#6 Bringing your therapist a cupcake. 🧁

In defence of enactments in psychotherapy.

Via B. Sweet Dessert Boutique

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Dear friends,

Many years ago, one of my patients showed up to her appointment with a cupcake for me. I, a baby therapist, was extremely startled. I made a detailed inquiry about the cupcake. She gave me nothing. “Oh, I just thought you’d like it!”

Enactment is the choreography of something not yet able to be put into words. A patient who cannot yet remember and speak about certain experiences resourcefully relives them instead, a pantomime of coded behaviour available for translation. A patient who cannot yet say “I feel a great deal of pressure to please you, lest you neglect or harm me as so many people have done before,” might bring us a cupcake instead. (Although, let me be clear: not all cupcakes speak the same language. 🧁)

Therapists take part in enactments too. A therapist doing something different or out of character with how they normally practice can be evidence that they have taken up their own role in the pantomime, drawn into the patient’s world and cast as a character from the past, initially mysterious but ultimately familiar and significant to how the patient has come to experience life. For example, the therapist (normally organised and thoughtful) forgets an appointment they have with the patient, the youngest of six children, who was often forgotten in the fray by their busy parents as they struggled to juggle the obligations of such a big family. It may be easy for such a therapist, busy berating themselves for being so neglectful, to miss the visceral insight they stand to gain from their lived experience of the patient’s inherited forgettableness. But this is the gold of enactment.

Enactment floats ominously around the therapeutic lexicon, batted back and forth amongst debriefing colleagues, but often accompanied by a sense that it is not entertained by good and proper therapists. It is easy to form a sense that enactment is bad. Enactment has also historically been defined as a behavioural communication that threatens the treatment. And some types of enactments do. If the patient repeatedly cancels appointments, for example, even in a way that is designed to have a communicative function, the treatment cannot occur. Instances of exploitation, violence or too-great-a-threat of violence, ultimatums that the therapist cannot fulfil, or any behaviour that exceeds the capacity of one or both of the parties in the treatment inevitably spells its ruin. We are right to do everything we can to emphatically defend our patients’ therapy from the destructive nature of these kinds of enactments.

The enactments that are usually discussed in psychology training are incontrovertibly alarming: extreme situations in which therapists engage in destructive or exploitative relationships with their patients that cause a great deal of harm. These stories are important too; a gift of the vessel of psychology is the rigour with which the patient is systematically protected from mistreatment by a system of ethics. However, if the intensity of this professional rhetoric becomes too rigid, we run the risk of losing our humility and creativity, as well as valuable opportunities for deeper understanding and therapeutic intervention for our patients.

Snacks, gifts, lateness, earliness, requests, offers, compliments, criticisms, rescheduling, emails and other communication between sessions, imitation, financial errors, flirtation, accidents, threats, forgetfulness and preoccupation, as well as all manner of unique and bizarre circumstances therapists and patients find themselves in, offer a potential wealth of opportunity for a deeper understanding of the as-yet-unspeakable. Placing constraints on ourselves and our patients is sometimes necessary as a means of maintaining the stability and containment that makes therapy possible (as well as protecting our own comfort and sanity). But equally, allowing something to happen can greatly further a therapy that might otherwise remain frozen for a very long time.

My patient’s cupcake was like a secret missive from a piece of her not yet able to testify to its hope and terror. If I had refused it under some faulty and anxiety-laden guise of professionalism, I am sure that piece of her would have fallen silent for a long time. Instead, it showed me something about how she had learned to navigate closeness and express gratitude and affection, about her readiness (or lack of readiness) to analyse what happened between us, and about how she had learned to protect herself from abandonment.

It was also extremely delicious. 🧁

In love, and the humble pursuit of a shared path to a greater truth,

Kate