Knox, Sarah

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Sarah Knox

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I Sensed You With Me the Other Day: A Review of the Theoretical and Empirical Literature on Clients' Internal Representations of Therapists

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Marquette Universitye-Publications@MarquetteCollege of Education Faculty Research andPublications Education, College of7-1-2003I Sensed You With Me the Other Day: A Review ofthe Theoretical and Empirical Literature on Clients’Internal Representations of TherapistsSarah KnoxMarquette University, sarah.knox@marquette.eduAccepted version. Psychotherapy Bulletin, Vol. 38, No. 2 (Summer 2003): 2-5. Publisher Link.© 2003American Psychological Association. Used with permission.This article may not exactly replicate the final version published in the APA journal. It is not the copyof record.Knox 1 I Sensed You With Me the Other Day: A Review of the Theoretical and Empirical Literature on Clients’ Internal Representations of Therapists  By Sarah Knox  “You know, I was spending time with my family the other day, and we were all getting back into our old nasty patterns, but instead of feeling upset and responding bitterly as I usually do, I heard your calming voice and felt you with me, and I was able to get through the situation without getting hurt.”  It is not uncommon for therapists to hear such words from clients. Therapists may, in fact, consider such statements an indication that therapy is succeeding and that clients are learning to translate what they experience and learn in therapy to their lives outside the therapist’s office.  Such statements reflect a phenomenon referred to as an internal representation, defined as clients bringing to awareness the internalized “image” (occurring in visual, auditory, felt presence, or combined forms) of their therapists when not actually with them in sessions, and thereby evoking the living presence of the therapist as a person (Knox, Goldberg, Woodhouse, & Hill, 1999). Through their internalizations, clients continue the work of therapy between, and perhaps more importantly, beyond therapy sessions.  In this short article, I will briefly mention existing theory and research regarding clients’ internal representations of their therapists, include some clinical examples to try to bring the phenomenon to life on the written page, and finally offer some thoughts about how these representations may be used in the service of therapy.  Theorists assert that clients’ internal representations are critical to the healing processes of therapy, and that clients’ improvement may be related to the extent to which they are able to evoke representations of the benignly influential components of the therapy relationship (Rosenzweig, Farber, & Geller, 1996), such as the therapist her-/himself.  Some writers further posit that many of the most important experiences that occur in therapy are those that foster the creation of these benevolently influential and enduring representations of the therapist (Dorpat, 1974; Edelson, 1963; Geller, 1984; Horwitz, 1974; Kohut, 1971, Loewald, 1960; Schafer, 1968; Strupp, 1978).  Once created, clients’ internal representations may function as the unassigned “homework” of therapy, as well as the psychological connective tissue between successive sessions (Orlinsky, Geller, Tarragona, & Farber, 1993), wherein clients continue between sessions to work on what they address in sessions. Just as athletes or musicians may improve Knox 2 by continuing to work on their activities between practices or lessons, so, too, might clients’ growth and healing be enhanced by such between-session processes.  Clients’ internal representations of their therapists may thus serve important functions outside of the therapy office.  Extant empirical research supports these theoretical positions, indicating that internal representations may indeed be helpful to clients. In the Knox et al. (1999) study, for example, the majority of the participants (i.e., 13 adults in individual psychotherapy who were interviewed using a semi-structured qualitative protocol) indicated that they felt positive emotions (i.e., calm, comfort, focus, grounding) when experiencing their internal representations of their therapists. In addition, these respondents reported that their representations largely had salutary effects on the therapy (i.e., the experience of the representations benefited or accelerated therapy and/or the therapy relationship).  Furthermore, most of the participants stated that they used their representations for introspection, and also as “between session mini-sessions.”  Similarly, Wzontek, Geller, & Farber (1995) found that self-perceived improvement in therapy was positively related to the participants’ tendency to use their representations to continue the therapeutic dialogue outside of sessions, as well as post-termination. With respect to when internal representations may occur, Geller and Farber (1993) found that clients’ representations were most likely to be evoked outside of therapy when painful emotions were experienced (e.g., sadness, anxiety, depression, guilt, fear, stress, self-hate). Calling upon these benign internal representations of the therapist in such circumstances may, then, help clients get through difficult events. To bring this phenomenon more clearly into focus, what follows are some examples of internal representation experiences that actual clients have reported.  Rosen (1982) described two powerful examples of the internal representations experienced by patients of Milton H. Erikson. In the first case, a patient felt too embarrassed to tell Erikson of a problem in a face-to-face encounter.  Instead, she drove to his house, parked in his driveway, and evoked his presence with her in the car.  This enabled the patient to think her way through her problem.  In the second example, a patient wished to take the therapist and zip her up inside of the client’s body, certainly a poignant means of holding on to the presence of the therapist. Reflecting the function these representations may serve between sessions, Kantrowitz, Katz, and Paolitto (1990) reported the words of one client as follows: “It [the client’s internal representation of the therapist] was like a continuation of the [therapy]. I mean that was part of the way I would think about myself—sort of imagine myself being [in the consultation room], and what would happen there, and how I would think” (p. 643). Knox 3 As additional examples, Knox et al. (1999) reported a variety of client internal representational experiences. In one example, a client saw her therapist’s “penetrating eyes” pulling the client to do what she feared, and saw the therapist’s smile when the client succeeded in facing her fears. Another client reported imagining her therapist extending her arms to the client, pleading with her to come for help when the client considered self-mutilation.  A third client described his internal representations as more dream-like, as non-literal images of the therapist in which the client experienced his therapist, similar to a Disney cartoon or medieval painting depicting angels and devils, sitting on the client’s shoulder. Finally, Knox et al. (1999) reported the case of a client who, when he had what felt like a breakthrough at work with a challenging colleague, immediately found himself, through his internal representation, envisioning himself talking to his therapist to reinforce what had been discussed in therapy. As these examples demonstrate, clients do find internal representations of their therapists helpful, and use them to continue the processes of therapy outside of sessions. How, then, can therapists attend to clients’ internal representations in the service of therapy? One idea is simply for therapists to broach the topic of internal representations with clients. In the Knox et al. (1999) study, several clients indicated during their interviews that although their internal representations were ultimately helpful, the clients were nevertheless uncomfortable about having such experiences, fearing that their presence indicated abnormality, dependency, or pathology.  As a result, the shame and embarrassment many reported feeling were alleviated simply by recognizing, via their participation in the study, that such experiences are not inherently pathological, but instead are relatively common occurrences in the psychotherapy process. Because the clients themselves were not comfortable discussing their representations with their therapists (few in this study reported having such discussions with their therapists), it may well be the therapists’ responsibility to open this up as a topic of discussion. Such discussions may thus normalize the presence of the representations, thereby allaying clients’ shame, embarrassment, and fear.  Given the strong positive use and impact of their internal representations that clients have reported, even in the presence of some shame or embarrassment, might not even more beneficial effects arise without such fears?  Once clients’ qualms about having internal representations of their therapists are reduced, it may also be beneficial to engage in a full discussion of the representations themselves: What form do they take (i.e., auditory, visual, felt presence, combined)? What triggers them? How often they occur and how long do they last? How do clients use them and what effect do they have on clients? What affect is associated with them? How do they change over time? Through such discussions, therapists and clients may come to understand the function the Knox 4 representations hold for clients, functions that may yield clues for enhancing the therapy itself. If, for example, a client’s representations are primarily visual, yet traditional talk therapy relies on verbal exchanges of information, therapists may want to think about alternative interventions they may use to better attend to a client’s visual way of processing his/her experiences (e.g., visual imagery). If the representations seem to occur only at particular times, or in particular situations, this may give clues as to when clients may be most in distress.  Likewise, if the frequency of internal representations suddenly increases or decreases, these changes may signal some alteration in the client’s well being and/or in the therapy relationship. Or if the reasons clients invoke their representations change over time, such changes may indicate that clients have resolved some issues but may still be struggling with other, as yet unresolved, issues. These are but a few of the many important questions therapists may wish to ask regarding clients’ internal representations of therapists.  It may be that therapists occasionally wish to proceed even further with regard to clients’ internal representations.  As found in the Knox et al. (1999) study, most therapists took no deliberate role in suggesting to their clients that they use internal representations. It is possible, though, that some circumstances might call for a therapist’s more active invocation of such representations. A client in the Knox et al. (1999) study, for instance, expressed a wish that her therapist would provide her with particular statements that she could use to calm herself. One of my colleagues took such an action with a client, with reportedly positive effect:  Her client was experiencing significant distress, having difficulty even grounding herself to present reality.  The colleague literally wrapped her arms around the client and held her for a few seconds. She then told the client to remember that feeling when the client felt that she was losing her grasp on reality.   Thus, in the same way that a transitional physical object may prove comforting to a client in distress, being able to evoke specific therapist words, images, or presence may likewise be helpful when clients face particularly troubling situations.  Imagine, for example, clients who are prone to panic attacks when in crowds.  Might it be helpful for the therapist to provide specific words clients could say to calm themselves at such times? Or might clients find it helpful to be invited to recall the therapist’s comforting face when the former faces distressing events?  Or as in the case cited above, to recall the therapists’ physical presence as a source of grounding and support? Important discussions of clients’ internal representations of therapists may, then, have several functions: to normalize the experience of representations, to explore their phenomenology and meaning, and to deliberately invite clients to use such representations in times of need. Knox 5 There also exist ample opportunities for further research of this phenomenon. As a complement to our present knowledge, for instance, it would be helpful to know therapists’ perspectives on clients’ internal representations. Secondly, is there any connection between client diagnoses and internal representations? Or between attachment style and internal representations? In addition, tracking the evolution of clients’ representations over the course of therapy may yield useful information about change processes: Are such changes, for example, associated with any parallel changes in psychological functioning? These are only a few of the many provocative questions that could be pursued in our efforts to understand, and thus better serve, our clients.  Biography Sarah Knox, Ph.D., is an Assistant Professor in the Department of Counseling and Educational Psychology at Marquette University.  She received her doctorate in Counseling Psychology from the University of Maryland in 1999. Her research focuses on the therapy relationship. Correspondence concerning this article should be sent to Sarah Knox, Ph.D., Department of Counseling and Educational Psychology, School of Education, Marquette University, Milwaukee, WI, 53201.  Electronic mail may be sent to sarah.knox@marquette.edu.   References Dorpat, T. L., (1974).  Internalization of the patient-analyst relationship in patients with narcissistic disorders.  International Journal of Psycho-Analysis, 55, 183-188.  Edelson, M. (1963). The termination of intensive psychotherapy. Springfield: Charles C. Thomas.  Geller, J. D. (1984).   Moods, feelings, and the process of affect formation. In C. Van Dyke, L. Temoshok, & L. S. Zegans (Eds.), Emotions in health and illness: Applications to clinical practice. Orlando, FL: Grune and Stratton. Geller, J. D., & Farber, B. A.  (1993). Factors influencing the process of internalization in psychotherapy. Psychotherapy Research, 3, 166-180. Horwitz, L. (1974). Clinical prediction in psychotherapy. New York: Jason Aronson. Kantrowitz, J. L., Katz, A. L., & Paolitto, F. (1990). Follow-up of psychoanalysis five to ten years after termination: II. Development of the self-analytic function. Journal of the American Psychoanalytic Association, 38, 637-654. Knox, S., Goldberg, J. L., Woodhouse, S., & Hill, C. E. (1999). Clients’ internal representations of their therapists.  Journal of Counseling Psychology, 46, 244-256. Kohut, H. (1971). The analysis of the self. New York: International Universities Press. Knox 6 Loewald, H. W. (1960). On the therapeutic action of psychoanalysis. International Journal of Psycho-Analysis, 41, 16-33. Orlinsky, D. E., Geller, J. D., Tarragona, M., & Farber, B. A.  (1993). Patients’ representations of psychotherapy: A new focus for psychodynamic research. Journal of Consulting and Clinical Psychology, 61, 596-610. Rosen, S. (1982). My voice will go with you: The teaching tales of Milton H. Erikson. New York:  Norton. Rosenzweig, D. L., Farber, B. A., & Geller, J. D. (1996). Clients’ representations of their therapists over the course of psychotherapy. Journal of Clinical Psychology, 52, 197-207. Schafer, R.  (1968). Aspects of internalization. New York: International Universities Press. Strupp, H. H.  (1978). The therapist’s theoretical orientation: An overrated variable. Psychotherapy: Theory, Research and Practice, 15, 314-317. Wzontek, N., Geller, J. D., & Farber, B. A. (1995). Patients’ posttermination representations of their psychotherapists. Journal of the American Academy of Psychoanalysis, 23, 395-410. 

I Sensed You With Me the Other Day: A Review of the Theoretical and Empirical Literature on Clients’ Internal Representations of Therapists

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I Sensed You With Me the Other Day: A Review of the Theoretical and Empirical Literature on Clients’ Internal Representations of Therapists

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