The title of this post is taken from a collection of essays by Judith Hubback who was a very thoughtful British Jungian analyst. I read the book more than 15 years ago but it is the title which sticks with me most as an apt descriptor of the therapeutic process.
Several people commented about or emailed me about the intense attack Alex, of In Treatment makes against Paul asking me more about my view. This builds on the notion of acting out that I wrote about last.
For those who do not remember or did not see, Alex came into a session and reveals that he has investigated Paul, allegedly because it is important for him to know who he is talking with, and he then unleashes a barrage of very personal things he has learned about Paul's wife and daughter. Paul becomes very angry and leaps up and hits Alex.Now, I would never argue that Paul's response was the model of professionalism but neither would I argue that it was beyond understanding.
What Alex did was an excellent example of acting out. The basic dictum of depth psychotherapy is to say whatever comes to mind. And I imagine someone will say that's what Alex did. But it is not what he did. To cite Young again:
"Acting out is a substitute for verbal expression. It is expressive, symbolic communication, but it is not relfective. The patient is acting rather than reflecting. Where acting out is, thought cannot be.
One feature of acting out is that the therapist is usually put under pressure to do something he would not otherwise do — to go after the patient in some way, e.g., to write to the patient or phone, to reveal something, to move, to change a session, to press the patient, to relent about a decision or take a firm line, even to lose his temper."
So the problem is not Alex's feelings of hostility or even hatred for Paul; the problem lies in the way he chooses to act that out. To put those feelings into words would have been well within the parameters of the basic rule. But to use the feelings to drive seeking out personal information about Paul and then use that information within the session to attack him is acting out and acting out in a way that is destructive toward the therapist and potentially the therapy as well.
We want Paul, carrier of our projections of the perfect therapist, to maintain his equilibrium and make some neat verbal interpretation of Alex's behavior, to absorb the attack and then provide helpful feedback to him. But is it reasonable to expect that? We saw when he talked with Gina later that week that even Paul found his own behavior unacceptable. We can agree that any physical response to a verbal attack by a patient is outside the bounds of appropriate behavior for a therapist. So think about what else he might have done.
Declare the session over? Yell, "Stop!" at Alex? Benignly say he could see Alex was angry with him? You can probably think of other things he could say as well.
Sure, we can debate what Paul might have said that might have been better. But let's consider this incident as a way of understanding why acting out is harmful to the therapeutic process.
Trust is the basic foundation for therapy to proceed. The patient must be able to trust the therapist to be ethical, professional and appropriate. But the therapist must also be able to trust the patient and we talk very little about that.
The therapist must trust that the patient will honor the contract they develop -- show up for sessions and pay on time. And that he or she will endeavor to put any and all feelings into words rather than into behaviors directed at the therapist. I expect that most any therapist who works psychodynamically has had (or will eventually have) the experience of a patient expressing doubts about their competence, criticism of their ability to understand, all manner of negative commentary. It is never fun to have a person say negative things about us to our face but we are at least prepared for that possibility and through experience learn how to handle it. As I said, had Alex come in and talked about his feelings about Paul, about therapy, about what it stirred up for him there would not have been a problem. That is grist for the therapeutic mill and well within the bounds of what we expect.
But going outside the therapy and deliberately gathering personal information about Paul and then using it against him in the session as a weapon -- I see the attack as stunningly hostile. It was an attack on the therapy itself because it calls into question whether or not Paul can trust Alex not to attempt to harm him. And we cannot work effectively with someone we believe not only could but might very well attempt to cause us harm.
Once again we come back to the reality that psychotherapy is a relationship and that for it to go well, both parties require some measure of trust and respect for boundaries.