Training for Psychotherapists

Run Away Session

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When Ventilation Dominates the Therapy Hour

Who has not experienced a session like the following, which was described to me by a therapist in training at the DEFT Institute:

“I just had a session that got away from me.  She ventilated the ENTIRE time despite my efforts to interrupt repeatedly.  After about 15-minutes I gave up and allowed her to do her thing….it was AWFUL!  I AM consistently impressed with the difficulty of the task at hand that is essential for health and healing.  Ugh!”

Yes, indeed, the task is difficult and here we have a client who is overriding her therapist’s interventions, which can be the result of multiple factors. Assessing these factors is the key to knowing what to do next to be most helpful. If the therapist’s countertransference is activated and the therapist begins to doubt or devalue himself, this will interfere with the therapist’s ability to stay present and to keep exploring the client’s will or choices with an open mind.

I don’t want to offer an overly simplistic “solution,” but will share a few suggestions that occur to me, keeping in mind this is not a substitute for supervision where we can track moment to moment phenomena. It appears that this is a highly resistant client who uses the defense of ventilation due to unconscious anxiety over intense underlying feelings (triangle of conflict). The therapist undoubtedly wishes to bring to her attention that this pattern of discharging, rather than fully experiencing her feelings, will prolong her suffering. The client could then be given a choice about whether she wants to attend to her underlying anxiety and reduce it so she can more freely access her feelings or continue this pattern of ventilation? But she is ignoring the therapist’s input. Timing is everything, and while these are perfectly appropriate interventions under certain circumstances, they may not be effective at other times.

Before addressing her ventilation and the fact that this will not help her, we need to ask whether the client has first declared what she hopes to gain from therapy and has she agreed to work with an intrapsychic perspective? Otherwise, there is no therapeutic alliance to explore what is going on within her internally and the therapist will risk a misalliance if she tries to address her ventilation or resistance to the therapist’s input. The client might be hoping the therapist will validate her view of the person she’s ventilating about, or perhaps she wants to assuage her guilt over something she did to this person, or she might be pursuing a fantasy that the therapist will help her find some key to changing this person. And how do we identify the client’s expectations so that she will understand whether they can be fulfilled realistically in therapy or not? If unrealistic expectations remain unconscious, she may well harbor resentments towards the therapist or the process itself.

We begin by asking about her goals for therapy. If she focuses on her frustrations with another person, we need to gently remind her that we are powerless to change anyone else and inquire into how she’d want to feel differently within herself as a result of therapy? If the ventilation continues, we’d want to reiterate that we’d love to help her with her sense of frustration but can only help her by taking a look at what happens inside her when this person behaves as he does. Would she want to do that? Hopefully, she will reveal something that will give the therapist an opportunity to help her see how her anxiety (or perhaps shame or guilt) is being ignored… and to see that these forces will keep her feelings out of awareness.  When she bypasses her own internal experience by ventilating  and focusing on the other person to the exclusion of herself, the price will indeed be steep.

If she still continues to ventilate and to ignore the therapist, I might say, in a caring tone, “You know, I’ve made a few comments that I think would help you, but I notice that you seem to talk over what I offer to you. It’s certainly ok with me if you prefer not to receive my input, but I am wondering how we will help you if this continues? What are your thoughts about this?”

Another possibility: “I see that you seem overwhelmed by your feelings towards so and so to the point that it is hard to focus on anything I’m saying or even to attend to your own internal experience. I wonder if you may be quite anxious? Have you been aware of this? Do you have problems with anxiety that you are aware of?” if so, I would inquire into all symptoms of anxiety and let her know that her anxiety comes up in the face of her feelings towards this person and that her anxiety will only get worse if we don’t attend to it rather than continuing to focus exclusively on him. I would then ask if she would want to get help for her anxiety in therapy? If so, I would reiterate that we’ll need to practice an internal focus rather than primarily focusing outside of herself.

If none of the above leads to anything productive, I would also leave open the possibility that this client may not really be motivated to do the work of therapy. She does have the right not to listen to her therapist. If that is the case, I would simply reflect this and work very hard on not blaming myself for a thwarted treatment. Any of us may need to remind ourselves that there are 2 people who make a successful therapy possible, not just the therapist!

Thanks to the therapist posing this quandary for giving us something to chew on that can be hard for any of us to digest.


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