Category: Therapeutic Issue

Repairing Self-Neglect in Clients with Complex PTSD

Posted on by Psychotherapy.net Team

The Somatic Legacy of Complex Trauma

People who experienced complex post-traumatic stress disorder (C-PTSD) or ongoing ‘complex’ childhood trauma consisting of neglect, abuse, and invalidation, develop strategies and defenses designed to make sense of the painful truth that their caregivers failed to provide essential emotional and physical attachment needs. These protective strategies, though geared for survival, become obstacles to overall health, self-expression, healthy relationships, and fulfilling careers.

Clients who endured abuse or invalidation during childhood developed exquisite sensitivity to external cues that helped them manage chaotic or unpredictable environments. This hyper-attunement to external inputs, a kind of hypervigilant codependence, evolved while clients were simultaneously repressing internal cues like hunger, thirst, fatigue, toileting, and comfort as a result of needs repeatedly going unmet. It becomes a survival strategy to not feel or acknowledge them. By having suppressed their basic physical needs, these clients experience ongoing internal tension expressed as anxiety and depression, dysregulation, and codependent behaviors.

Growing up surrounded by reactive adults who did not provide functional emotional modeling, clients’ emotional tools are restricted. They became over-focused on external sources of validation which contribute to ongoing anxiety and reactivity. This situation fundamentally disrupts clients’ capacity for implementing self-care and other functional behaviors necessary for a healthy life.

Developing in an unsafe environment, clients’ ongoing somatic experience is of underlying danger and unpredictability. With porous boundaries and distorted perceptions, they look for confirmation of this bias in every interaction, are poised to identify danger, and experience unbearable flooding. This frequently leads to hypersensitivity to criticism and rejection along with perfectionistic tendencies as a defense against chaos.

In multiple cases, I have found that encouraging these clients to pay attention to and satisfy cues like hunger, thirst, physical discomfort, and toilet needs as a primary intervention is transformational. Providing a supportive container to address their needs evokes a crucial new experience in which to foster change.

In session, I routinely encourage clients to make themselves physically comfortable, whether we meet online or in person. My office has yoga mats, pillows, a physioball, chairs, and a long sturdy Pilates table. Throughout sessions, I cue them to check in with their sensations using direct questions with non-threatening words like, “what’s coming up for you now,” “are you still comfortable or do you need to move,” “feel free to adjust, move, or make yourself more comfortable,” “what would feel safer in this moment?” My aim is to highlight internal sensations and give explicit permission to foreground their physical needs over anything else—something that their upbringing did not allow or was not safe for them to do.

Because breathing is foundational to life, breathwork can also be a powerful tool for addressing dysregulation, though it requires careful implementation with Complex PTSD clients. Some clients may find breath-focused exercises triggering due to their trauma—for instance, one of my transgender clients rejected breathwork entirely due to traumatic experiences in a religious cult.

I begin with gentle, non-invasive approaches like observing the difference between nose and mouth breathing to help regulate anxiety. From there, I guide clients to simply notice physical sensations: the feel of air moving through their nostrils, the natural expansion and release of their lungs and abdomen. To demonstrate healthy breathing mechanics, I use a Hoberman Sphere to illustrate what I call “three-dimensional breathing”—showing how the thorax can move in all directions: length, width, and depth.

While advanced breathing techniques like those used in Kriya Yoga can create profound physiological and psychological changes through specific patterns of inhalation, exhalation, and breath retention, my primary goal with CPTSD clients is more fundamental. Simply helping them feel safe enough to take full, unrestricted breaths often begins to release long-held patterns of physical tension and armoring.

Attending to the Body in Therapy

A 23-year-old man in graduate school was recently diagnosed with bipolar disorder and had a history of physical abuse. In session he would frequently jiggle his leg. I noticed this becoming more intense when we discussed an upcoming exam. I used immediacy to bring his attention to his movement and invited him to tune into what his leg might be saying. He expressed anxiety and wanting to flee. I said, “feel free to run out of the room. I will be right here waiting for you whenever you are ready to return.”

Though surprised, he got up and left the room. A few minutes later, he came back, grinning. That completed escape and safe reception upon his return was a lynchpin to his future empowerment and ability to connect with his deepest desires. Further work around hunger ignited a passion for cooking that helped him solidify connections with friends.

During a session with a 19-year-old non-binary client, they revealed that at work they were so overburdened they didn’t urinate for up to 8 hours. When I expressed surprise and concern, they reported their boss often neglected to allow breaks. Not only due to the questionable legality of this situation, but due to this client’s habitual self-neglect, I encouraged them to insist on being allowed to take care of their bathroom needs.

In case clients don’t feel empowered to stand up for their needs, I encourage them to blame it on me, their therapist. In this way, therapy helps them repair personal boundaries caregivers often neglected to help them build. Over the course of our ensuing sessions, this client reported on the transformation they experienced because of this new awareness. Not only were they able to stand up for themselves in other interpersonal situations, they went on to become stronger advocates for animal welfare.

A 45-year-old woman was seeking therapy for chronic illness and overwhelming guilt around leaving her mother and sister, both addicted to methamphetamines. By attending to her basic physical needs, especially hunger and rest, she was able to reframe her “abandoning” of her family into the recognition that as a child, she was abandoned by them.

Paying attention to basic physical needs begins to reverse codependency dynamics of over-focusing outward and under-focusing inward. According to codependence expert Nancy L. Johnston, external focus and emotional suppression are two of the four hallmarks of codependent behavior, along with self-sacrifice and interpersonal control.

***

Helping clients become aware of biological needs is a critical first step in healing. Empowering them to satisfy these needs is the next step in helping them feel safe and grounded enough to pursue life satisfaction. Providing validation for these unmet physical needs can, at times, be challenging. As much as possible, I guide clients in session to check in with their inner experiences. I am repairing the attachment function of attending to a child’s most vital requirements.

My experience has taught me that in cases of childhood neglect and abuse, not only is there the tension of feeling needs but also accompanying grief, shame, and rage elicited by not having needs met by caregivers. Validating and normalizing having needs while providing opportunities to feel and satisfy them mitigates fears evoked by vulnerable feelings. Healing trauma through this attention can repair the split clients were forced to assume when they buried or negated crucial survival needs.

Questions for Thought and Discussion In what ways do you resonate with this author’s premise? In what ways do your PTSD clients neglect their basic bodily needs? How do you integrate these needs into your therapeutic work with these clients?

The Challenge of Therapy During War: Psychotherapy in Ukraine

Posted on by Psychotherapy.net Team

The Emotional Ravages of War

The ongoing crisis in Ukraine has placed immense psychological strain on its population, creating a heightened need for mental health support amidst war, displacement, and uncertainty. Therapists working in Ukraine face unique challenges requiring resilience, adaptability, and innovative approaches. The war has caused massive, widespread trauma with millions displaced and exposed to violence. Therapists working either face-to-face or remotely with their clients encounter acute and chronic PTSD symptoms, anxiety, depression, and grief due to loss of loved ones, homes, and stability. There is also considerable intergenerational trauma in families with histories of oppression.

While Ukrainians have a history of resilience, the impact of intergenerational trauma and mental health stigma persists. Many of my clients attempt to minimize emotional distress or express it through physical symptoms. They have historically hesitated in seeking help, viewing it as a sign of weakness. However, online therapeutic platforms like Soul Space, the one through which I work, offer easily accessible and safe resources for support and self-help tools that empower these individuals.

The Challenge of Therapy During War

Therapists, such as myself, often face secondary traumatic stress (STS) from absorbing clients’ pain, leading to symptoms similar to PTSD. High caseloads also contribute to burnout and emotional exhaustion. Therapists often work with limited supervision, professional development opportunities, or access to private therapy spaces. Displaced populations pose additional logistical challenges to on-ground clinicians. Balancing professional neutrality with personal feelings about the war, while addressing clients’ immediate needs and maintaining a therapeutic frame, are frequent concerns that challenge clinicians under these circumstances.

While teletherapy has been invaluable to Ukraninans under seige, and has allowed me to support more clients than had I been on the ground, power outages, poor internet connections, and client inexperience with technology often impede its effectiveness. It has also been critical for me to prioritize self-care, emotional hygiene, peer support groups, and supervision to process my own emotional experiences as I serve those devastated by the war. I have also found it useful to limit daily trauma-focused sessions to prevent emotional fatigue. Techniques like grounding and meditation have helped me to maintain strength and clinical endurance.

I have learned to respect clients’ cultural coping mechanisms in order to build trust and support empowerment, resilience, and self-efficacy. I have relied on trauma-informed approaches that begin with safety and stabilization techniques such as grounding exercises and psychoeducation about trauma, while also processing with practical problem-solving to meet clients’ immediate needs. Soul Space provides psychoeducational workshops to maximize reach, provide structured, and self-guided mental health resources.

Case Example

A displaced family of four sought therapy after relocating from a war-affected region. The parents reported anxiety, irritability, and hypervigilance; while the children displayed regressive behaviors and nightmares. My approach required the establishment of safety and routine in therapy, psychoeducation to normalize trauma responses, and activities that built resilience and mutual support. Nighttime relaxation rituals helped the family with wartime-related sleeplessness, while gradually igniting bonds of trust and security due to invasive interruptions of regular routines. The parents practiced simple grounding techniques to contend with their own anxieties.

The parents learned about trauma responses in adults and children, and were increasingly able to reframe the children’s behaviors as survival mechanisms instead of simply seeing them as defiance. Several grounding exercises were also introduced to the children utilizing sensory modalities by asking them to say five things they see, hear, or touch when feeling overwhelmed.

To strengthen family bonds, I introduced therapeutic play and storytelling to allow the children to articulate issues of fear in a safe and imaginative way. The parents were given the chance to have planned conversations to foster emotional conversations and model healthy expressions for fear and grief. We also created a “Family Strengths Tree” where they could record examples of salvaged resilience to remind themselves of their survival capacities.

The family finally began processing their experiences. The children created a storybook representing their journey, necessitating a shift in the focus from fear to resilience. The parents explored their guilt and grief using cognitive processing techniques, reframing self-blame into self-compassion. Throughout the intervention with this family, and as with other wartime displaced clients, I integrated formal online training available through Soul Space with my direct face-to-face work.

During our work together, the family experienced reduced anxiety, improved communication, and renewed hope. The mother’s panic attacks became less frequent, and the father started to emotionally reconnect with his children. The daughter began socializing again, and the son had a drastic decrease in nightmares and bedwetting. Coping mechanisms and family bonds improved. Working with this family, as with others, I have come to rely upon additional training courses in trauma-informed interventions, networking, and the importance of adapting my therapeutic techniques to meet the realities of life in conflict zones, including shorter sessions or combining therapy with referral for humanitarian aid.

Questions for Thought and Discussion

Whether or not you’ve worked with clients in war-torn areas, how do you resonate with the author’s sentiments?

Which of the challenges raised by the author are similar or different from those you have experienced with traumatized clients?

What are some of the core techniques that you have found successful in working with traumatized clients?

Helping Clients to Understand and Overcome Traumatic Reenactment

Posted on by Psychotherapy.net Team

As a psychotherapist who has specialized in working with trauma victims for almost 40 years, I have experienced many clients who are suffering from traumatic reenactments—the phenomena that occurs when people expose themselves to situations reminiscent of an original trauma, placing themselves at emotional risk or in physical danger in a compulsive mimicking of the past. For example, a woman who was physically abused by her father may continually find herself being attracted to abusive men. A man whose mother emotionally abused him may continually become attracted to women who are overly critical toward him. Yet when I attempt to help these clients make the all-important connection between these current reenactments and past trauma I’m often faced with reactions like, “but I didn’t experience any trauma growing up” or “I’ve already dealt with my past abuse, it’s not still affecting me.” Clients tend to minimize, deny, or “forget” their past trauma experiences.

Why Do People Reenact Trauma?

While reenactments are experienced by many people, those who were traumatized as children (including neglect, abandonment, and abuse) have a tendency to re-enact or relive past trauma more than the average person. Other types of traumas can also create the need to repeat what happened to us as a way of understanding it and bringing closure. This includes acts of nature such as floods, earthquakes, and tornadoes; the death of a loved one; as well as fatal accidents. Several theories have been suggested to explain the phenomenon of traumatic reenactments.

  • Many experts understand reenactments as an attempt to achieving mastery. This means that a traumatized individual reenacts a trauma in order to remember, assimilate, integrate, understand, and heal from the traumatic experience. (1)
  • Some experts perceive reenactments as spontaneous behavioral repetitions of past traumatic events that have never been verbalized or even remembered. For example, Freud noted that individuals who do not remember past traumatic events are “obliged to repeat the repressed material as a contemporary experience instead of … remembering it as something belonging in the past.” (2)
  • Others suggest that reenactments result from the psychological vulnerabilities characteristic of trauma survivors. For example, as a result of a range of ego deficits and poor coping strategies, trauma survivors can become easy prey for victimizers. (3)

Ongoing reenactments usually indicate that a former victim is emotionally stuck and can be interpreted as a “call for help.” They are attempting to work through some aspect of past trauma by repeating it with another person, hoping that this time the result will be different.

We don’t consciously and deliberately set out to repeat a parent’s behavior, get involved with a replica of an abusive or neglectful caregiver, or repeat a trauma over and over. These are unconscious actions on our part. Sigmund Freud stated that such unconscious processes may affect a person’s behavior even though he or she cannot report on them. For example, Freud and his followers believed that dreams and slips of the tongue were really concealed examples of unconscious content too threatening to be confronted directly. Reenactments can be seen as this type of unconscious behavior.

In addition to Freud’s concept of reenactments being a need to repeat the past in order to get a different result, I would add that reenactments are often an unconscious need for people to understand what happened to them and why. Those who are caught up in reenactments are often troubled (consciously and unconsciously) by events that occurred in their past. Some are confused about why people treated them the way they did. Others blame themselves. Still others are in denial about these events. They are overwhelmed by emotions such as shame, anger, fear, and pain, emotions that are often suppressed or repressed. All this confusion and denial work together on an unconscious level, causing them to reenact troubling events in an effort to gain understanding and closure. For example, a girl whose father abandoned her will likely be preoccupied with discovering why he did so and may blame herself in some way. As an adult, this will likely affect her relationships with men, causing her to both doubt her ability to keep a man interested in her and to be attracted to unavailable men.

Reenactments often lead to re-victimization and with it, related feelings of shame, helplessness, and hopelessness. For example, it has been found that women who were sexually abused as children are more likely to be sexually or physically abused in their marriages. Therefore, gaining an understanding and control of reenactments is a primary way to avoid further re-victimization and shaming.

The Reasons Why Clients Deny Having Been Abused

Even though they may suffer from reenactments, some people insist they have not suffered from trauma or are not sure whether they have or not. The reasons for this are many.

Denial and Minimization

Many people don’t label their experiences as traumatic, even when they are. Others minimize the damage an event or series of events had on them. In fact, the majority of trauma victims tend to deny or minimize traumatic experiences. As humans, we will do almost anything to avoid facing the feelings surrounding being traumatized, feelings such as fear, pain, shame, and anger. One of the best ways to avoid such emotions is to deny that the trauma ever happened. For example, even if a client is able to admit to himself that he was physically abused by his father, he may still be in denial about various aspects of the abuse. He may have convinced himself that “it wasn’t all that bad,” (minimization) or that his father didn’t mean to harm him (rationalization). In the case of a client having been sexually abused they may have even convinced themselves that it wasn’t actually abuse because they enjoyed it or because they believe they were the one who initiated it (denial).

Denial is a powerful, unconscious defense mechanism intended to protect us from having to face intense pain and trauma. It can even allow us to block out or “forget” intense pain caused by emotional or physical trauma such as childhood abuse. The denial process is designed to prevent us from facing things that are too painful to face at the time. But it also defends us against the truth and can continue way past the time when it served a positive function.

Former victims of child abuse often deny that they were abused, deny that it caused them any harm, and deny that they need help. The following are the most common reasons why victims of child abuse tend to deny what happened to them and/or minimize the damage it caused them:

  • They don’t want to feel the pain, fear, betrayal, and shame that acknowledging the abuse would cause them to feel. The abuse is either walled off from conscious awareness and memory, so that it did not really happen; or it is minimized, rationalized, and excused, so that whatever did happen was not really abuse. Unable to escape or alter the unbearable reality that they were abused, some children alter it in their mind.
  • They don’t want to admit that they were a helpless victim. It can be humiliating and degrading to acknowledge that another person can overpower you or have control over you. Instead of admitting either of these two things, victims often prefer to take responsibility for the abuse. This is especially true of male victims since males are raised to be tough and strong and to always defend themselves.
  • They don’t want to admit that someone they cared about could harm them and cause them damage. For those who were abused by a family member, a close friend of the family, or an authority figure they respected such as a priest, a teacher, or a coach, to face the fact that they were abused is to experience the sometimes unbearable pain of admitting that someone they respected or loved could treat them in such horrendous ways. The most common way for children to explain behavior on an abuser’s part, especially if it is someone they respect or love, is for them to blame themselves.
  • Another reason some former victims deny that they were ever abused is that they repeated the cycle of abuse by abusing other children. In this situation they may have an investment in believing that parents have a right to discipline their children, even if it causes physical harm. Those who were sexually abused often convince themselves that children are never really “forced or manipulated” into sex with an adult or older child, but they do so willingly and that they get pleasure from doing it. This kind of denial not only keeps former victims from admitting that they themselves were abused but that they became abusive.

Repression vs Suppression

Repression (unconsciously blocking out traumatic events) and suppression (consciously choosing to “forget” traumatic events) are survival skills that help former victims of trauma to move on with their lives instead of being so completely overwhelmed with feelings of fear, shame, or guilt that they can’t function. Unfortunately, these defense mechanisms can make it difficult for clients to allow themselves to remember and process a trauma.

Painful feelings and memories can be very upsetting. Instead of facing them, clients often unconsciously hide them from themselves in hopes of forgetting about them. That does not mean that the memories disappear entirely. They can influence behaviors and can impact our relationships without us realizing it. Most important, repressed memories can show up in our lives in the form of reenactments.

It can be especially painful for clients to admit that someone they loved, and who they believe loved them, could traumatize them by being abusive or neglectful. Sometimes, instead of facing the truth they consciously suppress the memories of what happened. This was the case with my client Chloe:

“It’s not like I ever forgot about the sexual abuse. I just chose to lock it away and throw away the key. I couldn’t handle the fact that my own father, who I loved dearly and who was the only person in my childhood who was kind to me, could harm me in that way—could be so selfish to put his own needs ahead of mine like that.”

Dissociation

Another reason a client may have no memories or only vague memories of a trauma is the common practice of victims to dissociate. Some victims dissociated, while others were traumatized so severely that they lost all memory of the attack—much like car accident victims often experience amnesia after the crash (repression).

According to the Diagnostic and Statistical Manual of Mental Disorders 5th edition, dissociation is a “disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, perception, body representation, motor control and behavior.” Dissociation is a normal phenomenon that everyone has experienced. Examples of mild dissociation include daydreaming, “highway hypnosis,” or “getting lost” in a book or movie, all of which involve “losing touch” with an awareness of one’s immediate surroundings.

During traumatic experience such as crime victimization, abuse, accidents, or other disasters, dissociation can help a person tolerate what might otherwise be too difficult to bear. In situations like these the person may dissociate (detach or disconnect) from the memory of the places, circumstances, and feelings surrounding the overwhelming event, thus mentally escaping from the fear, pain, shame and horror.

When faced with an overwhelming situation from which there is no physical escape, a child may learn to “go away” in their mind. Children typically use this ability as a defense against physical and emotional pain or fear of that pain. By the process of dissociation, thoughts, feelings, memories and perceptions of the trauma can be separated off in the mind. This allows the child to function normally.

For example, when a child is being sexually abused, in order to protect themselves from the repeated invasion of their deepest inner self they may turn off the connection between their mind and body creating the sensation of “leaving one’s body.” This common defense mechanism helps the victim to survive the assault by numbing themselves or otherwise separating themselves from the trauma occurring to the body. In this way, although the child’s body is being violated, the child does not have to actually “feel” what is happening. Many victims have described this situation as “being up on the ceiling, looking down on my own body” as the abuse occurred. It is as though the abuse is not happening to them but just to their body.

While dissociation helps the victim to survive the violation, it can make it difficult to later remember the details of the experience. And it can make it difficult for a victim to come to terms with whether or not they were actually abused. If someone was not in their body when the abuse occurred, it will naturally affect their memory. For example, in the case of sexual abuse, if the person doesn’t “remember” the physical sensations of what the abuser did to their body or what they made to do to the abuser’s body, it can cause them to doubt their memory and add to their tendency to deny what occurred.

Tragically, ongoing traumatic events such as abuse are often not one-time events. For those who are repeatedly exposed to abuse or neglect, especially in childhood, dissociation is an extremely effective coping mechanism or skill. However, it can become a double-edged sword. While it can protect clients from awareness of pain in the short-run, a person who dissociates often may find that in the long-run his or her sense of personal history and identity is affected.

Grounding is a very effective practice to teach clients to help them come out of this dissociative state.

Basic Grounding Exercise

  • Find a quiet place where you will not be disturbed or distracted.
  • Sit up in a chair or on the couch. Put your feet flat on the ground. If you are wearing shoes with heels you will need to take your shoes off so that you can have your feet flat on the ground.
  • With your eyes open, take a few deep breaths. Turn your attention once again to feeling the ground under your feet. Continue your breathing and feeling your feet flat on the ground throughout the exercise.
  • Now, as you continue breathing, clear your eyes and take a look around the room. As you slowly scan the room, notice the colors, shapes, and textures of the objects in the room. If you’d like, scan your eyes around the room moving your neck so you can see a wider view.
  • Bring your focus back to feeling the ground under your feet as you continue to breathe and to notice the different colors, textures and shape of the objects in the room.
  • This grounding exercise will serve several purposes:
  • It brings awareness back to the body, which in turn can prevent being triggered or dissociating.
  • It brings us back to the present, to the here and now; again, a good thing when being catapulted back into the past by a memory or a trigger.
  • Deliberately focusing the attention outside yourself by being visually involved in the world helps bring a person out of a dissociative state and into reality where they can get in touch with their emotions and their memory.

Dissociative Amnesia

Dissociative amnesia is the inability to recall autobiographical information. For example, Betrayal Trauma Theory holds that for incest survivors, dissociative amnesia serves to maintain connection with an attachment figure by excluding knowledge of the abuse (betrayal blindness). This, in turn, reduces or eliminates anxiety about the abuse, at least in the short run.

Betrayal Trauma Theory is based on attachment theory and is consistent with the view that it is adaptive to block from awareness most or all information about abuse (particularly incest) committed by a caregiver. Otherwise, awareness of the abuse would acknowledge the fact that a betrayal occurred, and this acknowledgement would likely endanger the attachment relationship. Betrayal blindness can be viewed as an adaptive reaction to a threat to the attachment relationship with the abuser and thus explains the underlying dissociative amnesia in survivors of incest. Under these circumstances, survivors often are unaware that they were abused, or will justify, or even blame themselves for the abuse. In severe cases, victims often have little or no memory of the abuse or complete betrayal blindness. Under such conditions, dissociation is functional for the victim, at least for a time. (4)

Due to dissociation, dissociative amnesia or betrayal blindness, someone experiencing reenactments may have to trust the fact that they wouldn’t have the symptoms they have and wouldn’t have the deep sense that “something happened” unless they actually experienced a trauma. Other times some education can help clients to come out of denial:

The Lack of Specific Memories

The lack of specific memories can cause former victims to question their sense that something happened to them and even the flashes of memory that they do experience. Let’s compare this lack of specific memories with what often happens when someone has been in a traumatic car accident. Let’s say that you wake up to find yourself in the hospital. You notice that one of your arms is in a sling and that one of your legs is in a cast and that you have cuts and bruises all over your body. There’s no one around and you feel panicked, thinking, “what happened to me?”

Then someone you know comes into your hospital room and tells you that you were in a horrible car accident. You feel shocked because you have absolutely no memory of it. Not only that, but you can’t remember anything just before the accident. Just because you have no memory of the accident doesn’t mean that it didn’t happen, right? You have the broken bones and the bruises to prove it.

The same is true of childhood abuse. A client may not have any memories, but they have the results of the abuse as proof that it actually did happen. They have nightmares, flashbacks, and triggers, and they have self-destructive behaviors. If they were neglected or emotionally abused they may have low self-esteem, a tendency to be self-critical, or a tendency to push people away or, conversely, a fear of abandonment. If they were physically abused, they may have a tendency to be defensive or have rigid posture and a startled reaction when someone comes up behind them. They may have the habit of gritting their teeth, or tension in their jaw from all the repressed anger they are holding. In the case of child sexual abuse, they may have the unexplained pain in their vagina or anus, a negative reaction to being touched on certain parts of their body, powerful reactions when they see a movie about someone being raped or about a child being molested. Certain types of sexual acts or positions, or certain kinds of touches may repulse them, or they may dissociate when they are around certain people, places and things. These are, in essence, their “memories.”

The bottom line is that a client may never have actual “memories” in the sense of being able to “remember” or “recall” actual events. But that doesn’t mean they weren’t abused. Many of the clients I have worked with who do not have tangible memories have other indicators that they were abused. Some have flashbacks, others have what are called “body memories.” Those who were physically abused often have pain in the places where they were beaten, such as their back and buttocks. They often have a “startle reaction” when someone raises their hand in front of them due to the fact that they were slapped or hit in the head so often.

Those who were sexually abused can have pain in their genitals, anus, or breasts for no apparent (or medical) reasons and vaginismus (involuntary contractions of the vaginal muscles preventing penetration or making penetration extremely painful). Still others have such tell-tale symptoms as being repulsed by thoughts of sex, a fear of sex, an inability or repulsion to being touched, obsessive rape fantasies (either of someone forcing sex on you or you forcing yourself on someone else), or sexual addictions.

A Real Compulsion

It is important to understand that traumatized people experience a true compulsion to repeat repressed experiences. Even if the person attempts to keep the memory repressed, there is an opposing need on the part of the psyche to force the repressed material into consciousness. Thus, the repressed and dissociated events emerge to be re-experienced, often in dreams and nightmares (during sleep when conscious control must be let go), and then in waking hours as well. Clinical experience suggests that the compulsion to repeat takes on an almost biologic urgency, such as our need to urinate. We can hold our urine for only so long.

Examples of the Emergence of Repressed and Dissociated Experiences

Flashbacks are the most striking examples of repressed and dissociated trauma, and are frequently observed in clients with posttraumatic disorder, and some dissociative disorders. Flashbacks are involuntary recurrent memories in which an individual has a sudden, usually powerful, re-experiencing of part of a trauma or elements of a past trauma. These experiences are often frightening, catapulting the person back in time.

Those who are experiencing flashbacks are thrust back into the traumatic events both in their dreams and while awake. The reliving of the trauma is experienced as a real and current event. The traumatized person does not feel as if they are remembering the experience but instead, they feel the experience in the present. When someone is experiencing a flashback, they often lose awareness of their surroundings and are thrust back into the trauma, visualizing previous surroundings and people, and feeling they are the same age as when the trauma originally occurred. This points to the ability of the psych to repress and dissociate overwhelming experiences, as well as to bring them back into consciousness with full force.

Implicit Memories
Trauma “memories” often manifest in intense physical, perceptual, and emotional reactions to everyday occurrences and objects (triggers). These emotional and physical responses, called “implicit memories,” keep bringing the trauma alive in a former victim’s body and emotions again and again, often many times a day. Their bodies tense up, their hearts pound, they see horrifying images, and they feel fear, pain or rage. They freeze in fear or feel a sudden wave of painful shame and lose the capacity to speak. They feel an intense impulse to run away and hide from others.

Decades of research on the effects of trauma confirm that overwhelming experiences are less likely to be recalled as a series of images that we can describe or in a clear coherent narrative. Trauma is more likely to be remembered in the form of sensory elements without words—emotions, body sensations, changes in breathing or heart rate, tensing, bracing, collapsing, or just feeling overwhelmed. (5) When implicit memories are evoked by triggers, we re-experience the sense of threat, danger, humiliation or impulses to flee that we experienced at the moment of threat—even if we have no conscious verbal memory of what happened.

Those who insist that they do not remember any trauma often don’t realize that they are, in fact, remembering when they suddenly feel startled or afraid, when they feel shame or self-hatred, or when they start to tremble or shake. Because trauma is remembered emotionally and somatically more than it is remembered in a narrative form that can be expressed verbally, former victims often feel confused, overwhelmed or crazy. Without a memory of words or pictures, they do not recognize that what they are feeling is memory.

Most people also do not realize that we remember in different ways. With the thinking brain we can remember the story of what happened but without a lot of emotion connected to it. With our sensory systems we can remember how something felt. Our bodies might remember the impulses and movements and the physical sensations (tightening, trembling, sinking feelings) experienced at the time.

For example, many former victims feel uncomfortable stating that they were sexually abused because they do not remember whole events. Their memories are fragmented or unclear or consist of a few images, rather than an entire mental video of the events. They doubt themselves and think, “it can’t be true because I don’t remember exactly what happened” or “I must be making this up or I would remember more clearly.” But it is important to explain to clients that trauma cannot be remembered the same way other events are recalled because of the effects trauma has on the brain. When clients feel the impulse to doubt their memory or intuition that something happened to them, remind them that recalling events as a story or narrative is not the only way to remember. They may be remembering a lot more than they think.

Triggers

Your clients may feel surprised to learn how much they remember when they include the feelings, thoughts and physical reactions they experienced when triggered. Generally, a trigger can be defined as any stimulus that causes a reaction, often an emotional response such as anxiety, sadness, panic, feeling overwhelmed, flashbacks, nightmares, or severe emotional distress. A trigger is sufficiently reminiscent of a past event or process that it activates implicit (feelings, sensations, and nonverbal thoughts) or explicit (the what, when, and where of remembered events) memories in the present.

Types of triggers 
There are various types of triggers, including:

  • Sensory: sounds, smells, textures, or physical sensations
  • Time-related: certain times of day or seasons
  • People or places: people or places that remind them of a negative experience
  • Bodily sensations: pain or touch that reminds them of a negative experience
  • Substance-related: cravings or urges to use substances

Clients may also feel surprised to learn that there is an explanation for their seeming “overreaction” to certain things. For example, maybe they aren’t an “angry person,” but are simply experiencing feeling memories of anger that have been triggered when someone is selfish, controlling, or domineering.

Exercise: Discovering Your Triggers

My aim, in part, of writing this article is to help those of you fellow therapists who have clients who can’t make the connection between their past trauma and their current negative patterns of behavior either due to lack of memory, denial or minimization.

The following exercises and lists can help your clients discover their triggers:

  • Begin by asking your clients to notice the events, sensory experiences, or people that tend to trigger them (catapult them into the past, remind them of an abuse experience or some aspect of an abuse experience). For example: those who were traumatized by parental abandonment may become triggered every time a friend doesn’t respond to a phone call or text or every time their partner goes away on a business trip.
  • Next, ask them to begin making a list of these triggers.
  • As time goes by ask your clients if they see patterns regarding the things that trigger them.

Triggers List 

The following is an extensive list of triggers common for those who were traumatized by child abuse, abandonment, and/or neglect. Sharing this list with your clients and asking them to put a check mark next to the items that trigger them will help them become familiar with their triggers and in turn help them make the connection between their past trauma and their present reenactments.

  • Feeling abandoned or rejected
  • The sound of someone crying
  • Criticism
  • Someone being very angry
  • Someone saying mean or abusive things to you
  • Someone yelling at you
  • Someone raising their hand or fist near you
  • Someone threatening to hurt you
  • Mean or dirty looks
  • Seeing violence on TV, at the movies, or on the Internet
  • People in authority
  • Competition
  • Being lied to
  • Someone acting like they are better than you
  • Someone who reminds you of your mother
  • Someone who reminds you of your father
  • Being let down by someone
  • Being laughed at
  • Being accused of something you didn’t do
  • Being ignored
  • Feeling alone

Remind your clients that their symptoms and triggers are their memories. This is what my client Briana figured out after reading the triggers list from above:

“I was shocked to realize how many triggers I experience, almost daily. In some cases, I had been aware that some situations were upsetting for me, but in other cases I was completely surprised when I realized I was being triggered. For example, I’d been aware for a long time that I had abandonment issues due to my mother leaving me all alone with our father. I hated to be alone, and I always reacted strongly when my Dad went somewhere for any period of time. But I had blocked out the memory of what it was like before my mother left me.

When I read “the sound of someone crying,” on the trigger list, I became really upset. I suddenly realized it had always been a trigger for me, and I understood why. I suddenly remembered my mother crying for hours, almost every night. I’d completely blocked that out. Suddenly I not only remembered her crying but the reason she was crying. I remembered hearing my father yelling at her, accusing her of being unfaithful, of being a horrible mother, telling her I would be better off without her. That simple realization and the memory of how often I am triggered by hearing someone cry made it all so clear. My mother left me because she believed what my father had told her. Suddenly it all made sense.

“For years I’ve been reenacting the fact that my mother abandoned me. I always chose men who ended up leaving me or I would push men away who loved me, out of fear that they would abandon me. I knew on some level that it had to do with my mother’s abandoning me. But even knowing that didn’t stop me from behaving the same way. I’d always questioned how my mother could have done such a horrible thing. And I always blamed myself in some way. I assumed that I wasn’t loveable—that my mother couldn’t love me because I was such a bad kid. I acted out a lot as a kid, missing school, getting into trouble at school, that kind of thing. I assumed she left to get away from me, away from all the trouble I was causing.

“But remembering my parents’ constant fighting, and the horrible accusations my father threw at my mother explained it all to me. I knew how it felt to have him throw out accusations like that—he did the same to me all the time. And I knew how hard it was not to believe what he said. I could see how my mother had taken it all in and had come to believe that in fact, I would be better off without her. It wasn’t my fault at all. And it some ways it wasn’t hers’ either. It was my Dad’s emotional abuse that caused her to leave.”

Often, as it was in Briana’s case, what triggers your clients the most could be pointing towards what needs healing. Flashbacks can be messengers reminding us of what happened to us. In that way they should be considered our friends. They help us become aware of memories and feelings we have buried. In Briana’s situation, her reenactments had been due to her mother’s abandonment but more specifically her need to understand why her mother had abandoned her. Once she remembered why her mother left her, she no longer blamed herself and no longer needed to punish herself. She no longer needed to reenact the trauma of abandonment.
***

Hopefully, the information and exercises offered in this article can assist you in helping your clients determine whether they were, indeed, traumatized as a child or adolescent due to the abuse, abandonment or neglect they experienced and why they may be reenacting that trauma.

References

(1) Miller, A. (1984). Thou Shalt Not Be Aware. Meridian.

(2) Freud, S. (1961). Beyond the Pleasure Principle. Norton.

(3) Herman, J.L. (1992). Trauma and Recovery. Basic Books.

(4) Freyd, J. (1998). Betrayal Trauma: The Logic of Forgetting Childhood Abuse. Harvard University Press.

(5) Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. W.W. Norton.

©2025, Psychotherapy.net

The Art of Effective Couples Therapy: Negotiation, Compromise, and Sacrifice

Posted on by Psychotherapy.net Team

As a therapist, the language I use can shape the way clients navigate their relationships as it provides a framework where thinking and behaving can take place. In couples therapy, my main goal is to help clients cultivate, commit, and execute on their shared vision. Over the past two decades, I have found that helping clients redefine negotiation, compromise, and sacrifice is essential for fostering healthier dynamics and building a sustainable strong foundation for the future of their relationship. These are terms that are often misunderstood yet widely used and profoundly impact the quality of their relationships.

Clarifying Expectations: A Foundational Practice

In casual, low-stakes situations, many individuals tend to effectively clarify expectations. For example, hiring someone to paint a house involves clear discussions about the scope, timeline, and payment. Yet in personal relationships, particularly romantic ones, expectations are often unspoken or assumed.

Couples often bring different goals, values, and assumptions into their shared lives, which can lead to misunderstandings unless explicitly addressed. When the vision for a relationship is not clear and agreed upon, it can leave room for mismatched priorities regarding resources, which could lead to further conflict in a relationship. For instance, one partner may dream of moving to a new city, while the other wants to stay near family. Similarly, one might desire children, while the other feels uncertain or uninterested. Financial priorities can also differ, with one valuing saving for the future, while the other emphasizes enjoying life in the present. On a more conceptual level, one might define privacy and secrecy very differently than the other person.

These principles, however, extend beyond romantic relationships and can help clients navigate workplace relationships, friendships, and family connections. Making these distinctions is critical. Specifically, when working with singles or couples to carve out their shared vision, understanding these concepts is essential to fostering healthy dynamics and avoiding long-term resentment. Addressing these needs, visions and expectations thoughtfully is crucial, as they directly influence resource allocation and life priorities.

Negotiation: A Daily Practice

Negotiations are what we do daily to navigate life when we are partnering with someone (where to go for dinner, who picks up the kids, etc.). Usually the stakes are not as high depending on the sensitivities within a coupledom, and some couples might not even call it that. When I bring up the word negotiation, depending on the cultural context of the clients, they might be surprised and sometimes even offended thinking: this is not the language we use in loving relationships, and it is best to be left to the business world where transactions happen.

The way I expand on the concept of negotiation and help clients to come around, is to explain that, in any relationship, there are certain currencies involved (again, going back to the language we use, many people think that currency is only applicable to monetary entities). Based on social exchange theory, we are all looking for an exchange of some sort when we are interacting with the outside world. This might not be conscious or intentional; nonetheless, it is always present.

Therapeutic Insight: Negotiation provides clients with a sense of agency, it helps individuals learn how to take accountability over what they desire in life, show up for it, and articulate it with their partner. Otherwise, we all have seen cases that one went along with the other only to find out somewhere along the way that “this is not what I wanted,” while the other person didn’t have a clue. As a therapist, I can coach clients to approach these conversations as opportunities for collaboration, encouraging them to listen deeply, receive what is offered, and then formulate their responses in a thoughtful and authentic manner.

Compromise: Balancing Individual and Shared Needs

Compromise often involves ensuring both partners feel their needs are valued. This step helps partners identify areas of alignment and divergence, usually without resorting to defensiveness or rigidity. It requires mutual give-and-take and intentionality to avoid one-sided concessions. It is not always meeting in the middle as it is believed to be, because healthy relationships are not based on equality or 50/50 as many of us working with couples would agree. They are based on equity where everyone involved is satisfied in their own ways.

Therapeutic Insight: It’s crucial to remind clients that compromise doesn’t always mean equality in the moment—it’s about creating equity over time. I encourage them to assess whether the “currencies” being exchanged feel worthwhile and sustainable.

Sacrifice: When It Becomes Unhealthy

Sacrifice often involves one partner giving up something significant, which can lead to resentment if done without open communication or equitable acknowledgment. For instance, one relocates for her partner’s job, leaving behind her career and community while not having a chance to assess her own needs in short and long term and without continued communication as things evolve with this move. Without mutual appreciation and a plan to address her needs, resentment may develop, impacting the relationship’s health.

Therapeutic Insight: Help clients reflect on whether a potential sacrifice aligns with their values and long-term goals. Sacrifice should be a conscious, collaborative decision rather than an expectation.

Cultural Context and Relational Dynamics

When I’m talking about relational dynamics, I am also talking about what defines them for individuals and couples. Cultural, religious, and gendered expectations often influence how clients perceive negotiation, compromise, and sacrifice. For one couple, sacrifice might be the way to go (and might even be expected of a good wife) and for another, it might just be a figure of speech while in reality the description of the dynamic resembles a negotiation pattern for the therapist.

I have found that exploring these factors is essential to helping clients identify patterns that may unconsciously shape their behavior. Meet them where they are and empower clients to define their relational values and vision, rather than defaulting to inherited scripts.

Some Practical Applications for Psychotherapy

These are some practical ways I have incorporated the above strategies into my clinical work with couples:

With singles, I encourage clients to clarify their non-negotiables and flexible areas before entering relationships. This self-awareness equips them to negotiate and compromise effectively when building connections.

With couples, I guide each to regularly revisit their shared vision—perhaps at the start of a new year or on anniversaries. This practice ensures their goals evolve alongside their individual and collective growth.

In the broader context, I try to apply these principles to familial and professional relationships, helping clients navigate complex dynamics with greater intentionality and respect.

Case Application

Rory and their kids loved skiing, while Hunter despised it—not just the sport but the cold and all the logistics involved. Before they had kids, this wasn’t an issue. They simply did their own things in winter, and no one thought much of it. However, once their kids reached skiing age, the dynamic shifted. Rory planned to spend every winter weekend skiing with the kids, and Hunter realized what this would mean for him.

In the first year of ski school, Hunter found himself waking up at six in the morning to help pack lunches, wrangle the kids’ gear, and drive 80 miles to the mountain. Rory and the kids thrived on this, but Hunter was miserable. He felt he had no options: staying home without a car wasn’t fulfilling, and joining in was even worse. To Hunter, it all felt like an unwelcome sacrifice.

Entering the second year, Hunter and Rory recognized that their dynamic wasn’t sustainable. They began to negotiate in earnest. Rory explained her perspective:

I grew up skiing; it’s my passion. It’s really important to me to pass that on to the kids because they love it too. I hardly get to see them during the week, and bonding with them over skiing feels really meaningful. I don’t want to give this up, but I also don’t like feeling guilty all the time. I know this isn’t working for you. Is there a way we can make this work for both of us?

Hunter shared his struggles and feelings of resentment, and through multiple conversations and creative problem-solving, they found a solution that worked for both of them. Rory took over 90% of the labor involved in ski school, including handling all the gear and logistics. Hunter agreed to pack lunches and have dinner ready when they returned. Rory bought a second car, so Hunter had options on weekends. Hunter decided he would join them for a few ski trips each season for family bonding, but otherwise enjoyed rare, unstructured time to himself—a precious commodity as a stay-at-home dad.

This arrangement worked beautifully. Rory was able to share her love of skiing with the kids, which was incredibly meaningful to her, while Hunter gained much-needed personal time and no longer felt trapped in a situation he despised. Hunter and Rory’s story illustrates how healthy compromises work; neither partner “won” nor “lost.” Instead, they both gave a little and got a little. Through negotiation and compromise, they reached a solution that felt equitable and allowed them to move forward with confidence and mutual respect.

***

Negotiation, compromise, and sacrifice are integral to shaping a life together. By teaching clients to differentiate these concepts, I hope to empower them to engage in relationships as active participants rather than passive followers. Healthy relationships require adaptability, mutual respect, and clear communication. Whether clients are building a life with a partner, strengthening family bonds, or deciding on a career path, these tools equip them to foster meaningful, sustainable connections. As a therapist, my role is to guide clients in creating these shared visions with intention, ensuring their relational choices align with their values and aspirations.

Questions for Thought and Discussion

  • How does the author’s work resonate with your own couples therapy?
  • Which of the three elements of change do you use in your clinical work with couples?
  • What additional or different interventions do you use with couples?
  • How would you have worked differently with Hunter and Rory?

Healing the Wounds of Trauma through Play

Posted on by Psychotherapy.net Team

At the time of the disclosure described below, four-year-old Sam, was living with his maternal grandparents. His mother, who had a lengthy history of alcohol and drug problems, was living elsewhere with her boyfriend, and would come to the grandparent’s home to change her clothes and visit briefly with Sam. When the child made his disclosure to his grandmother, she shared it with the family therapist, who then reported it to the Division of Family and Children Services (DCFS). Upon their investigation, Sam’s grandparents became his foster parents. Sam was seen once by a DCFS-referred clinician who reportedly utilized physical restraint, compelling the grandparents to discontinue services. The family therapist referred Sam to me for play therapy. That therapeutic work is described in the following narrative.

A Story of Abuse

Sam and I were playing with his ocean animal rescue toys in our playroom. I had just prepared some snacks and drinks for us. Sam asked me if I wanted to smell his butt. I said, “no!” He said, “I put my finger in my butt, and I smell the stinky,” and laughed. I jokingly told him he would have to wash his hand because of germs and how they could make him sick. Sam said, “I stuck my head in the potty, Daddy told me to do it.” I asked him to show me, so he went to the potty, lifted the lid and put his head down into it. I asked why he did that, and he said, “Daddy told me to and put his hand in my butt. I asked, “Why did Daddy do that,” to which he responded, “I don’t know why Daddy put a toy in my butt.” I asked what toy it was, and he said it was his Daddy’s toy. I asked Sam what it looked like, and he said, “It was a dinosaur, a brown one.” I told Sam if that was true it wasn’t nice, and Daddy should not do that. Sam quickly responded with, “I’m teasing.”

We sat together in silence while I tried to process the information. Then Sam said, “It’s the truth. Nana and I didn’t like it.” I said, “I bet you didn’t. I wouldn’t like that either and it is not OK. If anyone did that to me, I would tell them no and then tell Papa so he could help keep me safe.” I hugged him and told him I was sorry this had happened to him, and it was not OK. He continued to play, and I joined him. After a while I went into the bathroom to cry and gather my emotions.

After Sam’s Papa (his grandfather) got home from work, I told him what Sam said in private, and suggested we did not overreact and just hear what he had to say. I asked Sam if he wanted to share with Papa what he told me about the potty. Sam told Papa, “Daddy put my head in the potty.” Papa said, “Well that is not nice.” Sam said, “Daddy put a dinosaur in my butt.” Again, Papa said, “That’s not nice either, Daddy should not do that.” Sam said, “I didn’t like it!” and I cried hard.” With outstretched arms, Papa told him to come to him, and Sam ran over. Papa cried with Sam, hugging him, and I joined them for a group hug. We all cried. We told Sam he was safe now and it was good that he told us so we could make sure this never happened again. Papa repeated what I said, and Sam leaned out of the hug looking at our faces, cried and hugged us both.

Creating a Safe Environment

Appointments were mostly held on Saturdays or Sundays when no other children were present to reduce the “clinical” feeling and to differentiate the building and the playroom from the previous treatment facility. Following each appointment, the family transitioned to a more spontaneous, non-therapeutic activity to put closure to the session. Having an awareness of what would happen after an appointment helped Sam know there was an end to playtime.

In my clinical experience children processing trauma must process their story (I call it The Twist) from all three perspectives: victim, aggressor, and hero/rescuer. Sam was no exception, and his therapy began in earnest.

My initial appointments with Sam, who was accompanied by his grandmother, focused on establishing the playroom as a safe and fun place, and letting him experience the personal power of coming and going. I never separated grandmother and grandchild, always including her from day one.  

Sam, his Nana, and I often began in the sand tray room. He would chase us around the room with the smelly ghost in his hand. Over several sessions Scooby-Do and his cast of characters joined the smelly ghost. The smelly ghost (held by Sam) was joined by a witch (held by Nana). The witch would fly around the room and scoop up Little Scooby (Sam) who could not cry for help. (How symbolically perfect to represent a nonverbal child at the time of the trauma.)

Nana and I would model alternative responses for Little Scooby: fight, scream, hit, call for help. She, along with a designated good witch, would take the bad witch to rescue Little Scooby. Sam would laugh hysterically and repeat the story as we continued to model different outcomes. One day, the smelly ghost took Little Scooby and flew out of the playroom down the hall into another playroom. Nana and I took our figures and followed! Sam had made the leap from symbolic to experiential!

Sam entered preschool that Fall, and his Nana was providing added support by driving him to and from school. One evening I received a frantic phone call from Nana stating, “Sam’s going backwards!” She added that she had volunteered to help on the school playground daily and on the first day, when it was time for her to leave and for the kids to go into the classroom, Sam ran to her wanting to leave with her saying, “Don’t leave me here Nana, I want to stay with you.” The teacher came and tried to grab Sam’s hand. Sam hid behind me. She tried again and Sam ran from the playground across the field toward the road. The teacher ran after him, and Nana yelled for her to stop, saying, “You are scaring him!” She stopped and I walked towards Sam telling him, “Come to Nana, I am not leaving.” He stopped running. When Sam finally calmed down, all three entered the classroom together. Nana remained in the back of the class until he was OK with her leaving.

When she finished her story, I said. “What more could you ask for? He did everything we have modeled in the sand tray for the past several weeks. He protected himself. He fought. He ran. He cried for help, and you rescued him!”

Taking it Home

Through his transference to his grandmother at home, Sam worked through incidents where his mother had failed to protect or had injured him. As Sam and Nana were building a snowman in the yard, for example, Nana went to brush the snow from his face. Sam flinched and withdrew.

After he flinched, she asked, “Did that scare you?” He nodded yes. “I’m sorry baby, I was just wiping the snow from your face. I didn’t mean to scare you.” He hugged her. Nana told Sam she loved him; he said, “Love you” and went back to building the snowman.

Sam recalled an incident at the kitchen table where his mother hit him on the mouth and drew blood. Nana was present but unable to intervene. Nana responded, “I’m sorry that happened to you Sam. Nana and Papa will not let anything like that happen to you again.”

After an extended visit with his paternal grandparents, getting Sam to sleep was a continual struggle. One evening, Sam became verbally and physically resistant to going to bed. He lost touch with reality and began physically attacking his grandparents. His grandparents placed themselves in a “safe” room. When Sam attempted to enter and could not, they reinforced the need to be safe. This broke the trance state and Sam began crying. His grandparents were able to provide him with comfort and safety. A powerful healing moment of play that would not have occurred in the playroom.

The Playroom

Sam’s most intensive work was done within the safety of the playroom. In role play with Sam and his grandmother, he worked on resolving the issues with his mother. He and his Nana had captured a bad person (me) and placed them in jail. Sam, sword in hand, was guarding the prisoner. Periodically, he would reach into the cell and poke the prisoner with the sword. Sam wearied and handed the sword to his Nana. While he rested, he would signal her to poke the prisoner. Nana asked him why when the prisoner was not doing anything and he responded, “Because you are my very best friend.”

The emotional level of the play suggested it was time to address the trauma he experienced with his father and have his grandfather join the play.

The play themes evolved from the sand tray to a psychodrama where we changed back and forth between witches, vampires, ghosts, werewolves, and zombies on command. Papa when directed would die and did so many times. Sam would play and replay a scene where the vampire would come out at night to bite him. It was gut wrenching to watch this little boy, eyes shut making mouth movements like an infant with no teeth to protect himself in his fight.  

It was intense and physically exhausting as four-year-olds with imaginative powers can be. Because vampire’s sleep by day, we would use the light switch to symbolize day and night to break the trance and regulate his high arousal level. Sam incorporated the light switch into the play quickly and was soon regulating his arousal level by himself.

In his final reenactment, our little vampire was in a sleeping state via light switch. His grandfather had carried him back to the therapy room and laid him on a cushion of pillows. Sam, pretending to sleep, had been lying peacefully and safely in his grandfather’s arms, a smile on his face. Sam jumped up from this peaceful state, grabbed his bottom with both hands and began to shout “A vampire bit my butt. A vampire bit my butt!” In the play the grandparents slew the vampire, and in the present, they reassured him they would protect him and keep him safe.   

Cops and Robbers/From Victim to Hero

In a later phase of our work, therapy took a new direction when Sam and Papa (the good guys), weapons in hand together went looking for the bad guys, (Nana and I). The bad guys were caught and jailed for lengthy periods of time while the good guys did their thing. We would be released to steal things so the good guys could catch us, return what was lost, and put the bad guys away.

Sam’s psychodrama shifted a final time when he incorporated his Nana, Papa, and I into his force of personal power.

When Sam’s play dropped in intensity to a symbolic level, and the family became busy with other things in the community, appointments decreased in frequency. The grandparents had knowledge and understanding of trauma triggers and how they manifested. They had demonstrated many times over the ability to handle traumatic reactions. The treatment ended by mutual agreement.

***

Since this writing, Sam has been legally adopted by his grandparents. He is secure in his attachments to them and surrounded with love, safety, and understanding when trauma triggers activate him. Sam is loving and caring for people and animals, which are his passion. He occasionally has anxiety but has learned that handwork, artwork, playing with figurines, board games, and card games calm him and bring him joy. He talks about his feelings freely and handles feeling overwhelmed by separating himself from whatever it is or requesting quiet time as needed.

We knew immediately after one session with play therapy this was the right treatment for Sam. We are grateful we found the right kind of therapy with Play therapy!

Jessica Kitchens on the Clinical Needs of Autistic Adults

Posted on by Psychotherapy.net Team
Lawrence Rubin: I’m here today with Jessica Kitchens, who describes herself as a conscious, inclusive, Indigenous and artistic leader dedicated to enhancing the lives of others through collaborative efforts. She also describes herself as Autistic, Indigenous, wife, mother of five, CEO, therapist, consultant, author, trainer, board certified cognitive specialist, addiction specialist and neuro diversity advocate. And of course, she is a clinician. Hi Jessica, thanks for joining me.
Jessica Kitchens: Glad to be here, Lawrence.

By Any Other Name-Late Identified Autism

LR: Let’s begin with terms. What is a late identified Autistic?
JK: Late identified Autistics are individuals that have been Autistic their whole lives but may not have been recognized as such because they have developed high masking capabilities. They decided that it was better for them to adapt certain behavioral patterns in order to fit in. It is something they have come to do automatically. They don’t know why; they just knew that they needed to. Later on in life, they recognized that this method of fitting into social norms, while self-protective, also came with a high cost. They begin to struggle as the demands of adulthood kick in, so to speak. Sometimes, they become aware of the burden of masking their own struggles when their child is diagnosed.
LR: late identified Autistics are individuals that have been Autistic their whole lives but may not have been recognized as such because they have developed high masking capabilitiesThe ability to recognize and then mask difficulties seems to be an advanced coping skill, but a very demanding, and perhaps tiring one. Do they reach a tipping or breaking point?
JK: Absolutely! There’s a lot of wear and tear that goes into high masking because of the psychological and emotional energy expenditure. Many of these individuals cope with masking by abusing substances or through process/behavioral addictions like gambling, shopping, and gaming, to name a few. That’s sometimes why they end up coming to see me, unless they are referred by family members or their employers or school personnel suggest it. But others simply burn out or shut down.
LR: I imagine they may also present with anxiety, depression, and/or substance abuse. But I can also see a therapist missing the Autism if they either don’t look for it or are not trained to look for or assess it.
JK: Absolutely. There are a lot of misdiagnosed individuals out there walking around with a higher proportion of them being female, but there are high masking males out there as well. These individuals may be diagnosed with bipolar disorder because the dysregulation can come out sometimes as mania, or they present symptoms of borderline personality disorder. I was personally misdiagnosed with generalized anxiety disorder.
LR: these individuals may be diagnosed with bipolar disorder because the dysregulation can come out sometimes as mania, or they present symptoms of borderline personality disorder
What are some of the reasons that a clinician, especially one that is non-Autistic, might miss the Autism diagnosis?
JK: Unfortunately, this is a common problem. We have a lot of professionals out there that are really good at what they do, but they have not had adequate or up-to-date training on what Autism now looks like, because they’re still looking at very old stereotypes. It wasn’t even in the DSM until 1980, and even then, they still had a very distorted view of what it was.It’s only now that Autistic researchers are coming out and talking about their own lived experience and we’re finally changing what the diagnosis looks like because there’s a lot of what I would call iceberg Autistics out there. They’ve masked for so long and kept a lot of this stuff underneath. Therefore, a lot of clinicians are over-relying on stereotypes and media representations of lower functioning, higher support needed individuals like Rain Man. They miss the diagnosis of Autism when they see someone like me, thinking something like, “you don’t you don’t look like my cousin who has Autism. So unfortunately, there are a lot of clinicians out there that are doing some harm because they do not have up-to-date training.
LR: there are a lot of clinicians out there that are doing some harm because they do not have up-to-date trainingSo up to date training would tell clinicians that Autism is far more, or far different than being able to count 496 matches on the floor, stimming, self-harming, or having real difficulties making eye contact, to name some of the more familiar symptom clusters. What are the new generation of trained clinicians looking for?
JK: A lot of times, these clients come in because of dysregulation, even though they may not use the term. They may find themselves easily dysregulated in their work environment or in their home environment. They may actually have a visceral, nervous system response to sounds and lights. And since Autism is a dynamic disability, they may struggle in their relationships because of difficulties with pragmatic communication. On a given day, these folks, me included, may have difficulty finding the simplest of words to use. When a clinician is trained to look for these subtleties, they are in a better position to ask the right questions.
LR: Are there benefits of first being diagnosed in adulthood?
JK: That’s a good question and one that a lot of them must decide for themselves. A formal diagnosis in certain settings, like school or work, can help them get accommodations, such as adaptations to the sensory environments, that can put them on par to where they can now be equal and function at a baseline level with some of their neurotypical peers. Sometimes they can get them without a formal diagnosis, but some work environments are exceedingly difficult in allowing that. And sadly, we still have a lot of ableism in work environments.For others not necessarily pursuing accommodations, formal diagnosis can empower them to re-consider their dysregulation, learn coping mechanisms such as mindfulness, and review their life in a way that now makes sense to them.
LR: sadly, we still have a lot of ableism in work environmentsWouldn’t we the want the newly diagnosed adult to be referred to a clinician who knows how to help this particular client?
JK: Absolutely, but unfortunately, there are clinicians out there that can do more harm than good if they don’t have the right knowledge to work with these clients. I’m very picky about who I work with because there’s a lot of nuances that go with the neurodiversity affirming framework, such as learning about the nervous system functioning of an Autistic adult.
LR: Have you seen any downsides to a person being diagnosed in adulthood with Autism?
JK: Within work environments, there are instances of ableism among managers or supervisors who work against accommodations. The problem can be institutional.
LR: So just as there are institutional racism and institutional homophobia, there is also institutional ableism?
JK: It’s heavy and it’s ingrained in all aspects of our culture. One of the things that I’m working on in my PhD research is decolonizing ableism by utilizing and looking at indigenous perspectives of Autism through my own and other tribes. I’m trying to view it through an indigenous and a decolonizing framework, because the Western medicine is entrenched with a lot of deficit-oriented stereotypes. It’s everywhere. It’s in our schools, it’s in our work, it’s in medical institutions. We do have capabilities. We want people to recognize that we are autonomous persons, and just because we struggle with certain skills, there are many things that we are still capable of, and many Autistic adults are quite gifted in many ways.
LR: How has being a late diagnosed Autistic influenced your professional trajectory and shaped who you are in the therapy room with clients?
JK: It’s changed everything. I was formally diagnosed a few years ago, but it was my youngest daughter of my five that was diagnosed before any of us, and now my youngest three are all formally diagnosed with ADHD and Autism. It’s one of those things that’s literally changed every facet of my life. Every conversation that I have with people is entrenched in this.The ways I review my childhood and how I view my future are now entrenched with this view which has also affected my research and PhD journey. I don’t ever see it going back. I’ve had to grieve a lot of my life, but there is no me without Autism because this is who I am. It explains so much. It explains all the things that I’ve probably struggled with my whole life.

Neurodiversity Affirming Intervention

LR: In the case of an Autistic adult, what is neurodiversity affirming intervention?
JK: A person-centered orientation seems to be the best for most of these clients. But knowledge and the understanding of certain Autism experiences like pathological demand avoidance or rejection sensitive dysphoria, goes a long way. So does using correct terms such as identity first language—using the word ‘Autistic,’ rather than ‘a person with Autism.’
LR:a person-centered orientation seems to be the best for most of these clientsWhat do you mean by saying that a person-centered approach is best?
JK: Meeting them where they’re at – a lot of times clinicians have this view that they need to fix people. That’s not what it is. You know? It’s more about matching that congruence and recognizing that you we are capable of so much beyond the narrow limits of what the diagnosis suggests. It’s about recognizing what skills can actually help us be the best that we can be as a person, whatever that looks like. Whether it’s mindfulness, EMDR, or CBT. It’s about grabbing from modalities of all types. Everybody’s different.It’s not about coming from a place of judgment. I don’t want to push my views on my client of what I think they need to be working on. I want them to have an idea of areas they want to grow in and using whatever tools and skills I have to help them get there.
LR: there is this misconception that people are being overly diagnosed, that we’re handing it out like candyAre there myths and misconceptions that clinicians bring into this work that hinders intervention?
JK: There is this misconception that people are being overly diagnosed, that we’re handing it out like candy. Clinicians who believe this go in with automatic blinders. In reality, Autism goes back generations in families, so a new diagnosis should not be that surprising or unlikely. And because these adults are bringing their children in for diagnosis, it makes sense to either formally or informally assess and perhaps even help that parent. And while it’s not a myth or misconception per se, internalized ableism on the part of the client or clinician, or both, can hinder the intervention process.
LR: Have you encountered resistance from some clients who are on the doorstep of the diagnosis?
JK: The only resistance that I’ve noted has not come from the clients themselves. It has been from their families because a lot of them take it as an affront to who they are or believe in some way that they caused it. And so again, that goes back to some internalized ableism. Sometimes, these clients come to me already knowing about the possibility. A lot of them actually did. Sometimes, it comes to them after I’ve planted seeds.
LR: the undiagnosed or unaware Autistic clinician is going to miss it in their clients if they’ve missed it in themselvesIs an undiagnosed Autistic therapist a potential risk to either neurotypical or neurodiverse clients? Or is the therapy potentially limited by a clinician who is unaware of – or resistant to – acknowledging their Autism?
JK: The undiagnosed or unaware Autistic clinician is going to miss it in their clients if they’ve missed it in themselves. I’ve been there too. I have to look back and reckon with the fact that there are some clients with whom I’ve missed important aspects of their experience because I wasn’t thinking about the possibility of Autism.

Transitions and Unique Challenges for the Autistic Adult

LR: We know that stress increases as life demands accelerate, so are older teens and young who have not yet been diagnosed at a greater risk?
JK:  It’s interesting that you ask that question because I was a co-researcher on a Delphi study on what independent living looks like to Autistic adults. And as far as moving out on their own or going to college or working, many of these young people start struggling all of a sudden, or at least far more than they had previously.They did well at home and well in school because there was a lot of structure and stability. But now all of the sudden they’re required to function on a higher level. Logistics are a different monster altogether such as paying bills and adapting to new, and complex sensory and demand environments.
LR: Is the diagnostic threshold different for teens than it is for adults?
JK: I would expect the clinician to be able to identify high masking, and to use multiple sources in the assessment of younger clients who may not be able to report fully. I think it’s often harder to diagnose a child because they can’t speak for themselves. If the clinician uses appropriate measures and asks the right questions, it can actually be easier because they can ask about the internal processes, not just your behaviors and what you do and what others see, but what the internal processes are.
LR: Can you think of a few assessment instruments off the top of your head?
JK: The Social Responsiveness Scale is one that was done on me. I felt like, man, that asked a lot of the right questions, and there was also a Sensory Profile that really nailed it, at least for me.
LR: many people on the spectrum actually have higher than average affective empathyWhat are some of the relationship and family issues that Autistic adult clients bring to you?
JK: There is an interesting challenge for Autistic adults called the double empathy problem. One of the stereotypes is that these people lack empathy, which is the furthest thing from the truth. Many people on the spectrum actually have higher than average affective empathy. The disconnect comes from alexithymia, meaning they may not be able to label that feeling, but they can feel it. A lot of them do struggle with Theory of Mind (ToM), also known as cognitive empathy. That’s the problem with necessarily putting yourself in the shoes of the individual and understanding their perspective.So, you might have two individuals with high affective empathy, but differences in their cognitive empathy. The double empathy problem manifests in, one or the other member of the couple or family member, not feeling understood. They might butt heads, which then leads to a lack of reciprocity. That’s one of those nuances that a non-neurodiversity affirming therapist might miss.
LR: What might be some of the challenges to Autistic parents?
JK: Parents also struggle with the double empathy problem. Some of the biggest communication struggles I had with my teen children were whenever we were coming from different places of reciprocity or understanding each other’s perspectives.
LR: What is internalized ableism?
JK: As a parent, it could be expecting an Autistic child to do something a non-Autistic child can do or expecting a partner to somehow be or act normally, without respecting their diversity and difficulties. That child or adult then internalizes that prejudice and may struggle unnecessarily, beating themselves up, instead of accepting certain limitations and learning effective coping skills.
LR: You identify as indigenous, and work with indigenous clients? Does Autism manifest differently among indigenous people?
JK: Absolutely. Here in Arkansas, I don’t have as many clients as I would if I was back in Oklahoma 20 years ago, which is where my tribe is, the Potawatomi. And we know the Māori in New Zealand have a word for Autism called Takiwãtanga, which means in your own time and place. They have a more positive frame of mind for Autistics.
LR: many Autistics have high affective empathy, and deep sense of justiceWe tend to pathologize differences, but I am now wondering about some of the unique skills and advantages associated with Autism, perhaps that a clinician could capitalize on.
JK: I feel like it’s different for everybody, but many Autistics have high affective empathy, and deep sense of justice. A lot of us are really hard-core advocates in general because of our empathy. It tears us up whenever somebody is being mistreated. Other than that, the noting of patterns. For me, it’s behavioral patterns. I was able to learn behavioral patterns early on to mask my differences, but it can also help me to note incongruences with my clients. We can also be quite analytic. Clearly, we have many broad capabilities, so stereotypes often simply fall short.
LR: Finally, what are some resources and organizations that clinicians can use to improve their identification and intervention skills?
JK: If you’re going to work with Autistics, you need to know about pathological demand avoidance, also known as persistent drive for autonomy, which is PPDA. PPDA North America is a useful resource for this, but there’s also NeuroClastic, which I believe is a 501 C3. They work the business side; working with businesses and hiring Autistic individuals and they do a lot of good. There’s also the Autistic Self-Advocacy Network.
LR: Is there anything I failed to mention, Jessica, or questions I could have asked?
JK: There are so many nuances to appreciate about this population, and it is so much more than reading the DSM when you work with these clients. You’re going to learn the most from individuals with lived experience and those who have entrenched themselves into Autistic research.
LR: On that note, Jessica, thank you so very much for your expertise and sharing your valuable time.
JK: No problem. I really appreciate it.

Teaching Clients Active Listening Skills to Improve their Relationships

Posted on by Psychotherapy.net Team

One of the most common questions I am asked when people learn that I am a therapist is, “How can you listen to all those people?” What prompts that question is a fundamental misunderstanding of what it actually means to listen to another person. In my work, I strive to make my patients better listeners, not just better at self-expression.

It is imperative that we challenge the assumptions people make about what it means to listen. Truly listening to another person so that they feel heard improves the quality of conversation and enhances the opportunity for understanding. It does not guarantee agreement, nor does it necessarily entail problem solving or changing anyone’s mind. Unfortunately, it seems that these days, people are far more interested in talking than listening, even if no one is listening to them.

As one patient said to me, “Once we stopped caring about facts, I was at a loss about what to say. Why bother to listen if the loudest person in the room always wins?” This can lead to what feels like a forced choice between joining the argument or leaving the conversation. Given the cacophony of disinformation and vitriol infecting our lives, strong listening skills are more critical than ever if we want to strengthen our connections.

It takes effort to be a good listener, but with practice the results can be truly life changing. Learning how is a teachable skill and foundational to good mental and physical health. There are five foundational components of active listening.

Five Foundational Components of Active Listening

First, an active listener must have a genuine interest in the other person, a curiosity to hear what they have to say. Too often we think we know what the other person will say before they speak, so we spend our time preparing our comeback rather than listening to what the speaker says. Or we write people off as soon as we learn one thing we don’t like about them, and refuse to listen to anything else they have to say. Consequently, our world gets smaller, and we have less intimacy.

Feeling trapped in this dynamic is a common complaint about familial interactions. For example, one patient shared, “Before I’ve even taken off my coat, my father will tell me that I must be so happy with my job. It’s because he is happy that I went into law like him. I brace myself before I get there for his greeting.” After many failed attempts to have a more nuanced conversation, she no longer tries to dissuade him of his belief but is saddened by how superficial their relationship has become.

Second, active listeners understand that agreeing to listen does not assure agreement. This needs to be recognized by both the speaker and the listener. If my goal as a speaker is agreement, I must make that clear up front. When a patient tells me about a fight they had with their spouse, I use my words to express understanding of their hurt feelings, not to say they were right and their spouse was wrong. Whenever we frame a conversation as having a winner and a loser, the quality of the relationship suffers.

Third, active listening is actually hearing what the speaker has to say and trying to understand their needs. Too often people attempt to show they are listening by trying to solve a problem. This often feels patronizing and may devolve into an argument. For example, a patient of mine reports, “When I come home from a bad day at work, all I want is for my wife to listen, not tell me what I could do differently. Tomorrow, when I am rested and have some distance from the situation, I might be ready to listen to suggestions for how to do things differently, but at that moment I just want understanding. Is that too much to ask?”

One strategy that can be helpful in these situations is for the listener to ask, “Do you want to be hugged, heard, or helped?” By clarifying the unstated need of the speaker, the listener knows the desired outcome for the interaction and what will feel like effective listening to the speaker.

Fourth, active listening involves acknowledging feelings as well as facts, without conflating the two. There is a truism in psychology that anxious people can’t listen, to which I might add, neither can enraged people. Communicating that I understand the depth of a person’s emotional state is a necessary precursor to understanding what has upset them so much.

Recently, a patient called to share that she’d been diagnosed with breast cancer. Before I asked her the stage of her cancer or what her treatment protocol would be, we discussed how she felt hearing that she has cancer. Asking about her feelings was essential to providing care for her. Later we would brainstorm how she could get the best medical care possible, but until she felt heard she couldn’t process the onslaught of medical information her physicians were sharing with her.

Finally, active listening requires listening to ourselves as well as others. By setting a time limit or voicing discomfort if someone is using offensive language or yelling, allows us to take care of ourselves as listeners and increases the likelihood we will be willing and able to engage in active listening. When being a better listener, we will hopefully find ourselves in more meaningful conversations that will enrich our lives.

***

Active listening can make us feel vulnerable. Sometimes the divide is too great and ending the conversation or ultimately the relationship is the right decision. But, hopefully, more often our efforts to listen will increase our understanding of one another and bring us closer. In our fragile world we need to honor the power of listening.

Questions for Thought and Discussion

How important is it for you to “teach” your clients to listen effectively?

Which of the author’s five components of active listening is most resonant with you?

Can you think of one of your clients who would benefit from improved active listening skills?

Becoming an Accidental DBT Therapist

Posted on by Psychotherapy.net Team

A Curious Professional Journey

I did not set out to become a therapist who utilized Dialectical Behavior Therapy (DBT). When I was in graduate school, I had hoped to become a therapist who worked mainly with married couples and families, which is where I put much of the focus of my training. I had taken a class that referenced DBT and had also heard what a nightmare clients with borderline personality disorder (BPD) were to work with. But since that was never going to be me (ha!), what did I have to worry about?

Turns out, quite a bit.

For my predoctoral internship I was matched with a clinic that specialized in working with families going through oversea adoptions. Often families who had successful adoptions would later discover that the children had attachment disorder. While at this clinic, I worked with various licensed therapists and families in a variety of modalities, including: individual work, EMDR, support groups, skills groups for the children and developmental assessments.

Attachment disorder is difficult to treat and the burnout rate among therapists who do this important work is high. The clinicians I worked with, and under, were passionate and gifted. I still bear a scar on my left arm from where a child who had become dysregulated bit me. In a conversation with my supervisor, he explained to me that many of these children with attachment disorder will grow up to be clients with BPD. This is not a population for the faint of heart, and while the success rate is not exactly through the roof, it was an important part of my development.

Fast forwarding to the end of my internship, I was out pounding the pavement, trying to find a job in the field without much success. A former classmate and friend of mine had recently interviewed for a job at a community mental health center. They were looking for an already-licensed therapist to train in DBT who was willing to work with BDP clients. My friend told me, “this job doesn’t pay for shit, so I’m taking a pass. Thought that you might be interested instead.” Funny right?

Despite the glowing recommendation from my friend, I applied. During the interview, the interviewer (correctly) noted my lack of experience with BPD. I remembered what my supervisor told me and responded that I had experience, I just worked with them earlier in the process when it was still seen as Attachment Disorder.

I never received feedback to know for certain if that’s what sealed the deal, but I had gotten the job. My friend had been right when he said it didn’t pay very much, but what it did offer me was training in DBT and that changed my life forever.

My Challenging Work with Sarah

For those not familiar with DBT, it is a skills-based modality with regularly assigned homework that incorporates concepts and practices drawn from mindfulness, Buddhism, Hegel, and basic methods of therapeutic validation. Many of these concepts are abstract, and often difficult for clients to fully grasp and embrace. It can be especially tough for those with developmental challenges typically associated with attachment and personality disorders.

For me to be able to explain them to these clients in ways that they could understand and implement in their daily lives, as well as during times of crisis, I really had to learn these concepts backwards and forwards, breaking each down to its essence.

One of my earliest clients, whom I shall call “Sarah,” was very hesitant to embrace these concepts. Partly, because they were difficult to understand, but Sarah had also been through a LOT of therapy before arriving at DBT. (DBT is rarely the first stop on a client’s therapy journey and as we say, “nobody gets to DBT by accident.”)

Therapy had yet to help her in any way she could appreciate. Her arms were covered in scars from many attempts at suicide and self-injury. Estranged from most of her family, she lived with her grandparents because no group home or assisted living facility wanted the liability risk. At the time, she proved unable to hold down a job of any kind. As such, Sarah’s world was small, and her human contact was limited to intermittent conversations with her grandparents, therapists, medical personnel, and DBT Group members during her frequent hospital stays.

During one session, we were talking about suicide and self-harm when Sarah stated that she was likely to die from suicide at some point, because what was the point of living if this was all there was to life? What would happen to her after her grandparents passed away? I replied that those were excellent questions. Her life as it was currently constructed was about survival and little more. Why would any therapist expect her to embrace such a life? For Sarah, being told that “things could always be worse,” was of little consolation. What was the point of staying alive when things could get worse?

One of DBT’s core concepts is referred to as “A Life Worth Living.” In essence, it asks the client what would have to change about their life so ideations like self-harm or trying to commit suicide would organically come off the table? Of course, we must survive before we can thrive, but what did thriving look like to Sarah?

Sarah said she wanted to be able to live on her own (or with occasional assistance that would come when needed), to have a job and her own money, and MAYBE (some pie in the sky stuff here) even have some friends! To her, that would be “A Life Worth Living.” I told her it was possible to have those things, but it is going to take work. DBT, like life, is like playing a sport. It requires clients to consider making choices that someone who could live on their own, hold down a job, and had friends would make. I challenged Sarah by asking, “are you making any of those choices right now?”

She reluctantly conceded that she was not. She could not fault her grandparents for not having faith she could live on her own; the paramedics were at their house at least once a month, if not weekly due to Sarah’s self-harm and suicide attempts. Her time in and out of the hospital and subsequent therapy appointments throughout the week, made it hard for her to hold a job.

I asked Sarah what she saw as the biggest obstacle to getting to her “Life Worth Living?”

“The cutting,” she said.

I agreed. If we could find other more skillful and adaptive ways to tolerate distress, the idea of her living on her own and being able to stay out of the hospital (and therefore able to work), seemed more plausible. That session was when Sarah committed to taking self-harm off the table.

This was no small commitment. Sarah used self-harm weekly for over ten years. Neither she nor I had any illusions that it would be easy for her. In a paradoxical way, self-injury had kept her alive as a coping skill on more than one occasion. She had a concept of how to resolve physical pain, while emotional pain seemed too overwhelming. In order for her to make this work, it was a matter of buying into DBT and its skills. Would the skills be as effective as a coping mechanism for her while keeping her safe? It was a leap of faith I was asking her to make – to put her trust in DBT and our therapeutic relationship. We were off.

Sarah’s Rocky Progress Forward

Gradually the ambulances stopped coming to Sarah’s grandparents’ house and while she never went to the hospital again, it was not a smooth, upward trajectory. There were setbacks, but one day without self-harm became a week which became a month, and then we were at her quarterly review. With her grandparents present, they attended many of Sarah’s appointments and reviews, Sarah proudly told them she had gone three months without hurting herself. She had been practicing her DBT skills (Distract, Self Soothe, Opposite to Emotion, Pros and Cons) and she had plans to share!

Sarah told them about wanting to live on her own and have a job. Her grandparents were pleased, surprised, and anxious all at the same time. These were big steps to take. While they praised Sarah for her efforts and progress it didn’t stop them from worrying. Sarah wasn’t derailed and instead offered to negotiate with them: if she could keep up this progress for nine more months and graduate from Stage 1 of DBT, would they support her? First in getting a job and second in finding a place to live?

As her therapist, I jumped in explaining that this seemed like a good Wise Mind (middle path between reason and emotions) compromise. Assuming she succeeded it would be a new experience with new kinds of stress and new opportunities for her to use her skills. If she could navigate holding down a job while using what she had been practicing, it would stand to reason she could do the same living on her own.

Her grandparents agreed to the plan – the smile it brought to Sarah’s face was one I hadn’t seen before. I wasn’t sure who was more excited at that moment, me or her! Being able to observe her having faith in herself and her future remains one of the most powerful experiences I have shared with a client. I did not know then what the future held, but I knew that DBT worked, and I could not turn my back on something that worked. From that moment on, I was a DBT therapist.

***

It’s been almost 25 years, throughout which I have worked with thousands of clients on achieving their “lives worth living.” I have seen clients who went from thinking about suicide almost every day to taking it completely off the table. Many were clients who now have healthy relationships and rewarding careers, just like Sarah. The work is challenging, and I am thankful for the support of a great team. The pride I take in seeing how hard these clients work on themselves is impossible to describe. They continue to make me a better therapist and I would not have it any other way.

Questions for Thought and Discussion

  • What serendipitous experiences have you had over the years that have opened interesting clinical doors for you?
  • In what ways are the core premises of Dialectical Behavior Therapy consistent with your orientation to therapy?
  • What are some of the limitations you have experienced or anticipate in the application of DBT principles and techniques?

Lessons in Tough Compassion and Male Resistance to Therapy

Posted on by Psychotherapy.net Team

As a counselor and educator, I often find myself reflecting on representations of therapy in popular culture. One film that has stayed with me over the years is Good Will Hunting. While the movie is celebrated for its exploration of genius, trauma, and relationships, what stands out most to me is the character of Sean Maguire, the therapist played by Robin Williams. Sean’s approach to therapy, particularly with a resistant male client like Will Hunting, is a masterclass in what I call “tough compassion.”

The Unsung Hero

Sean Maguire is a humble community college professor and clinician. He is a quick-witted, grounded therapist who connects with Will person-to-person. His approach is in sharp contrast to the two other high-profile therapists Will is forced to see, who never get on Will’s level. Sean is the kind of professional whose impact might never make headlines but is deeply felt by the individuals he helps. How the film represents Sean’s work really resonates with me as a counselor. While we may not gain the accolades of more visible professions, or write noteworthy, high impact therapy texts, get featured on TV shows, and so forth, our work of helping individuals confront their pain, realize their potential, and find healing—is no less meaningful.

Sean’s humility and commitment remind me why I chose this path in the first place. The scene where Sean and Will end their time together with a hug speaks volumes of the positive impact that Sean had on Will, that Will can’t even begin to articulate. And Sean knows it. The two men say so much without saying anything; the impact the relationship had on both men on such a deep level is clear. While this particular element of the movie inspires me, it is the way in which the movie demonstrated male resistance to therapy, and Sean’s tough but compassionate approach with Will that I love.

Male Resistance to Therapy

We can see in Will’s interactions with the other two therapists that he made outrageous comments and disingenuous intimate disclosure meant to derail the session and throw the counselor off his game. But with Sean, he is able to roll with the resistance (in a very Milleresque manner). He doesn’t get offended or distracted by the resistance, but continues to redirect with humor and direct questions back to Will (except for when Sean choked Will out on their first session, we’ll ignore that for now). This approach, over time, with some vulnerable disclosures from Sean about his life, losses, and relationships, eventually get through to Will.

Will starts opening up and letting Sean into his inner world. He begins to trust Sean. Will’s reluctance to engage with Sean reflects a broader societal issue, and one that I have often noticed in my practice: men struggle to open up about their emotions or seek help. Cultural expectations of toughness and self-reliance can make vulnerability feel like weakness. Sean understands this resistance, and rather than forcing Will to conform to a traditional therapeutic model, he meets Will where he is—both emotionally and relationally.

Tough Compassion in Action

Sean’s approach is what makes him so effective. He doesn’t back down when Will tests his boundaries. In their first session, Will mocks Sean’s deceased wife, pushing him to the edge. Rather than retaliate or shut down, in a manner of speaking, Sean asserts his boundaries with firmness (although I don’t endorse choking out your client). “You ever disrespect my wife again, I will end you,” he says. This moment is not about anger or dominance; it’s about authenticity. Ultimately, it is what earns Sean respect and credibility in Will’s eyes.

Sean’s tough compassion also shines in his willingness to challenge Will. He sees through Will’s intellectual defenses and calls him out on his fear of vulnerability. In another memorable scene, Sean tells Will, “you’re terrified of what you might say. Your move, chief.” This balance of empathy and accountability is a cornerstone of effective therapy, especially with male clients who may be guarded or skeptical of the process.

The Impact of Authentic Connection

The turning point in the film—and in Will’s therapy—comes when Sean shares his own vulnerabilities. By revealing his grief, regrets, and imperfections, Sean shows Will that strength and vulnerability can coexist. This authenticity creates a safe space for Will to confront his own pain and begin to heal. For me, this aspect of Sean’s character underscores the importance of being real with male clients. Therapy is not about having all the answers or maintaining a perfect façade. It’s about creating a relationship grounded in trust, respect, and genuine care—a relationship that can serve as a foundation for growth — and being willing to change up one’s approach to therapy with male clients, using a tough technique that’s counterbalanced by compassionate.

Lessons for Counselors

As I reflect on Good Will Hunting, I’m reminded of several key lessons for working with male clients:

  • Meet Clients Where They Are: Understand their resistance and adapt your approach accordingly. Resistance to therapy among males is not the end of the road, but a bump. So, roll with the resistance, and redirect back to the client with honesty, empathy, directness, and humor.
  • Balance Empathy and Accountability: Build trust through compassion while challenging clients to confront their fears and defenses.
  • Be Authentic: Share enough of yourself to foster connection without overshadowing the client’s journey.
  • Value the Quiet Impact: Recognize that our work, though often unseen, can change lives in profound ways.

Sean Maguire may not have had the fame of his academic peers, but his influence on Will Hunting’s life was transformative. As counselors, we may not always see the ripple effects of our work, but Good Will Hunting reminds us that our presence, compassion, and persistence can make all the difference.

Good Will Hunting is more than just a story about genius and redemption; it’s a testament to the power of connection in therapy. Sean Maguire’s approach—grounded in tough compassion and authenticity—offers a blueprint for counselors striving to make a meaningful impact, particularly with male clients. The film is a poignant reminder that while we may not always receive recognition, the relationships we build with our clients can be life changing.

If you’ve ever wondered about the quiet yet profound impact of counseling, Good Will Hunting is a must-watch, and if you’re a counselor, it’s a call to embrace authenticity, persistence, and the transformative power of tough compassion.

Questions for Thought and Discussion

  • In what ways do or don’t you connect with the therapeutic concept of “tough compassion?”
  • What movie featuring a therapist has inspired you, and why?
  • What emphasis do you place on connection in your therapeutic encounters, particularly with male clients?

When Clients Don’t Want to Talk about Their Feelings

Posted on by Psychotherapy.net Team

“My husband does these little things that get under my skin,” Naomi lamented as she sat across from me. “Like he chews his ice.” She scrunched up her freckled nose and clenched her fists. “I ask him not to. I ask him really nicely to please not chew his ice.” She shared some other things her husband did to annoy her. “Like, whenever I ask him a question, he’ll answer with a question. I’ll ask what he wants for dinner, and he’ll shrug and be like, ‘What do you want for dinner?’ I know I’m overreacting, but that makes me furious.”

Helping Clients to Put Feelings into Words is not Always Easy

“You feel furious,” I said. “I can’t stand that. I want to scream at him.” “What do you think it is about that question that makes you furious?” “I don’t care.” Her arms crossed; she was now tapping her foot against the carpet. “I don’t care why I feel like that. I just want to not feel like that. I want to stop being so pissed off at him.” This was not the first time Naomi and I had had this kind of impasse: me attempting to better understand her and her dismissing my attempt as a pointless intrusion. She wanted “tools” to change her feelings, specifically to help her feel less angry with her husband. “I get that you want tools to help you feel less upset,” I said, “and we can definitely talk about tools, but I think that in order to change your feelings, it’s important to first understand them.” “I don’t get that logic.” She straightened her posture. “No offense. I’m sure you help many people, but I’m not your typical client. I don’t want to sit here for 50 minutes whining about my problems. I don’t need a sounding board. I need tools to change my situation.” Over the weeks that followed, I obliged Naomi’s request to talk about tools, and we identified coping skills that had worked for her in other situations. All the while, I kept nudging her to further explore her feelings, my belief being that clients like Naomi ultimately benefit from developing greater emotional insight. Following one of my nudges, she indicated that her reluctance to talk about her feelings was based on her fear of becoming helpless. “I don’t want to turn into one of these whiners you see on TikTok. You know, these helpless women who can’t handle the slightest adversity and always complain about being victims.” “Well, goodness,” I said with playfulness, “I wouldn’t want to turn you into one of those women either.” She looked at me as I spoke these words, and we both laughed. This marked a turning point in our work together. I better understood her fear of becoming helpless, and she understood that that would never be my intention. Naomi started to more fully open up, and I began to sense that her anger over her husband was more complicated than she’d assumed. When she told me one afternoon how he had continued answering her questions with questions, I asked that standard therapist question: “How did that make you feel?” “Really pissed off,” she answered. “Beneath that feeling of being pissed off, what else did you feel?” “I don’t know.” She looked away and slowly shook her head. “I guess I felt like a monster.” “You felt like a monster?” I emphasized. “It’s like he’s afraid to disagree with me. I think he’s afraid that if he disagrees with me, I’m going to bite his head off. But I’m not like that. I’m really not so horrible.” “That must really hurt, to believe your husband thinks you’re this monster.” “It sucks.” Her energy had changed, her body now still, her head slumped forward. It now seemed clear that she had initially resisted exploring her feelings because what lay beneath her anger—what we would later describe as “shame”—was far more painful to accept than mere anger. The two of us sat in silence for several seconds. “I wonder if your husband knows that’s how you feel,” I finally said. “I don’t know. Probably not.” She looked up at me. “We should probably talk about it.” Naomi’s initial desire to learn new tools was not wholly misguided. Tools, or coping skills, are a necessary component of psychological health. However, coping skills often mitigate symptoms without bringing about lasting change. Sometimes simply adding more gasoline to a sputtering car doesn’t do the trick. Sometimes we need to look under the hood and figure out what’s going on. Naomi reported back the following week that she had had a heart-to-heart with her husband, the first such conversation they’d had in a long time. “We’re better. We’re not perfect. No relationship is perfect. But it’s good that we talked.” Questions for Thought and Discussion In what ways do you resonate with the author’s premise regarding feeling exploration? How do you work with clients who resist exploration of their feelings? In what ways might you have worked differently with a client like Naomi?