When working with trainees and supervisees, I frequently refer to the need for a psychotherapist to ‘stay in their chair’. Let me explain.
Psychotherapy is a relationship. It is a very intimate and unique relationship between the clinician and their patient, which is principally about the needs of the patient. This, however, does not mean that the psychotherapist acquiesces to every whim or request a patient may have. On the contrary.
The key to any successful relationship, whether a friendship, a romantic relationship or a parent-child relationship, is that there are clear boundaries. Often, if not always, when a patient comes into therapy it is because they have grown up in an environment where the boundaries were poor, inappropriate or non-existent. In other words, they grew up with relational deficiencies.
Poor boundaries create a psychological and at times physical environment, where there ceases to be a differentiation between self and other. This is often referred to as a merger. Where children grew up with a parent or parents with poor boundaries, the experience can be hugely impactful on their psychological and emotional development and, in attachment language, leads to insecure or disorganised attachment styles. In simple terms, it makes it very difficult for these individuals, once adults, to have healthy boundaries in two-person relationships; they are either at the mercy of the other, or conversely, make everything about themselves and fail to recognise the needs of the other.
As a psychotherapist with fifteen years of experience, I have yet to meet a single patient who crossed my threshold, who did not have issues with relationships and thus had attachment damage. It’s the work.
One of the primary roles of the psychotherapeutic relationship is to have a caring, loving relationship with the patient, that is in their best interests. It therefore is boundaried by definition.
One of the tenets of working as a psychotherapist is that it is always in the best interest of the patient for the clinician to hold the boundaries. Even if the patient pushes against these – and they will. Just as it is a parent’s role to hold the boundary with their child and hold their best interests in mind, since they cannot.
So, now we are coming to the meaning of ‘stay in your chair’ which I mean both literally and figuratively. Put simply it means stay in your role and hold the boundaries, because without boundaries, the psychotherapy ends.
Patients who have not grown up with clear and supportive boundaries will unconsciously try and recreate a familiar dynamic, generally stemming from their childhood, in the psychotherapy. Us clinicians refer to this as transference, which is a form of projection from the patient onto the clinician. The difference between projection and transference is that the role of the psychotherapist is to think about and understand the projection onto them, and within this to recognise the relational blueprint of the patient and whom the psychotherapist represents for the patient. In simple terms, the patient will attempt to ‘play out’ the most influential relational patterns from their childhood with their psychotherapist. And if this is not caught and thought about, then the therapy simply becomes a repeat of the patient’s childhood experience.
Whether a patient attacks or seduces, our role is to stay in our chair – to remain consistent and constant and to hold the boundaries. Patients will invariably ‘act out’, which is to say that they will embody and play out dynamics that are counter-productive to the therapy, but familiar to them. Our role as a clinician is to survive these acting outs and to protect the therapy at all costs, Sadly, the concept of psychotherapy has become increasingly diluted in the UK, in part due to a lack of differentiation between counselling and psychotherapy and a general ‘race to the bottom’ amongst training institutions. The result is that therapists increasingly have no concept of ‘staying in their chair’ and either move towards the patient when seduced into a collusion, or back away and abandon when attacked.
Lastly, this is not to say that as psychotherapists we should accept or ‘put up with’ attacks from patients. On the contrary, the boundaries are there to protect us too, and if a patient verbally attacks and cannot return to think alongside their therapist, then they may simply be unsuitable for the work, which is also a boundaried position to hold.
Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.
Further reading by Mark Vahrmeyer –
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