In this second part, we utilize examples drawn from our supervisory activity and the literature to illustrate the clinical facets of collusion and flesh out the conceptual elements provided to date.

Triggers

Triggers related to unresolved issues increase collusive resonance. In a psychotherapeutic setting, triggers can emerge from the therapeutic frame (e.g., a break in sessions due to holidays can activate unresolved issues related to separation) (Hilty, 2020), from the contents addressed in therapy (e.g., the investigation of traumatic events can activate unresolved issues related to intimacy) (Fox & Carey, 1999) or from nonverbal elements (attitudes, gestures, tone of voice, facial expression) as well as from symptoms, habits or stereotyped behaviors (Kestenberg, 1972). In the medical setting, triggers can be health issues, diagnostic procedures, bodily symptoms, or the delivery of bad news, which can provoke the eruption of unresolved issues, such as intimacy, loss, and self-worth (Stiefel et al., 2017).

In couples, life events can be triggers: the occurrence of a disease in one partner may, for example, lead to unresolved issues concerning dependency (Delvey & Hopkins, 1982); past life events have also been described as triggering collusion in psychotherapy (Welldon & Hacker, 2012).

Karlsson (2004) described collusion in the context of separation triggered by a dream. The psychotic patient had been receiving treatment for years and showed signs of improvement despite massive resistance. This success required considerable effort from the therapist, who had to endure repeated attacks from the patient with regard to their relationship. The patient announced that he would move to another town and therefore had to terminate therapy. In the last session, he reported a dream, which he immediately qualified as completely insignificant. The therapist insisted on focusing on the dream and even on writing it down. This insistence provoked an intense reaction in the patient, who felt threatened by intrusion. We understand this interaction to be an instance of collusion. Both the patient and the therapist, who had invested in the patient over the years despite his repeated attacks, were affected by the imminent separation. Otherwise, the therapist, who knew the patient very well, would simply have accepted the dream as a “departure gift” (our suggestion). In this context, we would like to underline the fact that the information concerning the unconscious dynamics at work in the description of collusion are rather scarce, even when the authors are psychoanalysts (Cassorla, 2001; Karlsson, 2004). This scarcity may be the result of privacy protection.

An instance of collusion related to attachment is derived from a psychotherapy session conducted by one of the authors. The patient peppered the therapist with questions. This situation provoked a growing irritation in the therapist, who started to distance himself from the patient, with the result that the patient accused him of being “cold.” During the session, the therapist recognized that the patient’s multiple questions were an expression of her clinging tendencies (anxious-preoccupied attachment) and that his irritation was a defensive reaction due to his own attachment difficulties (dismissive avoidance). Indeed, the patient’s development was marked by a conflictual relationship with her mother and a rather absent father, resulting in attachment difficulties and a functional bowel disorder. The therapist’s development was marked by intense and chronic intergenerational conflict, leading to attachment difficulties and panic attacks in early adulthood, which were resolved after psychoanalysis.

Modalities of Collusive Bonds

To the best of our knowledge, Willi is the only author to propose a meta-psychology by classifying complementary collusions as narcissistic, oral, anal-sadistic, phallic, or narcissistic (Willi, 1975, 1984). For example, in oral collusions, the unresolved issue concerns “nurturing.” The so-called progressive caregiver represses oral needs and vicariously experiences them through the receiver, who occupies a regressive position. Jacobs (1986) reports a case of such symmetrical oral collusion: the patient fed the therapist with abundant transference material, while the therapist in turn fed the patient with a transference interpretation. The topic threatening both the patient and therapist who engaged in this “stimulating” psychotherapy, however the dying of the patient’s husband remained unaddressed due to the collusion.

One may ask whether the psychic structure determines the modalities of collusive interactions. We have no arguments for such a hypothesis; Karlsson’s (2004) previously mentioned collusion with a psychotic patient did not indicate any specificities. In the context of psychosis, one can question whether the so-called folie à deux or folie en famille could be considered to represent collusion. We disagree, given the observation that delusions often persist after the separation of the protagonists (Arnone et al., 2006).

Manifestations of Collusion

Collusions become manifest through thoughts, attitudes, behaviors, the predominance of interactional dimensions in the encounter, deviation from good clinical practice, or intense emotions (Nos, 2014). By definition, collusion can only be recognized in retrospect, for example, after enactments or when therapists feel estranged by their own reactions (Cassorla, 2001). Because enactments often provide a clue regarding collusion, we briefly discuss collusive enactments. Enactments, which are equated by some authors with collusion (Severo et al., 2018), occur when a therapist responds in a manner that reflects the influence of the patient’s projection (Gabbard, 2020). Enactments, which are conceptualized as jointly created nonverbal actualizations of intrapsychic configurations, may be normal and resolved through thought and interpretation. However, they are collusive when they arise in response to a shared, unresolved issue (Cassorla, 2001), as described in the treatment of a patient with an eating disorder (Gubb, 2014). The therapist’s constant hunger and almost hallucinatory visualization of a pizza were not, as initially assumed, a response to the patient’s anorexic behavior. The therapist finally recognized that the collusion was related to a shared and unresolved issue concerning competitiveness, which she understood when she was eating pizza, a dish that she considered to be unhealthy and usually avoided. Unable to resist the temptation of unhealthy food and feeling guilty, the author realized that she was in competition with her patient, who was able to resist eating.

In couples, collusions may manifest in the form of a complete role reversal between partners after an event that disturbs the relational equilibrium, shared acting out due to the same unresolved issue (Godfrind-Haber & Haber, 2002), a blurred distinction between the perception and real existence of the other, deception when the partner fails to behave in the attributed way, ritualized behavior that is incomprehensible to a third party, or statements by partners that their sole problem is the fact that the other exists (Willi, 1975).

The following supervision illustrates the manifestations of complementary oral collusion: A young nurse had just started to work in palliative care and requested supervision because she felt exhausted and feared that she would have to ask for sick leave. She presented the case of an elderly patient with advanced lung cancer, with whom her relationship was initially harmonious. The patient had high expectations regarding medical care, and the nurse was proud to meet those expectations. However, the increasing demands of the patient caused their relationship to deteriorate. The nurse began to find excuses to avoid the patient. In response, the patient increased his demands, and he finally started to criticize her. This criticism provoked intense irritation and a great deal of anxiety on the part of the nurse, given her exigencies toward herself. During supervision, the supervisee realized that her high expectations and idealized identity as an unconditionally devoted (and nurturing) nurse contributed to the dynamics of her relationship with this patient.

Primary and Secondary Gains and Consequences of Collusive Defense

The primary gain obtained through the collusive interpersonal maneuver is the avoidance of an unresolved issue at the intrapsychic level (Dicks, 1963; Willi, 1975, 1984). Possible secondary gains (whether in the context of natural couples or patient-therapist couples) include gratifications associated with the attributed roles, vicarious participation, emotional discharge, prevention of separation, protection from painful issues and control over the object. However, collusion has certain consequences, including the distortion of reality, the repression of parts of the self, and the loss of self-object differentiation (Loewald, 1986).

Effects of Collusion on the Therapeutic Process and Coevolution in Couples

Some authors argue that collusion may strengthen the therapeutic alliance at the beginning of treatment (Godfrind-Haber & Haber, 2002). Such collusions, which are called “necessary collusion” (Cassorla, 2001) or “therapeutic collusions” (Karlsson, 2004), are thought to allow patients and therapists to avoid disillusion that appears to be too rapid. Notably, traumatized patients may remain unable to access trauma (Cassorla, 2018). A clinician who unconsciously adopts a prudent attitude allows the trauma to be addressed only after confidence has been established (Fox & Carey, 1999). However, if the prudence is due to the therapist’s own unresolved trauma, the therapist may ignore clues from the patient that indicate readiness to address the trauma (Fox & Carey, 1999). In this context, it is not appropriate to talk of “necessary or therapeutic collusions.”

Additionally, in psychoanalysis, collusion may remain unrecognized and have negative effects: it can limit reverie (Ogden, 2021), lead to therapeutic ruptures or immobility, imprison the therapist, impede creativity, or break the barriers between the conscious and the unconscious (Cassorla, 2018; Civitarese, 2021). A frequent collusion in the analytic setting is reported by the Barangers, with psychoanalysts being flattered to be viewed as idealized omnipotent figures; in such cases, analysis fails (Baranger & Baranger, 2008). Moreover, collusions may be the origin of abuse in therapy (Teitelbaum, 1991). However, the effects of collusion may not always be dramatic; some authors consider therapists in collusion to be able to continue to exercise a containing function (Cassorla, 2018).

Dicks claims that collusion in couples may be an attempt to overcome unresolved issues and an effort to self-heal by reappropriating lost aspects of the self in the relationship with the other (Dicks, 1967). We agree that some collusions in couples can be attempts at self-healing; however, successful self-healing occurs only through coevolution (cross-fertilization and mutual integration of the complementary characteristics of the partners).

A discussion of collusions involving individuals and groups (e.g., scapegoating) and collusions both within and between groups is beyond the scope of this manuscript and will be described elsewhere.

Facilitating and Maintaining the Factors Associated with Collusion

Factors unrelated to unresolved issues may facilitate or maintain collusions. Institutional rules, for example, can facilitate and maintain collusion; a discussion on how the larger context (e.g., dominant discourses) may facilitate and maintain collusion will also be addressed elsewhere. Role responsiveness or behavioral responsiveness, a primarily unconscious tendency to comply with the expectations of the other (Sandler, 1976), is part of a therapeutic attitude but can, when it becomes excessive, facilitate collusions, for example, a collusion between a “voyeuristic” therapist and an “exhibitionistic” patient (Wood, 2014). Some characteristics of the therapist (hypertrophic ego ideal) or of the patient, such as perversion (Wood, 2014) or suicidality (Nivoli et al., 2014), may facilitate collusions since they diminish the capacity to mentalize.

In couples and families, life events facilitate, maintain, and intensify collusions. Examples include illness and unemployment (Willi, 1975) or specific challenges such as adolescence and senescence (Zinner & Shapiro, 1972).

The Ending of Collusions

Collusion becomes manifest along a spectrum of collusive resonance, which depends on the intensity of the relational dynamics at play, the power of the unresolved issue at stake, the amount of primary and secondary gains to be made, and the severity and type of the collusion’s side effects.

Since collusions have defensive functions, which might fluctuate, they may end naturally (De Beà, 1989). For example, in the medical setting, amelioration of the patient’s condition and the associated decrease in defensive needs may cause collusion to terminate.

In therapy, the clinician can, as with projective identification, address the unresolved issue and the associated interpersonal dynamic or simply contain the situation. The issue of whether a therapist should also acknowledge his contribution to the collusive episode is somehow different than the possible self-disclosure of countertransference, which rarely seems to be beneficial for the patient. In collusion, acknowledging one’s own entanglement may be therapeutic and, to a certain degree, an ethical command. A possible wording for such an acknowledgment might be as follows: “We seem to have gotten entangled in an issue over…”. Such a stance does not imply sharing or detailing the clinician’s own unresolved issue but takes into account the fact that collusion is not just another problem of the patient.

Some authors claim that the very fact that a therapist considers collusion is an indicator of the readiness of the patient to work through it (Cassorla, 2018).

In couples, collusion usually persists, but its intensity may vary, for example, according to life events or challenges throughout the life cycle (Willi, 1975). In couple therapy, collusion can be addressed, or the intervention can focus on the modification of the relational dynamic, as in the case of Bagarozzi (2011), who attributed to a husband the task of serving as a coach for assertiveness training with regard to his dependent wife and thereby attenuated oral collusion.

Collusion and Setting

Collusions are also determined by the setting. In a psychoanalytic setting, which encourages regression in the patient—albeit to a lesser degree than in the analyst (Baranger & Baranger, 2008)—one can assume that collusion is inevitable, since the analyst must enter into communication with the patient, also on an unconscious level. On the other hand, in somatic medicine, collusions have the potential to harm clinician-patient relationships and even impair medical judgment (Atkinson & McNamara, 2017; Stiefel et al., 2017). Therefore, regular supervision can be highly beneficial with regard to identifying and preventing the formation of collusions.

Finally, in the couple therapy setting, collusion, especially in cases of complementary collusive bonds, may be more easily identified. The main reason is that mating, unlike the clinician-patient relationship, is usually based on free choice and that distressing relationships that nevertheless endure draw attention to a possible collusive bond.

The potential harm to the patient‒physician relationship but also to clinical judgment (e.g., oncologists’ therapeutic obstinacy in collusions pertaining to separation anxiety), motivates us to make use of the concept of collusion in the medical setting. This situation raises the question of what elements are sufficient or necessary to assume that collusion is at work. We maintain that a shared and unresolved issue (i), a defensive loop between colluders (ii), and intrapsychic avoidance through externalization (iii) should be demonstrated.