Speaking with Susan: Do we underestimate ourselves?
January 29th, 2014 adminDo we underestimate ourselves?
A therapist is concerned that she is not qualified to work with an extremely fragile patient who frequently dissociates and enters fugue states. Others have suggested she refer her client to a specialist in fugue states, thinking this therapist does not have sufficient expertise to work with her. In a listserv exchange, I inquired about the strength of the bond that the patient has with her and the therapist said that not only was it a strong attachment, but also that the patient is responding positively to treatment. The exchange went like this:
Susan: Without doubt, this traumatized patient is paralyzed around her feelings and the prospect of relational closeness. Nevertheless, I’d be most curious what she would say about her work with you thus far. I have seen completely unexpected and significant changes in people I viewed as hopeless for me to help, such as severe bi-polar and borderline patients, and some individuals with frightening psychotic process. Healing can be activated in surprising ways and sometimes we place more importance on our ideas rather than the client’s own assessment.
Once I worked with a schizophrenic man during my internship at Berkeley and I had just about no knowledge of this severe disorder. We’d sit on park benches in Menlo Park and I felt like I was babbling as he spoke in an obscure language I could not understand. I take no credit, but this man developed a level of functioning that impressed even my supervisor. He was able to leave the hospital and move forward to a completely new level of independent living. Something positive had occurred between us that I felt to be very real, yet I could not have quantified it.
Regarding your client with fugue states, I would not ask repeatedly for feelings as many people feel shamed when asked to identify feelings and they cannot. I would also reflect this shame when I intuit its presence and do self-other restructuring where it may be called for. Is she projecting that the therapist sees her as lacking or is judging her? Can she make room for her fears and moments of dissociation to exist and show compassion for her traumatic life experience that created these states in the first place? Could it be possible to allow for a non-judgmental awareness and curiosity that these states became necessary to ward off feelings too intolerable to bear for her caretakers and also for herself? Might she appreciate that she has the capacity to observe these states with the therapist? I would recommend emphasizing her courage in being able to share with you her frightened and defended internal state and wonder how it is for her to expose so much to you?
I would show appreciation for her strong motivation to show up to do deep work in spite of such formidable obstacles and carefully track her responses to such positive input.
Since my hypothesis is that shame is central for her, I would slow down with her, being as much in neurobiological attunement as possible (speaking slowing, carefully tracking moment to moment phenomenon, and commenting on subtle signs of rising feeling within her. I suggest conveying both implicitly and explicitly that it is ok to be where she is in the present moment. This is a woman with no awareness of her strengths, and yet she is demonstrating them impressively. Any signs of heightened risk taking in her attachment relationship to you are important to notice and build upon. Can she join you in greater appreciation and acceptance for herself? She will undoubtedly have resistance to this, and revealing to her that this pattern of withholding caring attention from herself is the first step in working meaningfully together.
Of course, if her assessment is that she experiences no movement in a reasonable period of time (which is not the case), then of course other treatment options would be indicated. However, I think it can do harm to not attend to her attachment to you and to her own feelings and observations about her work with you.
I also believe it can be harmful when we as therapists underestimate our own gifts and abilities! It’s great that you are so aware of her defenses and are obviously a most keen observer. I also know you to have great relational capacity and healing ability. Susan
Postscript: it was discovered that the client did not want to transfer from this therapist and her fugue occurrences dropped significantly in the course of treatment. Also, I just received a call today from a therapist who is attacked by self- doubt over working with a most impressive client. Yet the client chose him for obvious reasons. Our work as therapists involves not only helping our client’s to stop defeating themselves, but ourselves as well. Again, our ideas about our abilities and worth may have little relation to reality. And let’s remember that part of our work is to help clients to see that they are “good enough” and that we are too!!
I’d like to share a blurry snapshot of a photo I took with my IPhone of a full moon that was actually quite crisp. The vision was extraordinary to see and it stopped me in my tracks. As I reflect on it now, it came to me, “How can we possibly be any place but where we are?” We are intended for this moment. We are only asked to awaken.
It’s been increasingly freeing to separate myself from my mind, as I witness so many errors of its ways. It’s a magnificent tool but hardly a reliable authority on much of anything in any absolute sense. It tells me what is impossible and what I am incapable of and then it is proved wrong. I wanted to share this lovely moment so we might all remember our larger destiny.
