Book Review Essay: Born to Sacrifice: Our Unfailing Preoccupation with Being Good, on “The Analyst’s Vulnerability” by Karen Maroda

Maroda’s main thesis is that psychoanalytic treatment, and psychotherapy in general, is suited to people who have learned self-sacrifice much sooner than they were capable of reflective thinking. Some of us are apparently more active in challenging clients, and in not submitting to their worst behaviours, but in the end, it seems that we all come from the same root:

Our unfailing preoccupation with being good can be seen as a reaction formation—an irrational defense against our own guilt and anger about having precociously surrendered our own well-being. Focusing on the needs of others and developing a finely tuned ability to instantly read another’s mood, necessarily produces a degree of resentment. What child wants to be his/her mother’s or family keeper? Yet expressing this resentment runs counter to the role of soother and peacemaker, and therein lies the problem. I think that therapists of all persuasions have an aversion to expressing anger toward their patients or even feeling it, because it stimulates this irrational fear of not only failing to soothe but also to harm. This is the conundrum that we need to break free from (Maroda, 2022, p. 10).

The therapist’s passive and silent stance is as old as psychoanalysis itself. Psychoanalytic patients either tended toward not directly challenging the analyst’s silence, while others rabidly and repeatedly complained about it.  Many colleagues have told me of having analyses that began and ended in mutual silence. Recently, a colleague told me that many years after analysis had ended, her ex-analyst—now a colleague in the same institution—confessed to her erstwhile patient how difficult it had been for her to maintain the technique of analytic silence. If Maroda is right, this is only half the truth: the analyst was also comfortable not engaging relationally because she, like my colleague, was probably all too accustomed to self-sacrifice. That the analyst was deeply committed to her job was not in question, and her hiding and stifling of her reactions was not just technique, it was technique in the service of her hidden wounds, that could be neither healed nor properly seen, despite years of treatments, relentless study, and multiple supervisions.  My friend and colleague stayed silent, and neither one was able to stand-up and say: “What the hell is going on here?”

As children we learn very early that enduring is a virtue, and equates to “being good”. We restrain and repress ourselves, leaving room for others, respecting their space to an extent that no one would allow in the everyday jungle. Choosing psychoanalysis as a vocation means that we keep doing what we have always done.

To make matters worse, this deeply rooted family hyper-involvement has always been totally useless. One at least wanted that their efforts were recognized and effective. On the contrary, as Maroda (2022) writes:

Once identified as empathic and sensitive, then enrolled as the family’s therapist, we essentially felt enormous responsibility with little or no power over events or the behavior of others. All we could do was respond to the situations we were presented with, then make our best attempts to be soothing, empathic, or even entertaining. But we could not change the scenarios that were unfolding before our eyes (p. 13).

Some of us (including me) were recruited in order not to disturb, and to meekly absorb parental “not-me” (Bromberg) projective identifications, which I believe is a very subtle and powerful form of hyper-involvement, disguised as hypo-involvement.

For a hundred and twenty years we have been trained with the admonition that it is for the sake of the client that we must repress ourselves. This extreme effort has always reminded me of the ancient philosophers’ asceticism. Unsurprisingly, acquaintances often ask, “How do you stand peoples’ complaints all day long?” Until recently my answer has always been: “Oh it’s much deeper, more refined and empathic than just enduring.” 

No, it isn’t.

While analysts tell themselves “I have to hold on,” and are committed to endurance, what they are more likely to be asking themselves deep down is: “Why do I have to silence my frustration and anger? Do I have to put up with this?” As a consequence, treatment is constantly threatened and twisted due to therapists using much of their energies to keep their natural reactions at bay.  

Maroda thinks that this kind of availability is inhuman. In her opinion, this unnatural effort is to the detriment of the client for two reasons: (a) because sooner or later therapists will enact the unbearable pressure, and (b) because it’s a falsehood that tolerating every kind of offensive behaviour in our clients is helpful for them. In the latter respect, treatments revolve around the elephant in the therapy room that is never addressed; a fake masquerade where it seems that everything important is addressed, while nothing important ever is. That is to say, we are in conflict and in many respects are merely tolerating each other.

When clients are whiny, inconclusive, fierce, sadistic, passive-aggressive, unfair, delegating, persecutory, boring, repetitive, insatiable or feeling victimised, it is not helpful for them that we tolerate them “empathically”, without also addressing their defensive behaviours. In these instances, I agree with Maroda that we should appeal to their self-agency and sense of responsibility, instead of patiently stretching our empathic understanding. We should focus on making clear the negative impact they’re having upon us, in order to make them aware of the similarly negative impact they’re likely to be having on people in their day-to-day relationships. In my clinical experience with traumatized clients, for instance, I have often responded to them as if they had no free will or self-agency concerning the work around their allegedly “hard-wired” wounds, due to my too-literal reading of the literature about dissociation and neuropsychology. 

Needless to say, sometimes therapists are also unfair and selfish with clients, more often than we might typically concede. Given this, it’s probably more helpful if we make clear that we are addressing their shortcomings because we are personally having difficulty interacting with those aspects of them, instead of implying that we are just dispassionately aware that those aspects can cause unnecessary pain to them in their lives. 

Maroda’s point is that we should not mask personal conflicts behind transference-countertransference. The personal root of our intervention must be perceptible, instead of making believe that our intervention comes from “nowhere”. Therapists can be insensitive and hurtful, impatient or irritated, because no one is really able to constantly stay in the other’s shoes. Being ourselves often means not being able to tolerate others. Nonetheless, avoiding being ourselves means shrinking from the relationship. Therefore, the effort to mask our self-interest is damaging, while on the contrary, admitting to having our limits signals that we are not breaking the contact. Being self-interested is a key aspect of our being in relationship. This is not to say that the session then becomes “a marketplace”, as a client said, when he felt overwhelmed by my too-intersubjective approach. That is, the extent to which the conflict must be straightforwardly disclosed and addressed, instead of implicitly or indirectly being perceived and worked upon, is a matter of clinical tact and respect, as in all cases of self-disclosure, and no doubt there is always a transference matrix. But it is an embodied transference-countertransference matrix, as Renik (2006) points out, rather than an “ethereal” projection detached from the real relationship.

In therapeutic relationships there are grounds for conflict that have nothing to do with resistance or regression:

Too often the natural emergence of negative transference reactions is erroneously labelled as impasse, enactment, or negative therapeutic reaction … therapists tend to be conflict-avoidant and too often rush to re-establish harmony rather than allow aggression and conflict to see the light of the day. (Maroda, 2022, p. 176) 

Conflicts arise because people have different goals, expectations, and perspectives (Hirsch, 2008; Kriegman & Slavin, 1992), and therapists and clients are no exception. Hirsch wrote that analytic silence stirred up patients’ disappointment, so that much anger was only unilaterally verbalized in the sessions (Hirsch, 2008). This was most often responded to with transference interpretations, erasing the realness in the relationship. In previous decades, the real relationship entered the scene as part of attachment-informed approaches, intersubjectivity, and self-psychology. These bodies of theory appear to have inclined analysts more towards the “too-good mother” role, and a consequence of this has been less anger or aggression on the client’s side (children get angry with good-enough mothers!). Both the silent and too-good mother therapists repress their negative reactions to an extent that means “transcending human nature rather than embracing it” (p. 12). Analysts have tolerated too much under the flag of “empathy”, as they have also tolerated too much under the flag of negative transference.

Maroda’s proposal is that we make good use of conflicts, and that once therapists empower themselves, they will recognize a larger spectrum of intense negative feelings towards their clients, ranging from boredom, to anger, and even to contempt. These feelings are not born of countertransference; that is, they are not clients’ disavowed negative feelings projected into the therapists’ psyches. If these feelings are bravely managed in the here-and-now, this will bring the real presence of the therapist into the session, without any need of further self-disclosure. A client asked me if I thought he was boring and choking in his relationships, and I respectfully said: “Yes, if you behave out there as you behave in here with me.” He accepted my response, and I wondered why I’d hesitated so long to tell him.

The therapeutic stance that acknowledges space for self-interest conflicts between clients and therapists will probably make many analysts feel uncomfortable at first. They will be exposed to a kind of anger and conflict management that wasn’t taught during their training (Aibel, 2021). Analysts were trained to withstand negative transference and interpret it, but Maroda’s point of view is that self-interest conflicts are different from transference projections, even if they do partially overlap. Indeed, therapists must be careful about not disguising their self-interest-driven interventions as countertransference reactions. 

This way of engaging, compared to only expressing their emotions and being empathically held, will aid in fostering clients’ self-agency more than traditional analysis does, because when people feel free to negotiate their goals, their self-confidence and self-respect increase. The fact that the negotiation is taking place in an asymmetric relationship, where one side is invested with authority and idealization, creates an even greater sense of achievement and competence in the exertion of free will, and adds significant value to the therapeutic encounter. This is not only an interactive model, but a collaborative one. Needless to say, regulating emotions also remains a central focus. Given their more complex playground, these treatments will be more gratifying, more intense, and much more brief (Renik, 2006) than traditional analytic treatments which, as Maroda herself notices in her own practice, benefits all parties.

I have never thought that genuine self-interest could be detrimental to the therapeutic relationship. This was Socrates’s belief: that no people can really harm others if they are able to pursue what really matters to them. Self-interest is the basis for bilateral growth and respect, and I believe it is the real engine of an alive relationship: the mother takes pleasure in her children’s growth, and the children take pleasure in the mother’s milk. Win-win. This is, I guess, what Maroda’s point ultimately means.