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Come unstuck in therapy

Updated: Jan 27


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'People are trapped in history and history is trapped in them' - James Arthur Baldwin


This blog looks at how we come unstuck in psychological therapy. In particular, through adding to our reciprocal roles. Adopting a reciprocal role is a way to interact with other people. Reciprocal roles are roles which reinforce each other. In some situations this pairing creates a useful complementarity. If we want to stop change occurring and perpetuate a beneficial status quo. In other situations, reciprocal roles can perpetuate distressing patterns of relating. For example in purely sadomasochistic relationships. This blog details reciprocal roles, links them to common mental health problems and suggests practical changes therapists can make to shift roles.


How do reciprocal roles come about?


People develop a range of roles as a means to survive. In therapy, our initial preferences for interactions may suggest reciprocal roles. Alternatively, our role(s) may be unconscious. Bringing these into our awareness can help us examine their usefulness and consider if we want to add to them. As such some common reciprocal roles are listed below :

Role A

Role B

intellectualising

unthinking

emotional

unfeeling

hopeful

​hopeless

responsible

irresponsible

sadistic

masochistic

controlling

controlled

sad

angry

anxious

excited

seducing

seduced

disclosing

witholding

rejecting

rejected

selling

buying

parent

child

judging

judged

narcissist

acolyte

doer

done too

I suggest that, each role embodies only a part of a person. Allowing someone else to represent a different aspect for us. When paired together they may allow the two people to better cope with reality. So we get the lock of complementarity. This means they become harder to add to. We may appear phobic to the opposite role. Split off from a part of ourselves. In summary roles can over emphasise one aspect of reality and neglect another. A bit like a trauma reaction. Another way to understand problematic reciprocal roles is to look at how they may occur in common mental health problems.


Reciprocal roles in common mental health problems


Generalised anxiety - reciprocal roles which a) over or under value the benefits of worry b) focus exclusively on the future or past.


Social anxiety - reciprocal roles which a) differ in their fears of being authentic or causing offence b) people pleasing or finishing the session early, arriving late c) talking about other things d) acting as if we were incredibly fragile or inert e) seeing therapy as typical or wholly different experience of life.


Health anxiety - reciprocal roles which disagree about a) how desirable it is to accept uncertainty/mortality/vulnerability b) where expertise lies c) what is a realistic speed of change.


Grief - roles which contrast in their views of a) endings b) the period of our lives which is most salient c) marking the passing of time.


Depression - roles with a variety of approaches to a) experiencing sadness / anger b) status, education and/or income c) critical, shaming, demanding and/or punitive interactions versus helplessness or rescuing ones.


Anger - roles which disagree about a) the value of expressing sadness b) passive aggression or not saying if we are hurt by the other c) experiencing other feelings.


Paranoia - roles where there is a suspicion of motives or unquestioning interactions.


Violence - roles which include a) submission, masochism or a lack of boundaries b) a lack of explanation, abrupt interactions, non verbal communication c) rupture.


Medically unexplained symptoms - roles which vary in their a) experiences of uncertainty, control, confusion and anger b) feelings of exclusion, discrimination.

In the face of these reciprocal roles how could a therapist help?


Therapeutic responses


I think the job of a therapist is to create experiences useful to the client. Engaging in repeated, healthy and conscious interactions with reality. To me, this includes adding to the reciprocal roles we, consciously or unconsciously, take. In my experience the following habits are helpful to this process :

  • The client decides when they start and end therapy.

  • Communicating an expectation of honesty and that the patient will need things from the therapist.

  • Communicating that any therapy will only be partially successful. Holding realistic expectations of each other and sharing the responsibility for the process.

  • Opening each session with an invitation : 'What would you like to get from the session today and /or what would you like from me today?'

  • Offering the client choice about the level of structure, homework, silence, past/present/future focus, challenge, theory and /or practice in each session.

  • Co-creating a lawful, moral and rhythmic relationship.

  • Not placing myself between two significant relationships e.g. father and son.

  • Doing new things together e.g. taking turns in being vulnerable. In doing so add to our coping strategies.

  • Carefully articulating my immediate thoughts and feelings, as well as, more considered ones. Both provide different information. Sometimes saying nothing can be too ambiguous.

  • Noting what, and how much, is thought, talked about and emotionally experienced.

  • Paying attention to what is happening in my body as well as my mind.

  • Grounding myself, by slowing down, cleaning my glasses, drinking water, reducing my eye contact, facial expressions and saying what I am experiencing. Particularly when my emotions make it hard to think or my thoughts make it hard to feel.

  • Using my training and experience as a resource not an instruction manual.

  • Seeking regular feedback in multiple forms.

  • Witnessing, acknowledging and utilising breaks in the rhythm of therapy. In particular failures in responsiveness are acknowledged and repaired. Noticing what has gone unacknowledged in the clients experience.

  • Wondering how therapy might have re-enacted the harm the client experienced in the past? Saying 'I got that wrong, I am sorry and i wonder how that can be helpful for us both?'

  • Noticing what is not being thought, talked about or emotionally experienced. For example culturally taboo experiences like identity, sex, death, child abuse, incest, anger, violence and money. Before giving explicit permission to do so and modelling how this might be helpful.

  • Keeping an eye out for popular 'games people play' e.g. 'yes, but'; 'it's simple'; 'it's too good to be true'; 'if only' and / or 'why me.'

  • Sometimes allowing myself to be cared for as a precursor to people allowing me to care for them.

  • Identifying, and communicating, apparent similarities in early, and other, experiences. Like two children who compare their experiences (Ferenczi, 1995.)

  • Modelling that imperfect separate people can be loved and useful to each other. Integrating a memory of the other person to limit our capacity to damage ourselves and other people.

  • Reflecting on the session away from the session including through monthly clinical supervision. Identifying any possible dissociation. Sharing that reflection, demonstrating that the patient, and their experience, have a consistent place in our mind.

  • If desired by the client persisting when it is not clear how therapy can help.

I have learnt these good habits through twenty years of clinical practice. So I know being flexible, in response to the reality of each relationship, can help create therapeutic change. Avoiding a my way, or your way, battle. Instead communicating that both roles can be respected and added to.


These changes may be seen as diluting our experiences in therapy. I think this is no coincidence. In my experience, to work, therapy has to 'feel real but not too real.' This difference allows for play instead of just drama. So the interactions in therapy are consequential but without the usual consequences. All aiding the participants to tolerate a wider range of emotional experiences than outside therapy. Dilution for therapeutic effect (Benjamin, 2019.)


How to come unstuck in therapy


We have considered how we might come unstuck in therapy. Repeating patterns of relationships which have led to distress in the past. These reciprocal roles may be unconscious and pervasive on both sides. Bringing these possibilities into our awareness, recognising commons patterns, evaluating their usefulness to us and consciously shifting practise we when we seem stuck, can all help.


So, as I have said elsewhere, how many therapists' does it take to change a light bulb? Only one, but the therapist has to change first. The therapist changes first in order to facilitate a change for the customer. As a final graphical illustration, in this whiteboard video, I show how this process can work in a consultation (Perry, 2020.) I thank you for reading about my experience and I wonder about yours?


References

Benjamin, J. (2019, Apr, 1). Enactment and the theory of the third. Retrieved : https://www.youtube.com/watch?v=GA0dcQ13rt8&list=LLSr6fHMgXhGzrFJ1qwcKfJA&index=2&t=0s


Berne, E. (1968). Games people play: The psychology of human relationships (Vol. 2768). Penguin Uk.


Ferenczi, S., Dupont, J., Balint, M., & Jackson, N. Z. (1995). The clinical diary of Sándor Ferenczi. Harvard University Press.


Perry, A. (2020). A typical initial consultation, white board video. Retrieved : https://www.youtube.com/watch?v=sj7iek0lNYk


Ryle, A., Kellett, S., Hepple, J., & Calvert, R. (2014). Cognitive analytic therapy at 30. Advances in Psychiatric Treatment, 20(4), 258-268.


An earlier version of this article is available on my counselling directory page. See https://www.counselling-directory.org.uk/memberarticles/the-surprising-ways-you-can-come-unstuck-in-therapy

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