Many Masters
March 21st, 2012 adminAnnouncing New Events!
First presented in 2006 and back by popular demand, my special one-day event, “Penetrating Defenses to Awaken the Self,” will return on 6/9/12 at the Skirball Cultural Center in L.A. and on 6/16 at the Embassy Suites-LA in Glendale. So, finally it is here! Several video analyses will reveal the riveting road to buried affect, as patient and therapist grapple with sabotaging forces that resist emotional intimacy. I’ll also be presenting to the dynamic SFV Chapter of CAMFT on Sunday, April 15, from 9-11, on “When Therapy Stalls.” Also, there are few time-limited openings for my current training program, “Accessing and Integrating Deep Affect,” held one Saturday a month at the Skirball Cultural Center in LA. Register for all events at my website, www.warrenwarshow.com.
The Dilemma of Practicing Without “Answers”
My priorities for this post keep shifting. My first intention was to respond to the excellent questions raised by the marvelously dedicated therapists who began studying with me and then concurrently with others. They also made me aware of the confusion they are experiencing as they seek the expertise of “many masters.” So, suddenly I had two topics for this post and I will begin by exploring the latter.
Many Masters
I’m reminded of my own years in training and what it was like to be taught by several great teachers. In spite of their many similarities, I encountered the ways in which they inevitably contradicted each other through variations in interventions, timing of interventions and personal style. Sometimes there would be both positive and also negative evaluations of the same piece of material. While I found advantages to the range of exposure, I also oriented myself to a primary teacher to shepherd me through training. When I came to a fork in the road in a given session, I had to choose one path, one intervention in the moment. That being said, I also celebrate integration, when the timing is right at our stage of professional development.
The Teacher Within
As a trainee, I felt almost desperate at times to know the “right” thing to do as each new client presented a different challenge. I’d jokingly say, “I did the right thing but the client didn’t follow the script!” Some things changed for me with increasing experience and awe for the unknowable. While I still eagerly embrace the exciting discoveries of psychotherapy researchers, I no longer seek certainty (or see it as possible) given the complexities and mysteries of the mind and human relationship. I find substantial relief in this point of view. I’m also amazed at the information and guidance that comes to me in moments of stillness with a client, how something pops into my brain that takes us on a fruitful path. While not a formal researcher, I closely observe and experiment with my clients, relying heavily on “response to intervention.” I also appreciate and identify with the desire to master a structured approach with empirical validation. But within those principles we choose to adopt, there are surprising spaces for spontaneity. To my delight, many useful interventions that came to me in session gathered research validation or were written about by others without my knowledge.
Dr. Robert Neborsky’s comment, “Your work is best when you remain intuitive,” remains my cornerstone. I urge therapists to also tap into their own wells of creativity (assuming a foundational knowledge base, of course) and allowing unexpected “answers” and discoveries to present themselves. I find rigid theory of any persuasion to be an anathema and deadening to an otherwise amazing, dynamic process between two human beings, perhaps best described by Martin Buber as the “I-Thou” relationship. We should never push ourselves into a mold that doesn’t feel right from the inside, even when we have rationales to do so. Chew on each new teaching but don’t swallow anything that you’re not ready to assimilate.
Absolutism in Theoretical Orientation
Absolutism is based on a mirage that there is but one path, one correct way. That being said, teachers of a preferred approach tend to be highly opinionated, so that is well to keep in mind. It may be well to remember that Davanloo, whose theories influence my work and those in our community, did in fact ex-communicate just about all who studied with him and disapproved of aspects of everyone’s interpretation and application of his work. Also to be remembered about Davanloo is that his Central Dynamic Sequence, a powerfully effective series of interventions, were based largely on observation and feedback from his patients, who were meticulously and systematically interviewed during a time span of 40+ years. Jon Frederickson, a brilliant therapist and teacher who studied directly with Davanloo, stated that many of the theoretical questions explored below were never fully clarified by Davanloo. Ambiguity and personal bias can be found in all psychotherapy theories and practices but this does not have to diminish their value.
All opinions stated in this post are expressed with humility and the utmost respect for esteemed colleagues who may disagree.
Anxiety’s Relation to Feelings
Anxiety, according to Davanloo, is triggered by forbidden and painful complex feelings, activated in a current relationship but linked to a primary attachment figure. In other words, feelings that have a history of being responded to with rejection, contempt, withdrawal, etc., become too frightening to the child and later the adult to allow into awareness. Distancing defensive maneuvers to ward off a replay of relational pain often follows symptoms of anxiety.
Bridget Quebodeaux helps all of us with her probing questions and observations, e.g.,” I don’t see the feeling as coming up and the anxiety as coming from up to press down on it as you describe in your layer model. I see both feeling and threat response (anxiety) as coming from below—and when a system is healthy, the threat response is regulated and the feeling gets through the gate to be evaluated and responded to which will bring the system back into equilibrium/relief. When the anxiety is not regulated (the system has a tendency to be overwhelmed) the gate gets shut and the feeling cannot be evaluated and responded to. And defenses must be employed to manage the anxiety/bring the system back into a state of equilibrium. In my mind they both (F/A) rise from the bottom but anxiety gets to the gate first and shuts it. “
I don’t think Bridget and I are seeing these phenomena that differently, and there’s an issue of semantics. I do see anxiety as creating a “static on the airwaves” that interferes with a clear reading of the feeling signal. So, does anxiety interference “push down” on feelings, coming from the higher brain? I envisioned the “layer model” of anxiety as a cloud cover for feelings but not as part of the higher brain. Anyone who’s been highly anxious knows it overtakes everything else. The anxiety response does occur in a millisecond alongside core affect and both are primitive, coming from “below” in that sense. But the anxiety would not occur were it not for the immediately threatening rejection response to feelings that were originally intolerable to the parent and subsequently to the child. So, to my way of viewing this, the rejection of feeling occurs first and is the stimulus for fear. The physiology of fear and anxiety are not different. However, I differentiate core fear as being reality based and anxiety as a form of fear that may have been reality based at one time but no longer poses a rational threat.
This concept of causality is important to our patients because, once they make the link (forbidden feeling leads to anxiety), it becomes possible to separate their fear from their emotions. As an example, if I become anxious each time a dog enters my field of vision but don’t recognize that I’m having this reaction because a dog bit me once, I then have no power over this reaction. If I can examine the causality, I then can recognize that I am anxious because a dog entered the room and can differentiate between what kinds of dogs pose a true threat and which do not. The fear response will no longer be automatic and it becomes possible to regulate.
Does Guilt Over Rage Lead to Self-Punishment?
Bridget also asks, “In your opinion/in your model is the purpose of a defense to protect us from avoided feeling [and the unfortunate by product is self punishment]? Or is the purpose of the defense to punish the self and fear/anxiety is part of that mechanism? Or both?” There is tremendous complexity in any attempt to answer this question, and I will offer some perspectives here.
Defenses are fear-driven mechanisms… a child’s learned or devised antidotes to the pain of anticipated rejection, separation and unbearable feelings. From this perspective, defense is not a conscious attempt at self-punishment but rather a way to contain and divert dangerous emotional currents that threaten to erupt and destroy the attachment relationship.
Some ask if there is agreement that guilt over unconscious murderous rage causes the avoidance of complex feelings and leads to self-punishment? There has certainly been much theorizing on this question. Patients who have viscerally connected with murderous impulses towards figures they also love typically tell us or show us that they feel guilty. This is often made apparent by some version of, “I’ve done a terrible thing.” “How could I feel this way? My Mom did so much for me.” “I have no right to succeed in life when she was always miserable.” “I shouldn’t have talked about her but should keep the family secrets.” “This proves I’m a bad person and why would anyone want to be close to me?”
People do in fact begin to isolate themselves, place themselves in “solitary confinement,” and engage in a variety of behaviors to insure that no one gets close to them. They may recklessly abuse alcohol and drugs, gamble their financial security, jump from bed to bed, or literally kill themselves to destroy the self they believe to be disgusting and worthless. This can certainly be seen as guilt, both conscious and unconscious, leading to self-punishment. However, these self-destructive paths are embarked upon without the awareness of an available alternative. The person has internalized the coping mechanisms, which the parent(s) modeled, and also the self-hatred that was projected onto them (parent has contempt for himself and treats child with the same contempt or neglect).
When murderous impulses are uncovered in therapy, the patient often shuts down the emerging grief over the losses experienced in the relationship with that parent. There is a sense that, “Mom and I missed so many golden opportunities to be close and they can never be recovered.” However, this grief is stifled due to a return of defenses, which by nature harm the self that wishes to be open and free. Often there is also grief over the damage done to the self as a result of certain parenting practices. “Now I’ve had all these years of anxiety because my Dad had an explosive temper and it was completely unnecessary.”
However, guilt, shame and anxiety can shut down the grief, causing the patient to stifle his emerging feelings and withdraw from the therapist, which can be viewed as self-punishment. But I would rather describe this as inadvertently hurting the self. Some of my patients speak of their defensive parts with tenderness, not because they see them as good, but rather because they were primitive attempts to protect them, like a worn, tattered blanket that kept them warm as a child. Typically, the patient is not making a conscious decision to harm himself but that is nevertheless the result of their primitive defenses.
Two powerful cures for this kind of guilt over rage include internalizing the therapist’s empathy for these emerging feelings, normalizing the rage and welcoming the grief, and also discovering the intense feelings of love and essential goodness that lay beneath the rage (i.e., seeing rage as a righteous, inevitable, hard-wired protest against separation and loss). Rage can then be viewed, with the therapist’s help, as a conqueror of that which threatens attachment and closeness. It can be seen as a protector, a fighter for good, and a force that can enliven and energize the self in vital and necessary ways.
On the subject of rage converting to self-destructiveness, I frequently (not always) find that murderous impulses are a direct mirror of rage that has been turned against the self. A woman with migraines has unconscious desires to bang her mother’s head against the pavement. A man who gets shortness of breath has impulses to choke his father. A patient with jaw tension has impulses to bite and rip with his teeth. Do we conclude that guilt over rage therefore turns to self-punishment? I would say that what results from repression of feeling, often due to guilt and fear over feelings, is inherently self-harming. But there is a difference between that which is self-harming and that which is self-punishing. Most people don’t set out to harm themselves but to escape the unbearable. Even self-cutting can be a way to feel alive or to alarm others to gain needed attention or to be a release for unbearably painful feelings that have no other channel. Intense emotions demand loving awareness, which in itself brings release. Loving awareness = release. Loving attention to feelings and anxiety and defense = release and healing. From my perspective, this is an enormous amount of information to guide our work.
Additional perspectives on guilt from Maneet Bhatia: “Others feel guilty for having joyous feelings or having self-compassion e.g. ‘I would be cocky or arrogant and that is not good.’ ‘I am a selfish person when I think about myself.’ [Or, someone may feel] ‘guilty because they were sexually aroused and then shame because it makes them a “bad” person.’ So guilt is one of the many reasons why we avoid feelings from an Affect Phobia Therapy perspective.”
Another question: Does guilt belong on the defense pole of the triangle of conflict since it self-inhibits? I see anxiety, shame and guilt as being inhibitory affects, actual feelings and therefore not defense mechanisms as traditionally defined. I’m sure there will be additional ways to look at this.
Healthy Remorse
And finally, there is the form of guilt that we can describe as healthy remorse. This is guilt not over forbidden feelings (i.e. we see feelings as forces of nature that should not be judged), but rather guilt over actual actions or neglect that harmed another. There is a value to this type of healthy guilt when it motivates us to change and become more caring towards others. When we become aware of substantial pain we’ve caused others, whether purposeful or due to lack of awareness, there is a need to grieve. This type of guilt-laden grief would be correctly placed on the impulse/feeling corner of the triangle of conflict, therefore guilt as core feeling rather than an inhibitory affect.
Is it effective to inquire into the patient’s goals for treatment if defenses are ego-syntonic?
I believe that it is. True, the patient may be unable to assert a healthy goal because self-contempt or sense of unworthiness precludes this. However, inquiry into goals and aspirations uncovers where a patient is blocked as well as patterns of self-neglect, self-minimization and devaluation and lack of self-awareness. This provides the opportunity to bring this sabotaging process to the patient’s attention, in a kind and caring manner, which often mobilizes an increased alliance with one’s healthy strivings and with the therapeutic process. This also raises the important question whether the therapist or the patient should determine the problem to be addressed?
We can begin by highlighting a problem that we see, “Are you aware that you’re anxious?” and lead the patient towards a goal in this way and get good results. In the DEFT approach, however, the results are not all that matter. This may sound peculiar but there is an issue of showing respect for the patient by giving the patient’s observer the leadership position, even when the perpetrator is dominating. So, when we begin by asking, “What is it you hope to gain, internally, from our work together?” we give the patient the leadership position. I do not want to explore the patient’s anxiety or defenses without first gaining his permission to focus internally. This often evolves once the patient becomes aware that he does not have the internal focus to state a goal and is sufficiently bothered by this to work with the therapist to change this pattern of self-neglect. Again, we can arrive at similar places with different approaches, but I prefer to lead from behind.
Can the therapist’s empathy drown the patient’s healthy force?
Absolutely, if there is not a simultaneous focus on the patient’s lack of empathy for self. I’ve often said to a patient, “My caring alone will get you nowhere.” That being said, many patients have told me that the compassion they see in my eyes, in response to suffering due to anxiety and defense or for the pain of their attachment traumas, has allowed them to internalize this soft and caring response towards themselves. It is my sense that most therapists do feel empathy for their patients but that it may not come naturally to express it. Practice can make us better at anything. It is certainly valuable to practice showing empathy and respect by increasing the softness in our voice, by directing less, by holding a caring gaze, and by openly engaged body language (uncrossing our legs, sitting forward, etc).
There is fear and sometimes disdain amongst practitioners for the “overly” positive affects that a therapist may demonstrate to a patient. While a therapist can overwhelm a patient with positive feelings, this greatly depends on timing and attunement to a particular patient. If the patient responds with defense to positive affect, this then becomes yet another opportunity to explore the complex feelings aroused (a “pocket of rage” as mentioned by Abbass in response to love). At the same time, a patient may respond negatively if we appear to lack empathy or come across critically or with superiority, which is not always a projection.
Is it OK to have loving feelings towards a patient?
If we become a lone cheerleader and take full responsibility for treatment, we not only overwork but also can actually overshadow or dampen the patient’s healthy side. We must help our patients to differentiate the parts within that are healthy and the parts that harm the self, thereby creating an intra-psychic struggle. Sometimes our patients are not aware they even have a healthy side, and I teach numerous ways to raise this awareness and thereby instill hope. We present the patient with the choice to recognize their achievements, such as the fact that are in a recovery program or have married a loving partner. Ultimately, it is the patient’s right to choose which part they will allow to dominate. The patient is the captain of her ship, whether she sees that or not, and we should never usurp that role.
When a patient gives us access to their most vulnerable parts, sans defenses, sometimes occurring before and sometimes during breakthroughs to core affects, this intimacy often generates warm, close, even loving feelings within both patient and therapist. It just does. Should these feelings be revealed? The avoidance of such feelings can be a defense against emotional closeness. The expression of mutual, deeply felt appreciative feelings between therapist and patient can indeed be a joyful celebration of deepening connection made possible when defenses are relinquished. It is crucial to be aware if the patient’s healthy force is on board and is a true, engaged participant in such an exchange.
