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Sunday, December 3, 2017

Mutual Enactments Between the Client and the Psychotherapist in Psychotherapy

In a prior article, Why Your Psychotherapist Can't Be Your Friend, I began a discussion about the roles of the psychotherapist and client in therapy, which included the concept of mutual enactments in therapy.  In this article, I will delve deeper into the concept of mutual enactments with a clinical vignette that illustrates these concepts.

Mutual Enactments Between the Client and the Psychotherapist in Psychotherapy

Before I go any further, I think it would be helpful to have a definition of "enactments" in the therapy setting.

Although there are various definitions for enactments, depending upon whether psychotherapists are Classical or contemporary Relational psychotherapists, I prefer the definition given by Fonya Lord Helm in a chapter, "Enactments Leading to Insight for Patient, Therapist and Supervisor" in Enactment: Toward a New Approach to the Therapeutic Relationship edited by Steven J. Ellman and Michael Moskowitz, which is:

"An enactment is any action occurring during the psychotherapy or psychoanalysis that repeats an earlier similar experience or fantasy and communicates feeling...by nonverbal means in a way that will draw the therapist or analyst into a nonverbal communication" (p. 157).

In the past, the term "acting out" was used instead of "enactments," and this usually referred to the client's impulsive and improper behavior.  Although the emphasis was on the client's acting out behavior, it's also generally understood that psychotherapists can act out as well.

The term "acting out" is used less these days because of its pejorative connotation and also because the behavior is viewed from the psychotherapist's perspective in the type of hierarchical therapy where the therapist is seen as being "neutral" and "abstinent" as opposed to a more contemporary relational view of mutuality between therapist and client.

The contemporary view of enactments is that they are generally unconscious on the part of both the psychotherapist and the client.

In the past, enactments were seen solely as "mistakes" in therapy.  Now enactments are viewed most by therapists as an unavoidable part of therapy.

Whereas the ideal is to strive for no (or few) enactments, from a practical and therapeutic perspective, the reality is that there will be enactments, whether they are big or small and, once they occur, the therapist can discuss these enactments to further the work.

Although the focus in this article is on enactments between psychotherapists and clients, it's important to understand that enactments occur in everyday relationships, including romantic relationships, familial relationships, friendships and work relationships.

At this point, in addition to the vignette I provided in the last article, the following vignette will shed light on this dynamic between therapists and clients.

Fictional Vignette:  Mutual Enactments Between the Client and the Psychotherapist in Psychotherapy:

Liz
Liz, who was in her mid-30s, started therapy because she had longstanding problems in romantic relationships.

Although she had no problems meeting men, her problems began once the relationship became serious because she had difficulty trusting men in intimate relationships.

Her lack of trust in these relationships would manifest in her insecurity and jealousy with Liz imagining that her boyfriend at the time was cheating on her--even when she had no objective reason to think this.

When Liz began to feel jealous and insecure, she had difficulty separating her feelings from facts (see my articles:  Overcoming the Insecurity and Jealousy That's Ruining Your Relationship and Discovering That Your Feelings Aren't Facts).

Instead of observing and exploring her feelings with her boyfriend, she behaved as if her feelings were true and accused him of cheating.  She was so caught up in her emotions that she had no awareness that she was projecting her feelings onto the situation.  As far as she was concerned, when she felt her boyfriend was cheating, it must be true.

The pattern was that she would feel overwhelmed with jealousy and insecurity, accuse her boyfriend of cheating, he would be genuinely shocked and then he would try to defend himself against these accusations.

But no amount of denial or proof would dissuade Liz of her convictions that her boyfriend was unfaithful to her.

The more her boyfriend denied cheating and showed her proof, for instance, that he was with male friends at a basketball game, the more convinced Liz was that her boyfriend was lying.  And if her boyfriend refused to respond to her accusations, she also saw that as proof that he was guilty of infidelity.  So, there was no way to resolve this problem.

This is an example of an enactment in an intimate relationship.  It has many of the same qualities as enactments in therapy, which I'll discuss later.

As would be expected, this dynamic tended to erode the positive aspects of the relationship and would soon doom the relationship.  Her then-boyfriend would accuse her of being jealous and controlling, and she was convinced that he was trying to turn the tables on her when he was really the guilty one.

After each relationship was over, Liz had some insight into the fact that her accusations were irrational and she would have regrets.  But, by that time, the situation had gotten so bad that her ex-boyfriend no longer wanted to hear from her--let alone resume the relationship.

Every time Liz began to a new relationship, she vowed to herself that she wouldn't ruin it by making baseless accusations of infidelity.  But when she became jealous and insecure, the feelings were so powerful that she would lose all perspective.

These unconscious feelings overpowered her.   Once these feelings dominated her, she believed them to be true until she was out of the relationship.

When she discussed these dynamics with her therapist, she expressed sincere regret for the heartache that she caused in her boyfriends and herself and a strong desire to stop this behavior.

Mutual Enactments Between the Client and Psychotherapist in Psychotherapy

Her therapist sensed that Liz's regret as well as her sorrow for destroying her relationships. Her therapist was aware that, since this dynamic was unconscious at the time when it occurred, Liz was unable to control it.  She was also aware that Liz lacked the objectivity as well as the verbal skills to address this in her relationship when she was overwhelmed by these feelings.

Her therapist recognized Liz's behavior in her relationships as being enactments.  She also knew that there would probably be enactments in the therapy, and she would need to try to be aware of as they occurred.

Since Liz had been in therapy before, Liz knew that her family history, which was chaotic and dysfunctional, contributed to her inability to sustain romantic relationships.  But knowing this did nothing for her in terms of her enactments in her relationships (see my article: Intellectual Insight Isn't Enough to Change Problems).

From Liz's perspective, her prior experiences with therapy were disappointing.  The pattern was that the therapy would go well at the beginning, and then Liz would realize that she didn't trust the therapist.

Since she was unable to communicate her feelings of mistrust directly to her prior therapists in the past, she aborted therapy without discussing it, and she didn't respond to their outreach calls or letters (see my article: When a Client Leaves Therapy Prematurely).  These abrupt endings to her therapy were also enactments on her part.

After hearing about her previous history in therapy, Liz's therapist was aware that Liz might end this therapy abruptly too if she developed negative feelings towards her (also known as the negative transference).

Her therapist also wondered how much the prior therapists contributed to these enactments because of their own frustration and negative feelings about these dynamics.  She was aware that she would need to be vigilant about her own feelings about their therapy (known as countertransference) to minimize her own unconscious contribution to mutual enactments.

During the first few months, therapy went well.  Liz showed up on time for all her therapy appointments, she was compliant with paying her fee on time, she reflected on their sessions between sessions, and she discussed her reflections at subsequent sessions.

Her therapist enjoyed working with Liz and looked forward to their sessions.  Liz was intelligent and articulate about the issues they discussed, and she even kept a journal between sessions to write down her thoughts (see my articles: The Benefits of Journal Writing Between Therapy Sessions and Journal Writing Helps Relieve Stress and Anxiety).

But a month before her therapist was due to go on vacation for two weeks and she mentioned that she would be away, her therapist noticed an abrupt change in Liz's demeanor.  Whereas normally, Liz was relaxed in session, immediately after her therapist told her about the break, Liz looked tense and suspicious.

Her therapist mentioned her vacation in a month's time at the beginning of the session because she wanted to allow time for them to discuss any feelings that Liz might have about the break.

Her therapist could see from the abrupt change in Liz's demeanor that Liz had a negative reaction to the upcoming break, but Liz refused to talk about it when her therapist asked her about it.

From her silence and refusal to talk, her therapist was aware that she was witnessing an enactment on Liz's part, and she hoped not to get caught in a mutual enactment.

Based on Liz's history of relational problems, her therapist knew that Liz's reaction was probably unconscious on her part and Liz lacked the necessary insight and communication skills to talk about her feelings rather than enacting them in her sullen, uncommunicative behavior.  She knew it would be useless to explain this to Liz at the moment because Liz wasn't receptive to hearing an explanation.

Her therapist was aware that she was on the horns of a dilemma:  Liz was unconsciously trying to control her in the session by not talking and trying to make her feel guilty about leaving Liz (similar to how Liz tried to control her relationships with her former boyfriends).

Her therapist was also aware that, similar to Liz's dynamics with her former boyfriends, if the therapist attempted to encourage Liz to discuss her feelings, Liz would resent her and view her with increased suspicions.  But if she remained silent, Liz would feel that was too emotionally depriving and interpret that to mean that her therapist didn't care.

Ether way, her therapist would be engaging in a mutual enactment so she would have to decide quickly in the moment which course of action would be least disruptive to the therapy and might result in furthering the work.

Her therapist decided to share her dilemma with Liz, "I can see that you have feelings about the upcoming break in our therapy sessions.  I'd like us to be able to talk about that, but just now when I encouraged you to talk, you've remained silent.  I feel myself on the horns of dilemma.  Just like the dynamics in your romantic relationships, on the one hand, if I encourage you to talk, you see that as further proof that I'm doing something wrong and I don't care about you. But if I remain silent, you see that as proof that your feelings aren't important to me and I don't care about you.  Either way, you think I don't care.  Can you see my dilemma?"

Listening to her therapist express her dilemma softened Liz a bit.  She seemed to relax a little, and she nodded her head as if she understood what her therapist meant.

In the past, her therapist had spoken to Liz about what happened to her when she became jealous of her boyfriends as her being caught in a "vortex" of overwhelming emotions.

This idea of being stuck in a vortex came to Liz's mind now, and she told her therapist that she wasn't sure what she was feeling, but she felt as if her emotions were overpowering her.

Recognizing her new ability to even verbalize that she was overwhelmed and caught up by powerful emotions in the here and now represented significant progress for Liz.

Her therapist asked Liz to describe the vortex to her and she said she hoped to be able to help Liz to step out of the vortex.

Liz described feeling like she was in a whirlwind of powerful emotions that threatened to overtake her.  She said it was like being in the middle of a storm and she described those feelings.

Her therapist pointed out that Liz's ability to describe this whirlwind meant that Liz wasn't completely caught up in it--part of her was somewhat objective and could step out of the storm, even if it was momentarily, to observe herself in the storm.

Liz gave a barely perceptible nod to indicate that she agreed that she sensed a shift in her--something she had never experienced in the past.  She was able to say that, she wasn't sure why, but she felt unhappy about her therapist's announcement that they would be taking a break for two weeks when her therapist went on vacation.

Although Liz was unhappy about the upcoming break, she was pleased that she had achieved some objectivity about herself and her feelings by being able to observe herself, and she attributed this to their work together so far and her therapist telling her about the dilemma.

In the sessions that followed, Liz and her therapist continued to deal with Liz's unhappiness about the upcoming break and how abandoned she would feel (see my article: Coping With Trauma: Becoming Aware of Your Emotional Triggers and Old Abandonment Issues Can Get Triggered When Your Psychotherapist is Away).

Gradually, Liz made tentative connections between her feelings about the upcoming break and her distrust of her parents, especially her father, whom she described as a "philanderer" and "a rolling stone" who often disappeared from the household for months at a time (see my article:  Reacting to the Present Based on Your Traumatic Experience of the PastUnderstanding Why You're Affected By Trauma From a Long Time Ago and Overcoming Trauma: When the Past is in the Present).

Liz also made connections between her feelings of abandonment with her boyfriends when she felt jealous and her feelings of abandonment with her father.

With the help of her therapist, she realized that in the past, on an unconscious level, she sabotaged her relationships because she feared being abandoned, and she would rather end the relationship herself than endure the pain of being left (see my articles: Fear of Abandonment: Leaving Your Relationship Because You're Afraid of Being Abandoned and Fear of Abandonment Can Occur Even in a Stable Relationship).

This realization led to Liz's recognition that, on an unconscious level, she behaved similarly with her therapists.  Her fear of being abandoned by her therapists resulted in mistrust and caused her to leave therapy abruptly.

Liz and her current therapist talked about the possibility that Liz might be tempted to leave this therapy, in much the same way that she left her prior therapies, when her therapist went on vacation.

In the past, Liz had never contemplated this possibility prior to leaving therapy.  Instead of talking about her fear of being abandoned by her therapists in the past, she enacted her fear instead by leaving.  Unconsciously, her fear caused her to leave them before they left her.

Liz told her therapist that she didn't want to leave this therapy, but she had a fear that her therapist might not come back.  She knew this fear was irrational, and she discussed this with her therapist, but the feelings were so strong, she didn't know how to keep them from overwhelming her.

Her therapist taught Liz some self soothing techniques to help her to take care of herself (see my article: Self Soothing Techniques to Use When You're Feeling Distressed).

She also encouraged Liz to continue to write in her journal between sessions to have a way to discharge some of these emotions.

In addition, prior to going on vacation for two weeks, her therapist gave Liz the name of a therapist who would be covering her cases in case Liz needed to talk during their two week break.  Then, they confirmed their next appointment in two weeks.

During the two week break, Liz struggled with her fears of abandonment.  She knew that the intensity of these feelings were triggered by her earlier experiences of being abandoned again and again by her father when he went to live with other women for months at a time.

But, even though she recognized the origin of her feelings, she still felt overwhelmed.  She thought about calling the therapist who was on-call while her therapist was away, but she didn't feel comfortable doing this.

Each day Liz's feelings about abandonment got stronger, and she wrote about her feelings in her journal.  She hoped the days would go quickly so she could talk to her therapist about these feelings when her therapist returned.

But on the day when Liz was supposed to return to therapy, she "forgot" to go to her session.  The day came and went without Liz realizing that she missed her appointment.

When Liz came in for her next therapy session, she and her therapist discussed why Liz missed her appointment, which was another enactment.

Liz recognized that she had unconsciously forgot her appointment because she was angry that her therapist was aware and she felt abandoned.

Being able to talk more comfortably about her feelings was further progress for Liz in therapy.

Mutual Enactments Between the Client and Psychotherapist in Psychotherapy

At that point, her therapist recommended that they begin work on the trauma that was being triggered in Liz's relationships and in her therapies, which was her family history, especially her history of being abandoned over and over by her father (see my articles: Healing Old Emotional Childhood Wounds That Are Affecting Current Relationships ).

Liz agreed that it was time that she dealt with the source of her problems.

Conclusion
In the clinical vignette above, both the psychotherapist and client engaged in mutual enactments in the therapy.

Even when the therapist anticipated that there would be enactments, based on Liz's history, she found herself in a dilemma in the therapy where an enactment would be inevitable, and shared her dilemma with the client.

When the therapist shared her dilemma with the client, the therapist attempted to make the unconscious conscious for Liz by putting the dilemma into words rather than just behavior.

Even though Liz wasn't able to discuss the dynamic at that point, she began to become aware of her feelings and how they affected her therapist and the therapy.  This was a major shift for Liz, who had never recognized these dynamics before.

Recognizing a mutual enactment won't necessarily prevent future mutual enactments, as illustrated in the above vignette.

The therapist was aware of the possibility that there would be probably be an enactment on Liz's part after the therapist came back from vacation.

Due of their professional training and their own psychoanalysis, most therapists are more aware of mutual enactments prior to their client's awareness.  But, being human, psychotherapist also engage in enactments from time to time, as illustrated in the vignette.

Many psychotherapists agree that it's not a matter of if they and their clients will occasionally get caught up in enactments--it's more a matter of when.

What's most important is how therapists use these enactments, after they have occurred, to shed light on the unconscious processes that are going on between the therapist and the client. The therapist can then use this new awareness to further the therapeutic work and help the client to make breakthroughs.

Getting Help in Therapy
Mutual enactments are common in relationships of all kinds.

When mutual enactments occur in personal relationships, the people in the relationship often don't have the wherewithal to make these unconscious dynamics conscious, so they continue to engage in enactments which can be damaging to the relationships.

When enactments occur in psychotherapy, they are usually related to the client's earlier personal history.

The behavior related to the enactment will continue to repeat itself until the therapist helps the client to become aware of the enactments and they work on the underlying issues instead of enacting them unconsciously.

If you realize that you continue to engage in destructive patterns in your relationships, you might be enacting unconscious behavior from the past.

Rather than continuing to behave in an unconscious way that has a negative impact on your relationships as well as your sense of self, you could benefit from working with a psychotherapist who is skilled in identifying and working through enactments, including mutual enactments (see my articles: The Benefits of Psychotherapy and How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individuals and couples (see my article: The Benefits of Integrative Psychotherapy).

I have helped many clients to learn to recognize unconscious feelings so they can discuss them and work through them in therapy rather than enacting them.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.


































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