Alex asked the question below over on the Ask AG page and I am going to offer my take on it.
I am wondering if you have any insight on a psychotherapist’s role when a patient is demonstrating persistent, self-destructive behaviors? I’m referring to damaging, non-suicidal behaviors that artificially regulate emotions– such as self-injury, eating disordered behaviors (restricting, purging, etc.), reckless impulsivity, or drug/alcohol abuse (though this last one might be slightly different, I guess, since it compromises your mental capacity more extremely).
This is a really excellent question and in some ways goes to the heart of what therapy is about. I do want to be upfront though in that I am still working through my own behaviors with food so I approach this topic with fear and trembling. I would recommend approaching this post with some skepticism, dear readers, as I may be speaking out of the wrong orifice. 
This is a tough area and involves some complicated issues around boundaries. One of the long repressed needs that came roaring to life for me in my work with BN was my desire to experience a caregiver the way we are supposed to as a small child. Our parent is idealized as all-powerful and all-knowing, able to keep us safe and solve all our problems. I seriously idealized BN at the beginning of our work. (If I’m honest, I still do, but to a much lesser extent. I do at least realize he is an actual human being now. ) We discussed it once and he said that I needed to see him that way for a time so I felt safe. The problem arose, just as it does for all human beings, when I realized that while he is a safe person, he can neither guarantee my safety nor fix all my problems instantly (or even over the long haul). Like all teenagers when they realize this about their parents, I had to struggle with feelings of anger that he failed to be the all-powerful Wizard I wished him to be (although come to think of it he does look good in gray; but I digress. ). These lessons are difficult enough to learn as a child, as an adult they are even harder.
A normal part of human development is that we are dependent on our caregivers to get our needs met but as we grow and mature, our caregivers teach us how to identify our needs and act to get them met. Full maturity is reached when we understand and accept that our needs are our responsibility. We have to reach out to other people to get them met but it is our job to make them known and ask for what we need. If all goes well, this does not feel threatening, because our experience was that of getting our needs met consistently and being soothed when we couldn’t have what we wanted. Childhood neglect or trauma often short circuits this process, so that we are ‘frozen’ at the point of looking for someone to take care of us and meet all our needs.
And because we were never taught to regulate our emotions or identify our needs, we often adapted behaviors to cope that have now become maladaptive such as the ones Alex mentioned in her question: eating disorders, self-injury, alcohol abuse, etc. These are strategies that at one time helped us to survive but that now we recognize are hurting us. Combine all of this and the solution that we long for is for our therapist to take over and fix us. We want to hand these behaviors and problems over to them the way a child would bring a broken toy or skinned knee to parent and say “make it better.” In fact, at times I believe most of us can sometimes use these behaviors in a manipulative manner to attempt to force the therapist to care for us in the way we long to be cared for. It’s as if we are saying “see, see how bad this is! You must do something or I will be severely hurt and it will be on your head.” We use the threat of self-destruction to force their level of care to rise to where we wish it to be. That is also why this can be such an important area for a therapist to clearly hold their boundaries, despite how cruel or callous that can appear. They must not hold out the promise of being able to do more than they are capable of actually doing. Having the hope awakened of those unmet needs being met, only to be failed again, is even more damaging in the long run than our self-destructive behaviors.
An example: In the beginning of my individual work with BN, when my attachment was awakening and these unmet needs were pushing forward, I think I unconsciously tested him. I made an emergency call to him and told him, truthfully, that I was struggling with thoughts of suicide. I felt desperate and that he HAD to do something. Guess what his response was? He quite calmly told me that if I did not believe I could keep myself safe, then I should go to the hospital. Then he said he would see me at our next session and ended the call. I was SO pissed at him for being so calm about it and not getting upset and doing something that I forgot to feel suicidal. I never tried that again. I did talk to him at times when I struggled with those feelings, but I never tried to push him past his boundaries again. Oh and another side note on manipulation. I get really freaked if someone says I am being manipulative (somehow in my mind, it is a really terrible thing to do) and BN and I were discussing it in session. I think I was expressing my fear that I was trying to manipulate him. He quite cheerfully told me that I had every right to try to manipulate him. His job was to make sure I didn’t succeed.
But as much as a therapist might wish to do so, and no matter how strongly they long to keep us safe, they cannot change our behavior, only we can decide to do so. They provide a safe place by accepting us exactly as we are, problematic behaviors included, so that we can choose to change. (See Accepting the “not so pretty” parts for more details.)
What can get blurry is the fact that therapists are also committed to our safety. There is a need to address really problematic behaviors which are seriously threatening our well-being or our lives. In many places, a therapist is legally obligated to take action if you are an imminent danger to yourself or someone else. You can be hospitalized against your will for 72 hours in NY state if a medical professional believes your life is in danger. So there is an obligation on a therapist’s part to monitor these behaviors. But the solution is not for them to force us to behave correctly (most of us have experienced enough coercion from caregivers) but to point out and challenge our unhealthy behaviors and beliefs, to bring them to our attention so that we can decide for ourselves to change them.
Many of these behaviors are essentially about emotional regulation; they are attempt to manage pain or anger or grief. Any feelings that feel threatening to us or that would overwhelm us. It is at this point where I think a therapist’s role is the most crucial. Our work in therapy should help us to understand ourselves and what is driving our behavior. For example, my personal self-destructive behavior of choice is binge eating. I am significantly overweight to the point, here in my 50s, where it is impacting my health. Ironically enough, I started therapy decades ago to deal with my weight problem. I am just now starting to approach this. In examining why I eat, I have run into a huge tangle of issues involving the deep shame about my body (having one as well as how it looks), being overweight to “protect” myself from being attractive as that leads to men doing bad things (yeah, that one has Dad written all over it), turning to food to comfort me when no one was available, punishing myself for the terrible person I believed myself to be, pushing my emotions down and long-standing habits. Well at least so far. There is so much shame surrounding my feelings about my body that so far it has been oblique work, sort of sidling up to the issues, glancing at it as long as I can stand, then wandering off again. So the work is two-fold: undoing our reliance on an unhealthy coping mechanism and learning healthy ways of accomplishing emotional regulation. Our therapist is often the model for learning emotional regulation.
Change is difficult even when we are committed to it (and frankly I’ve never met an embedded unhealthy behavior yet that I haven’t been ambivalent about changing. These behaviors started with a purpose and were at one time effective, so letting them go can feel scary). I think one of the most important things about changing these behaviors is the need to be able to be honest about what is going on, to see the reality of what we are doing, to pull our unconscious beliefs into the light of day and rob the lies of their power. But in order to do this, we need to feel safe. I think a therapist’s role is to provide a place where it is safe to be honest about what we are doing to ourselves without feeling like we will be judged for what we are doing. So a therapist walks a fine line of accepting that we are the person we are and that these behaviors need to be looked upon with compassion while still helping us to see that they are not good for us. So they cannot make us change, but they can provide a safe place for us to see the need for change and act on it, while helping us contain the feelings that arise from changing our self-destructive patterns.
I do not believe that it is effective for a therapist to act in a shaming, punishing or threatening manner around these behaviors. If you are going to be truly free to speak your feelings instead of shoving them away, you need to know that all of who you are is acceptable, as is. A therapist who uses shame or punishment around these behaviors only succeeds in sending a message a client has heard too many times before. “You are not ok and if you do not change your behavior to please me, you will be abandoned.” Only when we know we do not need to change for the other person, do we truly feel free to change for ourselves.
So the therapist provides a safe, caring, accepting environment where you can talk about these struggles without fear of condemnation or rejection. They cannot fix you nor are they responsible too. But they can help provide you the tools you need to change what you are doing. They can provide you someone to be accountable to, not because you will be sent away if you don’t behave properly, but because they care about your well-being and will be clear about when they think you are endangering yourself. Honestly, I think this is a tough area for both the client and the therapist. The therapist has to manage their anxiety about your behaviors and not step in to fix you to make themselves feel better while still conveying to the client a sense of caring about what you are doing to yourself. And the client has to look to the therapist for things they can provide while facing the difficult realization that there are some things they cannot and that the hard work of change is theirs to do. There’s a reason it can take so much time to change these self-destructive behaviors.
