Survival Strategies

Survival Strategies

by Louis Cozolino
The challenge of therapeutic competence requires basic survival strategies that Louis Cozolino shares in his latest, The Making of a Therapist: A Practical Guide for the Inner Journey.
Filed Under: Suicidality, Trauma/PTSD

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Survival Strategies


 

Stories have to be told or they die, and when they die,
we can’t remember who we are or why we’re here.
--SUE MONK KIDD
 

one client came up, vigorously shook my hand, and said, “Good job, Doc. You’re just a suppository of information!” He then spun on his heels and left
A few years ago, I was giving a presentation about mental illness to a group of schizophrenic clients and their families. My hour-long talk included a description of symptoms, medications, and various forms of available treatment. After I was done with my talk, I took some questions, the group had a brief discussion, and we ended for the evening. As I was putting away my notes, one client came up, vigorously shook my hand, and said, “Good job, Doc. You’re just a suppository of information!” He then spun on his heels and left.

At first, I thought this might be a loose association. Then I began to suspect that he was telling me where I could put my “expertise” concerning his illness. Regardless of his true intent, whenever I begin to take myself too seriously, remembering that I am a suppository of information helps me to put things into perspective.

We do serious work. At times it can overwhelm us. Too often we are left to discover the risks and pitfalls of the profession on our own. Therefore, it is helpful to begin training with some strategies to increase our chances of having long and enjoyable careers. Following are a few “survival strategies” that I have found to be particularly helpful.

Don’t Panic in the Face of the Pathology

When I reflect on my past experiences, the clinical situations that have most challenged my ability to remain calm and centered have involved the following:

  • Suicidal threats and behaviors
  • Self-mutilation
  • Child sexual or physical abuse
  • The reporting of traumatic experiences
  • Dealing with a client’s sexual interests and/or advances
  • Bizarre psychotic beliefs

A competent clinician remains competent in the face of these kinds of challenges
If you are facing any of these, you need to remember survival strategy Number One: Don’t panic! A competent clinician remains competent in the face of these kinds of challenges. Anxiety is the enemy of rational problem solving, and panic leads even experienced clinicians to operate from survival reflexes instead of therapeutic knowledge.

Clients with painful experiences and frightening symptoms are accustomed to living in a world where others avoid and reject them. Our ability to remain empathically connected to them through the expression of their suffering sets the stage for therapy to be a qualitatively different relationship experience—?one where they are accepted, pain and all. Whether they are telling stories of their traumas or acting out their struggles in the therapeutic relationship, remaining centered, attentive, and connected is the foundation of our ability to provide a healing relationship.

he threw open the window and sat on the sill. He took the cord from the blinds, performed some clever knot making, and came up with a perfect hangman’s noose
Another reason not to panic is more subtle and more profound. Victims of trauma and abuse often find that sharing their experiences is extremely upsetting to listeners, so much so that they end up having to take care of the very people who are supposed to be taking care of them. Many victims report that others can’t tolerate knowing what they have been through and, sadly, this is often true. Victims learn to edit or silence themselves to avoid upsetting others, being rejected, and having to cope with the emotional reaction their victimization engenders. Not telling their story is the most untherapeutic outcome possible. By not panicking, you allow your clients to share their painful experiences, which frees them from slipping into the familiar but untherapeutic caretaker role.

One of my first clients was a young man named Shaun. He had a flair for the dramatic and would stride around the consulting room making grand gesticulations while wrapping his problems in eloquent words. On one occasion, he threw open the window and sat on the sill. He took the cord from the blinds, performed some clever knot making, and came up with a perfect hangman’s noose. He dangled the noose from his hand, swinging it back and forth like an executioner. Every so often he would look over to check out my reaction to his nonverbal communication. Alternately, he would lean out the third-?story window to the point where most of his torso hung outside.

This was my first clinical panic. I thought, “Oh, great, I’m going to be known as the intern with the client who jumped out the window during a session. There will probably be a famous lawsuit with my name on it. How will that look in my evaluations?!” Each time his head disappeared out the window, I turned around to look at the one-?way mirror, behind which my supervisor and other students were observing the session. With the expressiveness of a tragic opera character, I mouthed the word “help!”

In his wisdom, my supervisor chose not to intervene, and Shaun, fortunately, never jumped out the window. I later came to realize that Shaun was testing my ability to cope with his behaviors; he knew he was a handful. He wanted to see if I had the courage and centeredness to remain calm and stick with him in ways that his family and friends could not.

Over the years, I have had to deal with clients showing up at my door with gashes in their wrists, fathers threatening violence because I reported them for abusing their children, and tales of the most depraved human behaviors (the latter while working with victims of political torture and sadistic child abuse). Clients have had seizures, gone into diabetic comas, and experienced long and painful flashbacks during sessions. Although I haven’t always known the best thing to do, I always remember survival strategy Number One - - don’t panic. If I don’t panic, I can think about what is happening and what I can do.

Experience counts. The more you deal with situations like this, the easier it is to stay calm. Part of this is developing a “memory for the future” - - ?meaning that, over time, we become accustomed to facing frightening and dangerous situations, which are followed by conscious problem solving and good outcomes. Repetitive experiences like this form an emotional memory that we have access to in crisis situations and that reminds us that things will work out.

In addition to a growing sense of confidence, it also helps to have crisis - situation action plans prepared in advance. For example:
  • Early in supervision, discuss with your supervisor, in detail, what you should do in case of various emergencies such as when a client is a danger to himself or others.
  • Put emergency phone numbers, including your supervisor’s, on speed dial.
  • Schedule potentially problematic or dangerous clients for times when your supervisor or other backup professionals are present.
  • Alert others around you when you are meeting with a client who makes you uneasy so that they are on alert and can serve as backup if needed.
  • Pay attention to your subtle feelings and instincts about a client and discuss them in supervision

Expect the Unexpected

Never underestimate the value of preparation in being able to successfully deal with crises and problem situations. This leads to survival strategy Number Two: Expect the unexpected. When extreme situations do arise, keep some of the following principles in mind:
  • Don’t catastrophize. A client’s strong emotions such as angry outbursts and uncontrollable sobbing tend to shift in a matter of a minute or two.
  • Maintain boundaries. If a client has a feeling, it does not mean you also have to have it.
  • Stay centered. If you sit calmly, it will provide a sense of safety and calm to your client.
  • Provide structure. When a client is emotionally out of control, it is often helpful to provide gentle but firm instructions, such as “I think it would be helpful if you would sit down and focus on your breathing - - let’s do it together.”
  • Provide hope. While understanding your client’s feelings, also remind him or her that things will get better. Many clients find hope in the fact that you have helped others with problems similar to theirs. Tell them stories of clients similar to them who had positive outcomes.
  • Discuss strengths and resources. It is easy to forget our strengths, resources, and accomplishment when in a crisis. Taking a couple of minutes to discuss these at the end of a difficult session not only provides hope but also yields clues for additional interventions, such as the reestablishment of relationships and activities that have been forgotten during difficult periods.

It is easy to forget our strengths, resources, and accomplishment when in a crisis
I received a call on a Sunday morning with a request that I meet a young girl for an emergency consultation that afternoon. When I arrived at my office, I found Sandy slumped down in a chair, looking half asleep and half in shock. She looked so emaciated, her color so bad, that I felt immediate concern for her physical health. Once in my office she told me in an emotionless tone that she thought that she had been raped the night before in a parking lot outside of a nightclub. She was home for a week from her East Coast prep school and had gone out dancing with some friends. As was her habit, she had drunk to the point of unconsciousness, so she couldn’t recall whether the sex she had was consensual or not.

Sandy’s words flowed like water from a cracking dam; she wanted and needed to tell me everything on her mind and in her heart. She described a long history of bulimia, cocaine use, binge drinking, a number of serious automobile accidents, failing grades at school, and her victimization at the hands of numerous boyfriends. Sandy also told me of her loveless childhood and her parents’ sending her off to boarding schools from a very young age. She spoke for almost 90 minutes and I didn’t interrupt because I sensed her need to finally share all of her pain with someone who might be able to help.

Sandy said that she had “half a dozen” problems, many diagnoses, needed to be in several support groups, and felt that there was no hope for her. What had happened to her the night before wasn’t atypical for her; what was different was her feeling of hopelessness and thoughts of suicide. After this, she became silent, glanced over at me, sat back into the couch, and gave me a look that said, “Okay, your turn.” I was so immersed in her story and so impressed with her emptiness and pain that it took me a while to turn my attention to what I would say.

Sandy’s life clearly felt out of control
Sandy’s life clearly felt out of control. What I wanted to do was to take all that she had told me and to present it back to her in a way that demonstrated to her that I had heard what she said, understood the depth of her suffering, and could provide a perspective and plan that would give her hope of having a better life. I thought about all she had told me and came up with some ideas. This is what I told her: “Sandy, although it feels like you have many different problems, it seems to me that you have one core struggle - - the need to feel loved and cared for.” I thought that this might be correct because I could see Sandy’s posture change as the first tears poured from her eyes. “My sense is that although your eating disorder, alcohol and drug use, and bad relationships all seem like different problems, they may all be attempts to cope with the loneliness and anxiety you feel every day. Even your car accidents, where you drive your new car into a tree, may be a way to tell your parents something is wrong. With each accident, instead of hearing your pain, they only have another car delivered to your school.”

Having one central problem as opposed to “half a dozen” made Sandy feel a sense of hope. She took off time from school and I began to work with her and her family around issues of attachment, bonding, parenting, caring, and love. Sandy’s family wasn’t ideal for her, but she needed to learn that many of her parents’ emotional inadequacies were not because she was unlovable but because of their own limitations. They needed to learn that their daughter needed more than money from them and Sandy had to learn a healthier way of asking for what she needed.

Having one central problem as opposed to “half a dozen” made Sandy feel a sense of hope. She took off time from school and I began to work with her and her family around issues of attachment, bonding, parenting, caring, and love. Sandy’s family wasn’t ideal for her, but she needed to learn that many of her parents’ emotional inadequacies were not because she was unlovable but because of their own limitations. They needed to learn that their daughter needed more than money from them and Sandy had to learn a healthier way of asking for what she needed.

Crisis as Communication

As with Sandy, crises are often forms of communication--ways of communicating when words can’t be found or aren’t heeded. Many clients struggle with suicide and there are few clinical situations more difficult to deal with. Suicidal acts, gestures, and ideation make us concerned for our clients and ourselves. We are all told that we have a duty to protect our clients, but what is the best way to do this and still preserve the therapeutic relationship and the client’s confidentiality? These are difficult clinical situations that we learn to cope with but never get easy.

Roberta had been depressed for years. She told me that every few years she would try to kill herself
Roberta had been depressed for years. She told me that every few years she would try to kill herself in ways that were fairly lethal. Over the years, Roberta had come to understand that her suicidal actions were desperate attempts to gain the love and attention that she never felt she was given by her parents, siblings, or friends. Although it was clear to me that she wanted to live, I was concerned that she would someday miscalculate these calls for help and accidentally kill herself. One afternoon, she came to my office with a clear plan to commit suicide later that evening. As she described her detailed plan of getting a gun, going down into her basement, and setting the stage for her death, I grew more and more frightened. Her description was so detailed, I could vividly picture every stage of the process. I raced through options in my mind: barring her from leaving my office, calling the police, taking her to a hospital, and so on. I tried not to panic, stay calm, and think through the logistics, complications, and risks of these options. All of the interventions that came to mind had been done by Roberta’s previous therapists and had led to her ending each relationship. Was there something else I could do?

Still struggling to remain calm, I asked Roberta what she hoped to accomplish by attempting suicide. As she spoke, it became clear that she wanted her brother to know how alone and hurt she felt. She wanted him to feel guilty for not paying better attention to her. This soon flowed into a discussion of her wanting me to know these things about her inner experience and my empathic shortcomings. Roberta somehow felt that a suicide attempt was the only way she could make me understand the intensity of her pain.

By the end of the session, I had somehow assured her that I understood the depth of her suffering and why she would commit suicide, but that a suicide attempt (as a form of communication) would be redundant to what I already knew. I also assured her that I wanted our relationship to continue and that her past hospitalizations always resulted in so much shame that she discontinued her work with her therapist. Roberta and I made a standard suicide contract and scheduled extra meetings to help her through this difficult time. For me, the most important aspect of this session was my ability to avoid panicking, remember my training, stay in the role of a therapist, and hang in there with Roberta’s experience.

Don’t Try to Reason with an Irrational Person

This is survival strategy Number Three. It will save you hours of wasted energy and keep you from missing the important emotional realities behind much irrational behavior. Although we can generally rely on reason to aid us in finding solutions to complex problems, it doesn’t always work. Some people have such a firm image of what is true that they cannot be swayed by reason. The emotional circuits of the brain are easily capable of inhibiting or overriding rational thought; some clients only see things that fall in line with their prejudices and beliefs. Those fighting with God on their side seldom stop to think about the god leading their enemies into battle.

For a number of years, I worked in a hospital ward with actively psychotic individuals. I saw clients in both individual and group therapy and participated in many ward activities. During a session with a woman named Wanda, I became aware that she believed she was a few months pregnant. In discussion with the nurses, I was assured that this could not possibly be the case and that Wanda was suffering from a delusional belief. It made no difference that the nurses had told this to Wanda; she remained steadfast in her belief that she would soon be a mother.


To complicate things even more, during one of our sessions, Wanda revealed to me that she was pregnant with a cat
To complicate things even more, during one of our sessions, Wanda revealed to me that she was pregnant with a cat! I liked cats, but this one caught me by surprise - - I still hadn’t learned to expect the unexpected--and I decided that I definitely needed to do something. I suggested that she bring this belief up in group therapy later that day, assuming that when the other group members heard her story, they would help Wanda to realize the impossibility of her belief.

Based on my suggestion, she waited her turn in group and made her joyous announcement. Although there were some doubters at first, by the end of the hour Wanda had convinced the group that it was possible for a woman to become pregnant by a male cat if the conditions were right. Amazed and impressed by her skills of persuasion, I nevertheless refused to give up my reality campaign. After the group meeting, I asked the nurse to schedule a pregnancy exam so that Wanda could hear from a physician that she was not pregnant. That had to work!

The next week Wanda came back from her pregnancy test just beaming! She told everyone that she had been to the doctor and was happy to announce that her kitten was doing fine. In fact, she had even spotted a few whiskers during the pelvic exam. The group began planning a kitten shower and, under some pressure, I agreed to contribute a litter box. The nurses cried with laughter when I told them about the kitten shower my group was planning for Wanda. They had learned long ago not to argue with Wanda’s delusional beliefs. Apparently, I was not the first intern who had tried to get her to engage in “reality testing.” Wearing a sympathetic smile, one of the nurses suggested that I might have bumped up against the limits of psychotherapy.

We run into irrational beliefs all the time. The chronic alcoholic client will insist he can drink in moderation; the emaciated anorectic client will adamantly claim to be obese. Rather than feeling compelled to impose your reality, sit back and discover what the world looks like through their eyes. Be patient and understanding. As most people go through the process of therapy, they steadily reevaluate their beliefs with gentle, strategic, and well-timed doses of reality. As Wanda demonstrated, “in your face” reality testing doesn’t always work. Even very delusional clients often realize that their reality differs from yours. Your empathic availability may do more to bring them to consensual reality than any rational argument, and it will protect you from feelings of frustration that may be counterproductive.

Instead of trying to impose my reality on Wanda, I needed to learn that, despite her mental illness, she desired to be loving and nurturant
Instead of trying to impose my reality on Wanda, I needed to learn that, despite her mental illness, she desired to be loving and nurturant. Wanda was coping with other realities - - separation from her family, getting older, and never having children of her own. Her needs to nurture and be fulfilled as a woman were the eventual foci of therapy, as they should have been from the beginning. She needed to take her medication on a regular basis, so she could be home with her family, and her family needed to know how to care for her illness. Perhaps now I would have started therapy by going to the animal shelter and getting Wanda a kitten.

Don’t Forget a Client’s Strengths

After you’ve spent years in classes focusing on abnormal psychology, diagnosis, and treatment, it is easy to see pathology in every action and behavior. But, as Freud suggested, not every cigar is a phallic symbol. Because people are coming to therapy for their problems, it is easy for both client and therapist to get tunnel vision and forget to see the positive aspects of their lives. If your client has struggled with anxiety, depression, or trauma for a long period of time, they may have lost sight of the people, accomplishments, and good things in their life.

In your quest to diagnose and treat pathology, remember that every client possesses at least one strength. Whether that strength is a musical talent, the love of a pet, or a burning passion to ride motorcycles, it may boost self-esteem or motivate change. A desire to see lions in their natural habitat--or to show up a high school counselor who said they would never amount to anything-can be used as leverage to take on new challenges and inspire new behaviors.

Describing resources and strengths may help to put the problems you plan to focus on in perspective. Keep in mind, however, that this needs to be done with great care. You run the risk of having your client think that you are not taking their problems seriously and that you want to avoid their negative feelings. They may actually have a point if, based on your discomfort with their troubles, you try to steer the therapy in a way that communicates to them “just look at the bright side” or “keep a stiff upper lip.” With this caution in mind, try to balance your attention to “problems” with attention to “strengths.”

When people feel sad and guilty, they often deprive themselves of positive experiences
I have been pleasantly surprised on a number of occasions at the positive results I’ve gained from encouraging (and sometimes even harassing) clients into describing their strengths. I’ve found that encouraging clients to review their past accomplishments, positive relationships, interests, hobbies, and passions will actually lift their spirits. Having them reconnect with activities of interest as soon as possible in the process of therapy can also enhance their receptivity to what is focused on during sessions. When people feel sad and guilty, they often deprive themselves of positive experiences. If you prescribe these as part of the therapy, they may feel less guilty about doing them and rationalize their enjoyment as “doctor’s orders.”

Reprinted from The Making of a Therapist: A Practical Guide for the Inner Journey, Copyright (c) 2021 by Lou Cozolino. Used with permission of the publisher, Norton Professional Books, a division of W. W. Norton & Company, Inc. All rights reserved.
Bios
Louis Cozolino Louis Cozolino, PhD, is a professor of psychology at Pepperdine University and a private practitioner. He is the author of The Healthy Aging Brain: Sustaining Attachment, Attaining Wisdom (2008), The Neuroscience of Human Relationships: Attachment and the Developing Social Brain (2014), The Neuroscience of Psychotherapy: Healing the Social Brain (2010), and Why Therapy Works: Using Our Minds to Change Our Brains (2015). He lives in Los Angeles, California.