Category: Blog

Countertransference is not a Flesh-Eating Disease

Posted on by Psychotherapy.net Team

Among my varied clinical and clinically-related roles, I supervise master’s level counseling interns who are training in a variety of settings, from alternative schools to psychiatric hospitals. In our group supervision classes, we discuss a range of theoretical and applied concepts related to clinical practice. Frequently, countertransference takes center stage. Perhaps this is due to the nascency of their clinical skills, unpreparedness for or inexperience with self-reflection, lack of personal and interpersonal maturity, or all the above. In our meetings, we are never short on content for conversation or the inevitably painful role-play exercises that I inflict upon them. All in the name of their growth, of course.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

With few exceptions, my counseling interns have somehow latched onto the notion that countertransference is a flesh-eating disease; proof positive of psychological frailty inevitably resulting in psychic degradation, the inability to evolve into effective clinicians, and who knows, maybe contagion. I believe that these apocalyptic notions stem in part from the origin of the study of countertransference in psychoanalysis, with its emphasis on forbidden and deeply concealed libidinal urges, unresolved parent-child conflicts and other dark intrapsychic forces ever seeking sunlight and the opportunity to wreak havoc in the therapeutic sphere.

Try as I might to dispel this notion by deploying the most powerful tools in my arsenal of empathy, they cling tightly to the fear that countertransference is the enemy within, seeking to undermine, subvert and slowly erode their fortitude and confidence. And try as I might to demonstrate the opportunities countertransference presents for self-awareness, personal and clinical growth as well as healing, they recoil at the sound of the word! Maybe, I should just call it Steve.

Two examples might help explain what I and my student-interns have been experiencing. A student-intern who was a new mother to a 9 month-old was working in an alternative high school. She was assigned, ironically enough, a seventeen-year-old student who had given birth just months before. See where I am going here? My student was angry at this young woman who had abdicated her parental responsibilities to her own mother, refused to engage in attachment-related exercises, and had become increasingly depressed and withdrawn. My student seemed, at least temporarily, incapable of empathizing because she could not fathom how someone could neglect an infant when concurrently, she was in the process of building a deep bond with her own infant. When I suggested that her negative reaction to her client was rooted in countertransference, she initially recoiled and withdrew, but with encouragement and class support, opened herself just enough to consider how she was triggered by her client. Subsequent on-site and in-class supervision helped her to reconnect with the client.

Another counseling intern had taken on a new college-age student who had experienced several years of depression, family rejection, a profound sense of hopelessness, and who had a history of rejecting therapeutic intervention. When his own clinical supervisor made specific recommendations for how to work with this client my student resisted, arguing that the supervisor was not being sufficiently empathic, had disregarded his own ideas, and he planned to speak to the client about issues that the supervisor felt were premature. My student grew increasingly angry at his supervisor, more deeply intent on doing what he thought was necessary and walling himself off from the supervisor. This was the first rupture in the relationship between this student and the supervisor whom he had previously seen as supportive. As the class supervision unfolded, I suggested to the student and the group that this particular client could be triggering something in him related to past relationships or even experiences in his own life. As with the intern mentioned above, this young man felt embarrassed and disappointed in himself that he was perhaps being influenced by countertransference. I should have called it Steve.

As the conversation unfolded, this intern volunteered that just a year before, he too had experienced a severe depressive episode and felt misunderstood by friends and family who offered suggestions that he found destructive. “If only I had been a better clinician, I would’ve seen that coming”, he lamented. Well-intentioned as he was, this posture was unrealistic, and fortunately subsequent supervision and counseling helped this particular intern to continue along his own path to healing and professional growth.

***

In both of these supervisory moments, the interns better understood what countertransference was and was not. If our interns are always taking universal precautions to guard against the psychological equivalent of a flesh-eating disease, then caution and defense will win out over opportunity for both personal and professional growth. Sometimes, past and present painful and/or unresolved experiences and relationships scream out from within for attention, even for debriding if you will. Only in this way can clinicians, at any point in their evolution, build healthy psychological immune systems. 

Might Physical Activity be an Effective Antidepressant?

Posted on by Psychotherapy.net Team

The well-known recommendation to exercise in order to relieve and /or improve a wide variety of health problems may sometimes seem exaggerated. One might ask whether going to the gym or chopping wood will truly improve sleep, cognition, fragile bones, cholesterol levels, high blood pressure, and decrease vulnerability to developing diabetes, obesity, heart disease, cancer and Alzheimer’s disease. That is a lot to ask of a daily bout of physical activity. However, many studies over the past several decades have confirmed these positive relationships. Exercise is not going to prevent us from eventually exiting this world but engaging in physical activity may make us healthier while we are still in it.

Relieving depression should be added to the long list of benefits of physical activity-depressed patients may benefit as much from routine exercise as they do by taking antidepressants. Several years ago, an extensive review on the effects of an exercise program on clinical depression strongly indicated that physical activity may effectively reduce stress, anxiety, and depressed mood.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

A woman came to me for weight loss counseling because she had gained about 27 pounds while being treated with an antidepressant. With the consent of her therapist, she decided to stop taking the drug and instead signed up for a four-month exercise program with a personal trainer. After several weeks she not only lost weight but her depression went into remission. Her personal experience reflects that described in many studies in which depressed patients enrolled in programs of frequent physical activity such as walking, resistance training or a combination of both show improvement in their mood. Indeed, in another study, patients receiving medication (sertraline), exercise and the medication, or just exercise had the same rates of remission.

However, if exercise is to be treated like any other therapeutic intervention, do we know the most effective program? Should the exercise be mild or intense? Is it better to exercise outside in the fresh air and sunlight or does it not matter? Might yoga or other group exercise be more beneficial than solitary workouts or a walk because exercise classes diminish social isolation? Is there some way of identifying patients at the onset of their depression who might benefit from exercise rather than antidepressants therapy? How long should it take for an exercise program to produce a lessening of depressive symptoms? Many antidepressants take several weeks before they seem to have an effect. Should the patient wait the same amount of time to see if exercise relieves their symptoms?

These are questions that can be answered fairly easily with additional studies. What is more difficult is how to translate these findings to the real world. To begin with, who is going to treat these patients? Therapists are rarely, if ever, trained as exercise physiologists. And exercise physiologists may not have any training or experience working with depressed clients. Do these professionals even communicate with each other? A therapist may be able to refer a patient to a physical therapist for an initial consultation as to what kind of exercise the patient can do without injury or pain. But how should the patient follow up? Where will she exercise? Does he have to join a gym or a local Y to exercise? Who will determine the type of exercise program? What oversight is available to make sure the exercise program is carried out effectively and without injury or pain from overused muscles? Who will help /motivate the depressed patient to participate over several weeks rather than dropping out? And finally, even if exercise can be as effective as medication for depression, who will pay for it? Now visits to a therapist and medication may be paid for in their entirety, or at least in part, by health insurance. Therapeutic visits with an exercise physiologist rather than a prescription for an antidepressant is probably not covered under billing codes for mental illness and thus may be an out-of-pocket expense.

And yet, exercise should not be overlooked or discarded as an effective way of managing depression. Its value in increasing general health, sleep efficacy, and increased physical fitness in addition to relieving the symptoms of depression without the side effects of drugs cannot be overstated or overestimated. Isn’t it about time to figure out how to apply this knowledge?  

Surviving Attacks in Psychotherapy – An Occupational Hazard

Posted on by Psychotherapy.net Team

The sound of gravel being ripped from my drive is that of an angry 25-year-old man leaving his session with me. He is furious, and though he sat through the final minutes of the session with his emotions firmly in check, they spilled out as soon as he left.

He is angry with me because I have tried to find out why he walked out of therapy with me three months ago with no warning, and why he wants to come back now. He is here because it is a requirement of his psychoanalytic training, and though he gets some satisfaction from working with me, I don’t think he would be here if he wasn’t required to be. He is frustrated by my asking about the premature break earlier in the year.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

We are caught in a difficult transference. His acting out, his anger with me, his resistance and refusal to want to find out more about what’s going on make things difficult. But it’s not going away. By coming back now he has drawn further attention to it. He could have stayed away, and then no questions would have been asked. Not by me! But he’s come back because he must for his training.

I find my practice can run very smoothly (a superstitious side of me prevents me from saying more), but every so often an issue will flare up and the atmosphere is changed. Often clients who are in training prove the most difficult, particularly when they are ambivalent about being in therapy. I think of these experiences as attacks on psychotherapy. Evidence that an attack has been launched is demonstrated by particular behaviors, and frequently these are behaviors that manifest themselves in terms of boundary or therapeutic frame issues.

In this example, someone breaks off therapy and then expects to come back with no reference being made to their previous actions. The challenge then is how to find a way of working and thinking these things through with the client without becoming caught up in the attacking behavior. And without, as D.W. Winnicott put it, the psychotherapist retaliating and attacking back.

When these kind of aggressive and attacking experiences are enacted in psychotherapy, the psychotherapist is tested. The psychotherapist must find a way to keep working with the experience. And as they try to, the client finds more ways of provoking the therapist to retaliate. But retaliation might be fatal to the therapy. It might prove that the client is as unlovable as they already think themselves to be. It might lead to the end of the work. It might prove very hard on the psychotherapist’s sense of their own professional identity.

So, in the sessions that follow I have to find ways, despite the provocations, of developing the therapeutic relationship, trying to develop the relationship so that the client may come to lower their defenses so that in time, the client may become interested in the complicated dynamics that are at work. If this can happen, and the therapy can survive the attack, then the client may develop the sense that this therapeutic relationship is not like other murky, unfair and repressive relationships that they have or had, perhaps with their father. They may come to see that in their therapeutic work with me, they are outside of that original destructive parental paradigm. The negative paternal transference might be resolved. This could then be the beginning of profound change.

The attack, however it comes, could be a gateway to change. A gateway out of the stuck world of unhappy relating that the client has lived in. This may be what the client has come to therapy to resolve, although they probably don’t know that yet. The only problem is that the attack is real and happening right now. And the client’s way of finding opportunities to provoke the therapist into an uncharacteristic act of rejection are very hard to predict and can be very hard to work with and survive.

In the case of this particular client, it took some time for his anxiety and his aggressive and attacking behaviours and defenses to be contained within the therapy so that we could think about them together. This seemed to coincide with a more measured approach to his driving.

I have gained from my experiences of surviving these kinds of attacks without retaliating- they are always very hard work. They are an occupational hazard.   

Paying It Forward: A Fulfilling Reframe

Posted on by Psychotherapy.net Team

In one of my recent blog posts, I wondered aloud why the cobbler’s children have no shoes, and by association, the therapist’s kids don’t heed their parent’s sagacious advice. This bit of wondering was the epilogue to the latest chapter in our family’s chronicle, “children, can’t live with them, can’t live without them.” My subsequent blog was on the therapeutic use of metaphor as a means of making sense, when none seems apparent.

I don’t believe that I told you that every living creature that draws breath in our home was born elsewhere. This includes cats, dogs and our two precious children. Yes, they are both adopted. When I was more actively practicing as a psychotherapist, I sought out and perhaps was sought by families immersed in the drama of adoption which I consider to be sacred clinical ground. And I do strongly believe that adoption is in so many ways a drama whose seeds are sown in loss. Nancy Newton Verrier went as far as to refer to adoption and both its antecedents and consequences as a primal wound.

Mind you, not all adoptions are fomented in or are the result of trauma or leave deep and unyielding wounds. In fact, the flipside of adoption-related loss is being found or finding ways to connect either with birth parents or adoptive families…like in ours. And psychotherapists who work in the field of adoption would do well to appreciate the sheer joy, fulfillment, and connection experienced by multitudes of adoptees, adoptive parents, and families.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

However, the very real and oftentimes enduring legacy of disrupted attachment, loss, trauma and a lifetime search for connection do indeed swirl around and roil within the lives of those impacted by adoption. Just as the joys of adoption have been identified by clinicians and researchers in the field, so too have they chronicled the very real challenges, pains and manifestations of the adoption narrative in the lives of those involved in the process.

So, with that said, and as I typically do, I refer to a recent experience that my wife and I have been trying to reconcile as both of our adult children are now “out there” in the world, free perhaps of our immediate gravitational pull, and trying to either find or make a place in their own worlds that makes sense to them. Perhaps in this telling, adoptive parents, adoptees, and psychotherapists who work with these individuals will benefit.

If you promise not to tell anyone, I will reveal a confidence known only to my wife and myself. And that is: we secretly take credit for the wonderful characteristics that our children display and blame the rest on genetics. Nature versus nurture working for us. Yeah, baby, or should I say "yeah adult adoptees." It has been a most useful reframe for us during those painful moments when our kids’ behaviors have made no sense and my wife and I look at each other and say, “where the hell did that come from, must be genetics.” On the other hand, when our children shine, my wife and I are the first to belly up to the self-congratulatory bar and bedrink ourselves into comas of self-satisfaction-patting ourselves and each on the back for a damn good job of nurturing. I am fully mindful that some of you analytically-oriented clinicians out there might label this at best cognitive distortion or denial, and at worst, “folie a deux.” I, however, like to consider it as a self-serving reframe. Don’t we use these every day in our therapy practices if not in our own lives? I paraphrase Jeff Goldblum’s “Big Chill” characterization of a radio shrink who dryly asserted (as only he can and still does), “I can’t get by a single day without at least one good reframe.”

So, my wife and I received a phone call today from our son who recently, and seemingly abruptly, relocated two thirds the way across the country to live with new friends and their family. With distress, he told us that a member of that extended family was in dire need of support, so he was going to drive yet further into the wilderness to render the equivalent of missionary salvation services. This revelation came while we were still trying to make sense of how and why our daughter has herself seemingly adopted her own new extended family.

Desperate to make sense of these life choices that our children were making, which are so distant from the plans we had for them (which is probably the rub), my wife and I again turned to each other and rather than blame genetics, the adoption narrative, or the experience of loss for our children’s decisions, we invoked Article 1 of our adoptive parents’ constitution: when in doubt, reframe! And like magic, it worked. Because, in that moment, we were able to fully acknowledge and embrace the beauty of the adoption narrative which we chose to center around saving and being saved. Our children were simply yet powerfully paying it forward.
 

Family Therapy and Yoga: A Connection?

Posted on by Psychotherapy.net Team

Family therapy and yoga; what interesting companions. Through both, one seeks to move towards a union or connection – with self, others or the wider world.

Working for over 30 years as a family therapist in public schools, with thousands of families and students on a myriad of issues, I have promoted positivity as a means of achieving mental health. Many families are referred to me due to their child’s current and/or past difficulties functioning in the classroom, although I know that they usually also struggle in the home. Many of the parents do not make the connection that their child is a member of a family, just as they are members of a school community. Their view is often that “this is a school problem,” unaware of the connection between the child’s behavior in school and at home. They don’t see the connection, and there is that nagging word again! Connection. Helping these families, and particularly the parents, to shift their perception so that they may make the connection is the challenge.

In a similar vein, people often participate in my yoga class to gain physical, mental and at times spiritual flexibility. Or they may come for a sense of connection to something larger than themselves, both within and outside of the yoga space. Just as in the family therapy context, many of my yoga students do not make the connection that what they do in the room, so to speak, is directly connected to what they do outside of it. And just as with my school counseling clients, I try to guide them to focus on their total positive wellbeing.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Whether in therapy or yoga, people are seeking a shift, a change and a positive connection with something or someone. Or maybe, it’s simply yet powerfully the therapist or yogi with whom they want to connect. Maybe it is their spouse or child. The common thread is that all are seeking positive mental, physical and/or spiritual health.

Typically, I do not get to choose who enters the journey of therapy or yoga. and I rarely know the impact, influence or outcome. I do know that I trust the process, which is easy to do when all is going smoothly. But it during the challenging times when the real work takes place. The process of building connections, whether with self, others or the larger world is just that, a process. One step at a time, one intervention at a time, one breath at a time.

I recall working with an extremely angry 16-year-old who was resistant to change, connection or being in therapy. She grew up in poverty, witnessed domestic violence and lived with her grandmother as a result. Her reactions to peer conflict were swift and impulsive and like those she experienced in her family of origin- she’d yell and hit, no questions asked. While I attempted to build a relationship by connecting with her intellect and desire to graduate, she rarely came by my office unless in crisis. On one of those days as I waited to begin my mindfulness class, she ran to me in tears over a friend’s domestic crisis much like those she had experienced earlier in life. Particularly susceptible in the moment, she agreed to join my yoga class where I took her through some grounding, breathing and movement exercises into a final guided meditation Seizing the moment, I was able to connect with her and begin her on a path towards connection her with herself, the moment, and the possibility of positive change within herself. She left happy and connected. Who knew how long the impact would last? However, when I visited her class later that semester, she voluntarily stood up and recalled that moment aloud, proudly explaining its positive impact to her classmates. A connection was made. 

Treating Eating Disorders as Disorders of Eating

Posted on by Psychotherapy.net Team

All illnesses classified as ‘mental’ are comprised of psychological, behavioral and physical components. Treatment strategies for eating disorders vary widely from psychoanalytic exploration of the emotional origins of the disorder without physical or behavioral intervention to forced tube or intravenous feeding with no behavioral or psychological work. However, despite decades of clinical research into the ideal combinations of cognitive/psychological, behavioral, and physical interventions, the mainstream evidence base is not inspiring.

One obvious conclusion to draw is that clinicians need to redouble their efforts to address the psychological components of eating disorders. However, a different reading is that the purely psychological pathway leads us down a rabbit hole. This is the claim of a Swedish treatment method that has achieved significantly more success in treating the full range of eating disorders than any other method, but that has been more or less completely ignored by the mainstream of eating disorders researchers and practitioners.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Having treated more than 1,400 patients with eating disorders (around 40% with anorexia), the Mando Clinic, headquartered in Stockholm and led by Cecilia Bergh and Per Södersten, has achieved a 75% remission rate with zero mortalities, and 90% of those who reach remission progress to full recovery over a five-year follow-up period. (1,2). These results are considerably stronger than those achieved by traditional methods used in the treatment of anorexia and bulimia. The secret to their success is treating eating disorders as disorders of eating, rather than as disorders of psychological functioning. Specifically, people with anorexia usually start off eating too slowly, those with other eating disorders typically too fast; and both groups fail to sense and respond to satiety cues appropriately.

Rather than downplaying the behavior of eating as a troublesome side-effect of deep-seated psychological disturbance, the eating disturbance is treated as the cause of the psychological disturbances. Primarily, this means normalizing patients’ eating habits using the Mandometer (from the Latin mando, I eat), an app which communicates with a scale underneath your plate and provides normal curves for eating speed and satiety cues according to which patients gradually learn to adjust both. Alongside restricted exercise and rest in warm-rooms for an hour after eating, this simple behavioral intervention is the essence of the treatment.

Dig into their treatment practices a little more, though, and it becomes clear that the Mandometer and the heated rooms are just one part of their plan. Mando’s “case managers” are clinically trained to support patients through the program in ways that the Mando team calls “just common sense,” but that would probably look very familiar to anyone who practices CBT or any other kind of practically-oriented psychotherapy. Mando therapists use behaviorist techniques like successive approximation to help patients eat. The patient might be given a plate of food without having to eat it, then be asked to put an empty fork into their mouth, and perhaps then be invited to smell the food on the fork. Verbal reinforcement, small gifts, and promises of future rewards are given at every step. They say this is behavioral and not cognitive therapy, but are the dividing lines between cognitive and behavioral really so clear? Is it even helpful to draw them?

The medium is behavioral, but the effects are also in the mind. Likewise, the Mando team explains that the heat treatment following meals not only allows the calories that would have otherwise been used for thermal regulation to be used for normalizing bodyweight but also helps lessen the anxiety that interferes with eating. Moreover, the method includes other strands like the development of ‘emotional regulation’, understanding and appreciation of one’s body, improvement of self-esteem and self-awareness, and managing social situations and relationships– all concepts familiar to any cognitive therapist working with eating disorders.

The remarkable solidity of Mando’s evidence base compared to other methods does suggest that without a central focus on the eating, nothing else works well. But the possibility remains, for example, that CBT plus the Mandometer would work even better than either in isolation. The Mando team have made this suggestion in print, and in a personal communication to me, a partner in the clinic speculated:

“CBT may be improved if it used Mandometers during the meals, allowed negotiated meal size and speed, prevented exercise, and provided physical warmth for anorexic patients. The Mando method may be improved if its common-sense therapy was given more structure via CBT training, as long as the focus remains on fostering normal eating behavior and minimizing caloric expenditure, not on resolving deep psychological problems.”

So, the real question that needs to be answered next isn’t really “CBT or Mando?” It’s “which elements of either?” Other distinctive features of the Mando method include withdrawing patients from all psychoactive drugs (80% are taking something when they arrive); the case manager eating all meals with the patient (not just watching them eat) to begin with, and later going to restaurants with them; not allowing patients to know their weight, but asking them to focus on eating and resting; and negotiating everything, so that nothing happens without patient agreement, and agreement is sought via reasoning and evidence. Which of these components are crucial, which are nice to have or incidental?

The constant feedback between mind, body, and behavior doesn’t mean that it doesn’t matter where in the system you intervene. It does mean that if you don’t observe improvement in the entire system, you probably chose the wrong place to start. And the Mando team’s claim is that the behavior is the right place to begin, that it’s the fulcrum between body and mind, between BMI and the EDE-Q. Their work reminds us that people will never get better if you pretend (and allow them to pretend) that they’re better when they’re not, which is easiest to do if you elevate one measure (often bodyweight) above all the others.

As one Mando partner put it to me, in a discussion of risk factors for relapse, “Not actually being in remission is the biggest factor for relapse risk.” And being in remission means all kinds of complex yet mostly definable things, to which eating behavior may well be pivotal. There’s lots left to learn but putting the behavioral back in the cognitive may prove to be the best starting point.

1) Bergh, C., Brodin, U., Lindberg, G., & Södersten, P. (2002). Randomized controlled trial of a treatment for anorexia and bulimia nervosa. Proceedings of the National Academy of Sciences, 99(14), 9486–9491.

2) Bergh, C., Callmar, M., Danemar, S., Hölcke, M., Isberg, S., Leon, M., and Palmberg, K. (2013). Effective treatment of eating disorders: Results at multiple sites. Behavioral Neuroscience, 127(6), 878–889.

3) Södersten, P., Nergårdh, R., Bergh, C., Zandian, M., & Scheurink, A. (2008). Behavioral neuroendocrinology and treatment of anorexia nervosa. Frontiers in Neuroendocrinology, 29(4), 445–462.

The Lose-Lose Comment: A Therapist

Posted on by Psychotherapy.net Team

In my years of practicing therapy, I frequently would not know what to say. Once, a woman made a classic doorknob disclosure as the session was ending: “When I was 14,” she said, “my uncle sexually abused me.” A male patient made fun of me for not following a story organized around economic theory. A woman wanted me to praise her for resisting temptation the week before. At these moments, I would typically frame my predicament as egalitarian (be spontaneous and gratifying) versus authoritarian (be withholding and rule-bound), and I would choose the egalitarian path. Other therapists, I’ve noticed, have other ways of framing therapy dilemmas.

I wish I’d known at the time how to make a lose-lose comment. For example, with the first patient, I might have said, “If I just say goodbye right now, I seem to be communicating that what you said is not that big a deal. But if I ask you about it, I seem to be communicating that it’s such a big deal that our relationship can’t take it in stride. I don’t think this dilemma is new to you in dealing with the abuse. Since both alternatives have disadvantages, I guess I’d like to keep our agreements intact, while assuring you that we will talk it over next time.”

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Two of the many ways of understanding therapeutic success make sense of the lose-lose comment’s effectiveness. First, Gregory Bateson, the anthropologist, observed therapy in a VA hospital and concluded that therapists teach patients how to metacommunicate. He meant that many people do not take advantage of their capacity for reflection before taking action, largely because they never learned to talk things over in a reflective space, much less in their own heads. He said that almost all therapies of every orientation excel at this because virtually all therapies talk things over. The dilemmas I mentioned above pressured me to act, and the lose-lose comment demonstrates that even intense pressure can be reflected upon.

Transference resolution seems outdated as a therapy construct, but it can be understood in contemporary terms. Jonathan Shedler has said that therapy teaches the patient, “That was then; this is now.” I have long maintained that successful therapy depends on the fact that the patient will mess up the therapy in the same way that they mess up other relationships, and the therapist’s job is to help resolve these relational conflicts. In this context, many therapy dilemmas arise when the patient promotes a characteristic mode of relating and the therapist is trying to promote a therapeutic mode. The lose-lose comment is intrinsically therapeutic, even when the alternatives specified by the comment are not, so it restores or maintains the therapeutic relationship.

To the economist, I might have said, “If I fight back, our relationship becomes a stag fight, but if I don’t, I will lose your respect. I get the sense that you might not be too familiar with other ways of relating.” If the last sentence seems like a putdown, I could have said, instead, “I’m not sure how we got to this point.” To the woman wanting praise, I might have said, “If I praise you, then it might cast you as a little girl, the very image that precedes your yielding to temptation; if I don’t, you might feel lonely, which we have also identified as a precursor to temptation.”

The structure of the lose-lose comment can become monotonous, but it lends itself to other forms. I could follow up the lose-lose comment with something like “Are those my only choices? I wish I could think of a way to show you how important I think that is while also showing you that I think we can take this in stride.” Or, with the economist, just holding my hands up in a timeout signal might have gotten us back on track.
 

I Dont Know How To Be Sorry

Posted on by Psychotherapy.net Team

In my last blog post, I wrote about shame-proneness, the propensity to experience shame in response to ambiguous situations that elicit self-evaluation. For example, if Patrick failed a test and he thought “damn, I didn’t study hard enough; I’ll study more for the next one,” this would suggest that he felt guilt. But if he thought “damn, you really are a loser; you’ll never be able to do this,” this would suggest that he felt shame. When internal narratives of shame are not transient; when feeling small, worthless and insignificant permeate all experience, this is shame-proneness, which has long term adverse consequences.

When Mark and Claire came into session, I felt the tension immediately. I gave them each an opportunity to share why they had come in. Both described a history of explosive arguments and interpersonal volatility followed by calm reconciliations, then a rise in tension, then another eruption filled with angry tirades and verbal assaults.

“When he says he’s sorry I always want to believe him. He seems so sincere, but it never sticks. And I never know when things will explode again. Coming to couple’s therapy is our last chance.”

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Mark looked down the whole time Claire spoke, then with his face tight he said, “What do you want me to say. I tell you I’m sorry and it’s never enough. Nothing is ever enough and it’s your fault too. This isn’t all me.”

As I listened to their interaction, and assessed their interpersonal dynamic, I heard statements of blame thrown back and forth, which is common early in couple’s therapy, but I also heard Mark’s failure to empathize.

The ability to follow through on “I’m sorrys” implies guilt, because genuine guilt indicates the desire for reparation. In emotionally abusive relationships, such as Mark and Claire’s, what looks like contrition (which implies guilt) is really the voice of shame. If Mark had truly been able to experience Claire’s feelings (empathy), he’d feel guilty. He’d be able to tolerate the painful introspections that often lead to repair.

But their cycle continued, over and over, even after Mark said he was sorry. When this happens, it means that shame is masquerading as guilt. Shame undermines the ability to empathize with another’s emotions. Empathy requires transcending the interpersonal boundary and experiencing the emotions of another. Because shame is so painful, it disallows this from happening and instead, when the self-evaluative discomfort comes, it gets projected back onto the other; so, instead of seeing the other as the victim, they are seen as the perpetrator and hence the cycle continues.

While studying the relationship between shame, guilt and empathy, I found that there were two categories of empathy. Shame-empathy, which looks like empathy, but isn’t, because it’s not motivated by the pain of hurting someone else, but rather by the distress and fear of losing the other. It’s a self-focused experience, not an interpersonal one. Guilt-empathy, (what we think of when we think of empathy), on the other hand, leads to feeling the others pain and not wanting to do it again.

I heard Mark projecting blame. I watched his discomfort when Claire voiced her concerns. I noticed that he quickly retaliated for the smallest slight. I knew then that this was going to be a huge challenge. Empathy is fundamental to healthy relationships. When I work with couples where one has underlying shame, I know the only way it will heal is if empathy can be garnered, which means the shame needs to be processed. That type of examination is a slippery slope, because any introspection can cause more shame and more defensiveness.

I asked Mark, “What are feeling right before you respond to Claire?”

“I – I. Angry.”

“Can you say more?”

“Angry that she says those things to me. What does she want from me. If she’s going to blame me for everything, why are we even here.”

“I didn’t hear her blame you for everything.”

He folded his arms. “You’re taking her side.”

“There are no sides. My job is look at what’s happening and help you both communicate better. I have a feeling that the things Claire says make you feel bad about yourself.”

“That’s right. She’s always making me feel bad about myself.”

“I don’t mean to do that,” Claire said. “I have to be able to tell you how I feel and whenever I do, you get angry.”

“That’s not true,” Mark raised his voice. “You don’t tell me how you feel. You tell me about all of the shitty things I’ve done. What about all of the good things I do for you.”

“What do you imagine Claire is feeling right now?” I asked Mark.

“Satisfied that she got me to show you my angry side.”

“She looks like she’s about to cry. Do you see that.”

“She does that to make me feel bad.”

“You can’t see that she’s also hurting?”

“That’s because she always makes everything about her. I’m so sick of it.”

Tears rolled down Claire’s cheeks.

“Stop it,” he said. “You’re making me feel bad.”

I let this go on for a few more minutes and then I explained that I needed both of them to enter individual therapy and offered referrals.

Mark insisted that there was nothing wrong with him and that therapy took up too much time. I told them both that we weren’t going to be able to move forward in couples work unless they dealt with their individual issues.

Mark looked furious.

With some trepidation, I said, “I’m thinking that people have said things that made you feel bad as a kid. That’s not your fault, but it’s making everything you hear Claire say feel like the same harsh words. And Claire, without intending, the constant focus on what’s wrong with Mark is emasculating and evoking shame. I want you both to speak with your own therapists, otherwise this is never going to stop.”

They both conceded.

We agreed to continue our couple’s therapy, which I knew would be a difficult journey. It’s hard to get to the shame, but without doing so, empathy will remain compromised. The more Mark understood his shame, the greater his ability would be to recognize and experience Claire’s emotions within the context of their relationship. And the more he could empathize, the more Claire would feel her emotions were heard and valid. The more she felt that she had a right to her feelings the less likely she would be dissatisfied.

* Claire and Mark are amalgamates created to show the relationship between shame, guilt and empathy.  

A Counselor Visits the US/Mexico Border

Posted on by Psychotherapy.net Team

He sat nestled on a chair, clinging to his father. His quivering 6-year-old body told its story with every tortured word uttered by the man who tried his best to protect him. His father recounted the death of his wife at childbirth and of the life he had created for his beloved son, which included a small business and a supportive community. He recalled how one of his friends and fellow business owners had shared with him that the Mara (a violent predatory gang) had demanded a monthly payment and that he had refused. Two days later, the boy had opened the door to their apartment only to see the mutilated lifeless body of the man who had dared stand up to the gang. Later that evening, the boy’s father was visited by the very same gang who had killed his friend, and who now demanded the same payment from him. They threatened to kill both father and son if the extortion was denied.

Try as I might to engage the child as his father’s pain became more palpably agonizing, he clutched the man even tighter. The father continued telling his story to a pair of young pro-bono law students surrounded by a throng of legal advocates and other fathers recently reunited with their children. He recounted how after the threats, he had gone to the police for help and was assured of his safety and confidentiality. The next night, the child was awakened by the sight of his father being brutally beaten by both the gang members and the police. Desperate and frightened, the boy ran to the neighbors who united to save his father. With borrowed money, father and son fled the very next day. With coyotes on their heels, the journey to safety ended as he held his son aloft to protect him from the bone chilling cold of the Rio Grande.

Amidst the screaming of the men in uniforms, who flashed guns in their faces, father and son were arrested, violently separated with the sound of “How do you like your American dream, now amigo”? Two months later, the father was reunited with the boy at a Texas ICE Detention facility, awaiting probable deportation and the certainty that if he and his son were deported, he would be eagerly greeted by the Mara and killed, leaving his young son alone. If the boy remained in the US and he returned home, his boy would surely be orphaned.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

This story of human beings fleeing from Guatemala, Honduras and El Salvador was repeated over and over, replete with the most horrific violence imaginable. I thought that I had been prepared for this by my work as counselor in Greece where I bore witness to the trauma incurred by unaccompanied child refugees from Syria, Iraq, Afghanistan and other conflict zones. I thought I had been prepared by my years of counseling experience, but nothing prepared me for the trauma inflicted upon these helpless children by the United States policy of family separation. I accompanied law school students and faculty who were deeply affected by the inevitable experience of vicarious trauma and compassion fatigue.

In retrospect, I don’t believe that any educational or clinical knowledge would have adequately prepared any of us for what we encountered. ICE Detention Facilities and places where children are housed separated from their parents, are epicenters of disregard for human dignity, human rights and the immoral infliction of generational trauma on thousands of children. As mental health practitioners, we know this to be true. As lawful people we know this to be unjust. As decent human beings we know this to be immoral.

Mental health practitioners may be completely unaware of a client’s legal status because survival requires invisibility. A child may ostensibly be referred for depression, anxiety or behavioral problems, but be struggling with the pain of separation from their caretakers. Therapists need to learn the intricacies and ever-changing landscape of immigration and asylum that potentially impact their clients, whether directly or indirectly touched by the border separations. Even an otherwise healthy and intact family may in the blink of an eye be devastated by the breadwinner’s arrest and imprisonment. Therapists need to help their affected clients to identify coping skills and obtain grounding in extant and emerging pathways to the assessment and treatment of trauma. The world’s most vulnerable and most invisible will evoke an abiding respect for their unimaginable strength and resilience. If you believe in the inviolable right to the dignity and you are willing to walk the journey together with humility and heart, your client will experience love made visible through a shared humanity.   

The Luggage Tag

Posted on by Psychotherapy.net Team

I got a letter in the mail. It was from North Dakota, a place where I had never been. There were two Scooby Doo stamps on the right-hand corner, and a return address I did not recognize. I opened the envelope, and inside was an old brown leather luggage tag. I recognized my writing, and I knew the tag had once hung on the handle of my suitcase to identify that it was mine. Of course, it was meant to give information should the suitcase get lost. To let someone out there know where to find me, and where to send the suitcase.

Inside the envelope was a letter, folded in thirds. Typed out carefully in calligraphic script.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

“Hi, my name is Karen, and I work part time as a ramp agent. I found your luggage tag while working and wanted to return it to you. Here’s to many more safe travels.”

I put the letter down and I looked around my kitchen. Who sends a luggage tag through the mail? Why didn’t she just throw it away? Who was this person in North Dakota?

These questions didn’t leave easily. I thought about them all day. And the next, off and on. She must have brought it home, sat down and typed out a note, attached two stamps – worth about the cost of the contents! She had an intention to find the rightful owner of the tag, and she followed through with her intention. Luggage tag received. Made it home.

Maybe this could be really important. Maybe simply putting that tag in an envelope and sending it home could model something important and alter the course of the world just a bit.

I recalled the ideas I learned when training in a coaching program at The Arbinger Institute. I recalled learning something like this: Imagine seeing something on the ground, perhaps in your home or office, and not picking it up. And the immediate justification that follows: “Someone else will get it.” Or “not mine…” We then create a space between ourselves and the rest of the world. We put ourselves in a box of sorts. And the “other” in our mind, who will pick it up, becomes a sort of object, not a subject to whom we feel connected. What if we pick it up? Then we remind ourselves of how we are connected to humanity.

I have a similar experience at times when doing improvisational theater, a hobby I have enjoyed and studied for thirty years. Up on a stage, working with a partner, you never know what’s going to happen; brilliance or train wreck. But there you are, sharing a moment with someone, creating something. And it really only works if you care about your partner, if you are curious about who they are, what character they bring, and move the scene forward by providing gifts. A name, a place, a purpose, and the focus on your partner often helps move the scene along.

In a therapy office, whether I’m the therapist or the client, we work together back and forth to understand something new through a conversation rooted in curiosity with the potential to reach a greater sense of connection both to each other and to the world at large. We aim for less reliance on defenses, less fear of the world, and maybe even the generation of an impulse to help someone else.

A mother gazing at her infant… the infant gazing back. Back and forth they go. Like two improvisers sharing a moment. Playing and creating, taking care of each other up on stage. Like two people connecting in a psychotherapy consulting office. Exchanging ideas and feelings back and forth to reach a deeper truth. A shared experience of humanity. Like a luggage tag… traveling through the mail….to find its rightful owner.

What luggage tag can I send out into the world? What can we all do to surprise someone just for a moment? An unexpected hello. An offer to someone in need. The breaking of an estrangement of one sort or another. An unexpected gift from the tarmac finding its way home.

With a pen, a paper, an envelope and two stamps, I say thank you to someone on a ramp in North Dakota for reminding me for a moment of what it means to be human.