False Memory Syndrome and Memory Work in Therapy

Posted on May 5, 2012 by Brett Newcomb

Last week I wrote about doing work with sexual trauma survivors. Today I would like to talk about doing work with trauma survivors of all types. In particular, I will focus on the issue of memory work. One of the ways that people survive traumas is to dissociate. When they have dissociated, they often will have holes in their memory. These gaps can be specific to an incident such as having a car accident. One client remembered getting in the car to go to the grocery store and waking up in the hospital several days later. She had no memory of anything in between. The client was told that she had been in an accident, had been in the hospital for several days and she had had surgery. She would be ok, but she remembered nothing after getting into her car. She does not know where the accident occurred, what happened, or anything about the trip to the hospital. In her specific case, there may be memory loss resulting from a head injury, or it may be loss from the repression of the traumatic memory. If it is the latter, there is a very good chance that when she is strong enough to “carry” the memories, they will come back to her and she will “remember.”

The selective repression of memories that are scary or severely upsetting is an extreme form of a very common defense mechanism. According to Freudians, the first defense mechanism we develop is the one called repression. Repression is actually a form of selective editing. One does not really forget something, rather your unconscious protects you from something that it feels you cannot handle by causing you to “forget” it. It is not really forgotten it is repressed, blocked or covered up. It will stay covered up until your ego knows you are capable of remembering and thereby able to handle whatever the emotional content of the memory would be.

Another example that is very common of repressing or selective editing of memories is when a client comes in and says something such as: “I cannot remember my sixth grade year at all. I know I went through the sixth grade, but all I can remember is kindergarten through fifth grade, then I remember middle school.” It is not uncommon to find people who have significant gaps in their memories that are what we call horizontal barriers. It is as if a roadblock was placed over their memories for a certain period and they had to detour around that block of time. They remember everything before and everything after, but the period of time that needs to be repressed they have no “accessible” memories.

One other extreme example of repression is the example of someone suffering from Dissociative Identity Disorder, DID. (In the old days we called it multiple personality disorder.) In this case, the repression occurs in the form of vertical divisions or barriers, meaning that is that you will have a compartmentalized identity that has its own linear memory. A “part” or an identity will keep a particular history. They will remember the sequence of events that existed on the timeline of that part. If the “part” was present when they were in the sixth grade through high school, there will be linear memories of everything that happened to that part from the sixth grade through high school. What there will not be, at least accessible to that part, are memories of what happened to the other parts. The knowledge of these different parts is vertically compartmentalized and separated from each other.

DID is an artifact that is a survival skill for the client. It is obvious to the observer that in all actuality there are not separate people who live in and share one body. This is a heuristic construct that we use to discuss and explain the process of vertical repression. Each separate identity will have its own channel, its own accessible memory, as well as, its defined personality and skill sets. It will have a role to play in the drama that is the life of the client. Part of the healing process that happens in the therapy is the invitation for the vertical compartments to take down the barrier walls and allow the memories of each subset to be accessible and included in the memory life of the whole. This is very difficult and painful work, and it takes a lot of time, care and patience, not to mention skill.

A therapist who endeavors to do this memory work with trauma survivors needs to be very careful about the process they utilize to “recover” the memories. There is such a thing as the false-memory syndrome, which is an argument made by clients that a therapist unethically implanted false memories into them, which then led them to erroneously accuse people of things. These cases have gone to court and sometimes the therapist loses the case, ending up being responsible for major financial damages, sometimes losing their license to practice. These situations happen because the therapist did not follow the correct protocols in doing the memory work.

I believe that clients will not and cannot remember something until they can afford to remember it. By that, I mean if their ego strength is strong enough for them to remember and feel whatever the pain or horror is that they have repressed, if it has the capacity at this point to survive the knowing of what happened then they will be able to remember. Until they have gotten strong enough to do so, they will be unable remember. I have seen memories recovered under hypnosis, where the consciousness is blocked, then related either through having been taped in some fashion or by the therapist telling the client what they said under hypnosis. If the client is not strong enough to remember these events, it will not be a memory for them, but a recitation of a story that may just as well have happened to someone else. There is no sense of ownership or connectedness to the memories and the client does not feel as if they experienced the events.

Many years ago, I had a friend who could not remember his sixth grade year at all. He went to a hypnotist and “recovered” his memories under hypnosis. A tape was made and I was allowed to listen to the tape. On the tape my friend told the story of being a twelve year old boy who lived in a tent with his mother and young sister during the depression. His mother worked in the fields of California as a migrant worker. The boy was assigned to stay in the tent and take care of his three year old sister. It was a horrible year with grinding discomfort and poverty. At some point during the year rats came in while he and his young sister were sleeping and bit his sister, disfiguring her enough that she was put in the hospital. His mother lost her job and the children were put in an orphanage because the mother could not take care of them. This situation lasted for almost a year until extended family in Arkansas took all three of them in and they were back together as a family. My friend remembers none of this. He hears the story told in his own voice in extreme detail, but feels as if it is a movie, or a story he has read. It is not his story. Yet the information in the story makes a lot of sense in terms of the history of his life. He does not challenge that it really happened that way or that it affected him in his life. He simply says, “I don’t remember it.” And he doesn’t! If I were working with him in therapy as a client, I would work to get his ego strong enough to enable him to “remember” and take ownership of these events by experiencing the emotions that are associated with them. At the time that the tape was made he was not emotionally strong enough to feel those feelings, so he continued to block them through the defense of repression.

As a therapist, I invite my clients to remember their past. I work on their sense of capacity and their sense of safety. I teach them something that is called a fractionated abreaction. I do not want them to re-experience the trauma in its entirety. I want them to experience just enough to be in touch with their fears and feelings to know what they are, then to come back to the present and process what they know and remember. I do not want them to be re-abused by re-experiencing the entire scope of the event and replaying it in their minds. That is not necessary, and could be considered abusive.

In order to do this, I work with them to find a code word that will break through their “remembering” and call them back to the present. When they spontaneously go “back” and begin to remember and re-experience the horror of the trauma, I use the word to ground them and return them to the present. Then we talk about what they felt and what they remembered. These memories are owned by them because they actually had feelings about them. They are not just a recitation of the facts from hypnotized data mining of memories.

I never suggest memories and I never say specific things such as, “Let’s go back to the time when you were ten and your grandfather abused you.” I say things such as, “I want you to spend a little time drifting. Just quietly let your mind roam back in time to any place you know you need to go, to remember whatever you need to remember for us to talk about today.” Wherever they go and whatever they remember is entirely their own artifact and not one suggested by me. I am often surprised by what they choose, but always follow their lead. When or if they resist at some point in the “remembering,” I invite them to stop. They can only go at their own speed. These memories are extremely protected and resistant to recovery. They only way to get them out is for the client to safely have the power to visit them and experience them as the ego of the client heals and gets stronger.

The therapist does not guide it, direct it or control it. If you learn how to facilitate the conversation and empower the client, you can help them and protect yourself from the issues of the false memory syndrome. Memory work is an important part of the healing process for the damaged client. Your job is to create a safe, grounded environment that will facilitate the client’s ability to go back and remember. Your job is not to be the director of the play, or a fellow actor. As a therapist your job is to help the client recover whatever they need in order to live their lives today, in a way that is not dysfunctional and toxic. You have to be able to go with them wherever they need to go, but you must not send them or take them there. Believe in the process and trust the strength of the client.

You can’t remember it until you can afford to! If memories start to flood into consciousness it will be because your ego is now strong enough to deal with the feelings those memories will trigger. You will be strong enough to handle them, however upsetting and painful they may be. They cannot and will not come until you have the ability to process them and heal from them. This is a painful but safe experience, you will not be destroyed by your memories, you will ne made stronger because now, you will “know” what you need to know.

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Working With Sexual Trauma Survivors: What Do You Do?

Posted on April 27, 2012 by Brett Newcomb

Working with a client population generally known as sexual trauma survivors is very challenging work. Sexual trauma survivors are a very complicated mix of fragility and pain, along with an incredible will to live and survive whatever trauma they have encountered. Much of what survivors do is unconscious and reactive. There are a complex set of behaviors that are common to survivors of significant amounts of trauma. These skills will vary depending on the age of the individual, when the trauma occurred, how long it lasted, how comprehensively it encased their life, and whether or not the perpetrators of the trauma were persons in their life who should have been trustworthy.

As a therapist, you will encounter many clients who have experienced various forms of sexual trauma. Are you a sexual trauma survivor is a question you should always ask in a very direct manner in the very early stages of therapy. Clients may have experienced overt and covert forms of molestation. They may have been raped and tortured, and/or they may be victims of incest or abuse from “trusted” figures. It is really frightening to learn things that some people are able to do to children. As a therapist, you need to be able to hear these stories without becoming so sickened, or so angry that your own emotions overwhelm you. If you become angry at what you hear (and you WILL) you must be very careful to identify to the client that you are angry, but that you are NOT angry with them for what they experienced. You are angry at whoever was able to hurt a child and do the things that were done to them. It makes you very angry when children are hurt in any way by anyone. You need to further reassure them that you do not need them to be angry with the perpetrator. Your anger is your own, and you understand that they may not be angry at the person who hurt them. You must say these things softly, gently, directly, and repeatedly. Your client will not be able to hear them, nor accept the content of the message initially, but you must deliver the messages of your anger at the perpetrators quietly, consistently, affirmatively and repeatedly. If your therapy works, and the client manages to get better, having given them these messages will work to solidify your own trustworthiness and cement their ability to reality test the feelings and messages they receive from others.

You need to learn about abusers and how they operate when children are sexually molested. How are they connected to the victim and how do they perpetrate the abuse? What messages are given to the children to frighten them, blame them or seduce them into feeling some level of responsibility and ownership for what has happened? Were others that were important to the child threatened? It is common for the victim to hear, “If you tell, no one will believe you. I will find out if you tell and come back and kill your puppy.” I have had clients who were told this. I had other clients who were told that their mom, dad or sibling would be killed. Some clients were told that no one would believe them, but if they talk about it, they would be taken away from their families because they were such bad children. No one would want to love them or live with them once it became known how nasty and bad they were. Children who are given these messages, especially when something painful and shameful is happening, tend to believe them. They internalize the responsibility and the fear, and they learn to do something in order to survive the awful things that they are enduring.

One of the most important skills for the survival of trauma is the ability to dissociate. Dissociative disorders like amnesia, fugue or even dissociative identity disorder are amplified versions of a defense mechanism that every one uses. We all dissociate at some time. Dissociation is the ability to “go away” while something unpleasant, frightening or painful happens. Trauma survivors, especially those who live in systems where trauma is constant and the surrounding environment is always dangerous and frightening, learn how to “go away” whenever they need to. In its extreme forms, they do not feel pain, they do not remember the events and they do not experience what is happening to them.

If you are working with this population, you will need to learn to recognize when someone dissociates. What does it look like? What does it sound like? How do you know that they have just thrown a switch and “gone away?” What behaviors can you see or experience that indicate to you that someone is not feeling what is happening in the moment? Sometime clients develop a repetitive behavior like a cough, crossing their legs or tapping their fingers on a desk. Using these physical cues, they manage to “disappear” while an unpleasant or frightening event is taking place. Their bodies do not go away, nor resist what is happening, but their “self” goes away. It returns when the situation is over and the crisis is resolved. For others, it is less obvious. When you have spent enough time with them, you will recognize a change. The focus of their eyes changes from good eye contact and actively responding to the flow of the conversation, to eyes being half glazed over and a loss of focus in the conversation. They will continue to participate in the conversation, but their “self” will not actually be there. They may not remember what was said when the come back after the danger or anxiety has passed. The danger can be physical, like being in the presence of a “trigger” that reminds them that some trauma is about to happen (sometimes called a flashback.) The trigger may be a sound, a story or some physical sight or event that causes them to flashback to a previous experience and to shut down or disappear within themselves.

In therapy, once you have established a trusted relationship with the client, you can begin to “notice” their dissociative episodes. Gently say to them, “It seems to me like something just changed and that you went away somewhere. Did It?” They will typically start out by saying, “No, you are wrong. I am right here and nothing changed.” Accept what they tell you and say, “Ok, I accept that. I will always believe you and I believe you now. However, usually when I see these signs, it means that someone has dissociated. I need to know how you work, so I need to be able to ask you about it whenever I notice this change in you. You just keep being honest with me and I will eventually get it right. Is that OK?” If they feel safe, they will agree. As time goes by and you continue to work with them, you continue to point out whenever they shift out of focus and go away. Ask them if they just did that whenever you see it, and eventually, they will begin to recognize that indeed, they have shifted out of focus. At that point, do not gloat or laugh and say, “See, I told you so!” Instead, you thank them for trusting and for listening. Then ask them, “What do you remember we were talking about just before you went away?” They may not remember. Remind them what it was and ask, “Is there anything you remember about that topic or event that you want to talk about?” Or ask, “How do you feel when this topic or event is brought up?” You gently begin to accurately reflect back to them what you are getting from them. These messages may be that they are angry, afraid, sad or hurt. You reflectively listen to these messages by “hearing” them and by “reflecting” them back to the client accurately. Ask if they recognize whether or not this message is an accurate understanding of what they are feeling. Do this over and over, no matter where the story goes. Eventually, dissociative clients will begin to “feel” and “remember” when this happens, they will lose the ability to dissociate and go away from unpleasant memories.

When they are able to remember and share their feelings and experiences, you have to be very gentle and strong at the same time. They need you to not be frightened, disgusted or over the top with your own anger. They need you to support them, give them messages that you are proud of their ability to survive, that you know absolutely that they are not guilty of being bad. You honor that they were able to do whatever was necessary in order to survive, to get to this place. Then, teach them that the past is not a prologue and they can change the script of their lives and heal. They cannot change what was done to them. But, they can heal and not spend their lives as victims who constantly have to dissociate in order to survive.

As a therapist you must remember that your primary job in working with dissociative trauma survivors is not to prove anything. You are not an agent of the court, it is not your job to catch perpetrators or punish them. Your job is to help the client heal, to get strong and be able to live their lives free and healthy. It is not your job to pursue revenge or punishment. Your job is to relate to the client and help them get strong enough to heal themselves from the horrible wounds of the trauma they have experienced.

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Guilt vs. Remorse: Concepts for the Parental Introject

Posted on April 22, 2012 by Brett Newcomb

Feeling guilty about something is such a common occurrence. Most of have learned to feel what we call guilt from the messages our parents gave us. Our parents’ responsibilities required them to teach us boundaries of acceptable behavior. We were taught what was allowed, what was not allowed and what was forbidden. When we were very young, they utilized a number of different tools for controlling our behaviors and teaching us to control our feelings. Depending on the values of your family and on the skills of your parents, you may have been controlled with physical punishment, the withdrawal of attention, affection and/or approval. Perhaps as your parents disciplined you they included such statements as: “I can’t believe you did that!” “What kind of person are you?” “You should be ashamed of yourself.”

Have you ever given thought to what they were trying to do and how well they may have done it? Their disciplining behaviors may have been reflexive and automatic for them. Your parents may not have used thoughtful processes to determine what they should do and how they should do it. In all likelihood, they were most often responding to something we call the “parental introject.” The parental introject is something that all of us internalize around the age of four or five. It consists of a tape of messages about right and wrong, along with supportive statements such as; “You should be ashamed,” “Who do you think you are?” and “You are so selfish and self-centered.” Your parents attempted to “message” you so that you could internalize these messages into your very own parental introject to carry around with you 24/7 for the rest of your life. (It is your very own Jiminy Cricket to sit on your shoulder and keep you out of trouble.) Being able to internalize the parental introject is an essential element for socialization in any culture.

All cultures seek to transmit their value systems and behavioral controls from one generation to the next. Part of the goal of parenting is to teach these values and repeat them to the point of internalization by their children. Our children must learn how to behave and function within the constraints of our cultures. It is our jobs as parents, teachers and clergy to imbue these values with a panache that draws our offspring into a reflexive “knowing” of right and wrong which will then provide constraints around their behavioral choices. If our children become bound by those values, they will internalize the culturally held knowledge of right and wrong.

Let me give you an example of the kind of thing I am talking about. I am in my mid sixties, my friends and I were talking about how you are “supposed” to dress for church. My adult children laughed at us and said, “If you are there, it is enough, the rest does not matter.” Our conversation moved on to the current cultural fad of getting a tattoo or a body piercing. When I was in college studying things like anthropology and sociology, I was taught that anyone with two or more tats was displaying strong indications of being a sociopath. Today, that lesson would not hold! So very many people have moved to the “dark side” and gotten tattoos that having two or more is pretty common, and becoming more so. Now, it is not uncommon at all to find professionals, successful adults who have what are called “sleeve” tattoos that cover entire strips of their skin in a solid block of tattoos. I mention this to make the point that values change and the standards over time change with them. In my great-grandfather’s day, women did not wear pants, they wore dresses. Women were not even allowed to smoke in public without the danger of being arrested! They were taught that these standards were “right” and that they should reflexively and innately “know” what they could do, what they should do, and what they were forbidden to do.

In situations that are not emotionally charged, these internalized senses of “right and wrong” are what we call ethnocentric mores. Mores are values, identified with a culture or an ethnic group within a culture, that were transmitted between generations. These mores allow or support the picture of what to do that “feels right” and consists of reflexive behaviors that we do without thinking. We just “know” what we were supposed to do. Until were able to internalize the parental introject, the discipline and the controls were in the hands of our parents and our teachers (secular and religious.) Once we had internalized these values and they worked automatically within us, we needed less external monitoring. The monitor (the parental introject) had been programmed into us and we listened to its messages as we made our behavioral choices.

Those of us who have ever been tempted to do something that our introjects told us was wrong has had to listen to the message and feel the feelings of guilt. We may do what we want to do, but afterwards, we feel guilty, we may also feel ashamed because we know we have been “bad.” So many parts of our social system utilize the tools of guilt and shame to regulate the way we think and the way we behave. Others are often happy to point to the error of our ways and shame us, or guilt us, into behaving as they would have us behave. This may be about the way we dress, how we speak to our parents, whether or not we open doors for the elderly, are nice to strangers, go to church on Sunday, etc.. The goal is to restrict our options and cause us to be more “like” what we are supposed to be than we would otherwise want.

Many of my clients who have come from really dysfunctional families are severely blocked by their overwhelming feelings of guilt and shame. Their families will send them aggressive messages about their rejection because they have been “bad.” Many of these clients struggle night and day with guilt and shame. They vacillate between anger and despair at their sense of helplessness. They have a want or need to do something that they know their families will “be ashamed of them” for. When they act on what they want, they feel trapped and ashamed, they feel they are a bad person because they did not do what they “should” have done.

I try to teach them the difference between guilt and remorse. I believe that it is perfectly legitimate to be self-aware enough to know that you feel badly that you have hurt or disappointed someone. It is appropriate to know that sometimes you impulsively act in ways that are not thoughtful and considerate. Other times we want something so badly that we choose it even when we know it is “wrong”. Afterwards, how do we deal with having done it? We feel guilt, which is closely tied to shame. I think those feelings are usually driven by cultural demands and by the efforts of others to control us and our behaviors. I do not fault them for wanting to control us, but I believe that we are free moral agents who are capable of making our own choices.

Sometimes after I have made what I later determine is a mistake, I feel remorseful about it. I especially feel this way when I have hurt or disappointed someone I cared about or was responsible for. This feeling of remorse is very strong, and encourages me to remember and not repeat what I have done. I think it is more than a semantic distinction to make to call it remorse rather than guilt. Words do matter, and how we frame our internal monologue says a lot about our mental health. I find that clients who are burdened by the oppression of guilt and shame are not doing well with making self-owned choices. They are less likely to be independent and self-aware, they are more likely to be controlled and limited by the values of those who are important to them. I think good mental health requires that we become aware of the distinction between guilt and remorse and choose to frame our monologues in terms of healthy remorse, rather than unhealthy guilt or shame.

So, I tell my clients not to do guilt or shame. Rather take adult responsibility for your actions, even when they are impulsive, and do remorse or sadness. Follow these feelings with an honest conversation about whether or not you will continue to commit these acts knowing your level of choice making, your level of integrity and responsibility. You cannot remain a child, impulsively reacting or acting out, followed by cycles of guilt and shame as you maintain your ultimate innocence because you “did not know.” Your parental introject knows and it will kick you in the rear with guilt and shame. As an adult, you can reject this reflexive, automatic, culturally created response and make choices that are based on what you truly want with a willingness to pay the cost of your choices.

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Parenting the Adult Child: Inherent Conflicts

Posted on April 13, 2012 by Brett Newcomb

The internalized critical parent is one of our most insistent demons. We hear the critical voice of our parents disapproving of us and commanding us how to behave, feel, dress, think, and believe. Whether or not it is a reflection of how our parents really behaved is always a question. Our memories tend to be distorted. Remember going back to your childhood home when you are middle aged? Remember how small it was and, yet, in your memories how large it was? Time stands still in our memories and the visions of our youth have not migrated with our awareness. These memories of messages from our parents is called the “parental-introject.” I have two sons, one is sixteen and one is forty-one. My sixteen -year old and I have regular conversations about “reality testing.” When I want to talk to him about what I want him to do, or how I wish he would behave or problem solve, he always hears the critical parent. He anticipates that I am mad at him and will disapprove of him unless he pleases me by doing what I want. This is sometimes true, but never as often as he thinks.

That is not the way I want him to perceive me. I do want to advocate for what I believe is in his best interest and his growth. I want to encourage him to become the man he is capable of being. I want him to learn how to solve problems, take on challenges, discipline himself to reach HIS goals. Of course, I also want him to have goals. Right now, like many teens, he is drifting through life. It is just happening to him as one day follows another. His vision has a low horizon and from where I stand, I want to teach him to look up and anticipate. I want to stimulate him to grow into a capable and competent man, who is happy with himself and finds a career and lifestyle that satisfy him and makes him joyful. I try to talk to him about this vision within the context of our discussions about cleaning his room, making good grades, being kind and considerate to others and being respectful of others without being intimidated. I want him to learn to engage in conflict openly, honestly and effectively. I want him to learn to not fear failure and to avoid not trying. I want him to become self-confident in a reality based way. I want him to learn to be adaptive and independent. I do not want to control him or his choices. I do not want to “own” him and make him be a mirror image of me or my life choices. I have come to this through my own growth and through the necessity of learning from the mistakes that I made with my older son.

My younger son and I talk about how we are experiencing each other, how he anticipates my anger or my frustration with him and how that anticipation impacts his choices and his feelings. We are able to talk about consequences I provide to teach him discipline until he is able to internalize it. We are able to talk about strategies for resolving problems and for learning to reality test what is going on versus his anticipatory expectation of what is going on. We can talk about his urge to withdraw and be a victim when things don’t go well and my desire for him to learn to harness his frustration and anger and channel them into productive efforts to acquire his will and maximize his chances of getting what he wants. I can critique him without being critical of him. He gets it. And, it is truly a practice environment for him within a context of the safe holding environment. We are having regular conversations about his future, his right and his obligation to make choices. To anticipate and prepare for the cost of those choices is one of the most necessary of skills. We are moving towards the dance of separation. He will go off to college and become independent of me. I grieve for that, but embrace it with joy. This is what I have raised him to do. It has been my job and I have loved almost every minute of it.

My oldest son and I did not have this kind of relationship. We still don’t. We have never been able to talk about things the way my younger son and I do. Part of that has been my absolute failure to be able to let go of my “should” messages regarding him; how I felt that he should behave, the choices I felt he should have made, my inability to just enjoy the incredibly bright and attractive person he is. I wanted more for and from him. I wanted him to be “like” me, something he most insistently did not want for himself. He is critical of me and the choices I have made. I do not have a way of knowing how reality based and valid his criticisms of me are. I cannot find an objective place to stand to “see it” but, I would like to believe that he does not see me clearly. I know I do not see him clearly. That is something that I am working on. My biggest challenge seems to be letting go of my anger that he was not a replica of me and my values. He has chosen a different path. Intellectually I have accepted that. Emotionally, it is hard for me. Does this mean I am dishonest? Certainly that seems to be the challenge of my own brand of reality testing. My struggle today in my relationship with him is to figure out how to let him go from my brand of critical parenting and encounter him with affection and respect in the world he inhabits. I cannot force him to mold himself into my world. He has the right to live in his own world. I absolutely endorse his right to live as he wants and pursue his own happiness. We have both fought this fight together and against one another’s needs.

As my older son has watched me raise his younger brother, he has been angry and jealous of the changes in me. He remembers an angrier, controlling and commanding father than his brother knows. On the one hand, he is happy for his brother, but on the other he is angry with me. Why couldn’t I have done this sooner? Why could he not have this childhood and this relationship with me? I would argue that in many ways it was there for him and that he blocked it, but we disagree. My friends agree with my perceptions, his agree with his. At the end of the day, it is all about the perception. His perception of the internalized critical parent is one I cannot change. If it ever changes, it will be because he has learned how to let go of it and accept me for the person I now am, and not the projection of me he created. He has to modify what psychologists call his parental-introject in order to see me at all. It is funny, without being humorous, but we have the same fight. We each have to learn to see and accept the other as they are and not as the way we would have them be.

I think this is the battle we all have with our adult children. Are they ever really independent? Are they ever totally their own person? Do we ever quit trying to mold and create them as we fantasize they should be? How do they separate, individuate, become autonomous and independent, and free to just be?

As parents it is our job when our children are young, to provide structure and discipline. It must be externally supplied until the child learns to internalize it. In part, this process requires that they internalize our voices as parents, accept our boundaries and pay our consequences. Part of the dance of separation is the journey towards independence. As we relax the supervision, the controls and the boundaries they can explore within the safe box we have built around them. We want them to explore and fail, then learn how to recover. We want them to learn how to anticipate and choose, even to choose poorly, when the choices are cheap and survivable. If they don’t have these experiences when they are young, when they finally do leave us, they are not prepared to play the game of life. They won’t have developed the skills to make choices and adapt, as well as, survive poor choices or poor luck.

I am grateful to my older son. He was never an experiment, but I learned a lot about parenting and about letting go. A lesson I am still struggling to learn! I have become a much better father for my second son. I am continuing to try to re-negotiate my relationship with my oldest. I am fighting to be seen as I am, and not as he remembers me or as he wants me to be. I struggle to see him in this way as well. It is what he has asked of me, it is what I want, but it is still very, very hard to let go of the internalized stereotypical projections of my expectations. I, too, must learn to reality test.

Am I willing to pay the cost of my choices? Can I do what I am trying to teach? Will I learn in time? I hope so, the journey continues, the destination is not in sight. It is a challenge that I choose to undertake and strive to achieve.

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Passive Aggressive Behavior Redux!

Posted on April 7, 2012 by Brett Newcomb

Last week, I wrote about being passive aggressive. I discussed the reasons for it, the ways that it manifests and what one needs to do to stop themselves from being passive aggressive. This week I want to talk about what to do if someone with whom you are in a relationship is passive aggressive. I also want to talk about what to do if you work with someone that uses these skills to protect themselves.

If you are in a relationship with someone important to you who uses passive aggressive behaviors to get their way, it is extremely frustrating and angry making. You become “rage-ful” and helpless. It is extremely difficult to challenge these behaviors without looking like you are silly and out of control or at the very least, “over-reacting.” But you are not. It is a system that is additive in its damage over time, and you develop less and less room to breathe. If you have fallen in love with someone before you discovered this ugly truth about them, what do you do? Do you have to abandon the relationship? Do you have to become an ugly, hateful person just to survive? Is there some better way to participate in the relationship without becoming subjected to the displaced wrath and manipulation of the passive aggressive partner?

I think there are two essential survival strategies for coping with people who are passive aggressive, PA. They are both within your power, not your PA partner’s. You can control these strategies and learn how and when to use them. Then at least you have a “choice” and a chance to be proactive in your own self-care and in determining the boundaries of an intimate relationship. The strategies are “self-honesty” and “reality testing.” They are both harder than one would think, but are both necessary for survival and the reclamation of dysfunctional relationships.

First, I will discuss self-honesty. I find that many, if not most people have difficulty being honest with themselves about what they feel, what they want, and how they try to get what they want. We tend to use justifying excuses and camouflage behaviors to mask our real intent, even from ourselves. This occurs in part because we have been culturally taught that to be self-interested and self-honest is selfish and arrogant. I remember being told by my parents and my teachers that it was a bad thing to think about and pursue what “I” wanted. It was self -indulgent and it meant I had a character weakness. In reality they gave me those messages, along with others, about how I should feel and how I should behave as a strategy for controlling my behavior and making me easier to deal with. I was expected to be submissive to the wisdom of my elders and allow their control over my behaviors. I remember once when my father was about to beat me with an electric extension cord, I attempted to “reason” with him about the power of persuasion relative to the power of force. His pithy rejoinder was that he “did not believe in all that psychology crap” and I would do what he wanted me with a smile on my face and a good attitude or he would know the reason why! So as I explained last week, I learned to be passive aggressive and manipulative, to use hidden and unaccountable weapons in order to get my way. It was a learned survival skill, but it was not a way to develop intimate relationships.

I believe that healthy selfishness is, indeed, healthy. I tell my clients that I do not “do guilt,” I do remorse. I think guilt is a manipulative tool used by others to control your behavior and feelings. If you learn to be self -honest you can learn to admit what you really want and to go directly after it. You do not have to expend the resources and energy to go around three sides of the square in an attempt to hide and misdirect others, but you can more efficiently, go after what you want. You can also more deliberately admit what you want and proactively try to negotiate for it.

Reality testing is the other skill I advocate. To develop good reality testing many questions need to be asked: What is “really” going on? What do I “really” want? What is the real cost of my choices? What is the payoff of my choices? I can choose to live with and love someone that is difficult to love and who requires me to work very hard to make the relationship satisfactory. I cannot “honestly” be a victim and be stuck with someone who is inappropriate for me. If I choose them, that choice comes at a cost. For example, if my wife asks me to attend a school function with a bunch of elementary teachers and administrators, I should go inside myself and ask how I really feel about going. If I don’t want to go, I should tell her. She may then negotiate with me and tell me the cost of my not going would be that she would be unhappy and angry for several days, or tell me that if I don’t go, there will be no sex for a month, or that she will go alone, but “I will be sorry.” Or she could just honestly say, “This event is important to me, even if you do not want to go, will you?” I have a choice. I can say yes, because you matter to me, even though it is something I dread, I will go. Or I can say, no I hate that too much and won’t go. The point here is that whatever choice I make, I have to honestly reality test it. If I go, it cannot be as a victim. I cannot go begrudgingly and punish her by acting out and being angry and resentful. If I go, I must go openly and fairly. I cannot “fake nice” and then present a bill of anger and manipulation to be collected later. If I am not willing to do this, I should honestly say I am not going, and then deal with whatever issues that raises in our relationship openly and honestly. That has been an easy lesson to learn for me in this relationship because my wife does not have a passive aggressive bone in her body.

I remember in my first marriage times when my wife would come in as I was watching the evening news to quietly announce that dinner would be delayed. She needed milk from the store and had to go get it. If I were not alert and did not recognize the hidden message, which was “get up and go get some milk!” I was in huge trouble. If I responded, “That’s okay, I don’t mind eating later,” I would be making a huge mistake. My first wife did not come out directly and ask for what she wanted. I was supposed to guess. She always maintained plausible deniability. My present wife does not. When we first got married, I was expecting the behavior I had experienced for almost twenty years from my first wife. If the same situation happened, I would jump up and say, “Let me go to the store dear.” My wife would laugh and say, “No, you are busy, I can go.” I would say, “No, no, no let me.” She would reply, “ If I wanted you to go, I would ask you to go,” and then she would leave to go to the store. I would wait and watch for days for the price to be delivered for my “selfish” behavior. I was frustrated because the price never came. Eventually, I learned to trust that my wife was “honest” by reality testing. She would, indeed, ask me to go to the store if that was what she wanted. There was never ever a price to pay for her having to go. So, in part, the message is that having a healthy partner helped me learn to be healthier.

The second situation I want to examine is dealing with a passive aggressive coworker. If you take a new job, and everyone is being “nice” to you, the new guy, it feels good. Eventually, when the new wears off, you find that this workplace is much like all others. In every situation where you have a group of people, you are likely to have some who have issues, are jealous, angry, manipulative, and dishonest or masked in how they present themselves. They have different skill sets for acheiving their goals. It is not always as easy to confront situations at work because you do not always have the option to quit. The bills must be paid, obligations must be met. My answer to this dilemma is the same two skills. Self-honesty and reality testing are required for survival and satisfaction. You may have to make the honest decision that you cannot trust someone you work with. Perhaps they steal your sales leads, maybe they put blame on you for things that go wrong on a team project and take the credit for things that go well. You cannot afford to have illusions about their self interest and their strategy. You cannot allow yourself to be a “victim.” You must also act with self- interest and self -honesty. You may have to be aware that you cannot stay in this job. The cost of staying will be high and unsupportable over time. The point, then, is to admit this to yourself and begin to look for a way to transition to a new opportunity. Perhaps, you can transfer within the company if it is large enough to have other options, or to a new job, if it does not. What you cannot do is “lie” to yourself that if you just work hard enough you will be noticed and successful. It is not productive if you create a crisis and quit in a huff. Make a plan and work your plan.

If it is not bad enough to need to quit, then you can choose to stay and work on strategies to protect yourself. Keep good records and make sure you talk to your supervisor about your concerns. Learn to appropriately challenge the offender and talk about your limits. Always use “I” statements: “I have a problem with my breathing, and wonder if I could ask you to wear less perfume to work.” Not, “ someone around here is wearing too much perfume”, or “I have an issue that is causing me difficulty, I really need emotionally to have a sense of ownership about my space and wonder if I could ask you to stop sitting at my desk to use the phone.” Rather than, “This is my space, keep out you b***h!” Remember to document incidents and build alliances with others, but not in an aggressive, hateful way. There will be others at work who respond to the problem the same way you do, but they will not be as skilled as you at confrontation. Conflict is not inherently, or even mostly, a bad thing. It does happen, you will feel better and be more successful if you learn how to manage conflict rather than avoid it. Remember, self-honesty and reality testing are the two essential skills for resisting someone that is passive aggressive.

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Passive Aggressive Behaviors and the People Who Use Them.

Posted on April 1, 2012 by Brett Newcomb

Passive aggressive disorder is listed in the DSM under personality disorders. I am not sure whether or not I think we should continue to call this a personality disorder. Part of the problem is the degree of pervasiveness and dysfunction that is required to call it a disorder. I would rather focus on the concept of passive aggressive behaviors. In my opinion, there are numerically few individuals who would qualify for the status of a disorder in the DSM, but I believe almost everyone, at one time or another, uses passive aggressive behaviors.

I must confess that at various times in my life I have been particularly skilled at being passive aggressive. I used these behaviors as a way to protect myself from responsibility and to keep my independence. I was afraid of the consequences of being visible and owning my feelings and recognizing that I chose my circumstances. It was easier to be a victim of the misunderstanding or unreasonable expectations and demands of others than it was to say no to them and then deal with the consequences. I avoided the consequences of self-ownership and lived as a skilled “avoider” of responsibility for what I wanted and how I really behaved. I learned this as a way to survive in my family of origin. It was a dangerous family and the cost of being caught acting in ways less than expected was very high. I learned to dance among the rain drops without really getting wet. This allowed me to look good and have a defense against all charges, yet take my anger and cause frustration and rage in all who dealt with me. In this way, I was never “responsible” for letting them down. Dealing with me was like fighting Jello. There was no hard core, no center, nothing to grab hold of. I displayed no evidence that I was being oppositional. I was skilled at looking good and talking well so that it confused the people who were trying to challenge me or call me to account. The people around me were often out of control with their anger ( which I had provoked by my passive aggressiveness) and others looked at them askance, because they were raging and hateful and upset, without apparent reason. They were told (which I appreciated!) “He is such a wonderful, nice guy. How can you be so angry with him? What is wrong with you?” Others would look at my relationships and say, “He is so great and she is such a bitch, how can he stay with her? She is always mad and complaining! She really does not appreciate what she has.”

When I realized fully the cost to me of living with this defensive, yet provocative, strategy, I began to learn more about where these behaviors and “skills” had come from. Why did I learn to behave this way? What was the cost/benefit ratio for me if I continued to act this way? Even though I was skilled enough not to be obvious with these behaviors, I also knew when I was honest with myself that I was not happy and my intimate relationships were not really intimate. They were manifestations of the false self and were masks that I could put on and take off. Others sensed that I was not really the person I pretended to be and eventually would abandon or reject me, or attack me in their helpless rage. I could “win the day” but ultimately, I was alone in a crowd. If I wanted that to change, I needed to learn more about passive aggressive behavior. Why does it happen, how does it happen, how does it work, what is the cost? These were all questions I asked in order to learn how to change my behaviors.

Among the things I learned, is that no matter how perfectly you try to structure a relationship system that involves two or more people, there will ALWAYS be conflict. No matter the community, family or work dynamic and the perfection of the philosophy behind the structure of the group, if they include/involve more than a single person, there WILL be conflict! Conflict is unavoidable. It is not inherently bad or damaging, but it is just something that most people try to avoid. We do such a disservice to ourselves and our children when we teach, or allow them to learn how to be conflict avoidant. Conflict is a real and necessary thing that is innate to human behavior. We cannot eliminate it from our systems.

I have talked through the years with many individuals who have lived in religious communities, which they embrace because of their idealism and beliefs. They want to enmesh themselves into these communities and diminish their sense of self and selfishness. Invariably, they discover and are disillusioned by the reality of human dynamics. Within communities, as within families, there is hostility, selfishness, and jealousy over the possession of desired resources, of status and standing within the community, of power, of the affection and attention and respect of others. We are, by nature, competitive beings. We are like blue jay babies always screaming, “Feed me!” similar to Seymour in “The Little Shop of Horrors.” We are like that even when we do not want to be. So the challenge for people attempting to create families, work environments and communities is to construct a way of life that will minimize these reactions, but recognize that they are innate, human, necessary and inevitable.

So what do we do to reduce the damage that the passive aggressive people in our lives do? How do we structure our group to minimize the reality of conflict and competition? How do we learn to recognize in an early state the development of resentment, hostility, greed, or jealousy? If we learn to see the early warning signs of these issues, how do we “confront” them in a healthy manner?

I have been doing some consulting with a medical office. Most of the people who go into medical careers, like most educators, are what we call “conflict avoidant.” They go out of their way to avoid a situation of conflict and hostility. They are care-takers and often pleasers. These are preferred skills for survival that integrate well with their lifestyle and profession. Yet, even within these groups there is conflict. This always happens in human groups. Part of my responsibility to these practitioners has been to teach them that these conflicts are inevitable and to recognize their reactions to the conflict. Some people become aggressive and pushy as a way to get what they want. In response to this, those who are conflict avoidant tend to respond either by being passive aggressive or passive avoidant. If they are passive avoidant, they tell themselves that it does not really matter, they do not really care, they will not get themselves out of control over some trivial thing and then they stuff their feelings. Eventually, they have a melt down and there is a crisis. Both the individuals and the management then have to deal with a “crisis” instead of a problem. The cost of this type of behavior is high, both to the individuals and to the company.

For those who are not passive avoidant, the other option often seems to be passive aggressive. They manage to work out their hostility and resentment without being “accountable” for it. They “look good” they are “always in the right.” They are very difficult to confront or challenge, but they cause anger and rage within the community because they passively (out of sight, covertly) do things to frustrate those with whom they are in conflict or whom they resent. Little things, like leaving a mess on the desk, or not passing along a message, or dropping something into the conversation with others in the group that causes a misunderstanding, or a resentment, toward the “target,” but without ever being the one who said or did it. These skills are automatic, unconscious and yet deliberate. They effectively allow the individual who is passive aggressive to be a “player” without ever having to put on a uniform and take an at bat. There is no record or score. There is no opportunity to give them honest feedback. They never have to be accountable for their feelings or their behaviors. They are the good little girls who do what they are supposed to do and it is not their fault if the thing is messed up or gets broken. They do not have to pay the direct personal price, ever. They may have to pay part of the group price, but it is clearly not their fault. They are just good doobies who are going along with the cost because they are committed members of the group.

In the long run, it is better to teach people conflict management skills and encourage a process for open accountability. People must be encouraged, nay required, to speak in “I” statements and articulate their desires, frustrations, resentments in appropriate ways through the hierarchy. If we do not teach them to do this, and require them to do this, our community/family/workplace environment will be a place of tension, frustration and resentment. It will become toxic and we will all pay a price that we do not have to pay. Conflict is an inherent part of human relationships. Skill at being openly conflicted allows opportunity for resolution and growth. These skills can be learned and mastered. It is worth the price of admission even if we have to fight our discomfort and anxiety. Those of us who learned to be successfully passive aggressive, must eventually learn that we are, in reality, not successful. We are, at best, not accountable. Ultimately, we are hurt and alone and isolated. We may not know it because we use our skills to move on to another, similar, dysfunctional relationship. If you want harmony and intimacy and genuineness in your life, learn to deal with conflict in open and honest and accountable ways. Even when you do not get your way, the cost is a healthier self!

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The False Self and the Co-dependent on the Death of the Object

Posted on March 24, 2012 by Brett Newcomb

I spent time this week talking with some friends whose mothers had died. In each case, their parents passing was long enough ago that the intensity of the grief and loss had somewhat diminished. With the passage of time, my friends were able to reflect on their relationship with their mothers and the meaning of those relationships in their lives.

In the field of psychology, the mother and the relationship between the mother and infant are major areas of concern. In my classes at the University, I often say, “Well, you know, it is always the mother.” This immediately angers every woman in the place. My goal is not to anger them, but to make them aware of the importance of the relationship of the “object” (usually understood to be the mother) to the infant. According to Object Relations Theory, the mother’s primary job is to create a safe holding environment for the child while the child progresses through the stages of grandiose narcissism into the separation and individuation stage where the child learns that he and the mother, and in fact everyone else, are separate independent individuals. The child has to learn this reality and develop a sense of self and a sense of capacity that makes him a healthy, functioning whole person. Many of the theories of Freud, Winnicott, Bolby and others intensely discuss the minutia of these stages and their meanings. Those discussions, while interesting, are not things most people delve through, or need to. In this blog I will discuss the outcome of these reflections with regards to their parents and to compare those new “awarenesses” to the theories of the false self and the true self.

A question one of my friends asked me this week was, “Do you think now that my mother is dead, I will be free to act the way I want to?” What a powerful question and what an interesting topic to explore. What immediately comes to mind is, how long have you felt this way? What have you held back from experiencing because of your anxiety about how your mother would react to it?

One of the common use terms that is popular, but not a clinical term, is the term co-dependence. The underlying issue of co-dependence is the belief that people learn early in life that it is not safe to feel what they feel, want what they want, or behave in response to their own inner desires. What they learn is that they live in a precarious world where they must “pass.” They must learn to fake it and be sensitive to the desires and needs of the other (mom, friend, husband, boss, lover) and behave in ways that take care of the needs of the other in order to be safe, accepted and not abandoned. In response to learning this way of existing, the co-dependent does not learn to know who they are or what they want. They learn to make the devil’s bargain; “I will do whatever you want or need and in return, promise me that you will never abandon me and affirm me by giving me my “attaboys”, strokes of reward for pleasing you. Co-dependents cannot generate these feelings from within themselves; they must always get them externally from others with whom they have made this deal.

In therapy, I constantly work with people struggling with this reality. They do not often consciously know that they have made these bargains and that they are selling themselves out for safety, but they have and they are. My challenge to them in therapy always is; can you go inside and learn what you like, what you want and act in ways that will pursue obtaining your desires? Invariably they will say that they do not know what I am talking about, and that I am just not understanding. If they can only talk about what the “other” wants with me and I can help them figure out a way to give it to them, then my client will be “safe” and “loved” in the way they so hunger to be. They want to spend all their time in therapy talking about the other. Why do they act this way? How can I understand them? What else can I do to make them stop frightening me or hurting me? They never approach the conversation from the perspective of; “How can I make them understand me and what I want? When do I get a turn? They can barely ever make the “I want” statement about themselves, because they are never entitled or deserving. Their turn never comes. They are hurting and they attempt to assuage the hurt by pleasing someone else so that the other can make them feel OK. They do not have the concept of internalized OK-ness.

The technical terms for this concept include words like false self and true self. The underlying idea is that we learn to have a false self, a mask which we wear to present to the world as a way of protecting our inner self. This can be a healthy false self, like the person who has learned to be “ladylike” at all times and in all circumstances. (She would never say crap, even if she had a mouthful of it. She knows that ladies don’t speak that way.) These people are civil and socially adept and they know what they are doing, because they are behaving in ways that are internally consistent with their sense of self, their true self, even if they are behaving in deliberate ways to accommodate an external reality. For example: Have you ever been in the mall and seen a teenager that you just wanted to slap? You feel it so strongly but you deliberately chose not to do it. You behave politely and you make the situation work as best you can, you do not indulge your inner self’s desire to slap the obnoxious brat. This is the healthy false self. The unhealthy false self is the part that creates a persona that is not a reflection of internal integrity. With many of my clients, I find that they do not have access to their inner self so they do not know what it feels or wants. The access is blocked or denied by their false self, which is forcing them to stay in their masks and behave in ways that protect them and make them look good to the general public.

These individuals who are operating from the false self that is unhealthy are often very angry and become passive aggressive. Passive aggressive personality traits are a topic for another day, but in a nutshell, they are people that allow you to think you have an understanding and have agreed on things that they never intend to do, additionally, you will not find out that they never intended to do until it is too late. These individuals project their rage into others so their partners are often very angry. Fighting with them is like fighting Jello because there is no core to grapple with. The challenge for therapy is to help these people by recreating the safe holding environment of childhood, so that the true self can become self-aware, and begin the uncompleted task of childhood. They go through the separation-individuation phase and develop the healthy false self that is based on ‘making nice’ while you work to be true to your inner self and the pursuit of your real desires. Then they can learn a reality based negotiation with others and an honest awareness of who they are and what they really want.

Returning to the conversations with my friends, these people are all beginning to ask themselves how much of their true self is genuine and how much is a false self they learned to use to become safe with their objects, in this case their mothers. It is often easier to have this conversation when the object in question has died. The relationship with them becomes frozen or static, no longer dynamic, because the object is not here to interact with. The object is no longer changing, she is no longer illusive and judgmental. The reality of the physically existing critical parent is no longer intrusive and my friends can begin to challenge the projected, internalized critical parent in their heads. They can argue, experiment, challenge, and grow into themselves. They are behaving in new ways, but still waiting for the other shoe to drop. Will they be punished or rejected? Will they be happy or unhappy? Whose fault will the results be? Will they experience their real self or their false self? Which masks will they “choose” to wear and which ones must they wear?

Is it finally their time to shine?

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Working with The Most Difficult Client, The Health Rejecting Complainer

Posted on March 16, 2012 by Brett Newcomb

There are vigorous discussions among clinicians about the need for and the relevance of diagnostic labels. Arguments are focused on the idea that utilization of diagnostic labels help clinicians develop adequate or optimal treatment plans. For instance, if one is working with someone diagnosed with Narcissistic Personality Disorder, then there are established ideas about the best course of treatment. Clinicians can find those plans and are expected to follow them or be able to justify why and how they are treating this individual in a non -traditional way. There is the supportive argument that if other medical professionals become involved, when they obtain the diagnostic label they will automatically know much about the client and the treatment the client has received because of their understanding of the label. Counter arguments speak to the concern about confusing the patient with the label. It is believed that the label will get in the way of seeing the individual as a unique idiosyncratic individual and instead, have us see them as “a Narcissist”. The label becomes the representation of the client. A supporting counter argument is that the labels become part of the permanent record and will impact the client’s ability to obtain a security clearance, a loan, life insurance, or medical insurance.

While this is an interesting discussion with right on both sides, today I want to talk about a label that is not a designated DSM label. It is not a diagnostic brand, rather it is a descriptive characterization of the adaptive behavioral and emotional skills of a client. Many clinicians will tell you that this particular type of client, no matter what their DSM diagnosis is, will be the most exhausting, draining, difficult client for them to work with. They may fit in the diagnostic categories of many DSM labels, but this description will still apply to them and no matter what their label might be. They will still fall under this umbrella categorization because of their adaptive skills. This client is called the Help-Rejecting Complainer.

If you are not a professional, you will also have encountered this individual. It might be your boss, your co-worker, your neighbor or a friend. The primary description of the help rejecting complainer is that they are emotionally an empty vacuum that attaches itself to you and sucks the life, energy and creativity out of you. When they leave you, they are full of your energy and operating on your drive and creativity, and you are left depleted and exhausted and empty. You may recognize that you are angry, but it is difficult to place the blame on any thing specific that they have done.
The help- rejecting complainer will come to you with a level of praise for your ideas, your knowledge and your importance in their lives. They will say that you are the only thing between them and death or disaster. The tension will build as they place the responsibility onto you for solving their problem, telling them what to do, answering the questions of the universe. Most clinicians are flattered by this approach because all of us like to be needed and important. Many of us went into this profession because we are good problem solvers and have many creative ideas about approaching problems and conflicts in a variety of ways that allow clients to see the problems differently or at least tackle them from a new or different angle.

The help-rejecting complainer approaches us and says, “I need you, you know what to do, and I cannot find my way. You are my last hope, my lifeline and I trust you with my future.” They say this with attentive respect and positive energy. They cheer you along as you try to come up with a solution to their problem that will fit their circumstances and resources. All is well and good as long as you remember that you cannot make their choices for them and you cannot solve their problems. What you can do is make suggestions about ways to approach a problem or try a new behavior and ask them to imagine themselves operating in these ways and to anticipate what that might feel like if they did. What becomes frustrating about these individuals is that not for one second do they consider what you have suggested. They immediately have fifteen reasons why what you have proposed won’t work. This happens reflexively and immediately and their reasons are often plausible. What they will tell you is that you are really close and they sense that you are just about to come up with the brilliant strategy, but this particular suggestion just simply cannot work because……….. They tell you this immediately, they do not have to think about it, evaluate it, or consider how what you are asking them to do might work.

These clients are very seductive because they encourage and cheer you along as you toss out the first set of suggestions and try to come up with another workable possibility for solving the conflict. While you are doing that, the client reminds you of how helpful and important you are and is waiting with baited breath for your next offering. When you make it, as luck would have it, it too, will not work. The response that identifies the unacceptability of your suggestion again comes with immediacy and without any real consideration. They will gently remind you that you don’t understand, but that the idea that you are offering is impossible because of some set of facts or some involvement of others that they cannot control, and therefore it won’t work, but it still feels just so close. They then invite you to come up with another possibility for them to consider. They continue to tell you how good you are and how much they hope that you will be able to help them. The will announce that they have spread the word of your goodness and expertise widely and that lots of new clients will be coming your way because of the help you have given them. Then they want the next installment of your energy and creativity so that they can reject it immediately as well.

Clinicians must understand that this is not intentional behavior on their part. They do not stay awake at night planning strategies to frustrate you. This is how they survive. What is going on clinically during this process is that they work like a vacuum, they are sucking your energy and creativity right out of you. They actually resupply their energy by moving from individual to individual with whom they have these relationships. They do not need a therapist in order to get these energy refills, they can get them from complete strangers or friends who have not yet worn out and abandoned them. They appear to be so good and so positive, and so troubled and wanting help. Yet, they never accept help, never embrace responsibility for change, and get their energy needs met by feeding on the energy of others. They are not hateful or aggressive; they are just exhausting and frustrating.

Clinically, when you discover you have become ensnared by this type of client, the recommendation I would offer is to distance yourself emotionally from the reaction you have been having (Anger, frustration, exhaustion, depletion). Step back and remember what is going on. The challenge for treating this client is to frustrate him/her by not giving them suggestions. Instead, reflect back to them that you understand how frustrating it must be to be in their situation and make it sound so awful that you don’t know what they can do. Add to this conversation that you care about them and commiserate with them. Do a good job of reflective listening and do not get seduced into problem solving, no matter how tempting it is. When there are opportunities, do process awareness with the client. Discuss with them how it feels to be in a room and or a conversation with them from your standpoint and ask whether or not they have heard this from elsewhere in their lives. Ask them to describe for you what they feel when you do not meet their expectation. Look for their anger, see if you can find it and get them to own it. Do not do this by designating that you know they are angry and asking them to talk about what makes them angry, or what it feels like to be angry, instead, reflect back to them the behavioral cues that “mean” anger that you are experiencing from them and ask if they are aware of displaying these cues? Ask them to pause and reflect upon the experience of being in the room with you when you don’t know the answer to their problem and see if they can feel that in the moment and to talk about how that feels.

These clients are particularly difficult for most clinicians because they are so enjoyable and seductive at first. Very quickly (at least for experienced clinicians) they loose their seductive powers. The therapist cannot play the game and buy into the manipulation and shifting of responsibility that is practiced by the help- rejecting complainer. If you are able to avoid this trap, expect to hear that you are ugly, mean, and unhelpful. If they can feel safe with you continue to invite them to exist in your space and be real, then you can help them. You will never help them by problem solving and suggesting strategies and solutions. Your job is to be in the process with them, reflect it genuinely and to communicate respect and safety to them as you experience them accurately. When these needs have been met, the client will be in a position to make positive changes and experiment with new behaviors.

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Managing A Private Practice of Therapy as a Business

Posted on March 10, 2012 by Brett Newcomb

When I first began teaching in Graduate Counseling Programs, the focus of Counselor Training was on making good, skillful therapists. Prior to retiring, I taught over twenty-five years in the Counselor Education programs of two different universities. The goal was to educate our students about the nuts and bolts of what happens in the therapy session. I felt it was important to teach, and for students to learn, the essential skill sets expected of a good therapist.

As a therapist, how does one learn to meet a stranger coming into their office? How does the therapist make them feel as safe as possible, as welcome as possible, and eventually, as understood as possible? What are the things you can do to facilitate this process? What questions do you ask? What are you looking to see? How do you interpret what the client is saying? Additionally, what they are not saying so that you can really “see” them, and understand what is going on with them? It is critical that you develop the ability to recognize the conflicts that are causing them pain. Very often it is not what the client says that it is. You constantly evaluate whether or not you are helping them to be safe, to explore their conflicts and facilitate the opportunity for change in their lives.

It is impossible to know everything about a client, or everything about the issues that may walk into your office to be discussed. At the University we would offer classes focused on particular skill sets, such as class focused on facilitating group therapy. This is often done in the real world with groups of individuals dealing with the same problem, such as a divorce recovery group. Or it may be a group of people who fit certain parameters, such as a group of people who are all dealing with someone who has Alzheimer’s. We also offered classes to focus on particular skill sets, like interviewing skills or assessment and testing skills. Over the years, the class work and the subjects of the courses became standardized. Every counselor who became eligible for a license, an LPC (Licensed Professional Counselor), a credential offered in all fifty states, took the same basic courses and had to pass the same national licensing exam in order to be able to practice. It is my opinion that, as this standardization happened, the focus became less about training and developing skills, and more about portability of licensure and standardization of the knowledge base of facts therapists possessed. There are many benefits that come from this approach. I am not opposed to the requirement that if someone is an LPC, it can be presumed they have studied and mastered certain sets of data. My concern is how does one take all this data that was studied in school and convert it into useful skills in the service of clients?

I believe that the structure of most University Counseling programs is now focused on taking the Master’s level Counselor and preparing the student for becoming a PhD candidate. Increasingly, the focus seems to be how to make these people competent to enter a pool of candidates for college professorships, and NOT to teach them to be independent practitioners who earn their living serving the populations that come to them for counseling. This saddens me. I strongly believe that the need exists for qualified practitioners who can serve large segments of the population in an affordable and professional way. I don’t think there are enough college professorships out there for all the students in these programs, and I fear that they are being poorly served by having that goal become the focus of their professional training.

Since formally retiring, one of the opportunities in which I still participate is to supervise clinicians. My credentials as a therapist with over thirty years of clinical experience, my years as a counselor educator, trainer and supervisor, have positioned me to be someone whom other therapists seek out for support and mentoring. I find that the discussions I have with other practitioners is pretty evenly balanced between discussing clinical issues (diagnostic and behavioral details of clients along with consideration of how best to develop treatment plans and interventions) and the mechanics of operating a private practice.

Most of my associates feel that they obtained good training at their Universities in the subject matter and skill sets of being a therapist. However, they feel that they were not well served in the training that they received on the business side of running a therapy practice. There are many reasons why this may be so, among them the idea that most people who become qualified therapist will not ever be private practitioners. Most of them will go to work at social work agencies of one kind or another, or work at a Doctors’ office, under the supervision of the physician or psychologist. Of course many physicians and psychologists claim that that is the proper role for Master’s Level licensed therapists. Under this set of expectations, the therapist will be an employee of a hospital, an insurance company, a public clinic, etc. They will be salaried and have benefits of some kind. Their job will be to provide therapy to designated and provided clients and they will not run the business, nor be concerned with the “business” of the operation.

But for those who do imagine that they want to work for themselves, as professionals, serving the general public in the way they have been trained, operating an independent therapy practice is a trial and error, haphazard experience. There are no classes and few discussions about the day-to-day management of an independent business that does therapy as its raison d’être.

I find my supervisees to be fascinated and hungry to have conversations about how to make decisions of a business nature. It is outside their paradigm to think about therapy as a business. They have been trained to think of it as a service. The business parts were not thought about, talked about nor trained for. The following is a typical exchange:

Question: “What are you worth an hour?” Answer: “I don’t know”.
Question: “How many clients should you see a week?” Answer: “I don’t know”
Question: “How many sessions a week does it take to cover the nut of your basic expenses of operation?” Answer: “I don’t know.”
Question: “Will or should you take insurance reimbursement directly from the companies, or will you require your client to pay you directly and give them the paper work to pursue their own reimbursement?” Answer: “Huh?”
Question: “What do you do if a client does not keep nor cancel their appointment?”
Answer: “It depends!” (Happily feeling they got that right)
Question: “How much money do you want to make a year?” Answer: “It depends on the number of clients I see?” (Buzzer sounds! Wrong answer)
Question: “How do you avoid being destroyed by the cash flow cycle?” Answer: “What cash flow cycle?”

Usually after asking these questions, we get to the point that we talk about how the therapist wants to set up their practice from a business standpoint. We have evolved from talking about treating the client effectively and different clinical aspects of therapy to talking about; advertising, marketing, renting, equipment and supplies, support help, record keeping, taxes, license fees, liability insurance for both therapeutic negligence and clients who trip and fall in the parking lot. These are not the things taught or studied in school. But, they should be!!

I recommend to my supervisees that they anticipate and project goals for their practice. On average, how many clients a week will you see? What will you charge? What percentage of them will actually pay that? What is your collection and retention rate going to be? I ask them to project that amount over the course of a year. Then based on that level of gross income, I have them subtract their annualized costs for rent, insurance, advertising, phones, etc. After subtracting their costs, I have them subtract their taxes (I usually recommend estimating 28%) Next, we talk about funding retirement. After all this, they are left with their net income for the year.

I ask them how often they want to receive a paycheck? Divide the above total by that number of paychecks per year. Pay themselves ONLY that amount each paycheck. This will allow them to ride the cash flow waves of bad weather cancellations, flu epidemics, vacations, etc. in order to have a regular, predictable income. If they are seeing more clients than they anticipated, they can make quarterly adjustments. If they are see fewer on any given week it won’t result in a crisis. If they maintain the average over the course of the year, they should be OK.

With a well thought out business plan, they should be able to run their practice, plan for their retirement, pay their taxes, and live a “salaried” life as independent entrepreneurs. The challenges are they must maintain their client population, collect the money, and actually discipline themselves to live within their budgets. These are all “healthy” skills that will enable them to survive and prosper as independent entrepreneurs who operate a successful business, as well as being a successful therapist. If my supervisee balks at this discussion, I point out to them that in order to be a healthy role model and to demonstrate the values of discipline, intelligent planning and good choice making, they have to be able to: “Walk the walk, as well as to talk the talk!!”

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The Concept of Healthy Selfishness in Therapy

Posted on March 4, 2012 by Brett Newcomb

Have you ever wondered why you keep finding the same type of person to play an important role in your life? Why you keep having the same problems and the same crisis evolves in the patterns of your life? I have had a lot of clients who come in and talk about repeated cycles in their lives. Even though they seem to make changes and try new things, the same old problems crop up. They are quite frustrated and unhappy, and they don’t understand why this keeps happening to them.

When I spend enough time listening to them to think that I understand the patterns in their lives, what I often see is someone who was raised with a very controlling individual. If in childhood they had a domineering mother and the only way for them to be safe was to learn how to please her, then they would have developed the skills of early warning radars. These radars were intended to read the signals that she was sending regarding what she liked or disliked about how they behaved and who they were. They would have learned to suppress their own level of desire or interest because it might not be safe. The dominant mother would signal which things or behaviors were acceptable. Then child would have learned that he or she “liked” certain kinds of food, clothes, activities, even music or TV shows because those would be the things that Mom liked and those things were safe. Safety is a primary need and goal for the young infant. Without it, they develop massive anxieties and often become depressed and/or full of rage.

When it is time for them to leave home and get out from under the thumb of the oppressive mom, then they often find a girlfriend who will replace her. (For consistency, I will use the masculine example, but this happens to both sexes and this could be either.) The girlfriend may not look like Mom, but she has the same attitude and she controls the situation by nuance and the offering or removal of approval. This representation of the “dominant other” is like a powerful magnet, which draws the individual like an iron filing. They just get pulled into the orbit of the new magnet and their life becomes a quest for safety within the new relationship. Often I describe these patterns for clients as being like a silhouette that is offered to them. If they go and stand in the confines of the silhouette, then they are safe and tolerated, perhaps they even receive approval by the strong person in their lives. This makes them feel safe, but it does not make them happy. Happiness is not an unconscious goal, safety is. They may not be aware that they are unhappy, but they will strive to make themselves safe and assume that if they are safe then they will be happy. If this relationship ends, they will find another iteration of the same individual and repeat the same process over and over in their life.

This is the point at which they often come to therapy. If we are talking about men, as we are in this example, then they seek women who will seem to be different on the exterior, but they are actually looking for an opportunity to repeat the same cycle hoping that this time they will get it right and then be safe, and ultimately happy. Part of the problem they deal with is that they have never had the independence, nor taken the time to figure out what they really want or like. They do not know what they want or what will make them happy. The challenge in their life therapeutically is to learn to recognize the pattern under which they operate, and then to deliberately risk small incremental changes that allow them to explore new behaviors.

One of the primary sources of anxiety will be not having a mask to wear, or a silhouette to stand within, so that they know they are “safe.” They are dedicated to doing what is “right,” what they “should” do, and NOT to asking what they want to do. I repeatedly ask my clients to ask themselves, “What do I want?” My clients find this to be a very difficult question to ask themselves. They have never considered their desires to be an option in their lives. They were led to believe that it was an act of selfishness if they put themselves first. Selfishness, they were told, is always bad. As a therapist, it is my job to challenge these beliefs.

I believe in the concept of what I call “Healthy Selfish.” I think it unhealthy to not know the things you like and the things you want. I think if you do not allow yourself to know them and to exercise adequate levels of self-care by satisfying those wants and needs in ways that make you feel good (i.e. happy) you will find unhealthy and unsatisfying behaviors that you do in order to be safe. The relationship will become toxic and cycle through predictable patterns of acting out, failure and disappointment. Selfish behaviors that take advantage of or hurt someone else are NOT what I am describing. Behaviors that are done in service of the health of the self are self-ish. I am referring to a psychological concept, not a sociological one.

When a client comes to me for help in breaking the pattern, I ask the client when there is a break in their repetitive cycle of dysfunctional relationships, and they find themselves alone, to stay alone. I ask them to not rush into a replacement connection with a new mask or silhouette that they can wear to make them safe again. Although this will reduce their immediate short-term anxiety and sense of disconnectedness, it would not make them happy or break the repetitive cycle in their lives and relationships. So, if they are brave enough and strong enough to take a period of aloneness, they can learn that there is a huge difference between being alone and being lonely. When they are able to be alone, I ask them to repeat at least three times a day, “If I were free to do anything in the world, what would I want to do?” I warn them that initially they will feel stupid and that no ideas may come. They will sit with the silence for a few seconds that feel like an eternity, and then they will distract themselves and “remember” that they need to change the laundry, or go to the store, or pay the bills, etcetera. But, if they are able to do this, they will eventually discover that something happens. They will discover something that they want or like. Initially, it may be something silly such as “I want ice cream!” or “I want to go to the movies.” I encourage them to act on whatever it is when it pops into their head, if they can. But even if they do these things, they need to keep asking themselves, “Is this what I want?” This is productive, even if nothing comes but silence. Eventually, I believe, they will begin to get glimpses of what they really desire or really want to do. When this begins to happen, we make a plan. I help them figure out how make their desires real. We discuss the steps or behaviors that are necessary in order to make that option a reality. This begins the quest for happiness, instead of safety. If they take this journey for healthy selfishness, they will get off of the path of cyclic dysfunction in their relationships and no longer seek the silhouette of the domineering (m)other to tell them what to do so that they can be safe.

I believe in a healthy selfishness. I think part of doing good therapy is to help the client discover their own autonomy and to consider that they have a right and a responsibility to behave in ways that will make them happy. These are not short term hedonistic self-serving behaviors, but major life decisions that develop their freedom, their integrity and help them to live a healthy, self-satisfying life, not an empty life of service to someone else’s life or desires. You can break the pattern of just looking for safety and be happy. If you are ready, and if you have a good therapist, you can make these changes and become free of the cyclical repetitive dysfunctional pattern of always choosing the same domineering individual to be your partner (guide). Good Luck.

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