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Ask the Mental Health Expert Archives 2001-2004

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Patient's Pretense

Q. It may be well documented that very positive therapeutic relationships can result in a patient acting out a diagnosis to please the therapist. How can a therapist or patient differentiate between purely pathological behavior and pathological behavior that is shaped by the patient's natural desire to be what the therapist thinks the patient is? What can a therapist do to avoid training patients to act out according to the therapist's beliefs about the patients' illness?

A. You are raising complex questions that go to the heart of such concepts as transference, counter-transference, and acting out. But first, let's distinguish between the normal, non-pathological wish to please one's therapist (or teacher, or parent, or clergyman for that matter), and the pathological need to do so, of which one may be quite unaware.

When psychologists and psychiatrists use the term "acting out" in its strict sense, they are referring to such unconscious needs, usually with the sense that these needs are interfering with the patient's progress in therapy and emotional maturation. I also would distinguish between-on the one hand--a therapist's quite understandable and even justifiable wish to see the patient change his or her behavior in healthy ways; and, on the other hand, a therapist's unconscious need to shape the patient according to some neurotically-held belief.

Let's take an example to clarify this. A therapist who provides cognitive-behavioral therapy (CBT) believes that most mental disturbances arise because of irrational or self-defeating ideas, rigidly held by the patient. (For details, see any of several books by Drs. Aaron Beck or Albert Ellis). Now, any such therapist will encourage the patient to adopt certain new ways of thinking and behaving, in order to progress emotionally. There is certainly an element of training involved in this process--but it is done consciously and knowingly by the therapist, and not out of some need to control or shape the patient in the therapist's own image.

Conversely, the patient may point with understandable pride to a new, healthy behavior he or she has just learned, with a desire to receive the approval of the therapist. This is just basic human nature--to seek and enjoy the respect and approval of others. It becomes pathological "acting out" only when the patient is unaware of the unconscious roots of this need to please, and when such acting out leads to undesirable interpersonal problems. For example, the patient finds himself buying expensive gifts for the therapist, week after week. The patient may rationalize this by saying, "I just want to show my appreciation for my therapist's help. What's wrong with that?" But an alert therapist may point out that the patient does the same thing with his wife and his boss--usually to avoid being yelled at, or when the patient feels guilty. This would be a form of "acting out".

Therapists who are well-trained are also alert to their own unconscious needs and impulses. That may sound paradoxical--if it's unconscious, how can one be alert to it? But it's not as contradictory as it sounds. A well-trained therapist is taught, for example, to question why he or she is behaving differently or oddly with a particular patient. Why, for example, does the therapist always extend the hour to an hour and a half, with Mr. or Ms. X, but not with any other patient? Why does the therapist offer Mr. or Ms. X a ride home, but never do so with any other patient?

By learning to systematically observe and question these behaviors, the therapist can--in most cases--avoid the trap you suggest in your question. If you want to learn more about these issues, you may enjoy the book Psychoanalytic Psychotherapy: Theory, Technique, Therapeutic Relationship, and Treatability by Thomas J., Paolino. I also deal with many of these issues in my book, A Consumer's Guide to Choosing the Right Psychotherapist.

January 2002

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