THE CAPACITY TO TOLERATE AMBIVALENCE
by Martha Stark, MD / Faculty, Harvard Medical School
I present now another vignette that speaks to the distinction between an empathic response and an authentic response and highlights the importance of the therapist’s capacity to work through her countertransference in order to get to a place of being able to offer the patient an analytically useful intervention.
Kathy has been involved with Jim, a man who appears to be very attached to her but, nonetheless, periodically has affairs with other women. It is always devastating for Kathy when she finds out, but each time Jim resolves to do better in the future and Kathy takes him back.
One day, however, Kathy discovers that Jim has had a one-night stand with someone she had considered to be her best friend. To her therapist, she reports her outrage that Jim would be doing this to her – yet again and with her best friend! Kathy tells her therapist that the relationship with Jim is definitely over.
The therapist is easily able to be empathic with how Kathy feels.
But it is much harder for the therapist to empathize when Kathy comes to the next session with a report that she and Jim have had a good talk and have reconciled; Kathy explains that Jim is beginning to see that he has a problem and has promised to get himself into therapy. Jim has told her that he feels awful about having done what he did and begs her forgiveness.
The therapist, knowing that this is neither the first time Jim has promised to get himself into therapy nor the first time Jim has promised things will change, finds herself feeling skeptical; she is also aware of feeling horrified that Kathy would actually be willing to give Jim yet another chance! To herself the therapist thinks, "Heavens, when is Kathy going to get it!? Jim is never going to give her what she wants. Why can't Kathy just let him go!?"
The therapist considers the possibility of sharing with Kathy some of her sentiments (or, at least, a modified version of them); she decides, however, that for now her feelings are so raw and so unprocessed that she does not really trust herself to say something that would be therapeutically useful to Kathy, something that would further the therapeutic endeavor.
And so the therapist decides to respond more empathically to Kathy by trying, as best she can, to decenter from her own feelings of outrage at Jim's provocative behavior and of horror at Kathy's refusal to confront that reality. The therapist therefore offers Kathy the following: "You are outraged and devastated by what Jim has done but want very much to believe that this time Jim has finally understood that his behavior is unacceptable. You are encouraged by his decision to enter therapy, and you are thinking that he is finally beginning to take some responsibility for his actions."
Clearly feeling understood and supported by the therapist's empathic recognition of where she is, Kathy responds with, "Jim makes me feel loved in a way that I have never before felt loved. He makes me feel very special, and that means a lot to me." Later, Kathy goes on to admit, "I do know that Jim could always do it again. He has done it many times in the past. But I guess I need to believe that this time he will come through for me. This time it will be different."
The therapist's empathic response creates a space for Kathy within which she can feel safe enough, and nondefensive enough, that she can delve more deeply into acknowledging her need for Jim – that is, Kathy elaborates upon the positive side of her ambivalence about Jim. Later, she is able to get in touch with the negative side of that ambivalence, which she must be able to do if she is ultimately to work through her conflictedness about Jim.
In other words, for Kathy to be able, in time, to let go of Jim, she must come to understand both the gain (that is, what investment she has in staying with Jim) and the pain (that is, what price she pays for refusing to let go). In order to understand the gain, Kathy must be given the space to elaborate upon the positive side of her ambivalence about Jim; in order to understand the pain, Kathy must get to a place of being able to recognize, and take ownership of, the negative side of her ambivalence about Jim.
The therapist's empathic response frees Kathy up to talk about how it serves her to be with Jim; once Kathy has had an opportunity to do this, she is then able, of her own accord and at her own pace, to let herself remember just how painful the relationship has been for her.
Now had the therapist, instead of being empathic, been able to process her own feelings of outrage and horror a little more quickly, she might, alternatively, have used aspects of this experience to offer Kathy the following: "On the one hand I find myself feeling horrified that you would be willing to give Jim yet another chance (given how much he has hurt you), but then I think about how important it is for you to be able to feel loved (because of how unloved you always felt by your father) – and I think I begin to understand better why you might be willing to give him one more chance."
The therapist, by bringing together both sides of her own ambivalent response to Kathy, is here offering herself as a container for Kathy's disavowed conflictedness. Although, in the moment, Kathy might have lost sight of the negative side of her ambivalence, the therapist is remembering and carrying (on Kathy's behalf) both sides of the ambivalence.
The Therapist Has Capacity Where the Patient Has Need
We would say of the therapist that she has capacity where Kathy has need – the therapist has the capacity to sit with and to hold in mind simultaneously both sides of her ambivalence, whereas Kathy, in the moment, would seem to have the capacity to remember only the positive side of her ambivalence and the need not to remember the negative side.
The therapist's capacity to tolerate what the patient finds intolerable is the hallmark of a successful projective identification. The therapist takes on Kathy's conflict and, after processing it psychologically, makes a modified version of it available to Kathy for re-internalization. In time, Kathy may well be able herself to acknowledge simultaneously both sides of her conflictedness – that is, both the gain and the pain.