Affect, Relationship with Therapist in CT

    The Case of Gary Menu

    • The Case of Gary III - Life in a malevolent world. by Jim Pretzer, 10/25/97
      • Relationship with the therapist by Don Nathanson, FACULTY, 10/26/97

    Affect, Relationship with Therapist in CT
    by Jim Pretzer, 10/31/97

    The question about affect is a good one. Cognitive Therapy is known for focusing on thoughts, not affect, and some of the early works on CT give the impression that we spend all of our time trying to get people to think rationally so that we can stamp out affect.

    This isn't the case at all. Initially, CT was developed as a treatment for depression and, when we are working on depression, we don't encourage the client to "get in touch" with his or her feelings or to increase their expression of affect since this tends to make the depression worse, not better. With other problems, such as anxiety disorders or grief, it can be important to help the client recognize and face affect that they fear or avoid. When we do this, we don't have a set list of affects we refer to. We try to understand affect in the client's terms and it sounds like we look at affect in a less differentiated way than Don does.

    As far as changes in my relationship with Gary over time, I am sure that this ocurred but I do not have a clear recollection of how our relationship changed (other than his gradually risking greater openness and discovering that he could safely trust me). In CT we do not usually spend much time discussing the client's feelings towards the therapist unless we have clear indications that this is relevant to what we're trying to accomplish at the time. This is primarily because our time with the client is limited and we find that it usually is most valuable to focus on understanding and addressing the here-and-now situations in which they encounter problems.

    The intense emotional reactions to the therapist which are traditionally termed transference do not arise very often in CT (at least with Axis I disorders). Why? Because the therapist in CT is being straightforward, direct, and active in therapy. I would argue that Freud was right in thinking that a therapist who is a "blank screen" will maximize transference. The therapist in CT is anything but a blank screen. In working with clients who have Axis I problems, we usually are able to establish straightforward, collaborative relationships and do not need to spend much time addressing the client's feelings about the therapist.

    This does not mean that we ignore the therapist-client relationship. I would be most likely to ask about the client's feelings towards me if there are indications that they are having a strong reaction to something I said or did, if interactions within therapy are similar to interpersonal interactions in which the client encounters problems in real life, or if we are having difficulty working together productively.

    The way I deal with the client's feelings towards me would depend a variety of factors. If the client has misinterpreted something I said or did and their reaction is disrupting therapy, I might simply clear up the misunderstanding and then proceed with the session. If the client's reaction to me recapitulates a problem they have in interpersonal relationships outside of therapy, I might use this as an opportunity to identify the thoughts and feelings they are experiencing, help them understand the problem, and explore possible solutions.


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