Category: Therapeutic Issue

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?

Bethany Brand on the Identification and Treatment of Dissociative Identity Disorder

Posted on by Psychotherapy.net Team

Lawrence Rubin: Bethany Brand is a professor of psychology at Towson University. She’s an expert in trauma, specializing in trauma related disorders, including post-traumatic stress disorder and dissociative disorders. She also maintains an independent practice in clinical psychology in Towson, Maryland. Doctor Brandt serves on international and national task forces developing guidelines for the assessment and treatment of trauma disorders. Welcome, Bethany. Thank you for joining.

Bethany Brand: Thank you so much for having me.

Right Place, Right Time

LR: What got you interested in dissociative disorders, trauma, and ultimately dissociative identity disorder from a personal perspective?

BB: It was a number of things. One of the early experiences I had as an undergraduate at the University of Michigan was working in a shelter for women who’d been battered, which is what it was called back then—not interpersonal violence like we call it now. I started hearing about trauma and remember being very interested in it. In my first semester of graduate school, I was doing a psychological testing practicum at Johns Hopkins Hospital on the kids’ unit. This was in the late 80s, so many of the kids had been abused or neglected according to their charts. I asked my supervisor how that experience might be reflected in their psych testing—how would they be different? And there we were at Hopkins, one of the premier institutions in our country, and she did not know.

To her credit, she acknowledged that and asked her supervisor, who later gave us this fascinating off-the-cuff talk about trauma and his experience with traumatized kids. It was so compelling that I decided that was what I wanted to do my master’s thesis on. I was lucky enough at the time that Frank Putnam, one of the legends in the field of dissociation, called my graduate program, asking for students who might be willing to volunteer on his project—a longitudinal study of girls who’d been sexually abused. I was incredibly lucky to be at that right place at the right time, working with a pioneer.

To be honest with you, I wasn’t sure about the whole idea of dissociative identity disorder because we didn’t see that in the lab and that was not what we were studying, even though Frank was studying it at the National Institute of Mental Health. When I later went on internship at George Washington University Hospital, a woman there said she had multiple personality disorder, with whom I had done the testing.
The treatment team was a little skeptical, but my supervisor referred me to Judy Armstrong at Sheppard Pratt Hospital in Baltimore who offered to review the data with me. After she did so, she said, “You know what; you actually might have somebody with MPD.” After that, it was just luck because I got a postdoctoral fellowship at Pratt, where they had just opened up a trauma disorders unit, and where I did my dissertation on trauma. I remained there and began working very heavily with folks with DID, and other serious, complex trauma disorders. Right place, right time, and fortunately, amazing training with amazing clinical supervisors.

DID and the Dissociative Spectrum

LR: Before I ask you what readers most likely want to know, which is, “What actually is DID,” why the transition from “multiple personality disorder” as a label to, “dissociative identity disorder?”

BB: There were a lot of reasons, but just to be very brief; by calling it multiple personality disorder, many clinicians thought it was a personality disorder like borderline personality disorder, and it’s not in that category. The experts in the field wanted to emphasize it was a trauma related disorder connected to dissociation, not a disorder of personality. The name change was an attempt to reflect that.

LR: Well, I guess relatedly—and I may get back to my initial question—does the DSM’s characterization of DID as a complex post-traumatic developmental disorder, ‘capture it?’

BB: It’s a terrific start. It’s a foundational start, because it implies that it starts in childhood, which is what developmental disorder means. The research strongly points to very early severe chronic child abuse as the cause. But we also know that there is genetic tendency towards dissociation. And often these clients who end up as individuals who develop DID also have attachment problems because they didn’t have secure attachment. There are multiple things going on, but trauma really has an early childhood foundation.

LR: In your writing, you discuss TRD or trauma related dissociation and suggest that DID is almost always related to early childhood trauma and severe disruption of the attachment relationship. Is there such a thing as a NTRD, or non-trauma related dissociation?

BB: Yes! We all dissociate to some extent, so normal non-pathological dissociation can occur. It can be going into a state of automatic pilot. For example, when we’re driving down the highway and we’re really thinking about something, and barely remember the drive when we get home. Or we’re driving down the highway and we miss our exit because we’re so preoccupied, not because of traffic, but because of our mental disconnection from what we’re doing.

It can also happen at moments of peak spiritual experiences or athletic experiences when people can disconnect from their bodies or feel out of their bodies and have this incredible experience. But none of these experiences interfere with functioning.

LR: I imagine getting lost in a book or a song or a movie or a conversation containing elements of dissociation, but on the left side, or benign side of the spectrum.

BB: Exactly. Those are called absorption, and some people are very prone to absorption. We know from research that the more somebody is prone to absorption, they may be more at risk for dissociation. There’s been some debate over whether absorption should be called dissociation or not? For now, it is understood as one of the lower levels, not-so-problematic types of dissociation, which comes from self-report measures.

LR: Is it clinically useful to think of a dissociative spectrum with absorption type experiences on the left or benign side, and DID as the most extreme and pathological form all the way to the right?

BB: Yes, I think it is. But I’ll say that with awareness that some people living with DID really resent that, because understandably, this was an adaptation to horrendous, overwhelming circumstances. And so, I completely get it and respect that they had a brilliant way of adapting and getting through what would have been just harrowing experiences. The research actually supports exactly what you said.
As I said earlier, all of us dissociate to some extent. And then when you start studying dissociation and different psychological disorders, there’s a range of scores that people have on the different, self-report questionnaires. And it starts out with people having [scores] a little bit above what might be for people who are not struggling with any emotional disorder.

And then it gets at the highest level is folks with DID. And in between, there might be people with eating disorders and maybe borderline personality disorder, because there’s often a lot of trauma in those people’s background, and then you start getting into PTSD. And then the dissociative disorders indeed are at the end with the highest levels of dissociation.

LR: I would think that someone who is engaging in non-suicidal self-injury or someone who is in the middle of an intense food or substance binge is in an acute state that requires a certain amount of dissociation to be able to inflict that level of harm on to yourself.

BB: Is there some dissociation that goes on during those moments? The answer is yes! Often people are somewhat disconnected from their bodies. An example is a client who, with DID or severe dissociation, may be cutting and not feel it and be kind of fascinated with what they’re seeing under their skin, like really extreme cutting with the detachment. And they don’t feel the pain.

LR: Is it possible that someone with DID could be cutting while there’s another element of that personality that’s watching? Am I using the right nomenclature for the other “states?”

BB: There are people in the field that are really pushing for those parts to be called dissociative self-states. In the literature, they’re alternatively called identities, personalities, parts, and alters. We’re really trying to emphasize that whatever they’re called, that they’re all parts of one person. They’re self-states. They’re not different people. That’s why we’re encouraging that name to be adopted in the next DSM.

LR: I find myself gravitating toward more questions that may be more of a popular culture artifact, but I’ve heard that different self-states can have symptoms of a particular medical illness or disease while another is asymptomatic. Is that possible in your experience?

BB: It depends on what illness you’re talking about. We know that, depending on our emotional state, our blood pressure may change, right? And Frank Putnam, who I referred to earlier, did some of the early research showing that different self-states have different EEG patterns.

Simone Reinders in the Netherlands has done a bunch of research studying neurobiological differences among some self-states. She’s tried having professional actors impersonate self-states while they were hooked up with all kinds of biological markers, including brain scans. They could not emulate different self-states.

It’s remarkable. It’s not magic. It’s a disorder that is linked to neurobiological changes and differences. And of course, these different self-states are going to include the traumatized self state, the one that remembers trauma and has all the symptoms that go with that PTSD. When they’re scanned, of course you might expect their heart rate to be much faster and for them to have more activity in their limbic system, versus a part that’s very detached and doesn’t recall that trauma. The heart rate of that self-state is not going to be as elevated. And they’re not going to have the intense amygdala activation.

LR: I can see that if someone is in a moment of active sexual abuse, sexual trauma, that it’s in the body’s interest to down-regulate the heart rate and cortical activation.

BB: Yes. There are studies about that, talking about how animals go into survival mode and, you know, like the faint mode or the feigning death mode. There are some animals that have that response of total disconnection from their bottom up to allow them to survive attack. Well, there’s some parallels with humans that have been horrendously abused repeatedly. Their brains shift into dissociation as a survival mechanism.

Their access to memory can be quite different as well. One of the diagnostic requirements is that there be amnesia for some of their life experiences, that are not due to drugs, alcohol, or head injury. Or they may not remember key autobiographical events, like their own wedding. We call that dissociative amnesia.

LR: What are some of the myths and misconceptions about DID that clinicians should know about?

BB: There are a lot, unfortunately. One is that DID is exceptionally rare. On and across different prevalence studies, at least 1% of the general population meets criteria for DID. That’s the same prevalence rate roughly as bipolar disorder and schizophrenia. So, it’s not rare, but there have been some critics.

Critics of the whole notion of dissociation and DID have been putting it out for a long time in articles that are published in journals. And that has found its way into psychology textbooks that undergrads and grad students read that put forward that myth so that unfortunately, many people, even mental health clinicians, think it’s rare. Another myth put forward by the critics is that DID folks exaggerate their symptoms or are prone to create false memories of abuse.

When you actually compare people with DID to people with PTSD to what are called healthy controls, people who don’t have any emotional problem, and professional actors who try and emulate all of this stuff, there are some studies we’ve done that show that people with DID
are no more likely than people with PTSD to develop false memories.

The important thing that most mental health clinicians have not been trained to know is that they are highly symptomatic across a bunch of different domains. They don’t just have amnesia and different dissociative self-states. They also have PTSD. And we know PTSD is a complicated disorder with 17 potential symptoms. And so, at times they’re flooded with traumatic intrusions, pictures, awful memories, awful nightmares. And then there’s periods where they’re shut down and avoid it because it’s so awful to remember and feel that stuff.

And then there can be incredible periods of irritability and sleeplessness and feeling like they’re an awful person and different from the rest of the world. There’s a lot of research showing that dissociation is very common among people with PTSD. They also have major depression and because living with all these symptoms is so brutally difficult, many of them have substance use problems.

They try to knock out the memories by drinking too much or using drugs. They often also have eating disorders because they have a very difficult time tolerating their bodies. They blame their bodies for their abuse, and so they try and get really big so that nobody’s ever attracted to them or—and they often go back and forth, or they get really anorexic and starve themselves hoping to die or to look unappealing that way.

All of that is shown in the literature. And with regard to feigning DID, one of the ways that you look for malingering is when somebody is reporting too many symptoms or reporting exceedingly severe symptoms. They are much more likely to be classified as potentially malingering on some of the evidence-based measures and interviews for malingering. I’ve developed research that helps mental health clinicians and forensic experts know how to differentiate when somebody has true DID and when somebody is attempting to simulate it.

The critics also don’t really understand complex trauma. They are typically not clinicians or academics. But because so few mental health folks are getting trained in the evidence-based information about DID, they come away with these stereotypes out of textbooks that are just wrong. They’re just flat wrong. And myths.

LR: Is there a short list of the cardinal presentations that differentiate DID from some of the other severe forms of psychopathology?

BB: Back when I was trained, I was taught that if you hear voices, you are psychotic. But more than 75% of people who have DID hear voices.

LR: Schizophrenic?!

BB: Yes, schizophrenia or maybe the psychotic phase of bipolar disorder. I would encourage therapists to not automatically assume that hearing voices means psychosis. There’s a whole bunch of research, including people who don’t have DID, experience voice hearing, and this is strongly associated with trauma exposure. There have been meta-analyses that support this, so I suggest that clinicians always ask every client, no matter the setting, if they have been exposed to trauma. So, learn how to do a good trauma assessment.

If somebody endorses having experienced trauma, then ask about PTSD symptoms and dissociative symptoms. Ask about the different types of dissociative symptoms. Ask about depersonalization. Does the person ever feel numb when they should have feeling? Does the person ever feel like their body doesn’t belong to them? Do they ever see themselves at a distance, like outside of themselves, like they’re watching a movie? Those are three common symptoms of depersonalization, and there’s a range of other symptoms they can ask about, like do you sometimes feel like you’re younger or not your own biological age. Ask about voice hearing.

LR: What’s your gut feeling about why there’s such resistance among clinicians to embrace the reality of DID?

BB: It does sound farfetched, right? But that’s because people are misunderstanding the disorder. It is impossible for people to have multiple people inside themselves. It is impossible. Right. But, Lawrence, you don’t have a little Lawrence running around in your brain, and I don’t have a little Bethany running around in my brain. How do you know you’re not me?

LR: I’ll have to check.

BB: I stump my students when I ask that question. You know who you are because you know that you have a cat and that you’ve been married and lived in Michigan, and that you like Hello Kitty, and that you like certain kinds of music and food, and you have knowledge and memory of family and life experiences. But people with DID don’t always feel like all that.

First of all, they have periods of time missing. And so, they’re confused about who they are and what’s happened in their lives. But they’re not different people inside. Now, I’m going to say that, and some of the readers who have the idea are going to object to what I just said, because some people with DID do feel like they are different people.

That is their perceived experience, but people with DID don’t literally have little people running in their heads either. Our personalities are based on the neural firing of networks in our brains. And like we were saying earlier, there’s a neurobiological pattern that is characteristic for trauma related self-states versus ones that are very detached and don’t remember the trauma.

So, I think a lot of mental health people are mistaken and don’t understand what they have heard. It’s rare and I’ve been told this so many times, “Doctor Brand, I’ve been in the field for 30 or 40 years, and I’ve never seen a DID patient.” But I guarantee you, if they’ve really seen a lot of clients, they actually have, but missed it because perhaps they’re looking for dramatic presentations like Sybil. If it was that obvious, then when people switched states, it would be easy to diagnose. But that’s what movies do to make it look right to the audiences. That is not actually what DID really looks like.

A Tiered Approach to DID Intervention

LR: What is a multi-phasic approach to intervention with DID, and why is it considered the gold standard?

BB: It means that clinicians who work with DID and other serious dissociative disorders are realizing that there needs to be three stages of treatment. When somebody comes into treatment with complex trauma, and especially if it’s very serious, there needs to be an initial stage of stabilization of their symptoms. At this early stage, they may be suicidal, self-harming, drinking and using drugs, or engaging in some other kind of addictive behavior.

They often have really high levels of hospitalization, so they need to learn other ways of regulating themselves that are safe and that they can do out of the hospital. If and when they get stabilized, they begin learning how to regulate emotions in ways that ground them, which is the opposite of dissociation.

Once they’re stable and want to go on to stage two work, we are talking about trauma processing. That’s where they may then talk about some of the trauma so that gradually they can heal from that and not have so many intrusions of nightmares and flashbacks and horrible memories or feeling numb to it.

It’s an awful thing to feel like you’re deadened inside. That would be stage two work, which can take a very long time. So can stage one, by the way. And then comes stage three. For complex trauma—and I’m not just talking DID now—but in general, the person works more on developing their life, their friendships, their career goals; they’re no longer so focused on the past and trauma, but integrating into whatever kind of life and relationships they want.

LR: Is this in line with your “Finding Solid Ground” program?

BB: Yes. The program I’ve created with colleagues called “Finding Solid Ground” is a staged stabilization approach where we help clients learn about, first of all, grounding. But it’s not just for people with DID, but also for people with complex PTSD, and what in the United States is called the dissociative subtype of PTSD.

Our research is showing it helps all these folks, not just DID, but they learn to be more present to their emotions and deal with emotions in healthier ways. They learn about how to deal with PTSD so it’s more contained and not so intrusive so they can sleep better so that they’re not having these awful images pop into their mind and interrupt their functioning all day.

We help them learn to separate past and present. When somebody has very bad PTSD, the brain cannot really distinguish the difference between a flashback and the present moment. It feels to the person it is happening now. So, we teach them how to catch their warning signs that they may start being close to being at risk for intrusions of PTSD, that they might start dissociating, that they might start drifting towards self-harm, and then find ways to get out of that cycle. Among other things, we teach them a little bit about the neurobiology of trauma and that it’s not their fault.

LR: Is integration of self-states the absolute end goal for treatment?

BB: When I first accepted that postdoc at Sheppard Pratt in 1993, the emphasis in the field was integration of personality states. And yet that’s not what I was hearing and seeing was happening very often. I was the leader of a study where we asked experts around the world how many patients had they integrated in their careers. It was small numbers.

That may not sound like a jolt of lightning to readers, but it did lead us to rethink whether that was very achievable for most patients or not?

At the same time, many people living with DID do not want to integrate their parts because they have lived often for decades with these parts. And that helps them function from their perspective. That is who they are. They value their parts, or eventually you hope that therapy can help them learn to respect and value their parts rather than be at war. Some of the self-harm and suicide attempts are about one part trying to kill off another. At the time, they don’t recognize they will all die if they commit suicide. So now I have a different perspective and I think there are different options. I think clients should have the right to choose what they want their endpoint to be.

And that may change over treatment. In the beginning, some clients absolutely say get rid of these parts, but they don’t understand. They can’t. I use the metaphor that you can’t live by cutting out your heart or your liver. And it’s the same thing with self-states. You have survived because of the self-state. You can’t get rid of one. You can learn to work as a coherent collaborative group like a business or a healthy family rather than being at war.

DID and the Family Connection

LR: Are there useful systemic interventions that involve family, spouses, children?

BB: Of course, as a therapist, I’m teaching them, but I don’t want their spouse or partner to be doing therapeutic things. Right! But it gets really messy. If they have children who see them switch, and mom or dad doesn’t seem to remember things they’ve said or done, I find ways to explain DID to the kids in an age-appropriate way.

It is incredibly important that they’re not switching a lot in front of their children. Parents should be consistent no matter what, no matter who they are, whether they have DID, bipolar disorder, or PTSD. Children need consistency. So I would work with a client to help them develop the parenting parts and having them learn to look similarly and act similarly with the kids, so they’re not confusing the kids.

LR: In this context, can a person with DID voluntarily call on another self-state, rather than it “taking over” during a time of crisis or trauma-related moment?

BB: Yes. So that might be something that we’d work on, to go back to that last example, when they’re around their children. You would want them to work towards having parts that can be very supportive, caring, loving, consistent parents. And the parts that are little, that feel as if they are young children, terrorized, traumatized themselves, would be in the back of the mind.

All this is metaphor, however, right? There are no little people, right? But metaphorically, those self-states are taken care of internally so that they are consistent. Same thing with work, same thing when they’re driving.

LR: You said earlier, Bethany, that invariably, dissociative states and DID in particular are born out of severe trauma in childhood and attachment disruptions. At what point might a clinician begin to suspect dissociative identity disorder in childhood?

BB: Really good question. Some of the same symptoms that later develop and become more severe in adulthood can be seen in little children with the beginning stages of a dissociative disorder. One thing I haven’t mentioned is that adults with DID can go into trance states where they’re not responsive to the outer world.

Little kids start showing attention and zoning out. They’re often misdiagnosed as having ADHD. So again, we need all clinicians to be trauma-informed and trained. Not that they’re expecting to see a dissociative kid, but they might, especially if they have symptoms of PTSD like nightmares and flashbacks, or report having imaginary friends. Some talk about that for a second.

Developmentally, it’s normal for children to have imaginary friends. But if imaginary friends start to be frightening, or upsetting, or tell the child to hurt their sibling or a pet, or to destroy their toys, that’s not a “normal” kind of scenario. Little kids usually stop talking about imaginary friends around age seven. But people with DID report that they never went away. Those actually linger as parts of their dissociative self-states.

Keyword, Avoidance!

LR: There are clinicians who believe that if we look hard enough for trauma, we will find it. Is it similar for dissociation and DID?

BB: It might be! During medical training, students commonly think they have all the different disorders. The same thing may be happening in our field. For 26 years, I taught a course on differential diagnosis and interviewing. At the beginning of the class, I warned the students that they were going to be tempted to diagnose themselves along with everybody they loved or hated. It is a normal phase of learning the DSM but I asked them to be respectful and stick to the diagnostic criteria, so they don’t go telling people they’ve got borderline personality disorder.

There is a normal stage of training in which, at least for a while, we may overuse certain concepts as we’re learning them. But again, if clinicians are well-trained in differential diagnosis they will be less likely to overdiagnose certain symptoms and disorders—in this case, dissociation and DID. This is one of my research streams.

There is a lot of research out there, and I’ve written a book about how to assess dissociation and how to distinguish it from other symptoms and disorders. Here is where training is critical. The ways you treat schizophrenia and bipolar disorder are very different from the way you treat DID. Schizophrenia and bipolar are the two disorders that people with DID are most often misdiagnosed with.

People with DID don’t need mood stabilizers or heavy-duty antipsychotics. Instead, you do a trauma-informed stabilization approach. Two of my earliest DID clients were misdiagnosed with schizophrenia and treated accordingly for years. One passed away and gave me permission to share her story. By the time I saw her, she had horrible tardive dyskinesia. She had been disfigured by the treatment for schizophrenia that she didn’t have. Once we started working together, she got a lot better— not cured, but a lot better, and she was much more functional. She had dropped out of school and midway through high school, she went back and became a minister in her community.

LR: What do you see as the core elements of training that need to be incorporated into graduate programs so that DID can be correctly identified, and interventions designed?

BB: Only 8% of APA-approved doctoral programs require a course in trauma. That’s gotta change. Information about trauma should be a required part of graduate training in psychology, social work, and related fields. As part of that training, they also need to learn about dissociation and the range of dissociative disorders, and how you assess for dissociative disorders, and how you do differential diagnosis. And, of course, something about evidence-supported treatment. There’s only one program so far based on randomized controlled trial data that shows it helps people with profound dissociative disorders. But they should hear about that. That should be in the textbooks.

LR: What do you think is contributing to that incredible avoidance by the APA of mandating graduate-level trauma training at graduate level?

BB: A group of us have been pushing for different guidelines about working with complex trauma that finally got approved by the APA this last summer. But there is pushback. And a lot of us think there’s a political issue. Let’s just think about what PTSD means. The required criteria center around avoidance. You nailed it there!

Even people who’ve been traumatized don’t want to think about it. It’s human nature not to want to know, think, and talk about trauma. Believe me, it’s a hard part of my job. I do it, and of course I know how to do it. But hearing the stories of what has happened to little children is incredibly difficult.
And there’s some real doubters out there when it comes to thinking about child abuse. Maybe they should read a little bit about child pornography and child trafficking and how rampant they are, because we’ve got plenty of evidence that that happens. Some individuals report that part of their abuse was being the victims of child pornographers.

So, I think we don’t want to think about that stuff!

LR: Avoidance on a large scale.

BB: Avoidance. You nailed that.

LR: Not to get sidetracked, but I wonder if this is what Bessel van der Kolk experienced when he tried to get his developmental trauma disorder approved by APA.

BB: I’m sure that’s some of it, but not-unshockingly, it likely goes back to financial issues.

LR: It’s hard to imagine.

BB: At this point, the National Institute of Mental Health has never once funded a study of the treatment of DID. So, I have literally had to get donations to fund my studies. Do you think cancer researchers do that? Do you think researchers of any other disorder must have bake sales and pass the plate at college?
Where is the money in trauma right now? It’s in the Veterans Administration. I’ve heard this from various people who work there. They do not recognize DID, and they don’t want anybody in the VA system being diagnosed with DID, because that’s a real problem for our military, right? Everybody there has a dissociative disorder. Although believe me, I have assessed people in that system and helped them get honorary discharge. Anyway, there’s a huge amount of funding that goes to VA research and they emphasize working with adults. They want to keep the soldiers “strong” and ready to go or whatever the branches to ready to fight. Yeah. The childhood trauma.

LR: It’s hard not to introduce politics into conversations at this level. But do you have any concerns about funding for dissociative and other disorders as the incoming administration takes form?

BB: I do, and I think many, many researchers are very concerned about funding for new science research in general. But then when you get into groups like research on women, research on children, research on traumatized people, research on any kind of minorities, but especially LGBTQ groups, people are very worried. My funding has always been a problem. But I do have many generous donors.

Wrapping Up

LR: There’s so many big sales you can have, and winter is coming.

BB: So, we’ll have some hot chocolate sales and some coffee. Yes, there is a group called the International Society for the Study of Trauma and Dissociation (ISSTD). They do lots of multi-level, face-to-face and online training for dissociation and children, adolescents, and adults. They also supported RCT studies for our Finding Solid Ground program.

I’m strongly urging clinicians to learn about that program. We’ve got two books out there. One for people living with the disorder, and one for therapists. Our research shows that the Finding Solid Ground program works best when the therapist knows the program and the clients working with the therapist who knows the program.

LR: Has counter transference entered into your work with any particular client?

BB: For anybody working with complex trauma, there is going to be countertransference and traumatic countertransference. And the client will experience transference. There’ve been times I felt like I wanted to rescue somebody because they’ve had such a hard life. But you’ve got to keep the boundaries strong. I consult with a lot of therapists. One of the mistakes I hear from therapists is they do try and rescue, or they go too far. It’s not uncommon that therapists will see a DID client for free and become very burned out. I don’t ever advise that.

The psychotherapy research shows that people benefit from treatment more if they’re paying something. It’s also common for therapists to alternate between feeling helpless, like the child was back during trauma time, and at other times harsh and mean which the client may experience as harsh and mean, almost like the perpetrator or a non-protective bystander. Those three roles are extremely common in the treatment, so I teach a therapists to watch for that, to work on that, and to make that understood.

Something they actually talk about with their clients so neither get stuck in those spaces and can learn from it. It’s part of the healing, rather than becoming the point where the treatment comes off the rails.

LR: I think that we could talk for hours, Bethany. It’s been a fascinating conversation for me as I hope it was for you. Is there anything I’ve left out?

BB: Yes. There are people out there who have died because of this disorder, but there is hope, even despite the tremendous suffering. It’s important that these people know that they are not alone, and neither are their therapists. It’s important that therapists convey that they’re not alone, it’s not their fault, and that they are not weak or dumb. They don’t have to suffer endlessly, and neither do therapists need to feel powerless. There’s hope.

LR: I think the clinical world is a smarter place for your presence in it. Thank you, Bethany.

BB: Thank you!

When to Use Unexpected Techniques with Emotionally Overwhelmed Adults

Posted on by Psychotherapy.net Team

“Name it to tame it” has become a popular phrase among parents and those working with children. It denotes the principle that we can help emotionally overwhelmed children feel better by helping them put their feelings into words. Daniel Siegel provides an example of this principle. Bella, a nine-year-old girl, watched the toilet overflow after flushing it, “and the experience of watching the water rise and pour onto the floor left her unwilling (and practically unable) to flush the toilet afterward.” Her father later sat down with her and encouraged her to tell the story, allowing “her to tell as much of the story as she could,” and helping her “to fill in the details, including the lingering fear she had felt about flushing since that experience. After recalling the story several times, Bella’s tears lessened and eventually went away.” Putting these experiences into words, Siegel writes, “allows us to understand ourselves and our world by using both our left and right hemispheres together. To tell a story that makes sense, the left brain must put things in order, using words and logic. The right brain contributes to bodily sensations, raw emotions, and personal memories, so we can see the whole picture and communicate our experience.”

Putting Theory into Action in Therapy

I repeatedly experienced the power of this principle during the six years I worked with children in an elementary school. After I transitioned to working with adults, I would sometimes forget the principle. I can remember a session with Mary, a 55-year-old woman who could not bring herself to leave Harlan, her emotionally abusive husband of 30 years. She had entered therapy to find the resolve to leave, something her friends and even her grown children had long encouraged her to do. I spent the better part of the session encouraging Mary to give voice to that part of her that wanted change. She followed my lead and asserted her rights and needs. After speaking with passion for several minutes, she suddenly stopped talking and looked off into space. “I know everyone thinks I should leave Harlan, and I know their hearts are in the right place.” Her eyes fell to the ground, all the energy that had animated her just moments before now gone. “We were basically kids when we got together. We grew up together. There’s something about Harlan and me that others just don’t understand. There’s something that I just can’t put into words.” There was a heaviness to her words. She seemed to be saying, ‘Yes, on paper there are good reasons for leaving him, but these other reasons possess a power that ensures that things can never change.’ I had given Mary the space to share her story, but she was now telling me that part of her story could not be shared. She was suggesting that this part of her story, perhaps because of its ineffability, exerted a hold over her from which she could not escape. Consequently, she felt she could not move toward the goal that had motivated her to start therapy. As the session ended, her despair seemed contagious, and I too felt that she would never be able to articulate that part of her story. I thought about our session over the next week and couldn’t avoid feeling that I had failed her. Yes, I had empathized with her, and I think she felt that, but I had failed to give her hope. I shared my feelings with my own therapist, and she said something that reminded me of another popular principle among parents, one often described as, “the power of yet.” I hadn’t helped Mary put words to her feelings —yet! She and I would again talk about Harlan, and she would again say that there was something about their relationship that others didn’t understand, something she just couldn’t put into words. I would add that simple, powerful word. “There’s something you can’t put into words—yet.” Not unlike a parent, my job as a therapist is to sometimes help others find words for their experiences. Helping them find their words is not the answer to every problem, and indeed words cannot fully and adequately describe the depth of many important experiences. Yet. Helping clients put words to their most difficult experiences can be profoundly helpful. Mary could not describe a crucial part of her relationship with Harlan—yet. My work was to help her find those words. I thought back to my clinical supervisor’s statement that, when his clients struggled to describe their inner experience, he would ask if an image or even a color came to mind. The goal was not for them to provide a precise, granular description of their feelings at first, but to try to take steps in that direction, little by little, one word at a time. I now had hope, and I knew I would be able to share my hope with Mary. It might take time to get there, but with my encouragement, she would vocalize that aspect of her relationship that had never before been vocalized. And when she did so, she would feel less isolated and more empowered. I did not know what she would feel empowered to do, and neither did she. Yet. Questions for Thought and Discussion In what ways does the author’s message resonate with you? Not resonate with you? Based on the readings, do you agree that the author initially “failed” with Mary? How might you have addressed Mary’s decision to remain with Harlan?

A Day in the Life of a Very Old Therapist

Posted on by Psychotherapy.net Team

The day had not started well. I woke at 3:00 a.m. with leg cramps that wouldn’t go away. I quietly got out of bed, careful not to disturb my wife, Marilyn, sleeping deeply next to me. To relieve the pain, I took a hot shower until it turned lukewarm, then dried myself and returned to bed. The heat had soothed my muscles, and the cramps had subsided somewhat. I tried hard to go back to sleep. But when it comes to sleep, “trying hard” is always doomed to failure. Insomnia has been my kryptonite for decades. I had been tapering down my use of sleeping pills, reluctantly, as my doctor suspected they were accelerating my memory loss. I tried some breathing exercises. Time after time I inhaled, whispering “calm,” and exhaled, whispering “ease,” a meditation practice I’d learned years ago. But it was to no avail—the slight calming brought on by the utterance of “ease” soon morphed into anxiety, another old nemesis. I shifted my attention and focused on counting my breaths. A couple of minutes later I realized I had forgotten about counting and my ever-restless mind had wandered elsewhere. A year earlier Marilyn had been diagnosed with multiple myeloma, an insidious cancer of the blood plasma. She was in the midst of a series of chemotherapy treatments, which had yet to result in any significant improvement. Her warmth and the sound of her breathing were so familiar, my beloved bedmate for many decades. But now something new had joined us, this sinister illness, doing battle within her. I was pleased to see her resting peacefully that night and gently traced the lines of her face in the dim light. We’d been together, inseparable, since middle school. Now I spent the majority of my days worrying about her and trying to enjoy the time we still had together. Nights I spent worrying about a life without her. How would I pass the time? With whom would I share my thoughts? What loneliness awaited me? Noticing that my mind had strayed so thoroughly, I gave up the idea of getting back to sleep. I checked the clock and noted, to my surprise, that it was already 6:00 a.m. Somehow, when I wasn’t paying attention, I must have nodded off for a couple of hours.

Jerry: What’s Not to Like?!

After breakfast, I looked at my schedule. I had only two appointments that day. The first was a termination, the final session with Jerry, a patient whom I’d been seeing for one year. Jerry was a successful lawyer in his 40s who had come to therapy seeking answers after his girlfriend of two years had left him, the third in a string of failed relationships. “I can’t see why,” he’d said during our first meeting. “I’ve got a great house, a great job, tons of money. What’s not to like? I mean look at me.” He’d gestured at the well-tailored, clearly expensive suit he was wearing. Jerry was not what you’d call warm or reassuring. He was demanding, and often critical. He groused about my fee, suggested I get a better gardener to tend the plants along the walkway to my office, and, once inside, disparaged the artwork on the walls. He had come to me, he told me repeatedly during our first few meetings, because he’d heard I was the best, and he deserved the best. This was soon accompanied by a look of disappointment in his eyes that I hadn’t swiftly cured him of his troubles. Clearly, that look said I wasn’t the best after all. And yet, over time, we’d had success. What had worked? We had two important factors going for us. First, Jerry was highly motivated to make change in his life. Despite his prickly exterior he realized that he was in some way contributing to his relationship problems, and he was eager to put in whatever work was needed to address this. I had to slow him down, let him breathe, and see that part of the problem was the immense demands he placed on himself and me to magically “fix” him. “Imagine being your girlfriend for a few minutes,” I suggested. “What if you weren’t ‘the best,’ if your garden path weren’t expertly tended, if you didn’t look perfect on Jerry’s arm? Would Jerry love you and support you nonetheless?” “I doubt it,” he said. “Instead he would criticize you constantly, and you’d end up feeling crappy about yourself and your relationship. And . . . ?” I left the question hanging in the air. Jerry considered for a moment. “And you probably wouldn’t stick around,” he said finally. This realization, that being demanding and often unkind severely impacted his relationships, clicked for him. He could see the role he was playing and started to change. In the weeks that followed, he set about in earnest to improve. He began to catch himself whenever he was overly critical of me and whenever he complained that others in his life were inadequate. He took more responsibility for the way people, especially potential romantic partners, responded to him. And he set about curbing his sharp tongue. Jerry’s fierce drive to change himself was essential to the progress he made, but it was not something I could control. I could influence another factor, however: the powerful relationship he and I developed. From the beginning, Jerry had tested me: Why wasn’t my taste in art better? Where was my fancy car? Why hadn’t I been able to fix him all the way yet? Through all these barbs, I’d stayed in there with him. I’d been empathetic and warm, and also willing to push back when it seemed a challenge would do him some good. Gradually he softened up and stopped competing with me. As our relationship grew, his bristles felt less like attacks and more like witty, playful jabs that I could parry or call him out on. Little by little we built a strong connection, a “therapeutic alliance” as we call it in the field. This alliance, building it and using it, is the most important factor in my therapeutic approach. In what now seem like countless lectures, and numerous writings, I’ve stated that “it is the relationship that heals.” What drives change is not a worksheet that the patient fills out, a brilliant question the therapist poses, or a behavioral change the patient must chart daily. In my approach to therapy the honest connection between the therapist and the patient is the medium through which we discover, learn, change, and heal. Jerry and I had made excellent progress using that relationship over the course of the year we had together. He became friendlier, and when he occasionally still snapped at me with a disapproving comment, I would point it out. He learned to apologize and then, bit by bit, catch himself before saying something acerbic, and often, quite endearingly, replace such comments with attempts at compliments: “The lemon trees beside the path are looking much better this week” or, “You know, that statue of Buddha on your bookshelf is actually more interesting that I thought.” I looked forward to our weekly meetings and would be sad to say goodbye when today’s session ended at 11:50. But, for reasons that will become clear, we had agreed upon a one-year time frame at the beginning of his therapy. He had certainly made the most of it, and we were both hopeful that his future relationships, romantic and otherwise, would be richer and more satisfying.

Born of Necessity: One-Session Therapy

The second session on my schedule that day would be very different. It was with a woman named Susan, whom I planned to see only once. Only once!? How could I do anything resembling effective therapy in a single session? And why would I want to try? To explain, I need to rewind my timeline a bit to provide context. About five years before this, when I was in my early eighties, I noticed that my memory was starting to fail. I had always been a bit forgetful, misplacing my appointment book, glasses, or car keys with regularity. This was something different. I began to encounter people I recognized, only to have their names elude me. Occasionally I’d stop in the middle of a sentence, stuck searching for a familiar word. And, more and more frequently, I would lose track of the characters in movies Marilyn and I were watching. As this progressed, I began to think that, perhaps, I was no longer able to offer the long-term therapy I had for nearly 60 years. Instead of open-ended therapy that sometimes lasted three or four years, I decided to set a 12-month time limit, agreed upon in advance, for all new patients, hence my agreement with Jerry. I approached this new framework with some sense of loss, as it represented a major shift in my work, one derived from necessity, not desire. But soon curiosity, and my wish to continue being helpful, won out. Ultimately, I found this to be an agreeable solution. If I chose my patients carefully, I was almost always able to offer a great deal during our year’s work together. With some patients, in fact, there was an increased sense of urgency, and thus motivation, thanks to the time limitation. This had worked well, both for me and for my patients, for the last five years. Then around the time I was 87, I started to find I was more and more reliant on the summaries I recorded after each session to remember the details of my patients and that, even with these notes in hand, their faces and problems occasionally seemed alien. I was faltering, and I began to question the value of the care I was able to provide. I felt I still had much to offer, but it was clear that I could not, in good conscience, engage in ongoing work with patients, even limited to one year. And yet, and yet . . . the thought of no longer practicing was dizzying. Sharing with my patients, aiding them through their darkest thoughts, and joining them on journeys of discovery—for the majority of my life this had been my daily work and my calling. Who would I be, if not a psychotherapist? Truth be told I was angry and deeply frightened. I was not ready to feel this old, this useless. The thought of leaving therapy behind felt like resigning myself to rapid decline, followed soon after by my inevitable death. I pondered this dilemma. I had to put my patients’ needs first, so doing long-term therapy was out. But after so many decades of practice and research, I knew I had developed levels of insight and expertise that were rare, and still potent. Plus, I felt the personal need to continue contributing in some way. How could I offer something—enough to be helpful to patients, enough to keep myself engaged in the world—while also not endangering anyone? I came up with an unconventional idea. Perhaps I could meet with people for one-time, one-hour, consultations. During that hour I would offer everything I could—insight, guidance, a warm accepting presence—and then, if appropriate, refer them to a colleague who seemed well attuned to their particular challenges for ongoing treatment. The idea of such short-course therapy was profoundly foreign to me. I have always seen therapy as a longer-term endeavor—not the endless years of old-school psychoanalysis, but often several years, long enough to help patients search for better understanding of themselves and make meaningful change in their lives. The question of how I might be effective in single sessions could be an interesting experiment, if nothing else. For some time after coming up with this idea I vacillated between skepticism—Was this just a way of forestalling my own decline rather than offering anything truly beneficial to the patients?—and excitement—I knew I had skills honed to an uncommon degree and had been helpful to many, many struggling people, which undoubtedly had some value. I took the time to stare carefully at my own feelings. It was possible my pride would resist accepting this lessened importance. And yet I knew that, at some point, I would need to accept my decline and pass the torch fully to the next generations. I honestly did not know what this experiment would yield, which itself was intriguing. Thus, I began a new adventure of short therapeutic encounters, and investigation of what might be most helpful in a far briefer time frame for creating change than I had ever before conceived as effective. I announced my retirement from ongoing therapy, and my offer of these single-hour consultations—either in person in my Palo Alto office, or online—on my Facebook page. Within hours, requests for appointments started to pour in, far more than I’d expected. They came from all over the world, English-speaking countries of course, but also many other places, too—Turkey, Greece, Israel, Germany—as Zoom had collapsed the barrier of space. And they came from people in many stages, and to some extent many walks, of life. This single-session format, I quickly realized, would allow me to work with many people I had never been able to reach otherwise, people for whom ongoing therapy with me was prohibitively expensive. It was clear this would be a very interesting shift from the relatively traditional private practice I’d led from the lovely Spanish-style cottage in our backyard over the previous 20 years, and for decades before that working in the psychiatry department at Stanford University. Would it be effective for the patients? Would it feel satisfying for me? Only time would tell. It would certainly be new, and at my age, newness was nothing to scoff at. This, then, was how I found myself on that particular morning contemplating my first single-session consultation with Susan. I was excited yet concerned. I am not always filled with second-guessing, but after a restless night spent with my darker thoughts about Marilyn’s failing body and my own weakening mind, I had my doubts. How much good would I be able to do, really, in these short encounters? I had several things going in my favor, I reminded myself. First, my particular therapeutic approach has always been heavily focused on using what I refer to as the here and now. By this I mean that the interactions the patient and I have in the moment are the essential tools of change. Whatever problematic tendencies a patient has—their insecurities, their neuroses, the things they do that get in the way of their relationships with others—these are all likely to show up in the therapy sessions, through their interactions with me. Jerry, who had to have the best therapist, is an excellent example. Even though he came to me for help, and thus presumably began our work with a positive opinion of me, he constantly criticized me in many ways. Time and again I brought his awareness to this tendency. At first, he attributed the comments to my inadequacies, that I was overly sensitive and jealous of his financial success. But little by little Jerry began to see that he behaved this way elsewhere in his life as well, and that it impacted his relationships, and his happiness. This here-and-now approach is largely ahistorical, meaning that it does not rely a great deal on patients’ personal histories. Rather than spend great amounts of time digging through patients’ backstories, time which I would not have in these single sessions, I focus on the present, tuning in closely to every word and gesture they offer, as well as those that they omit. I was confident this approach would allow us to get into the serious work quickly. It also had the great benefit of dove-tailing nicely with the limited capacities of my faltering mind: remembering the past was increasing challenging, and recalling copious details about each patient was beyond me. But being present right here and right now, I could do very well. A second thing I had going for me was that nearly all of the people who requested consultations had some knowledge of me in advance. Over six decades I have written many books, including influential textbooks for student therapists, philosophical novels, and books of stories like this one that aim to demystify the process of therapy. Through these I have had the good fortune to become a well-known figure in the field, and most of the people who had requested consultations thus far had mentioned reading at least one of my books. It was clear from most of their emails that they saw me as having some amount of wisdom and power. I took this with more than a few grains of salt, knowing that we all sometimes seek reassurance from silver-haired elders. In fact, there was a small voice inside me, adolescent and rebellious, that wanted to shout out “I’m not that old yet!” and cancel this whole undertaking. But for the most part I was happy to play the role of guru on the mountaintop, realizing that I might be able to use the wisdom with which people imbued me and leverage that power to help them change.

Susan: Trying Out My New Strategy

Such was my state of mind as I settled into the chair in my office and opened a Zoom window to speak with Susan, a 50-year-old schoolteacher from Oregon who was deeply depressed. We quickly greeted each other, and I explained that I would only be able to see her one time, as noted in the Facebook posting, and that I hoped to be as helpful as possible. It felt very strange saying all of this, and I think I was laying out the groundwork as much for myself as for her. She nodded, then launched into her tragic story. Two years ago, at about 10:00 on a Thursday night, she had opened the refrigerator and noticed that the large cherry pie she’d made was nearly gone. She had planned to serve it the following evening to close friends who were coming over for dinner, but now it was reduced to a sliver of crust oozing deep red filling. What had happened to the pie? It was no mystery: no doubt Peter, her husband, must have eaten it. It wouldn’t have been the first time. “That gluttonous slob!” she exclaimed, bursting into tears. The fate of her cherry pie was too much. The last straw. She had to be at work until 5:30 the next day, an hour before her dinner guests would arrive. She would barely have enough time to get dressed and set the table, let alone bake another pie. The disrespect! Brimming with anger, she’d stomped upstairs and confronted her husband, who was already in bed. They argued for 10 minutes. Tempers and voices rose. He told her he had always been the main support for the family (not true! she protested) and that he’d eat any pie he damn well pleased. She retorted that he was an obese hog who was going to gorge himself to death. He told her to sleep on the couch and pushed her out of the bedroom, slamming and locking the door. “Fine,” she yelled. “The last thing in the world I want to do is to share the bed with a selfish glutton.” The next morning, her hard knocks on the bedroom door and loud calls to her husband were returned with silence. Finally, she and her two daughters broke into the room to find him lifeless in bed. They called emergency services, and when the medics arrived, they declared he had been dead for several hours. When police officers arrived, they sealed off the house and searched every room. Susan and her daughters were interviewed at length—clearly the police were considering the possibility of foul play, going so far as to infer that the pie might have been some sort of weapon. “How awful,” I said. “And how much have you recovered from your husband’s death?” “I’d say zero,” Susan replied. “No recovery. None at all. Perhaps I’m getting worse. I miss him so much, and I am racked with guilt about what I said to him that last night. And I’m also mad at him for leaving me. I cry all the time and now I’m the one who can’t stop eating and I’ve gained 60 pounds. I saw a psychiatrist here recently and he said that I was, in some way, identifying with my husband. What help was that? I’ve developed terrible skin problems and I can’t stop scratching myself. I can barely sleep, and when I do, I keep dreaming of Peter. When my daughters leave for college in a month, I’ll eat by myself in restaurants and people will look at me and, I’m sure, pity the dumpy fat woman eating all alone.” She caught her breath loudly, perhaps holding back tears. “That’s it, Dr. Yalom, I’ve unloaded on you. That’s everything. I don’t know what else to say.” She slumped back in her chair. “You know, Susan, I’ve worked a lot with women who have lost their husbands and your account of what you’re going through is not unfamiliar to me. Let me ask you something. You say your husband died over two years ago. Can you compare your condition now with a year ago? Is it different? Is it less painful?” “No. Just the opposite. That’s what torments me; I think of him more and more, and when I’m alone in the house I’m terrified of being sad and lonely forever. Damnit. It’s not fair.” “Grief always lessens, but it takes time. Usually, the course of grief goes through a predictable cycle. It’s most keen the first year when you experience the first birthday, the first Christmas or New Year’s Eve, without your spouse. But then, as time passes, the pain lessens. And later, when you go through the cycle of the special days for the second time, it becomes markedly less painful. But that isn’t happening for you. Something’s blocking you and I have a hunch it’s related to your anger.” Susan nodded vigorously and I asked, “Can you put that nod into words?” “I have no words for it, but I feel you’re right. It’s confusing. I’ll be drowning in sadness and then, suddenly, all I feel is intense anger.” “Let’s focus there, on your anger,” I said. “Just let your mind go there and for just a couple of minutes please share your thoughts with me. In other words, think out loud.” She looked puzzled and shook her head. “I don’t know how to start.” “It might be easiest to start at the beginning. Think out loud about your very first encounter with anger.” “Anger . . . anger. The first time I felt anger was with my first breath—at my birth.” “Keep going, Susan.” “There was anger when I was born. My mother’s anger. I remember her saying time and time again that she wanted a boy and if I had been a boy, she would have stopped there. She just wanted one child, and it wasn’t me. She let me know about it over and over.” “So you spent some of your early childhood hearing about how your birth, your very existence, inconvenienced her?” “Oh God, yes, she made me feel it all the time. Damn her for that!” “And your father?” “Worse. Sometimes even worse. His favorite joke, which he never tired of telling, was that the nurse made a mistake when I was born and brought the family the afterbirth instead of the baby.” “Ouch. Oh, Susan, how dreadful to have your father joke you’re not a person, that you’re a placenta.” “He thought that was such a funny joke. And my mother agreed. I’ll be honest with you. I know it’s unnatural, but I hated them. Both of them. My father especially. He wouldn’t pay for my college. He wanted me to work as a secretary in his store instead. So, I left home early and had to work my way through school.” She paused, letting these deep emotions swirl through her. After a moment, while she was still in that open tender place, I pushed her to go deeper. “And the anger toward your husband? Tell me about that.” “It wasn’t like my anger toward my father. Certainly not at first. I met Peter after I left home, when I was in college. We were sweethearts and he was good to me. His parents were well off, and he always had money. Whenever I was strapped, he’d help pay my rent or buy groceries. And I’d never had that kind of help or affection before. “Peter’s father was a politician and wanted him to follow in his footprints. Peter had the charisma—he could be incredibly charming and fun. But he was lazy, a poor student who gambled whenever he could, and eventually flunked out of school. He became a guard at a local bank, a job his father got him. He never made enough to support us or, if he did, he secretly gambled it away. Either way, he made it clear that I always had to work. I never took time off, except three-month maternity leaves when I had our daughters. I could never become myself, never be the kind of mother I wanted to be for my girls. Instead, I worked, worked hard. And you know what? Just a few days before he died, he told me he’d gotten too heavy to be a bank guard, and they’d moved him to office work, which meant a pay cut. He said it wasn’t a big deal, and I got so mad at him because he didn’t even care about his health. And probably I would have to find a second job to pay our bills.” “I hear lots of anger rumbling, Susan,” I said. “A husband who never recognized all the work you did, who never valued your needs and wants. A cruel father who saw you as either a problem or a punch line. And a callous mother who never wanted you, never offered love. Now they are all gone— mother, father, husband—all gone. And a good bit of your life has gone by as well. Oh, Susan, no wonder you’re angry. Who in your situation wouldn’t be enraged? I know I would be.” She nodded as I spoke. “How does it feel to hear me say that, Susan?” “Hard. Right. But hard.” “I want to take a moment to look at all you’ve accomplished in spite of them: two loving children, a valuable teaching career, and so much more. You’ve done so well, Susan.” She swallowed, taking that in. “I haven’t really been able to talk to anyone about this,” she said. “Everyone wants to remember Peter as a good person, remember us as a good couple. No one wants to talk about the darker side.” “Thank you for sharing it with me. Your anger is only human. Yet I suspect it presents a big problem. We feel we should never speak ill of the dead, that it’s wrong or somehow disrespectful. Does this ring true for you?” She nodded, tearing up. “Well, I disagree. Anyone in your situation, with the experiences you’ve lived, would have the angry feelings you’re experiencing. You’re judging yourself far too severely.” Susan was sobbing now, and I waited for her to calm down and breathe. “I don’t know what to do, how to stop it,” she said finally. “I’d like to remember so many other things about our life together. I really did love him. But now I’m just so mad.” “I suspect that as you accept your anger, accept that it is appropriate and you have good reason for it, those other memories will return. But it will take time.” “Maybe.” She nodded. “I hope so.” Then, in my most solemn voice, I continued. “Susan, I’ve listened carefully to everything that you’ve told me, taken it all in and pondered it carefully. I want you to know that I pronounce you innocent. Please hear that: I pronounce you innocent! You deserve a good life. You’ve worked hard, you’ve been a good mother, a good wife, and you deserve some happiness now.” She smiled through her tears, and I finished the session with a keen sense of having been helpful. I gave her the name of a therapist with whom she might continue. Clearly this old man still has something to offer, I thought on reviewing our meeting! I received a follow-up email from her a couple of weeks later which confirmed this. She thanked me for helping her, writing:

I won’t forget the moment when you said something like “apparently your mother and your father were not good parents, but even so you’ve done extremely well in life . . . I admire you for that.” You gave me a warm feeling of being seen and respected and supported at the same time. Also your pronouncing me innocent. I will never forget that remark, and the smile on your face as you said it. I will keep the sound of your voice in my mind and my heart.  

Thinking about it later that night, I felt this was one of my best therapy hours ever. I resolved to keep offering these unusual one-hour sessions, to see whom I could help and to glean as much as I could from the process. Equally important, I would share what I learned. Earlier, speaking of my desire to help patients, I left out the other major aspect of my professional life, that of teacher. Most of my work as a writer has been in the service of teaching young therapists and others practicing, or entering, therapy. Furthermore, many of my thoughts have gone against the grain, countering major trends in the field. While psychiatry has increasingly pushed medication as the solution to mental illness, I have championed human connection; while psychotherapists have increasingly been taught approaches that aim at symptom reduction, like cognitive behavioral therapy or solution-focused therapy, I have embraced curiosity and deep personal exploration. This dedication to sharing what I’ve learned has always been a powerful force driving me forward, and I began to feel that impulse again when thinking of Susan and imagining many rich brief encounters ahead of me. I would undertake this project not only to help those who seek consultation and to remain engaged myself, but also to pass on what I learn. Full book available here. From the book HOUR OF THE HEART by Irvin D. Yalom and Benjamin Yalom. Published on December 10, 2024 by Harper, an imprint of HarperCollins Publishers. Reprinted with permission.

Finding Healing Through Art: A Case Study in Art Therapy

Posted on by Psychotherapy.net Team

Art Therapy is a powerful form of psychotherapy that uses creative expression to help individuals explore emotions, process trauma, and find pathways to healing. Unlike traditional talk therapy, Art Therapy offers a non-verbal outlet, allowing clients to express feelings that may be difficult to articulate. By tapping into the subconscious, art can reveal hidden emotions, facilitating self-discovery and growth. In this case study, I’ll explore how art therapy transformed the life of Julia, a young woman struggling with anxiety and self-doubt.

Julia’s Journey to Art Therapy

Julia, a 28-year-old woman, came to therapy seeking help for anxiety. She described herself as “constantly on edge,” plagued by feelings of inadequacy and fear of judgment. She had tried various coping mechanisms, but none provided lasting relief. When talk therapy didn’t yield the progress she hoped for, Julia decided to explore art therapy as an alternative. Although Julia had no formal art background, she had always been creative. As a child, she enjoyed drawing and painting but had abandoned these hobbies as her responsibilities grew. During our initial session, Julia was open but hesitant. She expressed concerns about her lack of artistic skill, unsure if she could convey her feelings through art. I reassured her that Art Therapy wasn’t about creating “good” art, but rather, about expressing oneself freely and authentically. Together, we embarked on a journey to explore her inner world through colors, shapes, and symbols.

Session One: Laying the Foundation

To ease Julia into the process, I introduced her to a simple exercise called “Art for Emotion.” She was given a set of colored pencils and paper, and I asked her to draw how she felt at that moment. Julia chose dark, muted colors—black, gray, and navy. She created a swirling, chaotic pattern, which she described as a “storm” in her mind. This storm, she said, represented the anxiety that constantly loomed over her, making it difficult to focus and connect with others. As we discussed the drawing, Julia began to open up about the ways anxiety affected her life. She described feeling as though she were “drowning” in her responsibilities and unable to meet her own high standards. She admitted that she was often overly critical of herself, which only fueled her feelings of inadequacy. Together, we explored how these swirling emotions manifested in her daily life, from her job to her relationships.

Session Two: Exploring Symbols

In the second session, I introduced Julia to clay. Working with clay allows clients to engage with tactile sensations, which can be grounding and soothing. I encouraged her to create a symbol that represented her anxiety. After some thought, she molded the clay into a small, tightly-wound spiral. The spiral, she explained, was a representation of her tendency to overthink and get trapped in cycles of self-doubt. As we discussed her creation, Julia had an insight: she often felt like she was “spiraling” out of control when faced with uncertainty. By externalizing this feeling through clay, she was able to examine it more objectively. We talked about how anxiety is a natural response, but when it becomes too intense, it can feel like being caught in a relentless loop. Julia began to see her anxiety not as a personal failing, but as a reaction to stressors in her environment.

Session Three: Redefining the Self

By the third session, Julia seemed more comfortable with the process. She was starting to embrace the therapeutic benefits of creative expression, and her initial reluctance had faded. This time, I suggested a self-portrait exercise, asking her to draw herself as she currently saw herself. Julia spent a long time working on this piece. When she was finished, she showed me a drawing of a woman standing on a cliff, looking out over a vast, empty sea. The woman appeared small and vulnerable, dwarfed by the landscape. Julia described the scene as representing her feelings of isolation and uncertainty. The cliff, she explained, symbolized the constant pressure she felt to maintain control and avoid falling into despair. Through this self-portrait, Julia was able to articulate her fear of failure and the pressure to keep up appearances. She expressed how exhausting it was to always be “on guard” and how much she longed for peace. In our discussion, we explored the symbolism of the cliff and the sea. Julia admitted that the sea, while initially representing emptiness, also held a sense of possibility. She recognized that the vastness of the ocean could symbolize potential rather than just fear. This shift in perspective marked a significant turning point. For the first time, Julia began to see her anxiety not as an insurmountable obstacle, but as something she could navigate and overcome.

Session Four: Reclaiming Inner Strength

By this session, Julia had begun to show a marked improvement. She appeared more relaxed, and there was a newfound sense of confidence in her demeanor. For this session, I introduced a collage exercise. Julia was provided with magazines, scissors, glue, and a canvas. I asked her to create a collage that represented her ideal self—a version of herself free from anxiety and self-doubt. Julia took her time with this exercise, carefully selecting images that resonated with her. Her final piece was vibrant, filled with images of nature, people laughing, and symbols of strength like lions and mountains. She explained that the collage represented the qualities she wished to embody: resilience, joy, and courage. We discussed each element of the collage, and Julia shared how creating it made her feel empowered. By envisioning her ideal self, she began to see her potential beyond the limitations of her anxiety. She acknowledged that while she might always face challenges, she could choose how to respond to them. This realization helped Julia redefine her relationship with anxiety, no longer seeing it as a defining characteristic, but as one part of her broader experience.

Session Five: Reflecting and Moving Forward

In our final session, Julia and I revisited her earlier pieces. We discussed her journey through the Art Therapy process, from the initial storm of emotions to the empowered collage. Julia reflected on how far she had come, expressing gratitude for the opportunity to explore her feelings in such a unique and transformative way. She described how the process helped her develop a greater sense of self-compassion, allowing her to accept her imperfections without judgment. Through art therapy, Julia found a new way to manage her relationship with anxiety, one that didn’t involve fighting or suppressing her emotions. Instead, she learned to embrace her feelings, understanding that they were a natural part of her experience. She left therapy with a renewed sense of self, ready to face the challenges ahead with resilience and creativity.

***

Art Therapy offers a unique path to healing, one that goes beyond words and taps into the power of the creative mind. For Julia, the process of expressing herself through art provided insights that traditional talk therapy hadn’t been able to access. By working with symbols, colors, and textures, Julia was able to confront her anxiety in a safe and supportive environment, ultimately reclaiming her inner strength. Her journey is a testament to the transformative power of art and the human spirit’s capacity for growth and healing. [Editor’s Note: Please see our interview with Judith Rubin, Bringing (Art) Therapy to Life: An Interview with Judith Rubin, the preeminent pioneer in the field of Art Therapy.] 

Reasons Why Safety Precedes Forgiveness for Survivors of Abuse

Posted on by Psychotherapy.net Team

When your offender(s) can’t harm you now or in the future, you are safe. Can you forgive them? Like with all aspects of trauma recovery, the answer is not a simple yes or no. Safety isn’t just about the reality of you being safe, but how safe you feel. You might be safe but not feel safe. This is a common experience, as trauma hinders the ability to assess one’s safety accurately. Trauma tells us that we are not safe even when we are. Feeling is just as crucial in trauma recovery as being because these two experiences are often indistinguishable; for us, not feeling safe feels the same as actually not being safe. After World War II ended, forgiveness advocates might have said to Wiesenthal, “You’re safe now. You’ve survived. The Nazis cannot harm you. You should now be able to forgive.” Yet if Wiesenthal experienced trauma and did not feel safe for years after he was liberated, that would have been impossible. Survivors must both be and feel safe before they can genuinely forgive.

Forgiveness Without Safety Harms Survivors

“He’s a monster. He beat me and locked me in my room for days,” Charlie shared during an Alcoholics Anonymous (AA) meeting. “I can’t think about him without feeling angry.” Charlie began using alcohol at age 10 to cope with their stepfather’s emotional and physical abuse. By age 20, they were hospitalized for alcohol poisoning twice and had been arrested for disorderly conduct, as well as for driving under the influence—multiple times. At age 22, Charlie got sober, embraced their identity as nonbinary, and began attending AA meetings daily. AA helped Charlie to understand their trauma and use of alcohol as a coping mechanism, but the forgiveness advocates associated with AA nearly destroyed their recovery. “You need to forgive him,” was the message from Charlie’s AA group members. “If you don’t forgive, you’ll relapse, and if you relapse, you’ll die,” said Charlie’s AA sponsor. The AA group and the sponsor encouraged Charlie to forgive their stepfather by spending time with him. It did not matter to them that the stepfather continued to emotionally abuse Charlie; he often called them “a freak,” “a drunk,” and “a cunt.” The group encouraged Charlie to ignore these harmful words and approach him with compassion and empathy. Charlie followed this advice and spent more time with their stepfather, expressing compassion and empathy in the hopes that this would ignite forgiveness, which they were told would help them recover from trauma and addiction. Instead, this exposure invited further trauma as their stepfather continued to abuse them emotionally and physically, resulting in Charlie needing to be hospitalized with a broken leg and ribs after their stepfather pushed them down a flight of stairs. The AA group’s recommendation to forgive caused Charlie to place themself in unsafe situations, which led to retraumatization. As a result, Charlie stopped attending AA meetings, ended communication with their sponsor, and relapsed days later. Attempting to forgive without safety threatened Charlie’s survival. Some survivors have even been killed due to pressure to forgive their offender(s), which made them feel as if they needed to continue to participate in unsafe relationships. Psychologist Mona Gustafson Affinito writes, “Workers in the field of domestic abuse, for example, are familiar with victims returning to their abusers because they have been advised to ‘forgive’ the perpetrator. Physical and emotional injury, child abuse, and death of both victims and abusers have resulted.” Those who advocate for forgiveness should be aware that their recommendations might contribute to the deaths of survivors who are not safe. “How many battered women, for example, have returned to their batterers for more (and perhaps fatal) abuse because some counselor advised them to keep trying to save the marriage out of love and forgiveness?” asked philosopher Jeffrie G. Murphy. “I do not know what the answer to this question is, but I am worried that the boosters for universal forgiveness may not give ample thought to such issues.” Unfortunately, however, many laypeople and clinicians pressure, encourage, or recommend forgiveness to survivors without considering their safety. Regarding the risks of forgiving when one is not safe, practitioners of forgiveness therapy say that it’s not forgiveness that’s the problem, it’s reconciliation. They argue that reconciliation is to blame when forgiveness occurs without safety. “The argument seems to imply that forgiving is a way for the offender to keep a sinister control over the forgiver. If forgiving led automatically to reconciliation, then the argument would have weight,” write Enright and Fitzgibbons. They clarify their reframe with an example: “Suppose Alice forgives a husband who continues his pattern of abuse. Is she not now open to even deeper abuse? If she misunderstands forgiveness and confuses it with reconciliation, then, yes, she is open to further and dangerous abuse.” Many confuse forgiveness with reconciliation. People rarely know or communicate the distinction between these two concepts, and this mistake can cause harm. Practitioners of forgiveness therapy must be aware that though forgiveness is not reconciliation, forgiveness can lead to reconciliation, which may jeopardize a survivor’s safety. Therefore, all clinicians must provide survivors with psychoeducation regarding the difference between forgiveness and reconciliation and consistently assess the safety of survivors pursuing forgiveness. But at the end of the day, a debate over semantics doesn’t hold much weight when a recommendation to forgive could lead to a survivor’s death. When forgiveness is dangerous, it should not be a part of recovery. Of course, forgiveness without safety does not always lead to death. However, it can still harm in other ways. Forgiveness can encourage repeat offenses rather than deter them, giving the offender(s) the opportunity and incentive to continue their abusive behavior. Psychologist James K. McNulty conducted a study that found that the tendency to forgive correlated with continued psychological and physical aggression in marriage. He found that spouses who were more forgiving experienced greater psychological and physical aggression in their marriages over the first four years when compared to less forgiving spouses, who reported declines in psychological and physical aggression. McNulty expressed concern about how forgiveness can negatively impact relationships, writing that “the tendency to express forgiveness may lead offenders to feel free to offend again by removing unwanted consequences for their behavior (e.g., anger, criticism, rejection, loneliness) that would otherwise discourage reoffending.” Consequences are needed in relationships, but forgiveness can insulate offenders from the consequences of their actions, causing them to reoffend. During the first month of Charlie’s trauma therapy with me, they told me about their experience with their AA group and how their insistence on forgiveness had harmed them by encouraging them to reengage in an unsafe relationship with their stepfather. This prompted me to suggest, “What if you choose a new group that could better meet your needs?” “I can do that?” Charlie asked, surprised. “Why not?” I responded. “Your old AA group was no longer helpful. Why not see if another community could be more beneficial to you at this stage in your recovery?” Charlie hit the ground running, and within two weeks, they found a new AA group and a new sponsor who considered safety, not forgiveness, the top priority. This group asked Charlie questions such as “What do you need to stay sober?” “What works for you?” and “Do you want to forgive him?” Charlie felt accepted by this group, and as a result, they continued participating in AA, which became vital to their recovery. Months later, Charlie decided to estrange themself from their stepfather, which their AA sponsor, the group, and I supported, as Charlie reported that this estrangement was what they needed to feel safe. One year later, they received their one-year AA sobriety coin and have since continued to make considerable gains in their trauma recovery. You need to be and feel safe before you can forgive. If you are currently not safe, you cannot focus on forgiveness. You may be safe but do not feel safe, so forgiveness is currently out of reach for you as well. You may have never felt safe, and the experience of thriving feels foreign. However, it is entirely possible for you to both be and feel safe. The human brain prioritizes survival, but once this priority is met by reestablishing safety, the brain can refocus on thriving (recovery and possibly forgiveness).

Feeling Safe Enough

People often assume that certain types of traumatic experiences (physical or sexual abuse, combat exposure) are more impactful than others (financial, emotional, or spiritual abuse, abandonment, or neglect). Yet, studies indicate that children who experience emotional abuse and neglect develop the same or worse mental health issues as children who experience physical and sexual abuse. Therefore, we cannot assume that one type of traumatic event will have a more or less significant impact on a survivor than another. What’s more, response to trauma is highly dependent on the individual. [edtiquote:we cannot assume that one type of traumatic event will have a more or less significant impact on a survivor than another]I’ve worked with siblings who were close in age and lived in the same home throughout their childhoods, with the same abusive parents. These siblings never have the same experiences or the same trauma responses. They are always different. Comparing your traumatic experience with another’s doesn’t make sense; if trauma were a competition, every survivor would be a winner. All traumatic experiences are significant and valid, and so all types of safety are essential. If you are currently safe but don’t feel safe, you can begin to establish a sense of safety by accepting that all forms of felt safety are necessary. For instance, physical safety is not more or less essential than emotional safety. They are equally important. In the case of the former, you may need to feel that you are not in physical danger, and that the offender(s) or things that cause you harm cannot reach you. For the latter, the feeling of emotional safety might come when you are in an environment in which you can be honest about your emotions without feeling manipulated or invalidated. There is not one form of felt safety that should receive more or less attention or be taken more or less seriously. Every type of safety is essential in your recovery, especially since survivors often report lacking many different forms of safety. It’s common for survivors to report feeling physically, sexually, emotionally, financially, and relationally unsafe. Financial safety is a common theme in trauma recovery, which may be surprising. However, when you take a moment to think about it, it makes a lot of sense that this is so important. In most societies, financial security creates and sustains many other types of safety. Those with financial security can use their resources to support and promote their physical, sexual, spiritual, and emotional safety. Those without financial security are often the most vulnerable to experiencing trauma, less likely to be able to escape their offender(s), and less likely to receive treatment. In addition, those who do not feel financially safe often feel unsafe in other ways. For example, some survivors living in the United States do not feel physically safe because they cannot afford medical treatment if they become ill or experience an accident. Some clinicians believe that you will never feel safe until you are fully engaged in the recovery process. In this view, it is impossible to reestablish safety at the beginning of recovery. Instead, these clinicians promote intense emotional processing interventions, such as forgiveness, before you feel safe or are able to tolerate processing, believing that safety will be reestablished along the way. This line of thinking only makes sense if one believes in the existence of perfect safety, a sense of security that never wavers during the pursuit of recovery. It assumes that once safety is achieved, it never goes away, and thus, the intense recovery process can continue uninterrupted. As nice as this would be, it’s not how recovery from trauma works. Some days you might feel safer than others, and the circumstances of your life can change to bring you closer to or further away from the unsafe situations or relationships you seek to avoid. There is always the possibility of a step back in recovery, and that’s okay. It’s a normal part of recovery. No one feels safe all the time, not even people who haven’t suffered trauma. Safety cannot be a byproduct of recovery, something that happens once you start working. It must be the enduring foundation, and to lay such groundwork, the clinician must work with the survivor to establish safety before anything else. The truth is that recovery comes with safety, not the other way around. Perfect safety is unobtainable, but feeling safe enough is possible. Events and experiences can and will threaten your safety. If you’ve ever had a pet, you’ve probably seen this play out. For instance, imagine your cat is asleep on your lap. Suddenly, the cat jumps up, looks at the corner of the room, and freezes. The cat’s hackles are raised, as if static electricity has made their fur stand up. The cat is in survival mode; they heard something that caused them to feel unsafe. Then, after a few moments, the cat lays back down on your lap and falls asleep. The cat has reestablished a sense of safety and now feels safe enough to refocus on thriving (napping in the open). All organisms have moments of feeling safe (focused on thriving) and moments of feeling unsafe (focused on survival). They go back and forth, course-correcting as they go. The goal for survivors is not to reestablish perfect safety; that is impossible, and they never had it in the first place (none of us do). The goal is to reestablish actual safety and a felt sense of safety, which promotes your survival and makes you feel safe enough to focus on thriving. As you progress in recovery, your clinicians hope to see you become more resilient as your sense of safety increases. Reflections for Survivors Survivors who question the importance of their safety can ask themselves the following:
  • Am I safe? If not, can I prioritize reestablishing safety?
  • Am I feeling unsafe? If so, can I prioritize reestablishing safety?
  • Do I feel physically, emotionally, sexually, relationally, spiritually, or financially unsafe? Do I feel any other type of unsafety?
  • Do I know what I need to support my actual safety and feelings of safety? If so, can I communicate these needs to my clinicians and those in my support system?
  • Can I prioritize my need to feel safe enough over my participation in intense emotional processing interventions such as forgiveness?
Reflections for Clinicians Clinicians working with survivors can ask themselves the following:
  • Do I believe my client’s safety is vital in their ability to progress in recovery?
  • Have I assessed my client for all forms of safety (physical, emotional, sexual, relational, spiritual, financial, etc.)? Am I continuing to assess their safety at all stages of their recovery?
  • Does my client always feel unsafe, or are these feelings triggered by something or someone?
  • Am I helping my client reestablish both actual and feelings of safety?
  • Am I prioritizing my client’s sense of feeling safe enough before introducing processed-based interventions such as forgiveness?
* Reprinted with permission from You Don’t Need to Forgive by Amanda Ann Gregory copyright © 2024 Broadleaf Books