Patients seek psychotherapy for relief of symptoms and resolution ofproblems in living. Yet, they sometimes balk at the prospect of having to choose a topic without being prompted by therapist questions. This paper suggests that this apparently self-sabotaging behavior represents an acting out of a fundamental existential dilemma for many individuals, i.e., to be or not to be an adult.
Adulthood comes with the heavy burden of responsibility for making life choices, and the possibility of making the wrong choices. The psychotherapeutic situation, with its demand that the patient choose a topic, is a microcosm of the adult-adult relationship. The author proposes that the proper treatment for these patients is Generative Caring Psychotherapy, which promotes emotional growth and facilitates patients' transition from childhood dependence to adult responsibility.
When a patient refuses to work in psychotherapy, or attempts to sabotage the psychotherapeutic situation, it is thought that the patient's unconscious wishes or fears are working at cross-purposes with his conscious wish to be helped. The two most common explanations for what these unconscious wishes and fears might be are: 1. the fear of recovering unacceptable repressed memories, feelings, impulses (1), or internal objects (2), and 2. the wish to avoid change in order that everything remain predictably the same (3, p. 4). This paper proposes a third explanation which builds on and extends both of the first two.
GROWTH AND CARE
Emotional growth consists largely of movement from childhood dependence on caregivers to taking on responsibility for oneself. This process of growth varies from individual to individual; in some people it is very limited. Psychologically, separation from caregiver(s) starts at the moment of birth, perhaps earlier, and continues, mostly in spurts, throughout life, with a major spurt during adolescence and young adulthood. But even under the most propitious of circumstances, the child has lingering doubts about the merits of moving from childhood into adulthood. This is because taking care of oneself can be so burdensome, and being taken care of can be so pleasurable. Yet for many, the care and protection they received as children have, in actuality, been fraught with serious lapses, both intentional and unintentional. The recipients of poor, inconsistent, distorted, abusive, or incomplete care become adults, who are left with unconscious wishes to find proper care (in accordance with whatever their fantasy of care happens to be). These wishes are expressed in the repetition compulsion (3, pp. 22, 23) as reenactments of childhood primary relationships in current interpersonal contexts. Most often these reenactments take place in those relationships that most closely resemble the individual's early family situation, Marriage is a likely venue for these reenactments. Any "helping" relationship is fertile ground. Of particular interest to the readers of this journal is the relationship between psychotherapist and patient.
THERAPY AS A MICROCOSM OF FAMILY LIFE
The psychotherapeutic situation resembles that of the nuclear family. Patients find themselves locked in a struggle with internal representations of their parents and, transferentially, with their therapists. They feel caught between two contradictory wishes: 1. the wish to do the work of therapy and thereby increase their autonomy by becoming more responsible for themselves, and 2. the wish to remain a child and thereby attain the cared-for state about which they fantasize and for which they yearn.
After several years of therapy, this was clearly expressed by one of my patients. Mr. A., a practicing attorney. Mr. A. described how in his fantasy he sees himself lying in bed, being fed intravenously, surrounded by family who are all looking intently at him.
Another patient's statement illustrates how she played out both sides of her ambivalence about responsibility in one therapy session: