Speaking with Susan on a Vanishing Therapeutic Alliance
July 19th, 2012 adminScroll down for some Q & A.
The last several months have been hectic with 4 events back-to-back, as I’ve been presenting topics related to Dynamic Emotion-Focused Therapy (DEFT). It is great to be revisiting my blog as there’s lots to share, especially some of the powerful experiences that occurred during my special events, “Penetrating Defenses to Awaken the Self,” in L.A. and Pasadena on 6/9 and 6/16/12. I met so many lovely therapists who were exposed for their first time, or perhaps becoming reacquainted, with a therapy that accesses and integrates buried unconscious affect to have practical benefit to the patient’s current life. It was thrilling to feel the appreciation of many who will be bringing new energy to our L.A. community.
I had elected to show recorded session material of three patients who had suffered severe childhood trauma. They do not represent all of my clientele, but getting results with these highly resistant and fragile individuals can give all of us hope in the efficacy and wide applicability of depth emotion processing and integration in treatment.
Initially, as I looked out at the audience, seeing faces that were new, many seemed impassive and inscrutable. Why wouldn’t they be? They had no idea what to expect, perhaps anticipating a typical seminar that is primarily cognitive and intellectually abstract with a few brief illustrations of trauma work, since I’d promised recorded session material.
I looked for ways to prepare them for the intensity of emotional experience they would be witnessing, sometimes excruciatingly painful but also loving and joyful. They would also see an active therapeutic style utilizing targeted interventions for anxiety and defense as well as a high level of emotional engagement between the therapist and patient that would cause many to feel at times anxious, intimidated and overwhelmed. A few would be critical but many others would be inspired by the patient’s experience of accelerated recovery.
As the day progressed, I was very happy to see heads shaking up and down with apparent agreement and pleasure, smiles breaking out as we watched traumatized patients moving beyond their painful family history of isolation and restriction towards a greater capacity to connect. And then I began to see a number of people dabbing tears from their eyes. I was particularly watching one young man who had seemed quite stoical, causing me to conclude that he would probably remain unmoved and might even react negatively.
(Sometimes I puzzle over the fact that there are always a few who will dispute or judge the process that has obviously worked to change lives for the better, according to the spoken word of clients during their termination and follow-up sessions… clients with entrenched and challenging difficulties at the start of therapy. But beyond the testimonials of these clients, we see from recordings that their lowered anxiety levels is observable in their physiology; their newfound freedom of emotional expression is apparent; and the positive movement in career and/or relationships is a demonstrable reality. I’ve always felt that the assessment of our clients about their therapy, backed by positive feedback and response by friends, family and co-workers, is perhaps the best data we can have. This is why I recommend checking periodically with the client for his/her satisfaction with the therapeutic work. There is in fact data to support that this practice enhances positive outcome).
But back to my young man. Late into the afternoon, I was most surprised to see him choking back great feeling… he looked like he would cry outright. I was happy that my initial impression of him had been wrong. Many came up to me to express that they had had a profound and unique experience of a seminar.
ASKING SUSAN (I invite my readers to dialogue with me about their dilemmas) …
Turning to an inquiry I recently received from a therapist in training:
She says that her patient has a “KING KONG sized PSE. Some sessions, he is able to see the differentiation…then other times he refuses to. He continues to beat himself up in numerous ways. Some sessions he shows up and cannot identify the goal. His PSE is front and center and will obliterate any work previously done. He will dismiss the goals that were set in a different session and be adamant about ‘being a piece of shit’ and not wanting to talk about it.”
“I should say that I notice a pattern in people that were sexually abused as children AND the great difficulty that they have in identifying and being compassionate towards a healthy self. I am consistently having to form a new therapeutic alliance…sometimes he wants to work together, while other sessions he just wants to leave. Some days he does in fact do just that….LEAVES after 5-10 minutes.”
First and foremost, when a patient is not in the room, we cannot help him! When a patient goes from session to session without absorbing the work that has been done, we need to address this with the patient. What does the patient want to do with this disengagement from the therapy and from himself? If it continues, nothing will be accomplished. We can ask at the end of our sessions, “What have you taken from today’s work? How do you see yourself applying it in the coming week? Shall we check next week to see how you’re progressing?” If there continues to be no integration of the work from session to session, this particular patient may have a borderline personality disorder, an addiction, or another character disorder that will respond very slowly (if at all) to psychotherapy. In such a case, we need to lower our expectations and remember that we can only do our part in the process, not play both roles!
This therapist also wants to know what to do when her clients are moving into breakthroughs of unconscious affect but then back away from going deeper. She is frustrated when they don’t quite get there and I empathize. Often in the learning process we can feel so close and yet so far. This therapist may be helped to remember that we draw on the same powerful tools during and after breakthroughs that we’ve used in the phase of inquiry and throughout the treatment. We continue to address defenses and anxiety. Something like, “Your feelings are right there in the impulses in your hands. Hope you don’t abandon them again. Rather than go limp, would you be willing to let that energy move through you and out of you?” If a strong fist forms, ask what it would look like in a fantasy to release it.
Timing of interventions becomes even more important during a breakthrough to sustain the momentum as feelings are ready to surface and release. Be alert and prepared to intervene immediately if the process is slowing. We may emphasize our words more, such as encouragement, “You can do this,” “You’re doing great,” “We can handle this together.” “Remember why you’re here.” Keep interventions succinct, if possible. Speak to the right brain where images and feelings reside, not left brain with linear thinking and cognitions. That is, don’t get the patient off on a thought process. Instead, say something like “So, if you stay with this image of your sister standing defiantly in the garage…”
One highly esteemed colleague remarked that there is a fundamental simplicity to applying ISTDP theory. I get this. We address what is in front of us in the moment, i.e. feeling, anxiety, shame, guilt, defense. At the same time, anyone who’s ever practiced ISTDP knows that there’s nothing simple about learning to practice it and that, as stated by another teacher, it is in fact “deceptively simple.” I’ve mused about this apparent contradiction and concluded that both statements are true. Paradoxically, it IS simple while also being “deceptively simple” to actually apply in practice. Why? Because we have to recognize so many phenomena at once. But once we can “see” these phenomena, then there is an elegant simplicity to the whole process.
Let me summarize (and perhaps simplify) the basic principles!
When the breakthrough process is stalling, we need to ask…
1} Is the client connected to a cherished goal in his therapeutic work? Do we need to go back to stage one and lay the groundwork of clarifying a clear and realistic goal? Or have we laid the foundation well and the patient just needs a reminder, “Do you continue to fervently want to be free of this crushing depression that has been sucking on your life force for twenty years?”
2) Has the therapist done her part in educating her patient fully about the specific suffering caused by the client’s distancing behavior to avoid painful feeling, as well as the price of inattention to anxiety symptoms? Is the patient fully aware that when he submerges rage, he will also miss out on the full potential to feel love and joy and to actualize his dreams? Does he realize that it’s not possible to pick and choose feelings without limiting access to all of them, thus leading a limited existence?
3) Reaffirm the task, making clear what must be faced if the client is to have a happier future: “Then we must not abandon any part of you. It will be necessary to stay focused on your important feelings if we are to help you towards your cherished goals.”
4) Mobilize the patient’s will. “Is it your choice to continue then?” (Really make space for the client to “choose.” Don’t presume anything or insert one’s own needs). If the answer is yes, set the stage to go forward: “OK, so let us be aware that as you dive into your feelings and then tighten up or try to turn around, you will not enter the water smoothly and may in fact hit some hard places that have left you feeling like you are drowning.” (i.e. a metaphor for a return to detachment, loneliness, emptiness) “Is it your will to stay focused on your feelings this time and not turn back or move away when they are painful?” If the answer is, “Yes,” we can say, “Then, shall we be vigilant together to catch those moments when this occurs so you will not be defeated?”
Another question for Susan…
“Flashbacks and PTSD following an abusive relationship….Is this an internal emotional problem? If so, how do I conceptualize reoccurring flashbacks and apply DEFT?”
Yes, this is an internal emotional problem that begs clarification. I would frame the issue for the client by explaining that her flashbacks are an unintended form of self torment that occur because her feelings towards her abuser have not been worked through. She will need to face her feelings towards her abuser and turn away from these flashbacks to be free of them. Also, what are the specific anxiety symptoms of her PTSD? Once these are identified, she will need to recognize the need to actively attend to her anxiety symptoms to allow her fear reactions to subside. Does she want your help in becoming more attentive to her feelings and anxiety so she no longer enters into abusive relationships and thereby traumatizes herself? If so, then you have a clarified emotional problem to work with in therapy.
P.S. Will answer question on dealing with sexual feelings towards the therapist next time.
