PARADOXES IN THE

     THERAPEUTIC RELATIONSHIP

Magda Denes

In The Final Chorus, we note the passing of Magda Denes, Ph.D., a member of the original study group that, with Frederick Perls, Laura Perls, and Paul Goodman, founded the New York Institute for Gestalt Therapy. In our memoriam, we make mention of Magda's two books, In Necessity and Sorrow: Life and Death in an Abortion Hospital and Castles Burning: A Child's Life in War, her memoir of her childhood in Budapest. We received several requested asking if she had written anything about Gestalt therapy. The fact is, she wrote surprisingly little on the subject. Because of your requests, we decided to post the only article of Magda's ever to appear in The Gestalt Journal. It appeared in Volume III, Number 1, Spring, 1980 -- A Festschrift for Laura Perls in Celebration of Her 75^th Birthday.

--J. W.    

Whether psychotherapy is a science or an art has been an issue debated since its conception. I have no conflict in that realm. I am fully convinced it is an art, in the pre-populus sense -- disciplined and technically expert. My anxieties center on the nature of the medium -- volatile, unpredictable, standardless in its outcome, subjective in its worth, malleable, resistant, rebellious, compliant, ephemeral, limited -- a spark born to trouble, and soon extinct. Who would such contours shape? You and I. Hence, this paper.

Before I begin to deal with what I am going to deal with, I should like to specify that with which I am not going to deal. I am excluding from this discussion the classical Freudian paradigm characterized by its adherence to the couch, to free association, to the encouragement of transference neurosis via the analyst's conduct as a blank screen, its tenets of abstinence, deprivation, iatrogenic suffering, and cure conceptualized as the exchange of neurotic despair for a realistic sense of doom.

That the talking cure (and I am referring to non-Freudian models) is a paradoxic enterprise is no news. It is very likely, for example, that its primary vehicle is not talk, and that what it accomplishes is not cure. The currently fashionable word for the goal of psychotherapy is "change." Unfortunately there is no consensus as to what constitutes change, what brings it about, and when is enough enough. Thus, for example, Jay Haley says, "The 'cause' of change resides in what all methods of treatment have in common -- the therapeutic paradoxes which appear in the relationship between psychotherapist and patient" (Haley, 1963). He then goes on to delineate, by my count, six of these paradoxes which I shall quickly summarize because they are delightful, and true, and to my mind constitute largely an impediment to treatment,

1. The relationship is defined as compulsory in a voluntary framework, as in private practice. That is, the patient is told that he seeks help of his own free will and success depends on his cooperation despite difficulties. Within this voluntary frame the conditions are compulsory whereby the patient must pay, must not miss his appointments, and must not arbitrarily end treatment which he is advised ahead of time would constitute resistance, The reverse is true in compulsory settings as with forcefully hospitalized psychotics where within the compulsory frame the therapist tends to insist that the patient really wants treatment, only he does not know it. In other words, "whichever way the framework of the relationship is initially defined, within that framework it is defined as the opposite" (Haley, 1963).

2. It is never quite clear whether a therapist sees a patient out of choice or only as a way to earn a living. The relationship is defined as one of the most intimate in life and therefore the patient is encouraged to reveal all at the same time that the therapist makes it clear that when the session ends he has no interest in seeing the patient outside the office. An interesting corollary to this point is the fact that to the best of my observation, therapists tend to miss their work, not their patients. The usual comment after a good vacation ends is, "I am ready (or even eager) to get back to work," not, "I can't wait to see Joe or Jane," And if the comment were, "I can't wait to see Joe or Jane," the remark would surely be suspect, both by the person uttering it, and by his colleague-listeners. Similarly, at least to speak for myself, the people I love in my life, I often yearn to see. As a rule, I do not yearn to see my patients more often than I do, even when I think I love them, whatever that means in the therapeutic context. Yet I think that these occurrences, as I hope to demonstrate in the course of this paper, represent epiphenomena based on training and convention.

3. Haley's third paradox concerns the issue of blame. The patient is simultaneously told that he cannot help who he is while the very premise of psychotherapy is based on the notion that indeed he can help who he is. The same applies to significant figures in the patient's life. "His parents are at fault by their mistreatment of him, and yet they are not at fault because they could not help themselves" (Haley, 1963).

4. The therapist presents himself as the expert, but within that framework, he disengages from offering expert advice and puts the responsibility for the proceedings on the patient. In Haley's words, "This formal pattern of directing while denying direction is typical of psychotherapy. The patient cannot follow direction or refuse to follow it when he is faced with both messages simultaneously. Therefore, the methods he has used to provoke direction or oppose it become impotent."

5. The patient is told that the treatment circumstance and the relationship are special and he can be self-expressive as in no other setting because ordinary rules do not apply. As soon as he believes this, he is reproached for not reacting to the therapist as one human being to another.

And finally,

6. The basic framework of psychotherapy is benevolence. Within that framework, the patient is placed through a punishing ordeal which varies with the type of therapy. In other words, the patient gets consistently disapproved of until he spontaneously "changes."

Although the time element does not fit, my fantasy is that Haley read Searles on how to drive somebody crazy and then proceeded to delineate the curative paradoxes in the psychotherapeutic relationship.

Not that I think him inaccurate. I think his description is valid and, by and large, inescapable. But I regard that fact tragic. I regard it as an instance of our limitations. Contrary to Haley, I do not see the embeddedness in these kinds of paradoxes as conducive to change, I see it as something we suffer, and not well. In other words, I think of paradox not as a point of view but as an ontological characteristic of the existential condition of man.

From a substantially different and fascinating theoretical base, namely, structuralist theory, Edgar Levenson also regards change as a matter of paradox. In a current paper he writes:

My claim is that the psychoanalytic process, the healing process, is a language process which allows for, indeed requires, the synthesis of these two paradoxically oppositional aspects of therapy: the aspect of meaning, and the aspect of experience (Levinson, 1978)

He regards meaning as dependent on metaphor, (a culturally shared symbol) which lends constancy to human functioning. And he regards experience, that is, affective functions, as dependent on metonyms (contextual symbols, private and shared) which are devices for change. In treatment, the interaction of the two modalities, and their effect on the participants (both therapist and patient) is what produces progressively altered perceptions and interactions, which produces progressively altered perceptions and interactions, which produces ... and so on and on, 'til cure do us part. In other words, change occurs as a result of both interpretation and the relationship where the two add up to something greater than their sum. Content and context in this system become alternately focal with each focus changing and enlarging the focus to come. Change, then, is seen by Levenson, not as a matter of the therapist influencing the patient, but as a matter of discourse between two participants, both of whom are in process, and who interact in process.

In sharp contrast to this conception of change, Hans Strupp says,

Therapeutic change is largely due to skilled management or manipulation by the therapist, with the important proviso that the interventions occur in the framework of an emotionally charged affectional relationship (Strupp, 1973).

And again he says,

The full range of common influencing techniques is inevitably brought to bear on any psychotherapeutic relationship, and this indeed constitutes one of the defining characteristics of psychotherapy. Basically, these techniques are shared with education and other social influence processes (Strupp, 1973).

According to Strupp, the prototypical base for this influence ability resides in the original parent-child relationship. That is, the potential in a person for transference reactions is what makes psychotherapy a viable treatment method. In the absence of that potential, that is, if positive transference cannot be elicited due to massive early deprivations, psychotherapy cannot become the treatment of choice.

As to technique he writes,

In principle, the therapist subtly encourages the client to search for significant gratification in the therapeutic relationship. And when he vividly experiences these yearnings the therapist interprets them as infantile, thereby inducing the client to renounce or modify them (Strupp, 1973).

A paradox, to be sure. But also you know perfectly well what a woman would be called if she treated a man in a similar manner.

Still from another angle, Erwin Singer, also in a current paper, conceives of change as brought about by the effort the patient makes in the course of treatment to genuinely get to know his analyst. In his words,

If it is true that through self-knowledge and self- recognition analysts become capable of grasping the essentials of their patients' lives, and if, conversely, it is also true, as I have argued, that through their new found and rediscovered self-knowledge patients grasp the essentials of their analysts, then psychoanalytic success seems to me readily definable. It expresses itself in the patient's ultimately becoming as conversant with the analyst's personal visions, his psychological operations, and his hierarchy of values-including the discrepancies between what he professes and by what he truly lives-as the analyst, hopefully, has become conversant with these central aspects of his patients' lives (Singer, 1971).

The conceptualization here, with which I am in total agreement, if I understand it correctly, is a highly existential, and even Gestalt in view, whereby meaning is primarily dependent on function, on structure, and not on extraneous embellishments. The distinction drawn is between knowing someone and knowing about someone. Content information, that is, whether one likes bean or chicken soup, plays chess or the violin, is by and large, irrelevant, except as reflective of character and cognitive style which with enough alert attention one can grasp anyway without the bits of information. In this connection, the notion of the analyst as a role model becomes an infuriating concept, as opposed to a task model, which defines someone from whom you legitimately learn how to do something. The patient then changes because he learns not through mimicry, but through experience, a new mode of apperception which includes paying attention to what is, and not to what should be, or to what is said is. I label this an existential-Gestalt notion, but in truth the concept far precedes the label as illustrated by Antigone saying to her sister, Ismene, when Ismene is being uncooperative about burying their brother, "I cannot love a friend whose love is words."

What emerges then from this review of the various theoretical positions on change is a twofold notion. One, that apparently the patient has ceased to be a single entity in anybody's mind and he is now regarded as one member of a bipolar field where the entity is the patient-analyst dyad. Thus, the primary paradox becomes, to which several of the persons I have quoted earlier allude: can you be the observer of a process in which you are a participant? Or to put it still another way, how relevant remain the concepts of transference, counter- transference, participant observation and real relationship in the light of this new shift of vision regarding the interaction and its significance in the patient-analyst dyad?

Without being unduly partisan, I should nevertheless like to point out that the existential and Gestalt analysts have struggled with this issue for quite some time. In existential thought, World and Self are said to stand in a dialectic relation, the two comprising a unitary structural whole, where alteration in one, produces an immediate and corresponding change in the other. The dyadic, the I-Thou view of treatment therefore, is an inherent aspect of the system. This is so especially since world is defined as "the structure of meaningful relationships in which the person exists and in the design of which he participates" (May, 1958).

Buber, for example, in his chapter on "Healing through Meeting," writes as follows,

In certain cases a therapist is terrified by what he is doing because he begins to suspect that at least in such cases, but finally perhaps, in all, something entirely other is demanded of him-something incompatible with the economics of his profession, dangerously threatening indeed to his regulated practice of it. What is demanded of him is that he draw the particular case out of the role of professional superiority, achieved and guaranteed by long training and practice into the elementary situation between one who calls and one who is called. The abyss does not call to his competently functioning security of action, but to the abyss that is to the self of the doctor, that selfhood that is hidden under the structures erected through training and practice, that is itself encompassed by chaos, itself familiar with demons, but is graced with the humble power of wrestling and overcoming and is ready to wrestle and overcome, thus, ever anew. From the hearing of this call there erupts in this most exposed of intellectual professions, the crisis of its paradox. The psychotherapist, just when and because he's a doctor will return from the crisis to his habitual method, but as a changed person in a changed situation, He returns to it as one to whom the necessity of genuine personal meetings and the abyss of human existence between the one in need of help and the helper has been revealed (Buber, 1964.)

Obviously from the foregoing, once one speaks of paradox and this work the issues are myriad. Like a Pandora's Box or a Fortune's Wheel -- "round and round it goes; where it stops, nobody knows."

Another curious characteristic of current theories of change, although not unique to them, is the general striving toward a unifying principle. The assumption of each theorist is that all patients change in the same context and for the same reasons. Now, I say that this is curious, because when the same theorists look at the analyst's functioning they perceive great variability in all sorts of modalities and dimensions. Thus, for example, Levenson, in the paper I quoted before, referring to the success of one analyst as over another in a particular case, writes:

Both the theoretical position of the therapist, and his characterological unflappability, (which may well have made the theoretical position initially sympathetic to him) combined to offer the patient the climate of conviction, and faith in change, that led to her improvement (Levinson, 1978).

Again, in a paper titled "Countertransference Reexamined," Ed Tauber writes:

The choice of therapeutic posture must depend upon what is comfortable to the therapist and the conditions which best fulfill his productive use of himself. Ambiguous and ill-defined though these conditions be, perhaps only limited modifications of the self are possible ... Genetic, constitutional factors and temperament influenced and acted upon by social milieu; selective factors with respect to learning, what we "consent" to learn, what is blocked ... float together in mysterious ways (Tauber, 1978).

Later he also points out that some patient-therapist dyads work out better than others. But he regards the reasons for that also difficult to articulate or to predict.

Not long ago, the Princeton Center for Advanced Psychoanalytic Studies compared a small sample of highly experienced psychoanalysts, (that is, all the practitioners professed to be orthodox Freudian psychoanalysts) and concluded among other things that:

1. Members of the sample, when asked to describe the word "listen" (as in listening to patients), described something experientially quite different one from the other.

2. The analyst's personal perceptive and cognitive style influences the weight he gives to various facets of data. Some analysts have a greater tendency to synthesize or organize material than others.

3. There are considerable variations in what may be termed the "object relations" aspect of what takes place between any given analyst and any given patient, with the patterning seeming to depend primarily upon the analyst's personality (The Forum, 1977).

Now, I submit that what is sauce for the goose is sauce for the gander. If analysts have basic character structures, so do patients; if analysts have cognitive styles, so do patients; if analysts learn selectively, based on who they are, so do patients. I am making a case that the premorbid character structure, with its corresponding cognitive and perceptual styles and preferred contact modes, persists at least to some degree through most forms of psychopathology. Further, that if our professional task is indeed to treat and not to educate or to politicize, then the highly practical principle must apply: If it works, don't fix it.

It follows, therefore, that what needs fixing is the pathology and not the premorbid character structure. In terms of change, then, in psychotherapy, it seems to me the different character structures will respond to different catalytic agents as inductive of change. Thus, for example, (to follow the Nietzsche-Benedict-Spiegel character classifications, and thereby avoid connotations of morbidity), if we have an Appolonian person whose predominant style of concentration is peripheral, whose belief constellation is primarily cognitive, whose learning style is assimilative and whose preferred contact mode is visual, it is very reasonable to assume that he will change based on different cues from the environment than the Dionysian person, at the other end of the scale, whose predominant style of concentration is focal, whose belief constellation is primarily affective, whose learning style is assimilative and whose preferred contact mode is tactile. Clearly here, as in any other classification, the number of pure types is very small. I am using the typologies, simply to illustrate that overall character styles do differ from each other, both in structure and in functioning. I claim, therefore, that they must also be differently responsive, and to different aspects of the environment even when the process in which they are involved is change.

I think that my reasoning may also account for the fit between some patient analyst dyads and not others. The crucial variable, I think, is not presence, goodwill, loving-kindness, training orientation or any other factors specified so far, although all of them are obviously important. Still, the crucial variable seems to me to be a congruence in styles between therapist and patient which at their best fit, ignite and burn with a most vehement and illuminating flame.

This is not to say that a Dionysian therapist cannot treat an Appolonian patient. He can, although they both might be happier in a different combination. I am, however, saying that a Dionysian patient and an Appolonian patient will change in different subjective contexts, on different cues, and through different catalysts, regardless of the nature of their pathology and regardless of who treats them.

One more word on this topic. My thesis is not contrary to that core commitment of all considered psychotherapists, best put by Horace: "Nothing in life is alien to me." Except, I think, the phrase refers to feelings and outcomes, not to process. It refers to those black holes within and without, into which any one of us can fall by accident or inattention, as persons and as therapists. The knowledge of that vulnerability erects a bridge from each to each as it also reveals that our most solid claim on immortality is genus.

Earlier, I have said that the concept of transference and its related constructs need to be reexamined. For the remainder of this paper, that is what I propose to do.

I have been impressed of late by the fact that almost any clinical journal one is likely to read, has in its table of contents, at least two or three articles dealing with the notion of transference. The concept is being rethought, attacked, defended, cast aside, reified, affirmed, disparaged. It is, at any rate, featured at top billing on the marquee of contemporary psychoanalytic minds.

I should like to advance an hypothesis as to the reasons for this occurrence. By now, it is a generally accepted, even banal fact, that the decade of the sixties in America has dislocated the culture. It has altered communal sensibilities and it has established new standards in a variety of formally codified rules of conduct. Starting with the Camelot reign of Kennedy, social distance became reduced, partly as pretense, partly in reality. The young suddenly acquired status as did the have-nots, if not truly, at least on the level of verbal consensus. Styles in dress and speech and psyches received a new look. "Be up front" and "Let it all hang out" and "If it feels good, do it" became the consciousness-shaping slogans of the era. As is true of all new societal movements, the thrust of this change traveled simultaneously on several trajectories in the culture. Some were authentic, beneficial, growth promoting, reliable, long-lasting and fun. Others were the opposite. Still, no enterprise practiced in this context could remain unaffected. Psychotherapy proved to be no exception. Esalen, Encounter, Gestalt and joy all had their slowly eroding and altering effects. The cultural shift produced needs for new treatment modalities. Thus, new treatment modalities were evolved. These in turn confirmed the change in the culture, which increased the need, which confirmed the new modality. And so on and on.

The spirit of the times moved toward de-differentiation, leveling, premature integration, and confrontation in the mode of rage, By now, I am up to Viet Nam. Individualism became both aggrandized and devalued, at the same rate, that those equipped to deal with such paradoxes lost their credibility and were labeled effete. God died and with him died the power of Authority and the idealization of Experts. Women judged themselves as capable of gynecological self-examination and everyone agreed that shrinks have shrunk. The anti-hero in fact and in fiction carried the day. In other words, relatedness in the old mode became untenable, including in the psychotherapeutic situation, New patients required new analysts or else they required old analysts to change. Professional conduct which ten years before would have been considered heresy and would have been grounds for excommunication became the rule. The profession shifted in its practice, but remained until quite recently pristine although uneasy in its theories.

That in this work there has always tended to be a credibility gap between theory and practice, is well recognized by now. Still I am convinced that the contemporary theoretical focus on transference and its related tenets is an attempt to at last bring theory in line with ongoing experiential reality.

My thesis is quite simple. I am proposing that as the culture shifted towards a less authoritarian, less formalistic, and more confrontational style of relatedness between persons, so did the relatedness between psychotherapists and patients shift. Further, that this stylistic transformation was originally the result of a counter-cultural revolt against the technocratic objectification of man, and it was in the service of revitalizing the belief that subjective experience is a respectable source for the interpretation of the reality of the world.

The result of this view de-mythified all experts and particularly the analyst; and demystified the patient, at least in this particular regard.

Again, the tradition of existential and Gestalt thought has long contained this view. "World" in that system is always seen from the angle of the person who exists in it. It is a dynamic pattern which the person molds and creates, and it is always relational.

As a consequence of the relational view, however, various existential theorists have come to simply deny that transference exists at all. Medard Boss, for example, writes:

Transference is always a genuine relationship between the analysand and the analyst. In each being together, the partners disclose themselves to each other as human beings. No transfer of an affect from a former love object to a present day partner is necessary for such disclosure (Boss, 1963).

That seems a little like throwing out the baby and the tub together with the bath water. My own view is different.

I think that transference reactions do exist, in and out of the treatment room, if one defines them as reality distortions in the here and now.

Now granted, that psychic phenomena are over determined and that projection plays a major role in transference, it nevertheless seems to me, that some other considerations apply.

First, that dynamically transference can be seen, as a deja-vu phenomenon at the base of which we find faulty recognition. In other words, the distortion occurs on the basis of accurate perception, of real similarities between the former and the present day object, but since the former object is misremembered or not adequately recognized, the present object is taken to represent it.

Secondly, that although at any given moment, there may be transferential elements in the relationship between the analyst and the patient, (and I believe the transference is mutual, and it does occur in the relationship and not in one or the other member of the dyad), nevertheless, what takes place is not just transference. The transference reactions unfold in a context of two real people relating for real. The distortion and the reality are therefore always intermingled. Context and content merge.

Thirdly, that although generally speaking, the distortion of reality and the curtailment of perception represent pathologic trends in the personality, nevertheless, the maintenance of homoeostatic balance for short periods of time can be seen as adaptive. Transference reactions then, can be adaptive in this sense: in that in relating to the familiar is less taxing and less likely to upset equilibrium, than is the apperception of the new which requires a new response.

In another vein, what is generally referred to as "positive transference" seems to me to again contain large elements of reality. If you sit with someone two or three times a week who is attentive, kind, friendly, helpful and compassionate a good deal of the time, it seems to me quite expectable that you would develop positive feelings towards that person. In fact, not to do so, is a reality distortion which accompanies some extremely severe pathological conditions. Similarly with negative transference. Since the analyst at times does behave in traumatizing ways, there is a certain reality and justification in feeling negative toward him. Castor oil may be good for you, but you do not, as a rule, love it. The same considerations apply to the analyst. Caring seems to have the quality of "as if increase of appetite grew by what it fed on," Namely the act of caring and devotion tends to have a character of self-perpetuation (perhaps one is just running after one's investment).

Undoubtedly, the prototype for these experiences is the early parent-child relatedness. That, however, does not make the manifestation unreal. It just makes it mammalian.

One more point on this: The shift from interpretation to confrontation radically altered the therapeutic relationship. Traditionally interpretation has been a rationalistic exposition offered by the analyst to the patient based on the analyst's understanding and conceptualization of the patient's resistances and of the reason, usually instinctual conflict, for these resistances. Confrontation, on the other hand, is an attempt to bring the patient face to face with his own pathological modes. The emphasis shifts from "why" to "how" and "what." Confrontation also entails greater risk for the analyst because his immediate reactive mode is revealed. In other words, a confrontation always says as much about the confronter as it does about the confrontee. The same is not true of interpretation. Then too, since confrontation entails a dialogic relatedness in the here and now, there is no way to assert that the patient is reacting in terms of the past, to someone imagined, who is other than the analyst. To be sure, the patient's style of reaction is based in the past, as is the interpersonal efficacy with which he can voice his reaction, but not the reaction itself.

I am aware that it is possible to smile when one is hurt, instead of to cry. In which case we would term the reaction inappropriate. My point, however, is still that the style of the reaction is inappropriate, in this case defensive, but the reaction itself is embedded in the real interaction with the real analyst.

It seems to me that a tripartite conclusion emerges.

1. The patient's relatedness to the therapist has both transferential and reality components which are intermingled. Consequently, to talk of "the real relationship" or "the transference relationship," is an artificial distinction. Further, a person's relatedness outside the therapeutic context has the same characteristics.

2. The context in which transference reactions occur is real. Therefore, there must be some real element present in the relatedness to have elicited the particular distortion at the particular time. Consequently, it is very doubtful that one ever sees reactions which are purely transferential.

3. Given that one can view the patient and the therapist as a dyad in a bipolar field, no valid separation can be drawn between the patient's relationship to the therapist, and the therapist's relationship to the patient. Rather, they comprise a unitary structural whole with successive influences and adjustments which enlarge and affect one another.

It is difficult to end this paper neatly, because the issues I have raised, seem to me to lack closure at this time. If anything, they raise more questions for me than I had before. Perhaps I had best stop with some lines from e. e. cummings:

when skies are hanged and oceans drowned,
the single secret will still be man (cummings, 1957).

References

Boss, Meddard (1963). Psychoanalysis and Daseinanalysis. New York: Basic Books, Inc.

Buber, Martin (1964). Healing through Meeting in The Knowledge of Man. New York: Harper Bros.

cummings, e. e. (1957). 100 Selected Poems. New York: Grove Press, Inc.

The Forum. (1977) Society of Medical Psychoanalysts. Vol. X11, No. 4..

Haley, Jay (1963). Strategies of Psychotherapy. New York: Grune & Straton, Inc.

Levenson, Edgar A. (1978) Contemporary Psychoanalysis. Vol. 14, No. 1.

May, Rollo (1958). Existence. New York: Basic Books, Inc.

Singer, Erwin (1971). The Fiction of Analytic Anonymity. Human Dimension.

Strupp, Hans H. (1973). On the Basic Ingredients of Psychotherapy. Journal of Consulting and Clinical Psychology, 1973, Vol. 41 No. 1, 1-8,

Tauber, Edward S. (1978) Countertransference Reexamined. Contemporary Psychoanalysis, Vol. 14, No. 1.

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