Conclusion: Therapeutic Cautions - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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Conclusion: Therapeutic Cautions

Therapist Resources > Therapy Books > Opening the Can of Worms-Cple

Opening the Can of Worms, Complications in Couples and Couple Therapy
by Ronald Mah

The clinical style of interaction should vary according to different personality disorder diagnoses.  Borderline, narcissistic, schizoid, dependent and other personality disorders may each require a "different" therapist.  The therapist should consistently consider adapting his or her clinical style to the client throughout the course of therapy.  Therapy cannot be prescriptive, but commonalities and general recommendations can guide therapy.  Sound theoretical insight amplifies differential diagnosis and treatment for the skilled therapist.  Cooper (2011, page 9) discussed the work of John Norcross who coined the term "evidence-based relationship."  Looking at the match between the therapist and the client improves outcomes.  It should be self-evident that it is the therapist who needs to adapt to match the client as opposed to the client adapting to the therapist.  He identifies five important client characteristics that affect therapeutic efficacy across diagnoses:

Reactance/resistance- Individuals who get provoked easily and resist external demands get more from therapy that emphasizes self-control with minimal direction from the therapist.  Paradoxical interventions are not recommended.  On the other hand, individuals with low reactance respond well to more directive and explicit instruction.

Preferences- When the therapist accommodates to client preferences regarding therapy style, length of therapy, and therapeutic goals, the therapeutic relationship and drop out rate both improve.  

Religion/spirituality- Adaptation and honoring the spiritual and religious beliefs of clients improves therapeutic success.

Stages of Change- Adaptation and match to the client's readiness or stage of change improves success.

Coping Style- Therapy is more successful when the therapist matches therapy to fit with the client's coping style.  For example, individuals who internalize do better with interpersonal and insight-oriented therapy, while those who externalize find symptom-focused and skills-building therapy to be more effective.

The importance of these transdiagnostic characteristics may be significantly intensified with clients with personality disorders.  Resistance may not be as transitory as it may be for other individuals but deeply embedded as part of the personality disorder.  Attempting to work through the resistance or coming back to an area of resistance may be highly triggering and harmful.  With a personality disorder developing some alternative approach may be clinically necessary and more acceptable to the individual.  Personality disorders with habitual passivity would not respond well to an evocative or highly client-centered approach.  The therapist may need to take a more authoritative direction that would be well received.  The depth and intensity of client preferences may be under appreciated if the therapist is unaware of a personality disorder.  Preference may be better viewed as psychologically embedded requirements or fiercely defended boundaries. Characterological rigidity of personality disorders may also coincide with religious and spiritual rigidity.  The requirement for the therapist to flex to the religious or spiritual beliefs of the client would be sorely challenged if the beliefs are rigid and intrinsic to the characterological dysfunction of the personality disorder.  Working within the stage of change for the client may present fundamental issues working with someone with a personality disorder.  Such an individual may be conceptualized as being stuck in an ineffective stage of change- that is, non-change or lack of flexibility.  Psychoeducation may be the necessary and default stage that the therapist must address.  The therapist might consider that deep issues or trauma may have gotten the client stuck in a primary attachment stage without the resultant development of secure attachment.  The last characteristic may be the most challenging.  The coping style of the individual with a personality disorder is the dysfunctional personality disorder!  The therapist however could still follow Norcross' recommendations, but with great skills and caution to somehow limit the dysfunctional manifestations of the copying style/personality disorder while activating the functional aspects of the copy style/personality disorder.

The additional challenge of couple therapy is that each partner may have differing characteristics.  The therapist may use an approach that resonates with one partner's characteristics while simultaneously aggravating the heck out of the other partner!  The therapist often needs to be simultaneously conscious of all the internal working models in the session.  This includes the internal processes for both the partners and also for him or herself.  Each, any, and combinations of issues or processes can open the proverbial "can of worms."  There may be implicit patterns of attachment and relationships that are not openly acknowledged or activated.  There are unconscious or semi-conscious ways of interacting and relating that each person practices with expectations that others also hold and practice.  These processes ordinarily cannot be fundamentally changed.  However, they can be adapted or stretched if the individual becomes so invested.  The therapist needs to be aware of he or she holds and practices as a relational working model within the sessions.

"It seems to me that a related concept, implicit relational knowing (Lyons-Ruth, 1998), adds to this theory by focusing on the implicit, nonsymbolic way a person learned the process by which he or she cocreates a relationship.  This concept focuses on the interactive relational patterns that affect ways of being with others learned in the context of a child's relationship with others and communicated by way of highly practiced sequences of actions.  Mutual regulation then cocreates a dyadic system (Beebe and Lachmann, 1998, 2002; Tronick et al., 1998; Sander, 2002; Tronick, 2002).  For example, a child learns early in life what forms of affectionate approaches a parent welcomes or rejects.  These implicit modes become models for the child's affectionate approaches to others thereafter.  The modes may not be symbolically encoded and therefore are not accessible to conscious attention (Tronick et al., 1998; Tronick, 2002).  Because they are not conscious but are cocreated in an interactive system, they can be very difficult to access and change without the intervention of another, outside the dyadic system—creating a new, triadic system" (Feld, 2004, page 422).  The therapist should consider if he or she conducts therapy as an outside agent affecting the couple versus he or she has joined the system as an integral partner- the third partner.  With a person or a couple with a personality disorder, the therapist may be making a therapeutic mistake to consider him or herself outside of the system.  With the variety of personality disorders and the complexity in each disorder, the therapist should adapt his or her role as needed.  One or a preferred role should not be assumed to be appropriate without regard to the individual's embedded characterological style or pattern.  Therapeutic flexibility to consider a breadth of potential issues is vital to effective work, since the therapist's orientation and client presentation may not accurately identify key issues.  As stated earlier for example, the therapist should not fail to as assess for self-medication for pervasive anxiety and depression from the consequences of choices arising from characteristics of a personality disorder.  The therapist may find that an individual readily fits the criteria for PTSD, a personality disorder, or bipolar diagnosis and effectively use theoretical insight to guide treatment.  If the individual is willing to accept the diagnosis, it may empower and activate him or her to become more fully involved in his or her treatment.  Accepting a relevant diagnosis enables the individual to recognize his or her emotional triggers, mental processes, behavior patterns, and relational challenges and thus, to better problem solve them with the assistance of the partner and the therapist.  

However, an individual may rebel or deny a diagnosis vehemently.  This often occurs with substance or behavioral abuse or addiction diagnoses.  A diagnosis may be too provocative, too stigmatizing, and/or too demeaning for him or her to hold emotionally, psychologically, mentally, spiritually, or culturally- that is, "too wormy!"  Another therapeutic error thus may involve the therapist getting caught up in a labeling or diagnostic identification battle.  That can divert the attention of therapy away from a process of change.  Repeated therapist attempts to force acceptance of a diagnosis can create intense obstinate resistance that sabotage therapist-client rapport.  Therapy can proceed for the time being without the individual's acquiescing, as was discussed previously through using the term "self-medicater" in lieu of the addict label.  The therapist should accept resistance as another diagnostic clue about the individual.  Denial along with other defense mechanisms serves to protect the individual from anxiety that would otherwise be overwhelming.  The therapist should consider what would be so overwhelming and why the psychic structure cannot tolerate its presence.  Theoretical information and principles for therapy from a relevant diagnosis can still guide the therapist's communications and interventions.  Without verbalizing a label or the specific terminology from a diagnosis, the therapist can draw upon theoretical knowledge to identify behaviors and patterns of interaction between the individual and his partner.  The therapist can predict the extension of interactional patterns in the future.

Certain therapeutic orientations and therapist styles require the therapist to evoke insight, verbalizing, and ownership from the client.  Some individuals however lack sufficient insight or ability to articulate their feelings and thoughts.  Others may be resistant to taking ownership.  Individuals with personality disorders often have the roots of their dysfunction so deeply buried in their psyche that they are not readily accessible.  The therapist who fails to recognize such limitations will not only find therapy not progressing, but also lose credibility with the client.  The individual and his or her partner may develop increased rapport and trust in the therapist, if the therapist "guesses" past and present interactions and relational experiences within the couple and prior to the couple.   The therapist can use the characterological manifestations germane to the diagnosis to show he or she "knows" or "gets" the individual and doings, rather than trying to draw it out in prolonged clinical interviews.  It may be a mistake to attempt to draw out full individual and couple's histories in the session.  There may be significant resistance, distortion, and/or denial that will quickly close a small window of therapeutic opportunity.  This otherwise frustrating therapeutic process may enable an astute therapist to quickly build credibility and rapport.  For example, the therapist can "mind-read" the characteristic borderline behaviors of deep love and investment, devastating betrayal, subsequent remorse, and re-connection having occurred repeatedly.  This approach is discussed in depth in "Ouch!! Where'd That Come From?! The Borderline in Couples and Couple Therapy" (Mah, 2013): available at or on this website. That can include knowingly asserting previous experiences of being betrayed by other intimate people, including prior therapists.  Similar interactions for other personality-disordered individuals can establish credibility and rapport with them as well.  In the case of a bipolar individual, the therapist can ask about taking medication vacations without the individual's first disclosing about them.  In the couple, the therapist use theoretical knowledge to present the stereotypical responses of hope, disappointment, frustration, and anger of the invested partner, also without the partner presenting it first.  Verbalizing the emotional frustration of prior attempts to force change by the partner causes him or her to feel that the therapist "gets" him or her.  Rapport and credibility builds for the partner with resultant increased investment in therapy.

Several potential therapist mistakes can be addressed through the process of psychoeducation.  For example as mentioned earlier, the therapist can still engage in psychoeducation about a diagnosis with both partners without naming the diagnosis.  The psychoeducation is often an ongoing essential part of the therapeutic process.  It makes the characterological behavior patterns identifiable to each person, while setting the stage for their eventual acceptance of a human pattern characteristic of many individuals with similar life experiences.  Psychoeducation about self-medication for anxiety and depression does not require an abuse or addiction diagnosis.  Someone who holds a sanction against vulnerability can hear about and discuss the behavioral and eventually, the emotional effects of trauma without self-labeling oneself as a victim.  The therapist can find ways to do psychoeducation, yet honor individuality.  It would be a mistake to forgo educating individuals about emotional and psychological patterns because of fear of upsetting an individual's fragile self-definition.  Personality disorders, trauma, bipolar disorder, and substance or behavioral abuse or addictions along with many relevant emotional, mental, and psychological issues require the therapist to balance psychoeducation with validating individual uniqueness.

So what about Cole and Molly?  As soon as therapy began, their personal can of worms opened.  The therapist uncovered many important issues to address.  Each of these issues may require psychoeducation to set a foundation for therapy.  What about Cole and Molly?  It depends!  Psychoeducation like any intervention is not a generic process applicable without first accurate assessment and diagnosis.  The intensity and volatility of emotional reactivity is often the key assessment.  Interventions and strategies to address attachment, substance abuse, trauma, and other issues are often based on calm intellectual examination.  Cognitive clarity however is often impossible or lost when strong emotions dominate.  The symptom blocks the intervention, yet the intervention is needed to address the symptom.   Nevertheless, psychoeducation about this circular dilemma may need to be where therapy starts.  With accurate assessment and diagnosis of the origins of emotional reactivity, failure of interventions due to emotional reactivity can actually become a great therapeutic opportunity.  Psychoeducation coupled with the couple's failure to mute dysfunctional emotional reactivity often forces partners to finally face and accept heretofore hidden or denied underlying issues.  The therapist should lead partners to understand their seemingly illogical waylaying of healing behavioral changes can only make sense with the presence of some compelling energy.  This is the interfering third partner in the couple.  Another important clinical error comes from how the therapist handles therapeutic failure.  High emotional reactivity from various causes virtually guarantees there will be therapeutic failure.  The therapist should recognize continued arguing, miscommunication, hurt and loss, and recurrent battles as diagnostic cues to hone and adjust the conceptualization, strategy, and direction of therapy.

What about Cole and Molly?  They get mad at each other.  They get emotionally caught up or emotionally disconnected.  They simply need to stop it!  They need to eject or control the interfering third partner so to speak.  The therapist should try what should work to help them stop it: communication skills, directives, empathetic listening, and so forth.  And if such interventions work, then the therapist can celebrate!  And Cole and Molly can celebrate.  Or with the greater likelihood of such interventions not working (if they did, Cole and Molly probably would have worked it out without therapy), then more sophisticated levels of therapy should activate to deal with the out of control emotions.  The therapist should emphatically assert to the partners that, "If it should work, it would have worked… unless there was or is more to it."   What might "it" be?  The therapist may ask him or herself, "Is the emotional reactivity from trauma?  Is the volatility from a personality disorder? Or, what?" The therapist should then make deeper inquiries that will help Cole learn about himself.  And help Molly learn about herself.    Then help them learn about each other.  Perhaps, including and especially why each goes off emotionally on each other!  That is, why therapy… their relationship has not worked… yet.  Emotional reactivity that seems to waylay therapy and the relationship is a major symptom of a dysfunctional couple.  However, out of control emotions are also clear intimacy traffic signals that certain paths are blocked.  And have probably been blocked, diverted, or sped up (intensified) from way back.  The therapist needs to dissect Cole's and Molly's emotional stop signs, downward grades, potholes, and detours.  Then they can learn to slow down, speed up, start and stop, and travel on other routes.  Metaphorically, this can mean getting that dysfunctional third partner out of the driver's seat.  The therapist can only do this by gaining client acceptance of necessity for more sophisticated levels of work.

Therapeutic work does not promise that either partner can undo the past.  Clients will discover a lot of things that cannot be done.  Mostly it will be the simple, easy, or wishful changes that cannot be done.  Neither Cole nor Molly can magically change instantaneously.  However, looking into the sources of emotional reactivity can be done.  Taking what is learned can lead to attempts to reduce the volatility.  They can find safe places and roles for their metaphorical third partner.  The can of worms can be opened.  The worms can be acknowledged and examined.  It may be challenging and uncomfortable, but with the guidance from the therapist and skills developed in therapy, the partners can deal with the difficult feelings and problematic behaviors.  Energy can be honored but redirected.  Interrupting the cycles of unfettered destructive feelings can happen.  Injuries from out of control words and behavior can heal.  They learn that they can try new things… and then more new things.  Risks can be taken.  They discover they can be vulnerable again or for the first time.  They can risk trusting… a little.  Care can be experienced.  They can be disappointed, frustrated, and hurt again, and can keep trying.  Personal growth can happen.  All of the process serves to help them learn that they can do better and get better.  They experience that they can become more emotionally stable and their relationship can be more fulfilling.  They learn that someone such as the therapist and something such as therapy can help.  Individuals and couples learn that they can.  This may be the fundamental goal of effective therapy.  After acceptance that they can, then all that is left is more work. With more work, they may gain confidence that they will.  Eventually, their hope may be fulfilled because they have persisted.

3056 Castro Valley Blvd., #82
Castro Valley, CA 94546
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
office: (510) 582-5788
fax: (510) 889-6553
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