October 23rd, 2012 admin
Therapist:
Even though I know I’m helping my clients more than ever, and I have more clients than ever, the thought of hearing any more suffering suddenly became intolerable and exhausting to me. I’m not exactly sure what’s going on. Perhaps I’m feeling the responsibility of “healing” my clients too hard – like it’s my job to remove everyone’s suffering. I’m not sure.
Susan:
I think everyone has feelings like you expressed. I have. That’s why I mused about becoming a truck driver or a carpenter. Think of all the pretty scenery you’d get to see while cruising along or finishing a beautiful cabinet that’s utilitarian AND you know when it’s finished! 🙂 Sometimes we may feel like we’re working in ER … so much crisis and pain to witness and hold. And so much hope and expectation is placed in us. You might remember my phrase… warrior therapist. And we really do have to keep working to lower demands and pressures that we unnecessarily place on ourselves, such as “I’m a failure if therapy fails” or “I’m not worthy because I don’t know enough.”) We need plenty of R&R to supplement (do as I say, not as I do). Frankly, there are times when I crave doing things totally unrelated to psychology and need to follow these instincts. How about you?
Therapist:
My last client last night was exhausting. He’s doing tremendously better in all ways, but he asked, “Will I ever be relieved of the guilt and pain and fear I feel toward and about my father if he keeps acting like he does (abusive and always on the verge of self-imposed catastrophe, and guilting my client to save him) for the rest of his life?” I didn’t know the answer to the question and I still don’t. After that, we did a full rage, murder, burial, guilt, grief, compassion, love, etc. portrait re his father. At first afterwards my client said he felt much better, but then he said he felt depressed because, even though he felt better after the portrait, he knew in real life that his father would keep being mean, messing up his life and then turning to my client for help. I felt exhausted throughout the session. That session was the last straw for me.
Susan:
Often the perpetrator returns with a vengeance after great work in the office. People resist change, even when it’s positive. At the same time, there’s a reality that this client probably will always have pain and frustration with his father. What can be tougher than helplessly watching a loved one destroy herself? The good part is that the client says he’s doing better. Maybe defining realistic goals for therapy could help here. It IS realistic that he be able to go through life not being clinically depressed and dominated by her defenses; that he not internalize his father’s attacking projections; that he possibly reduce exposure to his father; that he not unduly ruminate and torture himself over what he is powerless to change; that he engage in self-care and seeks ongoing support from others. It is NOT realistic that he will be free of pain related to his father or that his life will never be interrupted when his father creates crises. Since he loves/cares about his mother, he cannot be unaffected by his suffering, even though his fathers suffering is largely self-imposed. He’s not going to divorce his father, I don’t think, so she will sadly remain vulnerable to feelings of grief, fear and anger. Remember the title, “I never promised you a rose garden”?
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October 16th, 2012 admin
Scroll down to read about the “contagion of shame” (Morrison, Herman). Check out new Gallery photos! Hope to get new training videos posted soon.
WEBINAR on Compassionate Interventions
to Dissolve Defenses
You and your friends are happily invited to attend two of my upcoming events this week and next. It’s my great pleasure to be presenting a Webinar again through the ISTDP Institute with my brilliant colleague, Jon Frederickson, on October 19, 2012,12-3 pm EST. You can register at www.istdpinstitute.com.
I plan to illustrate my own therapeutic style through role plays dealing with specific defenses with Jon Frederickson aimed at dissolving defenses in cooperation with the client. I hope to demonstrate the conveyance of compassion through carefully selected language, vocal tone, facial expression and other aspects of neurobiological attunement. There are other factors too, like how we promote a sense of equality, build upon client strengths and create a felt partnership through healing attachment and authentic, egalitarian relationship between client and therapist.
“Going Slow to Accelerate Later” at LACPA
Also, please join me for my presentation on mindfulness, “Going Slow to Accelerate Later,” as it applies to Dynamic Emotion-Focused Therapy (DEFT) at an LA County Psychological Association event. Follow the link to register.
| Oct. 22, 2012 |
09:00 AM – 10:30 AM |
|
LACPA Conference Room
17277 Ventura Blvd., #202
Encino, CA 91316 |
This will include recorded session material and a slide presentation with a brief overview on Dynamic Emotion-Focused Therapy (DEFT).
I’m loving the expansion of the DEFT/EDT community here in L.A., and feel extremely fortunate to have such great therapists participating! May everyone enjoy the fabulous photos added to the Gallery page, contributed by DEFT participants, as thoroughly as I have, as they capture our joy in learning and in supporting each other on this journey. I also thank each participant for your feedback on the program, which just keeps inspiring me to make the DEFT training better and better.
Please visit
www.warrenwarshow.com to learn about my current, ongoing three-tier training program, “Accessing and Integrating Deep Affect,” held one Saturday per month for 10 month blocks, at the Skirball Cultural Center in L.A. Therapists who feel a strong pull to do this training and have a serious interest… but need to check it out first… have the option to “sample the training” at any point for up to 2 consecutive months before deciding to commit to the program.
“CONTAGION OF SHAME” IN THE CONSULTING ROOM AND IN TRAINING
In our September and October training, we dove into the riveting topic of shame as it affects both clients and their therapists… and also myself (perfectionism perhaps?) as I’ve tackled the daunting task of sharing DEFT/EDT with high-aspiration therapists! Curiously, I’ve had some serious shame attacks myself while taking on this most central subject affecting our work. I endure my own performance anxiety/shame issues for one reason only … this work begs to be shared!
It also strikes me that my own shame experiences may actually be helping me to be even more empathic and attuned to the experience of therapists in training who doubt their competence. Seasoned therapists also have self-doubt and I believe that appropriate humility has advantages for all of us.
One of the topics we covered was “adaptive aspects of shame.” Epstein & Falconier: “[Shame] can motivate people to make positive change.” There is truth in the statement that the more you know, the more you know what you don’t know… which is an invaluable motivator. Therapists tell me it would be helpful for me to show session material that reveals my own struggles and I plan to do so in future trainings.
That being said, we can all celebrate those times when we really make a difference in people’s lives and we have reason to feel deeply gratified to be informed by such great thinkers and scientists as Sigmund Freud, MD, Habib Davanloo, MD, and many others.
It was my awareness of the shame experience in my clients that drove me over the past 10 years to painstakingly craft defense interventions to reflect the most sensitive language, to communicate equality with the client by sometimes revealing myself and eschewing the role of expert, and to convey the compassion that I truly feel around the pain of shame.
I also feel strongly that we are better when we avoid language that is directive or overbearing, “You need to..,” “You must…” “We will…” and remember to ask permission and to honor client choice. This does not have to be cumbersome to the process, as therapists tend to think, and it goes a long way towards building self regard, sense of self and reducing compliance. I know of clients who gained symptom reduction in treatment but retained the same degree of co-dependency/compliance and I think our therapeutic stance can have an impact on this. Generally speaking, “You Messages” provoke shame… “You’re doing it again…,” “You’ve forgotten…,” even perhaps “You treat yourself like you’re nothing.” As i write, I ask myself, could it be preferable to say, “After all those years of being treated like you don’t count, it’s no wonder you have learned to treat yourself as though this is true. Do you see what I mean?” “How is it for you inside to see this so clearly with me?” and “It’s so great you want to turn this around!” Of course, tone of voice and facial expressions are HUGE in their impact on how our communications are received. Do we lean forward or do we appear disengaged? How about an occasional comforting smile or look of compassion?
It was my pleasure to write an article entitled “Slaying the Serpent of Shame” and it contains transcript material on the treatment of a chronically depressed, anxious patient. It appeared in Volume 11, Number 3 December 2007, Page 6, “Ad Hoc Bulletin,” an international journal of the Dutch Association for Short-Term Dynamic Psychotherapy (the VKDP). It can be accessed through the Southern California Society for ISTDP.
So many of our clients feel shame acutely, as they enter our offices with their “shameful” problems. When we focus on internal process, such as anxiety and depression, it inevitably and simultaneously evokes shame as well as relief. I’ve always included toxic forms of shame and guilt in addition to anxiety on the triangle of conflict, as conceptualized by Davanloo and Malan, and have seen shame as a significant factor to be assessed in ego fragility. I agree with Herman that we must learn to “titrate shame” just as we use a graded approach with anxiety. I believe the importance of shame is under-addressed and was so pleased to discover the book, “Shame in the Therapy Hour” by Dearing and Tangney, which I heavily referenced in our recent studies. The authors said that they themselves had little exposure to shame work during their training and supervision experiences on opposite coasts.
Participants in our DEFT program expressed enthusiasm for this topic and all of us felt that something powerful occurred as we supported each other to deal with our own internal shame experiences. We discovered that as we do this, our own performance anxiety is reduced and we are therefore more able to be mindfully present for our clients.
The supervised live role plays were poignant, as our therapists-in-training portrayed client and therapist grappling with the often fragile, intensely vulnerable state of shame, sometimes leading to dissociation and high anxiety. After all, what can be more fear-enducing than the chance of becoming an outcast, stranded and alone. It is especially difficult to stay connected to a positive sense of self that can be separate from an excruciatingly painful state of shame-related unworthiness.Yet the effective therapist seeks ways to speak to the client’s observing capacity that has the power to intervene and save the self from drowning in shame. Shame inflicts not only great pain on the one experiencing it but also on others, as it so often it leads to hostile devaluation, withdrawal and separation.
SENSITIVITY TO SHAME ON LISTSERVE AND TRAINING PROGRAMS
It’s become something of a mission with me to support a therapeutic community that helps each other to refrain from shaming either ourselves or each other. Toxic shame is poisonous to any person or group. Recently, I felt personally challenged to find ways to address communications that I found to be shaming and devaluing on a list serve without engaging in the shaming of others or myself. How do we request that something be changed or corrected without sounding critical? It’s tough. And there’s always the punitive superego, doing its projection thing, that may misinterpret… not to mention the great difficulty communicating feelings electronically. I also want to say here, for the record, that I plead guilty to erring in choice (and quantity) of words at times and that I am by no means above anyone else in needing to work in this area. I didn’t entirely succeed at my endeavors but some very good things did evolve for me personally as a result of taking the risks of exposure, such as some deepening relationships and also learning a lot from the experience.
Brene Brown, Ph.D., had fascinating findings about the links between showing vulnerability and connection to others. Certainly when we communicate in a public forum about a controversial subject, there is indeed vulnerability. And also benefits!
Stadter tells us, “Therapists are vulnerable to shaming and being shamed by clients.” I would add that we are vulnerable to shaming ourselves and each other professionally as well. I have always encouraged my therapists in training to use the listserve as a resource. I may not always be available to answer their questions and others on the listserve can add valuable perspectives. It also takes considerable repetition of certain principles before they really sink into our minds. But some who posted questions about their cases were told to “speak to their supervisor.” It struck me that these are sophisticated people who don’t need to be told they can call their supervisor and who have made an inquiry on the list serve to explore additional ways of understanding their clients. Practically speaking, many therapists don’t have the funds for both training and a lot of supervision. So, it concerned me that these individuals might interpret that reaching out to the list serve was somehow inappropriate and that such information should only be obtained through supervision. Seems to me that a good use for a list serve is to share our expertise with one another and to also normalize our self doubts by sharing our vulnerabilities with each other. There were other areas that also aroused my concern even more and I hope that the lengthy discussion will bear some fruit along the way.
Gilbert tells us “Shame may be a major reason that important material is not disclosed during supervision.” Indeed, this is a clarion call to all of us who teach and supervise to heighten our sensitivity to shame inducing language and tone and to bring shame into the light of awareness for our therapists in training and for ourselves. Interesting, I’m finding myself using the phrase “therapists in training” rather than “trainees” as “trainee” creates an impression to me that doesn’t reflect the advanced knowledge and experience that many “trainees” have. Also, I advocate that teachers of the work promote a sense of equality and collegiality with the therapists we teach, showing a willingness to share our own limitations and stumbles, and also appreciating the way that our colleagues in training often teach us too.
And finally, I agree with the following statement:
“Therapists need to do their own shame resilience work. We need to do the work before we do the work.” Brown et al.
Posted in Conference, Other Topics, Shame, Therapist Concerns, Treatment Process | No Comments »
October 16th, 2012 admin
I received some very good questions for us to ponder and welcome yours as well … I reproduce one here in its entirety and also refer to my article on “How Much [Emotional] Intensity is Good Enough?” See the publications page at www,warrenwarshow.com.
Question re. “How Much Emotional Intensity is Good Enough?:
“Often I have clients, as they move into portraiting a scenario, they move into imagining themselves, for example, shaking a loved one and yelling at them or somehow expressing anger/rage. Then when I ask what’s next, they say that the loved one decides the client is right and the loved one is going to change / reform / apologize, etc. When they imagine the loved one reforming or apologizing or changing their ways, I double-check, asking if this is just fantasy or wishful thinking. “No,” my client answers, “I really do imagine him/her changing / apologizing, etc….” But IS this a fantasy defense?
The imagined reformation of the loved one or friend or boss etc. pretty much stops the action. In other words, we don’t move into a full portrait with the death, guilt, shame, regret, love, closure, etc…. I ask, and maybe there’s a little “guilt light” or “regret light” or words they want to say to but no, they don’t feel guilty, remorseful, or anything….They feel:
- relieved, better, happy, hopeful and that’s pretty much the end of that
- SOMETIMES a couple minutes later they feel fearful that the loved one will revert – in which case I try to lead them into a futuristic scenario with mixed results.
Although I’m finding the EDT/ISTDP/DEFT treatment style helpful to my clients, I always want to maximize the efficacy.
Do you think the above is effective? Is it necessary to go through the full portraiting every time to be effective? I know I can’t FORCE the client to go into the full deal, but is what I’m doing helpful? It SEEMS to be…but I wonder…
They ARE getting in touch with their feelings and they clearly feel relief, empowerment and pleasure at expressing them. I haven’t usually noticed left-over guilt (with a couple exceptions) or stuff. Usually the external relationship improves.They ARE getting in touch with their feelings and they clearly feel relief, empowerment and pleasure at expressing them. I haven’t usually noticed left-over guilt (with a couple exceptions) or stuff. Usually the external relationship improves. And we can always go back in a future session if more comes up. Or is just expressing their feelings in this way helpful?
So, I wonder:
- Do you think this sort of “half-portrait” is effective? Is it always preferable to go through the full murder every time to be effective? Or is just expressing their feelings in this way helpful?
- I know I can’t FORCE the client to go into the full deal, but is what we are doing helpful enough? I always want to “INVITE” them to express their feelings, not pressure them…
SUSAN’S RESPONSE:
I remember a therapist in training asking, “Do we have to do those damn murders?” She of course was asking whether healing treatment can take place if we don’t unearth the full range of complex feelings within our clients. The article I wrote and linked to above shares some perspective from Dr. Leigh McCullough’s research. From my personal experience, the more a client can uncover their full emotional truth as it resides within their body, the greater is the relief (e.g. freedom from anxiety and shame) and also the greater is the insight and integration related to feelings associated with early trauma. However, healing is relative and all gradations of healing have value.
When a client imagines in fantasy, after experiencing an angry impulse, that the loved one reforms or apologizes or changes their ways, I recommend exploring to see if the client is engaging in fantasy or wishful thinking in the service of defense. If they say, “No, I can really imagine them changing….” I would ask if this feels true to the character of the person they have angry feelings towards and remind them that being absolutely honest with themselves is crucial to healing. So, I might say, “Would Dad truly respond this way to the impulse you just portrayed?” Frequently, the client will recognize they using the defense of avoidance.
Also, the body holds the true answer to your question. If the client “stops the action” while there are signs of residual anxiety and holding in the body, then they have not released the full impulse. It is important to check to see if they feel a full release of impulse from within the body. The primary point is to see what they are truly feeling in a given moment towards a certain figure regardless of how the other person might be responding in fantasy. The client might visualize Dad apologizing, which will probably induce guilt, but this doesn’t mean that all the rage has been released from within them. If there is more inside, then we need to address the toxic guilt over feeling.
It is terribly important that we seek the truth of the client’s feelings as they reside in his body. The truth may be that the client does not feel primitive murderous rage or it may be that she does. What is true? The body will tells us so long as the person is sufficiently freed of toxic shame, guilt and anxiety to explore their internal experience without censorship or restriction.
That being said, I caution those who train with me to refrain from portraiting primitive murderous impulses without a fairly good idea how they will handle intense complex feeling as it breaks through… we need to be prepared to deal with the guilt and the defenses that often follow upon this experience.
REFRAIN FROM ALL OR NOTHING THINKING
So, to your question, “Do you think this sort of “half-portrait” is effective?” For a patient who is detached from feeling and is therefore unable to name it, the very act of identifying a feeling is progress and worth appreciating. There is healing in the experience that the therapist is interested in what we feel and conveys the ability to hold and to value all that we feel. When the patient is able to name their anger and the therapist does not pull away, this begins to lessen fear and shame around emotion.
In the cases you described, your clients have been able to connect with the motoric impulses that accompany their feelings in addition to naming them. This is great as it provides yet a further level of emotional expression, intimacy and self-awareness. Excellent. Moving towards fuller portraiting with some clients may require additional skills, as I’ve suggested above, or in a particular client’s case, it may not be applicable as not everyone has pmr to process. I admire your commttment to “maximize efficacy.”
That being said, I would celebrate the fact that, as you said, “They ARE getting in touch with their feelings and they clearly feel relief, empowerment and pleasure at expressing them. I haven’t usually noticed left-over guilt (with a couple exceptions) or stuff. Usually the external relationship improves. And we can always go back in a future session if more comes up”.
When you ask, “Or is just expressing their feelings in this way helpful?” I believe you have some impressive evidence that it is, such as “Usually the external relationship improves.” Trust your client’s feedback above all else. Congratulations on your successes.
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