Therapeutic Approach

Let us begin with an infant. That little person has very great needs, is very dependent on others, and has limited ways of making her/his needs known and getting them satisfied. If the parents/caretakers do a “good enough” (as in, it does NOT have to be perfect, but has to be pretty good) job in attuning to the child and meeting those needs, then things get off to a good start.

The developmental psychologists tell us that a little person does not begin to develop object constancy until around 18 months. Before that ability starts to develop, you can take a toy that the child is playing with and hide it, and the child will not then look for it; the child does not yet have the ability to keep a mental representation of the object in mind. After the ability starts to develop, the child will look for the toy, holler for it, etc., because she/he now can maintain a mental concept of it, even when it is out of sight.

In our practice, we have found the idea of object constancy inadequate to explain what was going (or not going) on with some of our patients. Conceptually, a patient could leave a session, and if someone had met them in the parking lot and asked them if they had a therapist, almost all of the time, they would have known the correct answer. However, if they found themselves in some sort of a crisis, they would never remember that they could call their therapist, even if the therapist had given them business cards to post on their refrigerator, put in their wallet, etc. Furthermore, they seemed to have no sense from session to session, that the therapy relationship could be helpful in any way. In other, words, most of the time they had literal object constancy, i.e., they could maintain a mental representation of the object (the therapist), but nothing else.

In trying to figure out what was going on, we eventually came up with the concept of relationship constancy. To go back to our idea of the good enough caretakers, if a child lives in that environment in the early years, then along with object constancy comes relationship constancy. That means that the child knows from experience that there is not only the constant of the literal caretakers, but there are good, and adequately predictable attributes to the relationships with the caretakers as well.   In essence, that child’s relational world is adequately positive and reliable. However, if there is not adequate predictability, or if the only predictability is that the relationship is poor, then no relationship constancy develops. Obviously, this is a matter of degree, but we have seen patients whose childhoods were so awful that they did indeed have NO relationship constancy. On the other hand, all human beings fail to achieve  complete relationship constancy or we would not have the relational shortcomings we all do.

In order to begin to remedy that, the therapist has to be in relationship with the patient in the role of “good enough parent.” That means we throw out the “blank screen/New York analyst” way of dealing with patients, and deliberately set out to do our best to create an environment where a good enough relationship can begin to develop. For the patients who have come from the worst childhoods, it can take a number of years before the goodness and constancy of the relationship begins to seep into the patient enough so that relationship constancy begins to grow. For this reason (and because for a long time no one knew how to treat these people, and even after they did, the treatment is so arduous for both the patient and the therapist that most therapists don’t want to mess with it), these are the people who are often deemed to be untreatable by the psychotherapist establishment.