Author: rezendevknowfully.com

Healing Trauma Through the Body: The Way In is the Way Out

Posted on by rezendevknowfully.com

Suzanne: A Case Study

Suzanne* arrives in my office due to a long history of anxiety, mild depression, problems sleeping, and relationship issues. She is 43, successful in her marketing career, and divorced, with a child in high school. She is a tall woman, but something about the way she carries herself makes her seem smaller than she is. She is wearing loose, dark clothing that doesn’t reveal much of her body. As she walks into my office for our first session, I am struck by the animation in her upper body, but I notice that she moves awkwardly because of the tightness in her shoulders, neck and upper spine. As I invite her to sit down, I notice that her eyes shift back and forth as if she’s looking for something. She seems uncomfortable meeting my gaze and looks quickly down at the floor each time our eyes meet. I can see by the way her shirt lies that her solar plexus area is very tight. It is clear that this tightness prevents her from taking a full, deep breath. She seems to be fighting upward against gravity, as if attempting to levitate. At the same time, I see and sense very little connection to her lower body. Her legs are almost completely still; they appear lifeless and detached. This gives her a weak and tenuous connection to the earth. “It’s as if everything from above the waist is surging wildly upward, like a thousand bees swarming skyward, out of a hive, centered above her navel.”
 
She complains of rapid heart rate, shallow breathing, food sensitivities, digestion problems, and difficulty staying asleep. As she talks, I can hear her mouth is dry. It makes sense to me that she is experiencing anxiety—my understanding of how the nervous system works lets me know that her system is stuck in a constant state of fear and readiness. As a Somatic Experiencing® (SE) practitioner, I can tell that Suzanne is in a common feedback loop that occurs in people who are attempting to manage their internal nervous system dysregulation. Shallow breathing and tightness in her chest keep her body in a constant state of oxygen deprivation. This escalates the anxiety, so she tightens the muscles in her chest even more. I take a mental note—I’ll need to address this pattern.
 
Suzanne begins to tell me about a recent conflict she experienced at work with a male co-worker. As she describes the situation, she cries easily but not comfortably, trying to hold back the tears. When she does begin to cry, she holds her breath and squints her eyes tightly, as if trying to squeeze the tears back into her eyes. She swallows repeatedly and her shoulders tighten even more. She’s working hard to keep the emotions in check. At one point in her description, she chastises herself for being so reactive. “I should be able to handle these types of situations,” she says. “Instead, when there’s conflict, I get totally emotional. Even though my mind is racing with thoughts, I can’t do or say anything. I feel paralyzed. I don’t act like a competent professional. I just sit there and cry like a little girl.”
 
She looks down, rounds her shoulders, and holds her breath. I listen to her words and make a note of how she describes her experience, but I am especially paying attention to what her body is telling me. “As I listen to her, I’m receiving a lot of information about her by paying attention to my own bodily experience.” I feel a little breathless and pulled upward in my own body—I need to keep reminding myself to breathe, soften my belly, and feel my feet and pelvis.
 

Approach

It is obvious from the above description that my attention is heavily focused on the physical presentation of the client.  Of course, I am not ignoring the content of her narrative, but I am especially attuned to the story her body is telling. My approach is guided by the principles of Somatic Experiencing, developed by Peter Levine from his research into the stress responses of animals in the wild. Physiological responses to stressful situations arise from what is classically called the sympathetic or “fight-or-flight response.” Levine noticed that once an animal was out of danger, its body automatically shifted to “parasympathetic” rest and recovery with gentle trembling, shaking, deep breaths, sweating, and sometimes more aggressive fight-reenacting behaviors—a process called discharge. These behaviors reset the nervous system to a pre-threat level of functioning. This discharge cycle appeared to be essential to recovery: experts repeatedly told Levine that if animals were unable to complete the discharge process, they would die.
 
Given that humans should be equipped with the same restorative capacities, Levine pondered, what makes us different? What gets in the way of our recovery? 
 
Through hundreds of hours of client sessions, Levine began to witness how clients’ bodies told their stories of trauma, even if the clients had no specific memories. Once Levine guided them into the sensate experience of trauma, the body then took over and finished what was unprocessed, or incomplete, much like the animals he’d observed. Clients receive the added gifts of increased body awareness, a stronger connection to self, a shift in deep-seated patterns, a more regulated nervous system, and a sense of mastery.
 
Why do humans need to be guided at all? The biggest obstacle is how inattentive and unfamiliar we are with our physical sensations. Our big, sophisticated brains constantly out-think and override our bodily needs. We are trained to ignore signs of hunger, pain, discomfort, injury, danger, as well as pleasure, saturation, and fulfillment. What’s astonishing is how forgiving and responsive the body is. As soon as we tune into it, shifts begin to happen.
 

Getting Unstuck

Within my framework as an SE practitioner, Suzanne’s symptoms imply something in her system is stuck, unfinished. I can assume that during some traumatic experience in her past, she froze or was overpowered by someone or something bigger, stronger, or faster. 
 
Suzanne’s array of emotional and physical complaints is typical of autonomic dysregulation. Dysregulation shows up in basically two extremes: stuck “on” and stuck “off.” The former can manifest as anxiety, panic, mania, hypervigilance, sleeplessness, dissociation, attention deficit, OCD, emotional flooding, chronic pain, hostility/rage, etc. This is the sympathetic branch of the nervous system, responsible for moving us out of danger. When traumatic material is unprocessed, the residual activation keeps a person locked in a constant state of readiness and reactivity. The client has an ongoing sense that “something bad can happen at any moment.”
 
Being stuck off shows up as depression, flat affect, lethargy, exhaustion, low impulse/motivation, chronic fatigue, dissociation, many of the complex syndromes, low blood pressure. This is the parasympathetic branch of the autonomic nervous system. In a healthy state of functioning, it is designed to bring the body back to rest and recovery after surges of sympathetic activity. When it goes awry, the system slows or shuts down too much, or “depresses” itself at the slightest trigger.
 
Clients may present with one extreme or oscillate between the two. At first glance, Suzanne presents more on the sympathetic scale, excepting her legs. I’ll want to guide her inward so we can begin to sense more deeply into her pattern.The goal of SE is to work through traumatizing events in non-traumatizing ways. If I can ease her through whatever defenses or strategies her body has taken on to manage the dysregulation, her body will take over and complete the necessary response that was not able to occur when she was initially traumatized. It will be part of my treatment plan with her to assist her body in feeling all possible impulses. She may want to cower self-protectively, defend herself, or run from the danger.
 
“SE therapists have to learn to watch, not just listen; to know when to slow down, when to point out and explore a physical response.” We must learn how to ask open-ended questions that invite curiosity about one’s experience in the moment. Our job is to support the client in accessing what is happening inside at the physiological level, and then to assist in the return to self-regulation. We are restoring the client’s system back to an organic level of functioning. The client grows in self-mastery, and the therapist is merely the guide.
 
SE uses a variety of techniques that are presented at a pace that helps the client to stay with every moment of the event without flooding, compensating or dissociating. Slowing everything down and keeping Suzanne focused on her bodily sensations will help us do this. It’s a bit like watching the event on a video, pausing at every single frame, and allowing each detail, emotion, sensation, bodily reaction, impulse, and defensive reaction to be felt and processed. Connecting to the physiological responses also prevents her mind from coming in and doubting or worrying.
 
In this sense, we can see that, for a traumatized person, going into the body and coming into contact with their physiological experience is the way out of their distressing symptoms. The way in is the way out. Many models of treatment focus on eliminating symptoms and behaviors, but SE takes the client into the symptoms knowing that the symptoms are the key to healing trauma. With Suzanne – as with all of my clients – I will begin my work with her wherever she is and with whatever her body is displaying in the moment. By focusing on one aspect of her physical sensations, we will be led into her body’s memory of the trauma. By moving slowly, and utilizing various techniques that prevent re-traumatization, her body will guide her through her own natural set of experiences, and gradually release the stuck pattern.
 

The Work: Careful Amplification, Attentiveness

To begin my work with Suzanne, I will want to take her into a direct experience of the physical sensations in her body. I first want to be sure that Suzanne has the capacity to work somatically with the material she is presenting. I will be able to assess Suzanne’s overall nervous system stabilization when I see how her body reacts initially as we begin to explore bodily sensations. I will also be able to get clear information on how she attempts to manage the sensations by watching her response to them. As she begins to feel her body, does she brace, collapse, tighten all over, hold her breath, dissociate, shut down, get angry or become judgemental?
 
As she is finishing her description of the conflict with the co-worker, she begins to tell me again of her general anxiety, in part, she says, because she can’t trust herself to respond in situations where she needs to. I feel as if this is a good time in the session to begin to tune into her sensations, so I ask her permission to explore her experience a little.
 
She agrees, a bit hesitantly, and I ask her to notice where in her body at this moment she is sensing the anxiety. She looks down and then says, “In my belly.” As she focuses her awareness on the sensations in her belly, she escalates quickly—her shoulders tighten, she holds her breath. She looks frightened. I remain calm and unalarmed because I have seen this many times. “Can you give me some words to describe the sensations?” I ask her. She puts her hand on her belly, and says, “It’s churning, hot, and it’s moving really quickly.”
 
At this point, “I know that I need to broaden her awareness and to help her know that she can touch into the intensity of her experience without becoming overwhelmed by it”, as well as to help her move her attention to areas of less intensity. To do this, I ask Suzanne if she can also notice the chair supporting her thighs, and the floor beneath her feet. My goal here is to build resilience and confidence, and dispel any belief Suzanne may have that she can’t handle this experience.
 
Secondly, by asking her to feel outside of an energetic hot zone, her body recognizes that there is more square footage for the intensity to inhabit. This naturally makes a little more space for the concentration of the sensations; they spread out. Thirdly, by contacting the periphery of her body, it helps Suzanne feel solid, reliable areas, which provide the sense of a container.
 
Suzanne closes her eyes and I see her body visibly settle into the chair. Her shoulders drop slightly, the muscles in her face soften and she is breathing more deeply. She seems to allow the chair to hold her a bit more, rather than holding herself up and off it. This is a very important moment and I want to grab it.
 
Suzanne looks up at me, surprised. I smile at her. “Tell me what you’re experiencing now.”
 
“Things are relaxing,” she says, her voice is softer and her words come out more slowly.
 
“What does relaxing feel like in your body?” I ask her. 

“My stomach has softened," she tells me. "I feel more air in my belly and I don’t feel as afraid.”
 
Another important moment. This is the first shift in Suzanne’s breathing pattern—a crucial element in the stuck anxiety pattern in her body. Remember, when breathing is rapid, tight and fast, it actually triggers the body’s fight-or-flight reaction. As the body goes into this reaction, the breathing becomes constricted, fast and shallow—a frustrating chicken-or-egg phenomenon. I want to expand on Suzanne’s feeling of being able to breathe. So I ask her to sense into her belly, noticing how it feels to have more air.
 

Relating to Anxiety

This experience lays the groundwork for Suzanne to be able to enter into intense sensations and then find a way to regulate them. I want her to really have a felt sense of this, so I decide to guide her into it a few times as practice. I ask her to consciously bring up something that triggers her feeling of anxiety, like her co-worker. As she thinks of him, the anxiety begins to rise again and I guide her into the sensations in her belly, then down to her feet. As we do this repeatedly, Suzanne discovers that if she moves into noticing her feet whenever the sensations of anxiety get too intense, she can stay longer and longer with the anxiety and the intensity subsides drastically.
 
I feel that we have done enough work in this area and I want to check in with Suzanne to see how she is handling this. Her face appears to be shining a bit; there is more blood flow and a pinker color to her cheeks and for the first time in the session. She smiles. I ask her about this. She looks a little sheepish, averting her gaze for a moment. Then she looks back at me and says, “This is cool. I feel so much more in charge.”
 
I want to anchor her bodily sense of being “in charge” so that she can access this when her anxiety arises. “I am hoping to help change her relationship to this anxiety—to become curious about it.” I want her to recognize that when she actually pays attention to it, at the sensation rather than emotional level, it usually subsides, rather than increases as most people fear.
 
This process of touching into her sensations of the anxiety, then shifting her awareness to the rest of her body, helping her notice any moments of settling or any shift that occurs naturally, is one of the many ways that SE supports the nervous system to re-establish its natural, inherent rhythm—one that flows seamlessly between excitation and relaxation, between contraction and expansion. This is the first step Suzanne and I have taken to restoring regulation in her system.
 

Unfinished Business

The second step we’ll need to take is to access what’s unfinished. Many traditional therapies focus on feeling, reliving, and ultimately putting behind many of the bad things that occur in childhood. While this can be an important part of the therapeutic process, and is definitely something I am concerned with, my SE orientation leads me to seek to explore this experience with Suzanne somatically. “By following the body’s wisdom, we are led to what didn’t get to happen in a client’s past.” We provide clients with the opportunity of re-doing the event—finding in the present the way that the body would naturally, organically respond if it was left to its own devices. This renegotiation is done almost entirely through visualization, and slow, intentional movements, deeply connected to sensations and procedural movement patterns. This allows the discharge process to complete, and the trauma symptoms are moved out of the body, while the nervous system is allowed to return to pre-trauma functioning.
 
To get to what is unfinished in Suzanne, I want to access the brainstem and the survival responses. The way in is via sensations, noticing physiological shifts, and sensing impulses. My work with Suzanne so far has tapped into a little (but not too much) of the activation, or the charge of the anxiety. Now it’s time to check in to the rest of her body—in particular her extremities. The extremities naturally spring into readiness and action when we feel threatened. When a person is unable to carry through with the impulse to flee or fight, these thwarted impulses interrupt hard-wired sensorimotor patterns. This is often the place where the system gets stuck.
 
Capitalizing on Suzanne’s feeling of excitement and mastery, I ask her if she’s willing to explore a bit further. This time, when she gives her assent, she doesn’t hesitate. I ask her to sense into the rest of her body to notice what else is going on.
 
She immediately reports, “I feel tightness in my legs and shoulders.”
 
Deciding to bring awareness to the less accessible lower body, I ask her to tell me where she feels the tightness in her legs. She reports feeling tension and tingling in her ankles and thighs. Suzanne’s lifeless legs indicate a parasympathetic orientation in her lower body—a common pattern in clients with a history of physical or sexual abuse, bullying, early surgical procedures, or any events that involve being restrained. Earlier she had described herself as “feeling paralyzed” and “crying like a little girl” in response to the conflict and perceived threat of her co-worker. It’s clear to me that at least some of this sense of paralysis originates in her legs. I encourage her to stay with the sensations and see what happens next as she does that.
 
“It’s getting tighter,” she says.
 
Wanting to gently encourage her, I murmur, “Stay with it, if that’s okay.” I see her legs jump and tense slightly and then become very still.
 
“I’m scared,” Suzanne says. “I want to move my legs, but I can’t.”
 
This is a very important moment in SE work—an experience that Levine describes as the brake and accelerator both floored at the same time—the core of the freeze response. It is high-level sympathetic mobilization, coupled with parasympathetic shutdown, similar to what happens when a circuit breaker blows when there’s too much charge going through a line. It will be necessary to separate the two impulses so that Suzanne’s defensive response can be completed.
 

Follow the Impulse

Before I can say anything else, Suzanne says again, “I’m scared. I know this feeling. This is like when my uncle would do things to me in the attic.”
 
While I am certain that we will need to explore the content that is beginning to naturally arise as a result of feeling into Suzanne’s sensations, at this point I want to stay grounded in her physiological experience. In my experience, if I chose to explore this reference to her uncle by asking her to tell me more about what happened in the attic, Suzanne would likely shift into an intellectual telling of the story. This would take us away from her body and what her body wants to do. In fact, her body has been telling this story from the beginning, now showing us the connection between her anxiety and paralysis in her conflict with her co-worker and her past experience of trauma.
 
I ask Suzanne if it’s okay to sense the energy in her legs.
 
She says yes, a little uncertainly. She pauses for a moment and then responds, “It feels very intense, like a strong humming feeling.” My initial impression of her “wild bee” energy seems accurate. I ask her to feel the energy and sense where it wants to go. I also ask if she can feel how she is holding it back. I encourage her to very slowly move her awareness back and forth between the wanting to move and the holding back. This technique helps to separate the conflicting impulses. 
 
Suzanne is alert and somewhat alarmed, but not overwhelmed, mostly because we have done good preliminary work earlier, where she learned to trust her body somewhat, and learned to trust her ability to handle intensity. As Suzanne tunes into the energy wanting to move, the holding begins to ease, and the impulse to move increases. I see her upper body relax slightly, while her legs begin to twitch. I point out the twitching in her legs and invite her to slowly feel that and follow what wants to happen. Her body wants to move in reaction to a threat (her uncle), but it can’t because the threat is larger, stronger and familiar. Several intense, involuntary impulses are happening at the same time: anxiety because of the danger, hormones racing through her system preparing for action, tightness and bracing in many parts of her body, feelings of helplessness, hopelessness and shame, to name a few.
 
I can see underneath Suzanne’s clothes that her thighs are contracting slightly; her feet jerk almost imperceptibly upward. I also feel the readiness in my own body, which I experience as tension in my legs; my heart rate increases. I am feeling a sense of excitement in my  body—these impulses are contagious, and many-less experienced practitioners initially make the mistake of getting swept up in the sensations, unintentionally pressuring the client and causing resistance. Not wanting her to feel pushed, I sit back, settle into the chair, and move my attention back slightly, to allow her to experience her own impulses uninfluenced by mine.
 
I ask her to feel into the tightness of her thighs, and to sense her calves and ankles. They very slowly begin to move on their own, and I encourage her to notice that.
 
““My legs feel powerful and strong, like they could leap over any mountain,” she says, her voice sounding stronger and more commanding than I’ve heard it yet in this session.”
 
“Stay with those sensations of strength and power,” I suggest to her. I can see that she is enjoying the strength she feels. She pushes her feet down into the floor, her thigh muscles contracting visibly. I see that her feet and legs continue to move very slightly, this time with larger movements. I stay alert for signs of dissociation, bracing, breath-holding—anything that would indicate that too much is happening too fast.
 
As Suzanne continues to experience the movement of her legs and feet, she says, “It feels great to move them.” Her legs pump slightly beneath her seat. “ I don’t think I’ve felt my legs for years. Its like I’m coming into them.”
 
I ask her to tell me a little bit more about what she is sensing. “Heat. Waves of heat coursing through my legs.” Her feet and ankles continue to move as she describes this. I know that the release of heat is a sign that her nervous system is coming into a greater degree of equilibrium. To continue to expand on Suzanne’s experience of becoming unfrozen, I ask her, ”What does it feel like your feet are doing?”
 
“I can walk away. I know I can walk away. I can run away if I need to.”
 
Her legs begin to tremble very slightly. Her face is flushed, radiating pleasure. I know we have done plenty for one session.
 
At this point, it's time to process some of what we’ve done. We talk about her experience and I educate her a bit on the SE model I’ve been using, explaining the fight-or-flight process of the nervous system and what happens when those natural reactions are unable to be completed. She shares some memory flashes that arose during the running, and we talk about ways she can play with the process of checking into her belly when she feels anxious—moving between the sensations in her belly and the sensations in her legs.
 

The Next Step

Future sessions with Suzanne would focus on fine-tuning the newfound skill of sensing the anxiety somatically,  and learning how to recognize it, and settle it before it overtakes her. We would look at other situations in which anxiety shows up, such as in the work place or during  moments of conflict, and see if we can generalize the skill in other settings. We would explore the abuse by her uncle, concentrating on what is unprocessed physiologically and emotionally, especially incomplete defensive responses. SE therapists learn to trust the body, more than the memory or recall of events. We know not to assign meaning or assume causality to what arises in the therapy session. Details of events change as they are worked out at the somatic level. Memory is unreliable at best, but the body holds the key to what is unfinished and needing to heal. We focus on allowing those physiological responses to unfold, which makes room for the body to organically return to homeostasis.
 
In the SE model, we consider our work to focus on resolving the strategies for coping with nervous system dysregulation. This dysregulation can occur as the result of trauma, but may occur even in the absence of specific traumatic events—early attachment issues, for example. What is primary to us is to restore the nervous system to a natural state of regulation. To this end, SE is well integrated with many modalities of therapy, adding richness and depth to other methods that may have a more primary focus on the emotional or cognitive aspects of experience. What is most important about the SE way of working with a client is our focus on the physiological, the sensations, the body.
 
A wealth of information can be found at the Foundation for Human Enrichment web site. A comprehensive SE Training program is available for those seeking to learn how to apply this method in their work. A vivid demonstration of SE is seen in Resolving Trauma in Psychotherapy: A Somatic Approach.

“When I’m good, I’m very good, but when I’m bad I’m better”: A New Mantra for Psychotherapists

Posted on by rezendevknowfully.com
Current estimates suggest that nearly 50 percent of therapy clients drop out and at least one third, and up to two thirds, do not benefit from our usual strategies. Barry Duncan and Scott Miller provide a comprehensive summary of the Outcome-Informed, Client-Directed approach and a detailed, practical overview of its application in clinical practice. Through case examples they demonstrate how most practitioners can increase their therapeutic effectiveness substantially through accurate identification of those clients who are not responding, and addressing the lack of change in a way that keeps clients engaged in treatment and forges new directions.

Introduction

At first blush, Mae West's famous words 'When I'm good, I'm very good, but when I'm bad I'm better' hardly seem like a guide for therapists to live by—but, as it turns out, they could be. Research demonstrates consistently that who the therapist is accounts for far more of the variance of change (6 to 9 percent) than the model or technique administered (1 percent). In fact, therapist effectiveness ranges from a paltry 20 percent to an impressive 70 percent. A small group of clinicians—sometimes called 'supershrinks'—obtain demonstrably superior outcomes in most of their cases, while others fall predictably on the less-exalted sections of the bell-shaped curve. However, most practitioners can join the ranks of supershrinks, or at least increase their therapeutic effectiveness substantially.
 
Consider Matt, a twenty-something software whiz who was on the road frequently to trouble-shoot customer problems. Matt loved his job but travelling was an ordeal—not because of flying but because of another, far more embarrassing problem. Matt was long past feeling frustrated about standing and standing in public restrooms trying to 'go.' What started as a mild discomfort and inconvenience easily solved by repeated restroom visits had progressed to full-blown anxiety attacks, an excruciating pressure, and an intense dread before each trip. Feeling hopeless and demoralized, Matt considered changing jobs but as a last resort decided instead to see a therapist.
 
Matt liked the therapist and it felt good finally to tell someone about the problem. The therapist worked with Matt to implement relaxation and self-talk strategies. Matt practiced in session and tried to use the ideas on his next trip, but still no 'go.' The problem continued to get worse. Now three sessions in, Matt was at significant risk for a negative outcome—either dropping out or continuing in therapy without benefit.
 
We have all encountered clients unmoved by treatment. Therapists often blame themselves. The overwhelming majority of psychotherapists, as cliched as it sounds, want to be helpful. Many of us answered "I want to help people" on graduate school applications as the reason we chose to be therapists. Often, some well-meaning person dissuaded us from that answer because it didn't sound sophisticated or appeared too 'co-dependent.' Such aspirations, we now believe, are not only noble but can provide just what is needed to improve clinical effectiveness. After all, there is not much financial incentive for doing better therapy—we don't do this work because we thought we would acquire the lifestyles of the rich and famous.
 
Unfortunately, the altruistic desire to be helpful sometimes leads us to believe that if we were just smart enough or trained correctly, clients would not remain inured to our best efforts—if we found the Holy Grail, that special model or technique, we could once and for all defeat the psychic dragons that terrorize clients. “Amid explanations and remedies aplenty, therapists search courageously for designer explanations and brand-name miracles, but continue to observe that clients drop out, or even worse, continue without benefit.” Current estimates suggest that nearly 50 percent of our clients drop out and at least one third, and up to two thirds, do not benefit from our usual strategies.
 
So what can we do to channel our healthy desire to be helpful? If we listen to the lessons of the top performers, the first thing we should do is step outside of our comfort zones and push the limits of our current performance—to identify accurately those clients not responding to our therapeutic business as usual, and address the lack of change in a way that keeps clients engaged in treatment and forges new directions.
 
To recapture those clients who slip through the cracks, we need to embrace what is known about change: Many studies reveal that the majority of clients experience change in the first six visits—clients reporting little or no change early on tend to show no improvement over the entire course of therapy, or wind up dropping out. Early change, in other words, predicts engagement in therapy and ongoing benefit. This doesn't mean that a client is 'cured' or the problem is totally resolved, but rather that the client has a subjective sense that things are getting better. And second, a mountain of studies have long demonstrated another robust predictor—that reliable, tried-and-true but taken-for-granted old friend—the therapeutic alliance. Clients who highly rate the relationship with their therapist tend to be those clients who stick around in therapy and benefit from it.
 
Next we need to measure those known predictors in a systematic way with reliable and valid instruments. So instead of regarding the first few therapy sessions as a 'warm-up' period or a chance to try out the latest technique, we engage the client in helping us judge whether therapy is providing benefit. Obtaining feedback on standardized measures about success or failure during those initial meetings provides invaluable information about the match between ourselves, our approach, and the client—enabling us to know when we are bad, so we can be even better. The only way we can improve our outcomes is to know, very early on, when the client is not benefiting—we need something akin to an early warning signal.
 
Using standardized measures to monitor outcome may make your skin crawl and bring to mind torture devices like the Rorschach or MMPI. But the forms for these measures are not used to pass judgment, diagnose or unravel the mysteries of the human psyche. Rather, these measures invite clients into the inner circle of mental health and substance abuse services—they involve clients collaboratively in monitoring progress toward their goals and the fit of the services they are receiving, and amplify their voices in any decisions about their care.

The Outcome Rating Scale (ORS)

You might also think that the last thing you need is to add more paperwork to your practice. But finding out who is and isn't responding to therapy need not be cumbersome. In fact, it only takes a minute. Dissatisfied with the complexity, length, and user- unfriendliness of existing outcome measures, we developed the Outcome Rating Scale (ORS) as a brief clinical alternative. The ORS (child measures also available) and all the measures discussed here are available for free download at talkingcure.com. The ORS assesses three dimensions:
  1. Personal or symptomatic distress (measuring individual well-being)
  2. Interpersonal well-being (measuring how well the client is getting along in intimate relationships)
  3. Social role (measuring satisfaction with work/school and relationships outside of the home)
Changes in these three areas are considered widely to be valid indicators of successful outcome. The ORS simply translates these three areas and an overall rating into a visual analog format of four 10-cm lines, with instructions to place a mark on each line with low estimates to the left and high to the right. The four 10-cm lines add to a total score of 40. The score is simply the summation of the marks made by the client to the nearest millimeter on each of the four lines, measured by a centimeter ruler or available template. A score of 25, the clinical cutoff, differentiates those who are experiencing enough distress to be in a helping relationship from those who are not. Because of its simplicity, ORS feedback is available immediately for use at the time the service is delivered. Rated at an eighth-grade reading level, the ORS is understood easily and clients have little difficulty connecting it their day-to-day lived experience.
 
Matt completed the ORS before each session. He entered therapy with a score of 18, about average for those attending outpatient settings, but continued to hover at that score. At the third session, when the ORS reflected no change, it was not front-page news to Matt. But a different process ensued. In the same spirit of collaboration as the assessment process, Matt and his therapist brainstormed ideas, a free-for-all of unedited speculations and suggestions of alternatives, from changing nothing about the therapy to taking medication to shifting treatment approaches. During this open exchange Matt intimated that he was beginning to feel angry about the whole thing—real angry. The therapist noticed that when Matt worked himself up to a good anger—about how his problem interfered with his work and added a huge hassle in any extended situation away from his own bathroom—that he became quite animated, a stark contrast to the passively resigned person that had characterized their previous sessions. One of them, which one remains a mystery, mentioned the words 'pissed off' and both broke into a raucous laughter. Subsequently, the therapist suggested that instead of responding with hopelessness when the problem occurred, that Matt work himself up to a good anger—about how this problem made his life miserable. Matt added (he was a rock-and-roll buff) that he could also sing the Tom Petty song "Won't Back Down" during his tirade at the toilet. Matt allowed himself, when standing in front of the urinal to become incensed—downright 'pissed off,' and amused. And he started to go.
 
This process, the delightful creative energy that emerges from the wonderful interpersonal event we call therapy, could have happened to any therapist working with Matt. The difference is that the use of the outcome measure spotlighted the lack of change and made it impossible to ignore. The ORS brought the risk of a negative outcome front and center and allowed the therapist to enact the second characteristic of supershrinks, to be exceptionally alert to the risk of dropout and treatment failure. In the past, we might have continued with the same treatment for several more sessions, unaware of its ineffectiveness or believing (hoping, even praying) that our usual strategies would eventually take hold, but the reliable outcome data pushed us to explore different treatment options by the end of the third visit.
 
Pushing the limits of one's performance requires monitoring the fit of your service with the client's expectations about the alliance. The ongoing assessment of the alliance enables therapists to identify and correct areas of weakness in the delivery of services before they exert a negative effect on outcome.
 

The Session Rating Scale (SRS)

Research shows repeatedly that clients' ratings of the alliance are far more predictive of improvement than the type of intervention or the therapist's ratings of the alliance. Recognizing these much-replicated findings, we developed the Session Rating Scale (SRS) as a brief clinical alternative to longer research-based alliance measures to encourage routine conversations with clients about the alliance. The SRS also contains four items. First, a relationship scale rates the meeting on a continuum from "I did not feel heard, understood, and respected" to "I felt heard, understood, and respected." Second is a goals and topics scale that rates the conversation on a continuum from "We did not work on or talk about what I wanted to work on or talk about" to "We worked on or talked about what I wanted to work on or talk about." Third is an approach or method scale (an indication of a match with the client's theory of change) requiring the client to rate the meeting on a continuum from "The approach is not a good fit for me" to "The approach is a good fit for me." Finally, the fourth scale looks at how the client perceives the encounter in total along the continuum: "There was something missing in the session today" to "Overall, today's session was right for me."
 
The SRS simply translates what is known about the alliance into four visual analog scales, with instructions to place a mark on a line with negative responses depicted on the left and positive responses indicated on the right. The SRS allows alliance feedback in real time so that problems may be addressed. Like the ORS, the instrument takes less than a minute to administer and score. The SRS is scored similarly to the ORS, by adding the total of the client's marks on the four 10-cm lines. The total score falls into three categories:
  • SRS score between 0–34 reflects a poor alliance,
  • SRS Score between 35–38 reflects a fair alliance,
  • SRS Score between 39–40 reflects a good alliance.

The SRS allows the implementation of the final lesson of the supershrinks—seek, obtain, and maintain more consumer engagement. Clients drop out of therapy for two reasons: one is that therapy is not helping (hence monitoring outcome) and the other is alliance problems—they are not engaged or turned on by the process. The most direct way to improve your effectiveness is simply to keep people engaged in therapy.

 
An alliance problem that occurs frequently emerges when client's goals do not fit our own sensibilities about what they need. This may be particularly true if clients carry certain diagnoses or problem scenarios. Consider 19-year-old Sarah, who lived in a group home and received social security disability for mental illness. Sarah was referred for counseling because others were concerned that she was socially withdrawn. Everyone was also worried about Sarah's health because she was overweight and spent much of her time watching TV and eating snack foods.
 
In therapy Sarah agreed that she was lonely, but expressed a desire to be a Miami Heat cheerleader. Perhaps understandably, that goal was not taken seriously. After all, Sarah had never been a cheerleader, was 'schizophrenic,' and was not exactly in the best of shape. So no one listened, or even knew why Sarah had such an interesting goal. And the work with Sarah floundered. She spoke rarely and gave minimal answers to questions. In short, Sarah was not engaged and was at risk for dropout or a negative outcome.
 
The therapist routinely gave Sarah the SRS and she had reported that everything was going swimmingly, although the goals scale was an 8.7 out of 10, instead of a 9 or above out of 10 like the rest.
 
Sometimes it takes a bit more work to create the conditions that allow clients to be forthright with us, to develop a culture of feedback in the room. The power disparity combined with any socioeconomic, ethnic, or racial differences make it difficult to tell authority figures that they are on the wrong track. Think about the last time you told your doctor that he or she was not performing well. Clients, however, will let us know subtly on alliance measures far before they will confront us directly.
 
At the end of the third session, the therapist and Sarah reviewed her responses on the SRS. Did she truly feel understood? Was the therapy focused on her goals? Did the approach make sense to her? Such reviews are helpful in fine-tuning the therapy or addressing problems in the therapeutic relationship that have been missed or gone unreported. Sarah, when asked the question about goals, all the while avoiding eye contact and nearly whispering, repeated her desire to be a Miami Heat cheerleader.
 
The therapist looked at the SRS and the lights came on. The slight difference on the goals scale told the tale. When the therapist finally asked Sarah about her goal, she told the story of growing up watching Miami Heat basketball with her dad who delighted in Sarah's performance of the cheers. Sarah sparkled when she talked of her father, who passed away several years previously, and the therapist noted that it was the most he had ever heard her speak. He took this experience to heart and often asked Sarah about her father. The therapist also put the brakes on his efforts to get Sarah to socialize or exercise (his goals), and instead leaned more toward Sarah's interest in cheerleading. Sarah watched cheerleading contests regularly on ESPN and enjoyed sharing her expertise. She also knew a lot about basketball.
 
Sarah's SRS score improved on the goal scale and her ORS score increased dramatically. After a while, Sarah organized a cheerleading squad for her agency's basketball team who played local civic organizations to raise money for the group home. Sarah's involvement with the team ultimately addressed the referral concerns about her social withdrawal and lack of activity. The SRS helps us take clients and their engagement more seriously, like the supershrinks do. Walking the path cut by client goals often reveals alternative routes that would have never been discovered otherwise.
 
Providing feedback to clinicians on the clients' experience of the alliance and progress has been shown to result in significant improvements in both client retention and outcome. “We found that clients of therapists who opted out of completing the SRS were twice as likely to drop out and three times more likely to have a negative outcome.” In the same study of over 6000 clients, effectiveness rates doubled. As incredible as the results appear, they are consistent with findings from other researchers.
 
In a 2003 meta-analysis of three studies, Michael Lambert, a pioneer of using client feedback, reported that those helping relationships at risk for a negative outcome which received formal feedback were, at the conclusion of therapy, better off than 65 percent of those without information regarding progress. Think about this for a minute. Even if you are one of the most effective therapists, for every cycle of 10 clients you see, three will go home without benefit. Over the course of a year, for a therapist with a full caseload, this amounts to a lot of unhappy clients. This research shows that you can recover a substantial portion of those who don't benefit by first identifying who they are, keeping them engaged, and tailoring your services accordingly.
 

The Nuts and Bolts

Collecting data on standardized measures and using what we call 'practice-based evidence' can improve your effectiveness substantially. "Wait a minute," you say, "this sounds a lot like research!" Given the legionary schism between research and practice, sometimes getting therapists to do the measures is indeed a tall order because it does sound a lot like the 'R' word.
 
A story illustrates the sentiments that many practitioners feel about research. Two researchers were attending an annual conference. Although enjoying the proceedings, they decided to find some diversion to combat the tedium of sitting all day and absorbing vast amounts of information. They settled on a hot air balloon ride and were quite enjoying themselves until a mysterious fog rolled in. Hopelessly lost, they drifted for hours until a clearing in the fog appeared finally and they saw a man standing in an open field. Joyfully, they yelled down at the man, "Where are we?" The man looked at them, and then down at the ground, before turning a full 360 degrees to survey his surroundings. Finally, after scratching his beard and what seemed to be several moments of facial contortions reflecting deep concentration, the man looked up and said, "You are above my farm."
 
The first researcher looked at the second researcher and said, "That man is a researcher—he is a scientist!" To which the second researcher replied, "Are you crazy, man? He is a simple farmer!" "No," answered the first researcher emphatically, "that man is a researcher and there are three facts that support my assertion: First, what he said was absolutely 100% accurate; second, he addressed our question systematically through an examination of all of the empirical evidence at his disposal, and then deliberated carefully on the data before delivering his conclusion; and finally, the third reason I know he is a researcher is that what he told us is absolutely useless to our predicament."
 
But unlike much of what is passed off as research, the systematic collection of outcome data in your practice is not worthless to your predicament. It allows you the luxury of being useful to clients who would otherwise not be helped. And it helps you to get out of the way of those clients you are not helping, and connecting them to more likely opportunities for change.
 
First, collaboration with clients to monitor outcome and fit actually starts before formal therapy. This means that they are informed when scheduling the first contact about the nature of the partnership and the creation of a 'culture of feedback' in which their voice is essential.
 
"I want to help you reach your goals. I have found it important to monitor progress from meeting to meeting using two very short forms. Your ongoing feedback will tell us if we are on track, or need to change something about our approach, or include other resources or referrals to help you get what you want. I want to know this sooner rather than later, because if I am not the person for you, I want to move you on quickly and not be an obstacle to you getting what you want. Is that something you can help me with?"
 
We have never had anyone tell us that keeping track of progress is a bad idea. There are five steps to using practice based evidence to improve your effectiveness.
 

Step One: Introducing the ORS in the First Session

The ORS is administered prior to each meeting and the SRS toward the end. In the first meeting, the culture of feedback is continually reinforced. It is important to avoid technical jargon, and instead explain the purpose of the measures and their rationale in a natural commonsense way. Just make it part of a relaxed and ordinary way of having conversations and working. The specific words are not important—there is no protocol that must be followed. This is a clinical tool! Your interest in the client's desired outcome speaks volumes about your commitment to the client and the quality of service you provide.
 
"Remember our earlier conversation? During the course of our work together, I will be giving you two very short forms that ask how you think things are going and whether you think things are on track. To make the most of our time together and get the best outcome, it is important to make sure we are on the same page with one another about how you are doing, how we are doing, and where we are going. We will be using your answers to keep us on track. Will that be okay with you?"
 

Step Two: Incorporating the ORS in the first session

The ORS pinpoints where the client is and allows a comparison for later sessions. Incorporating the ORS entails simply bringing the client's initial and subsequent results into the conversation for discussion, clarification and problem solving. The client's initial score on the ORS is either above or below the clinical cutoff. You need only to mention the client scores as it relates to the cutoff. Keep in mind that the use of the measures is 100-percent transparent. There is nothing that they tell you that you cannot share with the client. It is their interpretation that ultimately counts.
 
"From your ORS it looks like you're experiencing some real problems." Or: "From your score, it looks like you're feeling okay." "What brings you here today?" Or: "Your total score is 15—that's pretty low. A score under 25 indicates people who are in enough distress to seek help. Things must be pretty tough for you. Does that fit your experience? What's going on?"
 
"The way this ORS works is that scores under 25 indicate that things are hard for you now or you are hurting enough to bring you to see me. Your score on the individual scale indicates that you are really having a hard time. Would you like to tell me about it?"
 
Or if the ORS is above 25: "Generally when people score above 25, it is an indication that things are going pretty well for them. Does that fit your experience? It would be really helpful for me to get an understanding of what it is that brought you here now."
 
Because the ORS has face validity, clients usually mark the scale the lowest that represents the reason they are seeking therapy, and often connect that reason to the mark they've made without prompting from the therapist. For example, Matt marked the Individual scale the lowest with the Social scale coming in a close second. As he was describing his problem in public restrooms, he pointed to the ORS and explained that this problem accounted for his mark. Other times, the therapist needs to clarify the connection between the client's descriptions of the reasons for services and the client's scores. The ORS makes no sense unless it is connected to the described experience of the client's life. This is a critical point because clinician and client must know what the mark on the line represents to the client and what will need to happen for the client to both realize a change and indicate that change on the ORS.
 
At some point in the meeting, the therapist needs only to pick up on the client's comments and connect them to the ORS:
 
"Oh, okay, it sounds like dealing with the loss of your brother (or relationship with wife, sister's drinking, or anxiety attacks, etc.) is an important part of what we are doing here. Does the distress from that situation account for your mark here on the individual (or other) scale on the ORS? Okay, so what do you think will need to happen for that mark to move just one centimeter to the right?"
 
The ORS, by design, is a general outcome instrument and provides no specific content other than the three domains. The ORS offers only a bare skeleton to which clients must add the flesh and blood of their experiences, into which they breathe life with their ideas and perceptions. At the moment in which clients connect the marks on the ORS with the situations that are distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool.
 

Step Three: Introducing the SRS

The SRS, like the ORS, is best presented in a relaxed way that is integrated seamlessly into your typical way of working. The use of the SRS continues the culture of client privilege and feedback, and opens space for the client's voice about the alliance. The SRS is given at the end of the meeting, but leaving enough time to discuss the client's responses.
 
"Let's take a minute and have you fill out the form that asks for your opinion about our work together. It's like taking the temperature of our relationship today. Are we too hot or too cold? Do I need to adjust the thermostat? This information helps me stay on track. The ultimate purpose of using these forms is to make every possible effort to make our work together beneficial. Is that okay with you?"
 

Step Four: Incorporating the SRS

Because the SRS is easy to score and interpret, you can do a quick visual check and integrate it into the conversation. If the SRS looks good (score more than 9 cm on any scale), you need only comment on that fact and invite any other comments or suggestions. If the client marks any scales lower than 9 cm, you should definitely follow up. Clients tend to score all alliance measures highly, so the practitioner should address any hint of a problem. Anything less than a total score of 36 might signal a concern, and therefore it is prudent to invite clients to comment. Keep in mind that a high rating is a good thing, but it doesn't tell you very much. Always thank the client for the feedback and continue to encourage their open feedback. Remember that unless you convey you really want it, you are unlikely to get it.
 
And know for sure that there is no 'bad news' on these forms. Your appreciation of any negative feedback is a powerful alliance builder. In fact, alliances that start off negatively but result in your flexibility to client input tend to be very predictive of a positive outcome. When you are bad, you are even better! In general, a score:
  • that is poor and remains poor predicts a negative outcome,
  • that is good and remains good predicts a positive outcome,
  • that is poor or fair and improves predicts a positive outcome even more,
  • that is good and decreases is predictive of a negative outcome.
The SRS allows the opportunity to fix any alliance problems that are developing and shows that you do more than give lip service to honoring the client's perspectives.
 
"Let me just take a look at this SRS—it's like a thermometer that takes the temperature of our meeting here today. Great, looks like we are on the same page, that we are talking about what you think is important and you believe today's meeting was right for you. Please let me know if I get off track, because letting me know would be the biggest favor you could do for me."
 
"Let me quickly look at this other form here that lets me know how you think we are doing. Okay, seems like I am missing the boat here. Thanks very much for your honesty and giving me a chance to address what I can do differently. Was there something else I should have asked you about or should have done to make this meeting work better for you? What was missing here?"
 
Graceful acceptance of any problems and responding with flexibility usually turns things around. Again, clients reporting alliance problems that are addressed are far more likely to achieve a successful outcome—up to seven times more likely! Negative scores on the SRS, therefore, are good news and should be celebrated. Practitioners who elicit negative feedback tend to be those with the best effectiveness rates. Think about it—it makes sense that if clients are comfortable enough with you to express that something isn't right, then you are doing something very right in creating the conditions for therapeutic change.
 

Step Five: Checking for change in subsequent sessions

With the feedback culture set, the business of practice-based evidence can begin, with the client's view of progress and fit really influencing what happens. Each subsequent meeting compares the current ORS with the previous one and looks for any changes. The ORS can be made available in the waiting room or via electronic software (ASIST) and web systems (MyOutcomes.com). Many clients will complete the ORS (some will even plot their scores on provided graphs) and greet the therapist already discussing the implications. Using a scale that is simple to score and interpret increases client engagement in the evaluation of the services. Anything that increases participation is likely to have a beneficial impact on outcome.
 
The therapist discusses if there is an improvement (an increase in score), a slide (a decrease in score), or no change at all. The scores are used to engage the client in a discussion about progress, and more importantly, what should be done differently if there isn't any.
 
"Your marks on the personal well-being and overall lines really moved—about 4 cm to the right each! Your total increased by 8 points to 29 points. That's quite a jump! What happened? How did you pull that off? Where do you think we should go from here?"
 
If no change has occurred, the scores invite an even more important conversation.
 
"Okay, so things haven't changed since the last time we talked. How do you make sense of that? Should we be doing something different here, or should we continue on course steady as we go? If we are going to stay on the same track, how long should we go before getting worried? When will we know when to say 'when?' "
 
The idea is to involve the client in monitoring progress and the decision about what to do next. The discussion prompted by the ORS is repeated in all meetings, but later ones gain increasing significance and warrant additional action. We call these later interactions either checkpoint conversations or last-chance discussions. In a typical outpatient setting, checkpoint conversations are conducted usually at the third meeting and last-chance discussions are initiated in the sixth session. This is simply saying that based on over 300,000 administrations of the measures, by the third encounter most clients who do receive benefit from services usually show some benefit on the ORS; and if change is not noted by meeting three, then the client is at a risk for a negative outcome. Ditto for session six except that everything just mentioned has an exclamation mark. Different settings could have different checkpoints and last-chance numbers. Determining these highlighted points of conversation requires only that you collect the data. The calculations are simple and directions can be found in our book, The Heroic Client. Establishing these two points helps evaluate whether a client needs a referral or other change based on a typical successful client in your specific setting. The same thing can be accomplished more precisely by available software or web-based systems that calculate the expected trajectory or pattern of change based on our data base of ORS administrations. These programs compare a graph of the client's session-by-session ORS results to the expected amount of change for clients in the data base with the same intake score, serving as a catalyst for conversation about the next step in therapy.
 
If change has not occurred by the checkpoint conversation, the therapist responds by going through the SRS item by item. Alliance problems are a significant contributor to a lack of progress. Sometimes it is useful to say something like, "It doesn't seem like we are getting anywhere. Let me go over the items on this SRS to make sure you are getting exactly what you are looking for from me and our time together." Going through the SRS and eliciting client responses in detail can help the practitioner and client get a better sense of what may not be working. Sarah, the woman who aspired to be a Miami Heat cheerleader, exemplifies this process.
 
Next, a lack of progress at this stage may indicate that the therapist needs to try something different. This can take as many forms as there are clients: inviting others from the client's support system, using a team or another professional, a different approach; referring to another therapist, religious advisor, or self-help group—whatever seems to be of value to the client. Any ideas that surface are then implemented, and progress is monitored via the ORS. Matt and the idea of encouraging his anger illustrate this kind of discussion.
 

The Importance of Referrals

If the therapist and client have implemented different possibilities and the client is still without benefit, it is time for the last-chance discussion. As the name implies, there is some urgency for something different because most clients who benefit have already achieved change by this point, and the client is at significant risk for a negative conclusion. A metaphor we like is that of the therapist and client driving into a vast desert and running on empty, when a sign appears on the road that says 'last chance for gas.' The metaphor depicts the necessity of stopping and discussing the implications of continuing without the client reaching a desired change.
 
This is the time for a frank discussion about referral and other available resources. If the therapist has created a feedback culture from the beginning, then this conversation will not be a surprise to the client. There is rarely justification for continuing work with clients who have not achieved change in a period typical for the majority of clients seen by a particular practitioner or setting.
 
Why? Because research shows no correlation between a therapy with a poor outcome and the likelihood of success in the next encounter. Although we've found that talking about a lack of progress turns most cases around, we are not always able to find a helpful alternative.
 
“Where in the past we might have felt like failures when we weren't being effective with a client, we now view such times as opportunities to stop being an impediment to the client and their change process.” Now our work is successful when the client achieves change and when, in the absence of change, we get out of their way. We reiterate our commitment to help them achieve the outcome they desire, whether by us or by someone else. When we discuss the lack of progress with clients, we stress that failure says nothing about them personally or their potential for change. Some clients terminate and others ask for a referral to another therapist or treatment setting. If the client chooses, we will meet with her or him in a supportive fashion until other arrangements are made. Rarely do we continue with clients whose ORS scores show little or no improvement by the sixth or seventh visit.
 
Ending with clients who are not making progress does not mean that all therapy should be brief. On the contrary, our research and the “findings of virtually every study of change in therapy over the last 40 years provide substantial evidence that more therapy is better than less therapy for those clients who make progress early in treatment” and are interested in continuing. When little or no improvement is forth coming, however, this same data indicates that therapy should, indeed, be as brief as possible. Over time, we have learned that explaining our way of working and our beliefs about therapy outcomes to clients avoids problems if therapy is unsuccessful and needs to be terminated.
 
Barry Duncan writes: But it can be hard to believe that stopping a great relationship is the right thing to do.
 
Alina sought services because she was devastated and felt like everything important to her had been savagely ripped apart—because it had. She worked her whole life for but one goal, to earn a scholarship to a prestigious Ivy-league university. She was captain of the volleyball team, commanded the first position on the debating team, and was valedictorian of her class. Alina was the pride of her Guatemalan community—proof positive of the possibilities her parents always envisioned in the land of opportunity. Alina was awarded a full ride in minority studies at Yale University. But this Hollywood caliber story hit a glitch. Attending her first semester away from home and the insulated environment in which she excelled, Alina began hearing voices.
 
She told a therapist at the university counseling center and before she knew it she was whisked away to a psychiatric unit and given antipsychotic medications. Despondent about the implications of this turn of events, Alina threw herself down a stairwell, prompting her parents to bring her home. Alina returned home in utter confusion, still hearing voices, and with a belief that she was an unequivocal failure to herself, her family, and everyone else in her tightly knit community whose aspirations rode on her shoulders.
 
Serendipity landed Alina in my office. I was the twentieth therapist the family called and the first who agreed to see Alina without medication. Alina's parents were committed to honor her preference to not take medication. We were made for each other and hit it off famously. I loved this kid. I admired her intelligence and spunk in standing up to psychiatric discourse and the broken record of medication. I couldn't wait to be useful to Alina and get her back on track. When I administered the ORS, Alina scored a 4, the lowest score I'd ever had.
 
We discussed her total demoralization and how her episodes of hearing voices and confusion led to the events that took everything she had always dreamed of from her—the life she had worked so hard to prepare for. I did what I usually did that is helpful—I listened, I commiserated, I validated, and I worked hard to recruit Alina's resilience to begin anew. But nothing happened.
 
By session three, Alina remained unchanged in the face of my best efforts. Therapy was going nowhere and I knew it because the ORS makes it hard to ignore—that score of 4 was a rude reminder of just how badly things were going.
 
At the checkpoint session, I went over the SRS with her, and unlike many clients, Alina was specific about what was missing and revealed that she wanted me to be more active, so I was. She wanted ideas about what to do about the voices, so I provided them—thought stopping, guided imagery, content analysis. But, no change ensued and she was increasingly at risk for a negative outcome. Alina told me she had read about hypnosis on the internet and thought that might help. Since I had been around in the '80s and couldn't escape that time without hypnosis training, I approached Alina from a couple of different hypnotic angles—offering both embedded suggestions as well as stories intended to build her immunity to the voices. She responded with deep trances and gave high ratings on the SRS. But the ORS remained a paltry 4.
 
At the last-chance conversation, I brought up the topic of referral but we settled instead on a consult from a team (led by Jacqueline Sparks). Alina, again, responded well, and seemed more engaged than I had noticed with me—she rated the session the highest possible on the SRS. The team addressed topics I hadn't, including differentiation from her family, as well as gender and ethnic issues. Alina and I pursued the ideas from the team for a couple more sessions. But her ORS score was still a 4.
 
Now what? We were in session nine, well beyond how clients typically change in my practice. After collecting data for several years, I know that 75 percent of clients who benefit from their work with me show it by the third session; a full 98 per cent of my clients who benefit do it by the sixth session. So is it right that I continue with Alina? Is it even ethical?
 
Despite our mutual admiration society, it wasn't right to continue. A good relationship in the absence of benefit is a good definition of dependence. So I shared my concern that her dream would be in jeopardy if she continued seeing me. I emphasized that the lack of change had nothing to do with either of us, that we had both tried our best, and for whatever reason, it just wasn't the right mix for change. We discussed the possibility that Alina see someone else. If you watch the video, you would be struck, as many are, by the decided lack of fun Alina and I have during this discussion.
 
Finally, after what seemed like an eternity, including Alina's assertion that she wanted to keep seeing me, we started to talk about who she might see. She mentioned she liked someone from the team, and began seeing our colleague Jacqueline Sparks.
 
By session four, Alina had an ORS score of 19 and enrolled to take a class at a local university. Moreover, she continued those changes and re-enrolled at Yale the following year with her scholarship intact! When I wrote a required recommendation letter for the Dean, I administered the ORS to Alina and she scored a 29. By my getting out of her way and allowing her and myself to 'fail successfully,' Alina was given another opportunity to get her life back on track—and she did. Alina and Jacqueline, for reasons that escape us even after pouring over the video, just had the right chemistry for change.
 
This was a watershed client for me. Although I believed in practice-based evidence, especially how it puts clients center stage and pushes me to do something different when clients don't benefit, I always struggled with those clients who did not benefit, but who wanted to continue with me nevertheless. This was more difficult when I really liked the client and had become personally invested in them benefiting. Alina awakened me to the pitfalls of such situations and showed a true value-added dimension to monitoring outcome—namely the ability to fail successfully with our clients. Alina was the kind of client I would have seen forever. I cared deeply about her and believed that surely I could figure out something eventually.
 
But such is the thinking that makes 'chronic' clients—an inattention to the iatrogenic effects of the continuation of therapy in the absence of benefit. Therapists, no matter how competent or trained or experienced, cannot be effective with everyone, and other relational fits may work out better for the client. Although some clients want to continue in the absence of change, far more do not want to continue when given a graceful way to exit. The ORS allows us to ask ourselves the hard questions when clients are not, by their own ratings, seeing benefit from services. The benefits of increased effectiveness of my work, and feeling better about the clients that I am not helping, have allowed me to leave any squeamishness about forms far behind.
 
Practice-based evidence will not help you with the clients you are already effective with; rather, it will help you with those who are not benefiting by enabling an open discussion of other options and, in the absence of change, the ability to honorably end and move the client on to a more productive relationship. The basic principle behind this way of working is that our day-to-day clinical actions are guided by reliable, valid feedback about the factors that account for how people change in therapy. These factors are the client's engagement and view of the therapeutic relationship, and—the gold standard—the client's report of whether change occurs. Monitoring the outcome and the fit of our services helps us know that when we are good, we are very good, and when we are bad, we can be even better.

A Crash Course in Psychotherapy: Moving through Anxiety and Self-Doubt

Posted on by rezendevknowfully.com
"There is a way out," I couldn't help telling myself as I imagined the door to the small clinic office behind me. The room held nothing but two mismatched office chairs, a window with half-retreated, yellowing blinds, and the heavy smell of sweat, carpet cleaner and someone's lunch. My stomach was tied in knots, and air flowed in and out of my nose surprisingly easily, the way it always seemed to when my heart picked up its pace and my sinuses cleared in response.
 
There was no room in that cramped office for a break: no way Sam* and I could stretch our legs, distract ourselves by staring at titles on a bookcase, or recline in our chairs and close our eyes. There were just two feet of space between us, and I cringed at the thought of moving and accidentally having our knees bump. It was just us—his regretful disclosure, and my words that brought no comfort—that I had to be with, unless I bolted out that door.
 
I remember the simple instruction that was given to us psychotherapy interns during orientation week: Always sit in the chair closest to the door so you have a way out if your client places you in danger. This was a surprising prospect for me, a 25-year-old first-year therapist still in graduate school, who chose to work at an outpatient LGBT community mental health clinic. I pictured myself with clients struggling to come out to family and friends, coping with the loss of a loved one, or needing to heal from childhood trauma. This was, in fact, the case. But it was also the case that I would see clients who suffered paranoia, borderline personality disorder and severe post-traumatic stress disorder. “This is the way it works in the mental health field—the least experienced get assigned the most severely disordered and challenging clients”, whereas the seasoned therapists get to pick their client load, and more often than not, it seemed, stick to young women with relationship problems.
 
I stayed in that clinic office with Sam, because if I didn't, what was I proving to myself? What was I proving to my client? I could make it through this. He could make it through this. There was no physical danger, only a danger that I sensed we both felt coming from inside ourselves, screaming to us through our blood and pounding down on our chests. But this danger felt more difficult to conquer, because the perpetrator was all around and nowhere at once.
 

Sam

Two months after I started my internship, my clinical supervisor and I did an intake with Sam, who I was scheduled to see weekly for psychotherapy. In Sam's intake, he volunteered very little about himself. The soft lines around his eyes and mouth told me he was in his mid-30s, and he wore jeans and a flannel shirt. He didn't look at all like the gay men who worked at the clinic, with their pressed button-down shirts and neatly gelled hair, or the preppy Castro-neighborhood dwellers wearing pastel shirts with the collars up, tight designer jeans and Ray-Ban sunglasses. Sam came in carrying a skateboard and a messenger bag. His narrow, stubble-covered face was topped with a mess of light brown hair, and his Levi's seemed to almost fall off his scrawny body.
 
Sam refused to give us his last name, and the stiffness in his body turned to agitation when my supervisor and I asked him about his family history. "I don't understand why you need to know this," he told us, his eyes shifting around the room and his arms crossed tightly in front of his chest. We told him he didn't have to tell us anything he didn't want to—something I would find myself saying to him many times throughout our six months working together. I discovered later that day that he had disclosed more on the intake form than the interview. “The three fractured sentences he wrote under the History section spoke volumes: "Sexually abused as a kid. A lot. Don't know how many times."”
 
I already knew from his intake that Sam would be a challenge to work with. But when Sam told my clinical supervisor that he wanted to have her as his therapist instead of me, I knew I would be in for a rocky ride, and I would have to prove to Sam, despite my inexperience, that I had the clinical expertise to help him. I thought it would be easier to talk to Sam with my supervisor out of the room, and hoped he would feel safer that way since it would be just one—not two—therapists to contend with.
 
We spent the first therapy sessions with me mostly asking questions and him answering. Moments of silence brought his body to shift in his chair and his eyes to stare wide at the door, so I kept the conversation going any way I could. He told me about his boyfriend and the problems they were having. He recalled fits of anger toward his boyfriend that seemed to come from nowhere, and anxiety attacks at bars and parties. But I could see that something much darker and scarier lurked under Sam's surface and controlled his life. He continued to refuse discussion about his family and childhood, and even benign-sounding questions like "Where were you born?" would lead Sam to erect a wall of fear and anxiety between us. "I don't want to talk about it," he would say, his face turning white, his expression cold and serious. "Okay," I nodded, keeping my tone calm and even, and moved the conversation back to the present.
 

Beneath the Surface

The truth is I wasn't calm. I dreaded every session with Sam. I felt inadequate to deal with what lurked under the surface, and felt responsible for the tenseness between us. I had received basic clinical training on working with trauma survivors in school. I knew it was important to move slowly with Sam and not let too much be revealed at once, because the memories of his past could overwhelm him. But I felt like the therapy was moving too slowly, and that I wasn't reaching him at all.
 
Like a lot of new therapists, I was hard on myself. I pushed myself to be the kind of therapist Sam wanted and needed. His case consumed my thoughts: “I fantasized about having a breakthrough moment with him, where he would finally relax into our sessions and open up to me, and I would guide him through reclaiming his painful past with perfect expertise and confidence.” I often spent my entire supervision hour consulting on his case and brought what I had learned into our sessions. I taught Sam practical techniques to get a handle on his anxiety, and new ways to open up discussions with his boyfriend. I was doing the best job I could as his therapist. But the problem was, neither Sam nor I could see this.
 
About a month into his treatment, Sam came into session frustrated and anxious. He and his boyfriend had been fighting all week and were considering breaking up. When my empathic words like, "That sounds really painful," fell short of what he wanted, he turned the conversation to discuss me. He explained to me all the reasons why I was not a good enough psychotherapist: I was too young. I was inexperienced. I didn't look like what therapists are supposed to look like. I had no clinical specialty in trauma. I had no list of degrees. I wasn't a gay man.
 
I didn't know what to do other than take in all that he was saying about me. My face and body remained calm as I mentally halted the oncoming surge of panic, heat and tears about to erupt from my gut. I told him he was entitled to his feelings and opinions. I couldn't refute his accusations because they were, in fact, all true.
 
After he left the clinic, I grabbed my own belongings and sped through the clinic doors as fast as I could. I needed air and it felt as if the clinic itself were choking me. As soon as a cool San Francisco December breeze hit my face, my skin began to crawl and my stomach, arms and legs, and even my blood all felt suddenly, completely wrong. “I felt like there was a monster inside of me, and that I would soon be exposed for who I really was.” I needed to hide, and as I hurried home through the streets of the Mission District, I envisioned myself as a snake, searching for a rock to slither under.
 
Being in this state made me recall something I was currently learning about in my Severe Psychopathology class: the psychoanalytic defense mechanism called projective identification. I thought about how Sam couldn't tolerate his feelings of shame, fear, and disgust, and so was unconsciously transferring them to me. I learned that, ideally, the therapist is supposed to process these emotions to a tolerable state and return them to the patient. But I didn't know what to do with all these feelings; I didn't know how to process them and return them to him. The concept of projective identification gave me a framework to understand what was going on between Sam and me, but did not help me move through this impasse between us. I felt stuck and overwhelmed with his feelings, and unfortunately my defense mechanism of choice—analyzing, diagnosing and intellectualizing the problem—did not bring me peace of mind.
 
During the next few days my behaviors began to resemble the serious psychopathology of Sam and some of my other clients. I was hyper-aware of my surroundings all the time and hated leaving my home. When a friend coaxed me to go with her to a holiday party, I entered the house to find a kitchen full of acquaintances staring at me. “I was convinced they all knew Sam, and Sam had told them about what a terrible therapist I was. My dirty secret was out.”
 
When I peeked down the hallway I saw that the living room was full of more people lounging on couches, leaning against walls and chatting. I heard a mix of voices muddled together and I strained to pull Sam's out of it. I was convinced he was in that room talking to people I knew, even though as far as I was aware, we had no friends in common. It felt wrong for me to be at this party. I feared I would be called out: how dare I go somewhere Sam might be and put him in that terribly awkward position of seeing his therapist—his bad therapist—in public! I gave my friend who brought me there a quick goodbye, slid out of the house without anyone noticing, and hurried back home.
 
Sam couldn't tell me about his past, and about the horrible things that had happened to him. These feelings that were now overwhelming me were all I had to go on, and were the only hints about what he might be struggling with everyday.
 

Fight, Flight or Freeze?

It would be three weeks before I saw Sam again. He and I both left town for the holidays, and it was definitely a welcome break. When our next session approached, I began to panic. "I don't want to see him anymore. We're not a good match. I need another week. I'm not ready!" I told my supervisor in long, desperate attempts to cancel the session. I wanted someone, anyone, to tell me I could end the therapy with him. I wanted to be told that he was abusing me, that I shouldn't take it, and that I was unsafe.
 
My supervisor, professors and colleagues all empathized, but pushed me to continue seeing Sam. "You need to go back in that clinic room with him for you, not him," they told me. "You need to prove to yourself that you aren't going to let him run you down." I cried. I protested, and I fought it to the very end. But ultimately, I knew they were right. And so it brought me to this moment with him, locked in struggle, a wound exposed, and only myself to hold onto.
 
Sam arrived fifteen minutes late to the session, which wasn't unusual for him. I was somewhat surprised he showed at all and wondered, If he thinks I am such a bad therapist, why is he still coming to the sessions? His expression was cold and he refused to make eye contact. He began speaking almost immediately, and recounted a recent sexual experience he had with his boyfriend the night prior. As the story went on, it became quite graphic and disturbing. Sam described feeling pressured into doing something sexual he didn't want to do. He described freezing and not being able to stop it as it was happening. He was crying and I was startled by the sexual details I was hearing. There was something in me that knew that what he was doing—confessing this painful experience to me—was too sudden. My gut, along with words from the textbook on trauma lodged in my brain, were telling me the same thing: this could overload him. But at the same time, another part of me felt relieved that he was opening up to me and trusting me with the story. Was this the breakthrough moment I had been waiting for?
 
Everything moved quickly. Then, before I fully knew what was happening, he turned his face to me. His crying slowed to sniffles, and he squinted as if to focus and find something deep in my eyes. “His chin wrinkled and quivered as he said, "Now I feel like garbage—what are you going to do about it?"”
 
There was no rock for me to climb under. I had to stay there in that moment. And I had to respond.
 
"I wish there were something I could do to make the pain go away, but there isn't. I'm sorry that happened to you, and all I can do is be here with you through it."
 
"Sorry? You're sorry? That's bullshit!" he said, shifting back and forth in his seat, grabbing his hair with one hand and grinding the other one into the arm of the chair. "How can you just sit there and let me feel this way? How can you make me tell you that—make me feel so disgusting—then not do anything about it?"
 
Everything in the room came into micro-focus, and I felt pressed up against it all, like I was trying to push time forward more quickly to get out of the nightmare erupting around me. I thought about the door. I thought about what everyone told me—that I needed to get through this for me. I knew I couldn't make him feel better. I couldn't erase what had happened to him 30 years ago or the night before. I couldn't take away the pain he felt because of it. I couldn't soothe him—he wouldn't have let me even if I tried. “As his anger and accusations continued to fill the room, I repeated the only honest words I knew: "I'm sorry, there's nothing I can say to you right now that's going to make you feel better."”
 
As our 50-minute time slot came to a close, he became silent for a few moments, exhausted, with nothing else to say. Then, as if he had been watching the clock for when the second hand hit the mark, he hastily grabbed his bag, wiped his face and left the office. I didn't want to move, because moving would stir all the feelings inside me that I knew would soon erupt. I felt like I had been run over by a truck—flattened and broken. But I was alive; I could see and feel that much.
 
Finally I had to get up and leave the office because another therapist had reserved the next time slot. I went downstairs to the intern room. June, an intern in her sixties, was there doing paperwork. She read the destruction on my face immediately. "Are you okay?" she asked softly. I exploded into tears, and she wheeled her chair toward me and hugged me. I cried on her shoulder like a child who had just been beat up by a bully, crying to her mother.
 
"What's happening? What's going on?" Her eyebrows lowered, and her tone remained soft and calm, but concerned. June already knew about Sam, and had heard me process my sessions with him in group supervision, so she wasn't surprised when I told her everything that happened in the session, including what Sam said and all my responses to him.
 
"You said that? You said those things?" June perked up.
 
"Yes," I said, expecting criticism. But instead a smile broke across her face.
 
"It sounds like you did the right thing."
 
"I did?" I said, coming out of my sniffles, feeling somewhat pessimistic but more hopeful.
 
"Yeah, I don't know what I would have said . . . I mean, what else could you have said?"
 
"I don't know, but . . ." I trailed off, not knowing the end of my thought.
 
"Seriously," she repeated, "what else could you have done?"
 
I wanted to give her an answer that provided hard evidence against me: an analysis of the conversation that showed where I'd messed up and what I could have said and done differently that would have left Sam, and me, in a better place. I wanted to prove to her that I was not the right woman for the job.
 
"Not be his therapist?" I finally responded, hearing the desperation and uncertainty of my words, and realizing for the first time that I could not stay in this place any longer—needing other people to show me the way, trying to find a way out, and wanting to be someone else.
 
June laughed, threw up her arms and gave me another hug. "You'll be okay," she said. I began to laugh with her, because she was right: I was okay. In that session with Sam, I hadn't tried to escape. I'd stayed with myself, as scary as it was, and it hadn't destroyed me.
 

Truths Revealed

Something shifted in me after that. I felt like I'd won a battle, and I was proud of myself. I was tired of the fear and the self-criticism. I began to see the fruits of my labor with my other clients as they all made progress in their therapy, and I realized that I could be and was a good therapist. I began to see that “being a good therapist was not about being a punching bag or taking on my clients' pain, but about making my clients responsible for their feelings and behaviors.” I was not there to save anyone; I was there to help people help themselves, and even then, only if they would let me.
 
Something changed in Sam, as well. The next week when he came in for his session, he kept his head turned down and looked up at me with wide eyes, half smiling, searching my face again for something, but this time it was approval.
 
"Hey, I'm sorry for the way I acted last week," he said. "I guess I was pretty mean, huh."
 
"Thanks for your apology. I think last week was a challenge for both of us." I paused at this and he continued to look at me with wide eyes, now a little nervous. So I continued, "I have to be honest with you—you have definitely been a challenge for me to work with. I've spent a lot of time thinking about our sessions, and received a lot of guidance from my supervisor, and I think I've done the best I can."
 
"I think so, too . . . but the thing is . . ." I could see Sam searching for his words carefully as his eyes didn't move from one spot on the wall, "I guess I just can't trust you."
 
"Because of my age, level of experience, and stuff?" I replied easily, now feeling confident and relaxed.
 
"Yeah. To me, you're just not who my therapist is supposed to be."
 
"If that's the case, why do you keep coming back to see me?"
 
Sam paused at this and looked at the floor, rubbing the back of his head with his hand. "I don't know. I guess I didn't think I had a choice."
 
"You do have a choice, Sam."
 
"What is it? What's my choice?"
 
"You can continue to see me at this agency, or you can find a different therapist at a different agency."
 
"Like where?"
 
"If you decide that's what you want, I can give you some resources."
 
"Can you call them for me? Or can we call them together?" His leg shook as he spoke.
 
"No, you'll need to set it up yourself. I can't do the work for you."
 
At this he seemed satisfied. He made the decision to find a different therapist, and I followed through on giving him some resources. I realized that, had I been more seasoned and further along in my career as a therapist, things might have turned out differently. Perhaps I would have questioned his assumptions of who his therapist was "supposed to" be, and urged him to stick through it with me. But “as a new therapist, I looked truthfully at my limitations with a dose of self-empathy.” I also relished the huge wave of relief that washed over me after Sam made his decision. And so I felt satisfied with his decision, as well. I was helping him take responsibility for his care, as well as his feelings.
 
Within just a couple of weeks, Sam set up his therapy at an agency that specialized in trauma work. Despite the fact that he had already completed his intake and was about to start seeing a therapist weekly, he told me he wanted to continue our sessions, as well. I told him this wasn't going to be possible, since it is counter-productive to see two individual therapists at the same time. I was also curious about his desire to continue to see me, after all that he had said about me not being able to help him. So I asked him about it:
 
"Sam, why would you want to continue therapy with me since you say you can't trust me, and you have another therapist that you think you will be able to trust more?"
 
"Well . . ." he said, "you have been helpful in some ways."
 
"In what ways?"
 
"Well, like I learned how to be able to notice what happens to me before I have a panic attack, so I can stop them from happening…"
 
I nodded.
 
"And I learned how to talk to my boyfriend when I'm upset instead of letting it build up into an explosion." He looked at me matter-of-factly, like it was not new information, and not strange or surprising for me to hear that I had, in fact, helped him.
 
A part of me was tempted to bring this contradiction to his attention and say something like, "So, who's the inadequate therapist, now?" But I held my tongue. I didn't need to prove myself to him or any other client any longer.
 
Instead I smiled and said, "I'm glad I could help."
 

After the Crash, Moving Forward

“My six-month therapy with Sam, as difficult and painful as it was at times, turned out to be a crash course on becoming a therapist.” It taught me profound lessons about what my role as the therapist was, and how to sit with some of the most difficult material and still hold onto myself.
 
A year later, I saw how I had grown as a therapist from this experience. During a clinical internship in the counseling department of a Bay Area high school, I met with a student, Linda, who was in the acute phase of post-traumatic stress disorder. A few months prior, Linda had been kidnapped and raped on her way home from school. I passionately wanted to help Linda and my heart brimmed with empathy.
 
However, like Sam, Linda rejected my empathy. When I asked her questions, any questions, she would immediately tear and tense up.
 
"Please don't ask me about what happened. Please don't make me talk about it," she sobbed and quivered. Her body folded in on itself as she brought her knees and arms to her chest in the small plastic chair. I immediately thought of Sam.
 
"No one is going to make you talk about it. You can talk about whatever you want."
 
These words, and any other words from me, didn't calm her. In fact, it was clear that, from week to week, her anxiety in my office was getting worse. One week, her fear turned to anger:
 
"You're making me come here and talk to you, and I hate it! I don't want to talk to you! Stop making me talk to you!" Her body shook with fear and her eyes pierced me. I felt her anger come toward me, but I also recognized the fear that encased her body, so I didn't absorb the blame from her accusations.
 
"Linda, no one is making you do anything. You don't have to come to these meetings. It's your choice. I know you are very scared right now and I want to help you."
 
Linda continued to sob, and then, with her eyes to the floor, said in a very soft voice, "I don't want to come here anymore."
 
Linda was not ready to face the horrible demons terrorizing her. I didn't blame myself for this, nor did I take her demons on for her. I refused to cooperate with Linda's projection of me as the bad guy and helped empower her to take responsibility for what she was feeling.
 
I also knew how badly she needed help. So I asked her for one final request: could I speak to her and her mother together? Linda agreed, and I set up a meeting. Her mother poured her heart out to me about how sad she felt for her daughter, and the two of them cried and held each other together in my office. I explained to them both the symptoms and ramifications of PTSD. While Linda's eyes shifted around the room as if her mind was somewhere else, her mother listened closely to my urge to get her daughter help.
 
I left it up to Linda to contact me if she wanted to see me again, with or without her mother. I knew this would be the only way she would feel an ounce of safety in my office. However, I never heard from her again. “This time I knew that even the most skilled therapist in the world can't help someone if they don't want to be helped.” And I felt peace of mind knowing that I did all I could do: reach a safe, confident and competent hand out to Linda.
 

The Hard Way

Nothing I learned in any of my graduate classes could have prepared me for the emotional experience of being a new therapist. As they say, it is one of those things a person has to learn the hard way. Many of the difficult emotions I felt were due to a complex combination of my clients' and my own personal experiences in the world. But the self-doubt and fear were universal and part of the first developmental phase of becoming a therapist. True confidence comes with time and experience, and will only come when we dare to test ourselves and allow our clients to move us in profound ways.
 
*All names and identifying information of the clients and psychotherapists have been changed to protect confidentiality.

Family Therapy with Families Facing Catastrophic Illness: Building Internal and External Resources

Posted on by rezendevknowfully.com

Ten years ago my late husband Ronald William Pulleyblank, with the help of his doctor and with a small group of witnesses, had his ventilator turned off, after living on it for seven years. Those years and the ones since then have radically affected my life and my work as a psychologist. Ten years after his death, twenty-five family and friends dedicated a redwood tree in Ron's name. In this beautiful event, after so long, we were able to place his illness and death back in what Lawrence Langer calls chronological time.

Langer, in his book, The Holocaust, distinguishes between two kinds of time: chronological time and durational time. He says that we expect a life in chronological time, made up of a past, present and future. When crises become the norm of life, durational time sets in. This is time without past or future and with a recurring experience of a disturbing present that is difficult to organize, express or forget. Langer writes that because durational time cannot overflow the blocked reservoir of its own moment it never enters what we usually experience as the stream of time. Often we and the people around us expect our grief to last for a prescribed length of time. Depending on the level of stress during an illness, this experience can last for much longer than we would expect. This assumption and others often need to be challenged, if patients and families are to find ways to live with significant illness.

 

Challenged Assumptions, Dilemmas, Necessary Conversation

1. Assumption: We each are responsible for ourselves and must make decisions for ourselves.
 
The Dilemma: A particular illness belongs to the patient. How the patient perceives this illness often determines the decisions he or she wishes to make. At the same time the perception of the illness is often quite different for family members who are responsible for the patient's care.
 
An example: Harry, who is very ill, continues to want to drive his children to school. His wife fears that his illness makes it unsafe.
 
Necessary conversations: The couple has to reassess which decisions are independent decisions and which must now be mutual. The roles and the responsibilities in their household also must be reassessed. These conversations need to include the multiple perspectives of all family members and sometimes those of extended family, caregivers and the norms of the community in which they live. The tendency to focus on the needs of the patient over the needs of caregivers and family members often must be challenged.
 
Note: Who participates in these conversations, and in fact in all conversations, often depends upon cultural values and beliefs. Before developing a treatment plan, an assessment with the family of how decisions are to be made is essential.
 

Positive Choices

2. Assumption: There are always positive choices to make, actions to take.
 
Dilemma: Often outcomes about the course of an illness are unknown. Tolerating ambiguity is a prerequisite for making decisions.
 
Example: A patient has fast-growing prostate cancer. He has the choice of following a usual course of treatment with mixed outcomes or an experimental treatment with little or no clear outcome data.
 
Necessary Conversations: Family members work to increase their tolerance of stressful emotional states due to ambiguity. They examine strategies and past experience that may help them tolerate the unknown.
 

Family Resources

3. Assumption: We often hold the belief that each family should and can provide for ill family members.
 
Dilemma: Due to the complexity of treatment and duration of treatment, there is often too much stress on family resources. This can overload the system and make it impossible for one family to provide physical, emotional, spiritual, social and financial resources adequate for all family members.
 
Examples: There is an extremely high divorce rate in families with long-term illnesses and also a high illness rate in other family members.
 
Necessary Conversations: The family explores how to build a community of support. With this support they learn ways to advocating for the needs of all family members in the family and in the wider community vs. over-relying on already overwhelmed family resources.

Maintaining Life

4. Assumption: It is the job of the medical establishment to maintain life.
 
Dilemma: Though this is a central tenet of medical practice, maintaining care is not the direct responsibility of the medical world. Separation between medical decisions in emergency rooms and the implications for life following these decisions can lead to patients being kept alive beyond their capacity to enjoy life and the capacity of their families to sustain them. As part of this dilemma, there is a medical process in place to save lives, but often no ethical process in place that offers the patient and family members a voice in deciding when enough is or is not enough. In addition to life-threatening issues, realistic care plans that take into account family resources need to be part of the medical treatment plan.
 
Necessary Conversations: Family discussions before there is an emergency about how decisions ought to be made can be very helpful. Though health-care directives are useful in this regard, they need to be re-assessed as the situation changes. Convening multiple systems that impact family life so that there is a shared understanding of what is possible and what are the wishes of the family will sometimes address issues of fragmentation that lead to unwanted decisions. Integration of services also adds to the possibilities that families have of accessing needed resources.
 

Treatment Principles

Underlying these conversations are the principles of therapy, or the backdrop of any engagement in the treatment process described below:
 
Shared human experience: No one avoids illness and death. It is an experience that bridges, by its very nature, the therapist/client relationship; therefore our capacity to be seen is crucial in entering the often lonely experience of illness and death.
 
Spiritual Practice: Thinking of the therapy room or someone's home as a sacred space. Evoking the strength of prayer, meditation, not being afraid to ask for help in facing the unknown. Starting with silence, leaving time for meditation ending with silence. Sharing one's own spiritual practice and prayer.
 
A Narrative Overlay: Arthur Frank, in his article about illness and deep listening, describes three different kinds of stories related to serious illness. They are: Restitution Stories in which there is a positive resolution (this kind is a favorite of us therapists), Chaos Stories in which things remain ambiguous (our least favorite kind), and Quest Stories in which the exploration of the unknown is a goal of the therapy.
 
Social Activism: Patients are often marginalized. They are a group fighting not to be silenced, and part of the therapy is advocating with them for their rights.
 

Examples of Treatment Issues at Different Stages of Illness

At diagnosis: Keeping things the same—a wish not to tell. A man 77 years old is diagnosed with fast-growing prostate cancer. He is experiencing a profound sense of disbelief because, though he has been having difficulty with urination, he has been told over the last three years that this is normal. He's also been told that if he does have prostate cancer it is most likely to be slow moving and he will die of something else. No tests are done until very recently, when it is discovered that the cancer is fast-moving and advanced. While he is dealing with this disbelief, he has at the same time to decide about whether or not to choose the conventional treatment or an experimental treatment, and where to get treatment. His children are scattered. His wife is highly anxious and wants a decision to be made immediately. He wants to go slowly, still focused on his disbelief that the doctors he had had faith in seemed to have made a mistake in his case. His focus is on keeping things the same. His wife's focus is on fixing things. Slowly his adult children, who up until this time have never participated in their parents' decision-making process, join their parents in making a decision—the best decision that they can make, but still a decision with uncertainty. In this family, this has a surprising enlivening effect as if everyone knows that they don't know what will happen, and so they reach out to each other and build on the strengths of their relationships.
 
Note: There are many reasons for patients and families to wish not to speak of illness. It often creates a sense of isolation as one is seen as different. It can be seen as weakening. Around particular illnesses there are many fears and judgments. Communicating about illness can have negative effects on employment and parenting responsibilities. Understanding the reasons that people avoid talking about the illness can help the therapist work with the unique timing and pace issues within each family.
 

Ongoing Crises: Living with Ambiguity

In another family that I am working with, the father, age 50, has fast-advancing ALS. He cannot communicate except with a raise of his eyebrow. Though he has decided not to go on a ventilator, there are many caregivers, involved and the ALS Center continues to try to find ways to relieve his symptoms. His mood vacillates between passive acceptance and depression. He is on antidepressants. His wife is overwhelmed. She is angry that everyone keeps expecting her to do more. She cannot sleep at night. One daughter has begun her first year at college; another daughter is away at a boarding school. We meet together as a family. Each family member has extraordinary pressing needs that seem to conflict with each other. We have a series of conversations in which the grief that is the strongest shared experience is brought into their conversation with each other. With this shared experience, sorting out who needs what, who else might help, becomes clearer, though this is a good example of an ongoing chaos story that has no good ending in sight. Sometimes even taking the time for therapy feels like a burden since there are so many people providing different services.
 

Death and Dying: Letting Go

Sometimes people can make a conscious choice to die, as Ron did in turning off his ventilator. It took many months for him to make this decision. We had conversations with family members, ethicists, psychotherapists and spiritual teachers. Once he decided to turn off the ventilator off, he went through the process of saying goodbye to the important people in his life, even though he could barely speak. More often death is not planned, but sudden, and often a crisis. Inviting families to include conversations about death and dying can be helpful, but often patients resist this fiercely as they hold onto life. Sometimes these conversations work better not all together but separately, with different family members at first and then leading to a wider discussion. When families with adult children come back together as a family often old hurts reappear. These need to be addressed and everyone needs some time to catch up with each other in order to move forward together. Families with younger children have to match conversations about death and dying with the age of each child.
 

After Death: Going Forward

As I said at the beginning, many issues of distress last much longer than people expect. Careful assessment is often needed. Different family members have different responses. When working with children in particular, it is sometimes difficult to sort out what is PTSD and what is grief. If supported in these differences, family members and the family as a whole often mobilizes new resources to transform itself.
 

Summary of Suggested Therapeutic Practices

Diagnosis 
Dilemma: Maintaining the familiar with radical change
  1. Providing a safe container for the expression of intense shock and disbelief.
  2. Facilitating conversations about the diagnosis with children and extended family members.
  3. Bearing with the family the ambiguity of not-knowing the outcome.
  4. Searching for ways to maintain the normal everyday of life, especially for children.
  5. Shifting anxiety about not knowing to finding out information from others.
  6. Discussing ways that other family members and/or friends can participate in the crisis.
  7. Helping families make and/or face medical decisions and prepare questions for meetings with doctors.
  8. Advocating for families in their dialogues with medical and insurance systems.
Ongoing Crises 
Dilemma: Sustaining hope with continuing loss
  1. Normalizing a distorted sense of time and feelings of anxiety and depression as predictable responses to ongoing crises.
  2. Including your experiences with catastrophic illness and death.
  3. Paying attention for and treating overwhelming depression or anxiety in the patient and family members.
  4. Facilitating conversations about the meanings of illness and death in the family and in the wider social context.
  5. Searching out underlying values, beliefs and family history that have led to these meanings.
  6. Looking for stories and practices in the family and in the wider culture that offer other possible meanings and responses to illness and death.
  7. Bearing and talking about the ongoing pain with the patient and the family as they witness the illness worsen.
  8. Finding creative ways for the family to spend good times together within their limited circumstances.
  9. Allowing for the different experiences and needs of the patient and family members.
  10. Facilitating dialogues and planning that take into account these differences.
  11. Convening a wider circle of friends and family to facilitate ongoing support networks.
  12. Bringing nursing, medical, spiritual and social service providers together with the family to assess ongoing needs and to provide coordinated services.
Conscious death and dying 
Dilemma: Knowing the unknowable
  1. Providing openings for conversations about death and dying.
  2. Tolerating and experiencing intense grief with family members.
  3. Exploring beliefs, meanings and family stories about death and dying.
  4. Participating with families in discussions about the economic, ethical, social and spiritual implications of life support systems.
  5. Offering opportunities for friends, family members and spiritual teachers to participate in these conversations.
  6. Discussing desired rituals and practices in preparation for dying and death.

Bibliography

Boss, P. (1999). Ambiguous Loss. Cambridge, Massachusetts: Harvard University
Frank, A. (1998). "Just Listening: Narrative and Deep Illness", Families, Systems & Health. Vol. 18, No. 3.
Hanh, T.N. (1975). The Miracle of Mindfulness. New York: Beacon.
Johnson, F. (1996). Geography of the Heart. New York: Scribner.
Kuhl, D. (2002). What Dying People Want. New York: Public Affairs/Perseus Books.
Langer, L. (1975) The Holocaust. New Haven: Yale University
Levine, S. (1987). Healing into Life and Death. New York: Anchor.
Lewis, C.S (1976). A Grief Observed. New York: Bantam.
Polin, I. (1994). Taking Charge: How to Master Common Fears of Long-Term Illness. New York: Times Books
McDaniel, S. & Campbell, T. (1997). "Training Health Professionals to Collaborate", Families, Systems and Health. Vol 15, No. 4.
Pulleyblank, E. "Hard Lessons." The Family Therapy Networker. January.
Pulleyblank, E. (2000). "Sending Out the Call: Community as a Source of Healing, Families Systems and Health. Vol.17, No.4.
Pulleyblank Coffey (2003). "The Symptom is Stillness: Living with and Dying from ALS, A Progressive Neurological Disease." Chapter in: End of Life Care, Berzoff, J. & Silverman, P (eds.) New York: Columbia University Press (in press). **
Quill, T. (2002). Caring for Patients at the End of Life. New York: Oxford Press.
Rolland, J. (1994). Families, Illness and Disability: An Integrative Treatment Model. New York: Basic Books.
Spiegel, D. (1993). Living Beyond Limits. New York: Fawcett Columbine.
Staton, J., Shuy, R., Byock, I. (2002). A Few Months to Live. Washington D.C.: Georgetown University Press.
 
**Copy of chapter available from author. Contact at: epulleybl@aol.com.

Shades of Gray: When a therapist and her client are survivors of child abuse

Posted on by rezendevknowfully.com

Not a case to wow you with

This story is about humanness, grayness, and uncertainty in practicing psychotherapy. It's not about the times I've wowed a client with my perceptiveness and incisive interpretations. Neither will I focus on times when I've made a clear misstep, like mixing up two clients' stories. This is about intentionally making an imperfect decision to accept a college student as a client who was suffering from the effects of severe childhood sexual and physical abuse, while I at the same time was dealing with my own similar past. In the case I will present, it later became clear that Callie was living with significant dissociation and identity confusion.

My decision to work with her was based partly on the difficulty of finding a better alternative. But I can now say, in retrospect, that underlying this decision was my own difficulty in acknowledging the power of my past and the strength of my defenses. In the end, did I make the right decision? I must admit the results were mixed. Like a swirling mixture of white paint with distinct flecks of black, a picture emerges for me that now, from the distance of time, reads as gray.

I've seen many times over (on both sides of the couch) this insidious grayness seeping into therapeutic relationships. My first therapist took a position that suddenly put him in frequent contact with all my peers in my graduate program—the very people I had been talking to him about. His decisions and handling of the matter brought about multiple problems involving boundaries, trust and our alliance which were painful for me and ultimately interfered in our relationship and the work.

I, too, have found that in my current position, working at a counseling center in a small, rural university, unavoidable boundary questions pop up regularly. “Do I allow a client to join a student project I'm running at the university? Do I attempt to prevent a former client from later working as a graduate assistant at our center?” When I present to a class, will clients be in the audience? I imagine most therapists unwittingly find themselves in uncertain ethical waters from time to time and that guidelines for dealing with such matters offer no off-the-shelf solutions. Instead, they must be worked through taking into account the people involved and the risks and benefits of the available options.

In this article I will examine just one type of ethical dilemma, but one that any therapist with a traumatic past must face: “When are we far enough down the path of our own healing that we can safely go back and help someone else along?” To what extent are we actually in a better position to help our fellow survivors because we can relate to their pain and have a burning desire to help them? Or are we so familiar with the client's pain that it triggers our own pain and the ensuing defenses? Or is it a little of both, and if so, what then?

Tragic life story

Callie1 first became known to me through Ella, an experienced counselor I was supervising during her doctoral internship at our center. Callie was a plucky woman in her early twenties who was referred by one of her professors. His class was working on a project that had sexual abuse as its theme, and the professor sensed from Callie's reaction that it was raising some emotional issues for her. At first, Callie denied any emotional difficulty with the project. But this stoicism proved to be a thin veneer covering a deeply wounded individual. Her life story, as she related it over the course of one and a half years of treatment with Ella and me, was the most tragic I have heard.

Callie was bounced from caretaker to caretaker from the time she was six months old until she was eight years old. At four years old, she was repeatedly sexually abused by her mother's boyfriend, causing permanent damage to her uterus. The perpetrator went to jail. Her mother, who knew about the abuse and didn't prevent it, also abused her both physically and emotionally. Indeed, Callie recalled how on her fifth birthday her mother had taken away an unopened present she had bought for her because Callie had let child protective workers into the house. Callie recalled other punishments, such as being burned with cigarettes and being locked in a room for a week.

One of the most horrific abuses occurred after a teacher told her mother that Callie preferred to write with her left hand, but should be encouraged to use her right hand. “Her mother brought Callie outside and told her to hold her left hand behind the tire of their car while she drove over it, crushing the bones.” Verbal abuse included her mother calling her vulgar names and telling her that she had never wanted Callie, and in fact hated her.

Callie was also abused by another of her mother's boyfriends. Over the years, he broke approximately eight of her bones. Once he dropped her head-first off a balcony. After the injuries, she was driven to far-away hospitals so that no one would suspect abuse.

In therapy with Ella, Callie reported that she experienced recurring depression with occasional suicidal thoughts. She had been cutting herself off and on for about seven years. Significantly, she also stated she felt different than others. This hint at identity problems would prove to be a huge understatement.

Introducing Stacie

Callie let Ella know that she trusted her, and opened up to her about these very painful past and present difficulties. “In her tenth session, Callie arrived in fancier clothes and, to Ella's surprise, referred to herself as "Stacie."” Rather than question it, Ella decided to "go with it." Realizing this as an opportunity to understand a normally hidden part of Callie, Ella asked Stacie questions about herself. Stacie, she said, protects Callie. Stacie saw herself as different from Callie. For instance, Callie didn't like her live-in boyfriend, but Stacie did and worked to keep him around. Stacie showed up again the next session. She stated that she first appeared on the scene when Callie had been sexually abused at age four. In Stacie's mind, Stacie herself was never abused. In fact, she didn't even have the same mother or last name as Callie. Stacie asked Ella not to mention her existence to Callie because Callie would "freak" if she knew about her.

Ella agreed to this request, but disclosed in supervision that she was not sure if this was the right decision or not. We discussed Callie's ultimate need to know about Stacie, but decided not to push the issue at that time. We wanted to give Stacie a chance to express herself without fear of overwhelming Callie.

It was Callie who showed up for the following session. Although she talked of forgetfulness, she didn't see it as a real problem. “If she saw books around her apartment that she didn't recognize, she would simply think to herself, "I must have bought them."”

Ella's internship was coming to an end, and the termination with Callie was not a smooth one. Two months before Ella's departure, Callie called her in crisis. Walking to her off-campus apartment the night before, Callie had been raped by a stranger. For many subsequent weeks, Callie naturally felt terrified, and would sometimes even hide in her closet at night. Although she continued to present herself as Callie during these sessions, during one session she said she felt like a child, and during another she described feeling like she was in a dollhouse with others controlling her. Her depression and cutting behaviors increased, and she hinted at feeling suicidal. Ella spent the last sessions continuing to help Callie cope with the rape, and processing her sadness about friends graduating and their therapeutic relationship ending.

Unspeakable, unthinkable and unknowable

The decision about where Callie should be seen next for therapy was not taken lightly. Ella suggested the possibility that I take her on as my client. This option made sense for several reasons: I had supervised Ella over the previous six months, so I was familiar with the case; Callie did not have transportation, money or insurance, so a workable off-campus referral would have been difficult to arrange; and, with Callie's permission, I would be able to continue consulting with Ella while working with Callie. While a referral to another therapist in our center would normally be a possibility, our center only employs one other psychologist. Callie had expressed fear of the other psychologist because she looks similar to her mother. The reasons for me to see Callie were stacking up, but the idea made me anxious.

This is where my own past enters in. Like Callie, I was sexually abused as a young child on multiple occasions. For me, it was by my father. Here, the "un" words best describe my reaction: The terror was unspeakable. The sinking feeling I felt upon realizing that my own father was capable of hurting me in that way was unthinkable. In fact, the whole experience was unknowable. It was too much to take in, too much to remember. A severing process began taking place in my brain. I now believe I would actually forget the abuse between episodes. But when the circumstances that led to abuse would recur, I would remember. In my child mind I would plan how to keep myself safe. Unfortunately, my army of stuffed toys, oversized nightgown, and tucked-in pajama shirt were surprisingly poor defenses. This thing that was too much to know would happen again. By middle school, I feared I was becoming insane because I spent so much time out of my body and things felt unreal. For instance, I would be engaged with others at school and then suddenly feel as if my connection to both myself (my identity, body and past) and my surroundings had been severed. I felt more like a consciousness than a person. I would try to behave as normally as possible until the episode passed, but it was hard.

Today, I function well. I have come a long way through my own psychotherapy. In fact, it's easy to be lulled into a sense of having made it, having survived and moved on. Occasionally, something will trigger my memories, and my defenses will rush to the rescue, warping my sense of time, place, and self. It's hard to process information at those times, which I suppose is the point of dissociation. But that state is transient and I understand it. That said, I do sometimes wonder if what seems normal to me, like episodes of dissociation, may be more abnormal than I can appreciate.

At first, I declined to take on Callie as a client, but offered to meet with her temporarily while we worked out a more appropriate referral. Soon after termination with Ella, Callie cut herself deeply enough to require hospitalization. She did not remember making the cuts. I realized that, ideally, Callie should receive treatment from an agency that had emergency back-up and a specialist in Dissociative Identity Disorder (DID). I referred her to a crime victim's center in the nearest town that specializes in trauma treatment. However, I was surprised to find that the therapist assigned to Callie was less qualified to take her on than I was. In fact, I learned that no one at the agency had experience working with DID. Although the nearest city had appropriate referrals, it was an hour and a half away.

Soon after her release from the hospital, Callie cut herself again, and was again hospitalized. Like the last time, she did not remember making the cuts. As the only therapist currently connected with her, and with an obligation to manage our students' mental health crises, I continued seeing her for crisis management.

Entering the grayness

Over these sessions, I started gaining confidence in my ability to meet with Callie. I felt like my interventions were helpful. I revisited the idea of taking her on myself. I considered the facts: By default and necessity, I had already established a therapeutic alliance with Callie; I had an understanding of her past and current difficulties; I was knowledgeable about the psychological effects of childhood trauma; and I wanted to help her. I decided to take the plunge. I offered Callie regular psychotherapy sessions and she agreed. I looked into the possibility of consulting with a DID specialist for supervision over the phone and was able to set this up. I assured myself that if I ran into personal problems doing this work, I would process them with this DID supervisor or with my informal peer supervision group. I would like to announce that I opened up and worked through my past fully in this case, but in reality, I never found the courage to do this. Although I discussed my work with Callie, along with my less-private reactions toward her, I avoided anything that had to do with my own abuse. The anxiety that would get triggered when I contemplated bringing up my past felt insurmountable.

Callie was open and disclosing with me but also seemed a bit distant. I wondered if she was reacting to my own sense of uneasiness. I was aware of an internal sensation of steeling myself when she talked. I wanted to be receptive to her, but I could feel that I was also being self-protective. I was slightly unnatural with Callie, always trying to work against my instincts to defend myself.

Nonetheless, we were making progress. “At the suggestion of my supervisor, I began to talk to Callie about her alters.” She was resistant, so I proceeded cautiously. She admitted that her boyfriend would tell her that she was other people sometimes. He told her that she would occasionally drink from a baby bottle. When he would report on her strange behaviors, she would cover her ears and start humming. She also disclosed that she stopped reading her journal because she would read things she didn't remember writing, such as entries about her mother, but from a younger perspective. At times, she would get fuzzy in session and dissociate. She would say that she did not feel she was fully in her body. We would stop and do grounding work.

One evening I received a crisis call from Callie. Her boyfriend told her she had just pulled a knife on him in a threatening manner. Despite her objections, I called an ambulance to pick her up so she could be evaluated at a hospital. She did not remember this incident either, and I suspected involvement of the alters. In fact, there was accumulating evidence that the alters were "out" quite a bit of the time.
 


A gift to the therapist from Stacie upon termination of therapy.
This painting depicts Callie and the alters in front of the house in which they live.

A turning point in our sessions came when, again at the suggestion of my supervisor, I asked Callie, "Is there a Stacie there?" She paused. She said that she would find things with the name Stacie around her apartment. Also, her foster mother had given her a red-haired doll named Stacy, and she had always liked that name. I explained she had presented herself as Stacie to Ella.

The next session, Callie showed up looking differently. She wore make-up, fancier clothes and smiled a lot. I asked if she was Callie. She said, "No, I'm Stacie." For the rest of the school year, until Callie graduated, I would see Stacie often. Stacie knew all about the others.

“In all, Stacie told me about all 11 different parts or alters, including herself and Callie, ranging in age from 4 to 22” (Callie's age). In Stacie's mind, they all lived in a house where they each had their own room. In addition to Stacie, I also saw the four-year-old, Tracy, who missed her "mother" (actually, Callie's elderly relative who took care of her for several years). Jenna, who was sad, angry, and wanted to die, presented herself as well. Jenna called one day to tell me that her ribs hurt and she didn't understand why no one would take her to the hospital.

By the time of graduation, evidence of improvement came when Stacie started whispering things to Callie. Callie was apprehensive, but also intrigued at the prospect of getting in touch with another part of herself.

The silver lining

As we came to the end of the school year and were facing termination due to Callie's graduation, we talked about our relationship. She told me that she liked me and that I was one of only five people she trusted. However, she also disclosed her initial reactions to me that confirmed some of my fears. “She said that in our early sessions she felt I didn't like her because I tend to sit back in my chair and talk in the lower range of my natural voice.” She initially reacted to this, she said, by not liking me either, so she wouldn't get hurt. Also, she said that she did not find me as warm and open as Ella. However, she reported that her feelings changed over time and she grew to like and trust me. Because this feedback was different than any of the feedback I've received over the years, I assume that I was, indeed, somehow different with Callie.

Those words were hard to hear, but they also gave me a great opportunity. Callie had some borderline tendencies, and not surprisingly, in her relationships with others, she tended to split. I pointed out that she seemed to put people into two camps: perfect people who she saw as her saviors, and others who she viewed as "all bad." She immediately accepted this observation, and added that saviors who fail her fall right down into the "all bad" category. I told her that I hoped that our relationship helped her to see that there's actually gray in the world. I had my imperfections, but she had found that she could still like me, trust me, and connect to me overall.

And so, out of the gray imperfect mismatching of a wounded therapist with a wounded client, came a lesson that I hope has staying power for Callie. Sometimes gray is what we get, and sometimes gray is enough.

I will never know if I made the right decision in accepting Callie as a client. Healing from early trauma is a process with no definite end point. I do know that the timing was not ideal. I had not fully appreciated the power of my past, and was too ashamed and avoidant to seek out more intensive supervision when I suspected it was interfering. Indeed, based on my experience in working with Callie, I have become even more convinced of the value for therapists who are survivors to explore their past in supervision when working with client survivors. When ready to do this, I believe he or she will be in a more powerful position to help his or her fellow survivors.

Perhaps most therapists are never fully trained or completely ready to work with such overwhelming stories of child abuse, but certainly getting extra support for myself would have eased the burden. Perhaps if I had disclosed to my supervisor my concerns about taking on Callie due to my own past, she could have helped me talk through the pros and cons and we could have made a decision together. If we decided that I should go ahead and work with Callie, which I suspect would have been the case, I would have felt supported and therefore more confident in my decision. I believe this would have made me more confident in sessions with Callie.

Mostly though, I simply needed to express to someone the emotional hurt I felt—for the both of us—when Callie talked about the abuse and her longing for a loving parent. Her therapy was emotionally difficult for me, as well as for her. With more support, I believe I could have been less self-protective and more open to her pain.

It's been a year since Callie graduated from college. She has contacted me sporadically over the course of the year. After graduating, she moved away to live and work in the post-academic world—a heroic but ultimately shaky endeavor. She had searched for a therapist in her new city, but no one would take her on due to liability concerns. At her new job, coworkers began telling her that she seemed like different people at different times. Her thoughts turned to suicide. She moved back to her college town and was taken in by a middle-aged couple who had helped her through her college years.

By coincidence, after not hearing from Callie in months, I ran into Stacie last week. Smiling and radiant, she gave me a big hug. Her hair color had changed since I last saw her; she had added a reddish hue. She said she had dyed it on impulse the night before. I thought of her beloved Stacy doll. I wondered what Callie would think of it.

Thunderclouds, weapons and armor

Gray is the color of thunderclouds, weapons, and armor. We often use the word gray to describe situations of uncertainty. A blending of black and white, it represents a mixture of good and bad, right and wrong, danger and safety. It's harder to take a stand on gray areas. It's often not clear if we should turn back or soldier on. Ironically, gray is also a red flag. It warns us that if we decide to soldier on, we must go forward with humility and support, things which could have helped me to face myself more fully as a person and as a therapist. Whereas the basic supervision and consultation I received was quite invaluable, I was often left adrift and rudderless without the support and resources that I wish I would have engaged.

Just as Callie struggled to understand the gray areas in life, so did I. Gray is not something we choose, but so often something we get anyway. Gray was what I gave to Callie. I hope it was enough.

In such moments of hope paired with self-doubt, I remind myself what I told Callie: Sometimes we must accept a level of disappointment in order to take in the positives. We are called to accept our limitations, and do what we can do, even with the messiness and inherent contradictions life offers us. On one hand, my own childhood trauma offered me a way to understand and connect to Callie and her house full of alters; on the other, it kept me from being fully present with myself and Callie.

“Grayness is real, so running from it does little for those like Callie or for our own growth as therapists and human beings.” Perhaps in the meeting of my grayness with hers, some meaningful realness was forged that can sustain her in the roughest of times. Remembering that gray truth helps to sustain me, as well.

Notes

1 Names are changed to pseudonyms throughout the article, including the author.

Psychotherapy Isn’t What You Think: Bringing the Psychotherapeutic Engagement into the Living Moment

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Prologue

Psychotherapy isn't what you think. It isn't a healing of an illness. It isn't guidance from a wise counselor. It isn't the mutual sharing of good friends. It isn't learning esoteric knowledge. It isn't being shown the error of one's ways. It isn't finding a new religion. Psychotherapy isn't what you think.

Psychotherapy is not what you think. It surprises many people because it is not primarily about your childhood . . . or about what has hurt or traumatized you . . . or about the germs in your body . . . or about destructive habits you've acquired . . . or about negative attitudes you carry . . . .

Psychotherapy is not what you think. It is about how you think. It calls attention to unrecognized assumptions in how you think. It makes a distinction between what you think about and how you do that thinking. It is less concerned with looking for causes to explain what you do and more concerned with discovering patterns in the meanings you make of what you're doing.

Psychotherapy is about how you think. It is about how you live with your emotions. It is about the perspectives you bring to relating with the people who matter to you. It is about what you aspire to in your life and how you may unwittingly make it harder for yourself to reach those goals. It is about being helped to see that the change you seek is already latent within you. It is coming to recognize and appreciate the spark of something eternal that is your core.

Psychotherapy is not what you think; it is about how you live with yourself right now.

Psychotherapy Freshens How We Perceive Our Living

. . . It is appropriate to take several steps back in order to view in broader perspective what it is that is the focus of our concern. When we do so we are demonstrating the very theme we are expressing: Life is lived as a perceptual experience. How we "see" or define our own nature and the nature of the world in which we find ourselves is a crucial element in determining what our lives will mean to us and to those with whom we share this epoch of living.

The opportunity, necessity, and challenge of living is that each of us must create and live out a life. Ultimately this is an individual responsibility—even though that often may not seem to be the case. Many influences press us to disavow or, at least, to try to delegate this responsibility.

Recognition of this basic life truth of our ultimate self-responsibility is sometimes misunderstood as a kind of "blaming the victim" philosophy and in other instances is thought to be an absurd "Pollyannaism" which promises that anyone can do anything if only he will set his mind to it. Of course, neither of these is sensible, and certainly neither is accepted by the stance here presented.

It is obviously and irrevocably true that we live in a multifaceted reality which profoundly affects what we experience and what opportunities and obstacles we encounter in carrying out this basic responsibility for our lives.

When and where one is born, whether female or male, healthy or ailing, intelligent or of limited potential, into what sort of family, society, and times; and much else influence our lives' courses. Yet each of these factors—and the many others, including some of which we are only partially aware—open out into further arrays.

Literature, both popular and technical, provides many accounts of individuals who overcame crippling environmental and chance-inflicted handicaps to live rich and contributing lives. To be sure, often such stories also recognize how exceptional native talents were called into action and in turn facilitated the exceptional outcomes. But it would be naive to attempt to so dismiss all such instances as simply products of random gene combinations. Indeed there is the real possibility that the exceptional talents were in some measure the products of human will as it confronted those very handicaps.

Candidly, almost any of us who soberly examines his own history is likely to discover occasions on which he failed to use his powers effectively and other times when he stretched to go beyond what were his usual life patterns. Popular idiom says it, "If life hands you a lemon, make lemonade."

Yet by no means does this homily assure a happy ever-after outcome. We simply don't know the stories of unnumbered men and women of great potential who were overwhelmed by circumstances and never realized their potential.

The Therapist's Mission

Our work, as we view it in this book, is to engage with the client's way of grappling with his life, or in other words, with the patterns through which the client seeks to be safe, fulfilled, in relation. "To engage" not to learn about them; "engage" signals a more experiential process. That, in turn, implies that the therapist cannot simply be a detached observer but needs lived experience of how her client grapples with her life.

Those patterns constitute the client's implicit conception of his own nature, powers, vulnerabilities, and all else that is implicit in his way of experiencing his own being and employing his powers in life—i.e., the client's self-and-world construct system as it is structured to deal with possibilities, hazards, resources, and much more.

What underlies this stance is the recognition that the self is always defined in terms of its interaction with the environing world, and the world is always perceived in terms of its actual or potential effects on the self.

Another aspect of this conception needs to be made explicit: We are speaking here of perceptions, of how the self and its attributes and the world and its many aspects are perceived. Of course, perception here does not mean only visual or even sensory perceptions as independent existents. Although the sensory facets of our perceptions may prove of great importance at times, they always do so in larger contexts.

We live in a perceptual world—that is, in the world which our perception reveals. As we experience our lives we form percepts about this world's elements and aspects. These become de facto definitions, and rightly or wrongly they do much to determine how we will relate to that which they name.

Is the world a safe place? Can a woman deal with this kind of problem as well as would a man? How will this art authority respond to my paintings? Must I cultivate the big shots to get promoted in my job or will doing a good job be enough?

The Omnipresence of Death

The disease which results in 100-percent fatalities is called "Life." Life is lived between the brackets of birth and death, and that very stark reality subtly or openly affects much that we think and do. In earlier years we implicitly claim immortality, but even then the shadow falls from time to time. As we age, that warning is more frequent and demanding.

Death accompanies life day by day, moment by moment. It isn't an event that will occur in the future; it is an actuality in each moment now. Each moment's life lives on the dead corpse of the previous moment. My lover today dies in tomorrow's kiss.

Recognizing this, anticipation, apprehension, remembrance, and regret are appropriate but not if they obscure what is in this present moment. The very fact of ending can give vitality to that which is in fact now and therefore in some measure accessible, and it counsels action rather than delay.

Psychotherapists need to be aware—and to help their clients be aware—that the resistance is an attempt to delay the death of possibilities. Becoming genuinely aware of that inexorable fact may impel one to claim the life of what is immediately possible and avoid the death of inaction.

Searching is the life force (chi) being its own nature. Case formulations can so easily become like butterflies impaled on pins and put in display cases.

Psychotherapy and Changing

It is time to try to bring together the chief elements of the existential-humanistic perspective on life-changing psychotherapy, as I envision it. Other psychotherapists will, of course, have points of difference, and that is as it should be. We are considering an art form, and by its very nature, all art is not to be captured by any one artist. Thus each person must, perforce, produce a masterwork, and no explanations can ease that responsibility.

Effective Ingredients in Psychotherapeutic Change

To begin with a synoptic statement of this existential-humanistic perspective: Essentially and experientially, life is subjective awareness. Without awareness, we are not truly alive. The conditions for which we seek therapy (e.g., anxiety, impulse control, meaninglessness in life, difficulties in relationships) may usefully be thought of as likely to be the products of shrunken and distorted ways of being aware—that is, of being alive.

The range and depth of our awareness constitute the settings of our self-and-world construct systems. When that system is too confining or too poorly corresponding with the consensual world view, we experience anxiety, pain, futility, or other symptoms which may lead us to seek psychotherapy. The task of such therapy is, then, to explore the client's self-and-world construct system and then to facilitate the client's making needed revisions in it.

This system is the way in which the client survives, seeks fulfillment, and avoids harms; yet it is this same system that must be investigated and in which changes must occur as a result of the therapeutic work. Understandably, the work of therapy inevitably encounters resistance from the client's way of being in the world (i.e., that same self-and-world construct system). Thus psychotherapy must encourage and support confrontation with the negative effects of this system while supporting its positive contributions to the client's life.

The two chief ways in which the therapeutic process carries out this work are through (a) intensive attention to the actual way the client explores and utilizes her/his own capacities as manifested in the client's self-presentation in the consultation room and (b) coaching the client to improved skill and range in self-exploration in order to better understand his/her own self-and-world construct system. These tasks are best carried out in a setting of mutual respect and dedication.

This approach to the therapeutic work may be called life-coaching to contrast it with notions of psychotherapy as repair of injuries or curing of diseases. Coaching seeks to increase the positive life skills of the client rather than focusing on negative patterns as such.

Restating the Central Thesis

From Freud on we have been governed by the myth of historic determinism. This implied emphasis on the need to try to discover what happened in the past has brought us to today's information-centered approach. In so much of our work as therapists we tend to be caught up in collecting and disbursing information about the client. Such information may be the client's history, his current concerns, her relationships, and what she hopes to gain from the therapy. Our clients soon get caught up in this information about process.

However, all information is abstracted from the flow of time—i.e., the flow of life. The only truly actual element is the process of the moment in the client; yet clients and therapists have come to discount the momentary and seek "the long view."

What is advanced here is that therapists need to give greater attention to what is, in fact, actual. This means the subjective experience of the client in the moment. This means (in line with Hillman's views) abandoning the notion of finding causes. This means disclosing to the client her/his immediate experience.

I do not reject the notion of historical sources of much in our living, but I do insist that while history equips us with habit systems that can be useful (speech, social intercourse, and much else), these habits are at a level similar to muscle habits—available, repetitive, continually evolving, incompletely conscious, and only semi-voluntary. I can and need at times to adapt or override some habits to type these words, to drive a car, to do most of the physical activities of daily life. I can change and override emotional patterns when I am aware of them in the moment of their activation. However, so many of my emotional habits I only know about incompletely and after their functioning—i.e., as information about myself and information about what is past.

An emotional habit is a set or predisposition to respond in patterned ways to certain situations
What is here proposed is that pointedly identifying in the moment that which is activated but unregarded introduces a new element in one's internal governance. When this is done, a change process is initiated which can have far-reaching results.

What Is Life Coaching?

Life coaching is a mode of psychotherapy. It is, as the name suggests, a combination of concepts and practices through which a trained and dedicated person may provide a facilitating and renewing perspective and experience to another person. The recipient of this aid may be termed a "client" or "patient," but what is important is to emphasize the centrality of this person's own responsibility and self-direction.

Central to this conception is the conviction that many—perhaps most, possibly even all—the distresses which bring people to psychotherapy are at base the product of ineffectual and counterproductive life assumptions and the patterns of action and reaction deriving from them.

A similarly central assumption insists that relief or recovery from such distresses is only to be had when the distressed person comes to fresh perspectives on her/his life—its assumptions, patterns, and internal conflicts.

Reflections About Our Work

  1. The people with whom we are engaged are living all the time they're with us. They bring that-with-which-they-are-not-content to us. They live it out in our offices.
  2. We are not physicians, repairmen/women, or substitutes available to direct others' lives.
  3. We are coaches for those who are not satisfied with their experiences of being alive.
  4. The only change agency which produces lasting results is a change in a person's perception of her/his self and world.
  5. That change will only occur when we help them see more fully how they are living their lives right now, right in the room.
  6. The only reality about one's self is that which actual in this moment. All else is static, is without power, is only information.
  7. Recognition, insight, interpretation, and similar, familiar therapeutic products that are often mistaken for the goal. They are useful to the extent they evoke or express an immediate experiencing.

The Central Drama of Depth Psychotherapy

I will sketch here, in greatly over-simplified terms, the core processes as they are conceived in this orientation. This will permit reviewing key terms. It will also, I hope, foster a more energetic or dynamic sense of the therapeutic engagement than I (quite biasedly) think of as the "whodunit" approach to therapy—i.e., those modes in which primary attention is given to seeking cause-and-effect relations among elements of the client's history and complaints and then to teaching those connections to the client in the hope that the complained-of conditions will be eliminated or at least radically modified.

The basic drama of depth psychotherapy is carried out as a struggle between two opposing forces: on the one hand is a sense of possibility in combination with feelings of concern. These impel each of us forward in all venues of our lives. On the other hand, these positive impulses come up against other subjective elements in the form of forces or structures which seek continuity and predictability. These latter influences can be lumped together under the name resistances. As we explore them further it becomes manifest that they are chiefly expressions of our self-and-world construct systems, the very ways we define our own nature and the nature of the world in which we live. Obviously threats to these definitions, at the most extreme, are experienced as threats to our lives.

What is evident from the foregoing is that our lives are lived at the level of perception. How we see ourselves, our world, our needs, our powers, our potentials—this is the key to our living.

It follows then that psychotherapy must be concerned with perceptions. And, of course, that concern must not be limited solely to the conscious and verbalizable perceptions. Thus in the therapy work described in this book, we attend scrupulously to implicit perceptions as they are manifested in the living moment.

The phrase, "in the living moment," is particularly important. It is no exaggeration to say that the only reality we have is that of this living moment—the moment in which I write these words and the quite other moment in which you read them.

Even were we talking together in the same room, we would not have precisely the same "living moment" because of the multiple and contrasting histories we would bring to our engagement. Another implication of this recognition is that when the client tells about his experience, it is always a different experience than it was when it occurred.

The particular merit of the perspective I'm presenting here is expressed by references to "the actual." What is actual is what is at the very moment; therefore therapeutic attention and efforts need to be focused at the immediate now.

A Semi-Final Recognition

This book has attempted to summarize my thinking and experiencing about psychotherapy as of early 1998. It has fallen short of doing so. Thank the good lord!

Psychotherapy is concerned with life, with living. That means it is concerned with what is going on, what is changing and evolving, what is about to be recognized. A book is much more static than is actual, vital psychotherapy. What I have written has taught me about what I have written. When I rewrite the account of some point I want to express clearly, the point has changed somewhat. When I try to capture the new perception, it has already gone on ahead of me.

That is the way with life. That is the way with our thinking about life. Therefore that is the way with psychotherapy. We are—and we should be—always running to catch up.

You must excuse me now. I've got to hurry to find out what is next.

LIFE ISN'T WHAT YOU THINK*

Life isn't what you think. Life is.

Does the yolk know the shape of the shell?
Does the foaming crest know the power of the wave?

Life isn't what you think.
Life is going on . . . now.
Life is impending even as I write
and as you read.

Life is experiencing, but not experience.
Life isn't what you think.
Life isn't future, past, or even now.
For even that now is now past, now-past.

Life isn't what you think.
Life isn't what will be in the future
for when that future has become now
it will be now and not the now we foresaw.
Life is what is before it becomes what was.

Life isn't what you think . . . or what I think . . .
or what ever it might be.
Life is.

The Family Research Project: A Summary

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Sometimes a new idea offers such a radically different lens that it challenges conventional wisdom and even turns standard theory and practice upside down. Children of alcoholics (COA's) and adult children of alcoholics (ACOA's) were new ideas of this kind. We believe that our Family Recovery Research extends this revolutionary perspective. Since 1989, we (Stephanie Brown and Virginia Lewis) have been asking the question: Is there a "normal" developmental process of recovery for the family, similar to the long-term process of change that has been identified for the alcoholic and for children of alcoholics? What happens over time when one or both parents stop drinking? Are there predictable, defined stages? What is the impact of abstinence on the family and on the individuals within?

I have often asked over the years, "Why do people resist looking at recovery? Why does the focus of research and treatment remain fixed on the drinking alcoholic?" While so much effort has been targeted toward a "goal" of abstinence, the focus has always stopped at that point, as if everything is expected to turn out well once the drinking stops. It is not so simple. Abstinence marks a positive beginning rather than an end. Recovery is a difficult, painful process of radical change that is never easy and rarely smooth for anyone involved. Without knowledge about what to expect, including the paradox that what is normal and necessary to long-term positive change is also disruptive and even traumatic in the short run, the impact of such turmoil can cause further damage. Over the last six years, we have interviewed and tested 52 couples and families (those who were together for a least five years during drinking and who are still together in recovery), with sobriety ranging from a few months to over 18 years, in order to discover what recovery is like. We have examined the process of change according to length of sobriety within three domains: the environment, the system, and the individuals within.

Research Findings

  • The four stages of recovery already defined for the individual hold true for the family: Drinking; Transition, the move from drinking to abstinence; Early Recovery, the stabilization of abstinence with new learning, much uncertainty and constant change; and Ongoing Recovery, when massive change has been consolidated and the family is guided by the organizing behaviors, values and beliefs of recovery.
  • The environment, or context, of the drinking family is traumatic and harmful to children and adults. It remains unsafe and potentially out of control into Early Recovery, which may last as long as three to five years. In Ongoing Recovery, the environment is safe and not thrown off track by the difficulties and crises of "normal" life. One family looks back:
In the first year, we lived on pins and needles. There was more tension than there was during the drinking because no one knew what to expect. Before, the drinking was known; it was predictable. Now, our nerves were raw and ragged. We all feared an explosion. It took years before we felt calm and secure.
  • The unhealthy drinking family system must collapse as the family enters recovery, permitting attention to shift from the system to the individuals. Many families do not accomplish this collapse or they do not survive it. Because there is so much disruption with abstinence, and so much turmoil caused by the collapse of the system, many families break up, seeing that things have gotten worse, not better. Our data explain how outside support networks (12-step programs, treatment centers, therapists) provide a "holding environment" for all members of the family, a cushion and substitute for the drinking family system that has collapsed. Families utilize these outside supports to weather the difficult changes of the first three to five years. It may be five to ten years before a stable, strong sense of healthy family is secure. Change like this does not occur from inside the family in the vacuum created by abstinence. It requires external guidance and supports. Yet conventional treatment wisdom often leans in the opposite direction: much of family therapy is aimed at bringing individuals together, to focus on a "we." Our work demonstrates the importance of an individual focus during the early period. Another family remembers:
In early recovery we could begin to talk about an "I" and a "you." We didn't dare try to communicate as a "we." For the first two years, we didn't talk to each other without first calling our sponsors and we didn't talk about important things for at least five years. We led parallel lives and slowly got to know each other again.
  • The process of individual recovery takes years, not days or months, and can enable lasting, in-depth changes in the family. Unfortunately, there is sometimes an unrecognized dark side: children may be neglected as parents focus exclusively on their individual recoveries and abdicate parenting responsibilities. One parent told us:
Early recovery was a self-obsessed time for us. Our children had a "recovering Dad" and a "recovering Mom," but who was taking care of them? No one. I will be forever grateful for sobriety, but I have a profound regret that we abandoned our children in the service of our own recoveries.

The Trauma of Recovery

Data on the process of family recovery shocks us with mixed news: Yes, recovery is positive; the end of the drinking is extremely important and lays the necessary foundation for in-depth change. But that process of change, which we have called the "trauma of recovery," is difficult. Families may not survive it, and without sufficient knowledge or supports, children may suffer unknown and unintended consequences of this time of uncertainty, instability and radical change.

No wonder there is resistance to focusing on recovery.

It is hard to see what's really there and what is normal. In our culture we idealize short-term cures, "symptom reduction" and magic answers, refusing to understand or accept that solutions to massive problems require difficult, painful choices and a long time in the process of change.
 
We think it will be surprising to many that children experience a "trauma of recovery" in addition to the horrors of drinking. It is grim news to learn that children may feel worse, not better, just like their parents, and they may experience physical abandonment as well as continuing psychological isolation due to their parents' recovery.
 
There is great danger that news like this will be rejected, or denied. Or, we will rush to the obvious, but wrong, conclusion that parents should not follow individual recovery programs. We must face the fact that what is essential for parents may be inadvertently damaging for their children, but only if we deny it. Once we acknowledge this reality, we can address the holes in our treatment programs so we may better protect children AND support parents in their recoveries. We can also focus on the absolute need for support structures outside the family, which we are calling "community systems," and on the need to expand our ideas of prevention to include recovery. Our current theories and practice for the professional treatment of alcoholism and the family leave people hanging without necessary knowledge and support.

Helpful Interventions

What kinds of interventions can be helpful at what stage of recovery? Couple and family therapy in the early period of abstinence can provide education about the normal process of recovery, i.e., the turmoil and disruption to be expected, the need for parents to focus on themselves as individuals, and the importance of maintaining or learning parenting responsibilities, both concretely and emotionally. Parents need guidance in focusing on themselves without further neglecting or abandoning their children. Supportive couples therapy that does not shift the focus off of individual recoveries can provide necessary structure, concrete advice and education and a watchful eye on children's reactions and needs in early recovery.
 
As part of our research we have developed a curriculum for families with longer recovery—a minimum of six months and ideally at least a year. Called MAPS (Maintaining Abstinence Program), the classes provide a "map" of what families can expect individually, and as a system. During one meeting, a couple or family with many years of recovery (the "mentor family") shares the story of their drinking and recovery. We believe that this adaptation of the A.A. and Al-Anon sponsor can offer tremendous support and fill some of the holes which we know exist.
 
We also recommend adding an educational component to treatment programs that emphasizes the importance of family and the need to attend to family during the early days and months of abstinence. How to do this without sacrificing anyone's individual needs will require careful planning.
 
Finally, we see that couples and families with stable recovery can benefit from more intensive therapy, depending of course on their particular needs and circumstances. When individual recoveries are stabilized and secure, family members can turn their attention to relationships within the family without threatening their own progress, or forcing a return to old, unhealthy family interaction patterns.
 
We expect an outcry against our research because we recommend additional "treatment" and unlimited "continuing care" rather than less treatment, or even none. We believe that much of this care can be provided by volunteers who offer education, support, and the sharing of their experience as "mentor families" through an extension of the "apprentice model" of the 12-step programs. We see this need as an opportunity to strengthen an already existing bridge between the recovering communities and professional treatment. With an ongoing "holding environment" outside the family, individuals within can attend to their own healthier development. Later, they can shift their attention back to the family.
 
The now-grown-up child of two recovering parents listened to them tell the story of their recovery and then reflected on what recovery had been like for her:
 
From the time I was six until I was ten, my mother was in and out of treatment for her alcoholism. I went to Alateen because my parents needed me to go. I told myself that what was happening wouldn't be important to my whole life, that all of this was not traumatic. Now I know I was living in a vacuum, that I had nothing to hold onto. I was tuned out for most of this time. As I listen to them talk today, I know why. They weren't there for a long, long time.
 
This family talked about the process of coming back together. As their individual recoveries progressed, the environment became safer, and a new, healthy family system could develop. Father reflects:
 
By the time things finally started to work in the family, our two oldest kids were on their way out, so there was not time for bonding. They needed to push away, but there was nothing to push against.
 
The children, having grown up with drinking and the turmoil of early recovery, are now coming home—emotionally—to join this healthier system and repair the bonds of attachment with their parents. Much of the developmental work that should have occurred during childhood and adolescence can now take place…and does.

Edna Foa on Prolonged Exposure Therapy

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Exposure Therapy Explained

Keith Sutton: Welcome, Dr. Foa. To get started, why don’t you tell us a little bit about what exposure therapy is. Many of our readers may be unfamiliar with, or may not remember much about, this type of therapy.
Edna Foa: Exposure therapy is used mostly with anxiety disorder. The idea is that people who suffer from anxiety disorders—who get anxious when they confront safe situations or objects—are taught through exposure therapy to become less afraid, or not afraid at all, of the things they’re fearful of. So if the fear is a normal fear—like the fear of driving on the track when you see the train whipping by very fast—you don’t want to teach people to get over it. You don’t want to change people’s fear of driving over the track just in front of the train, because normal fears protect people from doing things that will harm them. The idea behind exposure therapy is that the therapist helps patients to confront or approach what they’re afraid of, because the things they’re afraid of are intrinsically not dangerous. Through exposure to these situations, they learn that there is no reason to be afraid of these situations. The disaster they expected does not occur. Originally, exposure therapy was derived from animal studies. In these experiments, scientists condition a mouse to become afraid of a red light by pairing the light with electrical shock. And after a certain numbers of pairings, the mouse will start showing fear responses when the red light is presented, even when it’s not paired anymore with shock. We call this response a conditioned fear. Then if we want to eliminate the mouse’s fear of red light, we present it with a red light without the shock. After repeated presentation of the light without shock, the animal stops showing the fear reaction to the light. That’s called extinction. In the ’60s and the ’70s, several experts, in England and the United States, translated the animal results to human beings and said, "Let’s suppose that the anxiety disorders—such as claustrophobia or fear of heights—are like a response that was conditioned. The person was conditioned to be afraid of elevators even though being in an elevator is not dangerous. So how do we eliminate the fear of elevators? We instruct the person to ride on an elevator many times until the fear is extinguished."

KS: Is that what’s called the flooding of the anxiety?
EF: Well, it’s called flooding if the therapist conducts the exposure very abruptly. And it’s called systematic desensitization if the therapist is doing the exposure very slowly in small increments, and if he pairs the exposure with relaxation. There were big debates in the '60s and the '70s about what works better, and whether flooding is dangerous. Some experts, like Wolpe, thought it was dangerous to do flooding because the person will actually become more rather than less fearful.
KS: Yeah, common sense would make you think that, wouldn’t it?
EF: No, not really. According to some theories, flooding should make the patient feel worse. But according to other theories, abrupt exposure should extinguish the patient’s fear more quickly, so it is actually more efficient.
KS: One of the central ideas around the exposure is that the anxiety peaks within a reasonable amount of time and decreases. Is that right?
EF: Well, it depends. Not necessarily. Let’s say that somebody is afraid of going to the supermarket. People with panic disorder, you know, are afraid of going to places where they cannot escape quickly, like sitting in the first row at the movies. It takes longer to get out from the first row than from last row. Experts did abrupt exposure, getting patients to sit in the front seat from the start of the therapy, and other experts said, "Let’s do it incrementally—let them sit in the last row first, and then in the row before the last, and then two rows before the last, and then five rows before the last."
KS: Is that the exposure hierarchy?
EF: Exactly. Gradual exposure gets patients used to each one of those stages, and eventually the patient will sit in the first row. Now, studies have found that doing abrupt exposure is as effective as doing gradual exposure, except that the patients in the gradual exposure suffer less. But flooding doesn’t really make them worse, as Wolpe thought. So we know now that we can do flooding, or we can do systematic desensitization. Both work. Today, experts don’t quarrel about this issue anymore; all therapists use more or less a gradual exposure, but not as gradual as systematic desensitization, because that takes too long and is unnecessary.So that’s what exposure is. Now, how does exposure work? It works because of a mechanism that we call extinction. Extinction is not unlearning what you learned, but rather it’s learning something new—it’s learning that what you were afraid of is not dangerous. Some experts say that the mechanism is the reduction of the anxiety—that gradually you’re less and less fearful. This is called habituation. But habituation is not an explanation for why patients get less fearful with exposure therapy.My theory is that exposure reduces fear and anxiety because the patient learns that the bad thing he thought would happen to him does not happen. Therefore, it’s very important to plan in a way which will ensure that the thing the patient is afraid of will not happen during the exposure. Let’s say after being raped a woman starts to be afraid of going anywhere by herself after dark. The therapist then plans exposures to places that are not safe after dark, and she is attacked again. That’s not a good exposure, because it doesn’t teach the patient that what she was afraid of does not happen.I always give the example of a person that is afraid of big dogs, but not of small dogs. The therapist decides to treat him by exposure to dogs, and brings to the session a small dog. Well, because the patient is not afraid of small dogs, this exposure will not work. Exposure needs to include the things that the patient is afraid of. The therapist then brings a big dog to the therapy session to do exposure. The patient enters the room, sees the dog, and gets very fearful. With the encouragement of the therapist, the patient slowly approaches the dog, which the therapist holds on a leash. When the patient gets close to the dog, the dog jumps on him and bites him. This is again not a successful exposure, because what does the person learn from it? He learns that he was right all along, that big dogs are dangerous.
KS: It reinforces that belief.
EF: Exactly, it reinforces rather than extinguishes the fear. So that’s the way exposure works. In order to implement therapeutic exposure, the therapist has to find out what the person is afraid of, then make a list of these things and organize this list from the not-so-fearful situation to most fearful situation, in a kind of hierarchy. In order to create a good hierarchy, the therapist teaches the patient to assign a number, on a zero-to-one-hundred scale, to each situation. This number signifies how much fear the patient would have if he would be confronted with this situation. It is important that the therapist makes sure that the situations on the list are not really dangerous.The therapist chooses a situation by saying to the patient, "Let’s choose a situation that is about forty on the scale. Which of these situations do you think you are able to do for homework next week or in the session with me?" The patient selects a situation and begins to practice approaching it, staying in the situation until he feels that the anxiety goes down and realizes that the fear is not realistic.So exposure works through two mechanisms. The first is that the situation elicits the patient’s fear—there is a match between the situation that the therapist is presenting to the patient and the patient’s own internal fear. The second mechanism is that the exposure situation contains information that is incompatible with the information that the patient has in his mind. In the example I gave you about the dog-phobic, if the patient is afraid that large dogs will bite him and the therapist presents him with a large dog that, over several instances, does not bite, the patient will cease to be afraid of big dogs. Patients don’t really need to be in the situation a long time—they don’t need to wait until the anxiety dissipates completely. They just need to be in the situation long enough to realize that what they feared would happen does not happen.

Transforming the Wounds of Racism: An Autoethnographic Exploration and Implications for Psychotherapy

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A young boy splatters my painstakingly finished painting, taunting me to go back to where I had come from. I accuse his ancestors of plundering my nation: "Look what your people have done to my people." (Saira, eight years old)

The stories of colonialism that my father had told me suddenly came to life and I felt bold and proud as I looked to my teacher for further confirmation. She remained silent as the other children laughed at me. I found myself shrinking away in that moment of humiliation. I think about that experience quite often and I imagine what might have happened if my teacher had affirmed my words. Especially, now that the cultural landscape has changed and I see white women with henna tattoos, and Indian fashions, designs and music everywhere I look. It is curious that what was once denigrated is now accepted and desired. This is both inexplicable and inspiring to me.

My brother and I are in the garden gathering brittle autumn leaves for the fire, savouring the sweet evening air in our lungs. Two white teenage boys peer over our back fence and throw stones and litter at us alongside racist jibes. I feel they are treating us like animals in a zoo; I feel fear rise in my belly but feel compelled not to show it. My father appears and gently asks them if they would like to join us. I feel bewildered and betrayed by his reaction. The boys sit beside us and floating embers settle in our hair as we eat baked potatoes plucked from the fire. We make reluctant and inquisitive eye contact with one another and as the fear dissipates, I can see they want to be a part of this simple activity of togetherness. (Saira, ten years old)

Racism was a part of the backdrop of our lives. It was not discussed and I was given no guidance on how to make sense of it. It is only now, many years later, that I recognise the gift my father gave me that night: he showed me that I could acknowledge and stay with the disquiet and dread of racism and that I could find ways other than fear and dread to be with it. During my dissertation research on this topic, I held onto these memories like a talisman.

Authoenthnography as a way to understand racism and trauma

I wanted to become a therapist who was not bound up in the rigidity of her boundaries, so that I could begin to stretch and push the boundaries of otherness and sameness. As a psychotherapist, I wondered how racism is explored or avoided in psychotherapeutic work. I saw that racism can often enter psychotherapy in a disguised form as it is difficult to express due to the fearful and defended nature of racism. This results in racist trauma being overlooked and minimised, which can be oppressive and silencing in itself. In this work, I have tried to illustrate how stories were told and understood in order to facilitate empathy with groups that are sometimes neglected and marginalized.

Autoethnography¹ has developed from ethnography, anthropology, sociology, and cultural studies and serves to challenge traditional historical relations of power. Autoethnography is different from autobiography in that it describes the conflict of culture and identifies how one becomes othered within a cultural and social context. This method of research allows us to remake and understand subjective experience from creative and analytic first-person accounts of people's lives. It makes use of interviews, dialogues, self-conscious writing, and other creative forms to facilitate an expanded awareness for the author and audience. Autoethnography is the study of the awareness of the self (auto) within culture (ethnic); it is a way to connect the personal with the cultural.

I have tried to create a more heartfelt space where wounds can be subjectively named and understood. I wished to engage in new ways of thinking about how therapists' life events can change practice and awareness for themselves and the field. The illuminated relationship between the researcher and the researched is made transparent in this work as it took me to places, internally and geographically, that I had never been…

This is not just a story about racist trauma—it is a story about longing, loss, and discovery. It weaves back and forth in time, and as a result, it is written in both the present and past tense.

Straddling two worlds

As a child, I was a keen observer, soaking up the living memories of my parents' homeland, of dance, song, and food that produced solidarity and unity. As a group, they felt alienated and displaced from all that was familiar. My aunts told and retold stories; this helped them maintain their cultural voices, and this collectively made them a powerful force in my life. The men were on the edges of these stories and were largely uninvited to storytelling as it was felt they were both "too important" to be burdened with the tales and too "weak" to bear the sorrow associated with them.

I straddled both the ancestral and modern worlds, and I was given the gift of being able to find myself within these stories. Despite the fact that these mementoes of my heritage were somewhat fragmentary, I was still left fascinated by them. My aunts came from a culture that emphasised togetherness and unity. In their dependent and highly emotional world, they sought kinship and solace with each other. This was in part because they became increasingly ambivalent about their splintered place and identity in the world due to the forces of migration.

As I grew older, I started to embody a western culture, and it became apparent that cultural differences were intolerable to my family, as any individuation was an annihilation of the collective. I felt increasingly like an outsider, both inside and outside the home. I was inexplicable and perplexing to them, particularly when at 13, I dyed my hair pink and daubed hand-painted feminist slogans over my clothes. My family clucked with pride when I responded to their coaxing by wearing a sari for a family event. I felt such sensual pleasure in the swaths of beautiful pea-green silk that I did not want to lose its "magical qualities." In turn, [I refused to take the sari off, ruining their hopes by experimentally skateboarding in it.] I was continually challenging their ideas of what a traditional Asian woman should represent and grappling with the contradictions and paradoxes inherent in this process.

Myself as witness

How do I trace the roots of my estrangement and disconnection from these men who were central to my life, to my heart? I have waited for a long time for them to come home—psychically, physically, and emotionally. I have always wished that they would be returned to me, like at the end of fairy tales. Through my research process, I felt like I was making the decision that I could not passively wait for their return any longer. Whilst being immersed in this research, I felt a strong need to reclaim my deeply yearned for yet seemingly irrecoverable lost connections.

I did not know for certain when I started this research that my father, uncle, and brother were lost to me by racism and its effects. These experiences were unheard and unspoken in my rambling and rather tribal family. I believe the speaking of racism evoked fear and shame that might further tear at the fraying fabric of my family. Racism, for me, was bound in the wrappings of humiliation and silence. It was so tightly swathed, I only heard it as a fearful whisper. I have subsequently discovered these traumatic racist experiences ranged from vague, insidious and intangible experiences to shattering, violent acts.

As I felt the oscillations of these unspoken narratives inside myself, it led me to create musings, fantasies and assumptions about the subject matter. I sat at my desk, feeling bewildered and paralyzed at the horror and pain of the family narratives, and despair at their disconnection from me, wondering how it was possible to get closer to the subjectivity of such experience. This possibility felt charged, potent and unfathomable. I deliberated and wondered repeatedly if I should speak with my family about the research—would it harm them further? What are the ethics of taking this into the public world? What would the research do to our relationship? Issues around confidentiality buzzed around my head and my colleagues and I talked about them incessantly.

I questioned the possibility further: What will my peers make of me? Would I be derided and discounted by the "therapeutic community" for revealing not just myself, but also my family? Would I be able to produce something evocative, powerful, and representative of our experiences? Is this the story of significant men in my family or my story of loss? Can I find the words for trauma that sits beyond language to describe what cannot be spoken? The question remained with no easy answers.

My father's scars

My father was disillusioned and troubled when he fled to England to practice law in the 1940s. His best friend and neighbour during the partition in India stabbed him. He only mentioned the scar on his stomach in passing when I pressed him to let me into his interior world. He believed Britishness embodied fairness and justice as he had been successfully inculcated into the colonial belief that he and his kind were inferior. He beamed with pride at redefining himself as a "brown English man" and negated his "primitive and corrupt" cultural origins with vitriol, never wishing to return.

In remaking his identity, he resolutely refused to believe that his struggle to secure a job as a barrister was due even in part to his colour. He was a dishwasher, a porter, and a lift attendant—all the while, trying to maintain his respectability and pride. He would arrive to work with his bowler hat and impeccable pinstriped suit each day. then change into his overalls to start his shift. He was inaccessible to us as he strove to carve out a place in the world, and his identity was embedded in his need to work hard and achieve. His failure critically punctured his self-esteem.

The eventual disaffection and disillusionment with his idealization of Britishness seemed inevitable. However, its impact was made worse because he was unable to digest the racism he endured. He saw the hostile, racist persecutory world making him feel small and powerless. He seemed to see racism and oppression everywhere. These crises led him to alcoholism and admission to a psychiatric hospital for depression.  “He sat on his prayer mat and cried like a child as he spoke of England like a lover that had abandoned and disappointed him.” He turned away from it as he had his homeland.

In turning away from Britishness and all it represented, my father turned further away from me. Had I come to embody what he could not bear? I could not find any comfort in taking my distress to him and he could not bear the weight of his child's woundedness. The effects of his trauma marked our family, and although we did not live through his trauma, we did live within its confines.

It is frustrating to feel the familiar inaccessibility in his death as I did in his life. What would he have discounted or embraced in these descriptions? My father was a harsh man who shielded himself from the world and eventually lived a hermit-like existence, but he gave me the best of his capacity to love. All I can name is what I know: that every day I spent with him he was unpredictable and closed off, living in a desolate land. I could not find him anywhere. And now I cannot quite find him in the untranslatability of these narrative descriptions.

While my own father was busily being a perfectionistic workaholic, my mother was whimsical, dreamy, furiously caught up in her culture and clan. My uncle represented a world of calm and safety. How do I adequately describe how much I loved my uncle? I have always found great comfort in looking at his face, the familiarity I felt in watching him smoking his cigarettes—his recognizable outline meant that my life slotted into place.

My uncle leaves… the unanswered questions

I now realize he was a mere young man at the time, but seemed then to offer a very different quality of attachment. I remember him driving a maroon Mini with a squeaky leather interior that I would slide around on. He would sit with me on the stairs when I had undigested bad dreams about cowboys and Native American Indians and would speak softly of worlds full of magic and kindness until I felt safe enough to fall asleep again. He taught me to gently put the needle on the record and wait breathlessly until the song would start in the smoky recesses of his room. He would capture my crinkle-nosed smile in his photographs and I felt rewarded with his attention and gaze.

His leaving to emigrate to Canada when I was six felt like an unanswered question and for a long time I wondered why he left, and yearned for him to come back. His absence was profoundly painful to me as a child. I wondered if my mother had sent him away or if his new wife asked him to leave. As I grew up, a part of me imagined it was due to racism. Not that I knew much of his experiences with racism, but I overheard fragments of conversations of how he "hated England," and that "terrible things happened to him." It led me to conclude that racism was the only conceivable reason he left. Why did I assume it was racism? Had I made something up? Perhaps it helped me believe as a young child that something terrible took him away rather than facing the fact that he had chosen to leave me.

"It felt embarrassing to talk about the humiliating aspect of it, your sense of masculinity is wounded and injured, you feel that you should have taken a stand but you did not feel able to as a man." (Saira's uncle)

Early on, I asked my uncle what he thought about my research—was it meaningful to him? He said he had many stories of racism and its associated trauma that he had not spoken of, yet they were still alive inside of him. I instantly felt relieved that these experiences were real and not entirely the result of my imagination, although I feared I would not be able to hear and bear these stories. How might the telling of these narratives benefit him? At this stage, I felt lost in the littering of these broken attachments and in a turbulent state of anxiety and confusion, although later I recognised that this was a place of important struggle and sorrow.

Unwelcome in the new world

My uncle arrived in England from Pakistan in the 1950s at 10 years of age accompanied by a throng of older and younger sisters with kilos of sweating Indian sweets wrapped painstakingly in silver foil. However, the family was ill-prepared for the cold as they arrived in the dead of winter in only their thin cotton shirts. All 10 children started their life in Britain in an asbestos-ridden caravan, confused and unsettled after coming from a place of wealth and comfort. Later, the family moved into one room with little space, and their material conditions worsened. They lacked any comprehension of the new culture or landscape they faced. This migratory journey remained an untold story because it evoked shame of their struggle to find a place of belonging and the emotional and literal poverty of their experience. The exodus was supposed to be rich with offers of new possibilities, the enticement laced with the promise that they would be rewarded if they worked hard and managed to forget the familiar sun, and the textures and colours of home.

My uncle was pleased to find that people were initially curious about him, his history, and difference. Later, this changed and it seems humiliation and shame coloured much of his experience as a young man. He remembers standing at a bus stop racially abused whilst those in the polite orderly English queue silently looked on, witnessing him being scorned and disrespected for simply existing. He felt the disdain when he was spat at for embodying and personifying otherness, his palpable foreignness and physicality making him a threat to himself. The skin he represented made him exquisitely visible and invisible.

"Look what the cat's dragged in" was his greeting on the first day at his new job; he was 16. He felt cheated; where was the promise of a better life? Then he was threatened with a knife in a public bathroom where a gang of men in a savage racist attack set upon him, dousing him in their anger and fury. He felt unwelcome in the new world.

He walked around in shame and isolation, wondering how he could make a mark on the world when his voice had fallen away. Humiliation tearing at his throat, he swallowed the contempt and its effects began to house themselves inside of him.

Connection and disconnection

My brother on my Uncle's shoulder, me in the park… I chew on the long feathery grasses that sway in the wind, shimmer in the sunlight; I thought I was eating the sunshine. (Saira as a young child)

These are the happiest times I can remember. I felt connected to the world and myself when I was with my uncle. My adoring view of him was in part due to the way he invited us into other worlds of music, song, and nature. I was full in the stillness.

He and the white English woman that he loved and hoped to marry sat together in the ordinary familiarity of the train carriage. He loved train journeys, watching familiar landmarks appearing and disappearing from view as the train juddered out of the station. This defining journey turned bad for him as a heavily built white man sitting across from him began to mumble and then roar at how "his kind" had defiled his partner's virginity, taking something from him—from all white men. “The pain of past racist violent blows he had experienced did not compare in their intensity to this expression of violent hate that was coming at him now.” The torrid racist expletives bounced around the walls of the carriage, exposing and belittling him.

The emotional impact was initially shock; he described feeling a numbing paralysis in his body. As they decided to escape and disembark at the next station, he wondered how his body would support him, when it felt so insubstantial. Time slowed to a stop as he felt the flush of disgrace and helplessness overcome him. The other travellers in the carriage looked on, some with interest, others with avoidance; did they find themselves agreeing with this man's hate? Is that why they did not protest? Or was it fear that this contempt would be directed towards them?

He felt his girlfriend was defiled in her association with him; it was as if she was contaminated by the colour of his skin into something more sexualised and objectifiable. They never spoke of this incident, but it was the beginning of the end of their relationship, because in that long moment, amongst all of the shame and emasculation, was her witness of his diminishment.

When he moved to Canada, he left me too, but more poignantly he left himself. The racism that had infused his world disconnected him from himself and those around him, such an unspoken cruelty when contact and connection was the gift he gave me.

"Racism was not the main reason I left"

I journeyed to Canada to meet my uncle, 30 years after he left England. To engage in a dialogue about something so personal and painful leaves me anxious and curious. I am researcher/niece/ psychologist/ therapist/child all at the same time. These multiple selves offer a dynamic shifting of one into the other, each adding a new voice. He is a stranger to me now, but there is a strong memory of childhood intimacy that attracts me to him. Yet I feel shy. I want to hide away in my researcher/therapist self to anchor me, but this dialogue requires courage to be intimate and honest. I wonder if I am capable.

We sit in his basement with a scratchy blanket on our knees, as I anxiously wonder if my new tape recorder will work. At the same time I wonder how my husband is, as I left him making polite conversation with my uncle's wife upstairs. Are they wondering what we are discussing downstairs?

He says slowly, "No, racism was not the main reason I left." My long-held assumption momentarily floats away. What does this mean now? He tells me he came to Canada to begin again: a new life, a new job. He does not want to be perceived as someone who cowardly ran away. Did my questions about his leaving further diminish him? It seems to me that he needs me to clearly understand his reasons for leaving. I feel a need to honour this, while still I wrestle with what this means for me and for him. Self-doubts creep in… Were my assumptions off base? Was I too committed to these assumptions before hearing his version of events?

Acts of reinvention

It is as if racism had blighted his life for many years; the hurt and the vividness of the memories live on and become ignited as he speaks of it after 40 years. He says he felt like a victim, which left him terribly alone and split him apart. He says, "I don't know if white people could relate, or appreciate the racist experience. You have to be on the receiving end of it. Only our people could understand this shared experience, to know what it is like to be spat at, to be hated. I do not know if they would be able to really make a connection. You have to live through something like that."

He became vigilant and wary of whiteness. It has been 30 years since he experienced such overt racism, yet he still sees all white people as outsiders. I can psychologically understand this but emotionally it does not fit for me. I cannot feel this way because our narrative experiences are different.

His own racism remains unacknowledged. He does not see it as racism, but rather as a wish to preserve the integrity of his culture, with the lines drawn in a colour-coded way. Whiteness must be kept out or at best treated with a large dose of scepticism. I try to wonder with him whether his racism precedes or emerges from his own racist trauma. How does whiteness threaten his cultural and religious beliefs? I try to get into a dialogue about this, but he is rigid and fixed in his ideas just like those who hated him for what his skin represented.

It seems these feelings became more pronounced when he began to reinvent himself. This reinvention of himself, he believes, was born from the isolation and emasculation of the racism that penetrated him. He needed to recreate and recapture a self by finding value in his culture after coming from such a place of shame. He found a resilience and strength that came from his community and culture, mainly from his spiritual connection to music. He made these connections to preserve a self that had been discounted. “He felt embraced and accepted in this place… a place to stand with his hurts.”

The more toxic effects of the shame and indignity went away, yet he remains mistrustful of anyone who tries to get too close. This mistrust includes me and I realise there is an awkwardness that sits between my uncle and me that does not go away.

I felt deeply hurt and angry by the racism he described, but more so that he had nowhere to take his woundedness. I begin to wonder if I in some way represented the England he had to leave behind. How do I speak of my anger at being left and feeling forgotten? I try to talk about this but the words do not come out right and they stick in my throat.

He reads the narrative that I have taken from him and insists he has nothing to add or

change. "It's an accurate description and it's interesting to know of you through doing this," he says. He sees my expression of sadness at his leaving England as his failure; I cannot quite find the words to explain how much he meant to me that made his leaving so agonizing for me. Is it too late? It is as if he has already turned away. His world seems to exist of outsiders and insiders. I think I begin to exist somewhere in between for him, as the residual effects of this trauma mean that he remains far away.

As we are preparing to leave, he shows me photographs he took of me as a child from an album as closed as his past. He tells me that his happiest memory of those times was the crinkly smile that I saved for him as a child. Despite this, I feel heartbroken all over again.

Healing some wounds

As I listened to and then transcribed my uncle's story, he maintained power over his words as he revised and amended his descriptions. I wrote the narrative piece that he had editorial control over. He was able to acknowledge his loss of self due to racist trauma, but the recognition of his resilience and his sense of agency was made real by the act of linking events to his act of self-expression. I noted that his resilience was activated to survive adversity. He expressed this resilience in the form of forgiveness: "I have survived so much and learned that forgiving others (racists) has helped me have another chance at life."

I grappled with the need to see my uncle as a survivor and hero, and preserve my continued idealisation of him. I can see how he continues to bear terrible scars that I naively believed could be bridged by this research. Yet, what was healing was making sense of these previously unspoken trauma experiences that we were no longer compelled to exclude, a behaviour that was normalised within the family. These narratives brought validation and the possibility of new attachments. However, this narrative was not entirely healing with orderly resolutions.²

My uncle's residence abroad meant the dialogue we were able to share in person was concentrated over a week and followed up by telephone and email contact. I felt disappointed that I did not have more time with my uncle in the research, but is this not how I began, lamenting the loss of my time with him? He seemed unengaged after a time and denied wishing to change the material in the text after the first few revisions. He said there were no negative effects of the research on him, but I wondered if he felt discomfort at our increased contact. I have now not heard from him for a number of months and suspect he wishes to re-establish some distance and renewed separateness. I have honoured this for now and so I continue to feel his absence every day.

In writing about racism and trauma, I am writing about my life, family, and community, which is quite charged. I have become careful not to contribute to the splitting in the world of racism, or in believing that the racist monster prevails and that those of colour are helpless and victimised. I have found that by opening up categories and sitting in between these splits and divides that I can see the situation more clearly. I cannot simply hate the racist, because I have loved those who have voiced racisms of their own, like my father and my uncle. Similarly, I have been touched by this work, wrestled with forgiveness and humanness, and appreciated that the resulting embodied awareness may go a long way in creating connections across divisions.

Coming home again

A gang of boys corners me and threats me, but they become half-hearted and change their minds because they are unsure of where to locate my colour or ethnicity. I feel initially relieved and then angry that they do not recognise me for what I am. I try to call them back. (Saira, eight years old)

I go to Mexico, Mexicans claim me; in Italy they speak to me in Italian that I grope to understand; in Paris, the police stop me and assume I am an Arab; and in India, they do not know where I am from. A client comments to me about how much she despises Pakistanis and how relieved she is that she can speak openly of her contempt, as it becomes clear that she thinks I am from Jordan. (Saira as an adult)

My family would joke and say, "You may as well be white." This was not just a form of shadism, but to emphasize my difference from them. My skin colour is not easily identifiable, yet I am kept othered and my difference is imagined. All of this points to the idea that skin colour is unimportant in itself, but the projections, internalisations and consequences it carries do matter. We cannot ignore or minimise this impact as sometimes it becomes a matter of life and death, be it physical or psychological.

I internalized the shame of my cultural difference, and my Asianness seemed inexplicably both a bad and a good thing. I have struggled with the shame that glued my insides together and writing this has been a battle of sticking and unsticking those glued parts. This work gave shame a place to speak from. I have wrestled with finding my voice and I recognise that the humiliation and guilt at being a witness to racist trauma has been like an eighteenth-century corset encasing me and defining my shape. I have reframed this narrative as one of transgenerational and intergenerational racist trauma. I intimately feel the terrible loss and abandonment by these significant males. Now I am less bound up and defined by this trauma. I am not sure, though, where I go from here.

The effects of these traumatic absences have left emptiness in my life, and acknowledging the pain and sadness of missing these men who were once vitally present has changed something between us. I am able to love them just as they are in the hope that there will be moments when they will be returned to me, which happens every now and then with a smile a word, a gesture, or a memory.

I am changed in other ways, as well. This is best illustrated with an ordinary encounter of getting into the same taxi with four years in between.

Sometime during the beginning of my research, I slide into the taxi as I register the racist hate in the taxi driver's eyes; he glares at me. I am surprised and uncomfortable as I inhabit his confined territory, his taxi seems like a closed-off, taut world of hate and revulsion that leaves me unsettled and unsafe but reminds me that this work means I have to be able to dwell in this place. (Saira)

Four years later, my research is in the final revision process, and another taxi ride…

After spending an afternoon revising my research, I am cooking rice with my mother… the aromatic Indian herbs and spices envelop me… nice to be home again. I feel a mixture of self-consciousness and pride about my project. I get into the waiting taxi preoccupied with these very thoughts. I look up and slowly recognise it is the same taxi driver. He recoils from me, as if I am able to pollute and invade his being. I look at him steadily, filled with curiousity. Where does this contempt come from? What does it do to him? I experience what I can only describe as warmth, expansiveness and loving compassion for him. I happily beam at him because he is representative of the journey that has reshaped me. I do not experience his hate as a terrible wound. I feel no fear. I am not shamed. In that moment and for a long while afterwards, I feel completely free. (Saira)

The implications of autoethnography for psychotherapy

I think about autoethnography interacting with psychotherapy not necessarily as an approach in itself or a distinct form of therapy, but as a set of attitudes towards self and other which can facilitate the creation of an internal bridging and connection. This means that rather than having a set of explicit tools to work with racist trauma, therapists are required to develop and seek out heightened processes of awareness and embodied ways of being. This awareness migrates into practice in a more accessible and less defensive way by helping the therapist engage in highly sensitive and profoundly painful areas of the client's story through varied subjectivities and reframing processes.

The interaction between autoethnography and psychotherapy is also a journey of personal discovery and a self-reflective process. This work became a therapeutically available surface that I could work on inside and outside my own therapy, transforming the relationships with those in research that I love.

For myself as a therapist, “this journey has enhanced my capacity to be more accessible and present in my client work”. I also feel more able to generate conversations and dialogue about racist trauma and the racial experiences of my clients in the therapeutic relationship. Through disentangling racism within myself and others, I find there is an encouragement of an alternative state of awareness that is more self-reflective, and less guilt-ridden and avoidant. This process produced a deepening of understanding and processing of self-generated and self-defined identities that was empowering as it undermined racist and racial stereotypes and helped me to encourage my clients to do so. I think I am better able to seek out such disconnections and attempt to create a worked for connectivity where I can be less constrained in my language and thinking, having developed the capacity to be more available to enter into the webs of racialised discourse in my clinical work and in myself.

Autoethnography can be a profoundly useful way of accessing memories of complex racially traumatic experiences that may be implicit and built upon sediments and layers of racial slights and injuries that contribute to psychological grief and social maladjustment. Skin colour plays an important part in structuring of the world, and the colour coding of the self and psyche. As therapists, we are called to work through this for ourselves and our clients; otherwise it will reappear as the therapist's unexamined countertransference and will perplex and confound the therapy.³ The engagement with otherness takes us out of what is seemingly familiar and encourages us to travel to alternative places within ourselves. It is from this position that I wish to dissolve detachment, isolation and marginalisation to create connections and healing.

Refuse to wither and die

These stories have found a home inside of me, and I realised that I have been writing this story for the whole of my life. Now that it is committed to paper, I can see how it has helped me to love.

Notes

2 Franks, A. At the Will of the Body: Reflections on Illness (Boston, Houghton Mifflin, 1991).

3 Dalal, F. Transcultural perspectives on psychodynamic therapy; Addressing external and internal realities in The Journal of Group Analysis, 30 (London, Sage publications 1997) p. 203.

4 Bronson, P. Why do I love these people: The families we come from and the families we form (London Harvill Secker, 2005).

For further information on authoethnography:

Ellis, C. The ethnographic 1, a methodological novel about autoethnography ( NY, Altamira, 2004).

Gottschalk, S., Banks, A. and Banks, S.T. Fiction and Social Science, By Ice or Fire, (Walnut Creek, Altamira, 1998).

Getting Off to a Powerful Start in Couples Therapy

Posted on by rezendevknowfully.com

I am pleased to offer you this lesson from my online couples therapy training program. It has been adapted from a lecture, and includes commentary from Michelle, our moderator, as well as comments from the audience. This will give you a glimpse into some of my principles for “Getting Off to a Strong Start” in Couples Therapy.

In this article, we’re going to focus on the following points:
  • Getting Off to a Strong Start
  • Three Types of Goals and Effective Goal Setting Questions
  • Six Essential Elements of Early Interviews
  • Developmental Change vs. Behavioral Change
  • Identifying Vulnerable Feelings
Speaking of “strong starts,” let’s get going on our lesson…

Getting Off to a Strong Start

Ellyn: Today, we’re going to talk about getting off to a very strong and powerful start in couples therapy. And I’m going to teach you principles that have to do with both your mental set, so how you think about what you’re doing in those early sessions and how you position yourself with clients; and I’ll also be teaching some specific how-to’s. But this is not a cookie-cutter approach.
 
You will be looking at integrating pieces of this in the way that works for you, and also integrating pieces in terms of what is best for the kind of couple that you’re working with. I’ll highlight some of the pieces that work better with some couples and some that work better with other types of couples.
 
First, getting off to a strong and powerful start means you being a leader. By the time you’re finished with this course, “I want you to feel like you are a leader—that you are active in your work, you’re not reactive, and that right from the beginning you’re getting the couple’s attention.”
 
You’re establishing yourself as somebody who is strong, and somebody who understands and is able to help them. Also, they’ll know that they’re going to do the work and that coming to therapy is not waiting for you to wave a magic wand. If they will do the work, there is hope they can get out of the conundrum that they’re presenting to you.
 
The tone that you set from the very beginning is crucial and is based on the answers to the following questions: Do you see pathology? Are you looking for pathology or are you looking for developmental stuck places?
 
Seeing impasses as developmental stuck spots will help you and your couple be more optimistic. You’ll be able to inspire them that they, in fact, can overcome and can get out of their negative cycles.
 
Your style and what you pay attention to will indeed determine the direction of the therapy. I am always thinking, “How do I challenge my clients to develop themselves and to look at the development of themselves as something that is positive, that’s exciting, that can be rewarding and not something that’s a drudge or way too difficult for them to do?”
 
There are predictable reasons for why relationships fail. The primary issues that most couples struggle with are:
  • There is a lack of development in either or both of the individual partners.
  • They have a repetitive history of re-triggering emotional trauma in each other and not repairing it.
  • They don’t have the ability to repair when they hurt or do damage to one another.
  • They lack skills or knowledge.
Couples often don’t understand why they are struggling. They think that there’s something wrong with them or something is inherently flawed about their relationship. When you are thinking about the couple in front of you, the goals that you are going to set fall in one of three main arenas:
  • The couple is coming to you for change, growth and development.
  • They are coming to dissolve the relationship, to be able, in fact, to say goodbye to one another, to go through a divorce or separation, to get help with the kids and the parenting and in the process of separation to resolve any resentment so it doesn’t fester and impair their future relationship or their parenting.
  • They need help making a decision. A common one is, “Should we stay together or separate?” Maybe one wants to have a child and the other one doesn’t, or there’s some kind of move or job promotion situation that’s creating enormous difficulty about whether they’re going to stay where they are or move. And of course, there is, “Shall we get married or shouldn’t we get married?”
You can slot each of your couples into one of these three areas as you begin to think about goals that make sense for them.

An effective couples therapist will, over time, become both decisive and incisive and be able to sustain positive momentum. So when the couple starts backtracking, or when they start getting bogged down, those are times that you want to intervene and intervene quickly so that you can keep the momentum moving forward in a positive way.
 
It is absolutely essential that you not get stuck in their negative cycles or allow their negative patterns to go on for a long time in front of you. You only need to see it briefly so you understand what they do.
 
Michelle: At that point, Ellyn might you point out the cycle that you’re seeing and explain it back to them?
 
Ellyn: Yes, I will point it out, because having a grip on the negative cycle is the beginning to disrupting it. It’s the first step of changing it. So as long as you’re sure that you’re not doing it in a negative, judgmental or critical way, pointing out their negative cycle can always be an effective intervention. What we’re going to look at a lot is the essential elements of early sessions and the whole process of goal setting.
 
Too many couples ignore their shortcomings and do not seek help until it is too late. Therefore you have people very often coming in to see you when they think it’s too late, when you might wonder if it’s too late—and indeed, sometimes it is too late. But the patterns have been going on a long time, and that’s why getting their attention and assessing with them whether they’re there to dig in and do the work is important. If the couple is ready to dig in and do the work, one of the things you want to ask yourself is do you have the time to see them? Do you have the time to work with them?
 
When I do a first session, I never do it shorter than a double session. It’s almost impossible to assess a couple, in my opinion, in a 50-minute hour. You’re talking about assessing two individuals and the relationship. Most of us would never spend just 25 minutes assessing an individual client, so I’m always asking people to come for a double session to begin with.
 
Usually when I’m getting started with a couple I want to see them frequently. I want to see them for a minimum of two-hour sessions, and this is especially true for those that are disorganized, hostile, fighting or on the verge of splitting up. It’s not a good idea to accept a couple who is in a bad situation if you’re not going to be able to make time for them in your schedule.
 

Essential Elements of Early Interviews

  • Make contact with each partner
  • Understand the problem
  • Name feelings being experienced
  • Empathically embellish those feelings
  • Describe the destructive cycle, but…
  • Set a clear direction… a way out (including delineating the importance of containment, repair and autonomous change)
  • Define your role and your expectations for them
These essential elements are spread out through the first couple of sessions. The first essential element is making positive contact with each partner. That is, establishing the relationship and being able to understand the problem from each partner’s perspective. Sometimes it takes more work to understand it from one partner’s perspective than the other.
 
As you’re listening, name feelings that you’re hearing that are being experienced. Be able to empathically embellish them, to describe the destructive cycle and point out a clear direction for change. Delineate the importance of each partner containing their reactivity. Another part of the early sessions is defining your role and expectations for them as clients.
 
Making contact is something every therapist learns in psychology or counseling 101. One way to assess how hard it’s going to be to make contact is to ask your clients when they first come in, “How do you feel about being here even though we haven’t done anything yet?”
 
Their responses to that question will let you know who’s going to be easy and who’s going to be difficult to connect with. It’s a common situation for one member of the couple to say, “I’m so relieved. I thought we would never get here. I’ve wanted to come for a really long time. I’m glad we’re here,” and for another member of the couple to say something like, “I don’t believe in therapy. I didn’t want to come and I think this is just a waste of time.” It’s pretty obvious who’s going to be the harder partner to make contact with!
 
Other aspects of making contact include:
  • Being friendly, kind and interested.
  • Appreciating their anxiety. Couples therapy is more unpredictable than individual therapy.
  • Acknowledging lack of control over what the other partner says or does.
  • Hearing their story in the context of the structure you provide.
  • Giving lots of positive strokes can be highly valuable in the early sessions.
Particularly, I like to highlight areas where I see a partner taking a risk, where I see them making themselves vulnerable and where they’re stretching themselves. I will do a lot of positive stroking of those aspects rather than focusing on anything that I think is contributing to their cycle. I also think it’s helpful to appreciate their anxiety. “Couples therapy is harder in many ways for partners to come to than individual therapy. They think to themselves, “It’s unpredictable what my partner is going to say about me.”” In individual therapy we have complete control over that, but in couples therapy they’re often anxious about what’s going to be revealed.
 
Another thing I would let the couple know is that I will provide a safe structure and context for them to tell me their story. So if the partner keeps interrupting or keeps saying, “No, it didn’t happen that way,” I’ll say, “Wait, stop. I want to hear the story from each of your perspectives.” I want to get the whole picture and not let them be interrupted by the other one.
 
Michelle: Can you say a little bit about the beginning of the session when you ask them the question, “How do you both feel about being here?” and one person seems motivated and the other one not? Can you tell me what you do with that information? Do you orient the sessions differently?
 
Ellyn: Yes. When one person says they’re motivated and the other person says they’re not, I know it’s going to be essential for me to make contact with the partner who’s not motivated. I’m going to be especially observant about how I make a connection with that partner.
 
“Sometimes making that connection might be as simple as saying, “I’m glad that you came in today. Do you know that you can come to couples therapy and not have to change anything about yourself?”” Because they are so afraid that the focus is going to be on them and that they are going to be required to change. You will always have better buy-in for homework with the motivated client. So I am less likely to give the unmotivated client homework until I have a stronger connection with them.
 
I’m working to understand the couple’s problem both cognitively and affectively. The problem that they are bringing to me is usually understandable based on a couple of things: It’s understandable and predictable based on the attachment style of each partner. It’s also predictable based on the developmental stage. For example, if the couple has been together more than two years and they’re still stuck at the symbiotic stage, that’s going to be a problem, and that’s going to require them to be able to work in the area of differentiation.
 
The problems that they’re coming to you with will be a function of their arrested development—and once you have a full understanding of our Developmental Model of Couples Therapy, you’ll be able to describe that to them. It’s also predictable based on how long the partners have been together. A couple that’s been together just six months is not going to have any effective differentiation and I can’t possibly expect that they would.
 
On the other hand, with a couple who’s been together for 10 years, has a chronic history of conflict avoidance and has never differentiated, I know that it’s going to take a lot of risk, push and challenge for them to get out of that if they’re going to change the core dynamic of their relationship. Part of understanding the problem is asking helpful, insightful questions. In that process I want them to begin to think more deeply about what they’re saying. I also want them to understand the problem from an emotional or affective standpoint, so I’m going to be feeding back a lot of their feelings as well.
 
Here is an example of how you might describe a destructive cycle. I made it a little more complex than you might with most couples just to put a variety of both feelings and behaviors into it. I might say to Sally, “When you feel hurt by something that Ted says, it’s difficult for you to tell him that you’re hurt or to request an apology. Instead, when you feel hurt, a part of you wants to hurt him back so you tend to criticize him.”
 
Then to Ted I might say, “When you feel criticized by Sally, your tendency is to disengage and withdraw. Sally then ends up feeling lonelier, and instead of the two of you being able to repair and reconnect, the cycle keeps escalating. It keeps repeating and each of you is left in pain.”
 
Then I might ask them how they’re responding to what I’ve just said. And I look for their non-verbal cues, as well, to see if they agree with me. Are they connecting with what I’m saying, and does it make sense to them? Then you are able to not only connect with their feelings, but empathically embellish on them even more. The more you empathically embellish on your clients’ feelings, the more understood they’re going to feel, and the more able you’re going to be to confront that partner later on.
 
I want to have those moments of good empathic connection early on. Those might come from commenting on their deep loneliness or their helplessness, or you might say to a client, “You have tried and tried. You’ve tried everything and you’ve been really stuck, because nothing at all is changing. In fact, it looks to me like at this point you’re beside yourself with frustration and you wonder if there’s even a way out.”
 
A lot of people will nod their heads or begin to cry. They really know that you know how hard it has been for them, because they have been trying. And they didn’t know what to do. They didn’t know how to get out of that stuck position. So they might feel like you get and understands them.
 

Goal Setting

Michelle: A lot of couples at that point will also say, “Yes, you’ve got it.” Their anxiety will come up and they’ll say, “Okay, so what do we do about it?” And they’ll want to move fast at that point.
 
Ellyn: Right. And because they want to move fast, that can actually be a good bridge to goal setting. It’s not enough to be understood. I know that it is going to take change on the part of each person to change the dynamics between them. So I’m going to spend some time now talking to you about goal setting.
 
When you hear the words “set goals,” it’s so prevalent in our culture that it sounds like it should be something easy to do. And yet “to do good goal setting with couples is an incredibly sophisticated and complex skill that takes time.” It’s usually integrated into several sessions. It’s not something you can do in just one session unless you have an incredibly insightful couple who’s been in therapy before and they know what they want to do.
 
The more disorganized the couple is or the more hostility there is, the more challenging it’s going to be for you to arrive at effective goals. And I want you to come away from this lesson actually being able to reflect on the couples that you’re seeing and really ask yourself, “In which of these cases do I have strong goals that make sense and that will help move this couple forward?”
 
If your answer to yourself is, “I don’t” for any particular couple, then you can back up and say, “This is a good time to reassess. Let’s see what we can look at as the next goals to undertake.” One of my favorite cartoons is of two couples talking in one couple’s living room. One says to the other, “The work being done on your marriage… are you having it done or are you doing it yourselves?”
 
The reason I love this cartoon is because so many couples wish that the work would be done for them. They come in either hoping that you have a magic wand that you’ll wave to change their partner or that they can sit back, wait and watch for their partner to change.
 
That’s why the skill of getting each person invested in changing something about themselves that will move the relationship forward means that you’re dealing usually with character issues in each partner. You’re also dealing with motivation issues and possible resistance to therapy issues.
 
What is an effective goal? To me an effective goal is one that requires an individual to do some self-reflection and self-confrontation. And you’re asking the couple about their values and you’re implying that a change is needed in their pattern of reactivity. You’re asking them to self-select some new standard of behavior and to hold themselves accountable to whatever the change is that they are working on.
 
One way to think of the change needed in their reactivity is to think about what this person needs to stop doing in order to create the space for change to occur. You might think about it in terms of what this partner needs to start doing, or what both of them need to do differently that would enable them to take risks and move themselves forward.
 
Michelle: Ellyn, do you ever explain to your couples the concept of making a shift within themselves? I think that’s counter-intuitive to most couples when they come in, because they believe the problem is with their partner.
 
Ellyn: Yes, I do, and one of the things I talk about with some couples is the principle of autonomous change. What I mean is, not saying, “I will only change if you change,” which is a common thing that partners do—they tie their changes to whatever the other person does. I tell them, "If you make changes regardless of what your partner does, you will be able to have a very rich learning opportunity, because as you make changes, you’re going to see what unfolds; you may be very pleasantly surprised by the changes that start to occur, or you may find that your partner does nothing." Saying something like that is actually directed at both partners, including the partner who may be inclined to do nothing because they’ll realize that it’s going to be observed if they, in fact, are doing nothing.
 
A good solid goal will be clear and it will contain action and behavior. You and I know some about the intrapsychic change that’s behind any particular behavior, but by putting it in behavioral terms for them it becomes concrete and somewhat measurable.
 
When you’re looking for these changes in behaviors and actions, you’re also looking at whether the person has a real motivation to accomplish them. If there’s no motivation to change, it’s a useless goal and not one that I want to accept.
 
If somebody says to me, “I should pick up more clutter. I should pick up after myself,” I might say back to them, “I wonder how badly you really want to do that. Is that something you want for yourself or something that you think somebody else is telling you that you should do?”
 
Usually they’ll say, “I’m getting so much criticism from my partner that of course I think I should do it.”
 
And I might say back to them, “I wonder how picking up would be helpful to you. Is there anything that you can see that would motivate you to begin to pick up more?”
 
That can go into a 20- or 30-minute conversation until you get the piece of motivation that would genuinely be motivating for that partner to start to clean up more clutter. You’re always looking for goals that are individually focused, not dependent on what the other person does. The goals can be contradictory, and by that I mean even as extreme as one partner saying, “I’m here to get help with ending this marriage and I’d like to do some of the steps that are involved to end this marriage in a good way.” The other person might say, “I’m here to build a positive marriage and I do not want this marriage to end.”
 
Even though these are such contradictory directions that will create anxiety in the room, they are genuine for each partner. And then you can figure out what that literally means for each of them to be able to carry those goals out. Always remember that knowing the presenting problem is not a goal. Typically, couples will say things like, “We have a communication problem and we need to communicate better.” Nothing about that is a goal.
 
“Don’t assume you have goals and objectives when you know the presenting problem.” When you ask most couples why they are there, the typical response is a description of their partner’s failures, shortcomings and things they do badly. They want to get relief by having their partner make the necessary changes. It’s very rare for them to describe to you what they need to do in order to strengthen the relationship.
 

Homework Assignments

Over the years I’ve challenged myself to come up with lots of different ways of setting goals with couples. I’ve used lots of different kinds of questionnaires, and I’m encouraging you all to experiment with what works for you in your practice and what works with different kinds of clients.
 
One very simple form instructs them over the week to go home and answer the following five questions:
 
What type of relationship do you want to create? I give them examples to help get them started: “You might say you want to create a loving intimate relationship, a relationship with a lot of team work. You might say you want a more companionate relationship.”
 
How do you want to be as a partner? This is asking for a frank self-assessment. How do they in fact want to be? Do they want to be somebody who makes time for the relationship, somebody who wants to negotiate solutions that are working for both people? How do they want to be in their day-in-and-day-out life?
 
What do you want to learn about yourself or the relationship? This is a request for cognitive knowledge that each partner would like to obtain. An example would be understanding your patterns as a reflection of some early childhood experiences.
 
What do you want to stop doing? Common examples are blaming, name-calling, withdrawing, or avoiding conflict.
 
What do you want to start doing instead? In evaluating responses to this question you are looking for constructive behavior that each partner will do when they stop doing the behavior that is contributing to the negative cycle.
 
Before I have people take it home and fill it out, I give them some examples of answers. A lot of times people will say things like, “I want to stop blaming and criticizing. I want to start giving my partner more positive strokes. I want to start saying what I appreciate and I want to start looking for more win-win resolutions.”
 
I ask them not to share their answers with each other until they come back the following session. Then I have them read their responses to each other and we work at refining what makes sense as a goal. You can also use this form to assess their progress as you go through the next few weeks.
 
Here’s another questionnaire I sometimes give couples as homework:
  • What do I want to learn or understand?
  • What do I want to stop doing? 
  • What do I want to start doing differently to build a more loving, giving relationship? 
  • What is most urgent for me?
One couple, Cindy and Jack, answered these questions. When they came back here’s what they had written:
 
Jack said, “I want to learn where my blind spots are that come from my family of origin. I want to stop withdrawing, and start being less defensive. It’s urgent that I be more able to do what I want to do.”
 
Cindy came back and said, “I want to learn about where I get stuck in loving my husband. I want to stop being like his mother and accept that I am his equal. It’s urgent that the abundance in our relationship continue.”

What do you think is wrong with these goals?
 
Participant: I think that neither one of them actually said something concrete about what they could do. They talk about what they want to happen, but they aren’t coming up with anything concrete that they could do.
 
Ellyn: That’s right.
 
Participant: “Learning my blind spot” might be necessary to understand and to stop withdrawing, but under what circumstances or how would he do that?
 
Ellyn: That’s right. There’s nothing concrete here; it’s vague. You don’t get a sense of what they’re going to do. With Cindy we don’t have any idea of how she might be like his mother and why it would be important for her to stop being like his mother. “When you ask the question about what’s most urgent, urgent usually has a timeline, not something so open-ended as wishing for “the abundance in our relationship to continue.””
 
For Jack, you can’t picture what he really means by being less defensive. And when he said that it’s more urgent that he be able to do what he wants to do, I wanted to know what kinds of things he wants to do. When I pursued that with Jack, he felt like it was completely impossible to spend any of his non-work time away from Cindy. When we began to define it further, one of the things that was urgent for Jack was to have the ability to have some individual time alone each week. And then it went even further that he wanted to be able to take some golf lessons. So we were getting into something that could disrupt the intensity of this enmeshed, conflict-avoiding couple.
 
Next Cindy started to refine her goals and it shifted to, “I want to understand why I feel depressed when Jack and I disagree. I want to stop walking out of the room when we have a disagreement. I’d like to learn how to talk through a conflict from beginning to end, and be willing to listen to Jack’s side. And it’s urgent that I stop catastrophizing conflict to mean that the marriage is over.” She was a very conflict-avoiding partner who was fearful. She would become extremely anxious at any moment there was conflict and because she would get so anxious she would leave, disengage, or get out so that the conflict couldn’t surface. She was terrified that conflict would end the marriage.
 
I talk about the principle of character a lot with couples: when you’re in a committed partnership, it tests your character. It tests your character in a way that most other relationships don’t test your character. It’s easy to be nice, warm and loving when you fall in love with somebody. And it’s easy to be nice, kind and loving when everything is going right. But when your partner acts like a human being, do you get indignant?
 
Do you get incensed that your partner is human and has normal flaws? Can you accept that maybe your partner gets a little anxious and testy if they think you’re going to be late for an airplane? Or if they’ve had two or three cranky kids all day long and feel spent, when you walk in the door and they don’t say “hello” to you in the best possible way, can you give them a break? Can you be forgiving?
 

The Three-Circle Exercise

To finish up this lesson, I am going to give you one more concrete way to set goals. At the end of the article, you will find a diagram with three circles, called “Uncovering Vulnerability and Shifting Negative Patterns.” This three-circle exercise is a way to establish more effective goals.
 
I ask partners, “When you are at your worst, how do you act with each other?” Sometimes I’ll even brainstorm a list and put it on a white board that I have in my office. We’ll create a little list of things like “get critical, blame, yell and break things.” Encourage them to tell you what they do when they’re at their worst. I choose four of the items in this list and write them in the circle diagram.
 
The next part is tricky. “Ask them to tell you the emotion that is hardest for them to show to their partner when they’re at their worst. When they’re at their worst the way that they act is covering a more vulnerable feeling.” In this particular case one client said, “When I puff up and get grandiose I’m covering up fear.” We worked to get to that. “When I break possessions I tend to be hiding the fact that I feel a lot of shame. When I scream and escalate it’s usually covering up the fact that I feel inadequate and helpless. When I yell, I don’t want my partner to see that I’m feeling very vulnerable or fearful.” Write four of their answers in the second circle diagram.
 
Then circle number three is designed for what they want to do instead of these things. When they’re at their worst, what do they want to shift that will make a definite change in the relationship? And here what that client said was, “What I want to do instead is I want to say that I’m frightened, be able to admit that I did something that may have been stupid and unthinking, and know that that’s just human. I also want to be able to take deep breaths and be able to take a timeout.” And the last one was, “I want to be able to say ‘I don’t know how to help you now,’ to my wife.”
 
I sometimes ask clients to take these diagrams home and post them somewhere that feels comfortable: somewhere they can look at them and refer to them. It gives you a wonderful tool when they come back and they’re talking about having had a difficult fight or difficult interaction. You can ask, “Where does it fit on here? Were you able to stretch at all? Were you able to do something new? Were you able to take a risk? Were you able to show your fear? Were you able to show that you felt vulnerable?” This is a powerful way to set some effective goals.
 

Conclusion

One way to know if your goals are effective is to see if the partners begin to grow and change. Over time they’ll assume new roles with each other, new responsibilities, and new ways of being. And the relationship will begin to move through its stages of development and become increasingly more interdependent.
 
I want you to ask yourselves, “Is there noticeable change in the couples and partners I’m working with or are they just spinning their wheels?” If they are spinning their wheels I would say it’s time to go back and reset goals with them. Couples work is one of the most rewarding, wonderful things you can do with your time and it will always challenge you to stretch and grow. It is not for the faint of heart.
 
If you would like to learn more about the couples therapy training program from which this lesson was excerpted, please go to http://www.couplesinstitutetraining.com/developmentalmodel. Or if you’d like to read a handout to prepare your couples for being in couples therapy please go to http://www.couplesinstitute.com/freehandout.