One of the most common mistakes therapists make in dealing with ambivalence in psychotherapy is to engage in a power struggle with a patient. Often when a patient is ambivalent, he may voice only one side of his ambivalence at a time. For example, if the patient says, “I am never going to get better,” a caring therapist naturally wants to instill hope. However, as the therapist voices hope, she is taking the positive side of the ambivalence. Consequently, the patient is likely to repeat the negative voice and may even state it more strongly. The power struggle develops as the therapist tries harder to win the argument for hope, leaving the patient to struggle to maintain his lack of hope. Instilling hope is an important therapeutic strategy; however, the timing is vitally important. Tracy’s story will help illustrate this point. Tracy was a young woman struggling with severe panic disorder, substance abuse, and an eating disorder. She had been in several treatment programs with multiple relapses. Part of her history involved being sexually abused by a former therapist about 5 years earlier. She had pressed charges and testified against this man in court. He was found guilty and was currently in prison.
Tracy often vacillated between expressing anger and feeling shame. These two emotions are diametrically opposed. Anger implies the right to be treated well and the need for protection, while shame implies the opposite. She spent about half of her time in sessions expressing anger regarding people who had let her down and the other half in shame, as if she deserved being treated badly. She would swing between the emotions, sometimes so much so that she asked me if I thought she was crazy. I responded that I did not think she was crazy, but I thought she was extremely ambivalent. When she would express her anger and I would attempt to validate her anger, she would swing to feeling shame. But when she was feeling shame and I tried to dissuade her of the feeling, she would switch to anger. It felt to me like we could never stay in sync and that she would discount anything I said. A typical conversation might go something like this:
Tracy: I am so angry that someone who was supposed to take care of me would actually harm me.
Me: He did harm you and that was wrong.
Tracy: No, it was my fault—I was an adult, I should’ve known better.
Me: It is common for people to feel shame after situations like this, but you must see that it wasn’t your fault.
Tracy: But why would I feel shame when I am so angry that he would do this? I thought he cared about me.
Me: You have a right to feel angry, because your trust was betrayed.
Tracy: No, you don’t understand. I was an adult. I shouldn’t have let things happen.
Me: I do understand that it is normal for people to feel shame and anger in these kinds of situations.
Tracy: How could you possibly understand my feelings? It didn’t happen to you and you weren’t there. [Now she really had me! She wins!]
There were moments when it appeared that I had “won” the power struggle, convincing her that there was reason to believe that she had worth. And she would say something like, “I guess you’re right, but I can’t feel it, so something must be wrong with me.” This was not a very satisfying win and it definitely didn’t change anything.
In these conversations, I felt powerless, ineffective, and at times frustrated with her. Why wouldn't she let me help her? Was she ever going to heal from this thing that, although horrible, happened so long ago? Was there something about me that kept her from trusting me? One time when I tried an object relations approach, I asked her that question. She actually told me it had no f’ing thing to do with me! That was one of those moments in life when you just wish the ground would open up and swallow you. But now, I look back at that moment and smile with fondness. She taught me so much!
Not only did these kinds of conversations happen between Tracy and me, they also happened in her group therapy. Other group members tried very hard to convince her that she should let go of the shame connected to the abuse by the therapist, that she had done nothing wrong, and that she had a right to feel angry. When they would get angry in her defense, she reacted by withdrawing. When others voiced her anger, she couldn’t feel it because her mind responded to validation by feeling shame. When she did respond, she “yes-butted them” at every turn. She couldn’t trust that they believed her, that they cared about her, or that they could possibly understand her situation.
Finally, after several sessions of feeling stuck with Tracy and realizing that she and I were both leaving sessions feeling frustrated with each other and with ourselves, I decided to totally go with her resistance. Frankly, this occurred more out of desperation than amazing wisdom on my part. So, when she started to express her shame about her relationship with the former therapist, I asked her, “Okay, what percentage of the situation do you think was your fault?” She stared at me and paused for a few minutes. My heart was beating faster than normal. I had no idea how she was going to respond. I was afraid that she would think I was “blaming the victim,” something that I was loath to do.
When she finally spoke, it was with a soft voice, as opposed to the typically defensive or argumentative tone that she usually used. She said, “No one has ever asked me that. But if I think about it, I believe it’s about 20% my fault.” So we talked about the 20% that she perceived was her fault. This became an amazingly empowering session for her. It turns out that there was a small part of her that was very afraid that she might let herself get into that kind of situation again. Trying to talk her out of feeling that way was not helping at all. Being afraid to address this with her was neglecting a very hurt, scared, and childlike part of her.
I believe that Tracy’s eating disorder was functioning as a communication from a part of herself, which believed that she had to be sick to protect herself from abuse and that she deserved punishment for the responsibility that she perceived was hers in the situation. Talking about the 20% that felt like her responsibility gave her hope that she would be better able to protect herself if a situation like this ever happened again. She needed to reassure herself that she had learned from the experience to better protect herself and to have clearer boundaries. Additionally, she began to explore things from her childhood that she thought had contributed to the 20% for which she felt responsible. She and I had been unable to delve into those issues because we had both been swinging to thoughts related to her being the victim and not to blame. I realized that I had been engaged in a power struggle with Tracy based on my own value of never blaming the victim. This was not in her best interest, and one of us always lost. When I put this aside and joined her resistance, it became a turning point in her recovery.
As part of Tracy’s process for termination, she wrote a letter to me summarizing our work together. She wrote, You helped me find strength within me that I never knew existed. You helped me to find my “voice” and to begin to listen to and trust my inner wisdom. You helped me to discover the balance … to find the middle ground of nonjudgment. You never attempted to wrestle the disorder away from me [I guess she had forgotten those first few sessions] … instead you helped me to find the will and desire to let go of the symptoms and to face what issues emerged over time.
I think I did these things by getting out of the way and helping her understand her ambivalence. I’m happy to say that she was still doing fine the last time I heard from her years later.
My book A Clinician’s Guide to Pathological Ambivalence: How to Be on Your Client’s Side Without Taking a Side can teach you how to avoid this and other common therapeutic mistakes by developing skills to work directly on resolving ambivalence. I would love to hear from you. Please scroll down to the bottom of this page (past the banner of recent posts) to leave a comment.