New Journal Article on the Importance of Relationships in Trauma Therapy

As you have probably guessed based on my blog, I have a beef with the misrepresentation of effective trauma therapy as being narrowly evidence-based, which often leads people to conclude that the best therapies are the most studied, which often defaults to cognitive-behavioral therapies. But, what the general public less frequently hears about is the vast evidence-based, research literature showing that the therapeutic relationship is the most important ingredient in effective trauma therapy (and therapy for lots of other disorders for that matter). Here’s a really cool new article that supports this fact.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

http://dx.doi.org/10.1037/pst0000228

Abstract

The therapeutic relationship and responsiveness/treatment adaptations rightfully occupy a prominent, evidence-based place in any guidelines for the psychological treatment of trauma. In this light, we critique the misguided efforts of the American Psychological Association’s (APA, 2017) Clinical Practice Guideline on Posttraumatic Stress Disorder in Adults to advance a biomedical model for psychotherapy and thus focus almost exclusively on treatment methods for particular disorders. Instead, the research evidence, clinical expertise, and patient preferences and culture (the necessary triumvirate of evidence-based practice) should converge on distinctive psychological guidelines that emphasize the therapy relationship, treatment adaptations, and individual therapist effects, all of which independently account for patient improvement more than the particular treatment method. Meta-analytic findings and several trauma-specific studies illustrate the thesis. Efforts to promulgate guidelines without including the relationship and responsiveness are seriously incomplete and potentially misleading. The net result is an APA Guideline that proves empirically dubious, clinically suspect, and marginally useful; moreover, it squanders a vital opportunity to identify what actually heals the scourge of trauma. We conclude with recommendations for moving forward with future APA practice guidelines. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

The Center of the World

A set of parents took a step back to ask if our discrete trauma treatment for their children was taking into account the impact of the horrible event on them, a question their couple’s therapist had asked them to ask. Without fully understanding what was meant, I shared the itch gnawing my intuition: I didn’t know the husband yet and his presence often disappeared from the room. The wife agreed that her husband wasn’t “therapized" like she was. He defended by saying that he’s been in plenty of years of therapy.

But, she’s been in therapy for years and years, and therapy revealed to her that she had been living in the world as is, but there was a floor beneath the world—one filled with nuance, complexity and layered meaning. Over the years, she realized that the floor was actually just a hallway to floors upon floors until you reach the center of the world, and she loved living in that world, exploring its ever changing and revealing landscape. Her husband only visited a few floors from time to time.

I actually freaked out for a second. How did she know about this world?! Who showed her?! I felt both validated and banal and needed to know the name of her therapist.

Afterwards, the nature of our trauma work plunged into the gravity of Kairos.

*shared with permission

Transforming the Ember of Rage

I met a man who experienced unbearable, unspeakable
and unspoken horrors at the hands of his
parents. He observed
that when they died he
grieved for just a moment, before
moving to the comfort of anger,

anger at the fact that they
would never be
able to restore his childhood
so violently wrenched. Then,
for the next ten minutes, he lost himself
in this rage against the world.

When he spoke of this grieving rage, I imagined
sifting through the ashes of a dying fire
discovering a weak ember of life.

But, as his rage engulfed, this ember
turned into a blaze of Pyrrhic victory burning
everyone.

I hurriedly gathered that ember
gingerly nursing it without igniting it,
to light a torch illuminating
the path to what he is truly fighting for.

I told him that he should fight
to reclaim his childhood—to be
surrounded by the safety
of love, so he can finally
play.

*shared with permission

Fighting for Love

A beautiful autumnal woman dragged her handsome winter boyfriend in
for one last desperate attempt to make this miracle work.
Her history of abandonment triggered by his enacted history of neglect.
He yearns for her, like tiny arms reaching for the mother
who left him stranded on a front yard
at an age too young
to understand in any other way than
he’s not worth taking.

He’s slipped past therapy his whole life,
a lesson in never letting anyone get close enough to hurt him or see his un-worth.
Christmases in the Caribbean, avoiding all reminders of love and family.

But, for her,
anything.

So she lashes him with wet tears,
angry when he turns away,
scared that this will push him away,
guilt-ridden knowing his history, but blinded by her own pain
and her own needs.

I help her see
herself as fighting,
fighting for love, fighting.
Fighting for “I deserve better.”
“We deserve better.”

He shrinks in self-absorbed self-flagellation, reliving
his unworthiness in every
cell. A prisoner
of his pain.

Now, I get angry.
I refuse to let him disappear.
I yell, “Do not leave her!
And, do not leave yourself on that front yard again.
Fight for her! Fight for yourself!
Open your heart and embrace her pain.
The greatest challenge and the greatest reward
left undone in your life is
to feel
to hurt
to love
to hold
and never, ever, let go again.

*shared with permission

The Wisdom of Negative Emotions

Part of the work with one patient revolves around this question: What is the value of sitting in uncomfortable emotions?

My patient tells me that his teen-age cousin from out of town is visiting him over the holidays. This is a cousin whom he wishes he could know better and support more. They and some other family members are having a holiday meal. My patient asks the teen what gift she is giving her mother for Christmas and the teen says, "Nothing, I hate her." My patient understands that the teen and her mother are struggling quite a bit, but he doesn't like the negativity displayed so publicly during a holiday meal. Over the course of the meal, my patient grows more and more annoyed by the teen's endless chatter about nothing and can't wait for the evening to end. He ends up feeling guilty for harboring such negative feelings towards his dear cousin and thinks maybe he's just not very patient with teenagers and is a bad older cousin.

After receiving his permission to offer some advice, I tell him that he can't dismiss his annoyance because it holds wisdom and insight about what he really cares about. His annoyance is telling him that he is frustrated in his desire to have a meaningful moment with her so that he can really get to know her as a person, a longing he himself expressed earlier in the session when he said so beautifully,

"I don't really know if my father ever thinks about me when I'm not in front of him."

Secondly, his annoyance is telling him that he really cares about feeling gratitude for the moment that they are able to share together with other family members during that meal.

At the same time, I remember how deeply he appreciates his mother's love for him. I visualize one of the earliest memories he has shared with me--sitting on her lap while reading a book--overlaid onto an image of the same energy holding him over the phone while she listens to him speak as an adult. I don't mention this explicitly, but feel it settling into my heart and coloring my experience of the moment.

Next, I imagine how he might be guided by what he cares about. I tell him I imagine him whispering to his cousin, "I wish we had more time to really talk and
get to know each other."
Like a hug.


Then, I imagine his cousin's energy settling and easing
out of her anxious wanting to be seen while being afraid of being judged,
manifest as the endless babble about nothing.

And in that same moment,
my patient's energy is settling,
his self consolidating, as
he sees himself more
compassionately
and imagines himself more
powerful and effective
in the world, achieving
the knowing he wishes for his cousin
and for himself.

*shared with permission

My Therapist's Journey: Play Therapy

The second biggest pillar of my early training was play therapy. I probably did more play therapy than anything else during grad school because I had a part time job placed in an elementary school treating about 15 children per week.

Children taught me a lot about how to bring spontaneity and playfulness into my work. Children will not put up with a neutral, distant person and will tell you whether you are doing right by them, whether you like it or not. If you listen, they will teach you how to be the therapist they need, but you still need to play and experiment for them to know "yes, more" or "no."

When I was thrown into play therapy, I never really received any clear instruction on how to be therapeutic. I even took a semester-long class on child therapy but didn't learn a thing about technique, just a bunch of theory. Now, it is true that some of the developmental and dynamic theories were informative and I found that children's imaginative play often paralleled real-life themes. For example, one five-year-old only watched Lion King up to the point of the father's death and then rewound the tape over and over again. Other children play out generalized themes of powerlessness, fear, family stress, social stress, anger or sadness. But, this work was plodding and it was often difficult to know how to make this play helpful in the real world. Furthermore, many young children quickly grow out of pretend play beginning around age 7 and move into board games and other rule bound games.

It was through hours of playing Uno and Sorry and Trouble that I began to understand that children at this stage were practicing a variety of skills: turn-taking, following the rules, reciprocity, fairness, impulse control, controlled aggression, good sportsmanship, decision making, frustration tolerance, planning, etc. I really began to understand moment to moment activities in terms of what skills or neuro-cognitive functions were being expressed and exercised.

I also had the amazing fortune of learning Ross Greene's Collaborative Problem Solving Approach early on and co-led parenting groups with him in an outcome study comparing his approach to Russell Barkeley's Defiant Child approach, which is a classic behavior management approach. I was beginning to see behavior as being the shaped by external reinforcements (as highlighted in behavior management), neurocognitive drives and deficits (Ross Greene), and internal psychic and relational drives (psychodynamic).

I was becoming more and more interested in diving deep into the moment-to-moment world of play and overlaying these paradigms onto the immediate behaviors and experiences. I started to care more about how things are being said and done versus what was being said or done. In fact, I rarely ever asked children how they were doing or bothered with helping them "open up." Instead, I just played as hard as I could. I tried to really imagine all of the imaginary actions happening between characters. I competed in board games with gusto. I began to figure out what the issues were as they emerged in moment to moment play and tried to figure out ways to correct them without leaving the play.

This obsession with the moment to moment process has carried with me throughout my work and remains a core aspect of how I work and what makes me effective. I listen and observe on so many levels at once: what's being said or done, how, when, why now, how it's connected to history or to other relationships, what's the deficit or the struggle, what's the yearning or aspiration, what's the hurt and pain?

In future posts, I'll give a nod to cognitive-behavioral approaches and then spend a lot more time on modern relational approaches as applied to individual and family work.

The Truth about Trauma Work

I was working with a couple terrorized by demons of severe trauma experienced as children, re-inflicted on each other. They lashed out at each other trying to cause as much pain on the other as they felt themselves. 

And I dove in head first with barely a safety line in tow. 

Utterly uncertain that I would be effective or helpful. 
In a zone. Half unconscious. 
Trying desperately, 
using everything I've learned, making stuff up along the way. 
Tracking them to see what worked; 
stabbed with pangs of regret and doubt when it didn't. 
Moving in and out of panic and beautiful poignancy. 

The session focused on de-escalating the husband, he with a history of violence, while
monitoring the fear and the fury in her eyes who suffered the violence. 
Trying to stay empathic to his pain, while
not forsaking the pained by pushing him
to acknowledge the pain he has caused. 
He moved between ferocious disappointment that everyone let him down and his unbearable shame that he in turn disappointed others in ways nigh unforgivable. 

My heart ached for him. 
Holding both his suffering and his crime was unbelievably difficult
and only possible for me because of the painful work
of accepting my own crimes and broken parts. 
It triggered in me a deep sense of sadness, shame, acceptance, and  compassion. 
Then tenderness, for both of us. 

I stayed with him, 
brushing aside the hurtful parts, mining for the hurt. 
Digging barehanded for shrapnel lodged in his heart, without anesthesia. 
Phantom pain from my own shrapneled heart burning in resonance. 

When something did work, it didn't feel like I could take credit. I'm so aware of how often the very same acts fail with someone else or in some other moment. The only conclusion I come back to again and again leaves me with a deep gratitude for the angel of therapeutic healing that blessed us that day and for the courage of my patients who grace us to co-create these magical moments greater than anything we could imagine or will alone. 

*shared with permission

two brothers learn to feel and heal

Yesterday i met with two young school-age brothers, whose mom brought them in so they can learn to get along better and stop fighting. I’ve met with them separately and the older one says he likes to hurt and tease his little brother because the little brother is annoying and makes up lies to get the older one in trouble. The younger one wishes that they would get along better but he feels like the older brother doesn’t like him and hurts him so he has to get revenge to make him stop and to hurt him back. 

The boys come in a little silly and aggressive with each other. They are huge, burly young boys dripping with testosterone. Last session, the younger made up this joke: whenever we said something that made him feel proud, he said, “I can feel my chest hairs growing!” I imagine them as bear cubs wrestling in the wild. The mother does a great job of keeping their energy in check and to my surprise these boys have always been able to sit through entire therapy sessions and stay engaged in conversation, a feat that I rarely see from school age children. 

We review that the purpose of today's session is to help them learn to get along better. Mom brings up an example from last weekend: the younger one had a baseball bat. The older one chimes in and says that the younger one was swinging the bat. The younger one denies swinging it; he was just holding it. The older one gets frustrated with the lying and they start going back and forth. 

We try to move past this by continuing with the story. The older one continues, saying that he was holding a large stuffed animal as a shield. The younger one interrupts, “It wasn’t that large." The older one gets agitated again, so we try to hurry on, knowing that this won’t get us anywhere. 

The older one says that the younger one then hit him in the knuckle and showed me the bruise. He’s getting really agitated and accuses the younger one of doing it on purpose. The younger one vehemently denies it and goes back to saying that he didn’t swing the bat. This makes the older one even more livid and the moment is escalating. 

I stop them from going back and forth about what exactly happened and ask the younger one what he is feeling. He takes this seriously and reflects for a while, which is so amazingly adorable because it shows how mature and willing he is to think about his emotions and it shows how much good parenting he must have received to want to access these feelings. The older one is capable of this too, by the way. 

Nevertheless, he can’t come up with anything. I ask if I can offer some ideas. He nods. 

I ask, “Do you feel bad?” 

“Yes”

“Why? Because you hurt your brother?”

“Yes”

“What should you do when you feel bad about hurting your brother?”

“…say I’m sorry?”

“Yeah!”

“But, I already did!”

The older brother cries out, “No, you didn’t! You never said you were sorry and you never feel bad!” 

Mom tries to jump in saying that she thinks she heard the younger one apologize, but she wasn’t in the room to hear it actually. 

I’m trying desperately to figure out how to move away from this back and forth quibbling, which all people get mired in.

I recenter back into what’s happening now and try to figure out why the older is mad right now. I say to him, “You know what I think is going on?” He gives me his attention. Another adorable hallmark of attachment security and willingness to de-escalate. “I think that just thinking about what happened and seeing your bruised knuckle is making you feel hurt again.” 

He tells me that that’s partly true but that more than anything he’s mad because his brother is lying! I love that he rebutted and clarified, because it’s such a sign of autonomy and agency, and engagement with the self-exploration. 

Then, I try to help him see that his younger brother is feeling defensive and bad so he’s trying to minimize what happened. He doesn’t care. I admit to myself that that strategy didn't work. He doesn’t want to acknowledge his brother’s experience when he’s hurt. 

So, I turn to the younger and repeat that his brother is mad and hurt right now, so what can he do to help his brother feel better. He starts by saying that his older brother needs to learn to tell the truth. His older brother gets angry and says, “He asked what YOU should do!” I nod in agreement. 

The younger one says, “Say I’m sorry?” 

The older one, whose head was down, snaps to and glares at his brother. The younger one smiles back nervously, I think. This part happened really fast, and I was in the middle of saying something like, “And that you didn’t mean it?”

The younger one says, “Yeah, that’s what I was trying to say," referring to his “lying” about not swinging the bat. 

The older one is not having it. 

I realize that I missed something and ask what just happened and why the older looked at his brother. 

The older says that the younger is lying. I disagree saying that if the older had looked at his brother while he was apologizing he would have seen that his brother was being sincere. The mother nods in agreement. 

The older continues, “But I’m getting this weird feeling on my side and I only get that feeling when I know that someone is lying to me about feeling sorry.” This is reminiscent of a breakthrough moment earlier in our work when we talked about how missing his mother when he is hurt is just something that his body naturally feels. He really liked that his body had a form of wisdom that made it okay for him to feel certain ways. 

The younger brother goes and sits on his mother’s lap. I can see that he’s upset because he opened up to be vulnerable and he was rejected. 

I realize that I was also quibbling and finally notice that the older boy has his head down. His face is reddened, and he looks sad. I ask him what he’s feeling. He doesn’t know. The younger brother chimes in, “Disappointed.” This is such a lovely acknowledgment that his apology wasn’t enough. But, the older brother lashes out, “No it’s not!"

Realizing that nothing we could say would feel good enough for this little boy, I suggest to him that he’s turning into the Hulk, which I’ve described to him in the past. I say that he’s so hurt that his Hulk is coming out to protect him and it’s making him want to be mad instead of hurt. I say, “It feels so much better to be mad than sad." 

He lightens up and agrees, “Yeah, being mad is fun! I like to hurt my brother!” 

And I think i can sense in the corner of my eye that the younger one is steeling himself for more cycles of useless vendettas, which is a realization that dawned on him last session and inspired him to want to work things out with his brother.

I interrupt the process and say, “Oh now I get it. You’re too upset to accept your brother’s apology!” 

He agrees and mumbles to himself, “I need to get the anger out.” He starts breathing deeply, clenching his fist and trying to figure out what he can punch, which is all quite adorable too because he’s acknowledging that his anger is limiting him right now and he’s taking responsibility for reducing it. 

However, I think he can do better. I tell him, “You know, I don’t think you need to get the anger out. I think you need to learn to stay in the hurt and get the hurt out.” He looks at me with a look of repulsion. 

I press on, "How can you do that?”

He says he has no idea. 

I say, “Well, you see what your brother does when he gets upset?”

“Yeah, he lies about me.”

“No, not that. He goes to sit in your mom’s lap.” She’s still holding the younger one lovingly in her lap. 

He looks up with another look of repulsion, like he’s too grown to run to his “mommy." His mother reacts playfully by extending her arms out to him, suggesting she can hold both of them, but also exaggerating the gesture to acknowledge his repulsion. 

I fold an insight based on this into the next thing I say: “I think it’s tough to be the older brother. Because once your brother came around, he got all the attention and you thought you had to take care of yourself, even though that’s not true.” 

As I’m hoping would happen, his mom jumps, “Yeah that’s right. I want you to know that you can always come to me. Like remember that time you came to me and said, ‘Mom, I need some alone time with you,' and we did. We had some really special time together?” 

The boy lightens up and I can tell that he’s okay and we have run out of time. The younger one holds up his hand and the older one mirrors it. It’s hard to tell whether this is a request for a high five or a threat. They stay like this and are smiling. They resume playing, trying to work out whether they trust each other enough to close the loop of intimacy they just created. 

Running out of time, I turn to the mom to debrief about what happened and she wants to bring the boys back to do this again. As we are looking at our schedules, the older one yelps. They were still playing this strange game of brinksmanship, and the younger one had slapped the older one’s hand. The rough play that got them into this place of hurt over the weekend is happening again, but this time it doesn’t escalate into such personal pain. They move on. The mother very quickly tells them both to stop but we are both rushing to warp up. They barely register her and just move on to enjoying more rough and tumble play, wild cubs again who are not harboring resentment as they balance the limits of playful aggression and connection. 

 

*shared with permission

My Therapist's Journey Part 1: Insight.

I've learned so many different types of therapies over the past 20 years and continue to take from everything I’ve ever learned. In a series of posts, I'm going to share what I've personally learned about therapy and becoming a therapist. I hope these posts help future therapists embrace their own journeys and help patients feel more informed and empowered to seek good and smart therapists rather than good and smart therapies that fit their needs in their current moment. 

Read More

Ode to A Depressed Person

I know someone who always feels like ending her life. I told her that I admired the way she lived, which is a ridiculous thing to say. Why would anyone admire someone who is always at baseline suicidal? I tried to unpack what I meant by it and this is what came out:

You, who bears this unrelenting weight of depression,
wake every morning and ask, "Why not today
finally Rest?" 

I know for you
life drags on
despite your protestations,

but I believe that you
more than anyone else has
this remarkable opportunity
, or maybe undesired obligation,
to choose life
every
moment.

See, for you, life
is not a given, 
like the certainty of sunrise.

Every morning, you must choose,
stay or go? 
Every morning, you ask yourself, why stay?
How do I make
today
at least bearable
and possibly worthwhile? 

Then,
to see you be kind and generous and loving,
I am left concluding,
that love alone fulfills life's purpose. 

And, I am reminded that for me love is the source from
which all worthwhile things must spring
(I worry so much about how much hate drives our politics these days)

Then, I feel
reaffirmed, revitalized,
and grateful, for you, who bears this weight, 
reminding me to love and
act in all ways from love.

My Patient's Lovely Description of Our Therapy

It's like you hold up a mirror and I really don’t want to look into it because I think I am so ugly, but deep inside I wish I were cute and pretty (she tears up). But, you keep holding up the mirror and show me that I just have some dirt on my face and you help me brush it off. Then I begin to realize that maybe I’m not so ugly...

Read More

Today's Touching Family Moment

Today a man,
who just months ago
was unsure
whether he wanted family therapy
(at least with me)
then only wanted to work on problem solving,
then only wanted to intellectualize,

finally cried
about missing his father,
grieved the imminent loss of his favorite uncle,
and shared how he suffers
a desperate longing
to connect
with his teen-age son
(who can't make sessions
because of other commitments).

And his wife and daughter
leaned into his pain
with tears in their eyes,
not talking,
not problem solving,
only conveying
love
and gratitude.

And I too honestly
felt moved
like listening to Adele
or singing Karaoke :-) 

And I reassured the father
that this new man
will draw his son
inexorably
like love
is wont to do.