Pathological Accommodation

"Pathological accommodation" is a term I first encountered through the readings of Bernard Brandchaft and the theories of intersubjectivity. I find this concept transformative to the work I do; it seems to apply to virtually every patient I've encountered (as well as most people I've known in my personal life). I feel compelled to write this at this time, as this subject follows naturally from my previous post about narcissistic mothers.   

At its basic core is the idea that children who are unable to develop authentic selves due to the various barriers put upon them by their parents learn that they must contort themselves into a false self or risk losing the ties to the parent(s) to whom they are most closely attached. This accommodation can manifest in one of three ways. The child who does not want to lose his bond to his caregiver learns to sacrifice parts of himself in order to preserve that bond. Alternatively, a child may decide that she will hold fast to her true self at all costs, only to find herself isolated and alienated from her caretakers. Finally, some children oscillate between these two poles, enacting an ambivalence in which they play the dutiful, obedient child at times and fiercely cling to their own wishes at others. In contrast to a healthy development in which the child is allowed to develop a true self and also maintain a secure positive attachment to one's parents, children who grow up being pathologically accommodating find themselves in a no-win situation, either sacrificing key parts of their identity or losing their close ties to the parents that are so important to them.

Most of the patients I've encountered fall into this first category. They come to me having lived their lives hiding parts of themselves and working hard to be the "good" boy or girl they believe they are supposed to be. They go through life accommodating others at all costs, and the price they pay is incredible unhappiness for having to squelch parts of themselves and contort themselves into who they think others want them to be. These people aim to please, though often while feeling deep-seated resentment and rage for having to do so. Most of the gay men and women I've treated learned to hide their sexual orientation at a young age because they were taught that it was "bad" and "unacceptable." Even more insidiously, most people are taught that their internal world of feelings -- particularly their anger -- is something dangerous, threatening, shameful, or wrong that is to be avoided at all costs. When one learns to split off their feelings instead of learning that all feelings are a healthy part of what makes us human, it becomes impossible to live fully and authentically. 

An intersubjective therapist is trained to look for how these issues show up in the therapeutic relationship. We must expect that the ways our patients have learned to conduct their relationships up until coming to us will also play out in the relationship that develops between therapist and patient. Thus, patients often behave like dutiful students, wanting to do what's "right" for my sake. Others act out by experiencing me as their parent who places demands on them and then they rebel by missing sessions, coming late, not paying on time, or engaging in risky behaviors outside of therapy. It is crucial to track the interactions in the therapeutic relationship so as not to ignore or dismiss these enactments and to not repeat perpetuating the unhealthy relational dynamics established in childhood. When we can speak to what's happening in our relationship and shed light on how the patient may be pathologically accommodating the therapist, then we have a chance to alter these patterns and allow for an alternate positive relational experience in which the patient (maybe for the first time) can learn to have a healthy relationship where she can bring herself fully into the room and be accepted  unconditionally. 

In future posts I will elaborate on some of these ideas -- such as the crucial role that anger plays, the power that shame wields, and the specific ways that people may act out in response to believing that they cannot express themselves authentically. For clinicians interested in learning more about pathological accommodation, I recommend the collection of Brandchaft's essays entitled Toward an Emancipatory Psychoanalysis