Emotionally Driven Coping Strategies

We spend a lot of time in our podcasts talking about hormone replacement, making good medical decisions, and preventative medicine. (See biobalancehealth.com podcasts with Dr. Kathy Maupin.) Today, I am going to share some thoughts on coping strategies, and the impact that our emotions have on the regulation of both our behavior and our bodies.

In the field of Psychology, we talk a good deal about the mind-body split, or the Cartesian Split, as it is sometimes called. It is a reference to Renee Descartes statement, “I think, therefore I am.” We understand this to mean that people who use logic, evidence and reasoning properties to try to solve all their problems and to “know” themselves, stay in their heads. Actually, therapists call these clients “talking heads” because they appear to be disembodied heads just floating, without feelings or true selves. It is just a verbal way to make a distinction about people who are out of touch with the information and data flow from inside their bodies. As a result of being out of touch, they are out of balance making use of only half the tools they might have for knowing what is going on with them and with their surroundings.

Balance is the key to harmony. In order to achieve balance we need to be able to access our emotional and physical side, as well as our cognitive or thinking side. There is always information being sent from these sources, but some of us have learned to close off those channels. We do not receive or process the data that comes from those channels as we try to solve our problems or deal with things in our lives. There are books in the popular literature that focus on trying to access all these channels and utilize them so that we are not just be predominantly one-sided. One example is the book The Power of Now by Eckhart Tolle. Part of the challenge is to access the data. Another part is to incorporate it in framing our understanding and developing strategies for problem solving and relationship maintenance.

Let’s review some of the basics. It is a given that everyone experiences raw anxiety. There are lots of theories to explain why this is so. Understanding why we are creatures who have anxieties is interesting in its own right and is sometimes helpful. I think the larger challenge is to determine what we do in response to these anxieties that we have. We develop a series of coping strategies, called defense mechanisms, to help defend us against the anxieties that we have. These feelings make us afraid and uncomfortable so we try to find ways to deflect, avoid or contain our anxieties so that we can function and we can feel better.

Our defense mechanisms are unconsciously developed as our psyche learns to “read” the incoming data. Through trial and error, it discovers ways to behave, either overtly or covertly, which successfully helps to reduce or avoid the data. We can develop physical behaviors like thumb sucking that are age appropriate and help soothe us so that our fears do not terrify us. As we age and learn more about interacting with our environment, our experiments become more complex.

We move from thumb sucking to more complex behaviors such as reaction formation or projection to protect us from our fears. Reaction formation is the development of both a belief and behavior pattern that allows us to behave the exact opposite of what we desire to do. We have a desire to do something which we feel is not acceptable and which we are afraid to do because it will lead to punishment or rejection which we cannot afford. So we deny that we feel that way (denial is another defense mechanism) and begin to act and speak in the exact opposite way so that we and the world believe that we want what we say and not what we secretly desire. An example would be someone who wants to look at pornography, but finds it morally objectionable or dangerous because it might cost us our job if it was known that we behaved this way. Or, it might cost us our place in the community and the respect we have earned for being perceived as a certain type of person. It would be destructive if it became known to others that we wanted to do these things. So we use reaction formation to develop a false self, one that projects the desirable value and contains our acting out behaviors. We become anti-pornography crusaders and loudly proclaim that it is awful and that no one should ever look at it. Several well-known politicians have fallen into this trap.

Another defense mechanism we utilize is the one called projection. This is when we find some part of ourselves to be threatening or objectionable and we want to hide from it. Since we cannot admit to ourselves that we feel a certain way, we deny it (denial again) and project it on to someone else. This way we can convince ourselves that we don’t really feel this way. It is the other person who desires it and isn’t that awful that they do? This behavior is common in loving relationships that are fragile and on the rocks. I may secretly desire to change partners but the social, economic, reputational, and moral costs of doing what I want are just not acceptable on any level. So I defend myself from this desire by projecting it on to my partner. She wants to do this; she is the bad person, she is looking for someone else. Ain’t it terrible? Isn’t she bad? If I say these things about her, I protect myself from the anxieties of knowing and feeling what I want, and from the public cost of behaving in ways that may be “true” to me, but are more expensive than I am willing to afford. Often these projections allow us to unconsciously act out in other ways, which will upset our partner but for which we are not going to be held accountable. Our partner becomes mad at us and eventually tires of us and our projections have become a self fulfilling prophesy and we become innocent victims who finally get what we secretly wanted!!

In therapy, I see a lot of what I call “globalization” of defenses. By that, I mean that when we are young, we discover a strategy that becomes our preferred defense. It can be any of the defense mechanisms: denial, projection, rationalization, reaction formation, etc. It works for us as children because our choices are limited and our control over the world is not very effective or complex. As we mature, our defenses become more complex and sophisticated. We develop more finely tuned and precisely layered defenses to protect us from anxieties. When these more mature and complex defenses work, our anxieties are contained and manageable. But sometimes they do not work. When this happens, we are said to regress or retreat to more primitive defenses, primitive meaning developed earlier and being less complex. When we do this, we resort to the one defense that we preferred to use as a child and apply it to all circumstances as adults. In other words, we use the only hammer we have in our tool box and everything in sight is a nail. (This is referred to the Law of the Hammer.) This strategy is not effective, it is not nuanced or complex and it does not work to solve the problem, but it may work for a while to contain the original anxiety. Since it does not work in the long term, our difficulties lead to new anxieties in an ever increasing spiral that we cannot contain or manage. Our lives begin to unravel because we cannot adapt or modify our thoughts and feelings to protect ourselves. We lose the ability to function in healthy and productive ways.

One of the main reasons people seek out therapy is that their defenses are not working to protect them. Their lives are falling apart, their health is deteriorating and they know that they need help, or they at least hope that there is help for them. Usually when they come to a session, they want to talk about everyone else and how if all the other important people in their lives would just change the way they think or behave, then life would be better. It takes a lot of work in multiple sessions to get them to begin to look at their own behaviors and their own desires. This must happen before they begin to consider whether or not the strategies they are using are helping or hurting. Only then can progress can be made and new behaviors be tried.

These are challenging issues because they happen so far from the realm of our cognitive approaches. They are reflexive, unconscious, and automatic. When they don’t work, they are very expensive to our relationships, our economics, and our lives.

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Professional Practice Issues for Personality Disordered Independent Contractors

Have you ever wondered how to manage an employee or an independent contractor whom you felt suffered from a personality disorder? It is an incredibly challenging task. Let us begin our discussion by assuming that this is an employee that you would prefer to keep. Obviously, if it were not so, you could arrange to dismiss them. But when they have some merit, offer some value or contribute some skill that you prefer to be able to access, you may want to keep them for a time. The necessary managerial calculus is a constant and ongoing reassessment of the worth of the employee/independent contractor versus the cost of the damage they do to your organization. Perhaps nothing is more clearly at issue than the cost- benefit ratio that a manager/owner has to calculate with regard to these individuals. You often make an investment in the contractor or employee, such as equipment, marketing, training, etc., before you realize that they have issues that make them difficult to manage.

In today’s world, many therapists’ practices are structured by an owner who undertakes to provide the basic necessities of business operation. These owners sign contracts to be responsible for the rent, hire secretarial help, manage the storage of files, track accounts receivable, pay the bills, market the practice and provide the clinical supervision required by the state. In return for taking these risks and maintaining these responsibilities, they make a deal with the independent contractor, who is a licensed individual. The licensed individual will provide the direct client services in an ethical and appropriate manner. This is a win/win for both the practice and the therapist who is an IC (independent contractor.) In the field of psychotherapy, the client “belongs” to the therapist not to the practice. If the therapist leaves the practice for any reason, the client always has the option to go with them. The practice must retain records and the therapist who leaves must retain records of the work that was done. They must both follow the rules of HIPPA and the ethical codes regarding custody and availability of records. Generally these practices are created around the idea of a fee split. The provider of the services, in this case the therapist, receives some agreed percentage and the owner of the practice receives the rest. This is true even when the practice accepts third part reimbursement. Usually the fee split breaks in favor of the owner of the practice and often has several break points for performance where the split changes. Usually these contracts can be cancelled with thirty days written notice by either party.

In my experience, the owner of this type of practice is also a licensed provider who has clinical skills and is comfortable with undertaking the financial and ethical risks in return for the payoff of the percentage of earnings of the various independent contractors whom they “hire.” They actually don’t hire them, of course, because then the practitioners would be employees and the rules and issues would change. However, the challenge I originally posed may arise in either setting: What do you do with a practitioner whom you feel has an Axis II personality disorder? Are they worth keeping? If so, how do you manage them to minimize the distress they inherently cause in the work place and restrict any damage to the client from the operation of their particular disorder? And, yes clinicians often have diagnosable conditions. Some even have Axis II disorders. They still practice and often do a great job when their skills are applied to clients who suffer from disorders different from their own. It might be interesting to ask those clinicians with whom I have worked through the years as a co-worker, supervisor or teacher what they think my diagnostic labels would be….., but I really don’t want to go there. Some of them read this blog and may feel compelled to respond.

Generally, when one presumes that a therapist has an Axis II disorder, one works to “lean” them in the direction of a client population who is not suffering from the same disorder. Often these clinicians have already done that for themselves, they may suffer from a passive aggressive disorder (Axis II) in their personal and professional lives, but they may specialize in working with children who are ADD, working with families that have co-dependency issues or depressive issues. This should pose no ethical problem for the therapist or for the practice at large. But it will pose a problem for the manager who is trying to manage the practice because the therapist will act out their personal issues within the office and they will bring some of their challenges into the relationships they develop within the office that have nothing to do with their client base. The other employees of the office will be angry and frustrated with them and with the manager for not dealing with them more efficiently. A lot of tension builds within the practice because no clear challenge is made. For example, passive aggressive behaviors cause others to get very angry and frustrated, but the individual that engages in them will claim innocence and be very hard to pin down and confront. As the manager of the practice, you need to know that this will happen and have a plan for regulating the relationships so that your office does not explode from frustration. In order to do this, you have to follow the general rules for dealing with individuals that have passive aggressive behaviors. You must have firm boundaries and rules, and you must enforce them neutrally and consistently. This is difficult to do because the individual involved will deny the accuracy of any challenge and will work hard to deflect any responsibility for their actions, or lack of actions. As the manager, you will be frustrated and your other staff will feel angry! Also as the manager, the goal is for you to manage the practice so that the clients are well served and that the staff does not explode. You need to make sure that you are not paying a greater cost in investment of energy than it is worth to keep this individual working for you.

Success in this domain is based on a constant and on-going reassessment of the value of the contractor whom is Axis II disordered. Are they worth the trouble? Can you maintain a consistent set of behavioral expectations with consequences for a contractor that is not an employee? Can you keep the other staff from playing the game of “I got you now, you S.O.B.” (See Eric Berne, Games People Play.) You must remain professional and must not get emotionally involved. Enforce the rules and require the appropriate behavior from your independent contractors, even when they claim innocence and ignorance. Some common statements you will hear are: I did not know. I did not do that. You misunderstood. The rest of the staff does not like me.

It is a challenge to work with independent contractors in the first place. It is a particular challenge working with one who is Axis II disordered. When you begin a relationship with a new contractor, it is usually not obvious that these issues exist. But once you are aware of the problem, you must deal with it on several levels. At best, your efforts are a holding action against disaster. You can contain the problem for a while, but eventually you will need to replace the contractor and work constantly to protect the client base that you serve. You have an ethical and legal obligation to the clients when you bring these clinicians into your practice, even though you are not the provider with direct contact. You also have an obligation to the clinician. If you undertake to “hire” them and work with them as professional providers, you must supervise, manage and consult with them to keep them coloring within the lines at all times. This is more difficult than you may imagine and it is seldom worth the cost in the long term. In summary, these clinicians are challenging and may contribute to the bottom line of the practice, but they will cost more in energy, frustration and exposure to risk than they are worth. You cannot technically “diagnose” them and you cannot force them to get counseling for their disorder (you can encourage, but not require.) However, you can manage them efficiently, consistently and hold them accountable to a standard of behavior. In fact, you must do this to be ethical and to protect the client base that you both serve. You must also know that your office will be in a constant state of uproar and the other staff will be angry and upset continually (and perhaps, the clients will also.)

Keep in mind the fable of the scorpion and the frog. For those who are not familiar with it: A scorpion and a frog arrive at a river bank in flood. The scorpion talks the frog into giving him a ride across the river by promising not to sting the frog, paralyzing him while they were in the middle of the river. Of course the scorpion violates his promise and as they are both sinking into the river to drown the frog asked, “Why?” The scorpion responded, “It is what we do!” The scorpion could no more go against his nature than he could fly. When you know that you are working with a scorpion and you get stung, it is your responsibility to deal with it, because the scorpion is made to sting. Protect yourself, your practice and your clients by having good boundaries and clear expectations.

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Projection as a Defense Mechanism

The Power of Projection as a defense mechanism is awesome. General thinking about the defense mechanism of projection is that it allows us to identify and acknowledge some aspect of ourselves that we cannot face as our own then project, or shine, it upon someone else. The result is we can then be hurt or angry with them for their audacity of having these thoughts or feelings about us! For instance, if I do not like my body image and feel that I am unattractive because of my weight, I can project onto my friend that he feels I am unattractive because of my weight. Then I am free to be angry with him or hurt because he feels this way about me. He, of course, has no idea why I am angry or hurt since these feelings do not belong to him. These are projections of my inner-self that have been put upon him by me, due to my inability to face the “truth” of those issues myself.

Another place where one often encounters projection, especially among adolescents is in the arena of love. If a boy and a girl are “in love” but, one of them is beginning to fall out of love or to be attracted to someone else, they often will begin to accuse their partner of “looking at” the boy in English class, or flirting with the captain of the football team, or of wanting to go out with someone else. This happens because the one falling out of love is not able to “own” these feelings and deal with them in a direct, honest way. Often the person who is projecting will hide behind such statements as, “I miss my friends and want to spend more time with them, but you won’t let me.” They are afraid to take the responsibility of saying, “I need time away from you.” The partner might then break up with them and they are not sure they want that. Perhaps, he just wants to experiment, check out things to see if they are really greener on the other side of the fence. However, he does not want to be labeled as the one who broke up the relationship or as the bad guy, so he projects onto his partner that she is emotionally shallow or that she is behaving badly and the responsibility for the breakup belongs to her. In his mind, his friends will side with him because he can spread the word (or spread his projection) among them that she is not to be trusted and that she has “done him wrong.”

More subtle forms of projection might include behaviors that are subtly self-destructive. These behaviors will manage to sabotage some goal such as getting admitted to medical school by “managing” to fail the entrance exam because they had not slept or studied enough. The claim will be made that they were not feeling well, had to work too many hours or their boss would not let them off to study. The responsibility will be placed on someone or something else. They are not be able to say to themselves, or to their important supporters, that they no longer think they want to go to medical school. Perhaps this has been a dream for years, or it has been an expectation of the family that the child will grow up to be a surgeon like dad. The child is not strong enough to just say that he wants to have a career in music, not medicine. He may fear rejection or punishment by his family if he does not become a doctor, and he may not allow himself to “know” what he really wants to do. So instead of facing this conflict and dealing with it directly, he will create a situation for which he is not responsible and cannot be held accountable, but which prevents him from going to medical school. Of course in these convoluted thinking patterns other defense mechanisms are also, by necessity, utilized. One that comes to mind here is rationalization and another is scapegoating.

All of these examples arise from circumstances where the individual who is projecting has some strong desire or feeling that determines what they want to do or how they wish to behave, but for which they are unwilling or unable to take responsibility and ownership. These fantasies may be so strong and driving for this individual, but they are not acceptable, they are forbidden or perceived as risky and shameful to the extent that the individual may not even be able to consciously articulate them, and certainly will not be able to overtly pursue them.

The challenge for the therapist who is dealing with someone that is projecting as their principle defense mechanism is to recognize what is happening. The therapist needs to gently uncover this conflict and lightly invite the consideration that perhaps some projection is taking place. The therapist cannot “attack” or “out” the client and say, “Aha, I know what you are doing and what you really want to do!” This will frighten the client off, and it is showing off by the therapist. Even when you are certain that you are correctly identifying this behavior, gently inviting consideration is an effective strategy for getting a client to consider that they may have some forbidden desires or some internalized critical self that is punishing them with self-hatred.

During therapy, one of the most important experiences for the client is to be held in the safe holding environment of unconditional positive regard. Carl Rogers taught us about this condition. The point is that the therapist does not have to like the client, approve of their goals or behaviors, nevertheless, the therapist must communicate to the client a genuine belief in the client’s right to be respected and heard honestly and accurately. You cannot sit upon a moral throne and judge your clients. The questions you ask in your head cannot be: Is this the right thing for the client? Is the client making a good choice? The questions must be more in the line of: What does the client really seek? How is the client going about getting what they want, even if the want is unconscious? What is the cost benefit ratio of the client’s choices and behaviors?

Once you have asked yourself these questions as the therapist, you must then begin to “suppose” the possibilities to the client. “Perhaps, this might be going on with you.” Or, “I wonder if you have ever thought or felt this way?” “Have you ever thought about doing something other than what you are doing?” You might even say, “If you were free to do anything in the world that you wanted to do, what would that be?” This is one of my favorites! It is hypothetical and speculative and takes no ownership or responsibility, so it can bypass the defense of shame or guilt that inhibit or “forbids” the client to behave in some specific way. The therapist asks them to speculate. “If you were free, without peril of punishment or shame, to behave in some new way, what would you choose to do? Can you think about it? Can you quietly sit and dream about some action or some behavior, if you were free to engage in, you would?” These are very powerful scripts. They allow someone to speculate and fantasize, without putting them at moral risk. You begin slowly to ask them to nibble at these ideas, to explore and imagine them in increasing increments.

When people begin to take the risk to change their script and their behavior they begin to do so at the periphery of their lives. They do not immediately go home and say, “I want a divorce.” They do not immediately walk in and quit their job. But, they begin to behave differently in someway in places that are safe, so there are no costs that will follow them home. They might experiment with someone with whom they are not in any kind of relationship to see how an outside party might respond. Perhaps, they try being more assertive with a waiter and will demand some special service in a restaurant they never frequent so that they can practice the behavior without significant consequences. They begin to practice and explore new behaviors at the edges of their universe and then gradually begin to incorporate them into their “real” lives. As a clinician, it is important to warn them that this is the usual sequence and that you do not expect them to go right home and challenge the most important part of their lives as a result of this particular session. You want them to experiment, you want to help them become more skilled and to carefully assess how that makes them feel? Does it really reflect what they want and are they pleased with the new behaviors? Are there costs that they are beginning to identify that they do not want to pay? Can they recognize that they are making a choice and have the power to change? Then and only then, do you begin to help them behave in a more coherent and congruent manner in their central relationships and their primary lives.

The challenge for the therapist in understanding the defense mechanisms is being able to recognize when they are employed and why. The therapist must spend time with the client learning to “know” the client and to hear them accurately, even when “accuracy” involves hearing things that they are not saying or are different from the things they are saying verbally or behaviorally. It is a critical skill set to acquire. But if you spend the time learning how to do it, you will be a much better helper and a more useful travelling companion in the lives of your clients. Good luck.

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Clinical thoughts on Treating OCD

Obsessive Compulsive Disorder can be a crippling thing to have. OCD can consist of obsessive thoughts or compulsive behaviors, it is often both. When it is both, the behaviors are often designed to neutralize the intrusive thoughts. They are a form of a kind of magical thinking that will keep anxiety at bay. If I arrange the coins on my dresser at night in some form or pattern, then my intrusive thoughts of inappropriate pornographic mental imagery will stop. The problem with this way of thinking is that there is never a set pattern of coin arrangement that will magically “work.” I have to keep arranging them until I “feel” that they are right, and then the anxiety subsides…….. for awhile. Sometimes what happens is that the compulsion to arrange coins develops its own psychic energy and I am compelled to arrange them until somehow, magically the compulsion is satisfied. It is only when that magic happenstance occurs that I can leave the dresser and go to bed.

People who suffer from this disorder discover that the amount of time and energy they begin to consume intrudes into their daily lives until their lives are no longer their own. Their lives are “owned” by or controlled by the obsessive thinking or compulsive behaviors. An example is a client I once had who was a young man in junior high school. He was an athlete and was very bright. Anxiety was an issue for him, he felt constantly that he would not be good enough to make the team, score the winning points or be the star unless he magically followed his routine every day. This kind of thinking begins, especially for athletes, when they randomly associate some behavior with an outcome that was successful, or unsuccessful. One has “lucky” socks that he must wear, another has a lucky bat that she must use. I once knew a high school quarterback who insisted that his lucky game socks could not be laundered until the team lost. They had magical powers and the team kept on winning. The team had an undefeated season, but lost the State championship game. Then the spell was broken and the socks were thrown away. (Boy, did they stink by then!) This boy and his team all believed in the power of the magical socks. In this case it was not an obsession or a compulsion, merely magical thinking. But the boy who had a routine he had to follow in order to leave the house had moved beyond just magical thinking. He developed obsessive thoughts and compulsive routines that involved counting and repetitive behaviors, as well as an order or sequence of steps that must be followed.

These behavior patterns become so intrusive that they prohibit you from being able to have a “normal” life. The boy in my example developed a series of steps he needed to complete, places he must touch with his right hand in the proper order and in the proper number of times so that he could get out of the door and go to school each morning. Each day it took longer and longer because he kept having to start over when someone would interrupt him, or something that he needed to touch in the sequence had been moved. He became more and more anxious and stressed, and it raised the stress and intensity level for his mother and siblings because they had to deal with his bizarre demands and ritualized behaviors everyday. His grades began to suffer because his rituals took more and more time, and he began to miss school or be very late. Finally his parents brought him to me for help.

Another example is a client I had who was reclusive. She could never quite manage to leave her home. She spent hours and hours each day in her bathroom getting ready to leave but she would become preoccupied by her cuticles and spend time working on them. She had to get them just right in order to finish getting dressed to leave. Consequently, she was not able to hold a job and had no social relationships that she could maintain. My client was eventually brought to see me by her husband. He was becoming extremely frustrated because she had lost the ability to function. She could not grocery shop, cook meals, meet her mother for lunch, and eventually, she was unable to even get dressed because the entire day was spent in the bathroom getting ready. This woman completely lost track of time. Hours and hours would pass while she was focused on getting herself “just right.” What we discovered was that while she was “focused” on these physical steps for getting ready, she felt no anxiety. When she was doing anything else, or more importantly, not doing these “reassuring” behaviors, she was riddled with anxiety that she found debilitating. Eventually, she found a cure for the anxiety in her compulsion, but the compulsion itself became a worse issue in her life.

As we took steps to limit her compulsive behaviors, her anxieties skyrocketed. I anticipated this and was able to prepare her and her husband, who was very supportive, to expect this and to plan for ways to contain it. They received a referral to a physician for appropriate medications and the supervision of them. Then we worked on a series of behavioral interventions and thought stopping techniques for the woman and her husband to learn in order to disrupt the compulsive behaviors. She had to gradually learn to find other ways to neutralize both the compulsive behaviors and the underlying anxieties. She had to take anti-anxiety medicines to keep her calmer so that she had the “breathing” room to be able work on changing her behaviors. Fortunately she had a good support system and was a strong, stubborn woman who was determined to get better.

In some ways, she was like the mathematician in the movie “A Beautiful Mind” who learned that he could not trust his own sensory information because his mind was playing tricks on him. He knew that he was imagining people and conversations no matter how real they sounded, or seemed. He had to learn ways to limit the damage the hallucinations and delusions were causing in his life. Because he was so brilliant, he was able to do so. If you have not seen the movie, please give it a look. It may help you to understand.

When working clinically with people suffering from intrusive thoughts (obsessions) and the need to repeat behaviors (compulsions), the therapist must work on at least two levels. We have to get the obsessions and compulsions under some level of control and that may take medicines in addition to therapy to be successful. Also, you must never lose sight of the reality that these issues are stress related responses. Where is the source of the anxiety? What is causing them to be so upset? Is it reality based, or is it a deflection or a projection onto an object that is “more acceptable” to be worried about? Be aware that these behaviors will grow in complexity and intensity. Their intrusiveness, if left untreated, will take over the lives of your clients. The therapist must provide a safe holding environment and must present themselves with confidence and quietness. You must believe that you can help them, and you must radiate that belief. You cannot be afraid of the symptoms. You cannot communicate to the client that you think the case is hopeless or out of control. If you cannot do it by yourself, get yourself involved with a team of professionals, including a physician, who can work with you and the client to achieve results. Work with the families or support systems of the client to teach them how to be supportive and helpful. Of course, for this you need permission of the client, but having a functional and helpful support system is crucial for progress to be made.

Everyone has some little snippets of these behaviors. However, they rarely rise to the level of a disorder. When you are stressed out you may discover that a song gets stuck in your head. No matter what you are doing, you hear that song intruding on your thoughts. You feel like you can’t stop it from playing. It will usually not be the entire song, but it may just be a phrase or a jingle. It will play and play and play and play……… That is a very small example of what an obsessive thought can be. Magnify that a thousand times or more and you will get a sense of what is going on for the person you are treating. Almost everyone has some form of ritual behavior that comforts them, from a baby sucking a pacifier, to a man putting his wallet in the same pocket every day. We learn to ritualize our behaviors. Think about how you get dressed. Most of us do it in the same sequence every day. If we are required or asked to change the sequence, it will most likely make us uncomfortable. It may make us upset or anxious. In severe forms, you may call it OCD.

As do most complex disorders, this disorder set requires both medical and physical interventions. It usually needs some medicines to regulate anxiety and calm the client, then it needs behavior modification to learn how to control the physical demands of the thought processes or magical behaviors. It needs cognitive, rational discussions of how to understand what is going on. The clinician needs to be open to all these modes of intervention. If possible, the clinician needs to be skilled in each of them, or to have a support team that will compliment the treatment plan. Do not forget the importance of the relationship with the client. Be connected, be supportive. Be confident and recognize that this is a very resistant disorder. It takes time, understanding and creating a safe environment to treat.

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Codependents, Hoarders and Guilt

This week I spoke with two different women who were in crisis regarding people for whom they felt responsible. One was the mother of a teen-age child and the other was the daughter of an elderly mother. Each was suffering in similar ways. They were flooded with anxiety, pain, anger, and frustration and attempting to deal with all of this by assuming a burden of guilt that did not belong to them. These women were both raised in cultures which encouraged them to be co-dependent.

I have known both of these women for years. They typically approach any situation by first attempting to understand what motivates the others in their lives to behave they way they do. They want to know why grandma, son, sibling or friend is inconsiderate or abusive to themselves or others. Why do they act in ways that are clearly destructive? In each of these situations, these women want to assume both a level of power and responsibility for making things better that they cannot have. In listening to them talk about their problems, I hear them constantly focus on “what can I do to make them see? Why can’t I just explain it to them and help them change their behaviors so that these destructive things they are doing go away? Why does it feel like my fault when they do not change their behavior and continue to experience negative consequences of their actions?”

I frequently ask these women, “What can you do that you have not done?” They will cry that there is nothing, but there should be something! If only they were smarter, stronger, had more power, etc. they could stop these behaviors and “make” the person they love both behave and be better for it. They are frustrated by their powerlessness, and usually they are frustrated because they have no one who will hear them or listen to them. That is one of the reasons they come to me. I will listen.

To me they can say whatever they want or need to say and not feel guilty. I will not laugh, nor will I accuse or deflect or shame or guilt. In fact most often, I am gentle and supportive and reflect back to them that these are the things I hear in what they are saying: I hear your strength, I hear that you are frustrated and maybe even a little angry with these people or these situations. I hear that you wish you had the power to make a change that would help, and that you feel guilty for not being smart enough, fast enough, etc. to cause the loved one to make these changes. I seldom do more than that. There is seldom more to be done. It is helpful to be able to vent, helpful to be heard, helpful to have a supportive and caring ear.

Sometimes we problem solve together, but I find that most of these efforts are focused on how to change someone else’s thinking or behavior. It is seldom what these women need. They need to be able to figure out how to change their own behavior and thought patterns. I talk to them about boundaries. It is usual in this type of situation that people do not have good boundaries. They allow themselves to be scorned, scolded, guilted, and dumped on. Their lives are disrupted and their hands are tied and their resources are consumed. Much of this happens because they do not have good personal boundaries. An example would be a story that was recited to me about how this person tried to help someone by doing something for them. In this case it was clean up a very disheveled house. The person to whom the house belonged was a very depressed hoarder. When the hoarder got home and found that their things were cleared out, cleaned and organized and that some of the things had been packaged for disposal since they were clearly trash, the hoarder exploded. My client could not understand why the hoarder was so angry with them. They were only trying to help and the person they loved was so clearly helpless in this matter. The situation was killing them, according to the perceptions of my client. It was a very painful discussion that my client and I had about who owned this problem and what the actual problem was.

I believe that the hoarder is ill and needs help. That being said, until they are ready to receive help, the hoarder cannot be helped. It is not helpful for them to be violated by the needs of their child or mother who is being “helpful” by taking away their freedom and power by arranging their stuff the way the child or mother feels the stuff should be arranged. It is not helpful, nor is it legal (in the case of an adult who has not been declared incompetent) for the relative to come in and dispose of their stuff! The need of my client to do this “for the good of her loved one” is dishonest. My client needs to do this for herself in order to feel comfortable about herself. My client is the one with the world-view that this behavior is unacceptable and shameful. She is the one who is trying to “arrange” the choices and behaviors of her loved one so that they fit comfortably into her expectations in order that her stress is reduced and guilt is avoided.

In counseling, we have to get each of these individuals (the child or mother and the “broken other”) to accept the honest exploration of their problem and their issues. Usually, the only client I have access to is the adult child or mother who wants to talk to me about their sense of being stuck by not being able to fix the one with the problem. They feel horrified, guilty and helpless. We work on their script, and on their boundaries. I try very hard to not spend time discussing why “her child” or her “her mother” behaves the way they do or has the issues they have. None of this is immediately relevant to the session I am having. What is relevant is how my client feels about it. What are THEIR problems and what options for their own behavior do they have? One of the biggest challenges my clients face is the ability to be honest and admit that they are not responsible for the choices of the other. Nor do they have the power and authority to take over and force or coerce their loved one to behave in “acceptable” ways. My clients really resist being able to hear this message. They tell me that I just don’t understand. They love this other person and it is their responsibility to step up and take care of them. It is their job to clean up their loved one’s life until the person is once again able to do so for themselves.

As a clinician it is hard to keep focused and not get sucked into the story. My client is the one I have access to. My client is the one in pain with whom I can work. I may have concerns about my client’s loved one, but I need to avoid getting sucked into a conversation of a speculative and hypothetical nature about how to cure and understand someone I do not know and probably will not meet. My clients are very seductive in trying to get me to do this, but I must be aware, strong and focused so I can avoid it.

Ultimately the potential for helping my clients fall into two areas. One is the safe holding environment where they are heard accurately and cared about so that they can cleanse themselves by venting, crying, raging, etc.. They have to do a data dump and I have to monitor the process of that. The second area is helping them construct better boundaries based on honest reality testing of exactly what their responsibilities and options are for dealing with their loved ones. These are distinctly different tasks and can happen in sequence or in parallel. We can interweave them both at the same time or deal with them one at a time. If we are interweaving them together, then as her counselor, I must be able to follow the story as it jumps around from venting and anguishing, to problem solving, to speculating about causation. I need to clearly remember that their other loved one is not my client and that I am not helping them. My client is the one in the room that I can work with. I have to create that safe holding environment and encourage good boundaries. I have to help them learn how not to be co-dependent. This requires perspective, discipline, attending skills and clear thinking on my part. I cannot get sucked into the story and I cannot chase the rabbit of the “other” who is not there. I must avoid the seduction of the power of speculative interest and cultural “shoulds.” I must help my client to change her way of thinking about the situation and to make free and healthy choices for themselves. This does not mean that we do not care about what happens to the problematic loved one, but it does mean that we are clear about the ownership of the problem and the limits of the power we have to take on responsibility for others.

This process is very painful for my clients. My heart hurts for them both.

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Basic Personality Structuring, is it nature or is it nurture?

Personality Change? Or Just Stretching the Envelope?

I have been driving around the back roads of several southern states for the last couple of weeks. It was a deliberate decision to stay off of the interstate and see the small towns, farms and people we would encounter along the way. I made this decision because all my life I have been driven in a regimented and focused way to travel as quickly and efficiently as possible towards the next goal in the plan in order to gauge my success. I wanted to discover if I could exist without the disciplined structure and the goal-focused activity that has been a hallmark of my adult life.

I chose to drive through southern states because I am from the South and wanted to revisit the formative culture of my youth. I have always needed a force to push against. I was raised to be competitive, disciplined, focused, aware and driven to achieve. Those behaviors are instinctive for me, and yet, there are other elements to include when thinking about what has formed my personality. I have always been a person who has seen life as a glass half-full. In therapy and in life, I encounter so many people who see life as a glass half-empty. They are negatively focused and expect things to get worse, not better. They develop behaviors and rationales that position them to be unhappy or victimized, rather than happy and in charge of their fate. I wonder why? As I have written before, my life as a child was no bowl of cherries. It was brutal; physically and emotionally abusive and deeply poverty stricken. I was desperate as a child to find a way out of the social class into which I had been born. I had every intention to find a way out of the poverty, the alcoholism, the cultural myopia and negativism of my childhood family.

Over the last two weeks I have had ample opportunity to think about and encounter the Yin and Yang of life. I have observed things from the mundane to the magnificent. I had no itinerary and no goal, other than to pick up my son in Kentucky on the last day of the month. I visited places like Turkey Scratch, Arkansas and the Great Smoky Mountain National Park. I saw lots and lots of interesting people, talked to some and watched many more. For me, “people watching” is the interesting part. It is my job as a counselor to watch people. In therapy sessions, nothing is unimportant or trivial. My job is to observe, analyze, interpret and attempt to understand who the client is and what they are really saying.

Especially important is the ability to read non-verbal communications. What does it mean when they laugh under tension? What does it mean when they deflect the conversation away from a subject? Is it intentional or is it unconscious? How does it fit into the whole self of the client? What is the message they are giving me and asking me to understand, boith literal and unconscious? Counseling is often exhausting work that requires focused attention and a constant testing and discarding of assumptions as information becomes validated or invalidated.

Personalities are complex structures, much like the facets of a diamond. Each facet can claim the light and shine and be the focus of attention. But we must never forget that the other facets exist and that they are also waiting for a turn in the light. Is the fluid movement from one facet to another just a random play of the light of life, or is it an intentional or predetermined path? Do we believe in fate or choice? Are we the actors in the play or the author who creates the script? Could it possibly be both at the same time? When I am performing the part and presenting myself as I hope others will perceive me (brilliant, clever, caring, gracious, etc.) is that really who I am or is it just a script I have learned to recite, a role I can perform on demand? Can I not, at the same time, be selfish, mean and small-minded? Can I be jealous, greedy, and sinful, yet still look to the ideals of great social and religious causes as a way to intend my behaviors? Am I able to stand with my head in the clouds and my feet in the muck of my own humanity? Damnbetcha! I do it every day, and most likely, so do you!

I have seen this paradox for over thirty years in clinical settings where I had a role of defined expectations for my behaviors. Now I want to see if I can back away from the discipline, the goal setting, the checking off of boxes on the “To Do” list. Can I let go of measuring my day, or even an hour, without feeling as if I have not proven my worthiness? I want to try to live life as an experience, a happening, not as a series of challenges and tasks to be accomplished. I want to be, rather than do. The problem is, I do not know what that means or how it feels. I have never lived this way, and I am not sure I can.

So, I took two weeks to experiment. What if I got up in the morning without an agenda and just let life happen? What if I just wandered where ever it seemed to flow or be interesting? Who would I meet, and more importantly, who would they meet if I were not in my role? In the beginning, it was harder than I thought it would be. Part of me desperately needed an agenda or a plan. Where should I go today and how do I count or measure it as successful? Should we see museums, Civil War battlefields, The Hermitage? Do I have time to watch the three black bears in the woods of the National Park amble through the forest? What if I spent the day sitting by a lake reading a book? What if I drove aimlessly around the back roads and stopped whenever I got the urge, instead of needing to get somewhere by a certain time to see someone/something?

Despite trying to get away from an agenda, I set some guidelines for myself. I was interested in my ability to not judge myself, or anyone else, against a standard of accomplishment. I would not measure my check list of “good vacation” behaviors, and I would not measure myself against the “success” or “failure” of the people I met. I would be interested in what I saw, who I met and talked to, solely for the stimulation they would provide and for the ability to experience them as a fluid process of existence rather than as a competitive structured calculation. This was difficult because I saw a lot of people who are not like me. When one encounters these differences, one measures themselves against the differences. When we meet people more wealthy than ourselves, we measure ourselves against their status and wealth. When we meet people more attractive than ourselves, we measure our attractiveness. When we meet people who talk funny or look different, we compare them to our cultural standard of “right” looking. This is an ethnocentric process we cannot avoid. It is a universal human condition. It has to do with “us-ness” verses “them- ness” that allows us to decide about safety and inclusion. Our cultures are part of what become inherent and reflexive ways to experience the world. It is necessary in primitive cultures for survival. It happens the same way we experience “food” vs. “non-food” items. If we are not able to see and distinguish what is safe and healthful, we will eat the wrong stuff and die. If we do not “know” our cultural rightness, we will become isolated and we will die (or worse yet, foreign/strange.) As I was attempting not to be my naturally judgmental and culturally bound self, what did I see? What did I experience?

In my travels, I saw an awful lot of obesity and tattoos! I heard lilting soft southern speech rhythms that reminded me of my youth. I saw hard-working poor people and vacationing people, who were less poor. I saw a lot of people who had blank faces, angry faces, overweight, cigarette smoking people who seemed tired and flat. There was not a lot of energy and not a lot of visible joy. I found myself wondering about the glass half-full/half-empty analogy. I wondered what was different about the people I encountered. H.L. Menken is reputed to have said, “The average man leads a life of quiet desperation.” What I saw made me fear that this may be true. In our times and in our economy, things are hard. Survival for a man and his family is a precarious situation. There is danger and much to worry about. Are we taught to encounter this reality and push to survive and to enjoy as much as we can? Or are we just taught to push to survive?

I also saw people who did not have very much, but they were jubilant, spontaneous, and happy. There were the three cute little girls who were each carrying a dollar to tip the waitress with. The youngest one proudly said to me with a grin, “we are going to give the lady a dollar!” We ate in one place where the temperature outside was 108 and their air conditioner was barely working. Our waitress was smiling and friendly, and her service was excellent. She was happy, although hot, and she made us feel good about the meal, if not the conditions. These people were clearly choosing to see the glass as half full. My question would be: Is this personality or training? Is it choice or circumstance that makes us dour or warm? Can we find a way to have balance between our outlook and our drive?

What is the path of enjoyment? Not hedonism, but experiential joy and happiness. Can I enjoy the sound of a fish jumping? Can I enjoy and experience the glow of a beautiful mountain sunset? Can I smile at the laughter of a baby or the taste of an ice cream cone? Can I see life as a glass half full even when things are bad? Not in a Pollyanna way that holds heaven is just around the corner, but in a grounded, experiential and real way that says in the midst of poverty, pain and exhaustion, there is still beauty and friendship and love to be enjoyed. Can I be nurtured by the process of life, rather than measure my life against a calorie count, a financial standard or touchdowns scored? Can I live and be, or must I always do? I have come to believe that we can do both, but that we can only do both when we have balance. Balance between the goal driven, disciplined structure of our doing, and the existential flow of our being. For some, like myself, this requires effort and consciousness, but I know now that it can be done. For others, there seems to be a blessed capacity to be and to enjoy without effort, even if the living of life does require the effort.

It has been an interesting two weeks.

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How To Deal With Your Partner’s Panic Attacks

This article is a contribution from a guest author who has had extensive experience with Panic Attacks and writes about them, as well as other anxiety related issues on his own Web Site. How to Deal With Your Partner’s Panic Attacks

For the person suffering from panic disorder, panic attacks can be devastating. Panic attacks represent the height of anxiety – intense feelings of fear, sometimes about one’s imminent death. Even after the panic attack has subsided the person can feel as though the wind has been completely knocked out of them, and a panic attack in the morning or afternoon can essentially ruin the entire day.
For the partner of someone suffering from panic attacks, each attack can feel like a tremendous burden. You’re there, watching your partner suffer from something entirely mental, and yet you cannot do anything to help. Often those with panic attacks develop related issues as a result of their panic attacks, such as agoraphobia, and these problems can affect the relationships as well.
It may be difficult to experience a panic attack, but it’s also difficult to be the partner of someone that suffers from them. Many partners have no idea what they’re supposed to be doing, and on occasion respond with frustration or anger at that this randomly occurring mental phenomenon keeps disrupting their relationship. So if your partner suffers from panic attacks, here are a few tips for how to handle the situation.
Tips for Partners of Individuals with Panic Disorder
• Inform Yourself
Those that haven’t experienced panic disorder often find it difficult to understand, so education is important. During a panic attack, the person can not only think that something is seriously wrong – they can feel it as well, with psychosomatic symptoms that legitimately resemble a heart attack, to the point where many of those that experience their first panic attacks get hospitalized. Understanding what your partner is going through is a crucial first step, because only if you understand it can you hope to empathize.
• Let Them Talk About It
Before, during, or after their panic attack, their panic attack is often the only thing on their mind. They need to share it, so that they’re not stuck inside their own head or afraid of talking to you about it. They’re going to need to talk, so you should try to let them talk.
• Don’t Try to Solve It
While you should let them talk about it, you should also refrain from trying to fix it yourself. Panic attacks may be an anxiety disorder, but they’re not like anxiety. You can’t really “talk down” someone a panic attack, because they’re often experiencing physical symptoms that aren’t going to go away because of your words. Let them talk about it, but also know that you’re going to have to let it run its course. Trying to solve it can actually make it worse, because you’ll be forcing the person to focus on their symptoms more in an effort to control them, and possibly making them feel ashamed as well.
• Don’t Bring It Up
An interesting – and unfortunate – issue with panic attacks is that thinking about them can actually cause them. So if your partner is not currently suffering from or thinking about panic attacks, it may be best not to ask them about it. As long as they know that they can come to you and tell you when they are suffering or have experienced one, it’s best to avoid the topic.
• Support Cures
Panic attacks can be cured. But they can only be cured if both you and your partner are willing to commit to a treatment. Several behavioral therapies have been created that target panic attacks. Combine them with a visit or two to the doctor to help rule out any physical causes and it is possible to live panic attack free. Know that as long as both of you are committed to relieving the panic attacks, they can go away, so caring about your partner and waiting it out are the best courses of action.
Creating a Better Relationship
Panic attacks are overwhelming experiences – experiences that many people struggle to even describe, and impossible to control without help. Partners of those with panic attacks may feel a bit frustrated at times, but it’s important to remember that your partner is really struggling. This isn’t like mild anxiety or even mild hypochondria. It’s an uncontrollable feeling of imminent danger or death. Use the above tips to make living with panic attacks easier on your partner and your relationship and know that there are treatment options out there for curing the disorder forever.
About the Author: Ryan Rivera had immense panic attacks that did damage his relationships before he found treatments.

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False Memory Syndrome and Memory Work in Therapy

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?

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

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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