Category: Cognitive-Behavioral (CBT)

For the Love of the Game

Posted on by rezendevknowfully.com

Have you ever had a client who asserts they do not need counseling, yet there they are, sitting with you? I have experienced this on more than one occasion. With these clients, I must often find creative ways to connect with them that offer a less threatening entry to the idea of talking to someone about life and their feelings about it.

A Reluctant Player Picks Up the Ball

One client in particular stands out, and I’m especially grateful to one of my counselors-in-training who helped build the bridge that allowed me to break through the client’s defensiveness. That moment opened the door to a genuine connection—one that invited him to work alongside me to improve his quality of life.

George was a 35-year-old male sitting in my office because his wife told him to get help or that she was going to leave. He had heard of me from a friend and that I was “good with military stuff” and since he was a Veteran, “well, here I am.” During our intake, George shared that he did not think his military time was relevant to his wife’s ultimatum. He said that she was often frustrated that after returning from work he would rather spend time watching sports than spending time with her. George didn’t perceive this to be a problem and thought she might simply be experiencing a period of neediness.

Around the time I was working with George, I had a counseling student/basketball coach who often used basketball metaphors for his own clinical skill development. Talk about opportune timing! I remember during one particular skills class he said that he had to overcome hurdles to complete one of his more challenging assignments. He said that this process wasn’t much different from reviewing a game replay film. This is when I realized how much I was learning from my student, so I decided to reach out to him to collaborate on this essay. I’m grateful to share that this marked the beginning of our journey together.

The Game Plan: Basketball as a Metaphor for Counseling

Working alongside my student taught me a great deal about the parallels between counseling and basketball, success in which depends upon continuous, real-time collaboration between the coaches and players to overcome barriers to victory.

Off the court and in the therapy space, making changes, evaluating resources, and identifying barriers are necessities. Often, clients start by presenting all the resources and support that are available to them. They discern throughout their counseling what issues they need to take to the court and which can remain on the bench. This process is parallel to the moment when coaches have to make the decision to bench a particular player for their own good or for that of the team.

In basketball, a player may indeed be able to score a few points, but giving them the chance to do so may not support the needs of the team as a whole or the be the best strategy for winning. Winning, even with the best players can still be a challenge. Unpredictability on the court is common and upsets happen. Just as in life, and in the therapy space in particular, unpredictable twists and turns must be considered, and strategies need to be revised. When working with George, where I was the counselor, but also a coach of sorts, we had to work together in order to discern clear goals and his true desires for the marriage.

The concept of “team” offered a useful metaphor for George’s place in the family. While I was working with him individually, I had to keep my eye on his team, or system. I had to account for both him and his “team.” He had come to counseling because his wife, his teammate, provided him with an ultimatum to go, or their marriage would end. The idea of losing her was not something he was willing to risk. That was not his goal, so we needed to strategize to come up with a game plan that would lead him, and his wife, to marital victory.

I was able to carefully navigate George’s system to understand his role within it, as well as explore his personal perception of what marriage and family meant, and the behavioral implications for not just him, but his “team.” I was able to reflect on his circumstances as if we were reviewing a game film. And just as game videos help players understand the difference between what occurred on the court and what they want to do differently next time, George was able to review, re-evaluate, and strategize before he resumed ‘marital play’ with his wife. Together, we created a therapeutic locker room, a nonjudgmental space to examine not only what was best for him, but also for his team.

This “locker room conversation” led to an exploration with George about his relationship with his wife, what he had to offer, and what he wanted in return, or in short, what he brought to the court of his marriage and what he needed in return. Even when players are at the top of their game, there are times when they need to come off the court and onto the sideline for both their own benefit and that of the team’s. The metaphor of shifting to the sideline and the “bench” to calmly and objectively re-evaluate his “game plan” seemed critical at this juncture in his marriage. Consultation with the coaching staff—me, in this case, served as a useful, and hopefully, productive “time out” in which George could decide what changes he wanted to make, if any.
I was able to process George’s strengths and weaknesses to support his awareness, processing, and empowerment towards goals. Coaches aid their athletes in understanding their skillset, areas in need of growth, and seek to empower them to improve upon their abilities to excel. To reach goals and excel requires analysis of strategies. Some skill sets may be more beneficial at specific times while others need to take the bench and allow their teammates to perform in order to obtain the overarching goal.

Collaboration between the clinician and client(s) and the coach and athlete(s) are essential to advance towards goal attainment. During George’s last session with me, he shared his fondness for a basketball movie called, For the Love of the Game. It was an apt ending for our work together, the results of which he could hopefully take back onto the court of his marriage.

Takeaways

I could have spent hours researching the sport, but true understanding only came through learning from someone who genuinely loves the game and is eager to share that passion. In the same way, I’m grateful to model for my student that even the most seasoned clinicians remain open to growth and committed to refining their skills.

Postscript: In working on this piece with Dr. Arcuri-Sanders, I (Daniel) was touched and honored to hear how she incorporated some of my thoughts and love for basketball into her clinical work with George. I felt validated in my pursuit of counseling licensure, my passion for basketball, and being able to connect the two.

The Anxiety Disorder Game

Posted on by rezendevknowfully.com

The Anxiety Disorder Game

What causes someone to commit so strongly to the need to avoid doubt and distress?

Imagine a man standing in front of an audience and suddenly being unable to think clearly enough to speak his next sentence, finally stumbling through, putting a quick death to his speech and walking out of the room in humiliation. It would be expected that he would worry about how bad the next time might be, even envisioning himself in a repeat performance. Picture a woman on a bumpy flight, unexpectedly becoming terrified of deadly danger, and not being able to calm herself until the turbulence ended. It would be no surprise if she avoided future flights anytime the weather seemed less than ideal. Consider a father suffering from obsessive-compulsive images of choking his infant daughter. That graphic horror would compel any loving parent to avoid being alone with his child.

An almost instinctive reaction to these traumatic events is adaptation, however not all adaptation is psychologically healthy. Unhealthy adaptation could include exaggerated worries, anxiety, and inhibition of the capacity to act on their environment in an attempt to create a feeling of safety or avoid these threats in the future. If these maladaptive responses continue then the person will develop an anxiety disorder. If we look more closely, it seems that many of these same people begin to develop a general maladaptive framework for operating in the world. Safety becomes of paramount importance. The person with an anxiety disorder believes that losing control of their feelings or circumstances can come quickly and easily. Given that belief, avoidance is an easily adopted strategy. When the person with an anxiety disorder avoids, vigilance becomes their primary safety behavior. Once they recognize a potentially troubling situation, they want to end it immediately. If their heart starts racing and their head gets woozy, they fight to get rid of that discomfort as fast as they can. If the discomfort cannot be stopped by escaping, then they begin what they think is a problem-solving process, however this is not problem-solving but only excessive worry.

The goals of worry make perfectly good sense given the crippling anxiety people have experienced. The problem is that this strategy only serves to increase the problems that they are designed to prevent. When we resist the physical symptoms of anxiety, we ensure that anxiety will continue. The adrenals secrete that muscle-tensing, heart-racing epinephrine through the body, the brain matches it, and we will become more anxious.

Using worry to solve problems will backfire. Worry is a problem-generating process since it causes people to think more about how things might go wrong than about how to correct difficulties. “The human mind is built to worry. Worry helps us to prioritize our tasks, and provides us drive to get each task done by kick-starting the problem-solving process.” People who are prone to anxiety doubt that they have the inner resources to manage their problems, so they use worry to brace for the worst outcome in an erroneous belief that they are productively preparing for the negative event.

Two other tendencies contribute to their struggles. Anxious people don’t want to make mistakes, believing they will have dire consequences. They also don’t want to feel any distress, and the goal of the worry is to stop or avoid uncomfortable symptoms as soon as they arise. That message—“don’t get tense!”—is a sure way to create a self-fulfilling prophecy.

All these tactics together become a powerful force structured within a powerful fortress that drives the decisions of anxious people. They follow a belief system—a schema—that tells them how they should respond to doubt and distress. The belief systems of some clients are so strong that they ride roughshod over the therapeutic strategies we employ. No matter what instructions and techniques we give clients, their overriding unconscious and usually conscious, goals are to end the doubt and distress.

Much of my understanding of these drives, to avoid discomfort and seek certainty at all costs, grew out of years of failures. If I began treatment by teaching someone brief relaxation skills, they would incorporate those skills into their strategy of trying to keep the anxiety at bay. If I offered assignments counter to their defensive belief system, clients would not follow-up on the homework, or they would become confused after leaving a session. If I were especially effective in persuading them of the importance of practicing skills, they would simply drop out of treatment.

For over twenty-five years I have gradually modified cognitive-behavioral treatment that included relaxation training, breathing skills, cognitive restructuring and exposure strategies, to address the special issues created by anxiety disorders. By 1992, for instance, I drew on dozens of discrete techniques, some old standards along with some new procedures, to help my panic disorder clients alleviate distress. But as the years passed, I felt that technique alone was insufficient. My experience taught me that if we focus on techniques without first challenging their beliefs, then their fear-based schema will overpower our suggestions.

Personifying Anxiety

Anxiety disorders have a clear strategy to dominate. They condition the person to three contexts: the situation that stimulated their fear, the fear reaction itself, and their use of avoidance as a coping mechanism. The person creates a defensive relationship with each of these: to become doubtful and anxious when approaching that situation, to feel threatened by their anxiety and want to get rid of it, and to avoid when necessary to stay in control. These strategies are incorporated both into the neurology and the belief system of the person. Each interpretation and behavior in response to anxiety is directly linked to this frame of reference. I use a cognitive approach in which most of the therapeutic time is spent addressing clients’ relationship towards the anxiety, not the anxiety itself. My goal is to teach clients therapeutic principles powerful enough to offset their faulty beliefs that they must battle anxiety and must become relaxed again quickly. Clients learn to mentally step back, away from a poor quality interpretation of the situation (“this is a threat”) and a failing strategy to respond to it (“I must stop it”).

In most ways, this approach matches the standard cognitive-behavioral protocol. However, this is also where I begin to diverge from some standard CBT strategies. To win over fearful anxiety, I believe the therapeutic strategy must meet the following conditions.

1. It must be able to compete with the power of fear and distress. This includes creating an emotional shift that is strong enough to match the drama of anxiety.

2. It needs to have a simple frame of reference that makes sense to the client. My most consistent task with anxiety clients is to keep a clear-cut message at the heart of our discussions. The sharper I am about a few points, and the more emphatic I am about using them as guiding principles, the more successful I am at influencing the client’s point of view.

3. It needs to provide a clear system to follow, with simple rules that guide their actions during fearful anxiety. Otherwise, consciousness gets swallowed up by the fortress of conditioning.

4. It needs to permanently influence neurology or, said another way, their physiological reaction to anxiety.

5. It needs to involve tasks that they feel are within their skill set.

6. It needs to help them feel in control instead of out-of-control. Anxious people regard themselves as victims of the anxiety condition. I want clients to feel in charge, to see themselves as the subject, not the object.

7. It needs to be simple enough and available enough for them to utilize during a confusing, anxiety-provoking situation.

Shifting the Client’s Game Plan

Anxiety disorders play a mental game and they create a game board with rules stacked in their favor. Anxiety wants to distract us by getting us to focus on the content and then to attempt to prevent problems being solved within that content area. For instance, in OCD the content is the possibility of causing harm to self or others through carelessness. In generalized anxiety disorder, it is worry about health concerns, money, relationships or work performance. In social anxiety it is the fear of criticism or rejection from others. This is a clever misdirection, since the true nature of the game is the struggle with the generic themes of doubt and distress. The end result is that the actual problems and solutions to the problems that drive the anxiety are not clear to the client.

The disorder only wins if clients continue to play their expected role. If instead they can see the pragmatic opportunities for viewing their anxiety as a mental game, then we can begin to generate a framework to manipulate. Early in treatment I want to accomplish two goals. First, I want clients to recognize this distinction between the content they have been focusing on and the actual issues of doubt and distress that they must address. Second, I want them to take a mental stance and take actions in the world that are the opposite of what anxiety expects of them. “Anxiety wins when clients seek certainty and comfort. “My goal is to persuade clients to go out into the world and purposely look for opportunities to get uncertain and anxious in their threatening arenas.

For instance, learning the skills of relaxation can be a great asset to recovery. But in training to win against anxiety, it is counter-productive to try to stay relaxed. It is best to seek out discomfort. This is one of the biggest early struggles for clients in treatment: to honestly take the stance of wanting to face the symptoms.

Fortunately, I wasn’t alone in creating such a new strategy. In addition to Eastern philosophy and principles of Zen Buddhism, my guides were Victor Frankl’s paradoxical intention, Paul Watzlawick’s reframing, which stems from the Mental Research Institute’s concept of second order change, and Milton Erickson’s fractionation and pattern disruption. Frankl’s work encourages the client to generate the physical symptoms he most avoids. Watzlawick and his colleagues were the first to define reframing as altering the perception of the problem, the solutions and client resources in such a way as to reinforce therapeutic interventions. Erickson’s fractional approach and pattern disruption aim to make small changes in the pattern of client behavior and the external circumstances instead of opposing the behavior and circumstances.

The Moves of the Game

There is an existential game to learn when dealing with anxiety symptoms. People make a judgment that the symptoms of anxiety are unwanted intruders and threatening enemies and they want the trouble to end. They keep hoping that one day they won’t experience any of these symptoms. Thus, they become trapped by their expectations. Existentially, there is no need for such judgment. The symptoms of anxiety disorders can simply exist, without being deemed good or bad. The anxiety disorder wins when clients judge the symptoms to be wrong and to be banished. In order to win over anxiety, they need to start by stepping back from their current experience, observing it and labeling it as acceptable to them in the present moment. Sounds simple enough in theory, and in the end, clients who recover will master this skill. They learn to stop playing the game by anxiety’s rules. But initially it takes all the clever persuasion a therapist can muster to unhinge clients from their old frames of reference.

In Chart 1 you will see some possible responses to the symptoms of doubt and distress. Clients enter treatment in the position of resistance. In their most resistant position they say, ‘This is horrible. I’ll lose if this happens.” Even the stance of “I don’t want this to happen” gives anxiety the upper hand, because the mind and body will move into battle mode. Ideally, if clients can respond by saying “yes” to the encounter, and accept exactly what they are experiencing in that moment then they will be back in control.

But for many, the anxiety disorder has become so dominant that the client cannot make such a shift directly. As they attempt to accept their doubt and distress, they do so in order for that discomfort to go away. They are still oriented in their natural position of resisting the symptoms. They are more likely to say, “Let me try relaxing into this situation, and I hope this works, because I’ve got to get rid of this feeling.” The skills associated with permitting the symptoms to exist often allow the client to slide right back into resisting.

For those cases, the game takes a different tact. We re-direct the attention of clients away from fighting the symptoms and purposely toward encouraging them. They choose to act as though the symptoms are good instead of bad, and something to be held onto, even encouraged instead of rejected. As clients master this game and learn its lessons, they develop the insights needed to shift toward a non-attached relationship. If they can endure the discomfort, they can learn. I created this framework of a game to help them endure and to teach them three overarching goals.

1) Step back and identify it as a game
The first critical move is to step away from the drama, observe the event and name it. In meditation and in moments of relative quiet mindfulness, when the struggle isn’t great, you simply “step back.” You let go of your attachment to the thoughts. With anxiety disorders, in order to step back, clients must be able to label the event as one in which the anxiety is trying to dominate their mind. During threatening times, the drama is often too enticing to easily drop. They have already generated an automatic and rigid label that identifies the situation as one in which they should become aroused and worried, for example, “This is a true threat to me.” I encourage them to replace this with any message resembling: “OK, the game’s on: anxiety’s trying to get me to fight or avoid now.”

This is one of the advantages of the game. By training clients in a specific protocol and by strongly reinforcing that protocol, they begin to look for opportunities to practice and they become more astute observers of these moments.

2) Stand down 

Once they step back, they need to engage in a strategy to convey to their mind that it is time to “stand down.” The body and mind need help in backing away from the fight-flight mode. If, in the face of a threatening situation, they attempt to say, “I want this experience,” then the mind begins to have a choice other than battle stations.

Clients also need to stand down from the ego’s archetypal win-lose predisposition—winning by domination—and replace it by a more paradoxical strategy of winning by manipulating the challenger’s moves instead of blocking them.
Chart 2 details this next set of moves in the game. Resisting will play right into anxiety’s hands as the expected move. Instead, clients begin the process of standing down by using one of two strategies. Each move is designed to embrace doubt and distress instead of pushing them away.

Standing Down–The Permissive Skills

The first level of the game is to allow the anxiety to continue instead of trying to stop it.

This is manifested in the supportive statements, “It’s OK that I’m anxious,” “I can handle these feelings” and “I can manage this situation.” This approach has a paradoxical flair to it that people often miss. You take actions to manipulate the symptoms while simultaneously permitting the symptoms to exist. With physical symptoms you are saying, “It’s OK that I am anxious right now. I’m going to take some Calming Breaths and see if I settle down. If I do, then great. But if I stay anxious, that’s OK with me too.” We attempt to modify the symptoms without becoming attached to the need to accomplish the task. This is a critical juncture in the work and the therapist must track closely the client’s expected move of, “I’m going to apply these relaxation skills because I need to relax in this situation.” No! While it is fine to relax in an anxiety-provoking situation, it is not OK to insist that you relax. That’s how anxiety wins.We reverse a common American catchphrase by saying, in the face of anxiety, “Don’t just do something, stand there!” When enough epinephrine pumps through the body then the brain yells, “Run!” Consciously overriding this impulsive message takes great courage, but pays great dividends. It differs from desensitization where we help the client gradually approach the feared situation under relaxed conditions. Here we confront their instinct to seek out comfort and encourage them to remain physically anxious and mentally as calm as possible. Instead of believing that there is something broken, they simply accept the status quo.

Going Toward–The Provocative Skills

Many people consider acceptance a weak strategy in the face of the fortress of fear that has been built in the mind. They need to shift from the permissive stance (“It’s OK this is happening”) to the provocative stance (“I want more of this discomfort!”). Here they learn to encourage the symptoms instead of just accepting them. This strategy is extreme and can be thought of as fighting fire with fire. Fear is intense and acceptance is soft. Fear will trump calmness and acceptance every time. I help clients shift to an attitude of provocation that is equally as powerful as, and can compete with, fear. I teach them to use their willpower and conscious intention to seek out an even more rapid heartbeat, to encourage their feeling of contamination to grow even stronger, or to hope someone will notice their hands shaking.

Why this line of attack? Because we want to interrupt the dysfunctional pattern in the most effcient way possible. The straightforward way, using acceptance, is not necessarily the most effcient way because it tends to be susceptible to the clients’ dominant paradigm of resistance, for example, “Let me try to relax here and I hope this works, because if I panic that will be awful!” Consciousness only has so much attention at any given moment. During an anxious moment, I encourage clients to commit themselves to play the game, and to focus their limited attention on following the rules: try to get anxious on purpose by encouraging symptoms. If they will bring their attention to the task of encouraging, even cajoling symptoms to become more uncomfortable, or for doubt to grow exponentially, then they automatically withdraw attention from their fearful goal of ending the doubt and distress.

When I suggest homework activities to clients, I use expressions like, “how about playing with this move?” and “perhaps you can fool around with these responses.” I imply that these strategies are malleable and temporary: “What do you think about just experimenting a few times with this move and see what happens? We can talk about it next time.” For some, we will literally play a game in which they score points for various types of responses to their worry or anxiety, or they will have to pay a consequence when they avoid or engage in some ritual to help themselves feel safe instead of threatened. An example of this strategy can be seen in the case of Samuel. One of Samuel’s fears was that he might unknowingly have cuts around his fingernails and cuticles that would expose him to the AIDS virus while shaking hands at work. Throughout the workday he conducted brief checks of his ?ngers. I gave him the following assignment:

  • Go to the bank and get 40 fresh one-dollar bills.
  • As you leave home in the morning, fold them and place them in your left pocket.
  • Each time at work that you compulsively check your fingers you are to move a bill from your left to your right pocket.

This is a simple intervention, but I gave it to someone who was already oriented to the game. He knew that the only way to keep those dollars in his left pocket was to go toward his distress of not knowing if he was being exposed to AIDS. As he began the game, a typical email from him would say, “By the end of the day, I only had $10 in my right pocket!” There was something about adding that “game” that refocused his attention just enough to lower his struggle and raise his success rate.

I hear this from clients time and again: when they focus on scoring points, or avoiding a therapeutic consequence that we create together, they notice that they become less attentive to fighting the symptoms. When they disrupt their on-going relationship with anxiety by struggling to play the game, they spontaneously become more tolerant of the situation and their distress diminishes. Over time, as they learn the surprise benefits of this pattern disruption, they can congruently adopt the permissive style.

As you might imagine, these people are not easily persuaded to really want this experience. However, this is not the point of the exercise. The point is that they try to associate themselves to the task even if their initial attempts are clumsy. Clients can be encouraged to pretend to want their anxiety, like a role in acting class. This is a cognitive skill, so the work is directed to what they are mentally saying during practice. As they try to subvocalize as if they want to increase their doubt or discomfort, they will automatically dissociate from their typical negative interpretations.

If a client has trouble encouraging the physical symptoms, for example, “I can never want my hands to sweat,” then I suggest a minor shift in their focus. Instead of directly requesting physical symptoms to increase, I ask them to request that the anxiety disorder make the symptoms stronger. Instead of saying, “Come on! I really want to faint right now!,” they say, “please, anxiety, make me more dizzy.” This seems to be just enough misdirection and dissociation to make it tolerable to them, and accomplishes the same goal of competing with their resistance.

The central strategy of the game is for clients to want to embrace whatever the anxiety disorders want them to resist. One of the primary ways I convey the logic behind this wanting is by first defining the process of habituation: prolonged exposure to a feared situation, bringing about a significant decrease in fear.

Wanting Habituation

Habituation requires three elements: frequency, intensity and duration. You have to expose yourself to your feared situation often enough or you won’t progress. When you practice, you need to get up to a moderate level of distress. Practicing while you try to keep yourself calm actually slows your progress. Practicing between 45 to 90 minutes seems to be the ideal amount of time according to the research. These three components of habituation guide all homework assignments.

I think there is a fourth element missing: the spirit of wanting to experience what you need to experience. Clients progress much more rapidly when they desire to have the habituation experience. Unless they are seeking and wanting frequency, intensity and duration as they go toward fear, then by default, they will be trying to do the opposite. They hope they don’t get anxious, that the symptoms don’t get very strong and distress doesn’t last very long. This makes no logical sense to me. If frequency, intensity and duration of exposure to distress and doubt are needed for me to get better, then I want to stumble upon a situation which stimulates my anxiety. I want to do that often, and I want my distress to last, and I want the sensations to be strong. These elements create habituation and habituation is my ticket out the door away from suffering.

Cognitive-behavioral therapy does not teach this specific orientation to clients, although I think it should. If it did, it would alter clients’ disposition toward the problem, help to guide their practice, give them motivation and I’ll bet that it would alter neurochemistry as well. Analogously, if we are receiving chemotherapy for cancer treatment, it would be poor therapeutic form to go to each appointment dreading it, despite the fact that the side effects can truly be dreadful. Instead, you should see the chemotherapy as your friend, augmenting your body’s natural ability to heal. That’s good placebo.

The most important benefit of applying the skill of wanting is that it speeds healing by truncating the habituation process. Clients learn rather quickly that if they invest in the stance of wanting, it returns to them the gift of a rapid reduction in their anxiety. They gain insight sooner in the process, after fewer practices and after fewer minutes within each practice. When they apply the skills of the game during practice, they actually have quite a hard time keeping their distress high (try as they might) or having it linger around for those 45 minutes. By paradoxically applying the orientation of wanting, clients have an “aha” experience during practice that brings freedom.

3) Master the skills of the game through applying technique and practicing (or being a “good student of the work”)
I discuss with my clients the idea of “being a good student of the work.” Good students, of course, are clients who commit to following through on a homework assignment, and then work hard to keep their commitment.

One of Moira’s many OCD compulsions involved her needlepoint work. Frequently she felt compelled to tug on the thread ten times as she tightened a stitch. I offered her a new ritual to adopt. Each time she tugged more than once, on that next stitch she was to tug ten-plus-two times (12). The next stitch she had to subtract three to the number, tugging nine times. Ten on the next stitch, add two, and so forth, until she reached one tug. Her ten-tug stitch became a ritual involving 113 tugs in the next seventeen stitches. She hated that! But she did it, because she was a good student of the work. By forcing herself to stick with our little game, she increased her conscious awareness of her thoughts, feelings and urges during the moments just prior to her compulsive action. At the moment of the urge to pull more than once, she became alert to the punishing consequence. This strengthened her ability to turn away from it. Within a week, that compulsion was of her list of troubles.

Skills Meet Challenge

Doubt relates to clients’ perception that their skills won’t match the challenges they face. If their assignment is within their skill level, then they will be more willing to go forward. This usually means we must lower the challenge and offer them a performance goal within their perceived skill level.

If I am an OCD checker, and I think I have just run someone over, I may yet have the skill to resist my urge to turn the car around and check the highway again. But how about pulling over and running around my car one time before I turn around? I can do that. And now I have interrupted the pattern, which provides me an opening for further changes. One day, as I am having the urge to check, remembering that I now must pull the car over and run around it (again), I might spontaneously decide that that is simply too much effort. At that point I will drive on, and thus experience, with little suffering, exposure to my feared outcome without engaging in my ritual.

Score Points! Win Prizes!

The assigned tasks can be so challenging, so threatening to clients’ frame of reference that they refuse to practice. Even if they do practice, their early efforts may give them only small gains. I mentioned earlier that I create a frame of reference of addressing anxiety as a game in which you can score points. For some clients I create prizes as extrinsic rewards in the early learning phase. Sometimes I offer them metaphorical images, for example, “Imagine that if you walk all the way to the back of the store and stay there 10 minutes that I will magically transfer $10,000 into your savings account. Could you do it then? Play to win, as though your life depends upon it.”

Currently, I have a large woven basket full of prizes, wrapped as gifts. In my anxiety group I bargain with clients: “Anyone who completes three practices this week can draw from the basket.” I have been hiding a $5 bill within two of the prizes as an extra incentive. Last month I rewarded the group member who earned the most points over the previous week with her choice among 12 new self-help books.

Recently I have generated a competition in the group during a several-week period. I agreed that for each member who practices at least 3 times I would contribute $5 into a weekly “pot” of money. I devised a point system to be used for every practice session. Each person decides where and how he or she will practice. Whoever scores the most points, wins the pot. The winnings can grow to be $90.

As you review Chart 3, you can see the essence of the provocative game and the weight of each type of activity. These illustrate the goals I want them to set during practice. They reflect the essence of paradoxical action in fearful situations:

In a threatening situation, step back and become an observer of your process, not be 100% the actor in the drama. Decide to be glad about having the doubt or distress. Put a little light smile on your face or in the back of your mind to reflect it. Then, invite whatever struggle you are having, whether physical symptoms or worries, to stay. Work on trying to mean it. If possible, try to strengthen your move by intensifying your reaction. [For example, I offer nine different choices, such as the previously discussed demand that anxiety make the symptoms stronger.] No matter how strong the doubt and distress becomes, you should treat it as if it is never enough. Reward yourself for every minute you actively invite the symptoms to stay or to get stronger. Accept that other people might notice some problem you are having and for extra credit: hope that they do! Then, when you are done with the practice, learn to support yourself. Drop that critical, disappointed voice.Creating the point system has a number of benefits. The client and I establish a broad strategy together that is manifested through specific actions during practice times. But they pick the practice times to apply the skills. They answer the question, “What can I do today to create some strong uncomfortable feelings for a while?” As they act on this choice, they are empowered and feel a sense of control. Once they are in the anxiety-provoking moment, the point system directly guides them to the therapeutic action.

It is poor strategy to get into a threatening situation and then decide how to act. In that setting, they are competing with a well-habituated set of instructions (“brace, worry, and avoid if necessary.”) Clients are much more likely to regress back to their safe actions, or inactions. When they understand the rules of the game and commit themselves to follow those rules, then recall them as they face threats, they have the best chance of winning

Social Anxiety Strategies

Social anxiety disorder gives clients shaky hands, a quaking voice and worry about the critical judgments of others. Here is the role that it expects of the client: to not want the experience, to avoid it when possible, and to try to get rid of it. When choosing to play the game they ask for the opposite of what anxiety expects: they want anxiety to make their hands shake, their voice quake and their sense of threat heightened. Not only do they request those experiences, but they want them to stick around as long as possible! The clients then attempt to exaggerate their wanting of this experience, and might “desperately plead” for social anxiety to generate shaky hands, or to “cajole” the anxiety to make the experience stronger. They can increase their score by hoping that people will criticize their boring talk or question their shaky handwriting. Earn enough points, win a prize! They refuse to play the game that the anxiety disorder expects. They take charge and push that game board away and pull up their own game board of seeking out doubt and distress when anxiety wants them to defend or run.

Julie

Julie decides to practice facing her social anxiety by eating lunch out alone. She walks onto the lunchtime crowd of “Moe’s Southwest Grill” and is instantly greeted by the cooks and other staff. “Hello! Welcome to Moe’s!” they yell, and the other patrons turn to see who’s entered. Julie begins to feel the flush of red rise in her face as she smiles and nods her head in acknowledgement. Then inwardly she smiles and says to herself, “Yes! Another point.”

Here she describes the process. I’ve added my comments in brackets to her key statements.

“I was really nervous walking in there. I felt like everybody noticed that I was by myself. But that was OK, because that was the point of the whole practice. [She is listening in to her inner conversation and she is permitting her feelings instead of blocking them.] Then having to find a place to sit and making that conscious decision: Am I going to sit with my back facing everyone? Am I going to sit and actually have to look at everybody while they look at me? I made the choice to sit and look at everybody while they looked at me. [She is taking control of the situation by listening in on her process and choosing the more intimidating option.] …I reminded myself that the longer I could stay and the longer I could be nervous and be OK with it, then the better it would be for me. [She has adopted a new belief system about her goals in the fearful situation: stay anxious to win.]

“I thought about how I could make it stronger. I thought that facing everyone while I ate would keep the anxiety going. I was just trying to think of ways to keep the anxiety going. [She is actively strategizing how to provoke symptoms as a powerful way to help her stop resisting.]

“I’m not as afraid of social anxiety as a word because I’ve taken social anxiety and I’ve turned it into a person instead of a condition. It’s not a mother, it’s not a father, it’s just this person or this entity and she wants me to take care of myself. She doesn’t want me to be embarrassed. When I do something that she thinks I could not do, she is impressed. I really like that because it is not a judgmental thing. It is like someone saying, ‘You really should wear a jacket, it’s going to rain.’ But you go out there without a jacket and it doesn’t rain, and they say ‘OK, you did it; you’re still a good person.’ So that’s how I’m thinking about it. [She now comprehends that those ogres, worry and anxiety, have been in her life to help her. They just do it in a clumsy way and she has found a better way. Julie will win this game for good.]”

OCD Strategies

OCD wants the person to try to get rid of any doubts about safety and to take any actions necessary to remove distress. Many OCD clients who fear contamination really do believe that at the moment of exposure they must repeatedly wash to save their life or the life of someone they love. Personifying OCD, I emphasize how it needs them to believe the specifics of their fears. Clients who win over OCD will hold fast to the belief that this is an anxiety disorder. As such, their battle should be with the physical symptoms of anxiety and the urge to end doubt. They should by no means battle with the content of the obsessions. It is never about germs or rabies or salmonella. It is always related to the fear of feeling distressed about threat. To play the OCD game clients set the overarching goal of seeking out doubt and distress.

Eventually, everyone in OCD treatment will do exposure (of the feared stimulus) and ritual prevention, which is the standard treatment for this disorder. But modifying the ways clients obsess or how they perform the ritual is the most efficient starting point for many. Starting with small, lower-threat changes allows clients to practice their new skills and experience early success. Instead of not washing their hands at all after they feel contaminated, clients can change how they wash, where they wash, or what they are doing mentally while they wash.

Jai

Jai was living in a residential program for teens. He struggled with about a dozen different types of washing and cleaning rituals, especially when it was his turn to handle the after-meal cleanup. One ritual required that after he was finished with his (thorough) cleaning of the kitchen, he was to squeeze the sponge ten times while rinsing it under running water.

In our first treatment assignment I asked him if he would fool around with the ritual by switching hands each time he squeezed. In this case, Jai got to keep squeezing and keep counting. He simply altered hands, and switching hands was only a minor threat to him. This is what I call throwing the symptom cluster a bone. You leave in place major components of the ritual or obsession, thus lowering the threat level. However, it is still a change that begins to erode the original fortress of symptoms. He agreed to the assignment, and returned the next week to report how easy that task was. I then suggested this further revision: would he be willing to explore his ability to toss the sponge in the air and catch it with the other hand for each switch? Again, he agreed to this small, silly shift and returned the next week reporting no problems with the task. The following week, he simply squeezed one time and set the sponge down without struggle.

Jai’s playful approach to modifying his ritual became a relatively painless means to arrive at exposure and ritual prevention. It served as a building block for some of his more difficult later encounters with OCD.

Jordan

Jordan, a physician, feared contamination with germs that might come in contact with her clothes during the workday at her medical practice. One of her primary rituals was to spray the entire front of her body with ammoniated Windex® as she left work. She used that same Windex® throughout her home when she felt threatened by germs. Ironically, while Jordan obsessed about becoming sick, her husband, who was also a physician in her practice, was developing serious respiratory problems from inhaling the ammonia. Over months, Jordan worked hard to tolerate switching the Windex® to vinegar-based, then to dilute it to a 50% solution and finally to a 33% solution. Each of these steps increased her doubt just enough that she could tolerate it and experiment with the change. Once she implemented the change, she incorporated it into her routine without much struggle.

But we could progress no further with this or the other safety rituals she performed. Jordan was stuck on the content of her obsession: things had to be clean enough. I failed to persuade her that her attention actually needed to be focused on the strategy of confronting doubt and uncertainty.

Vann

Vann came into treatment struggling with OCD checking rituals that lasted up to five hours a day. Often his concern was that he had missed seeing something he should have noticed: new scratches or dents on the trash can, dust particles under the telephone, an inappropriate item in the basement. Other times he checked as a way to prevent a disaster: an electrical cord will be wrapped around the trash can; his son will trip over some item on his bedroom floor; a fire will start in the kitchen or a flood will occur in the basement. Some days Vann would check a particular item over a hundred times.

Our first ploys involved gently modifying his relationship with his symptoms. For instance, he would check the trash can, but only in slow motion, ever so gradually picking it up and unhurriedly rotating it in his vision. Or he would study the telephone, but not allow himself to touch it. These were his first playful explorations into uncertainty and distress. By the sixth session we added a strategy of postponing. OCD would give him the impulse to check the basement immediately. He would choose to wait thirty minutes before he acted on that urge, again learning to tolerate his discomfort. Through this gradual exposure to the principles, by session nine he was able to avoid locking his house for five days.

Here is how he described his progress by session 10:

“In the past I would pull out the backseat of the car, and if there were dirt there, I would have to clean it up. If a bolt was there I would look at it and get stuck on the backseat, focused on that bolt. Now I do this intentionally. I lift up the backseat and try to make something really bother me, try to feel anxious. I feel that anxiety, replace the backseat, shut the back door of the car and walk away.

When I first started walking away I felt really anxious. I wanted to go back and look at something under that seat again. I felt as though I didn’t look at it hard enough and I’d want to look at it again. I would sweat a little bit, my heart would beat faster, I’d become very irritable and I felt very compulsive. I wanted to go check again! But I just decided I wasn’t going to do it. Sure enough, about two hours later the desire went away.”

Vann completed his treatment in eleven sessions over 5 1/2 months. In a follow-up twelve years later, he remained symptom-free and medication-free.

Conclusion

I began this conversation saying that when I work with anxious clients, I keep my points broad and simple and I focus on them repeatedly. My goal is to influence clients’ perspectives and shift their orientation. I encourage you to try the same.

Help clients to turn away from the content of their fears whenever possible. You cannot always ignore content, because clients will be wrapped up in it. But get past content as soon as you can and move into the core themes of people with anxiety disorders: their struggle with doubt and distress.

The central strategy is for them to want to embrace whatever the anxiety disorders want them to resist. They have two choices. They can “stand down” by choosing to let go of their fearful attention and accept the reality of the current situation. This is the permissive approach. When they have completed treatment, this will be their most common response: to say, “I can handle this situation” and to allow their body and mind to become quieter. The other option is to choose to stay aroused on purpose and actually encourage anxiety to dish them more trouble. This provocative choice is an excellent option during treatment, because choice number one is so difficult to embrace during early encounters. Conditioning and a set of false beliefs are calling the shots; they cannot simply relax on cue. Some treatment protocols will suggest that you help them expose themselves to the fearful stimulus and learn that they can tolerate it. I am suggesting that you put a twist on that set of instructions. Help them to take actions in the world that are opposite of what anxiety expects of them. Persuade them to go out into the world and seek out opportunities to get uncertain and anxious in their threatening arenas. This is a shift in attitude, not behavior. The behavioral practice is not to learn to tolerate doubt and distress, it is to reinforce the attitude of wanting them.

Our ultimate goal is to teach clients a simple therapeutic orientation that they can manifest in most fearful circumstances. Early in treatment, however, you will also need to provide a specific system to follow, with simple rules that guide their interactions with fearful anxiety. Using behavioral practice, encourage them to repeat this new interaction again and again, in all their fearful situations.

You can assume that one of the biggest obstacles to success will be poor planning just moments before the encounter. Whenever they wait until they are scared before deciding the best course of action, then conditioning and faulty beliefs will dictate that they struggle or avoid. In that setting, they are trained by fear to mindlessly seek safety and comfort. Before they enter any situation that is potentially threatening, they should review their objectives and remind themselves of their intended responses.

Thinking of their relationship with anxiety as a mental game offers both a broad therapeutic point of reference and specific actions that manifest it. Initially, your skills of persuasion and their belief in you will push them to challenge their faulty beliefs. After that, experience will be their greatest teacher. Once they have acted on these beliefs and gotten feedback during the fear-inducing event, that learning will put the power in their new orientation and it will be self-sustaining. They will then have a set of instructions, such as “anxiety, please give me more” or “I’m looking for opportunities to get distressed” that will point them toward simple choices during difficult times. And they will have a skill set (that I laid out in Charts 2 and 3) that they believe will match the challenge of the situation.

On the Therapeutic Power of Presence

Posted on by Psychotherapy.net Team

I’ve been a psychologist for almost 40 years, and I am constantly amazed at just how much neuroscience research is enhancing my clinical understanding of what psychotherapy clients may really need most. What I would like to talk about here is how the concept of presence—a state of grounded awareness of the present moment—can inform clinical practice and enhance the everyday lives of our clients.

Why Presence Is Important

Presence is a state of mind of selective and sustained attention where one is intentionally and nonjudgmentally receptive to one’s own senses, is active in reflecting on them, and is consciously directing their awareness to the present moment (1, 2). Presence first requires an awareness that we have, a capacity to experience it, and second, it requires the skills to make it happen. All clients—and clinicians—are on a continuum of both, so each client requires interventions tailored to their individual level of awareness and skills. But I am discovering more and more just how crucial it is to help clients learn how to be present with both difficult and life-affirming emotions. That is, how to sit with, better tolerate, and more fully embody those moments without reactively fighting them, distancing themselves from them, or becoming frozen by them.

Psychotherapy interventions are almost always chosen in the moment, because the timing of them is believed to be most helpful to the client. Cognitive-behavioral therapists may highlight a cognitive distortion, like all-or-none thinking; psychodynamic therapists may bring attention to a protective defense, like projection; Gestalt therapists may suggest the use of an I-statement to replace impersonal or blaming language. Even though the clinician’s application of their theoretical approach may be executed with textbook precision, the intervention can fall short.

For example, if a client repeatedly returns to a conditioned or protective response to difficult situations by jumping to unwarranted conclusions, by blaming themselves or others, or by characteristically pushing away or distancing themselves from their feelings, the best interventions of the clinician may not be enough. This is particularly true if developmental trauma or significant episodic injuries have occurred. When a client has difficulty taking in, processing, or applying the clinician’s intervention, or when emotional underpinnings of their symptoms may be so severe that access to the resources needed to make use of the clinician’s interventions are not available, building skills of presence may be needed.

The concept of presence is foundational to all psychotherapies but especially to somatic psychotherapies. From the early developers like Wilhelm Reich’s Orgone Therapy, Thomas Hanna’s Hanna Somatics, Alexander Lowen’s Bioenergetic Analysis, Moshé Feldenkrais’s Feldenkrais Method, and Ron Kurtz’s Hakomi Method to more modern approaches like Lisbeth Marcher’s Bodynamic Analysis, Pat Ogden’s Sensorymotor Psychotherapy, Peter Levine’s Somatic Experiencing, Raja Selvam’s Integral Somatic Psychology, and from the diverse work of Bessel van der Kolk, clinical practitioners have learned that using mind-body practices opens up new ways to strengthen their effectiveness—particularly for clients with chronic, unresponsive, recurrent, or refractory symptoms.

The Physiology of Presence

Modern neuroscience has provided a wealth of understanding of how presence operates and how it can be fostered. Being present in the moment causes neural and biochemical changes in the visual and prefrontal regions, causing increases in alpha and theta brainwave activity, reductions in autonomic nervous system activation, and changes in how information is processed and monitored. Research has shown that presence causes a cascading series of interactions between several identifiable regions of the brain, which sets in motion the activation of neurological and neurochemical changes that induce felt states of well-being.

More specifically, by setting our intention to be present, we activate a top-down process beginning in the dorsolateral pre-frontal cortex, which causes changes in two organizing cortical and subcortical superstructures known as the Default Mode Network (3) and the Salience Network (4). These superstructures coordinate distinct regions of the brain that are responsible for decreasing emotional arousal, reducing unpleasant self-referential thinking, and more effectively tolerating painful affect.

Merely intending to be present facilitates greater calm. When we begin to exercise greater presence, the Default Mode Network slows response reactivity. Additionally, substructures within the Salience Network (the anterior insular cortex and the anterior cingulate cortex) work synergistically with the Default Mode Network to a) detect mind-wandering to distressing thoughts and b) bring us back to a greater felt sense of calm and physiological homeostasis.

If our focus wavers, the Salience Network helps sustain our attention; it filters distractions; it slows our heart rate and breathing and decreases blood pressure and muscle tension; it increases heart rate variability; it downregulates the activation of our amygdala; and quite critically, it enhances our ability to monitor affective body states relative to actual occurrences in our external world. Stated somewhat differently, the neural circuit between the Salience Network and the amygdala allows us to accurately monitor the functional and dysfunctional interpretations we make about our outer world. For example, if we become frightened for no rational reason, presence triggers the Salience and Default Mode Networks that help bring us back to center.

Inducing Presence

There are literally hundreds of ways to induce presence in ourselves and in our clients. There may be several techniques that stand out and really work well for a particular client, and other clients may prefer using a wider variety of methods. Here are a few examples of ways clinicians have helped clients manage their physio-affective arousal by helping them make more consistent contact with the present moment.

Geller and Greenberg (5) believe that therapeutic presence is foundational to the therapeutic relationship, where the therapist’s whole self invites the client to become their whole self. The authors suggest the acronym P-R-E-S-E-N-C-E to organize a series of methods, where the client is asked to:

PAUSE (P)—stopping and creating a moment of stillness

RELAX/REST (R)

EMPTY (E) their mind of thoughts and judgements

SENSE (E) their physical and emotional state

EXPAND (E) their awareness of their external environment

NOTICE (N) the relationship or the connection between their inner and outer worlds

CENTER (C)—reconnecting with their core self and bodily groundedness,

ENTER (E) back into their immediate space or resume their actions or intentions prior to inducing the state of presence.

A method like this can be especially useful as an introduction to the notion of presence, as some clients may be quite unfamiliar with self-reflective and interoceptive processes.

In Somatic Experiencing (6), presence is induced when the clinician encourages the client to notice, observe, and become a witness to attendant body sensations, images, actions, impulses, emotions, or movements. If a calming or relaxing state is needed to temporarily offset the client’s overwhelming level of arousal, SE practitioners are encouraged to invite their client to slowly vocalize the sound “voooo,” which is reported to vibrate the vagus nerve, activating the parasympathetic (rest and digest) nervous system, and deactivating the dorsal vagal freeze response (7).

In addition to activating parasympathetic activity, the practitioner is also instructed to induce presence by prompting their client to notice their belly vibrating, to feel it do so, and to observe their overall physical reaction to making the sound. Levine also describes the use of Jin Shin Jyutsu, a Japanese mind-body system of self-regulation, where stronger states of presence and relaxation occur from better “energy flow” after performing a sequence of three body holds—placing one hand under the opposite armpit and placing the other hand over the opposite outer arm below the shoulder, placing one hand on the forehead and the other on the chest, and finally placing one hand on the chest and the other on the stomach.

For clinicians and clients who may be more familiar with interoception, Raja Selvam (8) highlights eight techniques for tolerating unpleasant emotions that also can enhance the experience of pleasant emotions. Each technique fosters greater presence with oneself and with one’s emotions:

a) breathing into and with the emotion

b) resonating with the emotion

c) heightening awareness of the emotion

d) visualizing the emotion dissipating, spreading more evenly in the body

e) vocalizing sounds that are congruent or resonant with the emotion

f) using self-touch to both support and make deeper contact with the emotion

g) enhancing one’s intention to make contact with, expand, or support the emotion

h) making very small body movements to release felt stuckness of the emotion

Applying these methods of presence to address an unpleasant emotion softens it and helps to better tolerate it. For clients with low tolerance for unpleasant emotions, the method is used in very shorts durations. At some point in the process, the client becomes aware they are tolerating the targeted emotion, when, at that point, they are prompted to notice the relief of having achieved it. Through the continued use of focused awareness and presence, the client is then guided to expand and make deeper contact with their relief. This typically results in a greater openness to and eventually a welcoming acceptance of the difficult emotion.

Other commonly employed presence inducing methods include inviting clients to:

a) name several things in their environment they can see, hear, smell, taste, and physically feel

b) scan and bring awareness to different parts of their body

c) take a long and audible sigh

d) gently stretch any part of their body

e) to look at something pleasurable in their environment and then to soften their eyes—relaxing their eyelids and facial muscles—while looking at it

f) simultaneously observe objects in their peripheral vision while focusing on a fixed point

g) toggle back and forth between looking at an object at a far distance—becoming curious about its nature, its history, its function—and then to notice how they are feeling about observing the object

Presence can also be fostered using the many forms of pranayama—a yogic breath control technique—an example of which is the mantra meditation So’ham, where on each in-breath one visualizes taking in all the positive energy of the universe and on each out-breath imagining expanding that positive energy to every part of the body. The very act of observing and reflecting on one’s internal states without judgement quiets the mind. Eastern philosophies and practices that emphasize living in the present moment are central to the many forms of meditation practiced throughout the world, which neuroscientific studies have shown similarly affect the brain superstructures discussed earlier (9).

As clinicians monitor their clients’ presence in sessions, they may already be well acquainted with when and how it fluctuates, and they may already be creatively using effective but less structured methods than those I have suggested. For example, I recently observed one of my client’s arousal level waxing and waning throughout a session, influenced by small things that were said by either them or me. By tracking these remarks along with correlated changes in their breathing, movements, and muscle tension, I was able to get subtle clues about what may be fostering or inhibiting presence. Monitoring my client’s real-time physio-emotional arousal, I was able to determine when the client was sufficiently present or needed support to do so—that is, whether they needed to build tolerance for a difficult emotion, rest from the unpleasant emotion, better regulate their arousal level, or expand their resources to address the emotion.

Lin: A Case Study

Lin had been my long-time client, who experienced significant developmental trauma from his father. At one point in our work together, he went through an extended period of unemployment in a vapid job market. Despite his considerable insight about his father’s impact on him and the substantial progress he had made with this issue, the stress of his unemployment was producing exacerbated and pronounced anxiety, which had brought him to the point of helplessness, exhaustion, and withdrawal. Lin’s precipitous overwhelm was also making it extremely difficult to calm him in the sessions, as he became more prone to unending ruminations about his difficulties, almost as if I were invisible to him. He was intellectually aware that his pondering was crippling him, but he could not relent from compulsively engaging in it while shaming himself for doing so. Despite my best efforts and those of his psychiatrist, something more was needed.

I decided to better employ the methods I have been discussing here to enhance Lin’s self-attunement. Although some aspects of what I was witnessing in Lin were related to his childhood, he was not in a resourced enough state of mind at that time to process interpretations about it. He was also not resourced enough to process feedback about cognitive distortions he was caught in, so I proceeded to address his immediate moment-to-moment, physio-emotional dynamic. He needed to become better present with how he was fanning his own flames, shutting me out as a support, and cutting himself off from his own psychic resources.

Because Lin seemed to need the simplest, most easily understood and tolerated intervention, I decided to begin the next session by encouraging him to take his time and look around the room, letting his eyes move the way they wanted to. . . and name five things he could see, then asking him to name two things he could hear, then one thing he could smell. Then I asked him how it felt to do so, to which he responded, “a little better.” I said, “That’s good, Lin.” He then quickly changed the focus and began characteristically ruminating on his troubles.

After empathizing with how tough a time he was having, I asked him how it felt at that moment in the session, and he responded, “Upset.” I then asked him if he noticed the shift he made, which he was able to acknowledge. I replied to him, “It’s excellent that you observed that, Lin.” Then I asked him to take a long, slow, audible sigh, where I could see him begin to settle. I could also feel myself settle a bit, which, in the resonance, helped me confirm I was on a good path in that moment with him. Although he soon began to agitate himself again with self-shaming accusations, it took him a little longer to start doing so. I’ve seen these delays occur with other clients, so it confirmed my intuition that his resilience for, and tolerance of, his troublesome emotions were growing.

I try to continuously monitor in real time my clients’ presence and their tolerance for unpleasant feelings. I think it helps me make better decisions about whether I should help them better tolerate their arousal or help them become better aware that they are tolerating it on their own. Sometimes clients need us to be their resource when they are having trouble maintaining access to their own inner resources. Sometimes it’s more important for them to see and feel our pride in them when they are handling their arousal just fine without us.

Gale: My Experience with Therapeutic Presence

This essay would not be complete without discussing the variety of ways clinicians wax and wane in maintaining their own steady presence with clients. Every day I work on learning how to be with my clients—to be awake, to how I repeatedly lose and regain attunement to them, to vacillations in my own internal emotional and physiological states, and to the subtle effects my degree of presence has on them. Being present is relationally essential: it facilitates empathic resonance, it prevents interpretive and empathic errors, and it makes my work and my life more enjoyable.

Like many, I grew up without being taught about emotions. It wasn’t until my late thirties that I realized I had feelings that I could identify and discuss. Through the study of academic psychology, through my clinical practice, and through my personal psychoanalysis, I have met many emotional mentors, some of whom, paradoxically, have been my clients.

Gale was a middle-aged, divorced client of mine, who regularly attended his sessions but who was highly reactive and talked incessantly without reflecting on his words or actions. Managing my own unpleasant internal reactions to him took some time. Although I recognized my countertransference reaction was stemming from my relationship with my father, this insight alone didn’t provide enough real and lasting emotional relief.

To regroup, I decided to take my own advice—that is, to apply to me and my own process with Gale, the recommendations I was making to my clients. In fact, this essay is a reaffirmation of what I continue to learn—how to authentically embody a better moment-by-moment attunement to “me” when being with my clients;how to give myself flashes of time to breathe, a moment to be with myself, to attend to me, to care for me, and to have an instant where I can honor and affirm my own existence.

As I permitted myself to focus on my needs while with Gale, a variety of methods to be more fully present spontaneously emerged. My next thought with Gale was to experiment with my own movement, so I consciously authorized myself to change my posture. Because I was so intent on focusing my attention on Gale, I realized that I wasn’t aware enough of my muscle tension and joint discomfort. As I crossed my legs, stretched my back, shifted my weight, I found myself quietly sighing. At first, it felt like a release, but it soon evolved into a wondrous return to a safe and grounded place—a place where I could give myself room to be with Gale’s loquacious tangentiality, without judging it or reacting to it.

From this place of peaceful inner calm, I started feeling more genuinely grateful for the relational space Gale and I were co-creating, and with it arose a greater sense of compassion and appreciation of his struggle. As I described in the earlier section on the physiology of presence, I could experience my arousal level diminishing, my dysfunctional interpretations of my outer world with Gale quieting, my capacity to accurately monitor my own body states increasing, and my tolerance for enduring my illusion that I was being ignored strengthening.

As if divinely inspired, my brain’s higher-order functions suddenly kicked in, and I realized at a visceral level that, not unlike myself growing up, Gale had no one in his childhood he could talk to about the things he wanted, for as long as he wanted. He never had anyone who wanted to be with him in the way he needed, to play with him on his terms, who conveyed to him that he was important, that he mattered. So, I sat with Gale, sometimes for whole sessions at a time, intently listening, staying present, breathing with intention, unobtrusively sighing, shifting my posture. . . until one day he began to slow and settle and finally voice, “I’ve had a lot to say,” to which I simply smiled and nodded.

At that moment, I could feel the resonance of his attunement with me and mine with his. Paradoxically, I became aware of what I believed I really wanted with Gale all along—not only for him to be aware of himself, but for me to be truly present with him, to connect with him, and to feel his connection with me.

References

(1) Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156. https://doi.org/10.1093/clipsy/bpg016

(2) Koch, C., & Tsuchiya, N. (2007). Attention and consciousness: Two distinct brain processes. Trends in Cognitive Sciences, 11, 16–22. https://doi.org/10.1016/j.tics.2006.10.012

(3) Malinowski, P. (2013). Neural mechanisms of attentional control in mindfulness meditation. Frontiers in Neuroscience, 7, Article 8. https://doi.org/10.3389/fnins.2013.00008

(4) Philip, N. S., Barredo, J., van ‘t Wout-Frank, M., Tyrka, A. R., Price, L. H., & Carpenter, L. L. (2017). Network mechanisms of clinical response to transcranial magnetic stimulation in posttraumatic stress disorder and major depressive disorder. Biological Psychiatry, 83, 263-272. https://doi.org/10.1016/j.biopsych.2017.07.021

(5) Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: a mindful approach to effective therapy. American Psychological Association. https://doi.org/10.1037/13088-000

(6) Levine, P. A. (2010). In an unspoken voice: how the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books. https://www.northatlanticbooks.com/shop/inanunspoken-voice

(7) Porges, S. W. (2011). The polyvagal theory: neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York: W. W. Norton & Company. https://wwnorton.com/books/9780393707007

(8) Selvam, R. (2022). The practice of embodying emotions: a guide for improving cognitive, emotional, and behavioral outcomes. Berkeley, CA: North Atlantic Books. https://www.penguinrandomhouse.com/books/673734/the-practice-of-embodying-emotions-by-raja-selvam-phd

(9) Bauer, C. C. C., Cabral, J., Stevner, A. B. A., Kirchhoff, D., Sousa, T., Violante, I. R., … & Kringelbach, M. L. (2022). Mindfulness meditation increases default mode, salience, and central executive network connectivity. Scientific Reports, 12, 13219. https://doi.org/10.1038/s41598-022-17325-6

Getting Started as a Therapist: 50+ Tips for Clinical Effectiveness

Posted on by Psychotherapy.net Team

New therapists are eager to help, which can be a strength and a deficit. To gauge the mindsets of supervisees or students, I ask, “What do you do in psychotherapy?” A common response is some form of, “People come in with problems. I need to have the solutions to make their problems go away.” It’s as if therapy is perceived as a special forces operation, picking off the bad guys.

It has been my experience that students and new therapists, when asked about their theoretical preference, express wanting to develop a cognitive-behavioral (CBT) skill set. This is likely, at least in part, because it’s what they are primarily exposed to in today’s graduate programs. Further, I’m told, “It gets right to fixing the problem.”

Upon further examination, their expanded definition is sometimes nothing more than identifying symptoms and providing coping skills. Psychotherapy is thus reduced to the fastest possible symptom reduction, as if it were a paint-by-number procedure. While seemingly efficient, there are inherent and fatal flaws in this approach, perhaps most thoroughly examined by Enrico Gnaulati in his, Saving Talk Therapy (1).

Over the years I’ve noticed an increasing assumption that therapy is not, or should not be, an exploratory process. Rather, there is an idea it should be neatly packaged solutions ostensibly remedying problems in short order. This is no doubt further fueled by the uptick in manualized, short-term (8-12 sessions) interventions, implying therapy is supposed to be short.

Despite the implication of these popular tools, psychotherapy is not a race. What’s more, it does not take long in the field to realize that it’s not unusual for any level of meaningful, lasting change to takes six months to a year, regardless of theoretical approach (2).

Sure, therapists wish to relieve patients’ symptoms as soon as possible, but it’s important to realize that ground must be broken to accomplish this. While therapists can offer immediate objective interventions, like diaphragmatic breathing to combat panic, or grounding techniques to interrupt dissociations, it is still necessary to examine the uniqueness of each person’s experience. Do we not need to get to know the person, and allow the person to get to know themselves?

Getting to understand the meaning behind people’s experiences can help unveil the foundational complication for ultimate resolution. This is not a Victorian relic. Modern psychoanalysts and existentialists operate as such, and traditional cognitive-behavioral therapists explore thought processes behind behaviors on the principle that thoughts drive feelings, which drive behaviors.

From its inception, psychotherapy was an activity in exploration and allowing the patient to unfold. By helping a patient explore their being, we help them come to realizations, make painful or shameful confessions, and share intimate details that almost certainly have a bearing on the problematic feelings and symptoms that led to seeking therapy. It is then that the more substantial work may begin of pulling up the anchor of deeply seated dilemmas, and allowing the person to work towards sailing freely once again.

While symptom reduction is relieving, symptoms are just the fruit of a deeper-rooted conflict. I’ve yet to meet, for instance, someone with illness anxiety (hypochondriasis) who simply developed the symptoms, which in turn can simply be given replacement behaviors, and life goes on happily.

While working with patients on reducing their preoccupation with perhaps having a serious illness, I’ve many times discovered they have an unusually pervasive fear of death. This tends to be correlated with a feeling they are not living authentically and fear dying because they have not truly lived. In effect, the hypervigilance for serious illness serves as a check to catch any illness that may prematurely terminate their chance to live authentically. Clearly, helping this type of patient recover from illness anxiety also involves resolving the driving conflict.

Even in this age of increasingly popular, ultra-brief CBT protocols, icons in the CBT field have illustrated that deeper exploration provides a foundation for more substantial work to begin. For example, Jeffrey Young created the “Young Schema Questionnaire” to help such exploration. This is a standardized tool created to help patients with deep-seated maladaptive beliefs explore the troubling way they conceptualize their world and how that leads to their struggle (3). Thus, this insight becomes a springboard for patients to identify and accept what needs changing, and bolsters a collaborative intervention environment.

While people come to therapy for symptom relief, it’s not always as easy as categorical symptom reduction with intensive exposure therapy or teaching them to be responsive and not reactive through a Dialectical Behavioral Therapy (DBT) skills manual. Even DBT, considered a relatively quick and effective approach to borderline personality disorder, involves some deeper exploration for sustained success, and averages six months to one year of treatment.

While successful ultra-brief and single-session therapy does occur, it’s usually a very specific issue with a very motivated person that makes it successful. Most patients are going to need to unfold.

Perhaps the fastest way to psychotherapeutic success is taking the required time, which will vary amongst patients. Before deep work can begin, a therapeutic alliance must be forged, where patients come to trust that the therapist is interested and cares. It is necessary to establish a dynamic where patients may be vulnerable and reveal themselves to expose the conflicts to resolve that will ensure long-term symptom relief.

People in therapy are seeking lasting change. What is the point of quick symptom reduction if the therapist does not work with the person to make sure improvement is sustained, and this newfound way of being has not been woven into the fabric of their lives?

Find Value in Silence

The poet Thomas Carlyle wrote, “Silence is the element in which great things fashion themselves together; that at length they may emerge, full-formed and majestic, into the daylight of Life, which they are thenceforth to rule.” It is no different in psychotherapy, but many therapists squirm in silence, and opportunities for things to emerge can get lost.

When I was new in the field, the most anxiety-provoking encounters in a session were periods of silence. I felt I must have something to say, lest I wasn’t being helpful. Even worse, perhaps it painted me as inept in the eyes of the patient. In time, I learned this was mostly projection, or the assumption others perceived me the way I was viewing myself, as an insecure new therapist.

Today, I’m often reminded of how disquieting silences can be at the outset, as practicum students confess or demonstrate a similar fear. While reviewing student’s practicum videos, palpable discomfort may follow the briefest silence, and there’s a desperate attempt to fill the void. The follow-up supervisory meetings are always rich as the student digests their experience, only to be surprised to discover that filling the void can threaten the therapeutic process.

Once meeting their “silence threshold” a therapist might tell themselves, as an excuse to break the silence, that the patient’s momentary quiet means they no longer want to discuss the topic. Panicked, the therapist offers impulsive commentary or abruptly changes the topic to have something to say. After all, who wants to see a therapist with nothing to offer?

Upon inspection, however, silence is not always indicative of, “It’s your turn to talk.” The patient could be contemplating something the therapist said. Perhaps, while silent, they are mustering the guts, or finding the words for, something that requires attention. Can you think of a time, perhaps in a meeting, when you had something to say but weren’t sure if you should, or how to say it? Now imagine having something critical to share, such as disclosure of abuse, or revealing something one feels ashamed about, and the space that could require to confess or articulate.

With that space in mind, when it seems like the right moment for clients to bring to light an uncomfortable item, any excuse to not have to might be capitalized on. If the therapist becomes talkative during such a pregnant pause, the patient might not try to bring up the topic again, at least not that session, Clearly, providing patients with an ample silence berth is a valuable gesture. With enough silence, they are more likely to crack and use the moment. Like a buried seed, once the shell breaks, new growth begins to emerge.

Indeed, try giving the silence an opportunity to resolve on its own. This will be less of a task with some patients than others, and will become easier as you get to know them.

I frequently sat in silence for up to five minutes with Corrine, a patient I knew well. She would trail off and become contemplative, sometimes spontaneously. At the same time, she began to rhythmically draw her fingertips of one hand down her fingers of the other hand and across her palms in a self-soothing activity. I learned to let Corrine be and focused on watching her hand motions for their hypnotic relaxing effect, which broke any of the silence discomfort I may have experienced as minutes ticked away. More often than not, she would start to reflect on something poignant we touched on immediately prior.

If she did not speak after some time, Corrine would look up and produce a pained smile. This was my cue to coax her. “If I know anything about you,” I’d begin, “when you get quiet and play with your fingers this long, something is brewing inside, and you’re either not sure how to say it or are a little afraid to.” Merely getting her to acknowledge this was usually enough to spur her on. It was as if my reminder of how well we knew each other assured her it was safe to broach any concern.

Being someone ashamed of her body and who generally didn’t think highly of herself, the material sometimes related to intimacy with her boyfriend. Other times, Corrine, afraid to disappoint me, struggled to let me know she had re-engaged in self-destructive activity like drinking benders. Both items were important grist for the therapy mill, which would have been lost if Corrine was not allowed to engage in her process.

When a therapist is just getting to know a patient, it can be helpful to be especially careful not to force away silence. This might occur with an observation like, “What are you thinking about?” It could seem you want to know too much, too fast. It is less confrontational to offer an observation, like, “It’s been my experience that when someone sits quietly in here, there’s something knocking that wants out.” If affirmed, helping the patient partner with their silence can help the state of arrested expression. Posing the paradoxical question, “If that silence was words, what would it be telling me?” has been notably productive over the years.

Other scenarios that can generate patients’ silence as if they are unused to talking about themselves, or are fearful of exposing themselves and appearing weak. This could be related to cultural matters, machismo, or fear of vulnerability. They might answer your questions as briefly as possible, and offer no spontaneous dialogue. Not surprisingly, this terse presentation is a common scenario in males, who are often socialized to feel negatively about help-seeking (4, 5). Autistic people, given the inherent social deficits, can present similarly. It’s important to know your audience, for, in these cases, prolonged silences that were beneficial for others could be very difficult to endure. A therapist would do well to seize these opportunities to teach a patient to interact and communicate.

In situations like this, the patient honestly may not know what to say, awaiting the therapist’s prompts. To promote a forum of focused sharing, the therapist can be productive by blowing on the embers that have begun glowing with simple persuasion, like asking for clarification or other details. Simply being curious and using the most open-ended questioning style is invaluable. “What more can you tell me about that?” “How has that affected you?” or “What’s been helpful to deal with that?” can gain discussion traction.

Showing those prone to this behavior that we’re interested in what they have to say, or gradually exposing them to self-revelation and having them see that it is not disastrous, can work wonders.

Clearly, if someone is not good at sharing themselves, a goal of therapy may have to be improving their ability to be more articulate and willing to share, so we can better understand and address the chief complaint.

Lastly, surely there will be purely oppositional silence, like with rebellious teenagers who see therapy as “stupid,” and they feel they’re forced to be there. No amount of cajoling is likely to make them participate, and it has nothing to do with being an unworthy therapist. Patients like this take significant rapport building, and supervision is often invaluable.

Ask About Meaning

“How does that make you feel?” has its place in the psychotherapist’s arsenal, but it’s not the sharpest tool. If therapists want to cut deeper, asking “What does that mean to you?” or “What’s that like for you?” can engender more robust revelations and therapeutic exchanges.

It’s been my experience that asking about feeling can be a perfunctory activity leading to a dead-end answer. Great, the therapist knows the patient is anxious, depressed or feeling betrayed, but then what? There might be a great leap from “how does that make you feel?” to offering depression or anxiety management skills. Perhaps the therapist attempts to reason with the patient that they have a right to feel betrayed. There is then a comment that the patient doesn’t deserve that, rendering the therapist a cheerleader. Then what?

Although well-meaning, these responses miss a major point of therapy. That is, the necessity to explore the patient’s experience. Whether analytic, cognitive, or person-centered-based approaches, patients must get to know themselves if they are going to change. Thus, feelings are not always the most lucrative query.

Therapists need to be able to mine for, and work with, substantive data for clinical gains. Thankfully, a little curiosity can go a long way. For instance, talking to someone grieving a close relative or friend, their feelings of sorrow and emptiness are often palpable. Asking what the loss means to them, however, can open new therapeutic doors. The emotional turmoil is not only the effect of the deceased’s absence, but the death causes reflections that instigate anxieties about their own mortality or unresolved conflicts.

One patient with this experience offered that since her parents died, it was as if there was nothing between her and the grave now and there is so much more she wanted to do. This revelation made it clear that the loss, though more than a year prior, stirred her own existential angst. Exploration of her life satisfaction and how to achieve goals to feel she had “lived more” followed. Another individual, in therapy after losing a long-term, close friend, lamented that the friend’s absence meant they could never better resolve a conflict that lurked in the shadows. Clinical focus turned towards self-redemption for his role in the conflict.

In another example, Jackson, a 16-year-old teen, while working through his parents’ divorce, discovered his girlfriend cheated on him.

“She said she was only sticking around because she felt bad for me,” lamented Jackson, tearing up.

“What’s it been like for you the past week since it happened?” I asked.

“So angry my head spun. I’m drained. I’ve got no energy to be angry anymore. I want to scream, but I don’t have the energy.”

“Sounds like insult to injury,” I offered. “You were already dealing with so much.” He nodded.

“Jackson,” I continued, “what does all this mean to you?”

“It means I’m on my own. I can’t trust anyone. My parents are too wrapped up in their mess to care about the mess they made for me, and, I guess, I just suck. I give my heart to someone for the first time, and without warning, it doesn’t matter.”

Asking Jackson about the meaning of his experience led him to put words to his internal landscape. This inside-out synopsis provided more than focusing on feelings could provide. His description created an opportunity to examine the maladaptive beliefs that germinated from the problematic experiences, which only served to compound his bad moods. Navigating these beliefs became part of the plan to relieve Jackson of depression.

Therapists working with trauma may also find it a therapy-accelerating question to help understand how trauma affected someone. Therapists can ask about symptoms and provide coping skills and guidance for achieving goals, but wouldn’t it also be helpful to know how a patient is shaped by the meaning they assigned to their experience? Having a patient share that their traumatic experience made them feel “forever broken,” for example, is more fertile ground than an inventory of symptoms to assign coping skills to for a treatment plan.

Asking this “forever broken” patient, “What exactly do you mean by ‘forever broken?’” was crucial to our work. They described an overidentification with the role of victim, perpetuating the other symptoms. Hypervigilance soared, nightmares involved reaching for goals, only to be sabotaged. Understanding this schema helped treatment in that the focus centered on empowerment; cultivating and magnifying other components of her life that negated the role of victim.

Often the juveniles I interview for court are enmeshed in daily marijuana use, binge drinking or vaping nicotine. Problems follow like infractions for marijuana possession in school, perhaps public drunkenness, or getting caught stealing vaping paraphernalia. During the assessments I ask not only about their use history and how it affects them, but what sort of meaning do they assign to the substance use?

I’ve been given answers that it is how they identify with their family, or that they can control how they feel and when. In the cases involving drug dealing, while the money is a motivator, drug culture guarantees excitement in an otherwise dull existence.

In each instance, asking about meaning yielded more potent information than “why” or “how” was likely to. Inquiring about meaning encourages an answer that captures more of the experience. This includes revealing deeper causal factors than self-medication or boredom, or at least factors that encourage the substance use under the circumstances.

Be Attentive to Your Intuition

My colleague, Joseph Shannon, a psychologist specializing in personality, once told me that “listening with the third ear” is a top skill to hone as a therapist. According to author Lee Wallas, the term was first used by the existentialist Friedrich Nietzsche in his 1886 book, Beyond Good and Evil. Given my lack of familiarity with the term I was intrigued, but quickly discovered it’s simply an elaboration of something most people are familiar with: intuition.

While this clinical skill might sound unusual, if you have ever sensed there is more than meets the eye to what the patient is relaying, you’ve experienced it. Clinically, the third ear quietly deciphers indirect communication, helping the therapist read between lines. Just as Spiderman heeds his tingling “Spidey sense” that something is askew and someone needs help, it’s important for clinicians to heed their “Spidey sense.”

Sometimes supervisees confess to encountering situations where it seems their patient is indirectly trying to say something. However, they wonder if it’s too speculative or confrontational to heed the tingling and “go there.” Usually, they fear they may be off the mark, deeming them incompetent and pushing the patient away. Some have justified their defensive unwillingness to consider their intuition by noting, “When the patient is ready, they’ll tell me.”

Or not. Not regarding the intuition could inadvertently prolong misery and unnecessarily perpetuate treatment.

Is it not part of therapist’s duty, part of the therapeutic process, to explore and help patients learn about themselves so they may advance? Is it not poor practice to potentially be encouraging internalization of things that need saying; to not help patients discover and deal with, emerging elephants in the room?

It’s not unusual that patients are on the couch due to some such ineffectual coping strategy as internalization or denial. Thus, the very thing the therapist might be apprehensive of doing is just what they need, and perhaps are even carefully, consciously, asking for. Would you be surprised to learn that sometimes patients (consciously or unconsciously) guide us to make the observation so they don’t have to say it? Something that requires purging may be too painful or embarrassing to mouth, and it’s easier to acknowledge than to explain in order to get it out there. Consider the case of Rob, a successful 34-year-old, who entered therapy for “feeling emptier with age.”

As we explored his life, Rob disclosed an early history of social anxiety that he overcame with therapy. He confessed he was a late bloomer for dating given his teenage angst, but had managed a few, year-long relationships as he emerged from his shell in his 20’s. “As a kid, all I wanted was a nice girlfriend, but I didn’t get that young adult dating experience. The older I get, the harder it is meeting eligible ladies,” Rob lamented. Not about to let it sink him, he accepted singlehood as best he could, travelling abroad and exploring locally on his own.

Rob occasionally traveled with friends, but the ones he had traveled with began having children and were no longer available for adventures. “My friends had to go have kids,” he’d joke, “They don’t know what they’re missing!” Despite this, he regularly spoke of being “Uncle Rob” and beamed when talking about his friends’ toddlers. Other times Rob said, “I do love kids, I just like to give them back. Kids aren’t for me,” noting they’d be hang-ups for his ostensible free spirit.

Soon, my Spidey sense tickled that Rob’s emptiness may well stem from being childless, and I had enough evidence to justify exploration. In a subsequent session, I said, “Rob, we’ve met a few times now, and I’d like to review a bit deeper. Given your history of social anxiety, it’s impressive you’ve become so social and had some successful romantic relationships. It’s got to be disappointing to have progressed exponentially with social comfort, just to encounter the frustration of not securing the relationship you always wanted. While talking about your frustrations with the romantic void, though, you’ve also made some curious comments about kids that I feel deserve exploration. On the one hand, you depict how kids cramp your style. On the other, your happiness is palpable when you bring up kids that are in your life. Correct me if I’m wrong, but I can’t help wondering if there’s an internal conflict regarding kids of your own contributing to that complaint of increasing emptiness.”

Rob eventually confessed, “It’s much easier to say you don’t want kids than to admit you can’t pull it together enough to make it happen.” What followed was an unfolding of Rob’s fear he’d be like his father, plus he feared his own children could be tormented with anxiety as he was. Being in denial allowed him to save face about imperfections. As Rob reflected, he realized that while he enjoyed the women he was with, when talk of longevity and family surfaced, he invariably sabotaged the relationship. He was capable of getting what he wanted, but subconscious security guards only let romance go so far.

Rob isn’t unusual in that patients may be avoiding the truth as ego damage control when they aren’t procuring what they want. As we explored over time, it came to light that the more Rob could not find someone, the more he traveled solo to prove he did not need anyone and to convince himself of his rationalization defense that kids just complicate things. He needed an excuse not only for himself, but as deflection for appearing defective to others.

Imagine if I had not shared what was on my mind about Rob’s material? Clearly, selective hearing for the third ear could have grave consequences to patients. Further, it is important to note that, unlike therapists we might see on the screen, it’s not about trying to shake sense into someone by saying, “Listen to yourself! You’re not finding a relationship because you’re in denial about wanting kids.”

Framed in a disarming way that makes patients see it’s to their benefit, your hunch can be explored and will likely make them interested in examining the idea and weighing its merit. Even if it’s off the mark, that’s not synonymous with therapist incompetence. It demonstrates the need for curiosity about the self, urges willingness to explore, and shows the therapist wants to get to know and understand them, which only strengthens the therapeutic foundation.

***

This content is excerpted and adapted from Smith, A. (2024). Getting Started as a Therapist: 50+ Tips for Clinical Effectiveness. Routledge., with explicit permission from the publisher.  

(1) Gnaulati, E. (2018). Saving talk therapy: How health insurers, big pharma, and slanted science are ruining good mental health practice. Beacon Press.

(2) Shedler, J. & Gnaulati, E. (2020, March/April). The tyranny of time. Psychotherapy Networker. https://www.psychotherapynetworker.org/article/tyranny-time

(3) Yalcin, O., Marais. I., Lee C.W., & Correia, H. (2023). The YSQ-R: Predictive validity and comparison to the short and long form Young Schema Questionnaire. International Journal of Environmental Research and Public Health, 20(3).

(4) Cole, B.P., Petronzi, G.J. Singley, D.B., & Baglieri, M. (2018). Predictors of men’s psychotherapy preferences. Counselling and Psychotherapy Research, 19(1), 45-56.

(5) Wendt, D. & Shafer, K., (2016). Gender and attitudes about mental health help seeking: Results from national data. Health & Social Work, 41(1), 20-28.

(6) Wallas, L. (1985). Stories for the third ear: Using hypnotic fables in psychotherapy. Norton.

Facing the Fear of Flying Together: Reconsidering Exposure Therapy

Posted on by Psychotherapy.net Team

Beyond Resistance to Exposure Therapy

Exposure therapy for anxiety and related problems gets a bad rap. It is often seen as mechanistic, simplistic, unimaginative, and even cruel. The suggestions that “coaches” or AI could do as good if not a better job with exposure treatment, compared to well-trained therapists, only reinforce these beliefs. This contrasts with the treatment outcome research studies that show it as one of the most effective approaches in psychotherapy.

During my early years of practicing in a CBT-focused clinical psychology program, we were taught and expected to use exposure therapy. Soon, I found that I was not looking forward to the sessions that included exposure, and I abstained from volunteering to take on new clients whose presenting problems indicated that they could benefit from exposure therapy. I viscerally understood why studies have also shown that a majority of therapists, even those who identify as cognitive behavioral, shy away from exposure therapy.

My supervisor was certain that my and my classmates’ feelings were related to what he believed was at the core of the exposure underutilization: Therapists are, by and large, very empathetic people and thus we hate “making” our clients suffer. If we only realized that a compassionate approach sometimes requires short-term pain toward long-term gain, it would lead to an exposure therapy renaissance — or so he believed.

His contention resonated with me. I certainly was concerned when witnessing my teen client’s face turn pale and eyes water while touching the floor, doorknob, and trash can in our clinic bathroom while engaging in exposures for contamination fears. And I deeply felt the anguish of a middle-aged mother trembling as she held a knife and recounted the obsessive fears of hurting her daughter. But very few worthwhile things come easily, without pain attached to them. With my supervisor’s help, I started paying attention to the uncomfortable emotions and physical sensations that were coming up for me during exposures and worked on accepting them in the service of helping my clients.

It was a long journey, but I slowly improved, vowing that the avoidance of my distress was not going to be the reason for the avoidance of exposure therapy. This was my way of bucking the trend — much more pronounced these days — in which therapists lean into validating, complimenting, and colluding with clients’ defenses at the expense of challenging, probing, and having difficult conversations with them. A majority of therapists I know have become very good at accepting clients and being liked by them, but not great at actually helping them change in meaningful ways. But exposure therapy is far from the only approach that can be challenging to do and can lead to heightened distress in the short-term. I would argue these conditions are true for any good therapy.

Another observation my supervisor made was that many therapists were afraid of “pushing clients too far,” potentially leading to crying, hyperventilating, or even decompensating. “First,” he stated impatiently, with a hint of agitation, “no client will decompensate because of heightened anxiety — this fear only mirrors unfounded fears that clients often have, and it needs to be dispelled through psychoeducation.” He then assured us that we would become better at knowing how quickly to go up the exposure hierarchy (constructed at the beginning of treatment to guide exposures) with experience. Over time, he insisted, good therapists get a sense what the optimal dose of exposures is. Like Goldilocks, we learn that it needs to be strong enough to cause significant anxiety, but not too overwhelming to paralyze the client. That was, in his view, the art of exposure therapy.

Over the years, I did become proficient in the practice of exposure therapy, even penning a Washington Post article extolling its virtues. I have witnessed the transformation of people’s lives with the help of imaginal, in-vivo, virtual reality, and interoceptive exposures. And, yet, I have felt that by focusing on doing the exposures, we are missing crucial elements that could help more clients decide to take the leap and keep them engaged until they improve.  

Most people are deeply ambivalent about change, especially the change that requires hard work and invites distress. When some realize that anxiety is contracting or even ruining their life, but they are not sure how to muster the courage to do something about it, internal (and sometimes external) conflicts ensue. Leveraging the therapeutic relationship to work with clients on these conflicts and on finding a way to integrate the parts of themselves pulling them in different directions is at the heart of what I do. In this process, my clients and I have come face-to-face with what it means to be human — to struggle with uncertainty, isolation, death, and the search for meaning. As Irvin Yalom suggested, all our fears emanate from trying to deal with these givens of the human condition.

Flying with Rick: A Case Study

“I don’t think I can get on that plane, I’m sorry,” said my client as we lined up to embark on a flight to Charlotte. He exited the queue and started walking away from the gate. When I saw him slowing down and stopping about 100 feet away, still facing away from me, I gave him a few minutes and then approached.

His face was contorted with fear and apprehension. I was concerned that he felt he needed to fly to be a “good client,” despite multiple discussions we had about him taking the pilot seat in his exposure therapy journey.

“I’m not going to ask you to get on the plane,” I said. “This is your choice.”  

Rick had contacted me a few months before and said he was in his late 20s, suffering from flying phobia. In our initial meeting, I explained how I practice Cognitive Behavior Therapy (CBT) with an existential slant. We discussed what our work might look like, including the exposure therapy part, in which one gradually confronts one’s fears. “So, you’ll fly with me?” asked Rick, with a nervous half-smile. “If need be?”

I hesitated uncharacteristically. Being a nervous flyer myself had never stopped me from visiting my family overseas, traveling, or doing exposure therapy with previous clients. But abstaining from flying during the pandemic had increased my apprehension. Still, how could I expect my clients to face their fears if I was not prepared to do the same? “Of course!” I said, before I could change my mind. I wanted to model the courage that is one of my strongest-held values.

We first explored Rick’s history. He’d been uncomfortable in planes for as long as he could remember. His mother was a very nervous flyer, so Rick’s family rarely flew. When they did, his mom looked petrified and once even dug her nails into his skin during turbulence. So, he came to his flying anxiety by both nature and nurture. As an adult, Rick continued to avoid flying, and the less he did it, the more afraid he became. He still felt tremendous guilt about bailing the night before the flight that was supposed to take him to his best friend’s wedding. 

Then, just before the pandemic, Rick was offered a dream job. Although it required frequent air travel, he decided it was too good a career opportunity to pass up. “I figured this would be exactly the kind of push I needed to get over my fear of flying,” he said. But the pandemic curtailed his new team’s travel, and Rick got few opportunities to fly. Later, when the U.S. reopened, he needed to be ready to fly anytime. He endured a business flight to Colorado with the help of Xanax but felt so miserable before the trip and after the medicine wore off, that he realized he needed to seek therapy.

We started by watching videos depicting a wide variety of flights, including turbulent ones, followed by vividly visualizing flying scenarios. I guided him to engage his imagination, focusing on all aspects of the experience, as if he were in a movie. When the imaginary exposures raised Rick’s anxiety, we practiced “sitting with” the anxious thoughts, feelings, and physical sensations. For example, I asked him to mindfully scan his body to notice where the uncomfortable sensations were showing up. Rick described his throat drying up and chest constricting, and he learned to allow them to be as they are, without judgment or suppression.  

We also practiced observing the stream of anxious thoughts and imagining “placing” them on, for example, leaves in a stream or clouds in the sky — thus letting them continuously come and go. We discussed how this acceptance approach works best in the long run. We also practiced several breathing and muscle-relaxation techniques to be used only occasionally when anxiety becomes paralyzing. I warned Rick against using these “quick fix” techniques habitually, as they could become another kind of counterproductive avoidance. After a few months, Rick said he wanted to try “the real thing.”

At the airport, Rick blurted out, “I really, really want to do this, but I think I’m getting a panic attack!”

“Let’s breathe together like we’ve practiced,” I said. “Inhale for four, hold for four, exhale for eight though the nose…And repeat.”

Soon, Rick appeared more resolute and started heading back toward the gate. As I walked beside him, I felt my own anxiety bubbling up, but I kept a calm demeanor. Just before joining the line of boarding passengers, Rick stopped again. “It’s like I want to go, but some invisible hand is not letting me,” he said.

It seemed like he still was not accepting his ambivalence. How much easier it is for all of us to externalize what we don’t like about ourselves!

“Perhaps the hand is also a part of you,” I said. “There seem to be two parts of you.”  

“Yes, it does feel like that.”

“What is each one saying?”

“One says, ‘You can do this, you’re strong, you’re not going to let the fear boss you around.’ And the other says, ‘You’ll faint or have a stroke if you get on that plane. If the plane doesn’t crash first. This is too much for you to handle!’” he said.

I waited, curious to see what he’d do with these two parts.

Rick asked for reassurance: “But it’s not going to crash, right?”

“Neither of us has a crystal ball,” I said with a slight smile, because Rick had been emphatic about his disdain for anything superstitious or new-agey.

He smiled back before his face turned solemn.

“I see more emotions coming up for you,” I said.

“A lot of irritation. Frustration with myself that I can’t be the person I want to be, that I am torn between these parts.”

“Is either part helping you expand or contract? Makes you larger or shrinks your world?”

“The first one makes me larger, but how do I make that one win?”

“It’s not about winning or losing. Only you know which one you’ll choose to listen to,” I said softly.

“I’m choosing to listen to the brave Rick, but the other part is still there…” his voice trailed off.

“That anxious Rick might always be a part of you. Can we just take him along for the ride?”  

The gate attendant announced the last call for passengers heading to Charlotte. My stomach began to ache. We might never get on this flight, I thought with mixed feelings. A part of me felt disappointed with my ineffectiveness as a therapist. And another part was relieved that I might be spared flying today. It was then that I decided that self-disclosure might be helpful to get us past this impasse — after all, we were in this together.

“The truth is, I’m not a fan of flying either, especially after a long hiatus. I haven’t flown since the pandemic began, and my hands are sweating.” I turned my palms around for him to see. “But I don’t want to look back on my life with regret for not taking a chance, the regret that I so often hear from my elderly clients.”

Encouraged by the look of grateful surprise that flashed across Rick’s face, I continued. “Imagine sitting with your grandkids on your 80th birthday. What would you like to tell them about how you approached this short and precious life?”

Rick’s eyes brimmed with tears. He rushed toward the attendant, but quickly turned around. “You’re coming?” he asked.

I followed him swiftly, letting my legs carry me and my anxiety. I was thankful he led us to the plane.

Once in the air, Rick was surprised that he was not as anxious as he thought he’d be. “Anticipatory anxiety is always the worst,” I said. When the plane started to shake and both of us noticed our anxiety rising, we practiced the acceptance strategies. The majority of the flight was smooth, and each of us enjoyed a soda and flipped through a magazine. On our descent, the plane shook slightly and moved from side to side as we went through a thick layer of stormy clouds. Rick’s face turned pale and he murmured, “What now?”

“You know what to do,” I said.   

Rick led us though some breathing exercises, and as his body relaxed a bit, he joked pointing out the window: “I am working hard to put my catastrophic thoughts onto these dark clouds!”

When we touched down, Rick turned toward me and mouthed, “Thank you.”

Now it was my turn to tear up. “Thank you. It was my honor to join you on this journey,” I said. 

***

I was grateful that we were able to find strength in vulnerability and face the fear together. When we own all parts of ourselves, we can come to terms with the existential givens in unison. Approaching each therapeutic encounter as an opportunity to delve into the fundamental challenges of human existence, we enable our clients to grow stronger in the face of life’s uncertainties. Rather than offering them absolute solutions aimed at minimizing their anxiety, we can join them in embracing the existential realities, along with the unease these bring. And confronting the core realities of our existence is essential for leading rich and purposeful lives.  

Exposure therapy is not about conquering anxiety but about finding a way to live authentically despite it. Instead of being technocratic cheerleaders, therapists using exposure have an opportunity to accompany clients on some of the scariest and most profound literal or figurative quests of their lives and witness the transformation that happens when we stop avoiding what matters.

“Have you decided how you’re coming back to D.C.?” I asked Rick as we exited the plane.

“I’m going to fly by myself!” he said with a smile. “And bring nervous Rick along.”  

Questions for thought and discussion

What were your impressions about this therapist’s approach to exposure therapy?

In what way or ways do you think the client benefited from her intervention?

In what ways have you found exposure therapy to be useful in your practice? Not useful?  

Psychodynamic Therapies: How Did We Get Here & Where Are We Going?

Posted on by Psychotherapy.net Team

I just finished reading Our Time Is Up, a wonderful combination of novel and memoir authored by the talented psychoanalyst and writer, Roberta Satow. Dr. Satow has created the most vivid description I’ve ever read of what real psychotherapy actually feels like — from the very different perspectives of the patient, the therapist, the supervisor, and the trainee. Most books on psychotherapy either miss its elusive magic or overplay its drama — this one has perfect pitch and puts you right there in the room.

Throughout my career, doing psychodynamic psychotherapy was always the part of my week I most enjoyed. Satow’s book both recalled many fond memories and inspired me to pull together what will likely be my final thoughts on what is wonderful about dynamic psychotherapy, and what are its limitations.

Psychodynamic Therapy’s Checkered Past

I’ll start with the checkered past — especially paying tribute to Sandor Ferenczi, the master clinician who was the underappreciated father of psychodynamic therapies. Next, I’ll evaluate the much reduced, but still crucial, role of dynamic techniques among the current chaotic and bewildering array of therapies. Finally, I’ll try to predict the future — what is the best-case final fate of psychodynamic therapies?

[Full disclosure] I graduated from Columbia University’s Psychoanalytic Center and taught its Freud course for 10 years. But I never was much of a fan of 4/5 times a week, on the couch, traditional, regressive psychoanalysis — regarding it as unnecessary and impractical for almost all patients and wasteful of resources better allocated to once a week, sitting up, long- or short-term dynamic therapies. While best at psychodynamic therapy, I also learned and integrated cognitive, behavioral, interpersonal, and family approaches. I think Freud was greatly overvalued in his own time and is greatly undervalued in ours — and I equally oppose blind Freud worshipers and blind Freud haters.

Freud: Great Model Builder, Lousy Clinician

Having invented psychoanalysis (in collaboration with his mentor, Joseph Breuer, and their shared patient, Berthe Pappenheim), Freud divided it into three separate endeavors: 1) research tool; 2) model of the mind; 3) clinical treatment.

Psychoanalysis as a research tool was at the outset enormously exciting — uncovering basic aspects of human nature that informed not only psychology, but also the study of myth, anthropology, sociology, art, and literature. But most new insights into the unconscious were made early on, and nothing really novel has emerged from the couch since Freud’s death.

Much more enduring has been the psychoanalytic model of the mind. Here Freud sat on Darwin’s shoulders — applying Darwin’s revolutionary, but generalized, discoveries in evolutionary psychology to the specifics of human behavior and symptom generation.

Freud borrowed from Darwin three crucial insights: 1) human mental functioning is just as derivative from our primate ancestors as is our bodily morphology; 2) much of our behavior derives from inborn motivations that reside outside our conscious awareness; and 3) these have been shaped by natural and sexual selection.

Freud filled in Darwin’s general outline with exquisitely detailed and specific analyses of the form and content of the unconscious and how one’s past experiences powerfully influence current hehavior. Freud’s model of the mind contained some bad (but then plausible) guesses which are the source of current ridicule — but the main concepts hold up extremely well and remain important in understanding people and treating them.

Freud never claimed to be a great therapist, or even to having much interest in psychoanalysis as a clinical art. He saw himself much more as an adventurer using psychoanalysis as a research tool in the scientific exploration of how the human mind works — awake and in dreams. Descriptions by Freud’s patients describe him as highly intellectual and patriarchic in his approach, using the therapeutic encounter to formulate and test his theories of how the unconscious works.

Ferenczi: Master Clinician

Sandor Ferenczi, Freud’s student & analysand, was the great clinician of early psychoanalysis and by far the most powerful influence in how psychodynamic therapies have since evolved and are practiced today. He was responsible for defining its healing qualities, introducing many major innovations, and adapting esoteric psychoanalytic theory to real world practice.

Here’s a summary of Ferenczi’s clinical contributions:

Therapeutic Alliance: Ferenczi emphasized the importance of negotiating a strong collaborative relationship with the patient, established on more equal terms, characterized by shared goals, and with mutually agreed upon roles and division of labor.

Interpersonal/Relational Therapy: Ferenczi was much more alive than Freud to the power of the healing relationship and the importance of establishing a strong affective bond with the patient. As his student, Sandor Rado, put it, “Insight never cured anything but ignorance.” The relationship is more curative than specific interpretations, however brilliant or accurate they may be.

Empathy: Ferenczi regarded therapist empathy as an essential tool in promoting change. Sharing feelings and feeling understood facilitates change as much as does gaining specific insights.

Here-and-Now: Freud mainly used psychoanalysis as a research tool to determine how past experiences shaped the unconscious and influenced current behavior. Ferenczi did this too, but also brought more focus to the triggers of present problems and how best to solve them.

Therapist Activity: Freud aspired to (but never really achieved) being a passive “blank screen” upon which patients could project their fantasies. Ferenczi was much more active and real in the sessions.

Patient Activity: Patients don’t get better just through free association and the insights gained in the therapy sessions — they must also widen their experiences and get out of repeated behavioral ruts. What happens between sessions is at least as important as what happens within sessions.

Corrective Emotional Experience: This was best stated by Ferenczi’s student, Franz Alexander, who said, “The patient, to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.”

Psychodynamic Therapy: Regressive psychoanalysis was originally a great research tool but has never been a practical treatment — it is way too resource wasteful, suitable only for pretty healthy patients, and risks creating excessive dependence and hiding in the treatment. Ferenczi’s innovations allowed psychodynamic theory and technique to be flexibly applied in less intensive, but very effective, sitting-up psychodynamic therapies occurring usually once a week.

Time-limited Focused Therapy: Ferenczi and Rank realized that long-term therapies were too intense and inefficient to treat the many people who needed help. They developed a remarkably useful brief dynamic therapy (currently much underutilized) that focuses only on understanding and changing the most pressing presenting conflict.

Self- Disclosure: Ferenczi was not shy about revealing information about himself if this would further the relationship or provide a useful model for the patient.

Role of Childhood Traumas: Freud’s first theory of neurosis attributed it exclusively to early childhood sexual traumas. But he abruptly and completely abandoned this causal theory in the early 1890s because such childhood sexual experiences were so commonly reported by his patients. Freud then assumed the reported experiences existed only in fantasy, rather than having actually occurred in reality. Ferenczi had the more balanced view that real childhood traumas do sometimes play a contributory, but not exclusive, role in producing adult symptoms and that they are not exclusively sexual.

Treating More Difficult Patients: Many classic psychoanalysts were often so picky about selecting patients that only the people who didn’t really need treatment would qualify for it. Ferenczi adapted psychodynamic understanding and techniques so that they could be usefully applied to the more severely ill.

In summary, Ferenczi, not Freud, was the clinical father of psychodynamic psychotherapy and his innovations shaped how it is still practiced today.

Psychodynamic Therapy’s Current Status

My previous essay; Psychotherapy Status Report offered a report card on the current status of psychotherapy. It nicely provided context for the more specific question of where psychodynamic therapies fit in. The short answer is that all psychotherapy practice is fragmented and chaotic — and that psychodynamic training and practice add to the confusion.

There is little integration among the more than 50 different named forms of psychotherapy. These are often seen as competing; most trainees receive instruction in just one narrowly focused method and many practicing clinicians identify with just one form of therapy. “CBT” is the most popular brand name, followed by “psychodynamic,” and “trauma-informed” which is becoming increasingly popular. There is also an age and gender disparity. Older therapists are more likely to identify with psychodynamic; younger with CBT; women with trauma-informed.

Training in psychodynamic psychotherapy is also chaotic. There are hundreds of different programs varying greatly in theoretical model, prerequisites, intensity, techniques, and accreditation. At one extreme are the traditional psychoanalytic institutes which are more selective, require many years of intense didactic and clinical training, often still use of the couch, and require personal analysis. At the other extreme, there are now psychodynamic training programs that are open to all and, remarkably enough, completely online.

There is very little research on psychodynamic psychotherapy because it does not conform easily to standardized clinical trial research designs and only a handful of its practitioners are research trained. The few scattered research studies suggest that psychodynamic therapies are equal in efficacy to better studied psychotherapies.

Dynamic therapy is gradually declining in influence. Most psychiatric residency programs now provide little or no training in psychodynamic therapies — even though such training is still often desired and sought after by some residents. Young therapists in other disciplines are less and less likely to be trained in dynamic techniques. And insurance companies are less likely to fund dynamic as opposed to other techniques that are less intense and better studied. The average age of dynamic therapists is rising, and its cultural relevance is diminishing. The future does not seem bright.

Future Directions

Will Psychodynamic Therapy Continue as a Separate Profession?

I hope not. Psychodynamic therapy was always my favorite technique, but only if combined with cognitive behavioral, interpersonal, and family techniques. Similarly, the training programs I created were based on the integration of psychotherapies, not their separation into separate silos.

I have long felt that psychoanalysis is too important to be left to the psychoanalysts. They have maintained an unfortunate rigidity in technique and teaching; have been resistant to innovation; and missed opportunities to expand their purview and influence. Their biggest mistake was rejecting Aaron Beck’s CBT. Beck was a trained analyst who originally conceptualized his innovations as an expansion of psychodynamic techniques, not a replacement. Had the psychoanalysts been wise, they would have embraced CBT as an extension, rather than rejecting it as a competitor. I don’t think that psychodynamic therapies should be taught in institutes that specialize in it. Similarly, I don’t think that “CBT” or “DBT” or any of the other 50 alphabet denoted therapies should be taught or practiced as a separate discipline distinct from other psychotherapies.

Instead, I think psychotherapy should be considered a unified therapy which includes within it a wide variety of techniques. And training programs should no longer brand themselves narrowly. Narrowly trained therapists become hammers looking for nails, rather than flexibly responding to patient need. Psychodynamic techniques should be highly valued because they are very valuable- but they should be valued as a component of psychotherapy, not as a separate specialty.

Will Psychodynamic Therapists Be Replaced by Computers?

I’ve written an entire blog on the history of computers delivering psychotherapy: their current role and their future potential. Bottom Line — there is nothing humans do that computers won’t eventually do better.

One small consolation is that computers will have more trouble and take longer replacing psychodynamic therapists than almost any other type of professional. More than most human endeavors, uncovering someone’s unconscious motivations and facilitating corrective emotional experiences are intuitive and inferential processes that don’t easily lend themselves to the number-crunching powers of machine learning. But given enough data and enough time, even these most human of skills may be mastered by artificial intelligence.

Should this pessimistic prediction discourage people from entering the field? I think not at all. First off, psychodynamic psychotherapy is a better hedge against computer replacement than almost any other career choice. But more important, doing psychodynamic psychotherapy is one of the most rewarding ways of spending one’s time on earth. You have the immense satisfaction of understanding and helping others, with the valuable added bonus of learning from your patients how to become a better person.

***

Which brings us back to where we started. Roberta Satow’s book is a great introduction for new psychotherapists and a great refresher for experienced ones. No manual of psychotherapy, and no textbook, can ever capture the special healing ambiance of the therapist/patient relationship. Only the lived experience of someone who has been a patient, been a therapist, been a supervisor, been a trainee — and can write really well — can bring therapy alive in a way that inspires and educates.

Questions for Thought and Discussion

In what ways do you concur or disagree with the author’s assessment of dynamic psychotherapy?

Would you consider training in psychodynamic therapy?

What kind of client would you refer to an analytic therapist and why?

Donald Meichenbaum on Coping with Loss and Traumatic Bereavement

Posted on by Psychotherapy.net Team
Lawrence Rubin: Hi, Don. Thanks so much for joining me today. You are most widely known for your foundational work in developing CBT but it is equally important that our readers know that for these last 35 years, you have been the director of research at the Melissa Institute for Violence Prevention and Treatment in Miami, Florida.
Donald Meichenbaum: (DM) Thank you for the invitation.
LR: You had previously requested that my first question be about the tragic and unexpected death of your wife, Marianne?

The Irony of a Trauma Specialist’s Tragic Loss

DM: We were married 58 years. My wife and I were vacationing in Clearwater, Florida, escaping the snows of Buffalo, where our permanent home is. My wife was tragically hit by a car at a pedestrian crossing. You know they have flashing lights, and this is sort of a warning sign. She was hypervigilant about not trusting people to stop, so obviously she would not have stepped off the curb if the vehicle had not stopped. But for whatever reason, the vehicle continued on and hit her. And in fact, she was lifted by a helicopter from Clearwater down to the trauma center in Saint Pete.I had called her on her cell phone thinking that she was late because she had a Zoom yoga meeting that she usually attended. I got a male voice, and he indicated that she had been hit and taken by helicopter down to the trauma center, but they would provide me with a police car to drive to the trauma center. I got there and the trauma physician indicated that she had already died. I asked to see her, went in and she was covered by a sheet. I pulled down the sheet, and she was pretty messed up from the accident.

I’ve worked with head injured, so I’ve been involved in seeing such incidents. Remarkably, her hand was still warm when I caressed it. There was a chaplain sitting next to us and I asked her to take a picture of me holding her hand. I actually sent that picture to my daughter-in-law who made it into a pillow. So, it was a traumatic bereavement kind of situation.

The irony is that morning I was giving a Zoom lecture for therapists in China on how to cope with traumatic bereavement and prolonged and complicated grief. And by four o’clock that afternoon, I was living my lecture. So, one of the interesting aspects of all this, and I’d be happy to discuss it with you, is what is the immediate and more long-term impact on an individual such as myself, who is in some sense is an expert on the area of interventions — having developed cognitive behavioral techniques.

Interestingly, there are hundreds of these kinds of accidents, many in Florida, of people — for whatever reason, where the driver is not complying with the pedestrian crossing. And there are multiple accidents and deaths in this particular way. So, the issue of traumatic bereavement as compared to a kind of prolonged complicated grief is an issue that I have been preoccupied with. And moreover, I’ll just add this final note before we open it up for your further questions. There are two aspects that are really quite fascinating in the aftermath of such traumatic bereavement.

One has to do with dealing with the grief. And the other aspect that is not readily discussed by clinicians is the sequelae that follow the sudden death of a loved one. And I will give both you and the readers to this presentation, a keyword that will change your life forever. This is the most important thing you should take away from our discussion. And the one word that you need, Larry, that will change your life if you do not already have it in your repertoire, is “passwords.” If you do not have the password of your significant other who died in a traumatic fashion, you are screwed.

LR: You’ll lose access to everything.
DM: Yeah, right. So, at a moment of intimate repose for your listener, they should lean over to their loved one and say, “I love you, but do you know our passwords and how to retrieve them?” So, you know I can fill you in and turn this into a kind of therapy session? And tell you the kind of trauma events, both dealing with the aftermath of the loss of my wife, but also the police reports, the autopsy reports, the life insurance, the banking, all of the credit cards — everything that goes with it.And the interesting thing is, if you are a clinician, one of the things you do in helping me is assessing, what is the lingering impact of this, what was the aftermath like? But it’s unlikely that you would have done that and asked does your social life change, and then a whole bunch of other questions that I’ve put together. In fact, the lecture that I was giving that morning to Chinese therapists, that entire 80-page handout that I provided them with is available to your listeners.

So, if they go to Google – Meichenbaum, Donald, Melissa, Institute – they will be able to download my 80-page tool plus other items on how to treat individuals who have traumatic bereavement and prolonged and complicated grief. So, if there’s anything I say that might be of help, I’m glad for that. And moreover, if there are people who want to contact me, they could do so through the Institute.

LR: I’m fascinated by the one word that you said clinicians, spouses, partners, family members should know, which is “password.” What’s the significance of imparting that piece of wisdom of knowing your partner’s password? And how did it play out in your journey?

DM: To access a number of accounts, my life was such that my wife Marianne was a wonderful wife, a very competent person. She was an actress, and she was a June Taylor dancer. She looked after all of our finances. I’m not a very competent person other than psychology. I’m a really good psychologist. I know a lot.

But when it comes to life, she was what I would characterize as my surrogate frontal lobe. And therefore, I never knew how to run appliances or bank machines or any of these kinds of things, and she looked after it. So, to gain access to that information, you really need the passwords. Fortunately, I have four wonderful children who are competent and loving and supportive, and that helped a great deal. So, we were able to, over a lengthy period of time — trust me, it took more than an entire year — to settle accounts related to adaptive functioning and financial issues and the like.

I won’t trouble you and your audience, but to highlight how unfriendly, how totally unfriendly the system is, to the 1,000,000 people who lost loved ones due to COVID. You know, the 20,000 individuals who died by interpersonal violence. You know, the incidence of mass shootings and all the other kinds of episodes, you know, the 48,000 who have to survive the suicidal death of a loved one. So, this discussion is absolutely remarkably timely, let alone the loss of natural disasters. I mean, just think of all the people at Maui whose lives are just upturned, and the many wars and the like. So, dealing with loss, grieving, traumatic bereavement, and mourning has to be on the top agenda of every clinician.

Difficult Therapeutic Conversations

LR: Working with adult children of elderly parents, clinicians have to enter conversations about what their plans are with and for them. And it seems to really behoove clinicians to engage these clients about the possibility of traumatic loss and unanticipated loss without pre-traumatizing them. How can we do that?

DM: We have to remind ourselves that what makes us effective therapists is the quality and nature of the therapeutic alliance that we establish, maintain, and monitor with our clients. So, to answer your question, I would advise clinicians to not enter that discussion without the permission of their clients. If I were in that situation, I would say something like, “I recently had a personal loss and I had a lot of lessons that I learned. And I was wondering if you would be interested or willing for me to share those.” So, my notion of being a good therapist is always to solicit permission from my clients, no matter what it is I want to ask. The third thing I would do is to say that, “you should feel free if this is not a good time or this is what we want to do, to put you in charge.” Remember that we, as therapists, need to be person-centered rather than protocol driven.

So, it sounds like, Larry, you had a whole bunch of to-do tasks that you think this elderly client or loved one should go through, right? You said you don’t want to traumatize them. Well, I agree totally. You know, so treat them with the same respect that you would want.

LR: How do we have conversations with our clients who may not even have elderly parents, but who are aware that they live in a world where there are dangers around every corner. How do you help clients prepare for the unpredictable without pre-traumatizing them?
DM: I have a kind of style of therapy, and I’ve actually highlighted this. I just put together a legacy course on what makes people expert therapists. As it turns out, 25 percent of therapists get 50 percent better results and have 50 percent fewer dropouts. So, my legacy course is, what characterizes those 25 percent of people and how can I elevate clinicians to that level? I have a kind of interpersonal style of respectful curiosity. And I really want to convey that to the client and wonder if they’re curious as well.I might say things like, we live in — how should I describe it — precarious times. With the COVID epidemic, with unpredictable violence, with multiple disasters and I must confess that I personally wondered to myself, and I wondered if you wondered to yourself about, given the unpredictability of life ever occurring, are we and our loved ones prepared for that? I mean, that’s my style of interacting. So, what I’m doing in that is actually sharing the rationale, and I’m extending an invitation.

My client might choose to take that invitation or not. And moreover, if I am going to see that person again in the future, all I want to do is plant the seed, then I will be able to follow up. I would say maybe this isn’t the right time or I’m not the right person. But as I look around, I think it might be advisable. And even something as simple as knowing the password of your loved one might be a good starting point. So that’s my way of engaging people.

LR: As simple as that. Simple, but complete.
DM: The key, or perhaps the challenge, is to deal with difficult issues in a non-traumatic engendering fashion.

Lessons on Grieving through Personal Loss

LR: In what ways, looking back, has your own clinical work and research helped you in your journey of grieving?
DM: Now that I’ve talked about the sequalae, let me take a moment and talk about the grieving thing. One of the things that’s really important for your audience to know — and there’s good research by George Bonanno and others that in the aftermath of loss — is that whether it’s due to traumatic, violent episodes like this, or whether it’s due to more prolonged, complicated grief as a result of having someone who’s been ill for a long period of time; there’s an expectation and different kinds of deaths have different kinds of impact.The bottom line is you need to recognize that most people are highly resilient. If you look at the data, most people don’t develop prolonged and complicated grief. So, the key aspect is, what distinguishes those who do versus those who don’t? And I even wrote a book called Roadmap to Resilience, that examines this and deals with it. In fact, your audience is welcome, in honor of my wife’s death, to view this and also my legacy course in her memory. So that’s one way of transforming pain into something good that will come of it.

And in fact, the Roadmap to Resilience has been downloaded for free on the Internet by 45,000 people in 138 countries. So now, let’s get to the heart of your question. In fact, George Bonanno wrote a really nice book called The Other Side of Sadness, which I recommend. It’s a nice little extrapolation on the kind of resilience engendering behavior. Therese Rando has also developed a concept that I’d like to comment on, that she calls “STUGs,” Sudden Temporary Upsurges in Grief.”

And in monitoring my own behavior, since I’m a psychologist and good observer, I’ve tracked my own STUGs. These kind of substantial or sudden kinds of upsurges of grief. And there are two kinds of STUGs in my life that I’ve discovered that have important clinical implications. The first STUGs are sort of sudden and unexpected. A song comes up, an invitation comes up to go to dinner with someone who doesn’t know about my wife’s loss. A couple walks by holding hands and lovingly convey their intimate connection.

And that hits me in an unexpected way. I’m moved to tears, and I have a sense of loss and the like. And there’s nothing wrong with that. In fact, I’ve come to believe that each tear that I experience in loss is not only a reflection of the loss and the grief and how much I miss her and the like, but it’s also a tear of appreciation. Of how lucky I was and grateful to have her in my life all these years. And then, I would have never had this career and all that without her. I’m a cognitive behavior therapist, so the whole thing is not that you cry, not that you feel losses.

It’s what is the story you tell yourself and others about that emotion? Each of us, each of your readers of this interview are not only Homo Sapiens, but they’re Homo Narrans. That we’re actually all storytellers. And the nature of the story we tell will determine — I’m going to suggest — whether you fall into the 20 percent who develop prolonged and complicated grief, or you’re part of the 70 to 80 percent who, in spite of the loss, everlasting loss, your STUG is this kind of sudden reminder.

LR: Unexpected!
DM: I sort of expect them, but they come out of the blue, right? The other kind of STUG which is interesting is something that’s a reflection of a prolonged type of routine or activity that we would have engaged in. So, I’m in Cape Cod, one of the things we would do is go down and have our sunset drink on the beach. A saxophone player would often be playing in the background from their beach house, you know, some Cape Cod song that we would have toasted to, kind of thing.Or we have our favorite restaurant, or our favorite hike or something like that. And I’m now doing those activities on my own. There’s another really interesting aspect to this, and that is, is the person who’s surviving the death, male or female? Okay, so most of my social contacts here in Cape Cod, and in other places, are a derivative of my being a partner of Marianne. So, she had a remarkable social network. She was just lovable and likable. There wasn’t anyone who didn’t fall in love with my wife.

And when she died, those social contacts sort of evaporated. People sort of give you occasional email and a “how are you doing?” But you don’t get invited to the same social occasions or dinners or other kinds of activities, so your network is really an important issue. And the important predictor here, especially among men, is loneliness. Okay, and there’s a higher incidence of husbands dying soon after the death of their wife, about 30 percent and so forth, and having other kinds of physical ailments than the other way around.

And then you need to distinguish between loneliness and isolation. Some people choose to isolate — they like being alone and so forth. Loneliness is yearning for this. And so first of all, in the aftermath of both traumatic bereavement and in terms of the mourning process, that becomes important. The other thing that your readers should take away is that there are no stages of grieving. So Kubler-Ross and Ron Kessler’s stuff about going through stages has no scientific basis for it.

And not only do you not have the five stages, but the expectation on the part of the clinician that people need to go through stages, and the failure to do so is a sign of pathology, is indeed problematic and possibly stress-engendering. So, when people don’t get angry, okay, then it’s deniable or they can’t handle their emotions. And I had a pretty good cause to be angry. This happened in Florida, okay? So, the guy who killed my wife got fined 160 dollars and lost his license for three months.

That was the total consequence. Not only that, in Florida — this is a wonderful state to live in if you’re going to retire — you don’t have to have liability insurance on your car. Okay? All you need to do is pay insurance up to 10,000 dollars. The helicopter cost of taking my wife from Clearwater to the trauma center was 68,000 dollars. So not only do I have, look, how much time do we have? You want me to go on and on? So, what am I going to do? And anger we know, gets in the way of processing trauma memories. Of all the emotions, that’s the one you don’t want to give up to. And that’s the one that clinicians should ask about in the aftermath.

So, if you go to the handout that I have, I have put together the most important diagnostic questions that clinicians should ask. Yeah, I give workshops on grief, and I actually bring my pillow and tell people. And I ask, if I’m your client, Larry, what questions do you think you should ask me? You’re a gifted clinician. What do you think are the most important questions you should ask me to see whether I’m going to develop prolonged grief disorders? Because there are now effective treatments. Shearer and others have created really good cognitive behavioral interventions, when I go on and on and review all the literature. So, I can make this a two-way street. I could ask you, what question do you think you should ask me first?

LR: What comes to mind is, how has your life changed?
DM: Wrong question!
LR: Okay, I could probably guess 20 times wrong.
DM: No, no. The first thing you should ask is, “how long ago has this occurred.” Okay, if this happened like last week or last month, that’s different than if it occurred a year ago. Okay? You know, and then there’s a whole set of questions you could ask about the circumstances, like you did at the outset. Okay, so getting to the notion of how you handle this has a kind of implied judgment on your part that I should be handling it.So, am I going to tell you how bad off I am or am I going to say oh, it’s not that bad, right? So, you have to establish a good therapeutic alliance with me, where I’m going to be open and honest. You know, I have trust engendering things, so I don’t know what your agenda is. Anyway, go to my handout.

LR: I will. I will.
DM: Please, I didn’t mean to put you on the spot.

LR: It’s refreshing and intimidating at the same time. What other guidance are you offering to clinicians who maybe are sheepish about asking the questions, or will not openly receive or seek out clients who have experienced loss? 

DM: The first thing — over and above the comment on stages — is that the field of psychotherapy is absolutely filled with bullshit. I wrote an article with Scott Lilienfeld called, How to Spot Hype in the Field of Psychotherapy. The next thing for therapists to understand is that the various therapeutic procedures are equivalent in outcome, and that there are no winners in the race. So that’s the next thing, just don’t believe the hype in these workshops where these people are saying that, “X, Y, and Z works better.”That traumatic bereavement is a common response, will lead to grief and mourning that leads to deteriorating performance is just not the case. So, the second thing that’s really important is that you need to ascertain from the client how to do therapy in a culturally and religiously, and gender-related kind of fashion. You need to ask the person — in my case, whether I’ve had other losses besides Marianne. You need to make me a consultant to you. Okay. And then you need to probe. How did I handle those? And is there anything I learned from them? So, you need to see me as a client as a resource person rather than someone you’re going to treat because you went to some workshop. Okay!

And apropos of the loss and transition website by Neimeyer and colleagues, they have a lot of techniques. Some of them are expressive. Some of these are customary activities that people engage in. So, you, the clinician, need to honor the way in which I want to cope with grief. Okay? And I recently went to a workshop by Mary Francis O’Connor who wrote a book on the grieving brain. And you need to recognize that some of the losses that people experience are natural and a reflection of love.

So don’t pathologize people’s grief or their coping techniques. If I want to avoid certain activities, I don’t go and get rid of the clothing and so forth. And there was a movie that Tom Hanks made that his wife produced called, A Man Called Otto. It’s a bit of a Hollywood version, but they did a really good job on talking at the gravesite. And doing the thing on the clothes. Here’s a wonderful thing that happens. When I cleaned out my wife’s closet, I found out that for the five years that we courted each other, we had written letters. And mind you, that was 1961. She saved all those letters. In 1961, a stamp was four cents. I read those letters as if she was present, each night I take out a couple. I’m now up to 1963, you know that stamps now cost $0.08 in 1963? Her presence, my storytelling, my doing this interview, my reading the letters, are all my own personal ways to honor her memory. The fact that I put the Roadmap to Resilience online for free in her memory.

If you go to the Melissa Institute website, if you’re interested, if you like this interview, go there and make a donation in my wife’s name. We’ve already raised 25,000 dollars for the Institute against violence prevention for her. I’m now in the midst of having done this legacy course of ten one-hour lectures on what makes someone an expert therapist, and then how to take those core principles and the transtheoretical behavior change principles and apply them to a whole host of diverse problems like grief and PTSD and anger and the like.

Each of those courses is only going to cost 150 dollars. Okay, that’s 15 dollars per CEU. All that money is going to go to the Institute in memory of Marianne. So, if you want more of what we’re talking about, track down this legacy course. If you do, there’s the likelihood you’ll be in the 25 percent group and you’ll be able to honor my wife’s memory. You get CEU’s for cheap.

The Role of Resilience in Healing through Grief

LR: You mentioned something earlier on, Don, about resilience as one of the really powerful predictors of how someone will move through their grief journey. Can you say a little bit about what a resilient griever looks like?
DM: In the aftermath of trauma or victimization, and with regard to whatever form it takes, resilience has been equivalated with notions of the ability to bounce back and with dealing with ongoing adversities. And it deals with the notion of personal growth. Margaret Stroebe and her colleagues have an interesting distinction within which people oscillate. That is, they have a variety of coping responses that are loss-oriented or restorative, and future-oriented. One of the things that’s interesting is that people can deal with it as a kind of Viktor Frankl type of observation.That people could deal with any kind of how in their life, as long as they have a kind of why in their life. Some sense of meaning, making purpose. This fits into my constructive narrative perspective that everyone is a Homo Narrans, or a storyteller. So, one of the things that becomes really interesting is how people transform their loss into some kind of effort to help others. So how did the Melissa Institute come about and my involvement therein? So, in the tragic killing of their daughter, Melissa, when she was at college in Saint Louis at Washington University, they have transformed the last 28 years – her loss — into a meaning-making activity.

You can go to the Trevor Project on suicide. You can go to Mothers Against Drunk Driving. There are numerable examples, I give multiple websites of how people have transformed their pain into something good. That doesn’t mean that you don’t continue to have an everlasting sense of grief. There’s nothing wrong with grief. It’s like any other emotion. The key is, what do people do with that emotion? Do they withdraw? Do they isolate? Do they become lonely? Do they use addictions? Do they self-medicate?

So, the key question is not, apropos of the resilience, or that people grieve. The fact that people are in touch with their grief is, in fact, a sign of resilience, right? It’s coming to, how do they honor? How do they memorialize? I deal a lot with returning soldiers. And the other kind of thing is that there are different kinds of losses. There’s loss of people, but there’s a thing called missing loss also. Like imagine people who have individuals who go missing in action. You don’t know if they’re dead right, or in Maui — you know, they haven’t found certain bodies. I mean, does that mean, is there more?

How do I, do I sort of get preoccupied and ruminate about the loss of my loved one, and how I wasn’t there? If I have guilt, shame, humiliation, if I have anger, if these kinds of negative emotions are that which drives me, then that’s the person, those are the folks who are going to be more likely to get stuck, who have hot cognitions and the like. So, you can talk about resilience being the absence of negative stuff, or resilience could be the restorative process on the other end. I don’t know if I’m getting close to your concerns, but…

LR: That resilience, and there are certain personality attributes and certain experiences that predispose people to resilient ways of being, and those people are probably in a better place to move forward in their lives after a loss.

DM: Here’s one of the things I failed to mention. The research indicates that people who have had a prior major depressive disorder are significantly more likely to develop prolonged and complicated grief. So, when I was asking the question, I ask, “Have you had similar losses in the past” and so forth? What we could do is look for vulnerability factors, okay, that are red flags as another tip. To see who would warrant evidence-based interventions, we’re pretty good.

If you look at my core task, there’s a whole way of how we, as therapists, do psychoeducation to educate people about grief. Or how do we help them develop various kinds of coping strategies? And how do we get them to follow through? The big thing is how do you get people who need help to want to come for help? And help them stay there? That’s the artistry of therapists.

LR: Is it more likely that those who have historically reached out to others for help, who have built lives that are rich in community, are just naturally predisposed?

DM: Well, a lot. There’s a fair amount of research by Camille Wortman and Roxanne Silver. Obviously, one of the building blocks for resilience is relationships. I mentioned I have four loving kids who really came to support, I have other people — professionally and others — who’ve come to support. But Wortman then really found a whole bunch of things that people do that are unproductive, that actually make people worse.

They have identified a variety of things that people provide support for, and actually make people worse. Like moving on statements. Things like, “You’re still a young, attractive, bright guy. You’ll find someone. How much longer before you die, You’ll be able to join him. This was God’s mission, He knew something.” So, there are lots of things that social support people offered, so that’s one of the questions you need to ask.

What, if anything, have people done or failed to do that you found helpful or unhelpful, right? Because you want to make sure that you, the therapist, aren’t doing something that I perceive as being unhelpful. So, if you’re a really good therapist, let your patients teach you how to do therapy. Don’t think just because you went to graduate school or took some workshop that you know how. Ask your patient, “What do you think is causing you to still have this lingering grief? And what do you think it will take to help you to move on? And what is it that I, the therapist can do to help you in that process?”

LR: You know, Bob Niemeyer suggests that therapists working in the arena of grief need to be what he calls the guide on the side, rather than the sage on the stage.

DM: Yeah. I like that. That’s a good metaphor. I like him a lot. I’ve read all his stuff. And, you know, my thing is, don’t be a surrogate frontal lobe for your patients. Don’t let the person’s emotions hijack their frontal lobe.

LR: And don’t, as the therapist, let your emotions hijack your presence in therapy. What about those therapists who themselves have had complicated losses, or unfinished business with their own children, parents, and spouses who have died?

DM: Well, I guess those therapists need to be honest with themselves and wonder how it impacts their therapeutic process. Those therapists need to be honest with themselves and decide whether, in fact, they need some therapy. That could help them deal with the issue. And the third kind of issue is, can they strategically use that self-disclosure in a way that facilitates or benefits the patient’s recovery? Rather than saying, you think you’ve got problems with your wife? You want to know what living with cancer has been like? And not only that, my father has Alzheimer’s, and now all of a sudden I have to listen to your shit, right?

So, you can judiciously, strategically say words are inadequate to describe what grief is like. I’ve been there myself. It’s not the occasion for me to share the details, but I want you to know I’ve felt the pain. Okay, I don’t know what the right words are, and you have to say it in an effective way. You can’t say, you think you got problems?

LR: In what way are you — are there any ways that you’re still practicing as a therapist now?

DM: I do a lot of consulting. I work with the head injured thing when people have cases, I train therapists who are doing supervision. I’m not seeing patients now like I did in the past, because I’m not in one place. I’m kind of a peripatetic clinician, so it’s hard to make a commitment to someone being there. I do some consultation with patients by telephone, since COVID.

LR: We could talk for hours Don and I do I hope we talk again. I appreciate your kindness and generosity.

DM: Thank you for the compliment and for inviting me on this journey.

©2024, Psychotherapy.net

Mapping the Heart Of OCD: Going Beyond the Conditions We Know

Posted on by Psychotherapy.net Team

“The heart has its reasons of which reason knows nothing.” —Blaise Pascal

Capitalizing on Empathy in OCD Treatment

Some diagnoses are no-brainers when it comes to treatment. Poll any therapist with a pulse and ask them what’s the best intervention for OCD, and you’ll get the same answer: Exposure Response Prevention (ERP).

ERP is a cognitive-behavioral technique whereby OCD sufferers stare down their biggest fears and learn not to blink. Intending to conjure up their personal worst-case scenarios — the terror of harming a newborn child, the yuck factor of hands submerged in an overflowing trash can in Times Square, or entertaining the possibility that they just might be a psychopath — ERP performs an unusual sleight of hand. By leaning into rather than avoiding anxiety, sufferers break OCD’s unruly spell.

Although highly effective at providing relief for symptoms, ERP is a mind and behavior-oriented approach that misses the most astounding feature of the OCD tribe: their enormous hearts. People with OCD are amongst the kindest and loveliest clients with whom I’ve worked.

And it’s not just my own bias, research confirms this big heart. Recent studies found that individuals with OCD show higher empathy levels compared to healthy controls. They shared the suffering of others in both self-reports and in a naturalistic task designed to test empathy in real time. They also reported more distress over their heightened empathy and are more emotionally responsive and attuned to others compared to healthy controls.

Such responsiveness is at the core of what makes therapists so effective, and yet for those with OCD, it misses two crucial pieces: the self-compassion and self-advocacy to counterbalance a weighted-down heart. Therapist burnout shows it’s possible to be too empathic, but have we ever looked at OCD from this perspective? Maybe we should!

A behavioral approach gives little room to map this expansive OCD heart, and it’s a real turnoff. Like the Grinch, many OCD sufferers don’t want to touch ERP with a 39-and-a-half-foot pole. Between one quarter and one half of people with OCD decline ERP, in some cases even before it begins.

I regularly take on the challenge of asking myself as a therapist: what more can I learn about this condition by entertaining something completely different? In the spirit of punk rock, what can I glean if I rebelliously take on the mainstream? With its one gold standard treatment, OCD begs the question: isn’t there more we can do to help OCD sufferers find their voice? Perhaps ERP is so popular that few have the audacity to question it. Maybe, as Pascal instructs, the heart has its own reasons. Such was what I learned with and through Kate.

Kate’s Therapeutic Journey

“I almost cried when I read your blog post,” Kate confessed during our first zoom meeting. A cinematographer based in LA, Kate was fast losing hope that she’d ever get past severe OCD that only relented, ironically, when she was on set. “I always thought that I was failing at OCD treatment, not doing it right. Like, why aren’t I strong enough to just sit through the anxiety? But when I read your work, I felt like treatment was failing me.”

Kate read my unconventional theory that OCD arises from an empathic and existential sensitivity that goes unnoticed and unsupported, and turns in on itself. That enlarged heart capable of so much love is also keenly aware of the chasm of loss set before us all. Is it any wonder that the majority of OCD sufferers worry that death might befall themselves or someone they love? Or that the ritual du jour might somehow stave off what we all wish to control? At its root, OCD is a keen awareness of the fragility of life and the myriad spells and incantations we use to hold on to it at all costs, even if we must lose ourselves first.

“My parents and siblings used to poke fun when I was little when I wasn’t ready to let go of my teddy bear like they all did when younger. I carried her everywhere; she was the sensitive heart nowhere to be found in my house. I hated that I couldn’t let her go, and even until recently, I felt that way about my OCD treatment. Why couldn’t I be fiercer and face my fears and just grow up? Why can’t I even do this ERP thing right?”

Kate felt guilty in therapy, too. She admired the OCD specialist who first gave her a diagnosis and regaled her with the promise of ERP. Finally, there was hope that OCD didn’t have to rule her world. If he had saved her — as she so often felt — why wasn’t she more appreciative?

As we talked together, it became clearer: feeling wasn’t on his radar. Her therapist didn’t listen or seem to care about all that sensitivity, and she felt rejected yet again alongside her teddy bear. “What does it matter what your obsessions mean?” he’d shoot back, as if to say, “get with the program, this approach isn’t going to get you anywhere.”

In conventional OCD treatment, obsessions are just noise in the system trying to distract from the most significant mission: full acceptance of uncertainty and ambiguity. While Kate always wanted to make meaning and find ever more intricate forms for her feelings, her therapist just wished she’d keep working hard and be satisfied with her progress. There was little room for her own authoritative and unique voice, all that good fire in her heart.

Kate could also detect something unspoken in her therapist’s heart: how much his identity seemed tied to one singular truth and how it rattled him to entertain otherwise. She vaguely knew something about herself — how she existed in the world — hurt him. But she never put those feelings into words. Instead, they metastasized into self-doubt, self-recrimination, and shame.

It clocked Kate in the face when she recognized her therapist’s philosophy in a meme widely circulating and praised on Instagram in the OCD recovery world: “OCD is just sound and fury, signifying nothing.” Borrowed from Macbeth’s famous line when the walls are closing in on his murderous exploits and he learns of his wife’s death (ironically, Lady Macbeth with her “out-damned spot!” is one of the most famous contamination OCD cases in literature), Macbeth’s phrase is one of horror, lamentation, and hopelessness. The world is a meaningless, obsessional march of tomorrow and tomorrow and tomorrow, a tale told by an idiot.

“What is wrong with me?” Kate wondered. “I’ve always been a failure in treatment just as in life.”

The middle daughter of a highly educated and successful family of Chinese immigrants to California, Kate constantly found herself on the outside. Family members pegged her as unable to let things go, and though they’d never outright say it, weak for not being able to be more driven and hardworking like the rest of the clan. “Even your work is all just fantasy,” her mother complained.

Kate’s sister had already long moved out of the parents’ house at 25 and was now in medical school, setting sights on buying her first home. Her brother, an IT specialist, always seemed to be able to fix just about anything. Kate was the anomaly, still living at home with her parents and never quite fitting into the alpha-driven landscape of her family’s California dreams.

“Why couldn’t she just enjoy the promise of all that beautiful California sunshine?” her father protested. Kate was always adrift in the riptides of her obsessions, what if she forgot the stove was on, burned the house down, and killed everybody’s nascent dreams along with it?

“It’s like I can never do what the mainstream wishes for me. Maybe that’s why I’ve gravitated to indie films so much. It’s my only refuge.”

“I’d reverse that. The mainstream has never really witnessed your profound heart. You have always tried to accommodate the mainstream — your family, your therapist, the world — but it has come at the price of who you really are. Your sensitivity has always been a part of what has made your vision so clear and full. It’s no accident that your OCD largely vanishes when your sensitivity is prized, as it is when you are working on films and the director gives you the go ahead to command what you need to get the right shot.”

Kate always had a whimsical and keenly observant view of the world, and it showed in her cinematography. She always knew which way to angle the camera not just to get the right light or best composition, but somehow, she evoked things out of objects and people that were somehow right there, but beyond them as well. Her prodigious talent landed her on projects that she most dreamed of; it was also one of the few places where she felt free from obsessional doubt.

“Because your parents didn’t see your sensitivity as a gift, it got housed in your own mind, and you had to protect yourself and them from its power. You sensed so much of what was happening in your environment but there wasn’t a place to communicate that. It becomes wild in our own minds, but we need relationships — and art — to tame it.”

Kate is in Good Company

Together, we joked about how many artists and innovators shared OCD and this unique sensitivity, if you were lucky, found a place to give it creative form. How Greta Thunberg, herself an OCD sufferer, marshals her profound sensitivity to the neglect of an entire planet into fierce advocacy to save us all from extinction. How young adult author and OCD sufferer John Green chronicles teenagers staring down their own cancer diagnosis in The Fault in Our Stars and writes of Aza Holmes, the greatest young adult character with OCD in American literature, in his novel Turtles All the Way Down.

Like Kate, Aza seeks her own center. Is she just a fictional character without any volition of her own? Is the 50 percent of the bacterial microbiome that makes up the human body in control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner has she found herself than she is lost again, spiraling about the possible infection she now has unleashed. Compelled to drain the pus and blood, Aza is a hostage of her own self-enclosed system of fear, love, and unboundedness.

The heart figures prominently in Aza’s story too. Her father, also a sensitive soul and unrepentant worrywart, mysteriously drops dead of heart attack while mowing the front yard lawn. Just as Kate is so aware of killing everybody’s dreams and truths in her life, Aza shares a moment of clarity with her boyfriend about the root of her OCD: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.”

“OCD is a sensibility of sensitivity, one that has an exquisite flame for creative possibility but when traumatically misunderstood and misdirected, it burns the house to the ground. If Gabor Mate specialized in OCD (Kate was a huge fan of this rock-star sage) he’d appreciate it with us too. OCD is more than just a biological glitch; nature and nurture are always in conversation, whether we choose to listen. OCD is trying to tell us more than even therapists are ready to hear. There’s interesting music in all that noise.”

Kate was accustomed to having her true interests and concerns fall on deaf ears. Her relationship with this therapist and with cognitive-behavioral therapy itself echoed her ambivalent relationship to her parents: while she was grateful for having been raised and financially supported by them, they minimized her interests as foolish and viewed her obsessions as just more evidence of her immaturity and self-absorption. Without a clear and secure sense of support from these relationships — her parents or her therapist — Kate relied on her own thoughts and rituals to hold her up.

And yet here was the rub! Untempered by any human relationship, these thoughts quickly became savage and cruel, expecting her to be able to live up to what her perfectionistic imagination could dream up: a world of all-or-nothing purity.

Kate suffered from paralyzing obsessions when out in public places, fearful that the looks of others somehow might cause her to implode. Triggered on subways, Kate left the NY film scene for California where she had more freedom to drive solo. But Kate never quite understood why her obsessions centered around this particular theme and not something else.

“It doesn’t really matter,” her old therapist used to say. That’s the trap of it. It wants you to give it attention and believe it has meaning so you’ll keep on going down the rabbit hole. It’s not to be trusted as your friend.”

But Kate, ever-so-fascinated by the motivations of the characters she tracked in the movies she made, knew there must be more. Obsessions had a funny way of both distracting and focusing us on the things we most feared and desired for a reason. Kafka’s Gregor Samsa didn’t turn into a bug just because he had some tic of the mind, but rather because he felt the alienation, oppression, and depersonalization of his family life and modern society combined.

Successfully Addressing the Heart of Kate’s OCD

We worked on a new kind of exposure response prevention, one that dialed down into all of her feelings and associations with her obsessional fear. As we did, Kate became a more sharply drawn character: she was terrified of being intruded upon, judged, and taken over by the needs of others around her. With her big heart, she was so tuned into the unexpressed fears and desires of everyone that there wasn’t enough room for herself. She sensed the fatigue in her parents, their loneliness for their home country, and their overcompensated worries about surviving. They had no idea that internally she was feeling for them, unconsciously trying to imagine every way she could help them control their fate.

She was compelled to avoid any places which might afford too much scrutiny — subways, planes, trains, long car rides— and wisely found the safest place to exist with complete freedom: behind the camera. There, she no longer was the stage for all the unexpressed feelings of others; she could now orchestrate them for her own artistic purposes.

I knew Kate was making progress in our treatment one day when she started our session rather abruptly, “I know you might want to talk more about what we only half-completed last week, but I don’t want to do that. This is what I need today.”

My heart swelled. I loved the grit, fire, and healthy aggression that I knew she needed to have to own herself, even if she risked temporarily losing me. When I expressed this, she was a bit dumbfounded, “You mean, it’s okay for me to ask this? I’m not screwing up your plan?”

“Kate, it’s always puzzled me why Aza Holmes needed to pick at her finger, but only now do I get it. It wasn’t just any finger; it was Aza’s middle finger. She needed to say a healthy ‘fuck you!’ to the people she loved — her mother, her best friend, even her own OCD — and trust that she was entitled to it. That’s what you’re doing now, and I love it.”

For the first time, Kate began seeing something strong and interesting inside her OCD, like the amethyst crystals spied inside a rock kicked to the side of the trail. She wasn’t broken inside, after all. New facets that other treatments said didn’t exist came into view.

Together, we found the heart of it, the mystery that constantly hovers somewhere between life and death, love and hate, and disaster and possibility. Like Aza Holmes, who had lost her father, her boyfriend, and her beloved Toyota Corolla Harold, Kate recognized the biggest truth of all: “To be alive is to be missing.” And yet, it’s in that unexpected place where Kate was found again.

Mary Jo Barrett on the Collaborative Treatment of Incest and Complex Developmental Trauma

Posted on by Psychotherapy.net Team
Lawrence Rubin: Hi, Mary Jo, thanks for joining me today and sharing your clinical expertise in the systemic treatment of incest and complex developmental trauma. Just before we went live, you were sharing an experience you had while giving a webinar this last weekend, and something caught my ear that I wanted to ask you about. You suggested that there is something different between what is currently being practiced in the field of incest and complex developmental trauma, and what, in your experience, is correct, or what should be practiced.
Mary Jo Barrett: That’s a good place to begin. When I first started, which was 45 years ago, I was a worker for the state, basically doing in-home counseling. I discovered that in all these child abuse and neglect cases, there was a significant number of cases involving incest and sexual abuse — whether immediate family members or close family members or clergy or whatever. I would go to my supervisors for guidance, but no one really knew how to treat it.
For example, Minuchin told me that I didn’t need to focus on the incest. I just needed to look at restructuring and building a hierarchy, and that the incest would then be alleviated. Carl Whitaker, who I was madly in love with, basically said, “You know what? I don’t know what to tell you.” At least that was honest. He said, “I do schizophrenia. You better figure out how to do incest.” He was my teacher, so I decided I needed to figure it out.
And so, over the years, I started asking my clients more formally about incest and sexual abuse. I also had my supervisees ask their clients. And whether I was conducting training in Europe or here, I began to ask the clients what the most effective thing about their therapeutic experiences was, and what about the therapy they had received made it “good therapy.”
Basically, nobody said “techniques.” They said what we know they would say and did actually say. It was the relationship between the therapist and client. But they even said more specific things. And of the specific things they said, I narrowed the list down to what I call the five essential ingredients of trauma treatment. But what they said applies to all models of treatment. And as we know, none of these models are better than the other I developed what I call a meta-model that applies to any trauma protocol that exists based on these five essential ingredients. And so, whether you do IFS or CBT or SC or any of the alphabet soup of techniques or protocols that are out there, they will be successful if they have the five essential ingredients.   

The Key to Effective Trauma Treatment is Collaboration

LR: What exactly are these five ingredients for effective trauma treatment?
MB: People, especially those who have been abused, need to feel that they have value, power, control, and connection. So, these “ingredients” include the client:

  • feeling valued
  • learning specific skills in finding resources
  • understanding contextual variables needed for an engaged mind state
  • developing workable realities
  • building a hopeful vision for the future

When a therapist, case manager, or foster care worker gets stuck with a client who has been abused or neglected, I suggest that they don’t go back to the protocol, but instead to the relationship.

LR: Going back to the question that I opened with, how do you see what’s in the zeitgeist now, what’s popular now, as being lacking in comparison to this collaborative model that you developed?
MB: The basic essence is that I go to the client to tell me what to do, versus going to a model or technique to tell me what to do.
LR: Can you think of a recent clinical instance in which the relationship seemed that much more important in the moment than any technique or model?
MB: Larry, every day! That is my model. Every session. In every session when you’re talking about trauma, there will be an impasse. I call it differently. In any moment, there’s going to be what I call a traumatic stress, which means the client, because of their trauma, is going to experience therapy as dangerous.
As we always say, survivors often see danger where danger doesn’t exist. I mean, that’s a standard thing. But that happens in therapy all the time. That’s because the therapeutic relationship is based on hierarchy and attachment. There is a hierarchy, right? I mean the therapist has more power. And the therapist is often controlling the sessions or the direction or what’s going on. And there’s a necessary attachment. There’s going to be an attachment between therapist and client.
Abuse and neglect are embedded in hierarchical attachment relationships. Now, the thing is, every time I say abuse and neglect, people might go, “But we’re talking about trauma.” And I’m saying, again, almost all the trauma cases we talk about revolve around interrelationship violations.
LR: So, if we practice anything other than a collaborative model, then we may in some way be replicating the hierarchical violation in the family that contributed to that abuse.
MB: I’d say that a majority of these clients anticipate and experience, from time to time, that violation in the therapeutic relationship.
LR: So, if the therapist moves too quickly or dives right into the trauma narrative or says, “Tell me about this,” or, “I’d like you to do this,” they are abusing their power? Even using directive words or a tone of voice or body posture can trigger a client so that they feel unsafe. And that’s when you would be cognizant of that, hypersensitive to that, and readjust any of those facets of your approach?
MB: Correct. And the collaborative change model is exactly that cycle. What you just described. And what’s interesting to me is that the collaborative change model is a natural model. And when I describe it, folks at the clinic say, “Oh, my god, yeah!” And the good clinician says, “That’s what I do in my sessions anyway.” And all I’m saying is, make it conscious. It’s a natural cycle of change.
The first phase is creating a context — which is creating refuge, making assessment, figuring out what’s going on — then making a direction, deciding what kind of intervention to use. And then when we start doing our interventions, which is natural, we’re challenging, right? And the relationship becomes embedded in this hierarchy because I’m sort of pushing and challenging by asking them to do something different. And in that moment, the client might experience a moment of fight-flight-freeze-submit. Or fix! And I have to, as a clinician, recognize that.
And in that moment, instead of pushing harder to make an assumption of, “Oh, they can’t tell,” or whatever it is, I need to stop and recreate a context of change. So, at that moment, I stop and say, “What do you need now? What’s going on? How do you feel? Should I slow down? What’s happening?”
I’ll give you an example. I had a client who often during the sessions would say, repetitively, “You don’t get it. You don’t get it. You don’t get it.” And I’d often get defensive. I’d sometimes want to say, “Well, help me understand,” or, “Explain it.” And then one day after the session, I was thinking, “I think that’s a trauma response. So, I said, “I’m wondering if when I’m doing something that triggers you, you experience me as threatening and go into ‘You don’t get it’ as a repetitive response.” And she really thought about it and looked at it and she said, “You know, I’ve often felt there’s things you do that remind me of my mother.”
This client’s mother was like Joan Crawford’s character in Mommie Dearest, and we’re not just talking severely abusive. I asked her what reminded me in those moments of her mother. In response, she said that I talked loudly, and it was the way I dressed in skirts. She experienced me as dressing in a way that was, for her, reminiscent of her mother, which she experienced as provocative. I don’t know that it was, but she experienced it as such, so for her, it was.
So, when we then had that conversation, and from then on, I did consciously change how I dressed on the days I saw her. And I consciously changed my voice. And after that conversation, she never said, “You don’t get it,” again.
LR: So, when she emphatically repeated, “You don’t get it, you don’t get it,” it was metaphoric for something like, “You’re not hearing me, that hurts, stop it, you’re not hearing me, you’re dressing in a way that confuses me. You’re not hearing me. Daddy did this, or Mommy did this, or my brother did this.” It’s like this broad statement of, “I am feeling abused right now.” She may not have been able to put a finger on exactly what element of your relational moment was triggering her, but “You don’t get it,” meant, “I am feeling powerless and unsafe.”
MB: Violated. She was feeling violated.
LR: She was feeling violated. Because you’re much more cognizant about the relationship and the attachment, and breaches in the attachment, you were able to look inward and ask yourself, “What could I be doing? How could how I be talking? What would I be wearing? What might we be talking about? What is it about the way I’m asking questions that could be replicating at some level what happened in her family?”
MB: Yes.
LR: Did I get it right?
MB: You did get it. I should bring up my PowerPoint. You’re doing a very good job. I have three slides that I use in trainings, which I introduce by saying, “These are the three watchwords or phrases of my faith.” The first one is by Mandela that says, “A good head and good heart are always a formidable combination.” The second one was by R.D. Laing who talked about the importance of awareness by saying something like, “If you aren’t aware that you’re not aware, there’s nothing you could do to make change.” And the third one is by Jay Woodman which says that “Life is a series of cycles of getting lost and finding yourself.” And that each time you’re lost, if you look at it as a possibility, then you will find yourself in a new place. And so, my thing is, therapy is a cycle of getting lost and finding yourself again. And once you’re aware of that, you integrate your mind and your brain, your heart, and you’re golden.   

The Healing Power of the Therapeutic Relationship

LR: Is there something about trauma, and incest in particular, that drives clinicians to cleave to techniques and theoretical models; bypassing what they truly know to be effective, with is the relationship?
MB: It’s an integration of the two. When we spoke with these clients, it was clear that they did need new skills. It was the third most important thing, not the first. But the first thing they said was connection. The second thing they said was they had to feel valued, and they had to value the clinician. Then they said they had to feel empowered. And then they said skills.
Everybody that’s developed a protocol model is going to argue with me and say the relationship is the basis of all those protocol models. I would say I got you; I believe you. But if you ask the people who are trained in those models, they will say the emphasis is on the protocol and the interventions.
And they would also say that the difference is that when they’re stuck or a client gets activated, that it’s “go back to the protocol,” versus going to the client to collaborate.
LR: I wonder if there’s something about trauma, and particularly incest, that compels clinicians, especially those who aren’t experienced, to have to “do something.”
MB: A hundred percent! This is actually the new thing that I’ve added to the “fight-flight-freeze” paradigm, which is “fix.” So, I think what happens when a clinician becomes overwhelmed — I call it a place of traumatic stress — fix becomes part of a trauma reaction. The traumatic stress reactions.
When a therapist falls into a “fix-it” state, that should be an indication that they are in the trauma field and are feeling dysregulated. They then have to get re-regulated in order to move to a different place. And it’s the same with the client, who at that moment needs skills to re-regulate themself. I don’t believe when a client or a therapist is dysregulating, that’s the time to automatically use a technique.
LR: So, by jumping in with “a fix,” the therapist might be trying to regulate themselves at the cost of their client’s regulation.
MB: I want to say one other thing which is not going to be popular. I believe that when therapists jump in with a technique, they’re hoping it’s a solution for the consumer of their services.
LR: Giving them something.
MB: Giving them something, which is capitalism. Everything is an agreement in the contract with my clients.

The Importance of Working Systemically with Incest

LR: Someone reading this interview might say, “Well, it sounds like she’s working with the individual,” but I know you’re deeply systemic. So, I’m assuming that this collaborative model infuses your family work around complex developmental trauma?
MB: Yes. Most of the clinical work I do is with couples and families. And this goes back to the research we did with these clients who said that rarely, if ever, did other clinicians include their family. So, what would happen is that after those sessions with the “other” therapists, these clients would go home and have abusive fights or get hit. Or a parent would continue the abuse or violate.
Here, I go back to what I said earlier. Abuse, neglect, and childhood developmental trauma are embedded in a relationship of hierarchy and attachment. So, I believe healing should happen in a relationship.
I want the therapy to recreate some of the crisis right in the room with me. So, if there’s a fight, and dissociation, we all can witness it together and address it in the moment — together. If there’s eyeball-rolling that then triggers the other person, I want it to happen in the room, because those are the cycles that cause the traumatic stress at home.
Everything I’m saying to you here and now is what I say in the first session. When I start a session, I want the safety in our relationship to spill over into their relationship. I want their relationship to be a source of regulation. Not me. I don’t want to be the primary person in their lives.
LR: I can see how this would apply working with intimate partner violence. But are you saying that in cases where there is past or present childhood incest, that you would work systemically with either the current or past family members?
MB: Let me delineate two things. One; when the incest is currently happening and its children, yes, I include everybody. But I have all sorts of rules and boundaries. If it’s currently happening, and in most states, if incest is currently happening, then usually the perpetrator, whether it’s a sibling or a parent or not, is kept away from the child, right?
So, I don’t bring the alleged offender, or the offender, into the room with the victim until they’ve acknowledged facts. So, if they’re denying facts and saying, “She made me do it,” or, “He made me do it,” or, “It never happened,” I don’t do family with them. But I would do family with other family members. But I don’t bring the alleged offender into the room until after they’re no longer denying facts. 
LR: Is that enough? Just getting past the point of denial? Would they have had to have done some significant reparative work of their own before you brought them into the room with the victim?
MB: They are in therapy. Yeah. I mean if it’s currently happening, then the offender is in individual and group therapy, according to how I think good incest therapy should happen. And the rest of the family are either in individual, group, or family treatment for whatever their issues are. And the kids could be in individual concurrently with the family therapy.And then when the violator has met certain criteria, then they can start coming into the sessions.

LR: So, who’s your client? In a case of incest, where it happens currently, or even in the past, who do you identify as the primary client?
MB: The family. But/and my collaboration is with all. It’s a team. I mean it takes a village. Absolutely. When we’re talking incest, it can’t be done effectively by one therapist.
LR: Do you or can you even work effectively with adult survivors of childhood incest?
MB: I’ve developed what I call the “family dialogue program,” which is for adult survivors with their families. And so, I do bring them together but it’s different. I often do it in these intense weekend workshops because if people live all over the country, it depends on if we’re doing therapy about wanting to talk about the abuse and neglect or are we doing what I call the third reality, which is, let’s just focus on the future. Let’s not focus on, did it happen, didn’t it happen, what’s going on? Let’s just focus on, am I going to come to your funeral? Am I going to come to Passover? How can we be in the room together? Am I going to go to my niece’s wedding? Are you going to ever meet your grandchildren? That kind of thing.
LR: That presumes that the perpetrator must take responsibility. They must be willing to listen, at least. Be present and listen. In other words, if you want to ever see your grandkids, you’re going to listen to me. You’re going to hear me. And that perpetrator may leave not feeling very healed, but at least he or she will have given the opportunity to the victim to be heard.
MB: And that’s why I call it the third reality. Because we’re just focusing on, “it’s not about your reality,” it’s about if you want to see your grandchildren. If I want to come to your house, are you going to be able to tolerate me…you know, me believing this and being in the same room as you.
LR: In a sense, it’s a way for the victim to recapture some power.
MB: Oh, absolutely. And that’s what most survivors will say to me. I mean a lot of people have said, “I was in therapy for 10 years, and that weekend with my father was the most important thing in my healing.”

The Gratification of Working with Trauma and Incest

LR: Okay, okay. My guess is that many in private practice would run when they receive a referral for incest. But you seem to run toward it.
MB: I don’t think people in private practice run from the adult survivors, but they run from when it’s currently happening.
LR: Why is that?
MB: Because I think it is one of the greatest taboos. And they never learned how to deal with it. And I think they never learned how to manage. And they often don’t understand how anybody can even want to see their father or their brother or their mother based on what they’ve done to me. Or done to them. Done to the victim. And so, I think a lot of them experience transference and/or feel inadequate.

I don’t know if it was a particular case, and I said to my husband, “What kind of person likes working with sex offenders?”
And in terms of me, Larry, I supposed we could get me on a couch to figure out why. I do remember very distinctly one time bolting out of bed, like sitting up straight. I don’t know if it was a particular case, and I said to my husband, “What kind of person likes working with sex offenders?”
But I would rather work with incest any day of the week over depression because people I work with change. And I see that change. I have seen plenty of sex offenders change. And I’ve had the fortunate experience of being able to follow up on some of my very first cases. I’ve seen one of my first cases 40 years after they stopped. It was an unbelievable experience.
Well, partly it was fun because I got to ask them all sorts of questions. I’ve always been a very creative therapist, where I just make shit up as I go along, that seems to fit. I remember one of my cases — it was incest and domestic violence. The father was in supervision and was told he couldn’t be within 365 yards of his family when he first got out of jail. He actually parked a mobile home 365 yards from the family home. And he was something else.
About a year into it, maybe less, I went back to court to get permission to have him come to family sessions. And he did. And one time, I was doing a good old family therapy looking for strengths, and I said to them, “You’re not always abusing each other. There are times when you’re not. Let’s talk about those times.” And the kids were younger, like 16, 11, and 10. I handed out these little recipe cards where I asked each family member to write down the recipe for nonviolence. Like a cup of this, and 3 tablespoons of that.
I gathered them all and laminated them, and then had them talk about it. The mother said, “It’s half a cup of going to church, and another quarter of a cup is no alcohol.” I mean that kind of stuff. And so literally 30 years later, I interviewed the same family. And the woman, the daughter who was the incest survivor was 40-something. I asked her a couple questions, one of which was whether she had gone to any trauma therapy. She said, “Why would I? I already had it.” So, I asked, “When you were getting married, or dating, what was that like? Were you always anxious? Were you afraid?” She opened her purse and pulled out the laminated card, and said, “I only dated people that had the ingredients.”
LR: Talk about having an impact. Wow, that must have felt great.
MB: I burst into tears. I didn’t do the initial interview, one of my graduate students did. But I was behind a one-way mirror, because who wouldn’t want to see one of their first clients? I went in and I asked them questions. So, in fact, there’s an example of the use of a particular skill. I don’t know that- would it have been the same if it hadn’t really come from them? I don’t know.
LR: Had you not had a relationship, they wouldn’t have taken the cards to begin with.
MB: Right, right.
LR: Do you see yourself in charge of the treatment village when working with the perpetrator?
MB: I have a case right now of sibling incest, and one of the kids is a young adult, but not even, I mean probably a teenager still, 18, 19, who is in individual therapy. I’m trying to do a family session because the parents have two children. So, the parents are involved, and the son who offended his sister. And I’m trying to coordinate. And the sister’s therapist didn’t call me.
LR: What recourse do you have?
MB: Well, the recourse I have is the parents. He is still a teenager. So, the parents can call this person up and say, “Our daughter signed a release, we signed a release. You need to call.” I’m not saying it in a nasty way. But I try to avoid doing that because I don’t need to start an adversarial relationship. But that’s the recourse I have. If the person was an adult, I mean I’d still have the parents to talk to their child and say, “Look, we want to heal this.” As it turned out, the son’s individual therapist calls me and cooperates. We have a great working relationship.

The Complex Arena of Incest Work

LR: Earlier on in one of our conversations, you said, “Incest is virtually neglected in our field.” Clearly, incest hasn’t stopped.
MB: Incest hasn’t decreased at all since I started in the field in ’78.
LR: What do you mean it’s neglected? By clinicians? By researchers?
MB: : I think everybody’s neglecting it. I think that the problem is that we’ve lumped trauma into one thing — complex developmental trauma.

I think that there is something very important to calling violence or violations what they are. Incest is unique. It’s not just a sexual assault. It’s unique because this is often a relationship where the people also have a very positive connection. “This is my parent,” they might say. I had a client way back, I mean again, 30 or so years, who wrote a poem. The one line that sticks out into my head was — and I don’t think she was writing it just to me, it was in general — she said, “I asked you to put an end to the abuse, and you put an end to my family.”

LR: Oh! Did she write the poem to you?
MB: I don’t think it was to me because I asked her. It was to the system. She’s another one that I still have contact with because periodically she’ll write me and say things like, “I just had a baby, just won a marathon.” I mean that kind of stuff. I think professionals feel anxious. I think they feel traumatized. I think it feels like you said. It’s such a moral violation that, as clinicians, we don’t know how to manage. How do I manage that I care about somebody? How do I manage that this woman stayed married to somebody who sexually abused her child?

I just think the taboo is so deeply entrenched that it causes such distress to those who work in this area. I just was working with a family where one of the children was sexually abused. And the other two weren’t. And when I talked to all of them, I said, “All of you were abused. But what happened to Susie is more of a moral violation.” And so that’s why people can’t tolerate it. I think there’s something about not being able to tolerate it. Like I said, I can find something positive. It makes sense to me that someone can be abused by a family member and still care.

LR: The popularity of complex developmental trauma overshadows the clinical attention on sexual assault.
MB: All I know is that so many clients tell me that people either never asked them or understood it. So, it just gets lumped into a category of trauma. And all traumas are not created equal. I’m not saying incest is worse than being physically abused. I’m not saying it’s worse, I’m just saying it has its own unique connected relationship with somebody they cared about who I also had many positives. And it leaves me even in some ways more confused because it isn’t linear or simple. Even if the person was abused by somebody that came and left like a babysitter or Boy Scout leader, with whom they also had an intimate relationship, it’s very confusing. 
LR: The deepest form of betrayal.
MB: Yes. I think sometimes clinicians can’t manage that level of complexity. Which goes back to your question; “Give me some techniques, it makes things less complex. I can feel better about myself if I know how to do this. Do that.” Larry, every single day, I go, “Wait, I don’t know what I’m doing exactly. What do I do now? I just had this explosion.”

I was sitting in the room last week with somebody that got up, grabbed something off my table, threw it on the ground, and smashed it. “I got to go,” they said So, I said, “Wait a minute, okay, let me figure out.” What was I going to say in that moment? “Follow my finger?”

LR: What did you do? How did you handle the moment?
MB: What I did in that moment was said, “I need a drink of water. You need to sit down. I am feeling afraid. And I want to talk about this. But right now, I need to calm down. And you need to. We both need to.” I had been seeing this guy for a while. It made sense to say, “We need to regulate.”

Well, the wife was there, and they have a child. But the child wasn’t there. I had a separate session with the child. And I had a separate session with the wife. I did break them all up. And then I had a session with him, and we just talked about it. And I talked to him. And of course, like every other, he said, “This is what happens when she does blah, blah, blah.” “This is what happens when my child…” And I explained to him that acts of violence are linear. I don’t think I said “linear,” but… “I get it. It is all these other things that activate you. However, you have to make a decision about how you’re going to react to these things.”

LR: I would see where a younger therapist, or a frightened or threatened therapist might have ended the session immediately, out of fear for themselves, out of loss of control of the session. But you saw it as part of the way the system functions, and your role in that moment was to regulate. To me, the external regulator, the governor of sorts. Is apology critical?
MB: Acknowledgment is important, not apology. Because people say they’re sorry very easily.
LR: So, how do you know when an acknowledgment is sincere and productive, moving forward?
MB: So, when somebody is going to make a formal acknowledgment, it’s a planned session where they write a narrative. They write it down, they talk about… Basically, I have them talk about facts, impact, responsibility. So, they’re giving it to me beforehand. And that’s part of the therapy process. They’re writing their acknowledgement as a therapeutic technique. So, they’re writing this, and that’s how I know it’s sincere.
LR: What are some of the common presenting problems that people come to therapy with that raise your incest red flags?
MB: Well, on that level, they probably don’t look any different than any other form of abuse, neglect, or violation. They really don’t. Eating disorders, self-mutilating, suicide. Any of those things. Most of these are symptoms, I think are survival skills. I think they’re skills that people have used over time to survive their abuse and neglect. And now it’s become problematic. The skills themselves are problematic. The skills work. If I drank too much, if I cut, if I was sexually promiscuous, if I was suicidal, if I was dissociating. It might have worked to avoid memory and pain. That’s how I tell my clients; that most of their symptoms are utilized to avoid memory and pain until they don’t.

And now the symptoms themselves are causing the pain. To me, incest doesn’t look any different. What happens is, as I start my sessions by asking people how they heard about me.

If they didn’t know my name, they might have typed in “trauma, abuse, childhood something.” And it’s not just “therapy.” Usually, they got to me, somehow, they typed something else in. Or they got to me through a therapist. And so, when they say trauma, which is usually what it is, I then say, “Look, if we’re going to talk about it, we’re not going to talk about it now. But I need you to know I feel really comfortable talking about incest. I feel really comfortable talking about sibling abuse. I feel comfortable talking if you beat each other up.” So, I’m just saying, down the road, if any of those things come up, I feel comfortable.

LR: Has there ever been an instance where all roads pointed to incest and the person allowed you down that road, right up to the door, and then just closed it in your face?
MB: No. When I take a family history, when I do a genogram, and everything points to incest, I might just say, “You know what? I just need you to know from what you’re telling me; I’m not saying it was incest. But there might be, it could have been. It feels to me like emotional incest at least. Like you are hierarchically your father’s peer. Or it feels like you and your brother turned to each other in ways to get affection that you didn’t get from anyone else or your parent(s).”

So, it doesn’t have to be. And this isn’t your question. But it’s a question people often ask me. Do you need to know all the story to help? And the answer is no. 
LR: And I think clinicians sometimes may forget that incest is a violation of hierarchy. It’s a violation of trust. And not all incestuous relationships are sexual. Are there any questions I could have asked or should have asked?
MB: Well, I mean we have maybe a couple of million. But I think what I would say is, you know, we should talk again.
LR: I would like that. Thanks Mary Jo.

Using Common Sense Problem-Solving and Worry Containment to Subdue Ruminations

Posted on by Psychotherapy.net Team

The Devil of Rumination and Obsessional Thinking

I often wonder how I as a therapist can best help clients who torture themselves by overthinking and over-analysing in a cyclical manner that essentially gets them nowhere. If it is not possible to help them purge themselves of such burdensome thoughts, is it at least possible to help them make peace with the “unwelcomed devil” of rumination?

I’ll start by reframing rumination as the devil we know, which may still remain a devil, but maybe less scary than the devil we don’t know.

Rumination is a form of obsessional thinking characterized by excessive, usually unwanted, and repetitive thoughts or themes that hijack other mental activity and it is a common feature of obsessive-compulsive disorder and generalized anxiety disorder. It is also dwelling on negative feelings and distress, and their possible causes and consequences. Furthermore, the repetitive, negative aspect of rumination can contribute to the development of depression or anxiety and can worsen pre-existing conditions.

Ruminative states, even for non-depressed people, are directly associated with negative affect. In fact, the more clients ruminate, the more they are likely to throw fuel on the cognitive fire, so to speak, and become entrapped in a vicious cycle, making them feel even worse. My experience with these clients has been that they ruminate in all three time zones of their lives — past, present, and future — on events of both real significance and seeming significance.

A method for tackling rumination that I have found to be particularly useful with these clients is to use problem solving, pondering, and positive reflection. If rumination is overthinking a problem and worries related to that problem, it makes sense to take a positive stance and use problem-solving skills to find the optimal solution that rumination seems to seek, and that could put it to rest. Furthermore, problem-solving strategies can be even more effective when they actually aim to resolve the problem the rumination seeks to magically dispel.

Classic problem-solving models in organizational psychology suggest a series of stages in problem solving culminating in the implementation of action, which can help individuals to either confirm that they are moving in the right direction or think about what changes they need to make in their plans — the verification stage. I also believe that linking problem solving and positive reflection with the specific actions can help to enhance clients’ confidence and sense of efficacy and help them to break the repetitive cycle of rumination.

Applying a Solution Focus

Integrating the above perspective into Cognitive-Behavioral Therapy and Solution-Focused Therapy, I may ask my client to identify and engage in a (small and feasible) first task related to the content of their rumination and plan to complete it as soon as they realistically can. For example, if an individual ruminates about their upcoming “job performance,” they could identify one or two minor work-performance-related tasks and aim to complete them initially.

This first step would not necessarily mean that they have found all the answers to their worries, but it would help them feel that they have at least done something, even quite small, which brought them closer to the achievement of their goal (a positive job performance review in this example). Moreover, from a positive reinforcement perspective, they could also plan to reward themselves with something enjoyable that they “deserve to do” (since they will have managed to take some action, instead of overthinking or freezing).

For certain types of rumination (such as work-related stress or perfectionism), I have found this approach particularly useful as my clients find it easy to find a series of actions or tasks that help them develop a sense of moving forward — and slowly moving away from the gravitational pull of rumination. However, there are other frequent types of rumination that, by their nature and content, do not lend themselves directly to interlinked specific actions, such as “is this the right job for me or not?” or for those clients who don’t have the practical or mental resources at a given time to explore how their rumination could be translated to any specific plan.

In such cases, I invite them to “take a break” from their laborious, constant effort to find a “solution,” which would cease the seemingly incessant pressure to ruminate. This suggestion, of course, is often challenging for them as it directly opposes the very nature of rumination — the underlying implicit, irrational belief that “I need to keep analysing a specific concern, until I find an answer or a solution that I am completely happy with.”

The client’s resistance to pause their overthinking may be underpinned by another implicit belief that “there is no way I will be able to relax and find mental peace until I get everything outstanding done and dusted.” This notion is sometimes effective to help clients increase their motivation to fight procrastination and eventually solve problems and achieve their goals. Nevertheless, at other times, it will just not be possible to solve something as soon as possible, nor to even envision the solution — leaving the client feeling even more frustrated, anxious, and predisposed to continued rumination.

In these situations, the biggest trap is not that they will still have “unfinished, disturbing (pragmatic or emotional) business,” but that they will have trained their brain to believe that it is possible not to have any unfinished business, not to have any more intrusive worries and that “when there is a will, there is always a way.”

However, this otherwise helpful and motivating attitude can often just fuel further excessive worry and rumination. The curious question then becomes, “how can the normally reasonable aim to solve problems as quickly as possible become a problem on its own?”

A Pragmatic Approach to Rumination

In my experience, western culture values a proactive, problem-solving approach that rewards and encourages taking responsibility, a sense of agency, and ownership of our lives, as opposed to being passive and reactive. My aim here is not to explore this cultural notion as such (which would entail a much broader philosophical discussion), but rather to highlight its limitations and to reflect on the ways that we can contain our excessively proactive stance, and the worries and perpetuated rumination that often accompany it.

I have come to believe that as important as it is to be proactive and to take responsibility, it is equally important to fundamentally acknowledge that we only have certain emotional and pragmatic capacity at any given time to deal with our goals and our relevant worries. Thus, we may need to decide that we can only deal with just one of our concerns at a time, while we may also endeavour to teach ourselves to tolerate and bracket all other ones.

Rumination by nature “demands” immediate answers and solutions. In contrast, I encourage my clients to allow their intrusive thoughts to emerge and claim their space, while at the same time, challenge them to fight their urge to engage thoroughly with them in-the-moment (which only fuels further and futile rumination). I encourage them to slow down and allow some time to observe their worries as they emerge naturally and unfold in their mind. At the same time, I ask them to make an “appointment” with that urge a few days later, at which time they can, if they choose, respond to their demand for their attention. During that appointment, they can calmly reflect on which of their worries really matter, which ones require more time to ferment, and whether there is any proportionate course of action they can take (or not?) in response to them. When they manage to gain some distance from the urge to ruminate, or from the rumination itself, they may find out that — not surprisingly — several of their worries no longer claim much of their attention.

Of course, this is much easier said than done. Worries are unrelenting. They have their backhanded way of persevering and drawing clients into their dark, seemingly bottomless pit without offering even a glimmer of light or hope that might otherwise offer a solution that feels “good enough,” and without offering the slightest means of escaping their gravitational pull.

An additional strategy I have found useful to help my clients with rumination has been to invite them to implement an easy, positive distraction at the time when their urge to ruminate emerges. This is indeed one of the common techniques, along with other ones such as mindfulness. However, positive distractions seem to be most useful when they are combined with a “reassurance” to our worries that we will indeed come back to them at a more appropriate time, when we will be better prepared and have the mental space to deal with them.

In this context, I have had clients set an appointment with their worries and I actually encouraged them to take this appointment quite seriously. Thus, when clients actually engage in these appointments, they often find that some of these worries have been impatiently awaiting their arrival and are still adamantly demanding their attention, while others have not. At that point, and only at that allotted time, the client is better prepared to address those worries, having built the patience and mental space to do so. As therapy itself is an ongoing process as is problem resolution, clients come to appreciate that it is not necessary to respond to the siren call of worries when they first arise. Pandora’s box will always be there waiting for them in the therapy room, and they will choose when to open it or not.

Most of the above points were at play in the work I have done with one of my favorite and long-term clients. Stuart, as I will call him, was ruminating equally about “small things,” like the slight slope on the floor of his Victorian-age house; and big things, like the dilemma of whether he would ever find a more meaningful job and career. I knew that saying to Stuart something like, “don’t think about this,” would just make him think about these concerns even more.

Instead, I said to Stuart, “you can think about this as much as you want, but could you possibly give up on finding an answer to your worry in-the-moment? And maybe, as you will still be thinking about it, could you also try to do surface research online about any jobs that are out there, that could potentially be meaningful for you in the future?’’ This intervention was a combination of a positive distraction, patience, and looking forward. When Stuart came back for his next session, he told me that even though his ruminations were still there, he was much more able to contain them. Was he then able to “become friends” with them? Well, not necessarily, but by practising to sit with them, slow down, and possibly add a positive distraction in the mix, his ruminations certainly became a more familiar, less scary, and more tolerable devil.

Stuart was a willing worker, as are many of my clients. But it was as important to build a relationship of trust and hope with him as it was to help him build a sense of hope and confidence that he could eventually subdue his ruminations and live freely.