In talking with several American and Italian colleagues, sometimes I have had the impression that confrontations were considered a therapeutic tool which should not be used by clinicians working from a Control-Mastery Theory perspective. Or, along the same line, that the sense of safety that we should ensure for our patients prevents us ipso facto from using confrontations in our clinical work. Confrontations, in fact, may make the patient feel temporarily less safe when first received, but eventually they can enhance the patient’s sense of safety and lead to important therapeutic progress. In this brief post I will try to illustrate this point.
If we read carefully what Weiss (1993) writes about the analysts’ use of their authority with patients (ibidem, pp. 50-54), and in particular if we read the case of Geoffrey B. (ibidem, pp.51-52), it is clear that there are circumstances where confrontations are very useful, if not required. In the treatment of this man, the analyst “confronted repeatedly the patient with his self-destructiveness. However, the patient provocatively continued to be promiscuous. Finally, the analyst told Geoffrey that unless he stopped his promiscuity, he (the analyst) would discontinue the treatment”. And, as if he were rebutting the above mentioned misinterpretation of the safety principle, Weiss adds: “The patient became angry, wept, and berated the analyst for his failure to maintain an “analytic” attitude. However, rather than stopping treatment, he stopped being promiscuous. Also, he became more secure and more trusting in the analyst, and he retrieved several of his parents’ failures to protect him from self-destructive sexual behaviors” (ibidem).
From this brief example of a passed protection test, we can see how we must ensure our patients’ unconscious sense of safety, but this unconscious sense of safety can be sometimes reached only after a period when the patient feels anxiety, pain and rage, feelings which are common in the testing phases of therapy. The more reliable signs of greater safety felt by our patients, in fact, are not their conscious feelings of ease during the sessions, but their capacity to work towards reaching their goals, their ability to become more involved in the therapeutic work and relationship (for example remembering previously warded-off memories), and their testing the clinician more boldly (see also Weiss, 1993, pp.131-132). Finally, the case of Geoffrey B. told by Weiss also shows how the patient’s sense of safety can, in certain circumstances, be strengthened by a confrontative attitude.
When are confrontations useful?
On the basis of my clinical experience, I would say that confrontations may be useful when patients, because of their pathogenic beliefs and unconscious guilt, want to do or are doing something which is clearly self-destructive, or are avoiding doing something which would be clearly positive for them. And this is often true with severely traumatized patients and with patients who tend to act out.
When patients tell or show us that they are doing something self-destructive, they are generally testing our willingness and ability to protect them in the hopes of disconfirming the pathogenic belief that they do not deserve to be protected. In this situation, being confrontational means passing their protection tests. This occurs frequently with patients who suffer from addictions, substance abuse, sexual promiscuity, suicidality, severe anorexia, other self-destructive behaviors or behaviors which could put other people and the therapy at risk. In cases such as these, it is often necessary to put as a conditio sine qua non for starting or continuing therapy, that the patient will not act out these behaviors and, if needed, will complete a hospitalization or a recovery or detoxication program. About these points, the utmost firmness is often needed, together with a clear explanation of the reasons why these conditions are being put in place. The patient must be given every reassurance about the availability of the therapist to support the patient in dealing with and understanding her/his painful feelings and their origins.
One month after the beginning of her therapy, Rita, a patient who had been a poly-drug abuser and heroin addict, “decided” to quit her detoxication program because of the discomfort she felt due to the side effects of the drugs they were giving her. When she told me this, I urged her to continue her program and to talk with the medical director about these side effects. And I added that I would not continue to see her in therapy if she quit the program. During most of that session, Rita was very angry with me: she thought that I was not taking into account her point of view and her discomfort, and that I did not trust her enough. I stuck to my position, and the only positive thing Rita was able to find in my words was the possibility of negotiating with the medical director what could be done about the side effects of her meds. With her mother, this had always been impossible. At the end of the session, she accepted my conditions reluctantly. And when, six months later, she completed the detoxication program, she felt proud of herself and said to me “thank you for your firmness”. She thought that she did not deserve protection because her mother used to shout at her but never really protected her.
In other moments of her therapy, Rita posed protection tests mediated by a passive-into-active strategy. In other words, she could abruptly become as aggressive, devaluating, and contemptuous towards me as her mother had been with her. And even on some of these occasions, after more than one year of therapy, I had to be confrontational with her saying something like: “You cannot behave in this way here. Stop it. I am not going to stand these your-mother-like behaviors”.
Another variant of her passive-into-active testing me was her presenting herself as being in pain during the session and not using any of my communications and attitudes to feel better. In those moments, I could feel empathically her suffering, and at the same time I felt that she was somehow blaming me for it while I was put in a powerless position. At those times, typical of the second and third year of her therapy, the best way for me to help her overcome those states was to say: “If you want to keep on feeling so, it is up to you”. After these communications, Rita was in general relieved and started to talk with me about her mother making her feel guilty for her suffering without giving her any opportunity to relieve her mother’s suffering.
However, being confrontational may be useful also in circumstances which do not imply testing, or even in circumstances when confronting the patient may imply failing some test for the sake of protecting her/him in reality.
Consider the following examples:
Chiara, a patient in her twenties suffered for a strong self-hate. During a session she received a text message from one of her friends inviting her to come over and spend some time together. On one hand, Chiara wanted to go on with her session, but on the other hand she was so afraid that saying no to her friend would jeopardize the relationship that she was strongly tempted to leave the session and meet her friend. I showed her how that behavior derived from her pathogenic belief that no one truly loved her or was interested in her, and that in order to not lose the people she loved, she always had to comply with them. She agreed, but thought that this was really true in the case of that friend. So she told me that she wanted to leave the session to reach that friend. At that point, I said to her: “You do not have to go. If you leave, you will never find out if your fears are true or not, and I am sure they are not”. Chiara accepted my point of view, but I had to repeat what I thought several times, and then I reminded her of several situations in her past when she had renounced very important things in her life because she felt she needed to comply with the people she loved in order not to lose them. Chiara kept on being afraid for several hours that she was about to lose her friend. But when this girl phoned on the following day, she felt a deep sense of relief: she understood that she had been in the grip of a pathogenic belief.
In this case, I do not think that Chiara was testing me; she was simply acting according to one of her pathogenic beliefs. However, my confrontation helped her become aware of her pathogenic belief and helped her work on disproving it, and on many occasions she reminded me how useful it was that I told her not to go.
Serena, a patient in her thirties who had always lived with her parents and has so far been unable to complete her professional training, during the third year of her analysis was able to find an institute which would have enabled her to complete her degree in one year. Serena had changed high schools three different times, universities twice, and training institutes three times, each time for a different reason. A few months after she started her new training program, she said to me that she was thinking of moving to anther town because she could no longer stand the chaoticness of Rome. When she said this to me, she was clearly anxious and afraid that I would object to her resolution. I was aware that she was presenting a transference test of her separation guilt – the main reason why she had not been able to move from her parent house. However, I thought that it was more important that she complete her training and start to do the work she had studied for. In other words, I thought that her resolution had a very important self-punishment component deriving from her strong survivor guilt and triggered by the possibility of completing her training and starting to working. For this reason, and being aware that I was somehow failing her separation guilt test, I said to her: “I know that you are going to be upset by my words, but I think now it is very important that you complete your training and start to work. Your moving to this other city will create several difficulties in completing your program, so I think you should stay here. When you complete your training, you can go wherever you want. I am not saying this because of the therapy, we could go on via Skype. But it is time for you to complete your training”. She was as disappointed and angry as I had suspected she would be and left the session without a resolution.
After a couple of weeks, she had to go to that town for a different reason, and when she came back she said she had been quite disappointed by it. A few months later, Serena left her parents house and went to live with a friend. One year later she completed her training, and we were able to work through her survivor guilt more deeply.
David, a patient in his thirties who suffered from deep self-hatered, used to always follow the same pattern in relationships with women. He first took them out for wonderful dinners in the best restaurants of Rome. Then he tried to seduce them by being smart, nice and joyful. Then he spent the night with them and did his best to make them happy and to satisfy them. After some time of treating women this way, David started to feel tired and to run out of money. Being afraid that these girls would not have loved him if he showed his “normal self”, he stopped replying to their phone calls and text messages. When these girls then showed their disappointment and anger over his not responding to their communications, he saw their reaction as confirmation of his self-hatered and thought he was right in thinking that nobody could love him for who he really was.
After he told me several times about relationships which followed this pattern, I decided to say to him: “Look, the problem is not that you are a jerk or a despicable person, but that you act like a jerk and a despicable person. You do so because you are afraid that no girl would love you if she discovered how you really are, but the way you behave will always push girls to think that you are a jerk. Your “solution” is the problem, not your true nature. So, stop acting in this way!” David was interested in my words, took them into account and mused about them when he felt that he should “disappear” with a new girl. He continued to be afraid that it would have been worse to show who he really was. However, slowly but progressively, he started to reveal his true self to women.
To sum up, confrontations sometimes may be needed, but they have to be delivered within a warm and generally supportive therapeutic relationship; their aim should always be to protect patients, and they have to disconfirm some of the patients’ pathogenic beliefs. Finally, it is particularly important that the overall attitude of the therapist while confronting the patient be pro-plan – i.e. different from the attitude of traumatic caregivers and from the attitude that the patient had with her/his traumatic caregivers during her/his development.
Confrontations are sometimes needed, but they should be protective and always pro-plan, even if they may sometime fail some testing dimension of patients’ communications and behaviors.
Weiss, J. (1993), How psychotherapy works. Process and technique. New York, Guilford.
 Within this context, with confrontation I mean interventions delivered by therapists using all their authority and aimed at stopping or pushing the patient to do something.