11

Good Fences Make Good Neighbors

Maintaining the Treatment Frame

The abuse of children is an inherent violation of boundaries and limits. Physical and sexual abuse clearly violate parent-child boundaries, as children are exploited for personal needs. These kinds of abuse ignore the limits of the coping capacities of children, overwhelming them repeatedly with stimuli that they are unable to tolerate. In treatment, many patients who have experienced childhood abuse will replicate the enmeshment and violation of their early experiences, breaching boundaries and challenging limits. Effective treatment must confront these recapitulations of abuse and help patients establish reasonable boundaries and limits within the therapeutic relationship, providing a safe and respectful framework for both the patient and the therapist.

Establishing a safe structure for treatment is a basic and essential part of the treatment for all patients, but it has particular relevance with patients who are survivors of severe childhood abuse (Briere, 1992; Chu, 1988, 1992c; Courtois, 2010; Davies & Frawley, 1994; Herman, 1992b; Pearlman & Saakvitne, 1995). Particularly in the early phases of therapy, many patients have frequent crisis situations, such as repeated and unpredictable reexperiences of traumatic events accompanied by despair and panic. They also experience intense impulses—often of a destructive nature—that feel compelling and overwhelming. These crisis situations often lead patients to seek increasing amounts of reassurance and time from their therapists. As the intensity of the therapeutic relationship heats up, therapists may begin to find themselves responding to frequent calls, increasing the frequency or length of sessions, and coping with intrusions into their personal lives. In these kinds of situations, therapists must understand the need for establishing safety and predictability in the therapy and must find some way of maintaining boundaries and setting appropriate limits.

ESTABLISHING THE TREATMENT FRAME

A treatment frame that incorporates the ground rules of therapy is one of the foundations of treatment. Therapists must be clear about issues such as the frequency and length of sessions, the availability of the therapist outside of the office, and the roles of both patient and therapist. The treatment frame serves somewhat different functions for therapists and for patients. Patients require a treatment frame that clarifies what they can consistently expect and count on and that ensures the safety of both parties by establishing the kind of boundaries and limits that were not a part of their early lives. Therapists must establish a treatment frame that minimizes the anxiety and stress that comes from the intensity of their professional work and protects their personal lives and privacy.

Therapists must be explicit about the treatment frame and should not assume that traumatized patients will inherently understand the norms of any relationship, let alone the special nature of the therapeutic relationship. Many patients from abusive backgrounds may not even understand the need for a treatment frame. Patients may actually invite boundary violations that feel normal to them (e.g., wanting the therapist to be more of a friend in order to feel more secure, or even inviting the therapist to engage in a sexual relationship as a way of experiencing safe intimacy). Although setting limits and establishing boundaries may be frustrating or confusing to patients, a strong treatment frame ultimately allows patients to feel safe in a relationship where the rules are mutually understood and respected.

Struggles around the treatment frame often seem to occur regarding the issue of therapist availability outside of therapy sessions. A certain amount of availability on the part of therapists is helpful, and some patients in crisis are able to make use of brief telephone contacts to feel reassured and contained until the next session. However, constant or extraordinary availability is problematic for at least three important reasons. First, escalating demands for therapists’ availability ignores the very real human limitations of therapists and their legitimate need to maintain their own separate lives. Second, constant availability leads to increasing dependence on the therapist to provide reassurance rather than compelling patients to find their own internal mechanisms of containing dysphoric affects and providing self-soothing. Finally, the expectation that therapists can always provide soothing and reassurance early in therapy is unrealistic. Both patients and therapists need to accept that throughout the early phase of treatment, patients may encounter pain that may be overwhelming, and that an important aspect of therapy is learning to find nonharmful ways of managing and tolerating psychic distress.

Therapists must establish very clear limits based on both their own needs and their judgment of patients’ needs and abilities. Exactly where the limits are set—within reason—is a function of what is tolerable for the therapist and what is helpful for the patient. For example, some therapists are willing to accept calls up to several times per week, whereas others are not. Some patients require someone to be available on evenings and weekends, whereas others need to be challenged to find ways of coping on their own during these times. If there is a clash between therapist and patient needs, such as the patient who needs out-of-office contact and a therapist who is not willing to be available, some other solution must be found (e.g., hotlines, a walk-in crisis center, other supports). However, the basic principle is not so much exactly where the boundaries and limits are set, but that there are clear boundaries and limits constitute a reasonable and workable treatment frame. Therapists who avoid setting and maintaining a clear treatment frame are likely to become exhausted and then either to abandon the therapy or to renege on explicit or implied promises. Although periodic renegotiation of the treatment frame is common, it is important to avoid situations where too much is promised, because retrenching is likely to result in patients feeling abandoned, betrayed, or abused. The following clinical example of my early-career dilemmas illustrates some of the relevant issues concerning limit setting:

Following my graduation from residency training, I took on the treatment of several patients with a history of sexual abuse in my private practice, many of whom were frequently in crisis. As a successful product of medical education and training, I had taken on the belief that I should be able to respond to meet the needs of my patients at any hour, day or night, even at the cost of sleep, health, mental stability, and family. I soon began to find myself awakened frequently at night by emergency phone calls, often to participate in long discussions around the issue of suicide. For example, one patient with dissociative identity disorder (DID) would sometimes call around 2 a.m. as a suicidal personality. In response to my asking why she was suicidal, she typically responded, “Because it’s my job”—a response to which, at the time, I had no idea of how to counter.

Over time, I learned that just continuing to talk for about 20 minutes would result in the suicidal impulses abating, and I could get off the phone, but by then I would usually be wide awake. I learned to dread the ring of the telephone and slept poorly, expecting to be awakened and not being able to get back to sleep. The introduction of a new puppy into my household and the responsibility of getting up at dawn’s first light to walk the dog brought me to the brink of physical and emotional exhaustion. Violating the teachings about not talking to patients about personal needs, I told each of my patients that I retired early and that I expected each of them to respect my sleep. I emphasized that I did not enjoy late-night calls and would permit calls for only serious emergencies after 8 p.m., and that the conversations would consist of a brief discussion about arranging immediate hospitalization.

Several of my patients became very upset at this limit. One patient retorted, “Fine! Then I’ll just kill myself!” to which I responded that a condition of the therapy was for the patient to call if seriously suicidal at whatever time. Another patient became very distant and panicky, and then called later just before 8 p.m. to be reassured that I still wished to work with her. After a very stormy period of protest and anger on the part of my patients, evening and night calls decreased dramatically to only one call every few weeks. One patient later explored how she was acting out her anger by sadistically calling me repeatedly at home. Another acknowledged that the limits made it both harder and easier for her: “Since I know I can’t call you, I just make myself shut down instead of fighting with myself whether or not to call.”

The guidelines in this discussion may seem rather obvious, but I have known many otherwise competent and experienced therapists to make major errors in permitting egregious violations of the treatment frame. Such therapists have tried to become friends with patients, engaged in activities such as extensive touching, holding, and even bottle feeding, entered into business arrangements with patients, or even invited patients to live with them. What leads otherwise competent therapists to fail to set adequate limits and to participate in major boundary violations? Several common patterns occur. Therapists may lose their therapeutic perspective and come to believe that their only alternative is to gratify patients’ demands. They may recognize patients’ own limited internal resources and fail to understand the need to help patients find ways of developing coping mechanisms rather than simply filling in the gaps in their functioning. Therapists may also come to believe that survivors of childhood abuse deserve and need a radically different kind of treatment than other psychologically injured patients. They may then proceed to implement a treatment based primarily on patients’ perceived needs, such as schemes to reparent or allowing unlimited regression.

Perhaps one of the more difficult scenarios that I have encountered involves therapists who have promised never to abandon the patient—no matter what the patient does. While this promise may give patients a certain amount of security, it also permits some patients to engage in uncontrolled and escalating scenarios to test the therapist’s resolve, which can be in the form of appalling and sadistic reenactments of past abusive interpersonal interactions. There is little evidence that providing a kind of unconditional love is either realistic or helpful to patients. In contrast, a therapy that is based on the patient adhering to the treatment frame and achieving maximal personal growth is far more reassuring and safe. The continuing treatment must always be based not on false assurances but on the condition that the patient is able to benefit from the therapy to make progress in treatment.

Boston forensic psychiatrist Thomas Gutheil, MD (1989), has witnessed many therapeutic misadventures as an expert witness in legal cases where patients have sued their therapists for engaging in boundary violations (e.g., engaging in a sexual relationship). He has described the phenomenon of a kind of bubble that can separate the patient and therapist from the realities of the external world. Within this bubble, the therapist empathically enters the intrapsychic world of the patient, where the needs of the patient are intense and compelling. Separated from the perspective and judgment of others, the patient and therapist then proceed on a course of action that may seem to make sense within the patient’s frame of reference but that lacks any kind of wider or longer-term perspective, and that almost inevitably damages both patient and therapist. Therapists in this situation are at least somewhat aware that the course of treatment that they are pursuing might be questionably regarded by other professionals, and they are often reticent about their decisions (e.g., “I know this is the right thing to do, but I’m not going to talk to anyone else about it because they wouldn’t understand”). It should be a red flag when therapists find themselves thinking that they would not want their colleagues to know about the course of therapy they are pursuing with a particular patient. Therapists who find themselves in this position should immediately seek consultation with a trusted senior clinician.

Patients’ reactions to their therapists’ interventions are powerful determinants of therapists’ behavior. Patients’ responses often seem alternately idealized (e.g., “You are the first therapist who truly understands me”) and devaluing (e.g., “You have no idea what I am feeling and can’t help me”). This is a pattern of so-called intermittent reinforcement that in classic operant conditioning theory is a particularly effective way of inducing compliant behaviors. The pattern of patients’ responses, having both positive and negative reinforcers, is extremely effective in creating a powerful bond that can be focused around meeting patients’ perceived needs. Thus, therapists may tolerate a pattern of slowly escalating demands and only become aware of the consequences when they find themselves constrained and overwhelmed by them.

The intensity of patients’ experiences also promotes premature and ill-considered decision making on the part of therapists. Patients’ wishes to be comforted, reassured, rescued, touched, or soothed are all too human and often intensely compelling. These real needs are often combined with an atmosphere of crisis, with the implied threat of patients decompensating or suiciding (“I can’t continue to live feeling like this”), and are conducive to ill-considered decisions. Therapists should remember that predictability and consistency provide containment rather than extraordinary therapeutic interventions. In particular, touch and physical contact are very problematic with traumatized patients, and therapists should be extremely conservative regarding such matters. In general, any major changes concerning limits and boundaries should be carefully evaluated. No such decisions should be made against the therapist’s better judgment because of a crisis situation. In fact, nothing in terms of the treatment frame should be changed in the midst of a crisis, because the full implications of any such change cannot be given the careful consideration that is necessary to make an appropriate decision. For example, even agreeing to something extra that is legitimate and within acceptable boundaries is almost never a short-term proposition; therapists should be aware that they are likely to be called on to continue to provide the extra intervention for years. Thus, changes in the treatment frame need to be fully considered and extensively discussed before being implemented. Therapists must take the responsibility for making decisions that maintain the treatment frame, keep the structure of the therapy intact, and promote patients’ healthy psychological growth.

THERAPEUTIC RESPONSIBILITY

The issue of therapeutic responsibility is another area that involves boundaries and limits. The locus of responsibility for achieving treatment goals or even remaining alive may seem obvious, but it often becomes quite unclear in the roller coaster ride of the therapy of severely traumatized patients. It is a common experience for therapists who begin treating an abuse survivor to find that the direction of the therapy shifts dramatically after only a few months. For example, the therapy may begin with some general agreement that the work is to improve the quality of patients’ life. However, therapists may soon find themselves in the position of attempting to convince the patient to remain in therapy or not to suicide. Clearly, some major change has occurred in the therapy. Understanding this change involves recognition of the conflicts and profound ambivalence of abuse survivors.

Abuse survivors are exposed to experiences that lead to internal psychological conflict in almost every major aspect of their lives. The intensity and circumstances of the childhood abuse leads to these seemingly irreconcilable psychological conflicts. For example, the child who is sexually abused by a parent often carries the incompatible feelings of “I love my father” and “I hate my father.” The intensity of these intrapsychic conflicts leads to the use of dissociative defenses, so that the conflicted feelings can be repressed and forgotten, or even apportioned into different parts of the self as in the case of patients with DID. As discussed previously in Chapter 7, abuse survivors are also conflicted concerning self-harm. In fact, they have deeply ambivalent feelings about virtually all major issues in their lives: I am worthwhile/I am worthless, I was abused/the abuse never happened, I was loved/I was hated and exploited, I was powerless and victimized/the abuse was my fault, I can have a life/I’ll never have anything, I want therapy/I’m afraid of therapy, I trust my therapist/I’m afraid of my therapist, and so on. These sorts of ambivalent feelings and beliefs are unbearably painful. Particularly when overwhelmed, it is only human for patients to ignore one side of their ambivalence.

Therapists may find themselves assuming one side of the ambivalent feelings—usually the therapeutic side. This dynamic can occur in multiple arenas resulting in the responsibility for finding solutions to impossible dilemmas being assumed by the therapist: how to or even whether to function, whether to remain alive, and even whether to continue in therapy at all, among others. Unfortunately, this dynamic allows patients to be unambivalently negative about these complex issues. The shift of therapeutic responsibility results in the therapist being placed in an untenable therapeutic position. Therapists and patients find themselves battling over these conflicts (some of which involve actual survival) rather than recognizing them as the projections of patients’ intrapsychic dilemmas. Among the untoward effects of such situations are the therapist assuming additional burdens, the patient failing to grapple with critical internal conflicts, and a foundering of the therapeutic process, as illustrated in the following example:

Barbara, a woman in her late 40s, entered therapy to deal with emerging depression, hopelessness, and isolation. Despite having difficulties with coping and almost no close friends or other interpersonal supports, she took pride in having held down a good job and having functioned at a high level. However, with the retirement of her boss, Barbara felt inexplicably betrayed. She began to increasingly dwell on the emptiness in her life and her failed marriage, and to vividly recall details of a very neglectful and abusive childhood. She began to abuse alcohol on a regular basis, often becoming more depressed and calling her therapist at night for comfort and reassurance. These calls were initially brief and helpful. However, over time the calls became more frequent and less productive as she became more depressed and seriously thought about suicide. She began to push the idea of confronting her parents concerning their maltreatment of her, feeling that if they apologized that she would somehow feel healed from the aftereffects of their neglect and abuse. When her therapist pointed out the dangers of such a course of action, Barbara accused him of being overprotective. Predictably, when she convinced him to call her parents to invite them to a family meeting, they refused, plunging Barbara into more despair.

The therapist became progressively more frantic, redoubling his efforts to help Barbara move forward in her treatment. He reminded her of her past accomplishments and considerable strengths but to no avail. Barbara began to talk about quitting therapy, as she could not bear to hurt the therapist by killing herself while being treated by him. Finally, after she was found unconscious by her ex-husband after ingesting excessive amounts of tranquilizers and alcohol, she was hospitalized. The therapist was able to use the hospital staff as consultants for his dilemma. After perceiving how he was carrying the entire impetus for Barbara’s treatment, he was able to approach her to renegotiate the treatment contract, saying, “I feel as though you and I have found ourselves struggling about a whole host of issues that primarily reflect your mixed feelings about them. Although I want you to stay in therapy and live, my feelings don’t really matter. You have to make the commitment to cope with these issues, and not depend on me to provide you with the reasons to go on. If we are to continue to work together, you will have to decide that you are willing to wrestle with the issues of your own welfare, learning ways to cope instead of expecting me to always be there to convince you to live.” After prolonged discussion, Barbara was able to commit to certain safety measures, including abstinence from alcohol and taking on the responsibility of working out a crisis plan. Much later on in her treatment, she was able to recognize how much she wanted the therapist to be the encouraging father she longed for and to take over and manage the burdens of her life.

Therapists need to encourage and help abuse survivors to carry the weight of their conflicts. It is not that therapists should avoid making their own stances clear (e.g., about suicide or the value of treatment), but they should help patients take on the responsibility of grappling with these issues rather than projecting them onto the patient-therapist relationship. Interventions regarding therapeutic responsibility need to be made with empathy and sensitivity, as it is all too easy for therapists to use the issue of responsibility punitively and to effectively abandon patients. Even the phase, “You need to take responsibility for . . .” can feel like a verbal cudgel if said accusingly or reproachfully. After all, these difficulties are often caused by the immense psychological distress of conflictual feelings and not knowing how to cope with them, not by lack of motivation or weak moral fiber. Therapists should demonstrate that they understand patients’ dilemmas and offer their assistance in trying to work out conflicts (e.g., “I know that you have very mixed feelings about therapy. I would like to help understand both your hopes and fears about therapy rather than your feeling that I am ‘making’ you attend therapy.”).

Obviously, the principle of expecting patients to assume primary responsibility for their lives and treatment does not extend to emergency situations where patients are acutely at risk of suicide or possible serious self-harm. In particular, confrontation concerning ambivalence about personal safety should not be made during emergency telephone contacts. In such circumstances, clinicians must do whatever is necessary for the patient’s safety and welfare (e.g., hospitalization). Once safety is assured, the issue can then be directly addressed in subsequent face-to-face meetings. In fact, therapeutic responsibility should be the primary issue discussed until some resolution is reached.

Another area of therapeutic responsibility that abuse survivors often have difficulty maintaining concerns basic interpersonal relatedness. Abuse survivors often have histories of being exploited and blamed. This difficulty may be recapitulated in the therapy, as such patients may have little understanding of their personal responsibility in the therapeutic relationship and may exploit and blame their therapists for any difficulties they encounter. Compounding this circumstance is the valid therapeutic view that the therapy is primarily for the patient’s benefit, and the therapist’s needs should only minimally interfere with the process. As a result, therapists may fail to set limits on behaviors that are not acceptable as a part of any workable interpersonal relationship, overlooking the need for patients to appropriately control their responses and interactions. Patients should recognize that they must share the commitment to the relationship and to the therapeutic process, the commitment to try to resolve interpersonal difficulties, and the commitment to maintain shared therapeutic goals. The following example illustrates this issue:

I was consulted by Dr. J. concerning a crisis in her treatment of Patty, a 44-year-old single woman with an extensive early abuse history. After three years of therapy, Patty began to despair of ever achieving closeness with others. Despite considerable gains in self-care and vocational matters, she still experienced intense fear when trying to make friends or function in social situations. In therapy she became increasingly angry, until virtually every session was a combination of stony silence and diatribes about the inadequacies of the therapist and the therapy: “I don’t know what you expect of me. You have a life and a husband and a baby and house. I have nothing! I hate you for that! You think this therapy is so great. What has it done for me? My life is over. I’m in a lot of pain and I have to pay attention to giving myself the relief that I need. You think I should continue to live but you don’t have to live my life! You just want me to go on suffering. Well, see if you can stop me. I can kill myself whenever I choose!”

Dr J. tolerated Patty’s anger for many sessions. She recalled that during a period of her own personal therapy she had been quite angry at her therapist, and that expressing this anger had allowed her to eventually achieve important insights on how she had felt unheard by her parents. However, Patty’s angry attacks seemed to only intensify and not to result in any new insights or gains. After hearing the story, I observed that the patient was caught up in a functionally psychotic transference. That is, she had lost the ability to understand that Dr. J. was not actually the source of her difficulties (unlike Dr. J.’s experience in her own therapy where she was aware that her therapist was fundamentally helpful). Patty was so consumed by her rage that she was effectively destroying the therapy. I made several suggestions about setting limits on the patient’s behavior, essentially about finding empathic and supportive ways to say, “Cut it out.”

Dr. J. subsequently was able to say to Patty: “I understand that you are truly tortured. However, I cannot allow you to continue to attack me. I think you have forgotten that I have spent years trying to help you and that I am not your enemy. Even though you feel tormented, you still are in a relationship with me, and we both have a responsibility for maintaining our relationship. You have frequently asked me not to abandon you. You now seem to be saying that you have the right to destroy and abandon our relationship. We cannot have a workable therapy if I’m constantly on the defensive or terrified that you might kill yourself.” Patty responded with genuine surprise, saying, “I didn’t know therapists had feelings!” She managed to control her attacks (initially with reluctance) and was later able to examine how she repeatedly found herself angrily challenging persons in her life with whom she felt the most vulnerable.

One other issue involving therapeutic responsibility has arisen as attitudes have shifted from widespread disbelief about patients’ reports of childhood abuse to sometimes too-easy acceptance of any such reports. Patients have sometimes asked therapists to validate or deny the reality of their past abuse when patients do not have adequate information to make such a determination. It seems quite appropriate for a therapist to acknowledge or even raise the issue of abuse when the history seems relatively clear, but given the vagaries concerning the nature of traumatic memory, it is difficult to respond to all inquires of “Do you believe me?” In situations where patients are uncertain about the reality of past events or when memories are clearly not credible, therapists should respond to these inquiries by acknowledging only the painfulness of uncertainty and being able to know the realities of what actually happened. Patients and therapists together should assume the responsibility of sifting through known facts, possible occurrences, fantasies, and conjectures until such time as patients can be reasonably clear about their own personal realities. See Chapter 5 for a more detailed discussion of this complex issue.

THE MODEL OF EMPATHIC CONFRONTATION1

Patients with trauma-based disorders frequently have worthwhile ideas concerning the course of their therapy, guided by a kind of internal roadmap. However, as discussed throughout this book, it is also common for patients to advocate unwise treatment strategies or to cling to very dysfunctional but ingrained behaviors. For example, patients may vigorously advocate for premature abreactive work without having established the psychotherapeutic foundations for safe exploration. Similarly, patients may insist that they have no control over their posttraumatic and dissociative symptoms, may persist in self-destructive, revictimizing, or risk-taking behavior, or may demand inordinate therapist availability and reassurance that result in boundary violations. When such issues emerge in psychotherapy, patients often manifest extraordinary resistance to change. After all, many of the dysfunctional patterns of behavior have long served as coping mechanisms, and no matter how unpleasant, are more familiar than the well-intentioned but unknown treatment course advocated by therapists.

Setting limits on patients’ dysfunctional behavior involves confrontation and is often an extremely difficult task. Patients with severe childhood abuse and a lifetime’s experience of abandonment and betrayal may have a tenuous sense of alliance with their therapists. Hence, therapists often hesitate to confront patients even with important therapeutic issues because they fear patients’ likely reactions of withdrawal, anger, and regressive and self-destructive behavior. However, confrontation of unsafe and/or dysfunctional patterns must be a part of the therapy, not only to guide the therapy in a positive direction, but also to prevent the therapist from becoming an unwitting enabler of continued destructive behavior.

Confrontation in psychotherapy has a long tradition of being an important part of psychodynamic treatment—to clarify resistances in therapy and to facilitate change (see, for example, Greenson, 1967; Mann, 1973; Myerson, 1973). Written in an era before acceptance of trauma as an important common etiology of adult psychopathology, two papers by two of my former teachers and supervisors—noted psychoanalysts Daniel Buie, MD, and Gerald Adler, MD—described the uses and misuses of confrontation in the treatment of borderline patients (Adler & Buie, 1972; Buie & Adler, 1972). These papers are still highly applicable to work with some traumatized patients. For example, confrontation was seen as sometimes necessary to help patients recognize “(1) the real danger in certain relationships; (2) the real danger in action used as a defense mechanism; and (3) the real danger in action used for discharge of impulses and feelings” (Buie & Adler, 1972, p. 101). The authors felt that confrontation of patients’ denial allows the therapist “(1) to help the patient become aware of his impulses, so that he need not be subject to action without warning; (2) to help him gain temporary relief through abreaction; and (3) to help him gain a rational position from which he can exert self-control or seek help in maintaining control” (Buie & Adler, 1972, p. 103). In discussing the misuses of confrontation, the authors stressed patients’ vulnerability to harm from confrontation caused by their propensity to feel abandoned, their intense impulses and inadequate defenses, and their tenuous capacity to form a working alliance. They noted that the therapist can misuse confrontation caused by countertransference “rage and envy when he feels he must rescue his helpless, demanding patient and then finds his efforts met by increasing demands and regression” (Adler & Buie, 1972, p. 109).

Many of the observations noted here are surprisingly apt in the context of the sometimes decidedly nonpsychoanalytic treatment of survivors of childhood abuse. However, it is a normative experience that clinicians find it difficult to implement confrontation in the psychotherapy of patients with severe childhood abuse. The need for confrontation may be obvious, such as danger to the patient, therapist, or therapeutic relationship, or behaviors that are out of control or sabotage the therapy. Although most persons find confrontation and conflict uncomfortable, therapists may be extremely reluctant to confront patients either because of countertransference difficulties (Chu, 1992a; Comstock, 1991) or the simple concern that confrontation will be misunderstood and make patients feel abandoned and betrayed. In fact, therapeutic confrontations are almost always initially misunderstood, but patience in reiterating concern for the patient and for the therapy often allows the confrontation to eventually be heard and understood as intended. I have proposed a model of empathic confrontation that offers a way of intervening that is effective in helping patients ally with therapists in a direction that is positive and therapeutically sound.

When making a confrontation, the demonstration of empathy for the patient’s position is absolutely essential. With survivors of extensive childhood trauma, particularly early in the therapeutic process, it should never be assumed that firm therapeutic alliance exists. Early in treatment, patients experience a sense of disconnection routinely between sessions, and sometimes repetitively within sessions, especially when there is a sense of disagreement between the patient and therapist. Feeling disconnected, patients sometimes actively push away a dangerous sense of vulnerable intimacy and retreat to views of the therapist as threatening or abusive. Thus, if no connection is established immediately prior to making a confrontation, the patient is compelled to hear the intervention as simply an attempt of the therapist to control, abuse, exploit, or deprive the patient.

The model of empathic confrontation is based on the need to establish empathic resonance as a part of making a confrontation or other intervention that is painful to the patient (Chu, 1992a). That is, it is crucial to reestablish some sense of alliance before saying something that has the potential for making the patient feeling attacked, defensive, guilty, or shamed. In practical terms, empathic confrontation often takes the form of a statement in two parts. The first part strongly communicates that the therapist understands the patient’s position, feelings, and experience. This can often be done in a few sentences. The second part (often connected to the first part by a “but” or “however”) contains the confrontation concerning the patient’s behavior. Two examples are illustrated here:

Kay, a 24-year-old woman who had been brutally sexually abused throughout much of her childhood, chronically cut herself on her arms and legs with a razor. She tended to cut herself whenever she was overwhelmed with feelings, particularly when angry or ashamed. Despite the urgings of her therapist, she continued to self-mutilate, claiming that she found the cutting helpful and that only her therapist found it objectionable. Moreover, Kay argued convincingly that the cutting was not intended to be lethal and that she had no other ways to cope with her feelings. Her therapist gently confronted her on this behavior, saying, “I understand that you don’t want to give up cutting yourself, and that the cutting has helped you survive. In fact, your cutting yourself has been an ingenious solution when you didn’t have anyone else to rely on. However, unless you begin to work together with me on this, you will not find other ways to deal with your feelings, and your therapy will not be successful.”

Kay responded by angrily accusing her therapist of trying to control her, to which the therapist responded, “I know that it has been crucial for you to have a sense of your own control in your life, especially when others have hurt you. I know you have often been controlled by other people, but I’m asking you to do something that will be helpful in your therapy, not to do something my way.” After some discussion, Kay was able to acknowledge the need to find a way to control her cutting and noted, “When people used to try to get me to stop, I always felt that they thought I was bad and didn’t want anything to do with me.”

Cheryl, a 35-year-old woman with DID, was hospitalized because of frequent flashbacks of horrendous childhood abuse. In the hospital she continued to be out of control, frequently having flashbacks late in the evening, during which she was so agitated that she needed to be physically restrained. When asked to control her behavior she angrily claimed to have no control over the flashbacks, and, in fact, didn’t remember them since she, Cheryl, wasn’t “out.” Her therapist said, “I know that it feels as though the flashbacks just take over and that you have no control. I also understand that you feel very separate from the other parts of you that were out of control. I know it is a core issue of your difficulties to feel alienated from the other parts of you. However, unless you can work very hard with me to begin to establish some control, and to communicate with your other parts, the therapy will not work, and neither I nor the hospital will be able to help you.” After a period of angry denial, Cheryl was observed to be exercising extraordinary efforts to maintain control, pace the therapy, and promote internal communication.

The work with adult survivors of severe childhood abuse can sometimes be extremely challenging. It is crucial that therapists maintain attitudes that are empathic but also based on solid psychotherapeutic tenets, such as maintaining a solid treatment frame and confronting patients’ dysfunctional behaviors. I formulated my model of empathic confrontation on the work of a pioneer in the treatment of patients with DID, the late David Caul, MD (see Chu, 1992a, for more examples of his work), who once wrote:

The therapist should be willing to exhibit appropriate respect for the patient… —respect, not indulgence. Respect does not preclude firmness and insistence on working together for progress. Respect does not preclude normal differences in feelings of the therapist with recognition that a wide variety of feelings toward the therapist will be forthcoming, especially early in therapy.… There has to be an element of cooperation that is woven as a thread throughout the course of therapy. The fact that a patient keeps coming back for sessions may be the main indication (even if unspoken) of cooperation by the patient. The therapist should always be willing to listen and accept suggestions and workable ideas. Sometimes it is difficult for a therapist to acknowledge the exquisitely sensitive nature of this “two-way street.” Continue to emphasize the fact that productive therapy will require some sort of partnership between the parties.… The therapist should be able to distinguish between candor and sometimes cruel hostility. Remember that these people are very sensitive and very vulnerable. I suppose candor might be described as being truthful in addition to being caring, considerate, and concerned. The therapist should not be afraid to appropriately admit that there are difficulties in the treatment and should attempt to openly discuss them. All attempts should be made to do this in a positive way and to relate it to the therapy, and not direct it toward the patient.… It will remain for the therapist to use whatever energies there are toward good judgment and careful consideration in providing therapy for this phenomenon that is of such magnitude that it will require all the help that we can get. (Chu, 1992a, pp. 101–102).

1 Portions of this section were adapted from the article, “Empathic Confrontation in the Treatment of Childhood Abuse Survivors, Including a Tribute to the Legacy of Dr. David Caul” (Chu, 1992a).