What Is Neutrality in Psychotherapy Anyway?

In our previous articles about narcissistic personality disorder (NPD) and how to treat it with an object relations psychodynamic approach, the issue of therapeutic neutrality emerged as central. It would be helpful to clarify what neutrality is.

A neutral stance on the part of the therapist can be instrumental in advancing dynamic therapy. However, it must be understood that a neutral stance is not the same as indifference or blankness. It should also be understood that absolute neutrality is impossible, and the concept should guide, rather than shackle, the therapist.

A therapist can, and should, be highly concerned about his/her patient’s well-being and can be intensely involved in the therapy and still have a neutral stance. Further, it is important to appreciate that when taking on a new patient, the therapist is not neutral: the therapist sets up treatment conditions that support the patient’s increasing freedom from symptoms along with his increasing autonomy and satisfaction in life. Few therapists would agree to join a patient whose stated goal was to get past his/her ambivalence about killing him/herself so as to be free to die by suicide. Neutrality comes into play only after the treatment frame (method of treatment and goals) has been set in place.

From the point of view of psychotherapy based on modern object relations theory, neutrality means that the therapist maintains an observing stance, while avoiding siding with any of the forces involved in the patient’s conflicts: urges to act, internal prohibitions against acting, and the constraints of reality. The reason for neutrality is that if the therapist maintains an observing stance in relation to these conflicting forces, the patient will be more likely to join the therapist in observing, reflecting upon, and eventually solving his or her problems. Addressing the patient’s conflicts in this way will not only help the patient deal with the specific conflict at hand, but will also help him/her achieve more autonomy moving forward in dealing with internal conflicts and life challenges. The simplest example is asking the therapist for advice about doing something. Rather than offer an opinion, the neutral therapist helps the patient explore the motives that would lead the patient to act and those that would stop the patient from acting. This exploration may uncover motives that were hidden from the patient’s awareness.

Neutrality may go beyond this basic level to elucidate information about the patient’s view of self in relation to others. An object relations perspective emphasizes how specific internal relationship paradigms determine the patient’s experience of self and others. These internal images strongly influence the patient’s behavior and can also influence the behavior of the other in interaction with the patient.

In the case of NPD, being arrogant and devaluing can provoke others to be defensive and even devaluing in response. This reaction of the other becomes part of a vicious cycle that can support the patient’s unfortunate worldview that everyone is striving to impose his/her superiority on the other. Such a worldview precludes any possibility for mutuality or intimacy in relationships.

Therapists may have an initial internal reaction to the NPD patient that is similar to that of others in the patient’s life: to feel angry at being devalued, and either to have the urge to strike back or to masochistically submit, accepting the patient’s devaluation. In these instances, the therapist’s emotional reaction to the patient is countertransference—reactions that can inform the therapist about the make-up of the patient’s internal world.

Neutrality and countertransference are intimately related: the therapist dedicated to maintaining a neutral position is more likely to observe his/her countertransference rather than to act on it, while the therapist who acts on his/her emotional reaction is deviating from a neutral position. In some instances, remaining neutral consists of not “taking the bait” to react, instead reflecting on the urge to react and using it to better understand the patient.

In the case of the patient with NPD, the therapist’s neutrality is an implicit challenge to the patient’s view that all relations are based on a superior/inferior paradigm—an invitation to reflect on it. By remaining neutral, the therapist avoids both the risk of mirroring the patient’s grandiosity and the alternative risk of submitting to the patient in a way that would help him/her maintain the grandiosity.

Remaining neutral in the heat of the intense emotional reactions that emerge in therapy is not easy, but it should be a skill we all strive to master. The therapist may be the only person in the patient’s life who manages to maintain this stance. In so doing, the therapist, with honest curiosity, invites the patient to participate in a shared goal: understanding what is going on internally and in interactions with others. This could be the first step in helping the patient move away from an internal world where defensive self-aggrandizement trumps any movement toward mutuality and intimacy. ■