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When Suggestible Patient Pleases Therapist (Conference Presentation)

Uploaded 11/6/2023, approx. 20 minute read

Dear colleagues, I am honored and delighted to be invited to deliver a keynote speech in our forthcoming conference in a few weeks. I've been asked to summarize my presentation and to provide it via video to the conference and this is what I'm doing.

My name is Sam Vaknin. I'm the author of Malignant Self-Love, Narcissism Revisited. I'm a former visiting professor of psychology in Southern Federal University in Russia. I'm currently a long-time member of the faculty of CIAPS, Commonwealth for International Advanced Professional Studies in Cambridge, United Kingdom, Toronto, Canada and with an outreach campus in Lagos, Nigeria.

I hope to meet some of you, those of you that I've come to know personally in previous conferences and others, make new friends and new associates and colleagues and those of you who have been with me in previous conferences know that my focus is on cluster B, personality disorders.

Now, personality disorders in general and especially Cluster B personality disorders share so many features that there is a substantial argument to unify them all into a single diagnosis, a personality disorder with various emphases or various overlays.

One of the clinical features shared by many personality disorders, borderline, histrionic, paranoid, schizotypal, etc., is suggestibility and suggestibility leads to the contamination, corruption and compromise of the process of therapy and in a variety of other clinical settings, including the diagnostic setting.

In short, suggestibility, also known colloquially online as people-pleasing, suggestibility renders the clinical therapeutic process suspect and is not to the benefit of the patient or client and not to the benefit of the therapist or the mental health practitioner.

Now, patients with personality disorders, they are for mentioned personality disorders, but not only with personality disorders, for example, patients with psychotic disorders, they pick up on subtle cues and signals emitted by the practitioner, by the therapist, by the psychologist, by the psychiatrist, by the licensed social worker. They pick up on these signals and then they respond to these signals by shape-shifting, by molding themselves, by modifying their behaviors, but not only their behaviors, their very cognitions and emotions to respond to the expectations, explicit or implicit, of the therapist or psychologist or psychiatrist.

These patients lose one identity and adopt another. It's a form of reactive identity disturbance, an identity disturbance that is attuned to environmental cues and responsive to them.

So if the psychiatrist, for example, is very interested in dissociative identity disorder, the patient is likely to imitate and emulate the syndrome. She is likely to elevate primary processes, unconscious processes, including defenses such as dissociation. She is likely to elevate them, afford them or accord them privileges over other primary processes and secondary processes, and then truly experience amnesia or depersonalization or derealization. She is likely to come up with a panoply or plethora of identities and even give them names. She is likely to report that she has memory gaps or memory lapses, etc. She is likely to mimic, emulate and imitate a person with dissociative identity disorder because she believes that this way she's going to please the practitioner. She's going to elicit from the practitioner attention, maybe even admiration at the very least interest and fascination.

It is a manipulative technique in many ways, but a lot of it is submerged in unconscious. It's just the wish to create a shared fantasy or a harmonious space where the patient merges, fuses with the therapist and becomes one with the practitioner, with the psychologist, with the psychiatrist. It's a way to reduce anxiety and to control aggression.

Patients with these kinds of personality disorders anticipate aggression because they often externalize aggression and often internalize aggression. They are depressive, they have eating disorders and so on because they are well acquainted with aggression. Aggression is an ingredient of daily life and a major component in their life.

These patients catastrophize. They anticipate aggression in the interaction with a mental health professional. To control this aggression, to channel it, to redirect it or to eliminate it altogether, to mitigate and ameliorate the anxiety attendant upon the catastrophizing. These patients play the game. They scan because these patients have cold empathy, narcissist for example, borderlines, histrionics. They scan the practitioner. They pick up on every cue, every signal, every expression, every utterance, every speech act, every word, every body language element, every micro expression, every facial expression. They pick up on everything. They're very attuned because these people have grown up in traumatic environments.

Most of these people experience adverse childhood experiences. These people have learned to scan other people in order to predict their behaviors. The patient scans the therapies, scans the psychologies, reviews the psychiatrist, does everything there is to learn and then creates an identity, molds herself, sculpts herself, shapeshifts, creates an identity that caters to the interests, fascination, predilections, proclivities, preferences, and interests and expectations of her therapist.

Again, if the therapist is interested in DID, she will become DID. If the therapist is interested in narcissistic personality disorder, the patient would become a narcissist or at the very least, narcissistic. The patient mirrors the practitioner, becomes the practitioner, emerges with the practitioner in this sense.

This symbiosis between mental health practitioner and the patient is very, very corrupting and contaminating and compromising. The diagnosis rendered in this kind of collusive environment, where there is essentially a conspiracy between the practitioner and the patient to please the practitioner, the diagnosis rendered are unreliable and often misleading with disastrous consequences for the patient.

The treatment metered out is wrong. Prescriptions of medication and of talk therapy go nowhere. The patient begins to exhibit convincingly clinical features which are nothing but mimicry. They're not real.

And so it could take the therapy or the clinical interaction or whatever nature, it could take it in a direction that is cataclysmic, as far as the patient is concerned, but very often also as far as the therapist is concerned.

And this is of course why many therapists are supervised. They attend supervision. It's especially an especially dominant practice in psychoanalysis, but not only.

Control analysis today is a feature that is built into the therapeutic relationship. Therapists go to other therapies in order to be kind of supervised, analyzed and monitored.

Now it's an open secret that some mental health practitioners lack boundaries. They're unboundaried and so behave inappropriately with patients sexually, emotionally, financially and otherwise.

But the vast majority of practitioners are okay. They're boundaried, they're in control, they don't let situations get out of hand. And if they do, they recuse themselves, they resign and they pass on the patient to another practitioner.

And yet in all therapeutic practices and actually in all clinical settings, there is always transference and countertransference.

Now transference and countertransference are very useful diagnostic and therapeutic tools.

In therapy, we learn a lot from the patient's transference and we learn even more from our reactions to the patient's transference.

Transference in psychoanalysis is a patient's displacement or projection onto the practitioner of unconscious feelings and wishes, which originally were directed at important individuals such as primary caregivers, parents, primary objects in the patient's childhood.

So transference is a displacement or projection or dislocation of emotions, cognitions, affects, wishes that were dormant for many, many years or decades ever since childhood and that were associated inextricably and intimately with highly specific objects with a mother, with a father, with a role model, with a teacher, with a mentor, etc.

The minute the patient enters the therapeutic space, these emotions, cognitions, effects and wishes are provoked, they're triggered, they're revived, they're resuscitated.

And this is the process known as reviviveness in some way. It's a kind of flashback. It's a kind of flashback.

So the process brings repressed material to the surface. What this repressed material is experienced.

Now why do I say it's flashback? I'm a great opponent of the oxymoron emotional flashback. A flashback is when someone experiences something as real even though it's not. Someone experiences a memory as if it were happening in actuality when in reality it's a memory and only a memory.

When primary processes are triggered in the therapeutic setting, it is clinically a flashback because the patient is unable to tell apart reality from the process in action. A fantasy defense, for example. A fantasy defense is a form of flashback. If the patient employed or deployed a fantasy defense in childhood and this fantasy is evoked in therapy, the fantasy that is thus triggered is essentially a flashback because the patient is unable to tell that this fantasy is not real, that it is distinct from reality.

So the conjunction of primary processes, cognitions, effects, actions and wishes which are conscious, they are therefore secondary processes and repressed material, this conjunction, this combination is overwhelming. It is likely to create in the patient a sense of threat which leads of course to catastrophizing, splitting and other infantile defense mechanisms.

And this sense of threat is a form of trauma and engenders the famous fight, flight, freeze reactions or form in this case.

The patient begins to form on the practitioner. The patient forms by converting the practitioner into someone else. So the practitioner represents a threat. The environment is ominous because the patient is triggered. The patient is re-experiencing very difficult emotions, horrible thoughts, magical thinking, suppressed or frustrated wishes. The drives are triggered, the instinct, the patient is in total turmoil and mayhem and feels, the patient feels she is about to disintegrate. It is a very menacious environment even if the therapist is understanding and humanistic, Rogerian and caring and containing and holding and accepting even there and then even if the patient, even if the therapist is in alliance with the patient.

Still the patient feels discomfort, egonstancy and even threat. The way to counter this anxiety which is an inevitable element in therapy. The way to counter this anxiety is to pretend that the therapist is not the therapist. The therapist is someone else. The therapist is mother. The therapist is father.

Counter-transference therefore in my view and in my work is actually anxiolytic.

The repressed material from the patient's childhood that surfaces, is brought to the surface, is re-experienced, is studied and is worked through in order to discover the sources of the patient's current difficulties, used to be called neurotic difficulties and to alleviate the harmful effects of these difficulties but all these processes involve what Freud called abreaction.

The negative energy associated for example with trauma erupts and threatens to dis-regulate the patient in the best case and consume the patient in the worst case.

This anxiety, attendant upon a feeling of disintegration, this anxiety can be ameliorated only by imposing a fantasy defense on the therapeutic space in which the therapist is no longer the therapist.

The patient in other words withdraws from reality, avoids reality by attempting forcefully to develop a shared fantasy.

The theoretical aspects of transference as you well know are not limited to psychoanalysis. We recognize transference in a panopoly of other treatment modalities. Almost all psychodynamic psychotherapies recognize transference and there's a broader meaning of transference. It's the unconscious repetition of earlier behaviors and the projection onto new objects and almost no school of psychology disputes this. It's a form of internalized repetition compulsion.

There is a repetition of earlier behaviors and the projection of these behaviors and their correlates of these behaviors emotions, cognitions and so on onto new subjects in the therapeutic setting.

The therapist, so as we saw, has to do with anxiety reduction or mitigation, amelioration and with a need to alter or change the perception of reality to impair reality testing so that the therapeutic environment becomes more manageable and less threatening.

Of course I am not disputing the fact that there is negative transference.

Positive transference in psychoanalysis is when the patient transfers onto the analyst or the therapist feelings of attachment, love, idealization, positive emotions that the patient originally experienced towards parents or other significant individuals all during childhood. So it's a projection of the positive aspects of childhood onto the therapist in order to render the therapist a figure with which the patient can do business without being hyper vigilant. A figure with which the patient can collaborate on the patient's own healing without being afraid to expose vulnerabilities and to be taken advantage of.

But there is of course negative transference as well.

Patients transfer onto the analyst or therapist feelings of anger or hostility that the patient originally felt towards parents or other significant individuals in childhood.

How would you explain this?

Within my theoretical framework negative transference would provoke the therapist to become an enemy, a persecutory object.

Why do this?

If the patient is truly anxious about the power of the therapist, the therapist's ability to penetrate the patient's mind, the therapist's capacity to manipulate the patient, the therapist's triggering of repressed material which is often very painful and traumatic, etc.

If the patient is very concerned about rendering the therapist an ally, a friend, a mother, a father, so as not to be hurt, the patient is focused on not getting hurt by the therapist.

If all this is true, why would we have negative transference?

Because of aggression. The entire process of therapy is aggressive. Therapy is an invasion of the patient's mind, home invasion, then rearranging the furniture.

Now Freud recognized the existence of externalized aggression in therapy. He called it resistances.

As part of the management of aggression within the therapy, the patient attempts two strategies.

One strategy, to convert the therapist into a figure that would not be subject to aggression. The therapist becomes a mother for example, where aggression is illegitimate. It's illegitimate to aggress against mother or against father.

So by converting the therapist into an amiable, loving, caring object, the patient renders the therapist an illegitimate target of aggression.

But then the only other option, if you can't aggress against the therapist, the only other option is to internalize your aggression, to aggress against yourself, acting out, acting in, to aggress against yourself.

But aggressing against yourself, for example, via depression. Depression is a form of self-directed aggression to some extent. So aggressing against yourself creates deep feelings of resentment, rage, anger.

The therapist is perceived as the cause of the self-directed aggression. It's as if the patient is saying, "I cannot aggress against the therapist and he makes me aggress against myself because the therapist has become an illegitimate target of aggression. I am forced to aggress against myself.

The therapist therefore forces me to destroy myself, to attack myself, to defeat myself, to torture myself, to be angry at myself, to loathe myself, etc.

The therapist is perceived as an object of frustration and frustration always leads to aggression. Aggressing therapy cycles between self-directed internalized aggression and aggression directed at the therapist who is perceived as the cause of the self-directed aggression.

So there's internalized aggression, externalized aggression, internalized aggression, externalized aggression, an endless cycle which is broken or terminated only when the therapy is successful and there is some healing or resolution of underlying traumas and primary processes and so on.

If the therapy is not successful, this cycle continues indefinitely.

We analyze transference and counter-transference not only in psychoanalysis. We interpret the patient's early relationships and experiences as they are reflected and expressed in his or her present relationship to the therapist.

So this is transference analysis. We learn a lot. The way the patient treats the therapist teaches us a lot about the way the patient has been treated by others.

It's important, significant.

Similarly, counter-transference is a very useful therapeutic tool.

Counter-transference is the therapist's reaction to the transference. The therapist, most therapists, not all, are human. Humans react emotionally to other people's emotions, aggressively to other people's aggression, with thoughts of their own to other people's thinking and with wishes and dreams to other people's wishes and dreams. That's where boundaries come in. If the therapist's boundaries are weak, then the shared fantasy that the patient desperately tries to impose on the therapeutic process is going to consume the therapist. The therapist is going to collude with the patient in forming the shared fantasy and in becoming a figment of that fantasy, an element of the fantasy, a narrative piece.

Boundaries are not only about inappropriate sexual behavior or emotional behavior. Boundaries are the refusal to conspire with the patient to avoid and reject and deny reality. It's all about forcing the patient to maintain an intact reality testing. The weakboundaried therapist agrees to play the part of a mother or a father and gradually is digested by the shared fantasy, subsumed into it, a process of fantasy osmosis occurs. Before he knows it, the therapist and the patients are enmeshed and tangled, involved in some dance macabre of transference and counter transference and transference to the counter transference, which are never ending.

And because there's a lot of internalized and externalized aggression involved, the total level of aggression increases all the time in unboundaried, inappropriate therapeutic relationships. And ultimately there's an explosion or an implosion of this kind of failed therapy.

The therapeutic alliance is not about fantasy, it's about reality. The goals in the alliance are realistic always. Any goal that involves fantasy is wrong and the therapist or practitioner should not allow the patient to alter, transmute the alliance, the therapeutic alliance, the agreement, the contract underlying the therapy, the treatment plan should not allow the patient to convert these into a dream, dreamscape, a fantasy.

This is then the patient is lost and what's even worse, the therapist is lost.

Counter transference. These are thoughts and feelings that are based on the therapist's own psychological needs and countries. The therapist is triggered by the patient as well. His own repressed material comes up. His own early childhood emotions and cognitions and wishes erupt. He has his own ab reaction and his own fantasy defenses and cognitive distortions, grandiosity for example.

Now all these may be unexpressed or revealed through conscious responses to patient behavior, but it doesn't matter because they operate as primary processes unconsciously.

Today we think in terms of transference and counter transference and we are aware acutely of the tendency or the inclination of some types of patients to aggressively, tenaciously pursue intimacy with a practitioner in order to generate a fantasy in which the practitioner is no longer a practitioner but a mother or a father and this fantasy reduces anxiety and allows the patient to cycle between external and internal aggression in a manageable way. It's under control. Patient is terrified of losing control because of the flashbacks provoked by the therapy.

Classical psychoanalysis of course, counter transference was viewed as a hindrance to the analyst's understanding of the patient.

But today we are not so sure we actually consider counter transference a source of insight into the patient's affect on other people.

In the case we must be aware of all these processes, contamination, corruption, compromise, transference, counter transference, unjustability, mimicry, people pleasing. They are all present in every therapy session ever.

It is a therapist's role to contain them and eliminate them when necessary but at least contain them.

Don't collaborate with your patient's need to please you to cater to your interests or fascination or to help you explore things. Patient is not there for you. You are there for the patient. You are a service provider.

Suggestibility is an inclination to readily and uncritically adopt your ideas, your beliefs, your suggestions, your attitudes, your actions, your analysis.

Whenever the patient agrees with you, it's a bad sign. The more the patient agrees with you, the more catastrophic the course of the therapy is.

Therapy is not about upholding your grandiosity. Therapy is not about being right. It's not about being superior. There's no hierarchy here. It's not a teaching moment. You're not a guru as a therapist. You're not a guru. You're not a mentor. You're not a leader. You're there to work with the patient.

And so stay attuned. If the patient is all over you, forming, admiring, complimenting you. If the patient agrees with you, never disagrees with you, never challenges you. Something is wrong.

Primary suggestibility is a suggestibility that involves overt influence. You can influence the patient with your body language, idiomotor suggestion.

So be careful even with your body language, even with your facial expressions. A smirk raising your eyebrows. It's wrong.

And this is precisely why initially in the practice of psychoanalysis, the analyst remained out of sight. The patient was lying on a couch and the analyst was behind the couch, at the head of the couch, sitting on a chair so that the patient couldn't see the analyst.

I think it is an excellent practice, by the way. And I regret very much that it has been abandoned. As long as the therapist doesn't join the patient on the couch, I strongly recommend it.

Secondary suggestibility, as opposed to primary, is a form of suggestibility that responds to indirect, subtle, hidden influences.

So it's indirect susceptibility or suggestibility.

I think said that there is a third form, tertiary suggestibility. It's the easy, uncritical acceptance by an individual of another person's recommendation because of social pressure, perception of superiority, the prestige of the person making the recommendation, fallacy of authority, and so on.

A bad therapist engages in all three forms of suggestibility. He signals to the patient with his body language, facial expressions, micro expressions. He signals to the patient via indirect, subtle messaging that, for example, he reinforces positively certain reactions of the patient and reinforces negatively other reactions. That's a form of subtle manipulation.

And a bad practitioner would elevate himself, would declare himself superior and authoritative, and would not allow the patient any space for self-expression, self-analyses and suggestions, which could be very useful because remember, the number one expert on the patient is the patient, never you. The practitioner is never the expert in the room. The patient is.

I provided you with a survey of the possibilities of corruption and compromise and contamination of therapy and other clinical settings.


May I remind you the diagnostic process, inpatient, outpatient, all clinical, all clinical spaces and settings are possible targets of victims, if you wish, of such processes.

The only defense against this is humility, the therapist's humility, the therapist's boundaries and the therapist's recognition that the patient is not, shall we say, a partner in the sense that they could evolve a joint or a shared fantastic space in which they will operate. It's not a cult. Therapy is not a cult. It's not easy to enforce everything I've just said. We are all human, including therapists, and their interactions in clinical settings, which are very triggering, very seductive, very alluring, very repellent, very off-putting, very attractive. We are all human.

But 99% of our training should be to put aside, not to deny, but to put aside some elements of our humanity and definitely to put aside our primary processes, our early childhood memories, cognitions, wishes, effects and emotions, and any repressed material which might interfere with the therapy.

If we succeed, if we succeed to set ourselves apart from the therapy, to become a helpful aid to the patient and nothing more, the therapy stands a chance.

Any other type of interaction who is likely to regress the patient to earlier stages of childhood and therefore to exacerbate the patient's condition.

Thank you for listening, and I'm open to any questions you may have.

I remind you, the organizers asked you to forward the questions to me via email. They'll provide you with email. And then I'll respond to the questions in a presentation, face to face, soon.

So thank you again.

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