Should a therapist cry with their patients?Read More
I work with a group of advocates who champion the cause of encouraging adoption of transition age youth. They go around the city talking to youth about holding on to the hope for unconditional family love and commitment, and they recruit parents to fulfill those dreams.
They hurt today when one young man in the audience despaired, “fuck family!”Read More
, a patient of mine comes out from under the dense fog of childhood traumaRead More
Today, a mother shared memories of being one of those little children who dallied walking to and fro from school, dreaming up fantastic elaborate worlds of little fairies hiding under blades of grass, building cities in piles of sidewalk snow. She was punished by her teachers for being so late, and now she worries that her own child will lose that precious imagination if labeled ADHD and medicated.Read More
I spent the day at a conference with panels and panels of renowned experts examining the nature of psychotherapy. These people have devoted their careers to understanding the process through which psychotherapy works. Yet, the discussion was leaving me bored and uninspired.Read More
Though many therapists are trained to believe that they need to suppress or control feelings of anger, I think it is incredibly important to use them in therapy because they often reveal important patterns in the patient’s life--ghosts of relationships past. When these feelings go unexamined, they can harm the patient because they can slip out in hurtful ways. But, when examined, they can be some of the most healing moments in therapy.Read More
This post is about how a trauma-informed approach, at least the way I view it, might differ from standard clinical practice.Read More
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.
A young infant cries, because that is almost all they know to do. An attentive parent says, “Oh, so tired!” and picks her up. The infant quickly settles.
Another infant waits for his mother’s gaze. When caught, he smiles; she smiles back.
A toddler is playing in a new and strange waiting room, sees a curious object across the room and looks pensively at her father. He says, “It’s okay.” She gathers herself and proceeds to the object, assured that her father still watches.
Leaving my office, a preverbal two-year old cries “broke!” because the head of his lollipop fell off. His mother, rushing to leave, says, “Forget the lollipop. Let’s go! There’s another one in the car.” The boy stays, absorbed in the tragedy. She threatens to leave him and walks towards the exit. He cries harder, “Broke, broke!” I say, “Oh no! The lollipop broke?!” He says “yeah” despondently, settles, moves on.
A verbal toddler watches traffic pass by, while I converse with my friend. He sees a truck, points and says, “truck.” My friend ignores him to continue our conversation. Growing agitated, he insists louder and louder, “truck, Truck, TRUCK!” Without missing a beat, my friend turns to him, says, “Truck!” and returns to our conversation. He settles; resumes his watch.
A preschool child yells, “I hate class! I don’t want to go! You can’t make me!” Her father asks, “Are you nervous about going to class?” The child looks down, settles comforted, waits.
A colleague shares her pain in our secondary trauma support group. The rest of us sit in silence, allowing our full presence to hold her pain among us, restraining our urge to make it better, fix it or hurry it away.
A new patient leaves me a voice message angry that I suggested an exposure exercise for homework. She has just read a news story in which another trauma expert derided exposure therapies. When she comes for therapy, I explain how the exercise is different in a way that satisfies her. I see the fractal of her infant self crying, desperate, and tell her, "Right now, I hear you also saying, 'I’m scared to start therapy and face my traumas, and I am not sure I trust you yet.'" She tears, breathes and settles, telling me how afraid she felt the night she called.
The need to be known is universal and devastating when denied. It’s rooted in an infant’s cry and flourishes into thou and I.
Sometimes change is hard. As a person changes in therapy, they become a better self. Some people feel really bad about who they were before therapy. For instance, many people become more caring for others and regret having lived so selfishly in the past. I think these people had to be selfish in the past because caring was too dangerous. When people have experienced significant interpersonal hurt, connecting with others just leads to more hurt. One’s self-protective instinct says, “Don’t you dare open up again!” Yet, as one grows in love, self-acceptance and healing, it’s hard to keep disconnected from others. Therapy heals the heart and when the heart opens it necessarily begins to connect with others. That’s its function: to remember and extend our interconnectedness. So, if this interconnected caring feels too unfamiliar, strange and frightening, remember what you really value and care about, which for most people includes love and being loved.
If anxiety and fear drives you, your only chance of thinking clearly is to remember what you value most. ...a soldier’s courage carried by love for fellow soldier, a patient’s perseverance for the sake of self waiting to be born.
I’ve been thinking a lot about managing difficult conversations recently because of some intense family work I’ve been doing and thought I’d write out my ideas to help me understand them. Please feel free to comment and ask for clarification to help me further my thinking.
So the bulk of what I seem to be doing in therapy nowadays when it comes to conversations is to help people attune to the multiple streams of discourse that are occurring simultaneously in any and all conversations. The most superficial stream is the actual topic and the words spoken. This current is the visible surface of every conversation. Under that is the current of feelings that are still visible from above but still sometimes requires the intentional light of attention to discover. Under that lies a deeper current about beliefs, particularly about the world and one’s values in the world. Here lie beliefs about how the world should work, how others should behave and how others should treat each other. The deepest and most difficult to find current of conversation is about beliefs about the self. What is this conversation implying about who I am as a person and my value as a person? Is this conversation making me look stupid, wrong, mean or smart, right, or otherwise virtuous?
Problems arise when the deeper currents are becoming agitated but the actual topic of conversation doesn’t move to focus on the underlying currents. Conversations about politics or religion are clear examples of when beliefs about the world become primary, but they are generally avoided because they agitate the currents of self-value, whether a person is fundamentally good and moral. Between parents and children, some conversations seem to be about mundane problems or challenges (like getting homework done or setting a curfew), but they suddenly and unexpectedly blow up because the conversation triggers feelings of “I’m a horrible parent” or “They’re treating me like a child and I am not a baby!” The tricky thing to do is to know when certain currents are taking primacy in a conversation and then being able to have conversations from that current.
When trauma is somehow in the picture (either trauma in the child, parent, or both), the waters become even choppier. Trauma has a tendency of hijacking any conversation, especially when there is strife, stress, or intensity. Trauma tends to escalate feelings very quickly too because one’s self-protective alarm response is easily triggered and rapidly mobilizes a fight or flight response. Trauma also gets deeply embedded in the currents of belief: the world is not safe, you are dangerous or scary, I can’t trust anyone, I don’t deserve love, or I deserve to be hurt.
In these situations, it’s even more important for people to watch for how trauma is distorting or impacting the current of conversation. And, when the conversation starts to feel heated, confusing, or frustrating, then I strongly believe that people need to take a pause to figure out what is happening at all currents of the conversation. Sometimes, this can be very hard to figure out, and people may not feel safe enough to share the deeper currents. That’s why a sensitive therapist can help people articulate the currents and do so in a safe way.
It’s still very hard, though; trust me.
(Originally posted on drjacobham.com)
herapy is such an interesting, magical thing and there are so many ways that it can help and for such a variety of issues. It's honestly hard to describe what makes it work, and I think most therapists would struggle to summarize an answer. I’ll give my favorite answer to how therapy works, recognizing that it’s definitely not the only answer.
Therapy helps people heal interpersonal wounds and build trust and love with other people and more importantly with themselves
Most people who seek therapy struggle in their relationships with others and this struggle often reveals struggles in people’s relationships to themselves, which in turn is often reciprocally due to earlier problems in their relationships to primary caretakers. It’s as if all relationships at every interpersonal and intrapsychic level are literally fractal--that is, they echo each other at different scales of experience. Even a person’s relationship to their therapist echoes this core, fractal pattern of relating. I personally enjoy working in this way and pay careful attention to my experience in the room with another person and the moment-to-moment nuances in our interactions. I trust that what happens in the moment is a fractal of the core issue, so exploring and healing the moment will heal relationships that expand out into the real world and pierce inwards towards one’s relationship to the imagined “Others” in one’s heart and to one’s relationship to oneself.
I find that this careful, attentive listening works really well when working to heal all types of family relationships too. This approach seems to help people get out of the rut of having the same fights over and over again. Most family fights happen because people are too afraid to speak from the true place of vulnerability and hurt. Instead, they lash out and attack back when they feel they’ve been attacked. People also have a hard time acknowledging and listening to each other, desperate to make sure their own voices don’t become diminished or drowned. At other times, ghosts of relationships past, self-hate and self-criticism haunt us and distort everything we hear into the messages we most fear hearing. For instance, we hear “I wish you wouldn’t do that” as “I think you’re stupid and disgusting.” Or, more commonly, we hear “I’m tired of fighting with you” as “I hate you and I’m leaving you,” which scares the heck out of all of us!
If my approach doesn’t fit with you, that’s okay. I think the fractal nature of experience means that many kinds of therapy can heal because the healing has a ripple effect across the levels of experience. For example, a cognitive therapist might focus on uncovering and challenging destructive core beliefs about oneself or others; a behaviorist might focus on coaching specific ways to change one’s behaviors in real relationships outside the therapy room; or a psychoanalyst might explore childhood history and/or its impact on the here and now of the therapeutic relationship.
So, the most important thing to consider when finding a therapist is not what type of therapy they practice, but how they make you feel when you talk to them. All consumers of therapy know this implicitly and act on this knowing by either showing up every week or missing appointments and avoiding therapy (I wish that more of clients would express their dissatisfaction with verbal feedback, instead, so therapists can learn and become better therapists).
There is such an incredible amount of hurt that flows like a deluge across the world. It crashes through us one interaction at a time as we are hurt and then hurt the next in return. The only way to stem the tide is to actively and defiantly say “I will no longer allow this hurt to pass through me and poison me.” Then, this commitment needs to be made again and again, because the tide of hurt is big and deep. It wells around us and springs from us. But, someday, the momentum can change, such that being light becomes a little more easy, less work. I promise. Be patient. In fact, that patience is one of the first and most important acts of love and light that stems the tide.
I think the most important skill--one which is very difficult to teach--is the ability, willingness, and courage to stand emotionally naked but steady in front of another human being and bear witness to that which is unbearable. To allow oneself to be fully moved by the devastating horror that trauma represents without being overwhelmed by it.Read More