AVOIDING LIABILITY BLOG

Temptations in Clinical Encounters

By definition, a temptation is an individual inner urge to break an external community rule.  Our community of psychotherapists has evolved a set of rules for all its members, without exception.  These rules embody decades of clinical experience, the knowledge that has come from trial and error, and the overarching concern for the welfare of those we are treating.  While over time some rules do change a bit, mostly we can call ourselves professionals because we all recognize certain rules as inviolate, never to be broken.

The rule about having no sexual intimacies is a major one, but will not be part of this column.  Therapists face other kinds of temptations that may be less dramatic but are just as important to resist.

Certain clients/patients can be very upsetting to us, and we naturally try to reduce that unusual amount of stress, even as we are also trying to conduct psychotherapy. Occasionally the stress is so great that we find ourselves tempted by the possibility of seeking immediate relief through releasing our anger in some way, or in removing ourselves emotionally from the scene.

While a neophyte therapist may not know about, or fully understand, some rule about proper professional conduct, good supervision soon corrects that.  For the rest of us, a temptation may occur suddenly without warning, or on the other hand an attractive fantasy may start to develop in our minds about something we might say or do with a particular patient/client who, if we are honest, is arousing strong uncomfortable feelings in us that are pressing for release or relief.  For example, people who are diagnosed as having a borderline personality disorder are typically highly frustrating for all but a few therapists.

The temptation is twofold: to take an action, and to think approvingly about it. The rules of our professional ethics pertain to our behaviors. But under stress we also want to provide ourselves with a justification for why a certain risky bit of behavior on our part is really all right.  We try to rationalize that the rule can be bent in this situation, or that the rule doesn’t apply, or that this is “the (allowable) exception that proves the rule.”

Basically, every therapist has his or her limits, and certain clients/patients can push us beyond our normal competencies. We may suddenly feel provoked.  Such patients/clients can overstress us, and make us feel overwhelmed and uncertain about what to do.  This is when we get tempted, to find some quick relief.

Psychology tells us that when faced with some major threat, we shift from normal behavior into Fight or Flight.  We start to get angry, or we try to create some distance between ourselves and the threatening difficulty a client/patient is presenting.  This is the way our emotions have become programmed by evolution and the imperative of survival.

So it is not a sign of personal weakness or professional incompetence if we feel very angry at or scared by a particularly difficult patient/client.  We are not responsible for the emergence of such all-too-human feelings; we are held responsible only for how we deal outwardly with these inner stresses.

The temptation is to find some form of quick release of our inner tension. But the high standards of our profession remind us that a therapist’s self-discipline includes the commitment to suffer in silence, temporarily, and endure the stress. Meanwhile, in the extra difficult session, we must keep our mouths shut, and do nothing except to continue to listen, until we can come up with a response that is therapeutic in intent and not a form of self-serving relief, by releasing anger or creating distance.

Besides the obvious scolding, cursing, or shouting at a client/patient, there are more subtle forms of inappropriately showing  therapist anger: raising a disapproving eyebrow, pursing our lips, letting a grim look with clenched jaw show on our face, letting our hands or feet start to move in frustration, sighing audibly.  Abruptly getting up and walking about our office may bring some relief, but what does it communicate to the person we are trying to help?

The other defense against patient-induced high stress is Flight, which also can take various forms.  Getting sleepy is an obvious one.  Letting our mind shift to imagining more pleasant pastimes is another.  Fantasies of enjoying a vacation can take us far away.  Thinking about how we’d like to shorten the session, or checking the clock a lot, are other indications of the Flight temptation at work.  Focusing on our hands or shoes, or anything else other than the client/patient, also insulates us from experiencing the stress of the session.  Having repeated thoughts about money or food or chores we must to do – all these can create distance between us and the person we are trying to treat.

Our professional ethics and practice guidelines all convey essentially the same principles:  stay focused on the patient/client; use part of your mind to think ahead to your next intervention, or how best to complete the session; use another part of your mind to become aware of any mounting stress and then how to neutralize it.  We can use reminders such as: This is part of the client/patient’s illness, to make me, and others as well, feel so upset.  I’m certainly uncomfortable, but I’m not in any real danger – so I don’t have to go into action.  I can be proud of myself professionally, if I just hang in there, try to learn from this, and don’t try to do too much at this time.  My basic reminder: don’t get overly invested in trying to change the person, when the person seems highly defended or highly obnoxious.

In summary, our clinical temptations (other than sex) are primarily to find ways to bring us relief from the unusual stress of dealing with an unusually difficult client/patient. We get frustrated, which means we feel both angry and helpless.  The human psyche then seeks immediate relief in Fight or Flight, while our training and sense of professional responsibility have rules: Don’t show anger (with a few careful exceptions), and Don’t disengage.

A temptation is “bad” only if we continue to justify our indulgence in it.  Giving ourselves temporary relief is understandable, but rarely is it therapeutic.  The impact of our Fight or Flight behavior is almost always negative, and corrosive to the relationship.  But if the stress of a particular session becomes so great that a temptation is acted upon, and we experience a lapse in our professional conduct, then it usually deserves our compassion, followed by careful self-study.

David C. Balderston, Ed.D., LMFT

New York City

 

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