Narcissistic issues and rescue fantasies
Clinicians enter the health field to help others and derive satisfaction from so doing. They have a sense of their own helpfulness and competence. However, these laudable attitudes may go astray into pathological narcissism and rescue fantasies. Informed consent represents the core of therapeutic work and should stand clearly at the outset.
The patient in the case refused to permit her previous records to enter into the treatment. A patient’s refusal to grant permission to obtain past records (or, at a minimum, to speak to the previous treater) should trigger active discussion of this matter. It may ultimately be a deal breaker to continuation of treatment, especially when the patient calls attention to problems in previous treatment. Many ominous pitfalls and therapeutic errors or impasses may be revealed by the records of, or remarks about, even failed previous treatments. Of course, great difficulty may attend locating previous treaters and obtaining records, assuming they kept records.
Grandiose and possibly counterphobic attitudes led Dr S to go ahead with treatment, despite being unable to obtain the patient’s past records. The expressed rescue fantasy (“I will save this patient”) and competitive strivings with devalued past treaters (“they failed, I will not”) also played a role in the decision. The narcissistic view that “I can treat anyone” is as erroneous as “anyone can be treated.”
The patient’s early idealizing transference was met with reciprocal self-idealization by the therapist. This reciprocity may create the so-called magic bubble,7 a conceptual sphere that begins with a mutual admiration society containing super-patient and wonder-doctor. The doctor then becomes impervious to consultation, supervision, good judgment, and common sense.
We can infer some dynamic conflict around countertransference-derived sadistic feelings in Dr S, who bends over backward, as it were, to avoid abandonment—even when responsible termination and referral would have avoided that form of malpractice, although that was not the patient’s subjective feeling about it. Consultee therapists often report fearing the anger of the patient if they were to suggest termination. The unneutralized rage of individuals with personality disorder has the apparent ability to intimidate even seasoned therapists.8
In addition to aggression, libido may play a role in delaying termination; gratifying erotic feelings and fantasies may account for the prolongation of some therapies beyond the appropriate point. A patient’s idealization of the therapist may have an erotic force.
A common precipitant to transference/countertransference problems is a personal crisis in the life of the therapist—for example, serious illness, divorce, or death of a loved one. Such stressors can easily weaken the therapist’s objectivity and ability to set limits early.9
You’ve gone this far . . . Some features in the case presented above are commonly encountered and merit particular focus. One is the “you’ve already gone this far . . .” approach, in which the patient points out that some boundaries have already been crossed and thus further transgressions are required or demanded. In this situation, therapist guilt about past boundary transgressions may be the driving force behind agreeing to continue. Conversely, threats of complaint about early boundary issues may frighten or coerce the treater into continuing or expanding the crossings.
Consultee clinicians encountering “you’ve gone this far” report a complementary reaction of “it’s too late to change.” In reality, it is never too late to change one’s approach and terminate and refer as indicated, although in fact that response may not avert unfortunate consequences. The distance gone “too far” all too often leads to very undesirable results.
Countertransference sadism. The ability to say “No” to a patient’s demands, knowing that this response will frustrate, anger, or hurt the feelings of the patient, requires that the treater be comfortable with sadistic feelings, since one will be causing pain to another. We suggest that the widely acknowledged decline in awareness and teaching of dynamic theory has left many therapists unfamiliar and uncomfortable with this common yet problematic countertransference response.
Issues of power and control may also explain difficulty in terminating. Some therapists may be reluctant to give up a position of power over the patient and thus continue to hold on.
Consultation phobia. A significant number of cases on which we have consulted reveal a highly disturbing unwillingness of the treater to obtain consultation, thus violating a sovereign principle of risk management, “never worry alone.” This reluctance empirically stems from 3 main sources: feelings of shame and guilt at what has already happened in the therapy; fear of reporting consequences (to Board or ethics committees) if the details are revealed; and, more regrettably, fear that the consultant will tell the therapist to get out of the relationship.
Failure to maintain termination. While flexibility and willingness to negotiate are hallmarks of good therapy, a necessary and indicated termination should be sustained, even against psychological and other pressures from the patient to retract it, replete with promises to change, as in the case example. Some patients may attempt to exert pressure on the present therapist by refusing to see subsequent therapists, although that is the patient’s choice. Consultation may be helpful in strengthening the treater’s resolve.
Documentation issues. Appropriate documentation is extremely important in the charged situations described, but our experience is that the record can cut two ways. Recording inappropriate behavior by the patient, and the patient’s failure to be able to remedy such behavior after ample time and assistance, can be extremely helpful in refuting claims of negligence or abandonment. Inclusion in the record of all letters and e-mails to and from the patient avoids the appearance of concealing potentially damaging materials. However, e-mails and letters from the therapist that display an inappropriate tone, excessive informality, hints of intimacy, and expressions of endearment are damaging rather than protective.
The need to finish. Even those therapists who are not highly compulsive may express an understandable wish to finish what they started: they resist the idea of terminating before the therapy is “completed.” This view acts as a strong deterrent to necessary termination.
The benefit of the doubt. Efforts should always be made first, in the service of informed consent, to negotiate an alliance-based, boundary-respecting therapeutic relationship. Clear explanations of professional limits should be freely given. Barring physical attack or serious threat by the patient, which may require abrupt cessation of therapy, most terminations should be discussed in advance, negotiated, and enacted in a professional process. A responsible termination with appropriate referral does not constitute abandonment.