I was debriefing with a trainee about a therapy group we co-led. We were talking about how to feel comfortable in the chaos of the conversation. The trainee is used to having only delivered structured treatments in which each session is fully prescribed. I explained that to be comfortable in chaos, I work very hard to make sure each moment can be explained with some framework or another, the most important of which is to intensely track the process and trust that working in the here and now will always reverberate into the depths of the person’s psychic needs and issues. 

So, what I really believe happens in therapy is that our past experience with primary caregivers leaves an indelible mark on our psyches in ways that most people don’t realize. It’s not as straightforward and obvious as “if you have been neglected in your life then you will fear being neglected again.” This much may be true. But, the interesting thing is what happens to your mind and how it plays out in the here and now. 

Continuing with the example of neglect, the deeper thing that neglect does is to make it harder to know what one actually feels let alone express it. Neglect leads to feelings of loss, abandonment, rage and self-loathing all covered over with a patina of dissociation and apathy. In the dark recesses, the neglected person feels like they must not deserve to be loved. Whenever they need someone to comfort them, they shut that need down. As if they think (though never actually hear or realize), “Don’t ask for comfort. No one will comfort you anyway.” Or, “Who are you to deserve that?!” Rage at being abandoned is redirected to the self for needing others in the first place. “Why are you so weak, selfish and pathetic? You should be a better person. Don’t be a bother.”

Then, what happens in the here and now conversation is that the neglected person in some way checks out of the conversation. They can become vague or confusing, quiet or cliched—talking a lot without say much. The listener can feel lost or confused. The listener may also feel unimportant or invisible because suddenly the neglected person is lost in their own head and unaware of the listener. The listener can’t get a word in edge-wise or can’t get the neglected person’s attention. The neglected person has hidden themselves either explicitly or in subterfuge. 

In these moments, the therapist tracking the here and now process can help the neglected person reclaim awareness of the given moment in a safe and tolerable way. The therapist can intervene in so many creative ways consistent with their own style and comfort level or in ways that are appropriate to the given moment or appropriate to the historical relationship with those in the conversation. The therapist can point out what they observe to be happening in the neglected person, in the listener or therapist, or between the participants. (e.g., “I notice that you suddenly changed the topic and began telling us a story that doesn’t seem to relate to the point” or “Hey, where’d you go? All of a sudden you seem to disappear”). They can simply break down what they saw unfold moment to moment, or invite participants to share how they are experiencing the moment  (“I just noticed that when XX asked for an explanation YY moved on without answering the question. What happened?”). Once this space for experience and need is made, the therapist can help the neglected person express their need for comfort in an assertive way that implies, “I have hope that you may comfort me” and, as equally importantly, “I deserve to be comforted.” And, in these small moments, the neglected person is not neglected. And, the legacy of neglect is kneaded out. 

Then, we do this again and again.