Shame and Annihilation in the Therapist’s Self-Management

Many of the people we work with suffer from relationship problems which are, in part, a consequence of dynamics the client is bringing to some portion of their social interactions.  As such, by design, these same clients construct scenarios that are bound to challenge the relational pull of the therapeutic relationship as well.  Sometimes these kinds of tensions are obvious: a client who is constantly threatening suicide, one who largely operates in denial of the fact that anything is wrong while appealing to the therapist to improve their wellbeing, another who repeatedly engages in dangerous and risky behavior.  Other times, it is something subtle, presented in such a manner that it tugs on a particular discomfort that exists within the therapist.  This might show up in a client’s understated presentation of a kind of hopelessness, an inconspicuous way they have of insulting others, or a dismissiveness that skirts just under the surface of most interactions.

These dynamics, particularly as they verge to the more extreme, can be quite difficult for therapists.  There is a kind of discernment that must go into deciphering the appropriate way to respond.  What I want to propose in this piece is that we look at one of the lenses that provides a useful framework for thinking about how to approach these types of enactments: experience-distant vs experience-near modes of relatedness.  Furthermore, I would like to reflect on the kind of internal dynamics that are elicited in the client depending on the kind of approach we find ourselves leaning into.

The language around experience-near and experience-distant might not be immediately familiar to folks.  My understanding is that it originates from the school of self-psychology and was in fact something Heinz Kohut introduced to the lexicon.  Playing into the paradoxical ways in which self-psychology is in fact deeply relational in its psychoanalytic construction, Kohut had become quite sensitive to the manner in which classical psychoanalysis could at times feel stale, disconnected, and more concerned with its metapsychological frameworks than getting into the lived experience of the client.  Experience-distant approaches are the ones in which we find ourselves offering an interpretation that feels more rooted in theory and something we are trying to figure out or explain about the experience the client is attempting to share with us.  On the other hand, experience-near approaches attempt to stay closer to the client’s reports as evidence of the raw phenomenological texture of their life and what is showing up in the consulting room.

As a basic concept, the two offer a useful way of describing the structures in which we either get into or get around what might be going on in the therapeutic environment.  The kind of experiences I outlined in the outset are ones which fundamentally challenge our ability to remain close to them.  Staying in it with a client who is constantly threatening suicide, who undermines or insults our attempts to engage them, or who brings a palpable sense of hopelessness into the relationship is a profoundly difficult task.  The feelings of desperation or attitudes about our own incompetence which they can evoke are the kinds of experiences we are otherwise conditioned to avoid.  There is a lot of developmental work that goes into the making of a therapist which is about learning how to be in those spaces.

That said, those who find themselves drawn to this dimension of clinical work eventually find some way to figure it out, and those who don’t ultimately become pretty careful about specializing and self-selecting clientele who are going to be considerably less likely to bring those kinds of tensions into the work.  Furthermore, in addition to creating distance though metapsychological interpretation, one’s underlying theory and philosophy about how to do therapy can do something for how one manages these kinds of interactions.  For instance, approaches which are by design less interested in using the relationship as the site of therapeutic inquiry are going to have a much clearer structure of how to approach these things when they arise, likely through some form of psychoeducation and skills-based coaching which is fairly rigid and manualized in its approach.  And for our most persistently struggling clients there is always the availability of higher levels of care.

However, there is one particular kind of therapeutic interaction that I want to evaluate in this context that I was thinking about quite a bit as I was making my way home from the office recently, as I think it is one of the most challenging for us to manage as clinicians if we do not have a framework for knowing how to approach it.  It can also be among the most damaging for the clients if we don’t handle it well.  Those are the moments when they make something that feels like an authentic appeal to us as a human being.

Our clients have a lot of subtle (and some not so subtle) ways of bringing us into contact with them.  Sometimes it is a direct appeal for a kind of advice or validation; perhaps it is a moment where something is shown or enacted with more affect than is typical of them; occasionally it is being so bold as to share something with us about how they experience us within a session.  Nearly every therapist I have ever met has had a moment of feeling overwhelmed by a client’s willingness to bring that kind of interaction into the session (for anyone who is a client of mine or elsewise a client of therapy, please know the difficulty in managing this is meant to be on the therapist and not yours—don’t let the possibility that they might be overwhelmed deter you).  And nearly as many have admittedly done the same thing early in the work when they were not sure what-all-else to do with that kind of experience: they interpreted it in a way that inevitably managed their own anxiety about the potency of the interaction.

The best way to understand experience-distant interpretations is by thinking about them as a kind of explanation or a commentary on something around what might be happening in the moment.  It is the moment of having a client seek some kind of reassurance and sharing some tidily organized rejoinder as a therapist, noting, perhaps, how this feels very reminiscent of the ways in which they would often appeal to their mother for a kind of comfort she seemed unable to provide, while then signaling—either verbally or through a silence meant to indicate it is their turn to speak—that they should then do something with that interpretation.  Experience-near, rather, is about offering an understanding of something that might be unfolding in the dynamic.  In reference to the above scenario, it might be offering something like, “I can sense the depth with which you want me to be able to provide you some kind of comfort, and yet I can also feel your expectation that I have already failed you in some way.  That must be such a painful experience for you.  There is so much history here.”

There’s a different texture to those two experiences.  And, as we often court paradox and these kinds of dichotomies in this space, one is not necessarily more right than the other.  There may be times when you sense the client might need you to turn down the intensity on what they are feeling and that a good explanation might actually be what they need in service of developing more of an observing ego.  Just because the experience-near seems more dynamic, that does not mean that kind of dynamism is always what is warranted.  We, both as clinicians and as people, are constantly doing both these things, modulating our exposure and vulnerability to what is happening around us by determining how much intimacy we can invite at any given moment.  There’s a beauty in that kind of mastery.  There’s also a horror that comes with not cultivating that technique clinically.

The challenge with experience-distant language, when it is used unwittingly, is that it can be incredibly shaming and pathologizing.  Offered insensitively, it anchors itself to a kind of hierarchical thinking which may carry a tone of “Here, let me show you what’s wrong with you…”  This can also lead to a kind of annihilation of any sense of a self that can show up effectively in the therapeutic encounter.  Those who offer from a more explanatory, skills-based mode of working can in fact boast “successful therapies” with desired outcomes.  Though, certainly a portion of those must come down to a client who takes what is given because that is all that is offered, and further, its offering reaffirms some failure of the world and perceived limitations around collaborative self-holding.

In the middle of his paper, Fear of Breakdown, Winnicott offers a series of “agonies” (he states anxiety is not a strong enough word in this instance) that can befall the client who finds themselves in an insufficient holding environment: disintegration, depersonalization, disconnection from external reality, and a kind of overreliance on “self-holding”.  Whatever sense of one’s own being it is that we are trying to evoke in the therapeutic process is destroyed.  What is important to remain tethered to here, is that the reason we enlist the experience-distant approach here, is because that is how we manage our own potential annihilation in this process.  The risks of willingly entering these spaces and joining the client in the difficult process of recontextualizing their futility around these dynamics is that we must inevitably feel their failures along with whatever it is we hope to gain.  We should not be Pollyannaish about this.  It is painful getting pulled into these kinds of enactments.

Of course, that is the point.  The kind of attitudes which the client is bringing into the work are secondarily, in some ways, a consequence of their growing up in a world where there was likely so much self-management of affect happening around them that they were never given the kind of tender presence needed to help them organize their own suffering and sense of self.  For those interested in learning more about the distinction between experience-distant and experience-near therapeutic responses, I will again make a plug for Martha Stark’s Modes of Therapeutic Action.  For the uninitiated it is perhaps the best introductory text for getting a wide swath of ways to think about the various modes of relatedness that arise in our sessions and how to go about being responsive to them.  There is so much more of ourselves that we can offer our clients than some objective and anodized take on what it is they are doing here.  Our affirming their existence, through the real impact they are having on us, paves the way for a transformative experience of interpersonal self-recognition, which can make possible a truly healing kind of therapy.