Verbal Ventilation: The highway to intimacy and the key process of therapy

Posted on by Psychotherapy.net Team

I was standing in the waiting room before my first session with a new therapist some twenty years ago, when I perused a cartoon that she had displayed on her bulletin board. In panel 1 of the wordless cartoon, a woman with a dark cloud over her head is talking to a friend who has a shining sun over hers. In panel 2, as the first woman gestures in a way that indicates complaining, the cloud covers her friend’s sun. In panel 3, the cloud emits a bolt of lightning, she angrily catharts, and her friend glowers along with her. In panel 4, the cloud rains on them as they embrace, commiserating in the rain of their own tears. In panel 5, relief spreads on their faces as the cloud moves away from the sun. In panel 6, the sun shines over both of them, as they smile and slip into pleasant conversation.

I have come to call this process verbal ventilation, and I believe it is a key healing process in therapy and a key bonding process in intimacy. Verbal ventilation occurs when an attunement to our feelings guides us in choosing what we say—a powerful enactment of Jung's dictum that feelings tell us what is important to us.

In therapy, verbal ventilation is the penultimate metabolizer of emotional pain. It is speaking or writing in a manner that airs out and releases painful feelings. When we let our words spring from what we feel, language is imbued with emotion, and pain can be released through what we say or write.
When my wife and I join each other on the couch after one of us has put our son to bed, we often reconnect via some version of this process. Spontaneously taking turns checking in with our feelings to use them to tell us what is most important right now, we share and process the ups and downs of our day.

Many times like my clients, what seems to arise in each of us is the need to share about what was most difficult, before the lighter stuff naturally arises to the forefront of our consciousness. Perhaps this is a reflection of a reality that the novelist David Mitchell describes thusly: “Good moods are as fragile as eggs, bad ones as fragile as bricks.” I once had an ex-priest client who called verbal ventilating traveling through the catacombs to get to the cathedrals.

I specialize in working with clients who were extensively traumatized in their childhood families. Many of them present as developmentally arrested in their ability to relationally regulate their emotional stress through verbal ventilation. Their parents routinely attacked, shamed or abandoned them for emotional expression. Now, whenever they have the urge to verbally ventilate, the critic steps in and slaughters their self-expression with self-contempt.

Neuroscience research increasingly suggests, perhaps through the vehicle of mirror neurons, that human interaction is a powerful process for helping us work through states of hyperarousal and intensely dysphoric emotion.

A key therapy task for my traumatized clients is the practice of verbal ventilation. While the client vents, we work together to deconstruct her critic. It seems that as I compassionately respond to her painful disclosures, we are engaged in a process of co-regulating her emotional pain. Perhaps mirror neurons are also the circuitry behind the process of modeling.

The cartoon described above also reminds me of my archetypal, favorite session, which fortunately occurs increasingly with my clients. Here is an example of it: A well-practiced client begins his session lost in an emotional flashback to his painful past. He verbally ventilates about it. He is the regressed hurt child, feeling bad, and part of him is sad and part of him is mad. He has lost the experience of feeling whole and integrated, and this loss is like a death that responds well to grieving.
As he cries and angers out his pain from his right brain, he is welcomed by my right brain commiserating with his grief. Our dialog also helps him to connect his feelings with an integrating, left-brain understanding. Typically, during the hour he moves back from the past to the knowing and integration he normally has when he is not regressed or in a flashback.

And typically, this is accompanied by an authentic return of his sense of humor (Duchenne laughter*), not the sarcastic, bullying, non-Duchenne* humor of his critic, with which he prefaced the session. He laughs with the surprised relief of having been released from what moments ago felt like interminable suffering.

Finally, I also notice that in the most successful therapies, my clients move on when they have formed a primary relationship in which reciprocal verbal ventilation is well established.

*See Judith Kay Nelson’s excellent book, What Made Freud Laugh, for an excellent exploration on these two types of laughter.

Gone in 60 Seconds: How to Handle a Mental Health Workshop Heckler

Posted on by Psychotherapy.net Team

Like most of you, as a psychotherapist, book author, and educator, I am often asked to give workshops, and educational seminars. For many of us, sharing our unique expertise is a part of our professional mission.

A while back I was contacted by a church group who wanted to give a series of eight different mental health workshops during the spring. Each of the workshops would be presented by a different expert. I was going to be the final presenter, number eight, and quite frankly was looking forward to presenting.

The week prior to my lecture, the workshop coordinator contacted me. His opening question threw me off guard. "Are you still sure you want to do the seminar?"

"Of course, I do. Why wouldn't I want to present?"

"I don't think you understand, Dr. Rosenthal. There has been a heckler in the crowd and she is so mean and critical that virtually all of the speakers who came before you said they wouldn't have done it, had they known how verbally vicious this woman was."

I must admit the reactions of the speakers sounded a tad extreme. "Look, why doesn't someone just put this woman in her place?"

Again he countered with, "I don't think you understand Dr. Rosenthal."

"Okay, please enlighten me, what exactly don't I understand?"

"Well, this woman—the heckler—is a well-known psychologist. At times she corrects the speakers on their information, and she seems to know more about the subject than they do. It has been very embarrassing for the presenters."

Now I wanted to deliver my speech more than ever. "Hmm. Let me ask you a question. I assume these are large crowds, but is there a way I would know who this woman is with 100% accuracy?"
The workshop coordinator explained that our friendly neighborhood psychologist from hell heckler always sat in the front row, dressed in a very distinct way, and that I could easily pick her out despite a crowd hovering near the 300 mark.

"Then, I'll do the lecture," I confidently announced.

The big day finally arrived. As I was introduced with a brief bio, and handed the microphone, I laid eyes on the enemy for the first time. Our friendly neighborhood psychologist from Hades was sitting right in the middle of the front row. She had a smug look on her face. Glancing at her body language I was certain she was ready, willing, and able, to sucker punch me or take me down at the knees, in moment's notice.

But trust me when I say Dr. Expert psychologist was in for a major unexpected surprise, because I was going to strike first. After making a few opening comments I asked the audience a very difficult, if not impossible question, I had researched. Just how hard was this question? Glad you asked. Well let's put it this way. If you could have magically placed Sigmund Freud in the audience the chances are good he would have nudged Theodor Reik, if he were sitting next to him, to cadge an answer. In any event, I asked if anybody in the audience knew the answer knowing darn well I had a better chance of winning the lottery that day and I hadn't even purchased a ticket!

I marched forward beyond the podium and into the crowd stopping right in front of you know who. I stared her right in the eye and said, "How about you ma'am? How would you answer my question?"
Miss Expert shared her answer. I was intentionally silent for a few brief moments.

I continued giving her an eyeball to eyeball stare and then I spoke loud and clear into the microphone. "Absolutely, positively wrong! Now I don't want you to feel bad. That's exactly what any other untrained person would say. But you folks are not psychologists, or therapists, or mental health experts, and that's why you are here . . . to learn something new."

It was at that moment that our psychologist's reign of terror ended. She grabbed her expensive designer handbag, grimaced, and made a bee line for the exit sign to the right of the podium.
Gone in 60 seconds. You've got to love it folks!

Diana Fosha on Accelerated Experiential-Dynamic Psychotherapy (AEDP)

Posted on by rezendevknowfully.com

“What You Think is Impossible, You're Actually Already Doing”

Polly Ely: Diana, welcome. As a devotee and student of Accelerated Experiential-Dynamic Psychotherapy (AEDP), I’m so happy to have this opportunity to interview you. Because AEDP is still pretty new to the world of psychotherapy, could you begin by explaining a bit about it?
Diana Fosha: Well, to begin with, unlike most models of psychotherapy that proceed from psychopathology—that start from what’s wrong and very reasonably want to go about fixing and healing it—one of the core characteristics of AEDP is that it assumes healing is already there to access from the first contact with the patient, including the most traumatized person that we encounter. It proceeds from the assumption of healing as a process and healing as a phenomenon—something to be entrained and engaged.

And we’re an experiential treatment, so whether we’re working with healing or attachment or emotion or what have you, we’re not so much interested in the narrative or people’s stories about it as much we’re interested in helping people drop down as much as we can into their experience and exploring the experience.
PE: In terms of “dropping down,” are there particular components or interventions that feel most relevant to AEDP that allow for that to occur?
DF: One of the things that’s characteristic of AEDP is to make the most of what’s there before trying to work with what’s not there or what’s maladaptive. So even when dropping down, if we see little glimmers of greater contact with the body, we would try to focus in on that little glimmer and enlarge it. I think more than anything else the stance is, “You’re already doing it so let’s just do more of it.”
PE: So you’re trying to amplify it, stretch it out, do more.
DF: Make you aware that what you think is impossible you’re actually already doing.

“I Don’t Have Any Feelings”

PE: So when you talk about greater contact with the body, how might you proceed with bringing something to life by making contact with the body in some way that traditional psychotherapists or eclectic psychotherapists might not feel as comfortable doing?
DF: Well, I’ll just say what we would do in AEDP and let other people judge whether it’s what they do or don’t do. For instance, the last person that I worked with was a man with a huge trauma history and a lot of disassociation. He walks in and he is telling me about some severe illness in a parent, and I ask him how he feels about it, and he says, “I don’t have any feelings.” So my question to him is, “What are you aware of?” And he becomes aware of a kind of subtle sensation in his chest—and that becomes our entry point. So we stay with that and I ask, “What does it feel like?”

“Well, it’s tense and it’s sort of a little dense.”

“Is it pleasant? Is it unpleasant?”

Over the course of a period of time, we really stay with what’s in his chest, which turns out to have all sorts of qualities of heaviness and pain—it’s a painful sensation. So before you know it, here I am with this incredibly intellectualized, supposedly in-his-head patient, talking completely in the language of sensation.
We’re no longer talking content. We’re no longer talking narrative. We’re speaking this kind of right-brain language.
We’re no longer talking content. We’re no longer talking narrative. We’re speaking this kind of right-brain language. He’s touching his chest with his hand as he’s palpating the spot where he’s experiencing this, and he’s starting to notice all these shifts and fluctuations, which are very much occurring in the moment. So within a few minutes, we had sort of “dropped down.”
PE: Dropped down and undone some belief about him not having any feelings?
DF: Right. Or that he’s all in his head or that he has an impossible time accessing his feelings.
PE: I see. So you’re developing capabilities and his belief in those capabilities, too.
DF: Over time, yes, absolutely
PE: So when I think about that—what’s happening in the body—how do we tie that to either the intellect or the story that they’re coming in with about whatever their perceived problem is? How might that be an inroad to the problem?
DF: Oh good question, because, of course, he’s not coming in because he has this subtle sensation in his chest; he’s coming in for a variety of issues and we’re just using it as an example. But really as we’re able to get more body-based and right-brained as a way of speaking about these kinds of phenomena, he and I are also having an interaction and we’re noticing what goes smoothly and flows and what’s difficult; what brings him closer and what makes him more distant?

And as we’re evoking what the pain is about or the sensation and what happens when I empathize, associations start to come up. “Did you ever have this kind of feeling? What comes to your mind about what this feeling may be telling you?” That becomes a way in, a much deeper way than telling the story or narrative. And eventually, the goal is to bring it all together—to bring it to a place where we can integrate experience with narrative, with understanding, with some sense of how his experience is linked to whatever issues he was having in his past.
PE: Sounds almost like you’re bypassing the thinking mind by calling on associations from that place in the chest that you’re talking about.
DF: I think that’s very much the case; or we’re trying to do that in the earlier part of the process, where we want to get experiential, construct something from the bottom up. In other words, not with preset preconceptions, beliefs, narrative coherence, but to let the story emerge from the kinds of experiences that are getting generated in the therapy. And then once we’ve worked with that, then we’re putting together basically a new narrative.

The Origins of AEDP

PE: What are the origins of AEDP? Did it spring forth from another model or did it come from your own curiosities about psychotherapy and what works?
DF: That’s an excellent question. I think the easiest way to answer that question is to tell you a little bit about my personal trajectory. My own training and development as a clinician was very psychoanalytic, psychodynamic and also developmental.
At the time I felt uncomfortable with the length of traditional psychoanalysis and its relatively cavalier attitude towards effectiveness and results.
At the time I felt uncomfortable with the length of traditional psychoanalysis and its relatively cavalier attitude towards effectiveness and results. So when I came across short-term dynamic psychotherapy in the work of David Malan and others, I was very excited because it seemed to be a way of working that preserved some of the depth. The analytic way of working, but at the same time, it was short-term, it was intensive. And the effectiveness of the treatment was one of the measures.

So I trained in a particular form of short-term dynamic psychotherapy developed by a clinician named Habib Davanloo, who developed a very intensive and very confrontational model of short-term dynamic psychotherapy. That was my early training and the first exposure I had to viscerally-based, deep feelings and emotions being systematically accessed in a relatively short period of time.

However, that way of working was confrontational; there’s a fair amount of stuff around aggression, which was not ideally suited to my personality or my way of understanding what’s needed in treatment. So from that point forth it became my personal goal to access the phenomena that I witnessed and learned in short-term dynamic psychotherapy and have things that are as visceral and as powerful and as transformative, but proceed from a place of being with the patient, rather than from a place of confrontation.

My other goal was to have a coherent theory for these amazing transformative phenomena. And I thought psychoanalysis, as marvelous as it is, didn’t have a good explanation of why the hell these phenomena were transformative in the moment.

You know, you start a session, you access this experiential phenomena, and 15 minutes later or half an hour later you’re in a, very different, transformed place. So it became important for me to try to have a theory that really reflected the phenomena of experiential psychotherapy. And over time AEDP, with both its theory and its practice, started to develop.

Resistance vs. Transformance

PE: You talk a lot of about transformation and for me, as a student, transformation is a word that was fairly new to me in the context of psychotherapy until I came upon AEDP. It just wasn’t a term that I ran across in my own training. I’m thinking about the word “transformance,” which is a term that you coined. It’s an important term and concept in the language of AEDP. Would you be willing to share a bit about its meaning?
DF: Well, it’s this idea of healing from the get-go—of healing not just being an outcome but a process that exists within each person that emerges in conditions of safety. That idea is not new to AEDP; it exists in spiritual traditions; it exists in humanistic therapies; it exists in some other existential therapies.
Whereas resistance is the conservative force in the psyche that causes us to resist changes or challenges, transformance is the force in the psyche that’s moving towards growth and expansion and transformation.
But still, our language tends to be very psychopathology-based, so that it seemed to me that a term was needed in our therapeutic lexicon to capture this notion of healing from within that we’re trying to tap. I coined the word “transformance” to capture that force and to have it be in counterpoint with resistance. So, whereas resistance is the conservative force in the psyche that causes us to resist changes or challenges, transformance is the force in the psyche that’s moving towards growth and expansion and transformation.
PE: I know for myself that one of the key elements of being an AEDP therapist is videotaping our work. What feels most important to you about that? It has some obvious teaching potential but I wonder if there’s more to it that you believe contributes to the process?
DF: I think it’s very much this emphasis on experience and phenomena and being able to witness firsthand the actual, live interaction. When a student comes to me for supervision, I’m not hearing his or her rendition of what happened. We’re having an experience together, witnessing what happened on video. It’s a huge help for the therapist because there’s no way that one can, in the moment, have access to the multiplicity of things that are happening in any given moment. So there’s this component of being able, after the fact, to look and look again and again and again, which is a beautiful way of learning about the richness that’s there.

Meta Processing

PE: Going back and looking at my work has been a huge place of growth for me as a therapist, and layers of new understanding emerge each time I watch a session. As I become more sophisticated in my understanding of what I’m doing, I’m able to notice more about the experience in the moment with my patients.

One area that is very key to AEDP that has been a struggle for me and where I’ve stretched a lot is around the idea of doing meta processing with the patient. Could you talk some about how you define meta processing and its value and why we, as therapists, may want to consider doing meta processing with our patients?
DF: Meta processing is huge and I think it’s one of the more important contributions that AEDP has made to the field of psychotherapy. I can explain it best by using a scenario. Let’s take somebody who comes in with depression and is feeling sort of sluggish or hopeless or whatever aspect of depression they have. And as a result of doing a piece of work—maybe it involves mourning—30 minutes later the depression lifts. They have a somewhat new perspective. They start to have a little bit of confidence in their own capacity to be effective in the world, right?
PE: Okay.
DF: So the depression lifts and the person starts to feel some efficacy. Well, at that point for us, what we want to do is process
PE: In that session.
DF: Right there in that session. What happened that allowed them to come in feeling lousy and now, half an hour later, they’re feeling more energized or more effective? So we then go through the experience.

The reason it’s called meta processing is that we’re processing the experience of what’s therapeutic about therapy. So—meta therapy. We might start to explore with the patient, “So you’re saying that you’re feeling better. And you have a sense that maybe you can be more effective. What’s that like? What does that feel like?” In the same way that we would explore what the sadness felt like or what grief feels like or what heaviness feels like. Now we’re beginning to explore what does energy feel like? What does vitality feel like? What’s it like that you and I, through talking together and doing this piece of work together, ended up here when we started back there? So that all these experiences that are quite implicit start to become more explicit, and then we’re doing another round of experiential exploration.
PE: So the next round is kind of concretizing what was learned in those first 40 minutes?
DF: Yeah. That’s a beautiful way of saying it. Concretizing, solidifying, increasing awareness, and consolidating it.
PE: And is that something that you expect your therapists to do every session?
DF: Well, we think about it in the following way: we have “Big-M” meta processing and “Small-M” meta processing. And “Big-M” meta processing is when you’ve had an experience like the one we’ve talked about—a very definite change for the better as a result of doing a piece of psychotherapeutic work. Whereas “Small M” meta processing is when there is a tiny little shift. The patient says something, you make a remark, and maybe tears come to their eyes because they feel understood. It’s not that you’ve worked for half an hour and you’ve done a whole process; it’s been one little exchange. “When I said that, it seemed to have moved you. What’s that like for you? What happened?” That’s a little meta processing. But it doesn’t have to be positive. It can be negative. Let’s say you say something and you see the patient sort of turn away or advert their eyes. So there’s been a very specific moment, a little change. We want to zero in on that and not have preconceived ideas about what it means. It doesn’t matter. The point is for the therapist to really get inside the patient’s experience, in a precise way.

So that’s how we use the meta processing and it’s probably accurate to say that rarely does an AEDP session go by without several instances of either “Small-M” or “Big-M” meta processing.

Existing in the Heart and Mind of Another

PE: I’ve been asked a few times if there’s any research that supports the accelerated outcomes of AEDP. How do you answer that question?
DF: That’s a very good question. There are about five research projects that are currently in the works on various aspects of AEDP—on outcome, meta processing, the nature of the changes that people experience as a result of AEDP training—but there are many, many components of AEDP that have been researched in the context of other experiential models. So while we have no research on meta processing or on dyadic affect regulation—because nobody else has done it—there’s infancy research that shows that mother/baby dyads where there’s effective affect regulation are the dyads that produce the most resilient babies. We have developmental research that shows that working with the feeling of existing in the heart and mind of another, which is a phrase we use that relates to attachment, is a huge aspects of resilience in the face of trauma.

There’s a lot of experiential research in the field of trauma that shows that processing previously unbearable emotions through to completion in a safe environment is one of the factors that leads patients to both stay in treatment and have better outcomes on some of the interpersonal measures. So many pieces of AEDP have quite strong empirical validation. The last piece comes from what AEDP shares with short-term dynamic psychotherapy, which shows that when you get past defenses and when patients and therapists are in close contact with core emotions, that contributes significantly to good outcomes. There’s a whole literature on that.
PE: You mentioned a few minutes ago how therapists report being impacted by working with this model. Can you say more about how their lives changed or their own personal processes changed?
DF: That’s a beautiful question. I would actually love to turn it back around and hear what your experience has been.
PE: Well, it has sort of paralleled my own deepening and ability to understand myself and where my defenses lie and where breakthroughs occur for me. It’s such a big question because, as I deepen in my understanding of AEDP, I see a natural transformation in who I am as a human being with other people; how I do in relationships with other people. How much vitality and life I feel within myself on a moment-to-moment basis and just how well I recover and how resilient I become. Without sounding like I’m proselytizing, I feel pretty transformed by it, to be perfectly honest.
DF: I appreciate your saying that. It’s a beautiful answer and people often speak of the parallel process in terms of their own transformation and deepening. I think that one of the other aspects is the gratitude that people experience at the generosity of the community. In the same way that we do therapy with affirmation and empathy and focusing on what people already do, the AEDP community is a very affirming, supportive community.

Especially for people who have had a lot of experience having to steel themselves against criticisms. You can certainly learn with a lot of harsh feedback, but I think the sense of learning through deepening, while being held and being in resonance with others; learning to pay attention to what gives you energy and vitality and what saps your energy and vitality and bringing that into the work—these are things that people are profoundly grateful for.

People have often said that they have a sense of coming home, which is very moving to me.
Way before they became professionals trained in fancy models and systems of interventions, there was just some intuitive sense of wanting to be with people and help them—some sense of hope and generativity that very often gets trained out of people in graduate school.
Way before they became professionals trained in fancy models and systems of interventions, there was just some intuitive sense of wanting to be with people and help them—some sense of hope and generativity that very often gets trained out of people in graduate school. People learn techniques and learn models and become very competent, but lose contact with some of that kind of naïve but very core sense of what it takes to heal in the presence of another. There’s something about AEDP that really draws on those innate processes by which we connect and heal and need to be with one another that lets people feel more alive.
PE: The word that comes to mind for me is “sustainable.”
DF: Yes, something about it allows you to sustain rather than burn out, and feel actually fed by it.

Men Get a Bum Rap

PE: I know recently you did some work around the differences between working with men and women and I’m wondering if there’s anything about that you’re excited about and would like to share.
DF: You know, I’ve really felt that men, to be perfectly honest, were getting sort of a bum rap in the world of emotion focused therapy. I have a colleague who sees couples and the typical set up was that the woman dragged their male partners in and they came because they didn’t want to lose the relationship. But they would always be revealed in the therapy as cut off from their emotions and not therefore able to use the couple’s therapy, so my colleague would send the men to me for individual therapy. These men would come in with their tails between their legs and feeling sort of sheepish or defensive or alienated. And when, in AEDP fashion, I’d look for the glimmer of what’s resilient or what’s healing or what’s transformance based and reflect back to them sensitivity or care or empathy, it was such a mind-blowing experience because they were so used to being told everything that they do wrong.

It was in that kind of informal way that I got interested in what happens to men in psychotherapy, especially in emotion- or relationally-based psychotherapy, because AEDP is so attachment- and emotion-based. So I actually went to do some neuroscience research and there’s a tremendous amount of the neuroscience research on sex difference and affect regulation.

And surprise, surprise, all the stuff that standup comics and guys in bars and girlfriends speaking to each other talk about—you know, everybody’s so-called stereotypes of the other gender—have some bearing in neuroscience.

PE: Which ones stand out to you?
DF: Well there are some real differences in how male and female brains process emotion. One of the main characteristics of male brains is that they’re actually more emotional—counter to stereotype—and have more right-brain activation than women, but that more visceral, raw sense of emotion is not as linked with language, so that modulation of emotion is much more problematic in men. Whereas connectivity in the brains of women is much more evenly distributed in the left and right brain, so that everything is much more connected for women. Under extreme emotional activation, language sort of goes off screen for men.
So it’s not that men don’t have feelings; they have tremendous, tremendous emotion, but the capacity to articulate is different.
So it’s not that men don’t have feelings; they have tremendous, tremendous emotion, but the capacity to articulate is different. And then there’s all this backlash in terms of shame and feeling inadequate for not being able to have an emotional conversation.
PE: That’s such an empathic way to be with men who are experiencing some trouble with expressing themselves.
DF: Yes, and I’ll tell you one other fascinating one, which has to do with face recognition. There’s an area in the brain that’s devoted to face recognition and women are superior to men in face recognition in all conditions, across the board. Under stress, women’s face recognition gets better and men’s face recognition gets worse. In stress-based literature they say that under stress, men’s sympathetic nervous system—the fight-flight response—is activated. For women, what’s activated under the same kind of threatening conditions is the limbic system and what’s been called the “tend and befriend.”

We women reach out, seek, and offer care. Reaching out to others means better face recognition, right? Presumably, evolutionarily speaking, the more you can recognize a face, you can recognize friend, foe, nurturer, etc. Whereas under stress, men sort of go inside, get strong, get into fight or flight, and are more isolated. It’s like the focus is on action and the face recognition drops off. So those are two things that seemed to me to bear very directly on our work, whether we’re working with individuals or couples.

PE: What are your suggestions for people who are interested in learning about or getting involved in AEDP?
DF: The first thing would be to visit the website, www.AEDPinstitute.com which is a focal point for the community and a way to just find out something about the model. We’ve got videos, presentations, downloadable articles, and trainings with different members of the faculty. You can also find out where trainings in various parts of the country are.
PE: Thank you so much for taking the time to discuss your work.
DF: Thank you.

Transforming War Trauma: The Healing Power of Community

Posted on by rezendevknowfully.com

"What's the matter? The war's over," someone said to a veteran. "Yeah, over and over and over," he replied.

Coming Home

It’s January, 2007, the first moments of the Coming Home Project’s first retreat for veterans and their families. Kenny Sargent and Rory Dunn are Iraq veterans who both sustained traumatic brain injuries (TBI). One was shot in the head, one was hit by an improvised explosive device (IED); both suffer from post-traumatic stress. As people mill around, Ken and Rory meet for the first time, up close and personal. Since neither can see very well, they touch each other’s wounds, comparing scars and experiences. They are like long-lost brothers. The process of making palpable emotional connections has begun.

We gather for our first circle—33 vets and family members from seven states, with four facilitators. In the opening moment of silence, as we remember those unable to be with us, Stefanie and Michael’s three-year-old son, Ben, is playing around the edges of our circle with Isaiah, his new three-year-old friend. Amidst the reverent quiet, we all hear Ben say, “My daddy died in Iraq.” We learn later from Stephanie that “Michael committed suicide six months after returning from Iraq.” Out of the mouth of babes, the first words spoken at a retreat have their own truth: something inside Michael died in Iraq.

We go around the circle, introducing ourselves. Stephanie, Ben’s mom, feels isolated in Houston, where she lives with the heavy legacy of Michael’s suicide. Her church has ostracized her. The group’s reaction is palpable: Stephanie is taken in like a family by a swarm of other spouses and parents.

At the end of the workshop, as we are saying our goodbyes, Rory gets up, makes his way over and we hug. He was angry and bitter at the outset, not just about his injury, but about failures in leadership and his friends who died in the IED attack and. “No one but a vet can understand another vet” were his first words. I am not a vet myself but a Zen master, psychologist-psychoanalyst, and the son of a combat vet.

After we hug, Rory says, “You’re alright.” Near his seat I notice a scrap of paper on the floor, pick it up and ask if it’s his. “Yeah, it’s nothing,” he says. I look at it and see quite a legible note, with three family trees. I ask him about it. “It’s all the people blown away by my buddies’ dying,” he replies. I ponder it: girlfriend, baby, church members, mother, father, sister, and so on—three little stories, three little family trees radiating impacts that eat at him. I offer him the scrap of paper and he gently reclaims it.

Love is a Force for Change

After the attacks of September 11, like so many others I felt that if we, individually and as a country, could withstand and reflect on the dreadful trauma we were experiencing, and not react in a blind knee-jerk fashion, we could bring the perpetrators to justice and at the same time forge alliances and communities of nations that would provide a strong foundation for genuine security for all going forward. Many were thirsty for revenge, but many in the peace community were calling for love. I gave some talks that presented love as a force for change, not some naive fantasy that ignored the powerful forces that had been unleashed. I was disheartened and frustrated that, despite the voices of millions here and around the world, and the counsel of seasoned military leaders, the drumbeats to war were impermeable to reflection, forethought, and considered wise action. Knowing the carnage that was to come, I felt helpless and angry thinking of the great damage our country would inflict not only on this generation, but on generations to come.

Rather than stew in this state, it dawned on me that, given my experience with meditation, healing communities, and trauma, I could join with others and make a difference. It was 2006. Troops were returning stateside in droves and, along with their family members, they were falling through the cracks of the unprepared, overtaxed and outmoded healthcare systems of the Veterans Administration (VA) and the Department of Defense (DoD). If we waited for the government to do something, anguish would only intensify and tens of thousands would fail to receive the care they desperately needed and had earned. Most service members who needed treatment, especially for unseen injuries such as post-traumatic stress and mild to moderate closed head traumatic brain injuries (TBIs) were loathe to come forward—afraid of losing their security clearances, their promotions, and, most of all, the respect of their buddies. I sensed that a compassionate, non-judgmental and welcoming community that included families could be an inviting and healing resource for them.

I gathered a cadre of San Francisco Bay Area therapists who began to provide free, confidential therapy for veterans and their families. We soon began offering retreats for veterans and their families—which we distinguished from psychotherapy so as to counteract the stigma of mental illness—that provided small peer support groups, expressive arts, wellness practices such as meditation and qigong, and vigorous recreational activities in the great outdoors. After a few retreats, we began to incorporate secular rituals into the program, and I enjoyed the dawning realization that the five elements that organically came to comprise the retreats were not a new “quick fix,” but were instead rooted in how we humans have, since time immemorial, worked to transform overwhelming trauma: Sharing stories in a safe environment (healing dialogue), resilience exercises such as meditation, yoga and qiqong (spiritual practice), expressive arts, being active in beautiful places (the healing power of nature), and secular ritual (adapted from reverent religious experience). Four core human capacities also emerged from these retreats—aliveness, bonding and closeness, self-regulation, and a sense of meaning and purpose—elements that help create a life worth living.

For veterans, the stigma of needing help is a major obstacle to getting help, but we noticed it evaporate by the end of our retreats, as isolation lifted and they experienced a sense of being in this together, of belonging. We knew we were onto something when, during the closing circles, participants’ comments began to echo across retreats. They said they’d never experienced an environment this safe, this trusting, where they could be real and reconnect with their fellow vets, their families, and themselves—where they could experience the belonging and camaraderie of service again, and feel free to open up, as much or as little as they were ready for.

Since beginning in 2007, the Coming Home Project has offered 25 retreats and workshops for families, male and female veterans, student veterans, and caregivers. We have brought in local health, education, employment, housing, legal, financial and other services so participants can connect with needed resources, and we recruited local volunteers to be part of our logistics team, enabling the veterans and civilian communities to get to know one another better. In their 2012 review of post-deployment reintegration programs, The Defense Centers of Excellence, a joint VA-DoD agency mandated by Congress to identify, study, and disseminate best practices for psychological health and traumatic brain injury, stated that “the Coming Home Project helps rebuild the connectivity of mind, body, heart and spirit that combat trauma can unravel; renew relationships with loved ones and create new support networks.” We were the only reintegration program of thousands studied that met all their criteria (successfully integrating psychological, behavioral, social-family and spiritual dimensions) that also had significant outcome data and whose pioneering research on post-traumatic growth with veterans and their families and caregivers was published in a peer reviewed journal of the American Psychological Association.

Stephanie
It’s March, 2007, and we’re preparing for our second retreat. Former Marine officer and Zen priest, Colin, and I pick up the van and await the arrival of several families in a Hawaiian barbecue restaurant near the Oakland airport. Fifty people from twelve states gather. 

Later in the day, in the safety of the small veterans group, 15 vets meet. Stephanie tearfully shares how she feels like a failure: as a soldier (she served as a Captain in the Army herself), as a wife, as a mother, as a person—in every way. She didn’t appreciate the gravity of her husband’s distress and couldn’t prevent him from killing himself. Sadness and self-reproach run deep. Several jump in to reassure her: “You have not failed.” They offer good points: God had other plans for you; you now can be of help in ways you couldn’t have before, and so on. But Stephanie’s expressiveness and emotion dry up as she seems to compliantly agree. When a third person prefaces his remarks by saying that he will offer something to lift the mood, I say, “That’s okay,” trying to keep alive the space for acceptance and disclosure that reassuring and uplifting comments often unintentionally foreclose.

Rory
In a pre-retreat roundtable Rory expresses how betrayed by the government he felt after he was injured—by their lack of responsiveness and accountability. His anger is powerful, but rather than being transformative, it seems to progress into a loop of escalating rage. The more angry he gets, the more the energy of the group intensifies, amplifies. Two people leave the room—one takes issue with Rory’s facts, another feels his comments are too polarizing. Rory, of course, has every right to express his outrage and sense of betrayal, and yet as his complaints become increasingly politicized, he alienates himself from the group. His TBI makes it especially difficult for him to regulate his emotions.

Over the course of the retreat, however, Rory begins to shift in a way I’ve never seen. Through frequent, long conversations with a high-ranking officer and fellow vet, one of the facilitators, he becomes noticeably lighter, more open to hearing others’ stories. He begins to share his experiences with a sense of measure, calibrating his impact, modulating it and bringing it to a close. The recognition and containment that his fellow vets give him is deeply moving to witness. Maybe Rory doesn’t have to repudiate everything about his military experience after all.

Claudia
Claudia is a female Iraq veteran who came with her 18-month-old daughter and her sister from Tucson. She had met Tonia and Ken, fellow veterans on the retreat, while on the TBI ward at the Palo Alto VA. She is friendly and sincere but appears vacant and taciturn. During a breakout group she stands around the perimeter, but toward the end she beings to speak, tentatively. Although she says she doesn’t want to read what she had written earlier during a journaling exercise, it seems that a part of her longs to do so. With a little encouragement, she begins to read: “My world has narrowed from what it was….” Her voice trails off. She describes her TBI and the difficulty she has remembering simple but important elements of her past. She feels that a crucial piece of who she was has been taken from her: she can’t even remember her daughter’s birth. She needs her sister’s help with tasks of daily living, as her short-term memory is also impaired. She is battling to retain custody of her daughter. Claudia’s reading has a palpably catalytic effect on everyone. When families gather later, the aliveness of her young daughter, the glimmer in her eyes, juxtaposed with Claudia’s memory impairment, her sense of vacancy and helplessness are striking, poignant and sad.

Mauricio 
At the big morning group early in the day, Mauricio provides comic relief when he states that of the two master sergeants in the group, he is on top of Ken. Everyone laughs about who is on top and who on bottom. He kids us about status and rank and we all laugh harder. In the smaller vets group, however, he is quiet. After Claudia reads, Mauricio opens up about how difficult it is to not be himself in mind and body. He can’t remember important parts of his childhood and it is a continuing blow to his esteem and to his view of himself, particularly given his role as master sergeant of the men under his command. It is an identity crisis of a different order from the normal developmental kind. It isn’t what he says as much as how he says it that makes an impression. He speaks slowly, with an undercurrent of deep emotion, but shows few visible signs of feeling, save a slight crack in his voice.

Jessie
Jessie was a sergeant major in the Army, blinded in an IED blast while serving in Iraq. He speaks with gravity and conviction, conveying a deep sense of betrayal that, after all he’s endured, offered, and sacrificed, he’s had to do it all himself, become his own advocate, find the services and the help he needs. A covenant has been broken. He asks if I will request that folks say their names before they speak. I invite him to make the request himself. He speaks simply and with dignity. After that, when people begin to speak they stop, remember his request, and say, “Sergeant Major, this is Jim,” addressing Jessie by his title.

We usually leave rank and degrees at the door, but this is different: it is an expression of deep respect. When people forget to identify themselves, Jessie gently reminds them, and later on, when Jessie begins sharing, someone says, “You forgot to say your name.” Jessie laughs and everyone cracks up, the role reversal incongruous, funny and poignant all at once.

“There are times during the day when we laugh until we cry, and laugh and cry both, sometimes not knowing which is which.” Our laughter helps us bear the pain and is good for the soul. Everyone knows that by asking people to say their names, Jessie wants to communicate and feel part of the group, wants to hear and recognize everyone, and in turn be recognized by all of us. Though he feels invisible to the institutions entrusted with his care, here among friends his desire for mutual recognition comes across loud and clear. And he is seen.

Paul
Paul comes in toward the end; he’s been resting. Given their brain injuries, some tend to get tired and nap in the afternoon. Paul had been feeling things out around the edges, beginning with the roundtable on Friday. He became upset with the figures Rory quoted during the roundtable, thought they were inaccurate, misrepresentative and needlessly polarizing. He struggled to stay open, thought about leaving, but finally decided to stay. When Paul and I first met, it was difficult to follow what he was saying since the injuries he sustained affected not just his appearance but also his speech. But by now, after two days, I and others can hone in and understand most of his words as well as his feelings. In the small group, he pours out feelings about how he was treated upon his return, and his struggles with physical, emotional and relationship challenges. We hear him.
 
The Children
In the small teen group, Mark, a Marine helicopter pilot during the first Gulf War, now Buddhist priest and facilitator, began begins with a moment of silence and then asks, “How are you doing?” Tasha is quick to respond, “You really want to know?” and immediately starts to cry. Her sister Alishya, strong like their mom, warns Tashsa not to open things up, but when they share their drawings in the closing circle, they also share how isolated they feel and how hard it is to speak their thoughts and feelings to their parents. With some difficulty, their parents, Tonia and Ken, listen and take in what they hear.

When the workshop ends, Tonia and Ken renew their wedding vows. Her eyes reach out for Ken’s, while Ken strains to respond and to make eye contact with Tonia, in spite of being unable to see much. It is heart-wrenching and heart-warming. After the ceremony, outside the room in the hallway, Tasha begins to cry. As Mary Ellen, a family friend and service provider, holds her, Tasha sobs and cries it all out. What is striking is that no one interrupts the pair; everyone recognizes the outpouring of feeling and lets it be.

Jesse’s daughter, Brittney, is feeling isolated, has no one to talk to, and doesn’t want to burden her suffering parents with her own feelings. “Brittney mentions that her father can’t see her face and therefore doesn’t know if she is sad or happy.” His blindness allows her to hide her feelings, but she feels guilty about doing so. She is afraid that expressing her true feelings will be too upsetting for her father.

At dinner on Saturday, Ben, now four, looks my way; he’s restless. I suggest we trace one another’s hands with crayon. He quiets for a while. I give him my drawing of his hand and he gives me his drawing of mine. We take them with us as we part. Claudia’s 18-month-old girl is dancing with exuberance. Paul’s son, Sebastian, three, calls my name several times. Each time I respond. He wants the give and take. I enjoy the call and response. Two days earlier I was an as-yet-unknown quantity, not safe.

As the retreat comes to a close, everyone is so thankful for the opportunity to meet one another in safety, trust and acceptance. I think about the flexibility of roles: now sharing one’s anguish and small triumphs; now helping another with his. And the humor—it rises up in a flash and fades again, sustaining us as we delve more deeply. Laughing and weeping at the same time. These qualities—flexibility, range of emotion, and sense of safety and trust—reflect the health and healing nature of the community. Such a community brings out the best in us, helping us grow emotionally, interpersonally and spiritually, as it offers a collective space to transform trauma.

We Become That Village

Claudia’s little girl, without her father; Ben without his; Sebastian without his mother. And the teenagers, Brittney, Tasha and Alishya, with loving parents both present, yet struggling with the dramatic and rippling impacts of their fathers’ injuries. Mothers, fathers, sisters, brothers; we all step in to fill the gaps. If it takes a village, we become that village.

What drives this remarkable opening to connection? It is the power of compassion that creates a field of unconditional acceptance and love—each of us supporting and being supported. That field becomes the vehicle, the “bigger container” that holds the grief, the loss, the anger, the powerlessness, the damage. And the precious shards of hope. Everyone can feel its power: the trust, the safety, the deep care. This collective field of compassion grows capacities for withstanding, regulating, expressing, and representing inner anguish. “The dynamic beloved community helps transform trauma, turning inner demons, ghosts that haunt the present and foreclose the future, into ancestors.” Real people and real inner capacities we can access when we need them. We take in and make our own the comrades, the camaraderie, and their beneficial qualities. We enjoy being and learning together. New possibilities for being alive open up. All this is the activity of healing.

As children we are taught to be aware of the consequences of our actions. Actions have impacts that ripple out in many dimensions and last a long time. These effects manifest in ways we did not anticipate. Being aware of and anticipating the consequences of our actions is a developmental achievement. Being responsible for the web of impacts that has ensued from our actions, intended or not, is, likewise, an ongoing achievement.

As a society, we don’t take very good care of one another. Our children, our elders, our natural resources are often ignored, overlooked, forgotten or mistreated. Ours is a disposable culture. But what we do not include, recognize and care for does not go away. The impacts last for ages, and they affect everyone. The web of life is our connective tissue: human, animal, mineral and vegetable. What we discard or fail to adequately care for, we do so at our own peril. Our veterans and their families unfortunately have too often fallen into this category. Their suffering, their humanity, their dignity and their sacrifice often go unrecognized.

Since we are interconnected at the core, what happens here impacts what happens there; even if there is no visible or logical link. Almost three million service members have been deployed to Iraq and Afghanistan. Factor in the children, parents, partners, grandparents, brothers, sisters and so on, and that’s a lot of people who have been directly impacted by these wars. As we learned from Vietnam, unattended to, the wounds of war fester and deepen, wreaking havoc on individuals, families, and communities.

"When the Hair Grows Over"

The impacts of war are legend. Some are visible but many are not. There are injuries we can see and injuries that are invisible to the eye but nonetheless radiate deep and wide into a person’s life, health and web of relationships. TBI patients and their families have a saying: “When the hair grows over.” When the visible injuries heal, the unseen wounds to mind, heart, soul and spirit often go ignored. I am not only referring to post-traumatic stress. There are many veterans whose problems do not meet the criteria for a diagnosis of PTSD, but who nonetheless experience profound disturbances in functioning and well-being, as do their families. The ever-present traumatic past crowds out the open present, collapsing hope and possibility. I don’t believe that post-traumatic stress should be classified as a “disorder,” although our inner experience does become disordered, and we ourselves can be temporarily disabled. But I see the loose constellation of clustered symptoms organized by psychiatry manual-makers as the psyche’s means of trying to recover from the shock and chronic helplessness of unimaginably overwhelming circumstances.

Post-traumatic stress and war’s other wounds are not just stress and anxiety problems; they impact our identity, our self-regard, sense of purpose, and our entire worldview. Sometimes war shatters it all. “Rebuilding damaged connectivity among body and mind, heart and soul, among thoughts, feelings, actions, beliefs, and relationships is critical.” There is also a cultural dimension to healing the unseen wounds of war. Although it is important to learn skills to reduce stress and anxiety and rebuild the brain’s capacities to modulate and manage strong emotions—to rebuild internal connections—it is equally important to rebuild connectivity among family members and within communities.

What we cannot hold, we cannot process. What we cannot process, we cannot transform. What we cannot transform haunts us. It takes another mind to help us heal ours. It takes other minds and hearts to help us grow and regrow the capacities we need to transform suffering. This is done in concert, reweaving the web of connective emotional, relational and spiritual tissue that cumulative trauma tears asunder. With another mind and heart, and an informed, compassionate culture, it is possible, to transform ghosts into ancestors.

Concealed within damage often lies great strength. Resilience runs deep but its resources need to be nurtured. It is like a seed that has been buried in a disaster; it needs tending, attending. When the great redwoods are damaged in a fire, their seedpods are not destroyed—there is devastation, but often the forest can return to health, with protection, care and skill. If we cultivate the intention to be of help, if we take the time and energy, if we realize that the responsibility for healing the impacts of war is collective, the seeds of renewal and transformation await us just beneath the charred wounds of war. It takes a village and it begins with each of us.

Irrespective of political or religious beliefs, each veteran, each partner, child, sibling, parent and grandparent, deserves our loving, skillful, attentive care for the visible and invisible injuries from serving in Iraq and Afghanistan. They don’t only need a new set of techniques or new understandings. They need us to harness our own humanity—head, heart, body and spirit—our native connectivity and capacity to respond, in order to make a difference. They need us to participate in creating a culture in which the wounds of war are lovingly and skillfully enveloped as part of a welcoming community, where they can heal and be transformed. Fundamental interconnectivity takes the form of a responsive community that holds the vets and their families in its attentive, loving embrace.
 

The Lying Artist

Posted on by Psychotherapy.net Team

Once upon a time and many years ago when I was a very new therapist, I worked with a client who had completely made herself up.

A lot of things never added up with her. For starters, there was her presenting problem. Some days she would report a diet of jelly beans (not many) and carrots, and yet she was never low weight. But since clients with eating disorders are so often metabolically out of sync, it didn’t seem completely unbelievable either. And her restricting and purging progressed in fits and starts, with days of nearly normal intake.

So I’ve often wondered, did the lies start from the very first moments of treatment, or even before she entered my office, or did they start later? When exactly, and why? She told me she was singing lead vocals with a band. She brought me flyers, with dates and locations on them. Then she met a young man, an up-and-coming actor. One day she came in with an engagement ring. There was a lot of drama in their relationship, and a few months later they broke up. Throughout, she stoutly refused family therapy with the parents she continued to live with. Should that have been a clue? Over time, her story got somewhat wilder. Her former fiancé had an affair with a girlfriend of hers and the girlfriend became pregnant. When the baby was born, he had a heart defect, and my client became a significant source of support to the child and her mother. She denied conflicted feelings. The child was near death.

I started my private practice in a different state and my client transferred to another therapist, a friend of mine. A couple of years later she transferred to someone else for a similar reason. Occasionally, my former client would call me with brief updates about her life and progress. The last time she called me, it was to confess that none of what she had told me or her other therapists was true. As part of her ongoing therapy, and to her lasting credit, she wanted to apologize. The baby who died so tragically had never existed. There was never a fiancé. The engagement ring was a cubic zirconia she bought at the mall. There was never a band. I was shocked into speechlessness and had little to say or to ask.

Initially, my sense of shame and betrayal was so intense that I could barely think about her. As I told the story over in my mind, it became more and more absurd, an obvious lie. Although I eventually remembered that in the 15 years since I worked with her, I have heard many stranger truths than the lies she told me, at the time I felt a total fool, shamed before myself and (it is some comfort to say) my also-fooled colleagues.

For years, now, though, I have wondered. I have remembered the times when she wept, or when her face turned bright red with sudden anger or shame. Was she simply an extraordinary actress, playing her heart out to an audience of one? Picasso famously said, “Art is a lie that makes us realize the truth.” Lying, it seems, was her art, but what truth did it reveal? Could she possibly have benefitted in any way from our therapy? How did she see me? Bumbling, naïve—a confidence woman’s mark? Or possibly idealized—too good and too perfect in her eyes to be sullied with the probably more boring and more awful truth? How much did I participate in maintaining her fantasy? Surely it was not possible for me to be taken in without some collusion on my part. Did she stroke my ego? Fan my insecurities? I don’t recall at all.

And what, after all, is true in therapy? We know we are shown the distorted perspective of one person as seen through the distorted lens of ourselves. Dreams and fantasies contain truths as genuine as what we call conscious realities. Sometimes the” lies” are the most revealing part of the story, pointing like a flashing neon arrow to the place we need to go: “I don’t blame my mother,” “I’m not afraid to live alone,” “It’s only a diet,” “I just don’t think about sex anymore.” And of course, even with the best of faith, memory always lies.

But still…there are lies, and there are lies. The therapy relationship relies on our clients mostly telling us their truth. I think of my former client often. Hers is a cautionary tale, but in some ways I choose not to heed the caution. The therapy relationship also relies on who I am, and though I make an effort not to be naïve or foolish, I cannot strive toward the openness, honesty, and awareness that makes for an effective therapy when I am harboring too much distrust or suspicion. And although it took a long time and several therapists, my former client did after all find her way to honesty, and that is a good ending and a good beginning.

The Therapist and the Fee: Why Everything Works out and Also Doesn

Posted on by Psychotherapy.net Team

A close friend of mine is a wonderful therapist, a child of the 60s, a gifted man, large-souled, big-hearted and wise. His practice nourishes him and is saturated with life. He is committed to a worldview that eschews anything close to greed. “I won’t ask my patients for more, at least not if I can avoid it,” he says. “Often I will wait years to do it.”

My friend’s position makes perfect sense to me. He is a thoughtful and principled man. His role as a professional is anchored in a deep caring for the poor and those who have less. People trust him and his love for them. Anyone can see why he is successful.

And yet what fascinates me is that there are practitioners equally effective who take the opposite point of view. They are practically bullet-proof around money. They regularly raise fees with no compunctions. One colleague, a psychoanalyst and social worker, charges $200 per session and raises the price every two years in $25 increments.

Both of these therapists have large practices and enjoy their work. Both of them claim that they work in the best interests of clients. In fact, my high-flying colleague insists that she raises her fees in order “to help” her clients. “It is selfish not to raise fees,” she insisted to me.

“Clients form an unrealistic dependency and attachment to me,” she explained. “When I raise them, it allows them to separate from me by getting angry at me. It helps me too to be sure, but it is also a gift to them.”

Who is “right”?

Of course, it would be difficult to establish what is right and wrong in a field where so many different, seemingly counter-intuitive actions can be therapeutic. Where else do you have a field in which the “giving” or “self-sacrificing” therapist who is easy on the rules, winks at missed sessions, lowers the fee at the drop of a hat, can often be counter-therapeutic?

And yet it is possible that both therapists are “right.” Each, by being whole-hearted in their approach, may have a struck a deal with their patients’ unconscious. In the case of my friend who almost never raises fees, he has communicated successfully to his patients a simple message: “I won’t easily leave you. I will be with you and be kind to you.” If you knew this man, you would know how genuinely he feels this and believes this and whole-hearted he is. This communication may be helpful to some people who have experienced the traumas of life. They trust his love for them and their love for him until they gradually integrate reality into their lives and mature.

The other therapist seems to have communicated the exact opposite message—that may be equally helpful: “I will always leave you. I will always raise fees and I will always take care of myself in this relationship as well as you.” Paradoxically, for some people, that may be a building block of psychological maturation. Patients may need to trust the therapist’s narcissism in order to accept their love. Bertolt Brecht once famously quipped, “I desperately need someone upon whom I can firmly not rely.”

The late Hyman Spotnitz, father of modern psychoanalysis asked: How do you know if someone needs treatment? He likened a person to a car. “If the driver turns the wheel to the right and the car goes right, or if he steps on the brakes and the car stops, he won’t need to bring the car to a mechanic. But if you turn right and the car goes left, or you brake and the car doesn’t stop, then you need a mechanic.”

People try to lose weight, to be better spouses, to not yell at their kids. We give ourselves all kinds of commands and yet some of us find ourselves moving to the right when we ordered ourselves left. Instead of saying no we said yes or the other way around. And we are astonished.

Many therapists are confused about what to charge in the first place and when to raise fees. One therapist in a supervision group I ran was skittish about her fees, but wanted very much to raise them. She drilled with the group over and over again: “I am going to tell that patient my fee is $150!” I am going to wash that man right out of my hair. And the group cheered her on: “You go girl!” But when it came to saying it to the patient, the actual number got stuck in her throat. “How much do I owe you?” her cooperative new patient asked her. “$110,” the therapist blurted out uncontrollably. “I hate myself,” the therapist later told the group. “I am a loser.” The group would have none of this self-attack. They warmly helped her to talk about her conflicts around money, which were deep, and within a short time she proudly set her fee with a full heart.

If you’re whole-hearted about what you do, as in the cases above, it usually works out just fine no matter what you do. If you are conflicted, it won’t and you, your practice and your patients will suffer.
We therapists may resist this as intensely as our patients, but most often, the way to find out more about what is right for you and what is in your heart, is to talk about it in treatment and supervision.

Self-Care for Therapists

Posted on by Psychotherapy.net Team

There’s a beleaguered mom on the couch in my office, and she’s feeling skeptical about my idea that she needs to “double-up on self-care.” She shakes her head—tosses it—and says, half-pitifully/half-defiantly: “Even if I had a few minutes alone, I don’t even know what to do to take care of myself. All I want is to sleep. Creativity is not even really a need right now—it’s like wishing for the moon. I just want to work, pick my kids up from school, and make dinner without feeling like I am going to punch someone in the face.”

We talk about martyrdom—about her own mom’s pattern (that she desperately does not want to repeat) of losing track of herself within a family and all the needs there, of the divorce, of the drinking. My client is clear, is crusading, that this will not happen to her. But I have to let her know that I don’t see her protecting the most precious resource in the family—the sanity and happiness of the mother. The red flag, to me, is her burnout.

So we talk some more, we identify three regular times in her day when she has a few minutes to herself: after school drop-off on her way to work; an occasional lunchtime when work is not too demanding; and on the way from work back to pick kids up from school. Then based on what she thinks she might enjoy, we identify three experiments she can try during these times: a journal and pen and a list of simple questions like, “how are you feeling?”, “what are you grateful for?”; a gentle, non-preachy meditation recording she can listen to; and a “mini” relaxation exercise we co-create, focusing on tracking her breath for a few minutes. This is not enlightenment, but it is a line in the sand symbolizing that the mother’s mental and emotional health is very important. I know too that if she can get in the habit of nurturing a relationship with herself, it will evolve and it may one day be enlightenment.

It should be enough to do this because the mother is a person who needs what every person needs. But it is worth saying, because of the sticky habit of martyrdom associated with mothering, that the whole family benefits—partners, kids, pets—when mother is happy. In fact, according to a study done at the Institute for Social and Economic Research, a mother’s happiness is the number one indicator for a child’s happiness.

Moms are my specialty, but I am writing today to make an association between therapists and moms. The day I worked with this mother on her first steps to reclaiming her relationship with herself, I spent the morning at an HIV+ Women’s Health Clinic from 8 to 12 seeing deeply troubled clients, then I saw private practice clients from 12:30-3:30; then rushed over to see my supervisor, then back to the office for several evening clients. I had my whole day planned out, down to the taxi I took to make supervision on time; and the important phone call squeezed in before a session with a client who is always a few minutes late. There was only one problem I realized by mid-day—I had not budgeted any time to get or eat food, all day. Many of my therapist friends and colleagues have told me of similar schedules, and when there is not a commitment to self-care, it is a big problem for therapists.

It was that day that the connection between mothering and therapizing hit me—both are based on nurturing others, both can tend towards an unhealthy martyrdom. I assert that both roles need a radical re-balancing program in the form of intensive, sumptuous, deep self-care for the nurturer. And the better the self-care, the better the mom or therapist will be at their job of caring for others. This is provable in the simplest of mind-body studies available to look into everywhere, but it is something I also know in my bones. When I am thinking, writing, resting, feeding myself really well, having sex, and laughing a lot, I am a great mom and a great therapist: I feel the creative energy and power that comes from a sense of flow and gratitude. From this place, giving feels natural and right.

Therapists, like moms, may have a tendency, in a life dedicated to listening intently to others’ troubles, to set aside or even sometimes ignore their own needs. But it is not easy to prioritize self-care for anyone these days. True self-care involves placing the self at the center of the spotlight for a time; and listening in, tenderly, to what the soul is asking for. It is a mysterious process. This is the realm of the numinous—what ultimately makes our lives feel fulfilling and where the deep joy that makes life worth living is found.

Self-care is a process of turning inward, thinking and feeling about what brings our unique self true refreshment. I’ve been through this process with a lot of moms lately and I’ve seen some beautifully unique ideas emerge that I think are worth sharing for inspiration: learning to play the drums, learning to surf, staying with a friend a few times a month, scheduling a regular date with a partner for sex in the daytime, cutting out drinking and instead writing in a journal every night at cocktail hour, starting to bike to work, making an altar to the things that bring joy, or drawing with kids.

I know it can be hard for moms and therapists, and lots of other conscientious people to institute a program of self-care. It’s vulnerable to look inward and try to figure out what really feeds and nourishes us. It is different than simply taking care of ourselves by going to the gym or getting enough sleep (though it can include these things). It is a process of experimentation, and it will probably be somewhat elusive at times. Many times our first guesses about what will soothe and inspire us are wrong—the pilates class is full of competitive supermodel types; the writing class causes us deadline anxiety; the date night dancing lesson is awkward. The important thing is to try to find what gives us that flow-feeling, that yumminess, that bliss. Like athletes who train every day to be at the top of their game, I think it makes sense for therapists to try to live in such a way that they are integrally joyful and feel a natural conviction that life is a gift.

Psychoanalysis is Alive and Well

Posted on by Psychotherapy.net Team

Although we have evolved many schools since Freud articulated psychoanalytic theory at the turn of the 20th century, in almost all of them conspicuous analytic features remain. These are so familiar that for the most part they exercise their dominance without our being aware of them or their origins. We may think psychoanalysis has been discredited and that almost no one practices it any longer, but there are ways psychoanalytic theory is present in our listening and thinking because of the vocabulary we employ and have come to take for granted.

An example, from an older use of language. Freud’s German word for cathexis (a word that goes in and out of fashion) is besetzen, which literally means the occupation of an area by a military force. The metaphoric atmosphere is of course lost in our translation, but not perhaps in our understanding of the supposedly aggressive way we take hold of an object and occupy it with our attachment. Even when we use a different vocabulary, when we say someone is “over-attached” to something, or “fixated” on it, we import the negative psychoanalytic attitude. Of course, a cathexis might also be viewed as a passionate interest in something; then we would not have to burden it with a military metaphor.

Or the word resistance: A number of implications reside in this word, most often hidden. Clients use the word, therapists who have never been trained analytically also use it and succumb to its seductions. It is tempting to believe that we, the therapist, know the right thing for the client to be talking about, and if she isn’t talking about it, she’s resisting it; that is, she is avoiding a thought or feeling we think she ought to be discussing. Our meeting together has been turned into a battle: between the client and the content supposedly being resisted. I try not to use the word, although my clients do. I tend, instead, to talk about self-protection. If someone seems to be venturing forth, then cutting herself off, then taking off on an apparent tangent, she might say: “I just can’t figure out what I’m trying to say. Am I resisting it?” I assure her that the timing of this discussion is entirely up to her. The choice is hers, to go forward now or to save it for another time. People tend to take this permission much to heart. I have noticed how often they touch back on a subject they didn’t feel ready to discuss, perhaps to mark it, to hold it as potential, to keep track of it. Eventually, when they feel safe enough the self-protection no longer seems necessary and the content emerges. Best of all, the timing of this important moment has been left to them. I see no reason to call this process of hesitation and caution, of delay and postponement, a resistance.

And then there’s the concept of repression, another word that has entered our common language. A wary, watchful, guarded, unexpressive, anxious and withdrawn person is said, even by people who do not know the technical meaning of the word, to be repressed. But known or not, the word carries implications. It is also used in our political discourse, where it evokes the circumstance in which a group of more powerful people is repressing another. We know this circumstance; it costs lives, evokes rebellion, is most often an affair drenched in blood. Our clients also have these associations to the word. Is it useful to bring this imagery into our understanding of an individual who has come to talk with us?

People coming into therapy for the first time seem to know the rules, the lingo, the appropriate behavior and much of this is, I think, a carry-over from psychoanalysis. They often expect a fifty-minute hour, as if this length for a therapeutic session had been written as law. I’ve had people say to me “Are you sure you’re doing this right?” because I invite them to go on past what they assume is the set time. “I know I’m not supposed to ask you questions,” is another popular assumption. “Or well, I guess I can ask but I know you’re not supposed to tell me the answer.” Who says? It is important for my clients to know the worldview I hold because, obviously, it is going to influence the type of listening I do. Having left psychoanalysis behind we are no longer constrained to be detached listeners. But do we sufficiently tell our clients who we are in our listening? I mean, really take pains to inform them? To explain the school we adhere to? And what its assumptions are? And if not, is that not still the shadow of psychoanalysis falling upon our work?

Vanquishing the Inner Critic

Posted on by Psychotherapy.net Team

In my work with clients who were severely traumatized in childhood, I sometimes feel hopeless in helping them to address and deconstruct their inner critics. I feel daunted by the viciousness and incessancy of their self-attack.

When a child is relentlessly rejected by contemptuous parents, she mimics them and learns to obsessively scorn herself. Like them, she focuses only on her defects and deficiencies; like them she radiates hate and scorn at herself. Her superego grows into an outsized critic as she, like them, blames and shames herself in a thousand different ways. Over time, she so thoroughly identifies with her aggressors that her critic rebukes her in the first person.

In her first session she may tell me: “It wasn’t disgusting. I’m disgusting!” Her inner critic virtually is her Self. In such cases standard tools, such as interpretation, mindfulness and unconditional positive regard barely make a dent in the critic. After numerous futile attempts to stir the client into resisting the critic, my urge to give up sometimes feels irresistible. Early in my career, I would think: “This critic stuff is so Psych 101. I have addressed the client’s critic issues so often that we’re both clearly sick of it. If I don’t back off soon, she’s going to leave. She’s just not going to get it. Her critic’s just too big for her to see. It’s a forest of self-hate camouflaged by the trees of this particular moment’s worries.”

Eventually, I learned that nothing would change for this type of client until we reduced the totalitarian hold the critic held on her psyche —until we eked out some psychic space for her ego to grow into a user-friendly manager of her psyche. Until this was accomplished, we would never awaken her developmentally arrested need to cultivate an attitude of self-support.

I now rely a great deal in early therapy upon psychoeducation and family of origin exploration. Out of an ongoing elicitation of the client’s childhood trauma, we weave an accurate narrative of how she was inculcated to habitually attack and scorn herself. I help her see that she was a tabula rasa as a child, and that her toxic “care”-givers brainwashed her into routinely hating, shaming and abandoning herself.

Psychoeducative interpretation about the genesis of the traumatizing inner critic is, in my opinion, a step that cannot be bypassed, and with such clients, I do it as much as they can tolerate. Sometimes, I derive motivation to persist with this very slow, repetitive process by garnering the energy of other countertransferential feelings that I have. For example, I now typically feel guilty and neglectful when I let the inner critic—the internalization of the parents’ contempt—get away with abusing my clients. At such times, I feel derelict in my human and professional duty to bring attention to how they are hoisting themselves on their parents’ petard.

I find now that I can no longer passively collude with the internalized parent by failing to actively notice it, as various adults typically did while he was growing up. If an adult does not protest when a child is being attacked with destructive criticism, s/he tacitly approves it. The child is forced to assume that contempt is normal and acceptable, as the witnessing adult forsakes her/his tribal responsibility to protect the child from other adults who perpetrate child abuse.

When I label the traumatizing behavior of the client’s parents as egregious, I begin the awakening of his developmentally arrested need for self-protection. I model to him that he should have been protected, and that he can now resist mimicking their abuse in his own psyche. With most of my clients, this eventually encourages disidentification from the aggressor and weakens the internalization of the attacking parent as the locus of the critic.

In my own case, I felt loved by my grandmother who lived with my family, but she failed to tell that my parents’ vitriolic rages were wrong and not my fault. In retrospect, I believe that her neglect crystallized my belief that I totally deserved their abuse. The stage was then set for me to morph their contempt into self-loathing, chapter and verse, for nearly two decades.

I have also noted that clients, who had one influential adult in their childhood who helped them to see that the destructive behavior of a toxic caregiver was wrong and not their fault, do not seem to develop such a ferocious, self-annihilating critic.

As therapists, we often have the unique opportunity to become the first person in such a client’s life to help him see how horribly and unfairly he was indoctrinated against himself when he was too young and impressionable to resist. Let me paraphrase Milton Erickson’s challenge to us all: We must remain resolute, brave and creative about repetitively confronting key deeply imbedded pathologies that do not easily resolve from our attempts to treat them.

Through the Anger Looking Glass

Posted on by Psychotherapy.net Team

On this past Sunday’s broadcast of “Weekend Edition” on National Public Radio, the focus was on the 50th anniversary of Betty Freidan’s The Feminine Mystique. In this book Friedan raged against the status of women in the 1960s. Although millions of people have read this feminist manifesto, it seems very few presently understand how anger in general and Friedan’s anger in particular could be a source of insight, motivation, and personal and social transformation.

Anger is an emotional state that has a bad rap. There’s far more written about anger control than about how anger, when nurtured and examined, can transform. As most mental health professionals already know, anger is an emotion, not a behavior. And emotions are acceptable and desirable. When anger fuels aggressive or destructive behavior is when it becomes problematic.

But since everyone knows about and talks about the destructive capability of anger—let’s talk about the constructive side of this emotion instead. Hardly anyone articulates anger’s positive qualities as clearly as the feminists. Feminist therapists consider “encouraging anger expression” as a meaningful process goal in psychotherapy for at least five reasons:

  1. Girls and women are typically discouraged from expressing anger directly. Experiencing and expressing anger without repressive cultural consequences can be an exhilarating freedom for females. Similarly, experiencing anger, but not letting it become aggression is a new and productive process for males.
  2. Anger illuminates. There’s nothing quite like the rush of anger as a signal that something is not quite right. Examined anger can stimulate insight.
  3. Alfred Adler suggested that the purpose of insight in psychotherapy was to enhance motivation. Anger is helpful for both identifying psychotherapy goals AND for mobilizing client motivation.
  4. During psychotherapy anger may occur in-session towards the psychotherapist. Skillful therapists accept this anger without defensiveness and then collaboratively explore the meaning of their in-session anger.
  5. Anger is a natural emotional response to oppression and abuse. If clients consistently suppress anger, it inhibits them from experiencing their full range of humanity.
For feminists, one goal of nurturing and exploring client anger is to facilitate feminist consciousness. Feminist consciousness involves females (and males) developing greater awareness of equality and balance in relationships. However, using anger to stimulate insight and motivation is useful in all forms of therapy, not just feminist therapy.

But working with (and not against) anger in psychotherapy is complex. The problem is that anger pulls so strongly for a behavioral response. Reactive anger is destructive. Clients want to let it out. Experiencing and expressing anger feels so intoxicatingly right. Clients want to punch walls. They want to formulate piercing insults. They want to counterattack. Unexamined anger is reactive and vengeful.

Imagine a male client. He’s uncomfortable with how his romantic partner has been treating him. You help him explore these feelings and identify the source; he recognizes that his partner has been treating him disrespectfully. But good psychotherapy doesn’t settle for simple answers. His new insight without further exploration could stimulate retaliatory impulses. Good psychotherapy stays with the process and examines aggressive outcomes. It helps clients explore alternatives. Could he be overreacting? Perhaps the anger is triggering an old wound and it’s not just the partner’s behavior that’s triggering the anger?

Relationships are nearly always a complex mix of past, present, and future impulses and transactions. When anger is respected as a signal and clients take ownership of their anger, good things can happen. It can be used to help clients become more skilled at identifying and articulating their underlying sadness, hurt, and disappointment. Clients can emerge from psychotherapy with not only new insights, but increased responsibility for their behavior and more refined skills for communicating feelings and thoughts without blaming anger, but in a way that serves as an invitation for greater intimacy and deeper partnership.

None of this would be possible without the clarifying stimulation of anger and a collaborative psychotherapist who’s able to help clients face, embrace, and understand the many layers of meaning underneath your anger. And it’s about time we learned a lesson from the feminists and started giving anger the respect it deserves.