Join Susan in Boston and Los Angeles

VIDEO DEMONSTRATIONS with SUSAN WARREN WARSHOW

IEDTA Conference, Boston

Sept. 26th-28th

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LACPA Convention, Los Angeles

Oct 19th

IEDTA Conference

REGISTER

IEDTA CONFERENCE:

From the IEDTA website: The conference is divided into sessions, typically three hours long, most of which will focus on our theme of new frontiers in EDT. Each session will feature contributions from several presenters, and all clinical presentations will be accompanied by video of actual therapy sessions. Conference-goers have an unparalleled opportunity to sample a wide variety of stylistic variations in the practice of EDT. Because the conference includes patient video, it is open only to licensed professionals and students in full-time training to become licensed professionals.

We are very excited about the slate of presenters, which includes most of the leading figures in the Experiential Dynamic Therapy field, along with contributions from other colleagues from around the globe.

LACPA CONVENTION:

Connect. Collaborate. Get Inspired!

When: Saturday, October 19, 2019, 8:30 AM – 4:45 PM

Where: DoubleTree by Hilton Los Angeles Westside

Featured afternoon speaker:

Scott Miller, Ph.D.

Topic: Achieving Clinical Excellence: Three Steps to Superior Performance

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Surmounting Shame

As many of you know, I’ve had a particular interest in studying shame on a case-by-case basis for at least 15 years. Shame is now emerging from the shadows in the therapeutic world, as more therapists are writing and teaching on this topic and the empirical research is burgeoning. I’m excited to discuss and illustrate how I work with shame in two upcoming presentations featuring analysis of recorded clinical material:

Shame in Psychotherapy: Bringing Theory to Life

Susan Warshow, LCSW, LMFT

June 25-26 2015, Aarhus, Denmark

Information/Registration: sonne@aarhuspsykologerne.dk

Penetrating Defenses and Surmounting Shame

Susan Warshow and Jon Frederickson

Sept. 26-27 2015, Los Angeles, CA

Information/Registration: www.ceuregistration.com

Shame derives either from not being seen or being seen as unworthy… and left alone to crash about with emotions that can only be resolved through connection to a caring other. Shame is one of the most torturous emotions to experience and can be highly delicate to respond to therapeutically. It’s been my consistent observation that when the feeling of shame can be brought to immediate awareness, in a manner that evokes tenderness and compassion for self, there is noticeable relief from tension and anxiety. This includes both client and therapist shame.

I’ve had a number of exchanges with colleagues who hold the view that shame equals self-attack and that we want to help the client to turn against this self-punishing process, e.g. “Now you attack yourself with shame.” While there is often self-devaluation involved with shame and there is unquestionable efficacy to this theory, we might also ask, “Who is doing the devaluing?” There is evidence that this collapse or retraction of self can occur in infancy and throughout life as an implicit state of being with non-verbal manifestations.

Allan Schore describes a “surface, verbal, conscious, analytic explicit self vs. a deeper nonverbal, non-conscious, holistic, emotional corporeal implicit self.” He states, “The ongoing paradigm shift from the explicit cognitive to the implicit affective realm is driven by both new experimental data on emotional processes and updated clinical models for working with affective systems.”  A defenseless child or infant incorporates shame as a bodily experience and body memory, e.g. an instant introjection of the scathing or disgusted expression on another’s face, especially when the experience is repetitive. The verbal conceptualization is a secondary process. For me, understanding shame through this lens captures the complexity and the relational component to the shame experience more completely than the concept of “self attack.”

The first tape that I presented at an International Experiential Dynamic Therapy Association conference showed a painful, painstaking process in which the male client was trying to tell me with great difficulty about a shameful, self-defiling behavior. Dr. Robert Neborsky told me that he felt a change moment occurred when I expressed unscripted, deeply felt, spontaneous sadness over his self-harming actions. A wordless world of feeling was communicated through the eyes, an antidote to the unseeing eyes of his mother. These moments form new body memories.

Communication experts have long recommended we not use “you messages” because “you” messages have a tendency to make people more defensive. Sometimes when we say, “Now you attack yourself with shame,” our client may respond with “Not only am I ashamed of my failure but now I am also ashamed of shaming and attacking myself.” There are many ways to help a client to transcend shame states both non-verbally and verbally, especially with careful attention to language and prosody. I will illustrate this process with video and lecture when I speak on this topic in more depth in my upcoming presentations on shame. How about using our creativity to think about more shame sensitive ways to comment on shame? E.g, “How sad this sense of unworthiness seeped into your body from the time you were a small boy, and now it feels like a real part of you. Someone must have passed this on to you but have you considered you no longer have to carry this raggedy robe around with you for the rest of your life?” Or a shorter version: “So would you say that we’re seeing that learned shame mechanism attacking you again?” “How do you feel about this? How would you want to respond to it?”

I previously mentioned therapist shame, which can be just as virulent as the client’s. I’ve often been asked to show my mistakes and fumbles in my video recorded material and to show sessions that didn’t work. The reason for this is intuitively obvious. We want reassurance that we are not alone with our struggles to perform as therapists and also to feel hopeful is spite of our shortcomings.

In my upcoming Denmark presentation, I decided to show a mix of older and newer work and to explore how my work has developed over the years as I sought to make my interventions more shame-sensitive. As I watched some of my earlier work, my language and tone actually made me cringe a bit. Sometimes even more than a bit. There might be a rushed quality to my voice, when the client had just shared something that was particularly embarrassing for him… and my mind was recapping something in a very left brained, clipped kind of way… “So what I hear you saying is…” Fortunately, those particular clients looked past my moments of flawed embodied attunement and improved anyway. But that wasn’t always true. Working with shame sensitivity has increased my therapeutic results.

Often, those times when we’re off the mark occur because our own shame avoidance, driven by the quest to “do the right thing,” drives us out of the moment and into our heads and agendas, missing important cues that are right in front of us. Recently I did a supervision session with a very talented therapist, and because she had a particular agenda in mind, she sped past the client’s mention of feelings of guilt. Our performance expectations cause us to speed up, when what is really helpful is to slow down.

We all know that therapists are just as human and vulnerable as the next person, though this often surprises people. Not only do others have higher expectations of us, but we often do as well. Shame can attack quite viciously when we lose a client, get lost in a session or experience harsh devaluation from a client. Therapist shame is also often activated when we are exposed to the work of some of the true geniuses in our field. One aspect of their greatness may be that they do what only they can do… be themselves. Their personality, even quirkiness and idiosyncrasies, sometimes comes through in dramatic and creative ways. They may say something we couldn’t imagine saying. Or they do something that would never seem natural coming from us. While we can learn great principles from them, there are some things we cannot reproduce effectively because it wouldn’t be us. Their vocabulary isn’t ours, their inflection is different and the way they would express something may not work for us.

This does not mean we shouldn’t study the skill set of these great teachers carefully, but we should really try to refrain from pushing ourselves to mimic them. Often theoretical breakthroughs become codified into a system from which one dare not deviate, as the system becomes the gold standard and all else is lacking. When we hold this view, it only activates our own shame and quashes our unique creativity. Shame and creativity are not likely to co-exist.

I can tell you from my own experience that it is possible to reverse our shame-driven tendencies through conscious awareness and having the intention to surmount them. We need to remember again and again that nothing is more valuable than being authentic and staying present in the moment. With these operating, we heighten our perceptiveness and release our creative intuition, thereby elevating our work.

When we move into a space of truly not requiring anything from our clients, including their “growth” or approval of our work, an exciting new space for unlimited exploration emerges. We can begin to enjoy and appreciate every tiny step towards true connection and self-disclosure, such as when a client can reflect upon his resistance in a new way or reveals annoyance with us for the first time… all can be seen and commented upon as hopeful developments. We no longer value only the big unlockings but also the little unlockings of intimacy, and this will create more satisfaction in our work. While I will still encourage the option to delve deeper into underlying feeling, as an alternative to learned restraints, I will no longer attach an implication of failure about the choices a client makes. They are simply choices and no one needs to be judged because of them.

A group of therapists were having a discussion inspired by Allan Schore’s recent evocative presentation at a UCLA conference, which he entitled “The Right Brain in Therapeutic Creativity, Connection, and Play.” They mentioned Big C and little c creativity, which I supposed was like a Van Gogh painting compared to one of my flower arrangements. While there is obvious validity in the distinction, something in me rebelled against linking the words “little” and “creativity,” as all creativity, including a therapist’s creativity, has a value that cannot be quantified. To do so can move us towards shame, and the following process that is beautifully described by Jean Baker Miller, MD, founder of the Jean Baker Miller Training Institute at the Stone Center, may become less likely:

“Most important of all, the therapist needs to learn how to participate in the therapy relationship in such a way that she facilitates “movement in relationship.” How does she do this? If she is really present and authentic, she will be moved, i.e. feel with the patient’s expression of her experience. If the therapist can make it known that she is moved, the patient will be moved, i.e. feel with the therapist feeling with her. The patient, thus, has the very valuable chance to know that her thoughts and feelings do reach another person, do matter and can be part of a mutual experience (Miller and Stiver, 1997). We think that this is the key source of change in therapy. It is so important because the basic trouble has been the disconnections in which the patient has little or no possibility of having an authentic effect on the disconnecting relationship.”

I’d like to share a bit of a transcript from a dialogue with a client that would not have transpired had either of us been in a state of shame or restricted receptivity to the moment. During treatment, she had shared with me her rage at God for apparently abandoning her almost at birth, leading to a state of despair. She’d had a violent, alcoholic father and a narcissistic, absent mother. After working with her rage towards her parents, something moved me to also explore her rage towards God, an avenue that is sometimes discouraged in the traditional therapeutic community. However, my interest helped her to have the experience of having all parts of her seen and held, which led to the following exchange:

Pt: I’m so grateful that someone cares…

Th: Me.

Pt: You.

Th: Me. Yes.

Pt: Somebody wants to help.

Th: Thank you so much. That’s such a beautiful feeling. Gratitude.

Pt: Thank you.

Th: You are so welcome. It’s such a privilege for me. You’re so worth helping. It’s striking isn’t it? This is another force. You talked about your rage at God. “How could God let this happen?” And now we see that God lets this happen too… would you say?

Pt: Yeah.

Th: I feel like the caring that I feel…(the caring) that comes through me…is very big. I feel it very big towards you. And I also feel like it’s coming through me…like it’s me, and its bigger than me. How does it feel to hear me say that?

Pt: It feels believable. I feel that too. Like if I look in your eyes, I don’t see just you. I see…or I feel a very—like a timeless sense of caring, eternal compassion and connection.

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Attend Penetrating Defenses and Surmounting Shame

Saturday, September 26 and Sunday, September 27, 2015

Olympic Collection Conference Center, Los Angeles, CA

Reach buried affect with compassion and skill…

• Disarm Distancing Defenses and Shame States
• Accurately Identify and Attend to Somatic Signals
• Sustain an Internal Focus for Accelerated Results
• Heal through an Authentic Attachment Relationship
• Apply an Evidence-Based, Dynamic Treatment

Register at www.ceuregistration.com

Clear, step-by-step instruction. Video analysis. Skill-building role-plays. Group supervision. Interactive lectures.

Take your skills to the next level and learn:

Methods to access and integrate unconscious emotions.

Targeted interventions to disarm defenses.

Means to circumvent shame, guilt and anxiety.

Purposeful tracking of feelings, sensations & cognitions.

Modifications for a spectrum of psychoneurosis.

Powerful, evidence-based methods.

Meet Your Presenters

Jon Frederickson, LICSW, is the Founder of the ISTDP Training Institute and the co-chair of the ISTDP training program at the Washington School of Psychiatry; chair of the ISTDP Core Training for the Norwegian Society for ISTDP; and on the faculty of the Laboratorium Psykoeducaji in Warsaw and the Italian EDT Society. He is the author of Psychodynamic Psychotherapy: Learning to Listen from Multiple Perspectives and the award winning Co-Creating Change: Effective Dynamic Therapy Techniques.

Susan Warren Warshow, LCSW, LMFT is the founder of the Dynamic Emotion Focused Therapy Institute (DEFT). She is a member of the board of directors of the International Experiential Dynamic Therapy Association, faculty of the ISTDP Institute, and a Certified IEDTA Teacher/Supervisor. Ms. Warshow has presented at numerous national and international conferences and many local teaching institutions. She has a private practice in Woodland Hills, CA, treating individuals and couples.

What They’re Saying . . .

Jon Frederickson is a world-class psychotherapy instructor, and a master at unlocking the therapeutic impasse. He presents highly complex and subtle subjects in a clear and accessible manner. … Jon’s teaching style is very supportive and considerate. … It’s important to have an instructor who teaches with respect and compassion for his students. I highly recommend Jon Frederickson to anyone who wants to take their psychotherapy skills to a higher level. — Tony Rousmaniere, PsyD

I have … been most impressed with [Susan’s] deeply insightful, sensitive, and fearless approach, leading to outstanding therapeutic results. — David Malan, M.D., Tavistock Clinic

…To be more effective and efficient in producing positive and lasting change in your patients, you couldn’t find a better teacher than Susan Warshow. With grace, humor, and deep compassion for both patients and trainees, she will guide you in the development of skills and capacities that will enhance your work and your life immeasurably.

— Patricia Coughlin (Della Selva), PhD, Faculty ISTDP Institute, Author of Lives Transformed

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Join me in Denmark for Shame in Psychotherapy: Bringing Theory to Life

June 25-26 2015, Aarhus, Denmark

This event is sponsored by the Danish ISTDP Society
For more information and to register: http://www.istdp-danmark.dk

From the Danish Society for Intensive Short-Term Dynamic Psychotherapy (ISTDP) website:

Susan Warshow is known for her empathy and warm approach both as a person and in her therapeutic work. During this two-day presentation, Susan will use recorded session material to illustrate and identify verbal interventions and non-verbal interactions that effectively reduce shame in the therapeutic relationship. Learning to create secure attachment and the development of self-compassion is central to this process.

Part of the therapeutic task is mobilization of the client’s will to give careful, moment-to moment attention to his/her internal world. However, this intense internal focus frequently activates shame, guilt and anxiety alongside rising feelings. Becoming sensitive to the nuances of shame helps the client move past this paralyzing force to new levels of emotional freedom. As the unconscious becomes conscious through an experiential process, it becomes possible for the client to integrate past experience in new ways, leading to changes in behavior and the development of more secure, fulfilling attachment relationships.

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DEVELOPING TRUST IN THE POWER OF SELF-REFLECTIVE PROCESS

UPCOMING EVENTS:

Penetrating Defenses to Awaken the Self with Susan Warshow and Jon Frederickson September 27th and 28th, Los Angeles

LACPA Continuing Education Series Working with Emotionally Defended Clients November 15th, Los Angeles

Milton Erickson Foundation Brief Therapy Conference Susan presents December 11, Orange County

DEVELOPING TRUST IN THE POWER OF SELF-REFLECTIVE PROCESS

I had a profound session this past week that once again demonstrated to me the power of building self-reflective capacity.Perhaps too often, we over emphasize intense emotional unlockings and under value the healing power of awareness of internal processes that harm the self, alongside the will to transcend those automatic, often unconscious, habits. This in no way is meant to diminish the immense value of depth emotion processing, but rather to consider the curative impact of pure awareness and will in relation to separating the self-enhancing from self harming aspects of the self.

My client came in severely regressed, weeping frequently, distrusting me, her husband and others, projecting her own relentless self attack, and fraught with anxiety. At times we focused intently on her devaluation of me and also of herself and her husband. She never wanted to acknowledge the progress we’d made together as she was highly suspect of it. Likewise, she didn’t want to acknowledge the caring of others towards her and was dismissive of anything good coming her way… or of anything good within herself.

It is always exceedingly gratifying to see the development of sense of self in a person in relatively short time. This female client became able to observe her projections and now challenges them, i.e. she has been able to see how she fuels her fears as a result of her projections that others disapprove of her or wish her harm… and she now actively intervenes when those projections occur and checks out reality instead. She is also intervening with her splitting defenses… seeing that neither of us is perfect and that she can make space for what is good and also what is limited in each of us. Therefore, she does not re-traumatize herself by robbing herself of an imperfect but still valuable relationship with me and most especially, with her husband. Essentially, she is becoming an acute observer of any self-harming parts of herself and applies her will to intervene.

It’s been a long time coming for me to trust in the power of this type of self- awareness. Therapists often feel like they have to move mountains or lift loads of bricks, but really we do something that is, in one sense, simple. We hold a light to what is revealed in a moment. We say, “Oh, so there is shame rising. Shall we look at this together?” (Differentiating adaptive shame from shame involving self attack or projection). Or “Shall we attend to this anxiety so it doesn’t continue to paralyze you?”

If our goal is to help others develop the most comprehensive awareness of their own processes, so that they may work with the moving parts within themselves to the greatest advantage, the therapist must have a (good enough) broad knowledge of the diverse phenomena that presents itself in a session…i.e. recognizing all of the defenses and all manifestations of shame, anxiety and guilt. Otherwise, how can we shine a light if we don’t know what we’re shining it on?

And then there is perhaps the most challenging part, which is our willingness to openly acknowledge reality with our clients… to share the truth of what we see in those we seek to help (assuming we have explicit permission to do so) and also to be aware of and guided by our own immediate experience (are we bored, anxious, experiencing an attack, shaming ourselves etc.).

But my central point in this post is that we seek to have FAITH that our work to heighten self-awareness (simply providing a caring mirror for the phenomena we witness, with fully informed consent!) and to stimulate the will to be actively kind and compassionate towards the self has enormous healing power… more than many of us can imagine. I overworked, overreached, and took on excessive responsibility. It is my hope that my own experience may help reduce the suffering incurred by other therapists. Probably the greatest challenge was to be able to step aside and trust that this healing force is at work when we shine the light with accurate attunement to what is occurring in the moment. When the client chooses to join us in this awareness, the results can be breathtaking.

REFLECTIONS ON 8th IEDTA CONFERENCE

I recently returned from the 8^th International Experiential Dynamic Therapy Association’s biennial conference in DC, a dependably outstanding experience. It was a great privilege to be a presenter among master clinicians from around the world, many showing exceptionally powerful recorded sessions, including riveting work with a gang leader, a hard core drug addict, and an explosive, alienated and detached cardiologist. All were deeply moved by the remarkable levels of emotional intimacy that were achieved and the significant internal shifts that followed, validated by the client’s poignant words. I thank everyone who created this event, most notably Jon Frederickson and Kristin Osborn. I’m grateful for all the touching, meaningful encounters with other therapists who were so kind, inquisitive, openly sharing, and genuine in their acknowledgements. Unforgettable experience. For more info, go to IEDTA.net.

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Client vs. Patient: Does Language Matter?

I’ve been focusing madly on the official launching of the new DEFT Institute website… never dreamed how involved it would become. The only delay is due to time needed to finalize editing of some taped lectures of mine that are offered for purchase. For those who would like to preview the site, it is at www.deftinstitute.com.

Please check out my two upcoming events (June 9-14 in VA and Sept. 28, 29 in LA) with therapist/trainer/author Jon Frederickson, a collaboration that I always find extremely exciting. Perhaps this is because Jon’s mind is a beacon to our field and I always experience the joy of discovery and new insights when I speak with him, appreciating his passion and brilliance in teaching psychotherapy. Participants at these events are in for a great treat! Jon is with the Washington School of Psychiatry in D.C.

Client vs. Patient

I’d like to share some comments I made on the IEDTA listserve in response to a most lively discussion on whether we should refer to those we treat as “clients” or “patients.” I then began to reflect on a larger subject… the impact of the words we select in our comunications. By the way, I don’t use any term other than “you” when speaking directly to the person in my office, but people seeking therapy will see how we refer to them when they visit our websites, hear us lecture or read our books. And how do these terms affect their feelings about seeking therapy? How do they affect their view of themselves and the fact that they’re suffering?

Generally speaking, I have always been an aspiring wordsmith and I chew on words constantly in session to see if my words have an empowering or disempowering effect. Of course, I always want to choose the former. Having intensely observed thousands of responses to my interventions over the decades and frequently inquired into the impact of my language (“How do you feel as I say these words?”), I conclude without a doubt that my choice of words has significant impact on the therapeutic alliance. Some words and phrases enhance the relationship and are more empowering and others do the opposite even though the differences in meaning does not seem significant. If I say, “You are destroying yourself” vs. “So you have this system that operates inside you, that once tried to protect you, and now it harms you,”  the client may feel less shame. As we know, use of “you messages” creates greater defense.

Also, it’s so easy for therapists to become vague in their language too. If you ask, “How do you feel this anger?” it is not as clear as “How do you feel this anger in your body? What physical sensations do you become aware of as you remember your husband….” The vague language can cause confusion in the client and thus greater shame.

I have learned that MFT’s moved away from using “patient” and substituted “client” possibly in the 90’s. This mattered to me because, when reaching out to colleagues, I want to “speak their language.” Yet my commentaries on many of the tapes I present are heavily sprinkled with references to the term “patient.” I’d never reflected much about this before receiving this feedback. I’ve discovered from the listserve discussion that there are strong preferences related to these terms among professionals. One person believed this represents a struggle based on feelings, preferences, and values between professionals, having no impact on the person seeking treatment. I would argue that words do in fact carry meaning and they get inside our bodies for good or ill. I see evidence that the medical model of mental health has in fact created much shame. How many times have I heard a client say, “I am sick.” “There’s something wrong with me.” “I must be crazy.” I’ve often responded, “There’s nothing inherently wrong with you. You just haven’t discovered this truth yet. Or tapped into your capacity for health.”

Some agree with Carl Rogers. From his website:”Rogers was deliberate in his use of the term client rather than patient. He believed that the term patient implied that the individual was sick and seeking a cure from a therapist. By using the term client instead, Rogers emphasized the importance of the individual in seeking assistance, controlling their destiny and overcoming their difficulties. Self-direction plays a vital part of client-centered therapy.” The word egalitarian also comes to mind.

My approach to therapy is very aligned with the teaching of Dr Paul Pearsall, one of the founders of positive psychology, which represents new research into optimum human functioning and emphasizes that which is healthy within us. He was selected by the Oxford Biographical Society as one of the 1000 most influential scientists of the 20th Century. He said, “For me… life is made difficult so it can be made more authentic, real and intensely meaningful. We suffer because we breathe, and asking why we must suffer is like asking why we must breathe. There is no life without it.” Indeed, we are all sufferers in this world and we rotate chairs continually between being on the receiving and the giving end of healing.

Since “patient” comes from the Latin word meaning “one who suffers,” then we could say we are all patients. How does the label feel? I think there’s a better term for all of us who “suffer.” In a word association test, if I heard patient, I’d think “sick.”

From Jonathan Mahrer, Ph.D., founder of Blue Mountain Counseling: “I use the word “client”, not “patient.” The word “patient” can imply a medical model in which the doctor works on and heals the patient, and the patient more passively receives the treatment. Psychotherapy is different.” And “The medical patient terminology can also imply that
you are sick, and can create a (to our minds) false dichotomy between sick and well, those who need help versus those who do not.” One author said, “A patient is the object of medical care, a client is the subject of medical services. In language as in life, an object is passive, a subject is active.”

As if we don’t have enough to keep track of in a session, now we must consider the impact of our language! Nevertheless, I believe it is well worth the effort.

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Shame-Sensitive Defense Interventions as Developed by DEFT (Dynamic Emotion Focused Therapy)

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.

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.

 “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.

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.

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:

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Speaking with Susan on a Vanishing Therapeutic Alliance

Scroll 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.

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Repairing Shame and Guilt

Webinar and Special Events:

My webinar sponsored by the ISTDP Institute on “Interrupting Defenses as a Form of Compassion” is coming up on 5/11/12. Go to istdpinstitute.com to register. There will be live role plays to demonstrate how we can work effectively with a wide variety of defenses.

Also, I’m offering a one day special event to be held on both 6/9 in LA and 6/16 in Glendale on “Penetrating Defenses to Awaken the Self.” Go to www.warrenwarshow.com to register! This event includes recorded session material showing a style of dissolving defenses that conveys and evokes compassion for self in our clients/patients.

SHAME AND GUILT

We’ve had a passionate exchange of ideas and conflicting perspectives within our professional community on how to conceptualize and deal with shame and guilt with our patients. Are they affects? Do they inhibit, hence are they “inhibitory affects,” or are they defenses to be treated as we treat all defenses?

As I share my perspective, I put forth one caveat, I do hold all my theories lightly, as suggested by Nemeroff!

I just spent an entire session in which the patient was flooded with guilt because she’d injured a close friend. Her friend was hurt because my patient had cancelled a special celebration that her friend had planned for her (albeit with her friend’s compliant permission). My patient avoided her painful feeling of guilt (due to love) by projecting (“She was critical of me”; “She was overly sensitive”) and repressing the pain of guilt. The session involved delicate work but it led to some new awareness that took her back to how she defended as a child against being unfairly blamed and had been transferring her mother onto other people. She also saw how she mercilessly attacked herself. She was also able to reconnect with her love for her friend and saw the value of a simple apology. As she allowed the feeling of guilt to be experienced, she noticed a rise in anxiety over the sense of vulnerability over letting in how important she was to her friend… and how important her friend was to her.  She realized that she had been afraid to similarly expose her own hurt feelings over past events when her friend had also treated her dismissively. This also opened a door to recognize her defenses of numbing, denial and minimization, which she did not want to carry forward.

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Many Masters

Announcing 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.

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