Jennifer Stevens, Ph.D., ABPP

Impasse in Psychotherapy

Impasse:

A predicament affording no escape; deadlock

(Merriam Webster Dictionary)

Psychoanalytic Definition of Therapeutic Impasse

Unproductive therapeutic processes; deeply entrenched and mutually contributed to knots that bring lively work, development, and change to a halt.

Q: Who is responsible for an impasse in psychotherapy?

A: Both therapist and patient contribute to an impasse.

Most often these contributions are unconscious.

Definition of Psychotherapy:

“An encounter between a big mess and a bigger mess”

(E. Semrad)

Patients AND therapists bring into the

therapeutic situation:

early relational histories, internal objects & object relations

preferred forms of relatedness

unconscious conflicts & defensive styles

differing capacities to bear painful feelings

needs, wishes & fantasies for the treatment and the treatment

relationship

Therapists have:

Our preferred theories/ways of understanding our

patients and what we think they need from us

Limits of our knowledge and technical skill

Limited understanding of patients’ difficulties

Three conceptualizations of

therapeutic impasse

Defeating Processes

Negative Therapeutic

Reactions

Therapeutic Misalliances

Defeating Processes

Martin Cooperman, M.D. (1979)

Sudden change in emotional atmosphere of productive treatments

Relation between therapist & patient becomes conflictual (e.g. power struggles and accusations)

Transference:

Patient is angry, attacking, and symptomatic

Countertransference:

Therapist is hurt, frustrated, lost

Therapist’s competence is in question – by both patient and therapist

“Each patient… described feeling hurt, humiliated,

or badly used (narcissistically wounded), and

rendered helpless by a considered and concrete

act of mine which directly affected the

arrangement of the therapy …. With each, I had

arbitrarily forced into focus our separateness.”

(Cooperman, 1979)

Separation makes clear:

Limits on dependability, availability, and “being in it together”

Therapist and patient differences in wants, needs, and authority

The patient

Feels hurt, angry & humiliated for needing the therapist

Tries to regain sense of control through vengeful attack on

therapist & their work

Goes to great lengths to defeat own treatment and potential for

growth

It is the responsibility of the therapist to:

Be engaged in ongoing self-

reflection

To become alert to signs of impasse

To work to develop an understanding

of the impasse

To accept responsibility for

his contribution to an impasse

Negative Therapeutic Reaction (object relations view)

Is a paradoxical response to positive change

Marked by a radical change in course in a productive treatment

Includes a significant change in the nature of the treatment relationship

Internal Object

A mental/emotional representation of an important person

Often representations of care givers of early life

Related to internally

Influence of Internal Objects

How we feel about ourselves

What we can imagine for ourselves

What we expect from others

The quality of our relationships

Our Patients’ Bad Internal Objects

Do not recognize the separate, autonomous existence of the patient

Thwarting of the patient’s development

Persecutory; critical

Often related to patient’s psychiatric symptoms

Development requires separation from internal objects

Patients’ responses to separation from internal objects include:

Anxiety Guilt Loyalty conflicts

Concerns that differentiation will

destroy internal objects

Frightening feelings of emptiness

Changes in the Transference & Countertransference Patient begins to experience therapist as source of painful experience

Patient experiences therapist as dangerous

Patient threatens to leave treatment because unhelpful

Therapist tries to hold the patient in treatment

Both stuck in a repetitive cycle of holding on and trying to get away

Reflective Space Collapses

Move to action vs. representation of experience in language

Possibility of reflecting on process is eradicated

Patient’s and therapist’s words are used to act on the other (to coerce, to convince, or to control)

Therapeutic Misalliances(Langs, 1975)

Therapeutic alliance

A largely conscious agreement between patient and therapist

about the commitment to the task of psychotherapy.

Therapeutic misalliance

Unconscious joint commitment to an alternative task aimed at

the avoidance of difficult to bear affects and the gratification of

relational longings. A mutually agreed on misuse of the

therapeutic situation and relationship.

Patient’s Unconscious Participation in Misalliance

Interested in recreating and living out early relationships vs. understanding impact of early relationships

Engaged in a goal that runs counter to the explicit aims of psychotherapy

Presses toward action

Sources of Therapist’s Unconscious Participation in Misalliance

Unresolved intrapsychic conflicts stirred by particular patients

Inappropriate needs for sexual or aggressive expression

Struggles with the limits of the therapeutic frame

Longings for closeness

Efforts at feeling important and valued

Countertransference Indications of Misalliance

Therapist:

Notices lack of progress or depth in the treatment

Becomes aware of deviations in usual ways of intervening or behaving

Feels like something is not right

Begins to dislike or feel manipulated by patient

Therapist’s Response to Countertransference

Listen for possible commentary on therapist’s difficulty with the therapeutic alliance

Possible themes to listen for: manipulation, poor parental functioning, collusion

Engage patient in exploration of his experiences of therapistandperceived difficulties with the treatment alliance

Consultation, consultation, consultation …