Intensive Short-Term Dynamic Psychotherapy

Is it allowed to introduce someone to your patients for marriage?

"Hello Jon! I hope you are well. A student asked a question that I wanted to know your opinion on: Is a therapist allowed to introduce someone to his or her clients for marriage?" Thanks to one of our community members for this question?

The student poses the question as if it were a matter of rules: right or wrong.
Instead, it is also a matter of ethics and clinical impact.

Let's think about the clinical questions we could ask the student to help learn how to think clinically about their question.

Suppose a therapist introduces his patient to someone as a possible marriage partner.

How might the patient perceive this on a conscious and unconscious basis?
How might the patient submit to the therapist like they submit to others?
How might the patient trust the therapist's judgment and distrust their own judgement, continuing a pattern of deferring to others? How might the patient experience this as another example where the patient is treated like a child who should be directed by authorities and parents?

How might this enact the transference?
How might this enact a transference where the patient is treated as incapable and must follow the instructions of parents and family?

How might this enact unconscious power dynamics?
How might the therapist be using the asymmetry of power to direct the patient, thus enacting the power dynamics of the family?
How might the therapist be unknowingly claiming to "know what's best" for the patient, thus reinforcing a passive, submissive transference?
What impact does it have when the therapist's desire becomes a factor in the patient's desires?
How will the patient feel if the therapist does not trust their search but tries to influence their search instead?
What will happen if the patient feels as if they must follow the therapist's desire (hint or suggestion) as they have learned to follow the desires of others?

How free is the patient to say yes or no, based on her transference?
Has the patient differentiated enough from their parents, family, or therapist to be able to feel free to say no, or does the patient have an unconscious tendency to submit to the desires of others, to be a people pleaser? If the patient is a people-pleaser, what impacts would the therapist's suggestion have on the patient and the therapy?
If the patient is a woman and you are a man, how might this
enact her oedipal conflict?

In an authoritarian country, how might such a suggestion enact an authoritarian transference?
What makes you the authority on what a patient should choose? Who is the authority on their life?
What impacts will it have on their ability to exercise their authority over their choices if you unwittingly take the authority role and choose their partners?
What might lead you into enacting a controlling parental role rather than analyze it and the countertransference that goes with them?

In the therapist's countertransference, we might wonder: why does the therapist feel it necessary to influence the patient's desires and choices?
What is happening in the transference that is leading you to feel the pressure to control the patient rather than analyze their conflicts?
Given that the choice of a partner is between the patient and their partner, why does the therapist feel the need to intrude as a third party? Is there an unanalyzed oedipal transference in the therapist, leading the therapist to want to compete or intrude into a two person relationship?
Why does the therapist feel the need to influence or direct the patient's choices?
What are the pressures leading the
therapist to abandon analyzing the transference to enacting it?

These are among the clinical questions a therapist should ask.
Rather than judge the question or urge, our task is to analyze it.
"What is leading me to want to enact the transference rather than analyze it?"
"I am treating this action as if it has no psychological meaning. Yet I am a psychologist. What is leading me to engage in denial and abandon my identity as a therapist?"
"What are the meanings of this potential action for me and my patient? What do these meanings tell me about what we need to focus on in the therapy?"

Through this kind of clinical thinking we can engage in ethical action.
It is not about simply following rules.
It is about the principle: always analyze the feelings, urges, and actions occurring in the therapeutic relationship.

As the supervisor for the student, your task is not simply to tell them the rules, but to ask questions like these so the student—through answering those questions—learns and experiences the principles that guide clinical thinking. When students do not know how to engage in clinical thinking, they naturally assume therapy is about following rules: rules made up by others.

When students ask if something is right or wrong, they often implicitly enact the authoritarian transference: inviting you to tell them what to do. So if you tell them the rules, you would enact that transference in the parallel process.

Instead, you ask questions so the student learns to think clinically about these situations. By answering these questions, the student learns to think clinically by doing the clinical thinking. And they will also learn a new way of relating since they can think out loud with a separate mind: something not possible in an authoritarian transference enactment.

Why depend on people when I can rely on AI?

"Increasingly, I see patients who expect perfect attunement, wise answers nonstop, extended availability, referring to how AI offers them these components. As if there is no friction, disappointment, or misunderstandings in real life.
How do you see this development, and how would you respond to such patients?" Thanks to one of our community members for sharing this question!

Of course, all of us wish for perfect attunement and understanding from imperfect humans.
But since we are human, flawed, and with limited knowledge, none of us can be the perfect fantasy others wish we could be.

No wonder we wish for an AI realization of our universal fantasy world where there is no friction, no disappointment, and no misunderstanding. For living in the real world with real events and real people, we will always encounter the friction of different desires, thoughts or feelings in others. Others will never be the same as our fantasies, so our fantasies will be disappointed (though we often think instead the other person disappointed us). And because your inner world is known and felt only by you, it is impossible for any person to know exactly what it is like to be you. Thus, our understandings of one another can only be partial.

Babies learn to bear this difference between fantasy and reality as children or as adults, but some of us never learn, always seeking that fantasy. Some claim that through meditation or some other practice that they have become the ideal. Others try to manipulate others into becoming the "ideal" partner. Then, supposedly, having found an emotional clone, no disappointment or friction would occur.

Now, some hope that, finally, at last, the fantasy emotional clone has been found in AI. So the question is this: does AI offer perfect attunement and perfect wisdom?
More importantly, can AI love a baby into being? Can AI love you?
What does a human's love offer you that the simulation of love by software cannot? Can a machine feel you, or is that something only a person can do? Does that matter to you? Does AI understand you and feel you, or is it just good at analyzing language based on being a Large Language Model? Does that matter to you? If not, why not?

Jon Frederickson, MSW
Author, Co-Creating Change: effective dynamic therapy techniques
The Lies We Tell Ourselves: how to face the truth, accept yourself, and create a better life, Co-Creating Safety: Healing the Fragile Patient
Psychotherapy videos and skill building exercises at:

Home - ISTDP Institute Through education and training, The Intensive Short-Term Dynamic Psychotherapy Institute prepares therapists to practice ISTDP in a clinical setting.

Why don't I feel better?

Sometimes clients say they feel good during the session, but afterward, their problems return, and they feel hopeless. As a result, they have difficulty trusting the process of therapy. Even though previous therapy tools/tips were only temporary band-aids, it was still soothing to have something concrete to work on in between sessions. So, when they're working in a more open-ended way, they sometimes feel lost and hopeless. A couple of clients have said that if not every session feels good, they doubt the process and feel hopeless. And some clients appreciate their insights from the work but want actionable steps to use that insight. Otherwise, they see the insight as useless. How do you conceptualize this in ISTDP?

What causes symptoms and problems? Defenses. So if symptoms returned after the session, defenses returned. Why? Feelings were triggered after the session. So the return of problems is a great opportunity to inquire. When did the symptoms return? What was the triggering relational event?

The patient may distrust the therapy, thinking the therapy is causing their problems. The problem is that they are trusting the defenses that cause their defenses. If they don't see the defenses and how they cause the problems, naturally, they will assume therapy is the problem. Instead, we must help the patient see the sequence of causality: a relational event triggers feelings, feelings trigger anxiety, anxiety triggers defenses, and defenses cause symptoms and presenting problems. Unless that causality is clear and EXPERIENCED in the therapy room, the patient will mistakenly think therapy is the cause, or the patient may have a cognitive insight but without an emotional insight. And then, no change occurs.

The patient wants something to work on. Wonderful! A big sign of motivation! Here are some options: "So this week, whenever you have critical thoughts or are feeling depressed, ask yourself this question: "If this anger were not going onto me, where would it go instead?" "Whenever you feel really anxious this week, ask yourself, "What happened with a person just now that would have triggered these feelings and anxiety?" "Whenever you are tempted to provoke your wife to be angry, ask yourself, "What am I feeling guilty about that is making me want her to punish me?"

You see, any therapeutic focus in the therapy room is something the patient can continue to work on during the week, if you give them the right questions to continue their self-inquiry. Remember that one goal of therapy is teaching patients how to continue their own self-analysis after therapy.

Now for actionable steps. The patient wants to know how they can do the opposite of their defenses that cause their problems. "We have seen how asserting yourself with your boss makes you anxious, and to deal with that anxiety, you do whatever he wants even though those fall outside your job description. So the next time, he asks you to rub his back, what would be the opposite of saying yes to his request?" She will, say, "No." Then you might say, "So this week, how would you like to practice saying no to him instead of yes?"

Remember: an actionable step for the patient is doing the opposite of her previous defense. And you ask her what step SHE would like to take to avoid being another boss to whom she would submit!

The patient says that insights are useless unless they lead to action. The patient is right! We come to therapy to change, not to continue suffering from our defenses. So join her! "Of course, an insight by itself doesn't help you. Based on what you have learned today, what is causing your problems? If you face what makes you anxious this week, how might you do the opposite of your previous avoidance strategies?"

"The “Thou” is not a thing to be analyzed but a partner to be addressed. Language that turns the Thou into an “It” (e.g., objectifying, purely theoretical speech) has stepped out of the dialogical sphere." Ferdinand Ebner