Dave: Therapists tend to be good at being kind and patient with difficult people and they know how to put up with their patients’ demanding and outrageous behavior. Too often the demand for good manners persuades therapists to compromise their integrity in the attempt to maintain the relationship and to make their patients feel worthwhile. But compromising integrity interferes with the effectiveness of therapeutic work. My goal is to induce change usually in the form of growth. I don’t do supportive psychotherapy. A key to good changeful therapeutic work is the capacity to maintain my integrity in the therapeutic relationship.

An adequate therapist is constituted by this curious combination of qualities; sweetness, patience, cunning and ruthlessness in an artfully balanced blend. They contradict and are counterbalances to one another. Most therapists know about sweetness and patience. Few know enough about ruthlessness. Ruthlessness sounds horrid. Stripped of counterbalances it can be devastating; suggesting heartlessness or indifference. But when there is caring ruthlessness in the proper dose can be therapeutically effective.

When therapists seek consultation from me about difficult patients, I make comments, in a sense give them “lines,” language to use in the therapy session. But the language is usually not grounded in kindness or patience. It is grounded in integrity, including cunning and ruthlessness. Many therapists have a tendency to be too passive, too accepting, too careful. I coach them to be ruthless and cunning. I borrowed these words from Castaneda’s splendid book The Power of Silence. He suggests the sorcerer’s apprentice has to learn to be sweet and patient, ruthless and cunning.

Likewise, therapists need to know all of these. In the supervisory context the lines I suggest are almost always a blend of “ruthless” and “cunning.” The therapist who is seeking help with a therapeutic impasse is usually amused, but one way or another tells me, “I don’t think I can say that.” They don’t say what I suggest, but they relax a little with their difficult patient. Our conversation affects their mindset. Cunning is a way to resist being maneuvered to do the will of patients. Ruthlessness means maintaining integrity in the face of the patient’s demand to compromise my standards.

During the Iraq/Afghanistan wars, I spent several years working two days a week in a civilian-run mental health clinic near a very active Army base. We had a contract with the Department of Defense to take care of active duty military patients, soldiers recently returned from combat, soldiers preparing to deploy.

A Case: A seasoned social worker therapist at the clinic consulted me about a demanding chaotic patient; a Staff Sergeant, a combat veteran who had deployed to Iraq three times in five years. He had been injured physically and psychologically and was in the process of leaving the army early because of his injuries. She said, “I need some help, this guy is very difficult for me. When I see his name on my schedule, I find myself hoping he will cancel. He makes so many unreasonable demands. I can’t do anything about them, but I feel so pressured. He does not know how to question himself. He wants a new psychiatrist. His meds aren’t right. The doctors don’t listen to him. He calls me repeatedly to make demands and to complain about how he is being treated. I feel so inadequate.”

My social worker colleague had worked with him for four months. She is a particularly sweet and patient person, with a tendency toward shyness. Sweetness and patience are virtuous characteristics, but too often therapists get cornered by their virtue. The demand to be patient and kind interferes with honesty, leads to being politically correct, a virtuous way to be dishonest, a virtuous way to double-cross yourself. I made some suggestions. She was amused, but said she didn’t think she could say anything like that.

At the end of the day I was finishing my notes and getting ready to leave. The social worker therapist came to my office to tell me about her interview with the very difficult sergeant. She could not suppress her Cheshire cat grin. She described the interview in which the sergeant was talking about all the ways the world let him down and pressured him. She was feeling her usual strain, but she surprised herself when she said to him, “I don’t know how to tell you this, but you should probably know it.” “What?” “I don’t believe you.” He laughed when she said it. “Ohhh! I don’t think anyone believes me anymore.”

Feeling her integrity suffusing hormone-like through her body and mind, she continued, “It’s because you complain too much.” He was settled down, less pressuring, less defensive, no longer trying to legitimize himself. Then Ms. Patience Sweet surprised herself (and me) again by saying, “Or maybe it’s because you are just plain crazy.” That is insulting, but she said it signaling non-verbally she was playing. I call this a therapeutic double bind, a therapeutic insult. Again, she got his attention.  He was amused not insulted. I suspect part of his amusement was with her poker-faced demeanor. Her sweetness and patience, which were the more prominent features of her personal style made it possible for him to take it in.

Further on into the session he began complaining about his case manager. He had called the case manager, he had left messages, but she didn’t call back. He called his first sergeant to complain. He called the medical director of the base hospital to complain about the case manager. “Did you call the base commander, the general?” she asked. This was a deliciously absurd expansion of what he had done. Unless he is a fool no NCO calls a General to complain about anything. “No,” was his response. “Maybe you should call the president. He would certainly want to know about this terrible treatment.” He began laughing again, “I know, I know I’m a pain in the ass. But you know, I am so scared about what will happen to me when I get out. I don’t know what in hell is going to happen to me.”

That is a sample of ruthlessness, colored by cunning, a sample of playful ruthlessness at work. It is not malicious, capricious or sadistic. It could be harmful if done out of anger by a sadistic therapist, but in this case she cared about this man. There was fun and personal pleasure for her, but it was a side benefit. Why should we do this? It is in the interest of increasing consciousness. It is in the interest of health. It is in the interest of helping people assume responsibility for themselves. But even more important, it is in the interest of conserving the therapist’s energy. And what was behind his exhausting bluster?  His fear of what would happen once he left the Army. For military veterans it is not easy out there in our world of chaos and crisis, the world we think of as normal.

 

 

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