Stage 3: Identifying Maladaptive Relational Pattern

The work of the third stage of treatment is to diagnose the maladaptive relational pattern of the patient, based on the methods of interaction he or she has used to develop a relationship with the therapist. For this relational diagnosis to be accurate, the therapist needs to be present to the patient on all levels of functioning. The therapist needs to be affectively, behaviorally, and cognitively attuned to the patient's world and his or her method of living in that world.

Because it is unlikely that patients will overtly state that they are trying to manipulate and control their therapists, and because patients have developed powerful manipulative skills over years of practice, the maladaptive relational pattern is often elusive and difficult to identify.

As a result, it is difficult for the therapist to assess how the patient's nexus of behavior, cognition, and affect interact to create the maladaptive relational pattern. Certainly, we have to listen to and observe the patient via the sense of presence discussed in Stage 2. But, presence also means being present to our emotional response to the patient. In fact, the therapist’s emotional response (countertransference) is often a good indicator or barometer of the patient's maladaptive relational pattern, as he or she tries to induce us into the pattern.

To complete Stage 3 effectively, the therapist needs to sort out positive and negative countertransference issues. Negative countertransference is the therapist’s emotional reaction to the patient based on the therapists' needs and past relationships. These have to be brought into awareness and resolved through therapist supervision and psychotherapy. Positive countertransference, on the other hand, is the therapist's genuine emotional response to the manipulations of the patient, and is an excellent diagnostic indicator of the patient's maladaptive relational pattern. However, therapist’s need to be trained to distinguish the difference between positive and negative countertransference. It is not something one can learn without supervision or training.



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