Kicking the Patient: Immediacy in the Consulting Room

A case is presented of an adolescent with a history of substance abuse. The case is discussed from the perspective of Time Limited Dynamic Psychotherapy (TLDP). The patient's Cyclical Maladaptive Pattern (CMP) involved remaining attached to significant others by avoiding all conflict and seeking to please them as much as possible out of a fear of abandonment. The therapist became "hooked" into counter-transference enactment--kicking the patient--thus playing the role of the rejecting adult figure that fails her. The patient and therapist were then able to break out of this cyclical pattern and forge a new kind of relationship. This experience led to the patient developing a healthier relational pattern in her life and, hopefully, may lead to her experience of God being able to break free from her expectations as well. Introduction I have relished the opportunity to discuss a clinical case from a contemporary psychodynamic perspective, especially in a special issue intended to honor the memory of Randy Sorenson. Like so many others, I mourn the loss of Randy as friend and colleague. We would often discuss the intersection of theory and practice. Randy found nothing more practical than good theory. He influenced my thinking in this realm in immeasurable ways and his "DNA" is found all over in my teaching, writing, and therapy. I was especially influenced by Randy's thinking about intersubjectivity in the therapy process. His grasp of the contemporary psychodynamic literature and the cutting edge research on psychotherapy was amazing. I would like to discuss this case from the perspective of the work of Hans Strupp and the Vanderbilt research project. Strupp developed a form of case formulation around a patient's Cyclical Maladaptive Pattern (CMP) (Levenson, 1995; Strupp & Binder, 1985). This unhealthy pattern of relating develops from the patient's early formative relationships and the failures or losses associated with those relationships. Once the therapist identifies the patient's repetitive relational pattern, they can together establish goals for a change in that pattern. The focus, therefore, is not on symptom reduction but on changing the patient's way of relating to others in their world. This change of "worldview" will then lead to the reduction of the symptoms that prompted the patient to seek treatment. These CMPs are very relevant to understanding the patient's spirituality. I have generally found that the CMP predicts and explains much about one's relationship with God. If the central relational figures in one's early life were cold and withholding, so will God usually seem. If they rejected and abandoned us, one might fear the same from God. Was father abusive? It might be frightening, then, to call God father. Or maybe God becomes the idealized father, all sweetness and light with no disciplinary role. Strupp's research has resulted in the development of Time-Limited Dynamic Psychotherapy (TLDP), an interpersonal approach to modifying patients' CMPs (Strupp & Binder, 1985). TLDP, a centrally psychodynamic approach, integrates aspects of psychoanalytic, interpersonal, object relations, self-psychology, cognitive-behavioral, and systems theories and therapies. If the therapist determines that a patient can benefit from TLDP the treatment length is often set at 26 sessions from the very beginning. The patient will "fit" what they need to accomplish into the timeframe that is provided. The time limit also helps to generate the appropriate amount of anxiety to bring the patient's issues to light. I have found the central premise of Strupp's short-term, dynamic approach to psychotherapy to be very powerful in my work. Essentially, the therapist enters into a relationship with the patient, assuming that the patient's CMP will emerge in this intimate relationship as it does in most of the patient's other relationships. The primary focus of the therapy is on the observation of the therapeutic relationship rather than on technique. …