Mirrors of the Mind 2018

One of my photos was selected for Mirrors of The Mind 2018. Someone approached me about the caption beneath the photograph, and I thought I would share it here:

Therapy is about opening doors on each door is unique. Interior garden back into me. In my work, I hope to help others to discover the Freida territory that lies beyond the gates, walls and locks of the psyche. We often discover tragic neglect of the intended parts of the south. This saddens me and stirs my compassion. But I have learned I cannot rush in even though I yearn to relieve pain. I must stand respectfully at the entrance and take each step forward with the permission of the other. After all this is another is this private world. I do not attempt to open doors uninvited. There is something sacred about that for me. It is a privilege to be granted entry.

Doors have always intrigued me, especially when they have a history. They hold so much promise and mystery. What lies beyond them? My mind associates Ainsworth.s attachment styles to each door. When my therapeutic partner begins to share my interest, appreciation and compassion for all that lies within the self, it is as if the doors slide open on their own accord, the magic mechanism. Neither of us is pushing. The door itself has life and will.

Strolling in the late afternoon in San Miguel D’Allande and discovered this doorway with its infinite textures, patterns, and striking colors coming together with perfect synchronicity. Similarly made those in my care discover the beauty that lies within them and feel enough safety and freedom to swing open their doors to the delight of self and others.

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Can Shame Be Useful?

In the article Can Shame Be Useful? by SALLY L. SATEL and SCOTT O. LILIENFELD, the authors raised the question, “under what conditions does shame end up prodding people into correcting their course? ”

“An important influence appears to be whether people buy into the notion that a habit is under or out of their control. In a meta-analysis — a mathematical synthesis of previous studies — just published in The Journal of Personality and Social Psychology, the University of Connecticut psychologist Colin Leach and one of his doctoral students, Atilla Cidam, examined the links between shame and “constructive approach behaviors,” such as helping or cooperating with others, apologizing and making amends for one’s failures.

They found that study participants who were vulnerable to experiencing shame were less inclined to engage in corrective actions when they believed their mistakes were not fixable, such as when they had no opportunity to apologize to someone they’d offended. In contrast, participants were more inclined to engage in positive behaviors when they thought their errors could be repaired.”

I believe these findings can be extrapolated to one of the primary tenets in DEFT practice. This involves the types of interventions that sustain hope when facing those actions or defensive habits that have harmed others or have caused us to feel we have fallen short of our ideals. When we attempt to dismantle harmful defenses, we need to be simultaneously building the sense that something new can take its place. When we are working with an interplay of guilt and shame, the aforementioned meta-analysis validates that hope is essential to the change process. I find that hope is often built upon direct experiences of having an impact on others, and this may begin with impacting our therapist’s emotions and perspectives. And it is also built on the sense that we can build a new relationship to ourselves that is kinder, more compassionate and offers greater freedom.

Here are a few of the factors that come to mind that can generate hope during the therapeutic process:

1) A direct experience of one’s capacity to repair.

• We can consider that repair in our relationships to others begins with repair in relationship to ourselves.
• When we help our client to develop capacity to extend forgiveness and compassion towards one’s own shortcomings and failings, it is often only then that he can find the strength to admit them to others.
• Self condemnation precludes reparative action.

“Can we extend compassion to you because you were taught to withdraw from others, that this became automatic, and that you have not had alternatives at your disposal, as you are discovering them now.” “From this place of compassion for yourself and caring for your friend, would you want to express your remorse to your friend for having withdrawn from him?”

2) Therapeutic reminders of evidence of one’s capacity to impact self and others.

Therapists do well to refer frequently to instances when the the client has been kinder or more attuned in interactions with others. “I like how you said that.” “That was very generous of you.” Or “It’s great to see you extending more acceptance and tenderness to yourself.”

3) Knowledge of what constitutes repair, in cases of injury to another. Therapists can explain that this involves:

1. Saying I’m sorry while feeling genuine remorse, a painful visceral sensation.
2. Dropping all qualifiers
3. Stating the injury as accurately and forthrightly as possible
4. Leaving space for the other to express hurt and angry feelings without interruption.
5. If the injured person is not accessible, making one’s best attempt to behave differently in future relationships. Therapists often need to help people to see the value in breaking cycles of traumatization. Even when someone we’ve injured had died or is unavailable, our efforts to change hurtful patterns are reparative in terms of the human family.
6. Differentiating attempts at repair from the ultimate outcome of the attempt.

Therapists can help their clients to appreciate attempts at repair, regardless of success. True relationship repair requires an exchange of energies between two people and we can only be responsible for our personal role. Any attempt to be vulnerable and genuinely apologetic is to be recognized.

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A Client Snaps at her Therapist: Shame Perspectives

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Avoiding Eye Contact and Shame: When do we discuss it?

It was deeply satisfying to present again to the LACPA SIG chapter this month to such a responsive audience. We were looking at how shame shows up in a session. As I see it, a person who presents with depression, envy, grandiosity, aggressive anger and contempt is likely to have underlying shame that begs to be addressed. Recorded material helped us to get a clearer idea about DEFT interventions and role-plays helped us to practice them. When I invited a shame-based client to have a conversation about her difficulty making eye contact with me, a participant raised a great question about whether and when such directness is beneficial.  I thought a discussion of it would benefit others.

When a client is having significant difficulty making eye contact, I typically find a way to talk about this guided by a heightened sense of shame sensitivity, even in a first session. There is a widespread perspective that it is best to wait a period of time, perhaps weeks or months, to develop sufficient connection with the client to address something as intimate as eye contact. Therapists have understandable concerns that such directness will lead to even greater shame. There is truth in the fact that anytime we draw attention to shame, especially the avoidance of eye contact, there will be a temporary increase in shame. Shame never wants to be seen and interpersonal exposure mobilizes shame. If it’s not handled helpfully, therapists have an understandable concern for potential malattunement. Therefore, I don’t advise therapists to draw attention to shame, especially the avoidance of eye contact, without having some skill development in shame work and emotional attunement.

Some of the elements of such shame work include: seeking permission to speak about non-verbal and body-based responses; differentiating compliance from a try alliance; putting the shame response into a normalizing context; tracking co-mingling anxiety; having the skills to work with projection of judgment; developing observing capacity so the shame response can be seen as separate from the core self; offering alternative paths to the shame state; creating enough safety in the relationship to support this degree of intimacy and deeper work.

I really empathize with the therapist who had reservations about stepping into this kind of shame work, and her fears were grounded in some realities. I myself felt the same for many years. However, I now have a different perspective having discovered that delicate shame work can be successful early in treatment, depending as much  on HOW something is done as on WHAT is actually done. When certain elements are not present, any intervention can backfire including addressing the avoidance of eye contact, whether the intervention is made in the first session or the thirtieth. I’ll speak more about them in a moment.

So why would we forge ahead and deal more directly with avoidance of eye contact? The reality exists that when someone is afraid to look at us, this person does not feel safe with us and is threatened, either consciously or unconsciously. This is a state of distress that is usually accompanied by a deep sense of unworthiness and self-judgment that is being projected onto the therapist. There are different approaches that can, over time, help build a greater sense of comfort with the therapist and reduce shame, but when the forces that cause someone to look away from us are not addressed directly, the client remains unconscious of them and therefore largely at their mercy until such time as help is provided. When shame is dominant, it will close doors to emotional intimacy and stall the therapeutic process until it releases and becomes less of an obstacle.

I remember one of my teachers saying to me something like, “Why not interrupt suffering sooner rather than later?” This really stuck with me and has caused me to stretch myself in my work by trying out greater directness and openness with my clients. This doesn’t mean that I just jumped in and said what I’m thinking or observing without first reading a number of signals from my client that indicate an alliance is operating. These include subtle signs of reduced fear in the eyes or a drop in muscle tension as well as verbal affirmations that tell me I have a partner who wants to take this track. Moment-to-moment feedback that my client has explicitly chosen to walk the path of internal exploration with me, including bodily and emotional exploration, is so vital to a successful process.

Let me share a segment of a powerful first session with a woman I would consider to be a victim of spousal abuse. It was impactful because both of us acknowledged that something deeply moving had occurred, and it began a journey of change and highly productive work together. When she started the session, her speech was pressured to a very noticeable degree. She spoke almost breathlessly and rapidly, describing different facets of her recent separation from her husband. He drank too much and could become scary and also treated her very dismissively. He didn’t bother to invite her on weekends away and eventually became involved with a friend of hers, which was devastating to her. She sunk into depression. Her body was locked in pain in a very visceral way. Her tears were just traces of the mountain of grief and rage she had no idea she was containing at an unconscious level. She presented mostly like a tightly controlled, very pleasing young woman who at one time was a popular cheerleader.

I began to take particular notice of her difficulty with eye contact when she commented on her husband’s affair with her friend. I very gently began to inquire about this in the context of compassion for her discomfort. Tone is everything here. I also immediately asked her permission for us to have this conversation. When I do this, I am very careful to be sure my question is raised in an open-ended way, allowing space and acceptance for the client to decline. Any signal that such exploration is unwanted would stop me immediately.

However, as frequently occurs, she indicated that we could proceed. I should emphasize that this was not the first question or second or third that I asked. There was some time in which we had exchanges that indicated she saw me as being in attunement with her and also felt some confidence in my ability to help. Also, it was important that I did not tell her she had a difficulty meeting my eyes. This would definitely have been shaming. I posed this as an inquiry, inviting her collaboration as a co-observer. Did she notice what I noticed? I also put in in a context so as not to suggest she never makes eye contact. I mentioned that her tendency to look away from me seemed to happen as she was describing the breakdown of her marriage. Again I enlisted her help as a co-observer, “Does this seem true for you?”

She did in fact have a very good capacity to observe herself, and I complimented her for this ability. A big door opened as she told me how ashamed she was that her marriage had failed. She saw herself as a failure at her age and as a woman with little hope for the future. She blamed herself for having deficiencies that would cause her husband to stray. Her self-diminishment was heartbreaking.

Her reaction suggested she probably imagined I saw her in the same way she saw herself. So I asked her sense of how I was feeling and reacting to her disclosure? Not surprisingly, she confirmed that the projection was operating. She hadn’t been conscious of her tendency to project, but began to be curious about it. Rather than just tell her that I did not see her as she assumed I would, I suggested she could, if she wanted, take a look into my eyes and see what she actually saw. It was entirely up to her. She very tentatively began to move her eyes closer to mine, and there were several minutes that were among the most beautiful I have experienced in practice. I felt my whole body infuse with compassion that was soft, tender and embracing. It was a feeling that just swept over me. Within myself was an intention that she would see in my eyes pure acceptance and even love.

After a significant period of time, she suddenly broke into sobs. She later affirmed that she had seen the compassion in my eyes and it was a new, deeply felt experience for her. Working with shame so often goes beyond the verbal or intellectual dimension. It is a state of being that is transmittable and transferrable when it is genuine and authentic. It seemed like a transfusion of compassion for self. And of course this could not take place without sufficient willingness to receive. In this woman’s case, we also addressed in this session her extreme harshness towards herself. Not only was she reeling from the wound of betrayal but also from her own condemnation of herself, which justified her husband’s deceitful actions and pushed her rage out of awareness. We would discover how greatly she wanted to protect him and keep her attachment to him alive.

I attempted to make very clear that her ability to move forwards in her life, to find greater peace and satisfaction, would depend on her active intention to keep compassion for herself alive within her. Her avoidance of eye contact with me was the key signal, in this first session, to her enormous sense of unworthiness. If you’ve ever had the experience of a deeply satisfying massage, the practitioner probably had a way of moving her hands towards those points in the body that require attention and attuned pressure to release. The psyche is very similar. We can massage around the knots for long periods of time, but when we have permission to bring our touch to the points that are tightly held, the release can be exhilarating for both the therapist and client alike!

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Surmounting Shame: Video Analysis of the Change Process

DEFT Institute and Insight Center Present

Surmounting Shame: Video Analysis of the Change Process

April 16, 1:00 pm – 5:00 pm with Susan Warren Warshow, LCSW

West Los Angeles, CA

Register: https://insightcenter.org/schedule/video-analysis-with-susan-warshow/

Early registration: $125
Full tuition: $165
Please note that early registration ends March 11, 2016.

This is the first in a series of video workshops presented by Susan Warshow and co-sponsored by the DEFT Institute and the Insight Center. Upcoming events: 7/30, 9/16 & 9/17 (with Jon Frederickson) and 10/29.

To pre-register for 7/30, 9/16 &9/17 or 10/29, visit: https://deftinstitute.com/dvdday.html

Susan Warshow will demonstrate how Dynamic Emotion Focused Therapy (DEFT) can effectively overcome therapeutic obstacles and facilitate depth emotion processing and integration, an approach to healing attachment trauma.

DEFT interventions emphasize sensitivity to shame states that are triggered by self-exposure and emotional intimacy within the therapeutic relationship. Research validates that the more we facilitate the expression of affect in treatment, the more we will see positive positive change. Clinicians also know that accessing complex trauma-related affect, to be distinguished from explosive rage or helpless weepiness, is no easy matter.

Numerous self-protective barriers shield the most vulnerable parts of the self, and they are often deeply entrenched, unconscious and powerful. DEFT teaches specific skills and also greater awareness of the factors contributing to neurobiological attunement, the development of self-compassion and a strengthened sense of self. When the therapeutic relationship is experienced as sufficiently safe, it becomes possible for transformational shifts in the self to occur along with greater relational capacity.

This workshop will illustrate through video analysis of client sessions:

• An approach to accessing unconscious emotions
• Elements of shame-sensitive psychotherapy
• DEFT interventions to disarm defenses
• How to monitor and attend to anxiety
• Tracking of feelings, sensations and cognitions
• An integration of evidence-based methods

At the end of this workshop students will learn how DEFT:

• Activates a therapeutic partnership
• Responds to vulnerable client states
• Uses a graded, attuned approach to fragility
• Makes meaning of somatic signals
• Recognizes the neurobiology of emotion
• Tailors interventions to client capacity
• Conveys compassion for the cost of defenses
• Uncovers the roots of character armor
• Repairs and reduces ruptures

Susan Warren Warshow, LCSW, Board Certified Diplomat, LMFT, is the founder of the Dynamic Emotion Focused Therapy Institute (DEFT), which began its three-tier training program in January 2012. She is an international presenter, has published several professional journal articles. She is on the faculty of the ISTDP Institute and is an IEDTA Certified Teacher/Supervisor. She has a private practice in Woodland Hills, CA, and offers online therapy for individuals and couples, specializing in anxiety, depression, relationship issues and defeating personality traits. She also offers clinical supervision, coaching and consultation.

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Listen to Susan Speak About Shame on the Dr. Kim Taylor Radio Show

Listen to Susan and Dr. Kim Taylor talk about shame. Susan answers these questions and more: What is shame? What are some common triggers for shame? How to the two genders experience shame differently? How do we recognize shame in ourselves and others? How do we reduce shame in ourselves and others?

Listen to the Interview

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Speaking with Susan: Working with Defense Driven Affects

Working with Defense Driven Affects

A therapist emailed the DEFT Google Group about an insight she had in supervision with Susan and shared the following reflections on a term that was introduced in the DEFT Training: Defense-Driven Affects. The therapist was working with a client who has a pattern of making herself small and helpless, being self-deprecating and at times, literally folding herself into a fetal position.

“We talked in class this week about ‘undoing a projection’ before exploring the feeling of rage that has been ignited as a result of the projection. (I’m furious that you have attacked me, when in reality, I am viewing my own self-attack as originating in you. Since the attack originates within myself, my rage will be endless and I need to stop fueling this rage if I am to have peace). I’m just starting to realize that when working with other defense-driven affects, such as weepiness or projective anxiety), I often empathize with these feelings rather than attempt to “undo” the defense that drives them into being. My empathy for these feeling states can appear to deepen the relationship—but I’m beginning to see that that shifting my first response could be more helpful in promoting meaningful change.

For example, I had a supervision session today and we looked at a piece of work in which a client was criticizing herself and then curling up into a ball (literally). In the session I went with empathizing…”Who wouldn’t collapse under that kind of self attack?” Had I gone to capacity (she’s actually quite capable), we could have challenged the perception that she is small and defenseless and must cower in the face of this internal attack mechanism. I think this is really going to impact my work. And I just thought I’d share that, and I would love to know how others are making sense of it.

A fellow therapist in training questioned: Here’s what I wonder about your case. She collapses into a ball, feeling helpless, powerless. I wonder if it’s an enactment of the little child, feeling like this when her caretakers “attacked” her… very alone in this, and too small and vulnerable to be competent. If you follow that, will she not get to core affect?

Susan responded: I agree that this behavior is a re-enactment of a very early phase. However, I don’t believe you are likely to get to core affect by following her helplessness, because this often leads to more helplessness, like a downward spiral. This is a familiar place to retreat and it appears to the self to be the only option. I get the image of an animal burrowing into a cave, going deeper and deeper into a place that promises safety and comfort. Only it loses it’s life experience in the process. If people could just follow their defenses, and the feeling that are driven by a perceived need to defend, they wouldn’t need therapeutic intervention. As I see it, personal growth comes from new awareness of an alternative to old patterns and a new way of seeing the self (with a caring other) as capable of exploring a different pathway. For most of our clients, reaching core affect is anything but automatic since resistance is just what it says… “I’m not going there. It’s too dangerous.” I find it to be pivotal to offer a clear alternative to an entrenched, self-harming pattern, which also engenders hope and a vision and an ideal to begin striving towards.

There is a defensive system occurring almost simultaneously here that involves activation of the affects of shame and anxiety that is fueled by cognitions (belief that I am powerless) and accompanied by defensive behavior (curling into a ball). It has been shown that shame begins at around 3 months. These recoiling behaviors act out the impulses that accompany shame and fear.

I use the term defense driven affect because these affects (e.g. the shame and anxiety that we see in the curling up client) were triggered originally in response to a perceived relational threat… a relationship upon which the client felt utterly dependent… and is now occurring in the transference. We want to help the client see, of course, that she no longer needs to activate the same behavioral and emotional response associated with childhood relational threats. We want to help the client clarify present relational reality of self and other and separate this from past traumatic reality. “Can we greet the feelings inside of you rather than recoiling from them and diminishing yourself?” “How do you anticipate that I will respond to the feelings inside of you?” “Does it serve you today to respond to the feelings inside you in this way?”

A possible scenario is as follows: the child attempts to get Mom’s attention to a need. Mom looks away and is not responsive and cannot be reached. The child has a direct experience of powerlessness (not yet cognitive) and deflation and viscerally feels shame and fear. Curling into a fetal position follows these occurrences and should the neglect or absence continue long enough, eventually shutting down and feeling nothing, a state of detachment (Bowlby). As the child gets older, there are also cognitions, such as “I am pathetic. I am worthless.” Thoughts and language eventually come on line to describe her experience. The behavioral adaptation to the feeling associated with danger may be regressive or repressive in nature.

The client does not see an alternative to these patterns and we want to provide an experiential and explicit alternative.

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DEFT and LACPA: Working with Emotionally Defended Clients

Working with Emotionally Defended Clients:  Dynamic Emotion Focused Therapy (DEFT)

Presenter: Susan Warren Warshow, LCSW   

ADDITIONAL $20 FOR DAY OF REGISTRATION.

In this workshop, therapists will be introduced to a powerful somatic and emotion-focused psychotherapy that incorporates evidence-based approaches. Clients are helped to overcome barriers that block healthy adaptive affect and impede the change process, i.e. maladaptive defenses, defensive affects and toxic forms of shame, anxiety and guilt. Targeted interventions that are carefully crafted to disarm defenses and facilitate the integration of buried affect will be demonstrated through recorded session analysis.

Evidence mounts that working through intense unconscious affects and integrating them within the self is an effective path to healing trauma. However, many clients have formidable protective walls as well as defensive affects (e.g. weepiness, projective anxiety and rage, sexuality used to divert from underlying feeling, etc.) that prohibit access to underlying feeling and stall the change process. Tools to overcome this challenge will be explained and demonstrated in this presentation on Dynamic Emotion Focused Therapy. Microanalysis of the DEFT psychotherapy process will teach how the soil is prepared and fertilized to form a durable therapeutic alliance that makes it possible to surmount common obstacles to healing. If time allows, there will be an opportunity for live session role-play with problematic clients.

Susan Warren Warshow, LCSW, is the founder of the DEFT Institute.  She is a Licensed Clinical Social Worker, Board Certified Diplomate, and Licensed Marriage and Family Therapist. She is on the faculty of the ISTDP Institute and is a Certified IEDTA (International Experiential Dynamic Therapy Association) Teacher/Supervisor. She has published several journal articles on the application of ISTDP with patients across the spectrum of psychoneurosis. She has a private practice in Woodland Hills, treating individuals and couples and specializes in anxiety, depression, relationship issues, and self-defeating personality traits. She presents at conferences and workshops nationally and internationally, including several presentations for the International Experiential Dynamic Therapy Association (IEDTA) biennial international conference.

Certification of Attendance for Continuing Education Credit

These workshops are sponsored by the Los Angeles County Psychological Association (LACPA). LACPA is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. LACPA maintains responsibility for the program and its content. LACPA also is approved by the Board of Behavioral Science as a provider of Continuing Education Units (CEU) for MFTs and LCSWs: Provider No. PCE 276. The licensee is responsible for maintaining records of completed continuing education coursework. LACPA supplies a document that certifies the licensee was present for the entire program and earned the continuing education credits.

It is important to note that APA and BBS continuing education rules require that LACPA only give credit to those who attend the entire workshop. An evaluation of the workshop must be completed. Those who arrive more than 15 minutes for a six hour program, 10 minutes for a four or three hour program, 5 minutes for a two or one and one half hour program; after the scheduled start time or leave before the workshop is complete will not receive CE credit. Partial credit may not be given.

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Celebrating a Success: Penetrating Defenses to Awaken the Self in Los Angeles

Thank you to all the dedicated and passionate therapists who made Penetrating Defenses to Awaken the Self with Susan Warren Warshow and Jon Frederickson such a success!

Follow this link to view special moments from a very special weekend:

https://vimeo.com/76287234

Here’s what a few attendees had to say about the Los Angeles Conference:

“I applaud you, and Jon, for being so willing to share your work via taped sessions, so we could really see it in action – both the intense transformative power of it, as well as the inevitable non-linear nature of therapy. Ebb and flow, dead ends, mistaken interpretations and therapeutic efforts that fail, as well as moments of connection, deep emotion, and powerful change for the client. It takes courage to put one’s work on such display, and for that I am very grateful.”

—Alan Solomon, Ph.D.

“Thank you again for putting on the conference. It has made us both on fire with optimism and life direction which is priceless.”

—Chris Moule

“I attended the “Penetrating Defenses…” workshop this past weekend and I want to let you know that I implemented techniques I learned during the workshop with results I’m very happy with. I was more focused on the need to interupt my clients’ defenses and was able to do so readily which really did facilitate their ability to identify/engage with their feelings with greater depth. I’m so happy! This is exactly what I needed to improve my practice. I have been reading “Co-Creating Change” which I find very helpful and clear and which assisted me today with implementing skills. I’m so glad I attended the training and feel excited about the prospect of further training.”

—Alma Morales Risse, LCSW

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Run Away Session

It’s my pleasure to be sending free video segments and commentary  from one of my training programs entitled “Identifying and Handling Defensive Affects”  to all who subscribe to my mailing list. If you wish to subscribe now and receive this gift as well as notices of my special events and other resources, go to www.deftinstitute.com and fill out a simple form on the “Contact and Mailing List” page.

When Ventilation Dominates the Therapy Hour

Who has not experienced a session like the following, which was described to me by a therapist in training at the DEFT Institute:

“I just had a session that got away from me.  She ventilated the ENTIRE time despite my efforts to interrupt repeatedly.  After about 15-minutes I gave up and allowed her to do her thing….it was AWFUL!  I AM consistently impressed with the difficulty of the task at hand that is essential for health and healing.  Ugh!”

Yes, indeed, the task is difficult and here we have a client who is overriding her therapist’s interventions, which can be the result of multiple factors. Assessing these factors is the key to knowing what to do next to be most helpful. If the therapist’s countertransference is activated and the therapist begins to doubt or devalue himself, this will interfere with the therapist’s ability to stay present and to keep exploring the client’s will or choices with an open mind.

I don’t want to offer an overly simplistic “solution,” but will share a few suggestions that occur to me, keeping in mind this is not a substitute for supervision where we can track moment to moment phenomena. It appears that this is a highly resistant client who uses the defense of ventilation due to unconscious anxiety over intense underlying feelings (triangle of conflict). The therapist undoubtedly wishes to bring to her attention that this pattern of discharging, rather than fully experiencing her feelings, will prolong her suffering. The client could then be given a choice about whether she wants to attend to her underlying anxiety and reduce it so she can more freely access her feelings or continue this pattern of ventilation? But she is ignoring the therapist’s input. Timing is everything, and while these are perfectly appropriate interventions under certain circumstances, they may not be effective at other times.

Before addressing her ventilation and the fact that this will not help her, we need to ask whether the client has first declared what she hopes to gain from therapy and has she agreed to work with an intrapsychic perspective? Otherwise, there is no therapeutic alliance to explore what is going on within her internally and the therapist will risk a misalliance if she tries to address her ventilation or resistance to the therapist’s input. The client might be hoping the therapist will validate her view of the person she’s ventilating about, or perhaps she wants to assuage her guilt over something she did to this person, or she might be pursuing a fantasy that the therapist will help her find some key to changing this person. And how do we identify the client’s expectations so that she will understand whether they can be fulfilled realistically in therapy or not? If unrealistic expectations remain unconscious, she may well harbor resentments towards the therapist or the process itself.

We begin by asking about her goals for therapy. If she focuses on her frustrations with another person, we need to gently remind her that we are powerless to change anyone else and inquire into how she’d want to feel differently within herself as a result of therapy? If the ventilation continues, we’d want to reiterate that we’d love to help her with her sense of frustration but can only help her by taking a look at what happens inside her when this person behaves as he does. Would she want to do that? Hopefully, she will reveal something that will give the therapist an opportunity to help her see how her anxiety (or perhaps shame or guilt) is being ignored… and to see that these forces will keep her feelings out of awareness.  When she bypasses her own internal experience by ventilating  and focusing on the other person to the exclusion of herself, the price will indeed be steep.

If she still continues to ventilate and to ignore the therapist, I might say, in a caring tone, “You know, I’ve made a few comments that I think would help you, but I notice that you seem to talk over what I offer to you. It’s certainly ok with me if you prefer not to receive my input, but I am wondering how we will help you if this continues? What are your thoughts about this?”

Another possibility: “I see that you seem overwhelmed by your feelings towards so and so to the point that it is hard to focus on anything I’m saying or even to attend to your own internal experience. I wonder if you may be quite anxious? Have you been aware of this? Do you have problems with anxiety that you are aware of?” if so, I would inquire into all symptoms of anxiety and let her know that her anxiety comes up in the face of her feelings towards this person and that her anxiety will only get worse if we don’t attend to it rather than continuing to focus exclusively on him. I would then ask if she would want to get help for her anxiety in therapy? If so, I would reiterate that we’ll need to practice an internal focus rather than primarily focusing outside of herself.

If none of the above leads to anything productive, I would also leave open the possibility that this client may not really be motivated to do the work of therapy. She does have the right not to listen to her therapist. If that is the case, I would simply reflect this and work very hard on not blaming myself for a thwarted treatment. Any of us may need to remind ourselves that there are 2 people who make a successful therapy possible, not just the therapist!

Thanks to the therapist posing this quandary for giving us something to chew on that can be hard for any of us to digest.

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