The therapeutic use of ‘no’

Contributions from child and adolescence

In normal development, the infant is both weaned from the breast and simultaneously invited to explore new foods. Similarly, the teenager, both excited and apprehensive about attending a planned party, protests when the parent says no, but thanks them the following day. The parents, believing in their decision, cared sufficiently to say no. ¹ In an equally limited clinical literature, polarised positions are described.^2-4 Rather than engaging in a battle for control, therapy should allow the child to experience themselves being out of control, breaking rules in order that they may themselves become aware of and use their own internal brake. For us to attempt to provide control for them only serves to undermine their own sense of uncertainty. ² The contrary position argues for the relief that containment provides for the similarly desperate child, and notes how this important developmental task becomes lost by parents and services that retreat, reward, rescue or retaliate. The critical task is to remain firm at the contact boundary, to tolerate intense affects and challenging behaviour. Without clear boundaries the person comes to believe that they are invincible, and that the ordinary rules do not apply to them. ³

A third position attempts a reconciliation by exploring the social context, and noting the shift from Victorian childhood and how patriarchy has been replaced by a democracy. Parents are friends rather than authority figures, and guilt, complicated by social stressors, blood tie asymmetries, opulent neglect and discomfort with one’s own aggressive feelings, leads to ineffective parenting. As a result the child becomes both the feared and fragile object, for which limit setting is deemed inappropriate. ⁴ When limits are tried and the child becomes angry, buried feelings become frighteningly reawakened and placed on others, and whilst the parent has become free to be the child again, the clinician is expected to solve the problem. Casement notes:

It is often not easy to set limits, especially when children are at risk, and statutory responsibilities can compel a clinician into collusion with the manipulative client. There are bound to be occasions when this seems to be unavoidable, but it needs to be borne in mind that it can only perpetuate the clinical problem of dealing with anxiety in this fashion. The relevant question is to ask whether we are preparing the person in problem solving or are we moving, however imperceptibly, towards collusion and avoidance. ⁵

Contributions from the adult literature

Parallel debates occur in the similarly scant adult literature. From the bleakness of the person with borderline personality disorder, the small measure of control associated with mutilation may make the yield particularly satisfying in a life in which the person otherwise expects nothing. The feelings that arise in response, however, and the importance of being able to accommodate these feelings, are crucial. Waska notes:

These turbulent patients often leave treatment in very abrupt and unprocessed moments. It is suddenly all over and that is that… We can not always prevent this. Rather than seeing it as a complete failure…struggling with these is critical to our ability to help such patients because these are the exact issues that the patients can not bear in their lives and if we can not bear them, then the patient has no hope of ever surviving them. ⁶

There is a similar debate on how best to proceed, the less intrusive approach being played out through texts that seldom mention ‘no,’ the opposing position arguing that limit setting enables the establishment of a secure base from which new feelings may be experienced.

The task is not necessarily easy. Limit setting is typically imposed against the will of the patient, and the therapist’s approach may be received by the patient as authoritarian measures designed to deprive, infantilise or punish.^7,8 Reluctant to be seen as a disciplinarian, the clinician retreats as in the fable of the camel’s nose:

…the camel, it will be recalled, asked leave to put his nose inside the merchant’s tent on account of the cold weather, this favour granted, he proceeded by means of flattery, deprecation, ridicule and ‘logic’ to insinuate himself gradually and totally inside the tent. There was no longer room for the merchant, who was then forced out into the cold, warmed only by the scorn of the camel for his foolishness… The beginning psychotherapist finds himself in the merchant’s shoes when he grants permission to the anxious patient to telephone him when anxiety becomes unbearable. Soon no part of his life is exempt from intrusion, while curiously enough, no improvement has occurred in the patient’s symptoms. ⁹

It is only by saying no that we can concentrate on the things that are really important, the issue being not being whether to say no, but how and when, for if very serious forms of acting out are not controlled, a fiasco may result in which therapy turns into just another avenue for the patient’s habitual pathology.^7,8

From an adult perspective, saying no is necessary under two conditions – when there is a threat to a person(s) or to the psychotherapeutic work. The latter includes disruptive, disorganised, deviant or dependent behaviour, or by the chronic depressions whereby the person withdraws altogether.^7,10 The usual strategies to manage these aspects of therapy have been either ineffective or the patient’s acting out is too gratifying or provides too much relief from the sometimes difficult work of therapy. ¹⁰ Equally distracting for the therapist are the entanglements outside the therapeutic setting. Often treatment requires numerous contacts with family members, employees and legal personnel, each necessitating detailed discussion. Under this load the therapist does retreat, reward, rescue or retaliate, which further distracts the therapist from the work.^3,10

Tincture of ‘no’

The fundamental principle behind the how of limit setting is clear identification of the specific behaviours that need to be altered and equally precise articulation of the consequences if those behaviours persist. ⁸

Both the child and adolescent and adult literatures are struggling with similar issues – the alarming and bewildering behaviour of those that have been profoundly hurt. Those that argue for limit setting, irrespective of age, articulate a number of principles.^6-12 These include doing so within a philosophy of care, with an understanding of the person and what they are attempting to communicate, and with a view that is clear in the therapist’s mind. Limits should be few in number, realistic, transparent and related to agreed goals. We must decide when to let a young child climb on the jungle gym. If we wait until he is older, he may have fewer falls, but the price of this protectiveness is that the falls he takes when learning later may be from far greater heights, as he is able to climb higher and in riskier situations. ¹¹ Limit setting is akin to the caring but disciplinary role of parenting, and although giving in feels more like loving than limit setting, saying ‘no’ is an act of love.

Finally, saying no includes an understanding of responsibility, for:

…the person with a suicidal character structure has become used to letting himself fall toward death as a means of coercing others into catching him. He must be helped to recognise that the treatment plan will gradually remove some of those catching arms, leaving him with increasing responsibility for not letting himself go. ¹¹

There is a radical difference between truly caring for someone and being responsible for them, ¹² for the realistic clinical task is to understand the person and to bring to bear competent treatment, but no more. ¹³

Does it work?

If inappropriate or untoward demands are not met the patient will not become sicker. The patient may complain bitterly, may make things more unpleasant, for those nearby, or may report increases in symptoms, but beyond this initial flurry, no clinical evidence of worsening of his condition is seen. The fact that this is found repeatedly to be true is of the utmost importance to the decision to set limits. ⁹

Surprisingly an evidence base for this confident statement comes from the addictions and the renal literatures. In the former, staff noted that although their methadone programme had been successful, behavioural problems in refractory patients had jeopardised its credibility. Seventy-one patients were randomised into two groups. If urine tests revealed illicit drug use 2 months in a row, subjects in both groups were sent letters of which there were two forms. One outlined their illicit use and expressed general concern. The second group received the same concerns but with a 4-month warning of irrevocable discharge, including a specific date when methadone withdrawal would begin. The structured treatment group achieved significantly more months free of illicit drugs. ¹⁴ The reaction of discharged methadone patients was likened to Kubhler Ross’ acceptance of death. There was initial disbelief, followed by anger, panic, and distressed family contact, until the person accepted the situation, began to mobilise their resources, join another group and continue the task of recovery. ¹⁵

In the renal literature, Brenda Paton took issue with her nephrologist who indicated he would no longer dialyse her. The court found that Paton violated every condition of the order. She continued to use barbiturates, failed to restrict her diet and would frequently appear for treatment late or at unscheduled times in a drugged or intoxicated state. Paton bothered other patients, cursed staff members and required 30 emergency hospitalisations over an 11-month period. The court held that neither Paton’s nephrologist nor the hospitals were required to treat her, this decision upheld 4 years later. ¹⁶ Examples from psychiatric practice, in particular when working with people with borderline personality in the community, have recently been published. ¹⁷

Whilst effective, two caveats apply to limit setting. The first is a footnote whereupon the authors note that if the patient has a genuine emergency, they will succeed in communicating and behave in quite a different manner. ⁹ The second arises from the unintended consequences of zero tolerance, including an unhelpful rigidity and inability to use discretion, explore alternatives or for consequences to be proportionate.

Concluding remarks

This paper has been an examination of the therapeutic use of ‘no’. As a team, we have begun to recognise and to say ‘no’ to our own acting out, inappropriate diagnosis and prescribing, and to the patient’s acting out through threat and deliberate self-harm, in order that we may concentrate on the things that are really important. Both parties in the therapeutic relationship have experienced a renewed enthusiasm that has been reflected in attendance, morale and outcome.