) signals a rise in the unconscious therapeutic alliance, suggesting we are on the right track. Without this, irritation can be a sign of a misalliance due to a mistake by the therapist.” Great question and great answer!
Obviously, it is never our intent to irritate a patient. After all, that would not be therapy but sadism! If you act like a jerk, the patient will rightly feel angry toward you, without mixed feelings, and without any therapeutic result.
So why do we ask for feelings? To form a healing relationship. In this bond, together with the patient, we embrace the formerly unembraceable: his complex mixed feelings under the anxiety and defenses.
When we invite the patient to form a healing relationship, feelings arise. These feelings trigger anxiety and defenses. As we regulate anxiety and point out defenses, we implicitly welcome and accept his entire inner life.
In response, the patient’s forbidden anger rises. If it is accompanied by sighs, we know that the anger is simultaneously connected to love, complex feelings that cause the anxiety. That is our unconscious signal to continue exploring. When the patient says he does not have feelings, he does not feel irritated, he does not feel anger toward you, these negations are further unconscious signals: feelings can emerge as long as they are negated—another sign to continue to explore feelings. Even the patient’s defenses are signs that we are going in the right direction! After all, if there is no treasure, there is no lock on the door.
Let’s suppose, however, that the patient believes you really are trying to irritate him. Then we have a conscious misalliance, which must be corrected. “Thanks so much for letting me know. It’s not my intent at all to irritate you. So let’s back track for a moment to make sure we’re on the same page.” Then remind the patient of the triangle of conflict causing his problems. Then remind him of causality: how his defenses are causing his problems. Then remind him of the task you two agreed upon: to face the feelings under the defenses so that he can feel and deal instead of avoid and suffer. It’s just as important for patients as it is for colleagues who view our videos to understand what we do and why we do it. Otherwise, both patients and colleagues will suffer from a misconception about the work.
Sometimes a misalliance will occur later in the work, even when the two of you agree on the conflict, causality, and task. If you point out defenses constantly without inviting feelings toward you, the patient will experience you as a critical superego, leading to a misalliance. If you challenge defenses before the patient has begun to resist closeness with you, you will get a misalliance. If you challenge or confront the resistance to emotional closeness prematurely, you will get a misalliance. If you challenge a fragile patient, unable to tolerate the sharp rise of feelings, he will project his anger onto you, and then you will have a very bad misalliance.
And, to be absolutely honest, a good therapist will sometimes be very irritating. Why? We are supposed to be honest, telling patients what they do that hurts and sabotages themselves. There is no reason for patients to be ecstatic when we tell the truth. As the ancient Roman theologian Tertullian said, “The first response to the truth is hatred.” So when we point out defenses and the destructive impacts those defenses have, patients will become angry with us. And, if we look honestly within ourselves, who among us hasn’t felt a flash of anger internally when someone has pointed out the truth about us? So in response to their anger when we point out the truth, we ask: “So what feelings are coming up here toward me?” Even if they are angry when we tell the truth, we don’t ask them to lie about their anger. Instead, we invite them to explore and feel it as fully as possible.
After all, that’s what we do in a healing relationship: face the truth and our feelings about it.