Wednesday, December 29, 2010

Parasitism as Psychotherapy

There is a lot of literature and professional discourse in the area of transference and counter-transference.  It is a staple of clinical supervision and represents some core concepts relevant to quite a few therapeutic models.  Anyone providing, or claiming to provide, psychotherapy must be aware of, and have at least a modicum of training on these core concepts.

So, why is it then, in the public mental health system, there is so much confusion and ignorance on such basic concepts?  Is it because graduate counseling and social work schools are vocational factory farms intended to get people in, take their money, then move ‘em out with their rubber stamp degrees?  Is it because the public mental health system attracts mediocre and failed therapists (I don’t think so because private therapists are hardly any better)?  Is it because of the confusing eclectic din of contradictory theories and “evidence based” practices that make it impossible for directors, clinical supervisors, and therapists alike to develop any kind of coherent vision of what they are doing?  Is it simply due to lack of oversight and supervision that individual professionals gradually drift into their own personal comfort zones, un-self-aware, and motivated by their own emotional needs?

Do I sound too harsh a critic?

I see it every single day in the field.  Every day.  The same dramas get played out endlessly with every possible variation, yet always the same.  The client with the borderline personality or complex PTSD or dysfunctional patterns of meeting their needs, whatever you want to label it, it plays out the same anyway.

On the one hand you have professionals who are frustrated at being manipulated and lied to by their client; cynical at dealing with clients who have no interest in working on their  issues or getting better but seem to only want to suck as much as they can out of the mental health system; and angry at colleagues who blame them while covering up, making excuses, and enabling the client’s manipulations and anti-social behaviors.

On the other hand you have professionals who, with great self-importance, take up the cause of these poor misunderstood individuals.  Somehow these professionals develop a shameless belief in their own “special” ability to connect and understand.  They quickly conclude and profess that all the client’s problems stem from the negative judgments of others, including judgmental mental health professionals.  They seem to believe that the “cure” is to empathize and sympathize with their client, while never questioning their client’s beliefs or behaviors.

I have news for you.  If you find yourself falling into one of these camps, you need to stop what you are doing and step back to find some objectivity.  Psych 101:  if you are emotionally enmeshed or reacting strongly to your client, you are not going to be able to provide any kind of real therapy.  And that is exactly how it plays out.  Clients who get this kind of dual reaction/enmeshment treatment don’t get better.  The reactors just play out the role of perpetrator, thus reinforcing the client’s belief in their own victimhood and allowing the client to dodge any responsibility for their own behavior.  The enablers do just that, they cover up for their client and enable them to continue with their dysfunction.

The enmeshed enablers are probably the worst of the two, simply because they will continue the “therapeutic” relationship for years and years and years regardless of the complete lack of progress.  What develops is a sort of emotionally symbiotic parasitism that’s paid for by Medicaid.

On the one side of the symbiotic relationship is a client whose dysfunction has led them to get all of their emotional needs met through therapy and the mental health system.  In other words, therapy is an end in itself.  The negative and positive relationships they develop with professionals feeds their emotional need for drama and attention and emotional enmeshment.  There is no desire for actual improvement.

On the reverse side of the symbiotic relationship is a professional who is hungry for attention and recognition and a feeling of efficacy.  As long as the therapist stays on the client’s good side by joining them in their denials, rationalizations, and reification of their victimhood, the client will return the favor by singing the therapist’s praises and generally playing to their ego.  The bigger the ego of the therapist, the more susceptible to this they seem to be.  These arrogant professionals believe they are somehow immune to counter-transference and ignore clinical best practices.  The result is they feed their client’s pathology without end and seem to be oblivious to the fact that their client never gets better.  It doesn’t seem to matter because both client and professional are getting their emotional needs met by the relationship and Medicaid pays for it all without question.

There does not seem to be any end in sight to this pattern.  It has been a major problem in the mental health system since it was first identified in the mid 20th Century.  But in spite of the mountain of literature and treatment guidelines, professionals continue to make the same mistakes time and time again.  How can a therapist help a client face their hard-to-face issues when the therapist isn’t willing or able to face their own issues and seriously look at how their counter-transference impacts their efficacy?


  1. Seen this all too often.The therapy never stops. No guidelines or target dates for completely the therapeutic goals are ever set.

    New name for it: Supportive Counseling.

  2. As I consumer, I bought this fiction that a parent-child relationship with my therapist magically would be healing. Instead that relationship led me into the habit of capitalizing on wounds as cry sessions, rewarded with love and solace from my therapist. Talk about wrongheaded!

    Now I feel conned, as if I purchased snake-oil at the carnival.

    Thanks for this blog and questioning some widespread fallacies in the therapy.

  3. Thanks for this post. I agree that the asymmetrical/parasitic structure of therapy relationships is the source of much harm.

  4. Well done. This captures my experiences in therapy fairly well. And in reading therapy forums and blogs where others give accounts of their therapy, seems much of this dysfunction is the norm. At the core of therapy is the relationship, and this relationships rests on a foundation of unexamined assumptions, toxic power dynamics, and denials and delusions. The biz won't look at this, and seeks to explain away harmful therapy via client blaming, or failing that the one bad apple therapist trope.