Tag Archives: therapeutic alliance

Technique without soul is dead

By Peter Allen December 10, 2019

As a licensed professional counselor, I am interested in what is helpful or effective for my clients. As a client in therapy, I am equally interested in what helps me to reduce my own suffering and develop better skills for navigating the larger world in which I live. Therefore, I consider myself a student in both respects. The clinician in me studies to achieve greater skill and experience, whereas the client side of me is ever sensitive to what is helpful in everyday life. I have had many experiences as both clinician and client that inform my approach, depending on which chair I happen to be sitting in on any given day.

There is one particular experience I had in therapy that has taken me years to integrate and use toward positive ends. At the time, I had been seeing a therapist for a few weeks. I was there to work through some old resentments and anger that were bogging me down and interfering with what was an otherwise good life. A trusted colleague and friend had referred me to this particular clinician, an older man with years in the field and a positive reputation.

After a few sessions, I remember thinking that the therapist was a little aloof for my tastes and perhaps a bit too professorial. He was kind but in a detached way. I had the sense that he did not think about me or my problems after he left the office for the day. Reflecting on my experience with him, I realize it was not what he did that sticks in my memory so much as how he taught me what not to do.

I had been attempting to work through some of my aforementioned anger issues with his help but had become somewhat stuck. He gestured toward a large, cube-shaped pillow on the ground in his office, measuring roughly 3 feet on each side. I hadn’t paid this object much attention until that moment, which is strange because a large cubed pillow in any office strikes me as noticeable in hindsight. The therapist asked me to repeatedly strike the pillow while verbalizing the very things that were upsetting me. I looked at him incredulously, and I remember specifically thinking, “This is stupid.”

I voiced my reservations, telling him openly that I did not think hitting a pillow and venting my anger in this way would be of much help. He smiled at me, trying to be reassuring, and encouraged me to try the exercise despite my misgivings. And so, I did.

Not surprisingly, I felt stupid. I was a grown man standing in a quiet therapy office hitting a large, cube-shaped pillow and trying to muster real anger in hopes that it would overtake my embarrassment. It did not. It caused me instead to feel like a petulant child who was not getting his way. Later, I would in fact feel the anger that was elusive in that moment, but my anger would be directed at the therapist rather than at the other people in my life.

What went wrong?

We processed this event immediately afterward in a somewhat perfunctory way, owing to my new resentment toward the therapist. I told him that I felt stupid, and he listened without comment. He was less interested in how the exercise reflected on him and more interested in my experience of it. The session ended on an anticlimactic note. I left his office and decided not to return. I should note that I could have given him more decisive verbal feedback about my experience, or inquired further about his intentions or technique. I did neither of those things, so in a way, perhaps I cheated him out of an opportunity to learn and grow. I take some comfort in the thought that his training and development were not my responsibility.

Upon reflection, I came to see that this therapist had disregarded valuable information and feedback I had given him in session. He used an intervention with me that he had likely used countless times before with other clients, and perhaps with some success. After all, he had gone to the trouble of purchasing that strange cube-shaped pillow. He executed a technique despite my obvious resistance because he thought he knew better than I did about what might be helpful. My experience was that I felt unimportant, unheard and embarrassed.

After reflecting on this somewhat minor event, I finally came to understand some of the dynamics that had played out in that room. The therapist was applying a technique without any soul — or, in other words, without first establishing an emotional bond or connection with me. Because he had not forged such a connection with me, the intervention was an abject failure. He assumed that the technique alone was powerful enough to overcome my reservations or, as I’ve said, that he knew better and I just needed to trust him. In my attempt to be the good client, I placed my trust in him, and he showed me that he had not earned it yet.

A basic critique I have of this method is that it does not translate to my life in the world. Hitting objects when one is angry has no application in the real world. We cannot repeatedly hit the table if we become angry in the middle of a corporate board meeting. This method is not encouraging the development of further skills; rather, it is reinforcing a negative human behavioral habit.

Although it took me many years to understand what I had experienced in that therapy session, I eventually arrived at an obvious answer: I went there assuming the therapist was, in fact, an expert, but the person who instructed me to hit the pillow was simply a flawed human being using a flawed methodology. He, like me, is in the process of learning and growing, and, as such, he is still making mistakes. I accept this, and I accept him as being in process.

Cause for reflection

Being on the receiving end of this intervention gave me license to truly examine its effectiveness, or lack thereof, in my own life. This small experience also led me to reflect on how often I — and perhaps, we, as clinicians — may be deploying techniques in a mechanical and disconnected fashion, whether we learned these methods in school, from a trusted mentor, or from a celebrity therapist. I have come to believe that when we do this, we are elevating and accenting the academic concept at the expense of an interpersonal connection.

What benefits our clients is subject to debate, of course, and reasonable people can disagree about this. We learn a variety of evidence-based practices, techniques and theories in the hope that we can help reduce our clients’ pain and suffering. I have colleagues I trust and respect enormously who approach therapy from a more scientific standpoint. They have a toolkit of interventions they use for a variety of presenting problems. Presenting problem A gets intervention B and so on and so forth. I also know brilliant clinicians who use a primarily interpersonal approach, in which the central and ongoing interventions are kindness, consistency, nonjudgment and acceptance.

I would be willing to gamble and say that the majority of therapists artfully blend the scientific with the interpersonal. What is scientific in counseling is by definition methodical, detached and concerned with evidence. What is interpersonal is by definition emotional, involved and subjective. There need not be tension between these two concepts; skillful therapists braid them together.

Carl Rogers, the founder of client-centered therapy (also known as person-centered therapy), came to the conclusion that the interpersonal approach actually produces scientific, measurable results. I will not dive too deeply into discussions of duality and what the superior approach might be (in part because I don’t know), but it is incumbent on the professional counseling community to ascertain anew each day what is effective versus what is ineffective.

My conclusion was that my therapist at that time was relying on pure scientific technique, which lacked warmth. Therefore, what I experienced was his detachment from me and his failure to respond to the verbal and nonverbal feedback I was conveying to him in that moment. My bias, of course, is the golden thread in this entire experience: I lean mostly Rogerian as a counselor, and my therapist had failed to honor one of Rogers’ most important insights — namely, that I am the expert on myself. My therapist put himself in the role of expert, which was a natural result of his unique life experiences, training, upbringing, biases and blind spots.

Undoubtedly, this therapist’s approach has been helpful and effective for many people over the decades that he has been in practice. With the enormous variety of human beings on this planet, an enormous variety of styles and approaches in counseling is merited.

I have concluded from this experience that technique without soul is dead. The cold application of scientific knowledge in the therapy office lacks humanity. However, using only warmth and empathy without technique can be amorphous and ungrounded. I occasionally find myself wanting to revert to technique alone for its definitive attraction — namely, that it is an intellectual and finite concept and therefore seems easier to grasp. Conversely, when I rely too heavily on an interpersonal connection, even as a Rogerian, I find this to be limiting in a different way.

For me in my process of development now, the interpersonal connection is what builds trust, and that is what allows techniques to flourish and gain traction. When techniques are successful and helpful, and when clients experience real change from them, the interpersonal connection thrives. In this way, a skillful pairing of these approaches serves to reinforce the strength of both of them.

I have tremendous empathy for my previous therapist, despite my obvious critiques of him. It was easy for me to see, both then and now, that he meant well. I also have the benefit of being able to evaluate his approach, whereas my own approach is not subject to his scrutiny. I have an inherent advantage in this sense because nothing I have done is under the microscope. That being said, readers of this article may find fault with my analysis, and I welcome a robust debate. I am grateful to him in a noncynical way for showing me what type of therapist I do not want to be: detached, professorial, expert. I strive to become more and more who I want to be as a counselor: someone who is involved, humble, and allied with my clients. In short, I strive to become the professional whom I needed that day in his office.

 

****

Peter Allen is a licensed professional counselor at East Cascade Counseling Services in Bend, Oregon. Contact him at peterallenlpc@gmail.com.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

****

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Client suggestibility: A beginner’s guide for mental health professionals

By Jerrod Brown, Amanda Fenrich, Jeffrey Haun and Megan N. Carter August 12, 2019

In the context of mental health treatment, suggestibility refers to a client’s vulnerability to accepting information provided by a third party as true, regardless of its veracity. This can result in the client providing inaccurate guesses or statements in a verbal, nonverbal or narrative format. Influenced by a range of individual, psychosocial and contextual factors, the client may be convinced that events unfolded differently than they actually did or that events that never took place actually occurred.

Such behavior is often encountered when clients are uncertain about what happened or what is true, lack confidence in their own memories or ability to understand, or are unable to discriminate between what is real and what is not. As such, suggestibility can profoundly limit a client’s capacity to navigate the various stages of the mental health system.

Suggestibility is a complex and multifaceted phenomenon that mental health treatment specialists rarely take into consideration, largely because of the lack of research on it and the limited availability of training opportunities on the topic specifically tailored for these professionals. The research that has been conducted is largely circumscribed to the fields of criminal justice, forensics and the law, where it is well-established that clients who are more suggestible are more likely to provide unreliable eyewitness accounts, spurious alibis or even false confessions to crimes.

Across mental health treatment settings, suggestibility may result in inaccurate diagnoses and ineffective or problematic goal and treatment plans. Given the importance of this topic, we aim to briefly describe the phenomenon of suggestibility within the context of clinical interviewing, assessment and treatment planning. We will also suggest future directions that may assist mental health professionals in addressing this threat to effective clinical decision-making.

Minimizing suggestibility risk in clinical interviews

Certain forms of questioning can increase the likelihood of suggestibility. A suggestive question is one that implies a certain answer, regardless of the client’s actual perspective. Such questions intentionally or unintentionally seek to be persuasive, often by using wording that excludes other possible answers. For example, asking “Where did your father hit you?” instead of “What happened with your father when you got home?” is leading. It promotes a response that would affirm the interviewer’s hypothesis that a physical assault took place and largely excludes the possibility that no altercation occurred.

Questions framed in a negative manner also can have a suggestible impact and are confusing to the client. For example, asking “Didn’t you want to run away?” rather than “Did you want to run away?” is biased in that it may make the client feel guilty for not saying that he or she wanted to run away.

To avoid asking suggestive questions and to lessen the likelihood of receiving false responses from clients, consider using the following strategies:

1) Use open-ended questions while avoiding or minimizing the use of forced-choice and either-or questions.

2) Allow the client to speak in his or her own words, and avoid interrupting the client.

3) Do not assume that you know what the client is trying to say when he or she is unable to fully convey his or her ideas.

4) Accept “I don’t know” responses as potentially valid.

To further illustrate this point of decreasing suggestibility within the context of clinical interviewing, mental health professionals should try to avoid the following approaches when questioning clients:

  • Use of closed-ended questions
  • Giving an impression that implies the client is providing the wrong answer
  • Implying that a certain answer is needed or required
  • Leading questions
  • Misleading questions
  • Negatively worded statements
  • Persuading the client to change his or her response
  • Pressing the client for a response
  • Rapid-fire questioning
  • Repeated lines of questioning
  • Biased statements
  • Subtle prompts

How often questions are asked may also have a suggestive impact. Clients may perceive repeated questioning as a sign that they have not responded in a manner that the counselor deems “correct” or acceptable. Indeed, repetitive lines of questioning in which the client is asked about details of events that either did not happen or that the client does not remember well may result in the unintentional formation of false memories or confabulation (i.e., filling in memory gaps with fabricated memories or experiences).

Asking more general questions about an incident (e.g., “Tell me about what happened at the park”) and then later following up with related questions (e.g., “How often do you go to the park?”) has been found to be a useful method for verifying or clarifying information that might appear to be inconsistent or illogical. Regardless of the questioning style, however, it is advisable to allow clients as much time as they need to respond to questions and to verbally reinforce that they can take their time when answering questions.

In addition to questioning style, the counselor’s nonverbal behaviors, including facial affect, gestural affect and intonation, both before and during the interview, may increase the likelihood of suggestibility and threaten the validity of the information elicited. An example of facial affect could be smiling when a client is providing certain answers but not others. A gestural affect might include leaning forward when a client is providing certain answers but not others. Intonation as a means of nonverbal communication could be providing feedback using upward inflection when a client provides certain answers but downward inflection when he or she provides others. These nonverbal, and often unintended, means of communication are forms of both positive and negative feedback that can shape a person’s responses and increase the risk of suggestibility.

The context of the interview can also affect the likelihood of suggestibility. For example, false reports are more likely if an interview is conducted in a stressful situation (e.g., having an appointment with a therapist immediately following a family conflict). Environmental factors (e.g., a small room without windows or air conditioning on a hot summer afternoon) can also be influential. Providing clients with frequent breaks and avoiding very long clinical interviews is encouraged, when possible. The time between the occurrence of an event and the interview that focuses on the event can also influence suggestibility because clients can become more confident in the accuracy of their false accounts over time. Context within the realm of a clinical interview can include any of the following either prior to and during the actual interviewing process:

  • Body language of the counselor
  • Duration of eye contact from the counselor
  • Environmental distractions (lighting, noise, temperature, etc.)
  • Length of the interview
  • Pace of the interview
  • Tone of the counselor’s voice

Mental health professionals should also take into consideration personality and social characteristics that can influence suggestibility. These may include tendencies toward confabulation, acquiescence, memory distrust, low confidence, desire to please, extreme shyness and social anxiety, avoidant-based coping strategies, fear of negative evaluation, lack of assertiveness, attachment disruptions, fantasy proneness, and psychosocial immaturity (e.g., irresponsibility and temperament). Professionals should also consider cognitive factors, including executive function and memory-related problems (e.g., short-term, long-term and working memory), intellectual limitations, diminished language abilities, and deficits in theory of mind (the ability to understand mental states in oneself and in others).

Preparing for and debriefing from the interview

Understandably, many of these characteristics initially present as invisible, meaning that clients who are highly suggestible may not overtly appear as impaired or vulnerable. Clinicians would benefit from screening for such traits in the initial interview with new clients to determine the prevalence of traits that are likely to contribute to suggestibility. Specific screening tools for suggestibility, such as the Gudjonsson Suggestibility Scale, can help clinicians in determining a person’s level of suggestibility. This will also assist clinicians in understanding how best to proceed as it relates to interviewing techniques and treatment planning to account for an individual’s level of suggestibility.

False or misleading information can have a negative impact on diagnostic accuracy and treatment outcomes. Accordingly, it is important that mental health professionals not only conduct interviews properly but also prepare for and debrief from them properly. Prior to beginning an interview, counselors are encouraged to review client records (psychological testing, mental health records, criminal justice records, etc.) that may reveal a behavioral pattern of suggestibility and provide a resource for corroborating a client’s statements. Cross-referencing this information with information obtained from collateral informants is also recommended when appropriate. The importance of awareness of one’s self throughout the interview is an important factor for reducing the risk of suggestibility. This includes monitoring one’s verbal and nonverbal communication that could provide feedback to the client regarding potentially desirable versus undesirable responses.

It’s worth noting that some special situations may require clinicians to be more aware of their questioning style and require adaptations and flexibility on the part of the clinician to minimize suggestibility. For instance, those working in correctional and jail settings should consider how suggestibility presents among incarcerated populations, to include those with mental health needs and low intellectual functioning. Substance use is another variable that can have adverse effects on the accuracy of the information obtained during a clinical interview. Furthermore, when interviewing children or adults with neurocognitive and neurodevelopmental disorders, extra precautions may be necessary to reduce the risk of suggestibility. Finally, it is important to note that individuals with exposure to negative life events (e.g., the death of a parent or sibling, exposure to physical violence) may be more susceptible to suggestibility.

Conclusion

Given the importance of collecting accurate information, it is essential that mental health professionals acquaint themselves with the phenomenon of suggestibility. Unfortunately, many mental health providers lack the necessary awareness and training related to the detection and screening of suggestibility among clients.

Mental health professionals should seek to establish routine procedures to better identify clients who are at an increased risk of susceptibility to suggestibility before proceeding with the interviewing process. Such a procedure could include a validated suggestibility screening tool and a checklist of variables that research has found to increase risk of suggestibility among certain mental health treatment populations. We encourage mental health professionals to be aware of the various personality, social and cognitive factors that may influence some clients to be suggestible.

Suggestibility can have a negative impact on the various components of mental health treatment, including intake, screening, assessment, psychological testing, treatment planning, medication compliance, perceived understanding of treatment concepts, and discharge planning. For this reason, we urge mental health professionals to gain an increased awareness and understanding of this complex and multifaceted phenomenon.

One suggested step for moving the field forward is for mental health professionals to engage in self-study and continuing education via in-person and online training courses that focus on the evidence-based assessment and management of suggestibility. It is also important for mental health professionals interested in understanding suggestibility and its implications to review key research findings on at least a quarterly basis and to consult with recognized subject matter experts. Clinical interviews should be conducted through developmentally sensitive and suggestibility-informed approaches that consider the client’s psychiatric, neurocognitive, social and trauma history. By taking such steps, the potential negative impact of suggestibility can be minimized, thus paving the way for positive outcomes.

 

****

 

Jerrod Brown is an assistant professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center for the past 15 years and is the founder and CEO of the American Institute for the Advancement of Forensic Studies. Contact him at jerrod01234brown@live.com.

Amanda Fenrich obtained her master’s degree in human services with an emphasis in forensic mental health from Concordia University. She is currently completing her doctoral degree in the advanced studies of human behavior from Capella University and is employed as a psychology associate for the Washington State Department of Corrections Sex Offender Treatment and Assessment Program.

Jeffrey Haun is employed as a forensic psychologist for the Minnesota Department of Human Services, where he conducts a variety of forensic evaluations and offers consultation, supervision and training in forensic psychology. He is an adjunct assistant professor in the Department of Psychiatry at the University of Minnesota and an adjunct instructor at Concordia University. He is board certified in forensic psychology.

Megan N. Carter is board certified in forensic psychology and has received the designation of fellow from the Association for the Treatment of Sexual Abusers. She has worked as a forensic evaluator at the Special Commitment Center, Washington state’s sexually violent predator facility, since 2008. She also maintains a small private practice focusing on forensic evaluations and child welfare issues.

 

Letters to the editor:ct@counseling.org

****

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Voice of Experience: Giving away power

By Gregory K. Moffatt July 11, 2019

“Are you Dr. Moffatt?” a soft voice said as Antoine (not his real name) stepped into my office.

I nodded. He was a 20-something African American male. He explained that he had been arrested for assault. His court requirements included completing 12 counseling sessions for anger management. I quickly perused the copy of the court mandate Antoine had brought with him as he stood by respectfully.

“So, let me get the picture,” I said. “You got in a fight. A white guy arrested you. A white guy represented you in court, and a white guy sentenced you and sent you to see a white guy for 12 weeks. Is that about right?”

Antoine tried to stifle a smile but failed. “Yeah, that’s pretty much it,” he acknowledged.

“Well,” I said, “according to this court document, the only mandate is that we have to meet for 12 weeks. We can do whatever you want. We can talk about life, sports, or stare at the wall. Whatever you like. At the end of 12 weeks, assuming you show up, I’ll sign off. Or, if you like, we can work on what might have led to your arrest. If we do, then maybe I can learn something about you, and you can learn something about yourself and hopefully never see a jail cell again.”

When I tell that story to new clinicians, they argue that it would have been unethical to see Antoine for 12 weeks but not do therapy. We would have done therapy, but that isn’t the issue. The mandate didn’t require that I show progress or that the client cooperate. The document only required him to attend.

I’m not playing word games. Alcoholics Anonymous has done this since its inception. Individuals can attend, not say a word, be resistant, and they can show little or no progress or even relapse. Showing up is a giant step on the long road to recovery.

Predictably, mandated clients bring resistance with them. We have no power to force any of our clients to change. The wording of the court mandate allowed me to give away power from the get-go by stating the obvious: I couldn’t force Antoine to change or engage in therapy. (Be aware that some court mandates do require growth.)

I also gave Antoine power by stating something else that was obvious. He was nonwhite, and I was just another white man in a system in which he had no power. I gave him permission (power) not to trust me, and in so doing, ironically, I began to earn his trust.

Mandated counseling makes giving power to our clients especially challenging, and resistance is predictable. Because I’m white, I was pretty sure Antoine assumed that I wouldn’t understand him or his culture. He had no reason to trust me. If I had been in his shoes, I wouldn’t have trusted me either.

Giving away power is one of the things in our therapeutic tool boxes that can help us earn trust very quickly. My technique worked. Within minutes, Antoine was at least willing to give me a chance.

I do something similar with child clients because children are also mandated in a way. Guardians bring them to me — a stranger — often without even asking these children their thoughts about it.

But like Antoine, young children learn to trust me almost as soon as they cross my office threshold. I meet them at the door, welcome them in and say, “You can do about anything you want in here. If there is something you can’t do, I’ll tell you.”

Some children test me with a question such as, “Can I break something?”

“If you feel like you need to,” I reply.

I often watch them as they roam around my playroom, shooting occasional glances at me, seemingly waiting for me tell to them what they can’t do. Saying “no” is rarely necessary.

Antoine turned out to be one of my favorite adult clients. If I hadn’t given him power from the start, he probably still would have shown up and been respectful and cooperative. But growth may not have happened.

Instead, over our 12 weeks, he was fully engaged — starting with our very first session — and he grew tremendously. Several times I saw his eyes light up as he had epiphanies about his decision-making processes. He gained insight into his behavior and developed numerous coping and problem-solving strategies that make it unlikely he will ever see the inside of a courtroom again, at least as a defendant.

I still think about Antoine and his sly smile during our first meeting. Witnessing his growth was satisfying, and that is why I became a counselor in the first place. I doubt I would have ever earned his trust without giving him power from the beginning.

 

****

 

Gregory K. Moffatt is a veteran counselor of more than 30 years. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

 

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Caring vs. carrying: A therapeutic review of empathy and boundaries

By Laura Sladky July 8, 2019

“When you hurt, I hurt.” Does this adage sound familiar? No doubt, it stems from a benevolent place, but it inherently reinforces poor boundaries and misses the heart of empathy entirely.

Instead of joining in on someone else’s experience (which is not entirely possible because we do not share the exact same experiences), empathy is more akin to “You’re hurt by this.”

Empathy recognizes the feelings in each experience, names them, and honors them by listening intently with an “as if” quality — listening to another person as if this situation were their own but without making it their own. Empathy honors another person’s experience without trying to take it from them by adding on, comparing, rescuing or minimizing. In short, empathy requires boundaries.

 

Empathy is not sympathy: Empathy is often misunderstood for sympathy. By definition, sympathy is expressing pity or sadness for someone else’s situation or misfortune. Furthermore, sympathy seems to have an unspoken “Thank goodness that didn’t happen to me” undertone by association.

Although it is appropriate to express sympathy in reference to a person’s genuine loss, sympathy misses the heart of empathy because it does not approach another’s experience with an “as if” quality. Offering “I’m sorry you’re in pain” often feels dismissive and does not foster the core conditions that encourage further discourse.

Empathy is not rescuing someone from his or her experience: “If I could, I would fix it for you.” As human beings, prosocial behavior dictates that we care for others. In learning of others’ strife or struggles, there is an inherent temptation to “fix” or help even when it is not necessary.

I work in an elementary school as a school counselor. I can confirm with certainty that parents spend so much time trying to help their children (for example, by bringing forgotten homework or a jacket in case their child gets cold) that they often rob these students of the opportunity to feel and learn. In the case of the forgotten homework, students are more likely to remember to turn it in on time in the future if they are allowed to feel the discomfort of not having it once. Repeatedly rescuing someone from their experience prevents the processes of acceptance, coping and moving on that are required to fully feel an experience.

Finally, rescuing someone from their experience rather than allowing them to experience natural consequences is the picture of poor boundary setting. Empathy allows for the full and complete exploration of thoughts, feelings and behaviors, with no intent to short-circuit the process simply because we cannot tolerate someone else’s pain.

Empathy does not minimize someone’s experience: Author and researcher Brené Brown maintains that no empathic response begins with “at least.” For example, if a friend discloses that they just received a cancer diagnosis, the temptation might be to immediately highlight the good in the situation rather than holding space for their feelings and experiences toward their current situation. (“At least you have a great doctor! At least you’re able to afford the health care!”)

There is certainly a time and a place to exercise positive cognition to influence feelings and subsequent behavior. It is essential to remember, however, that active listening is just that — listening, not adding on (“Let me tell you about my aunt who had cancer”) or minimizing (“At least …”). Empathy does not absorb or modify the worries, problems, sadness or experiences of others. Empathy is standing still inside a moment, caring for another and sharing their experience — without carrying their load exclusively.

 

The science of empathy

Research suggests that mirror neurons allow us to grasp the message of and accurately respond to others. These neurons help us understand the feelings of others more accurately and approximate their experience. For example, if I see someone laughing, my brain is primed to join in alongside them, noticing the crinkle around their eyes and the upturned corners of the mouth that indicate a genuine smile.

As social creatures, we are constantly scanning one another for biological markers associated with feelings. While mirror neurons help us adjust to another’s feelings, it is important to note that, if left unchecked, we can “take on” or linger in someone else’s feelings.

 

The need for boundaries

As counselor clinicians, it is necessary for us to maintain boundaries to center the work around the client’s needs, to monitor for transference and countertransference, to attune to our worldview and how it affects the way we work with clients, to uphold ethics and to prevent compassion fatigue.

One of my favorite professors once mused that in his work with clients confronting substance use disorders, he cared about his clients deeply, but not so much that he was unable to continue to do his job. At first, I was unclear about the meaning of his statement. Now I understand that his declaration of boundaries allowed him to recognize the importance of his work without absorbing his clients’ challenges as his own to the point of burnout.

Empathy intersects boundaries in accurately understanding the experience of another without taking it on as our own. Enter the importance of self-care.

 

Final thoughts:

Author Glennon Doyle suggests, “Pain is just a traveling professor. When pain knocks on the door — wise ones breathe deep and say, ‘Come in. Sit down with me. And don’t leave until you’ve taught me what I need to know.’”

Empathy does not require pain or sorrow to be present. Rather, empathy is present whenever two individuals are together. In the fine-tuning of our responses to the thoughts, feelings and experiences of others, we are more in tune with ourselves and can better serve our clients.

 

****

 

Laura Sladky is a licensed professional counselor intern and licensed chemical dependency counselor who currently works as a school counselor in Dallas, Texas. Contact her at l.perry09@gmail.com.

 

****

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

 

Healing from multiple personalities

By Todd E. Pressman May 28, 2019

In April 1996, I began a course of psychotherapy with a woman named Angela. She came to the first session with vague feelings of anxiety and the need to “find a safe place.” This seemed usual enough for me after 20-some years in practice. Little did I know that our first meeting was the beginning of one of the most extraordinary therapeutic journeys I would ever encounter.

Although Angela had always suspected something was different about her, she did not realize that she had multiple personality disorder (now called dissociative identity disorder). She only knew that she was filled with fear much of the time and that there were large gaps in her memory.

Early in our work together, Angela had a dream of being in a bicycle repair shop — a wondrous place with huge escalators carrying bicycles here and there to be repaired. After watching many bicycles come in damaged and leave repaired, Angela asked the owner of the shop (me) if all bicycles could be repaired. In the dream, I answered “Yes.” When Angela showed me her own bicycle, which to her seemed hopelessly damaged, my response in the dream was, “There are no bicycles beyond repair.”

This was the message Angela needed to begin her therapeutic adventure. Through the course of her recovery, in which she integrated more than 70 personalities and opened up into one of the most spiritual people I have ever met, I deepened my own conviction that, truly, that are no “bicycles” beyond repair. In other words, there are no souls that cannot be healed and no injuries that cannot transform into a higher level of understanding and peace.

 

Angela’s story

The early part of our work together was simple and straightforward: Angela needed to know that there existed such a thing as “a love that didn’t hurt.” It was hard for her to trust that our therapeutic relationship could be the safe place she was looking for, that she could dare to start whispering family secrets without reprisal, that, together, we could be bigger and stronger than her fears.

Angela began her life as the victim of extreme abuses, as is true for most people with multiple personalities. From the time Angela was 4, her father, whom she trusted like any innocent child would, began sexually abusing her, while her mother stood by in passive compliance. When Angela resisted, her father threatened her, saying the devil would take her away if she did not agree to what he wanted to do and, in fact, if she did not enjoy it. At such a vulnerable age, Angela managed to do the impossible — she held in her screams and learned to say “thank you” and “I love you” in response to these abuses.

As these kinds of extreme torments continued, Angela forced her natural expression of self deeper and deeper down until, one day, she found a new solution: She would “project” herself into a certain picture that was hanging on the wall, a picture of a beautiful angel protecting a little girl and boy. Angela would make herself the little girl and her brother the little boy and bring the angel to life in her mind. She would do this so thoroughly that, for a time, she could live in that picture and escape her torture.

At a certain point in her therapy, Angela felt compelled to chronicle and perhaps publish her story. This served two purposes. First, she would be able to reach out to others — those with multiple personalities and those who simply needed to find their way through emotional struggle. She wanted to offer the help she was finding in her own recovery. Second, sharing her story would be a powerful way to take a stand against the thought that she needed to preserve the family secrets and stay victimized by them. That book, The Bicycle Repair Shop: A True Story of Recovery From Multiple Personality Disorder as Told by Patient and Therapist, became a reality.

In notes that Angela shared with me after the book was published, she provided the rarest of accounts of how the first moment of splitting off (dissociating) occurred:

 

One day, my father’s touches were worse than ever. His huge body pressing against mine was more than I could bear. … The pain grew greater until [the point of] what I thought was my last breath. I felt as if my arms were being yanked, pulling my body from its skin — my insides were separating from my outside to pull my body from the spot where I sat. My legs felt as if they were bolted to the ground. It was as though someone was trying to pull me from the other end out of my skin.

I was surprised to find myself standing in a picture that hung in my bedroom. A picture of a Guardian Angel watching over two children. Where was I? Who was it that was still with my father? I was not aware of what was going on. All I knew was that I was safe. The memory of what was happening before was successfully erased. That was how “four” was born, my first personality of many.

 

This remarkable description shows the adaptive function of multiple personalities: When one personality could no longer stand the circumstance of the moment, a new one would take over. This was the strategy Angela would use to grow her “family within” to help her navigate the abuses she was being exposed to.

 

Meeting Angela’s personalities

Through her therapy, Angela came to understand how each of these personalities was created to fulfill a specific role, protecting her from some unique threat that she could not handle by herself. In this way, she would simply stop “being” Angela and become someone who could better handle the situation.

First, there were “the little ones” — all children — including Four, Six, Schoolgirl and Crystal. Four was the first one I met, an absolutely adorable, sweet little girl who wanted nothing but to feel safe and loved. She was clearly terrified and felt solace only in my presence. When I would go away on vacation, for instance, her pain was so great that she could not tolerate it and would go “underground.”

Crystal, on the other hand, was immune to such pain. She was a beautiful little girl with curly blond hair and bright blue eyes (different in physical appearance than the others). Her strategy was to imagine that she was not, in fact, part of this family. She fully expected that she would be rescued by her “true” family any minute and taken away from the abuses.

Then there was Patrick. He was one of only two male personalities whom I met. In creating Patrick to be gay, Angela was imagining a model of a male who could be gentle, nurturing and safe.

The Boss was the other male personality, and his function was to “control” the children. In manner and even appearance (Angela’s face would change dramatically whenever the Boss showed up), he was like a classic Chicago mob boss. I must confess, I felt rather intimidated by him at the beginning. Later, however, I managed to convince him that I was an ally, someone who could help him find a better way to keep the children in place through understanding and meeting their needs. You can imagine his resistance, but in the end, we became a great team. (At one point, after we became “friends,” the Boss confessed to me in a hushed voice, “I’m working on getting rid of these.” He was referring to Angela’s breasts.) This was one of the rare occasions in which Angela’s external reality and the inner life of her creation did clash. Still, she was working on a “solution” that would enable her to keep her constructed world intact.

Eventually, three personalities came forth as those who would stand “out front”— those who would interact with the world — while the rest stayed inside to manage Angela’s inner experience. Angela, of course, was the primary personality, and she was the one who would take responsibility for handling the affairs of everyday life. Angie, on the other hand, was a party-loving, sexually profligate personality whose purpose was to have a good time and forget all troubles. She was especially skilled at “knowing what men wanted” and used these wiles to get men to do her bidding. At the other extreme was Angel, a spiritual personality who would remind the rest that they were safe and loved in God’s care. Angel would become a most important presence in Angela’s recovery because this spiritual aspect led the way to her final experiences of forgiveness.

At a later point in therapy, a personality was needed to “house” the others in a more neatly integrated whole. This was one of the few times in which I actually witnessed the creation of a new personality. The personality wanted to choose a name for itself that would bring it to life, so to speak, and it came up with Tang — a combination of Todd (my name) and Angela. This, she explained, was the result of my saying to the family, “I need you not to make any decisions without me because I am part of the family” — a necessary prevention against Angela trying to hurt herself or sabotage the therapy in some way.

Tang was a fascinating entity, representing the point at which Angela was 99% integrated. Angela described this sensation as if there were a body inside of her body that almost completely filled her up. There was just “1%” of space between them inside.

She also allowed the little ones at this point to create a magnificent collage. They knew they were about to “disappear” into the one personality that was Tang, and they wanted to be remembered this way. The collage showed what they felt inside: a single body with many faces, some happy, some sad, some shy and some covered with bugs who had been very afraid. Angela once told me that upon my calling Tang’s name, all the eyes of these faces opened up at the same time to look in response.

One by one the personalities came forth to express their need and tell their story. As Angela and I understood their core message, we were able to find a way to meet the need that was more adaptive. This required that Angela bravely face the fears that had been too horrible to withstand in childhood, trusting that it was safe to do so now. Borrowing my strength and trusting my words — that the people and circumstances of these memories could not stop her from standing up to them with my support — she did what she couldn’t dare do back then.

With a new and profound belief in her right to be free, she stood up to the abuses and said “Enough.” One personality even took on the name Shark to show her teeth and “devour” the fear that they represented. As Angela looked at her fears this way, always in manageable doses, she gave herself the message that she was no longer at their mercy, and one by one, the personalities that had been born to manage these fears would fulfill their purpose and integrate back into Angela.

 

Facing fears

With the right combination of safety and support, Angela was able to discover the great secret of all healing: When we face our fears, they lose their power over us. At worst, we find a problem that now can be managed. Often, the fear disappears completely because it can no longer scare us into running away from it. In this way, we find ourselves to be “bigger” than the fear, and so its illusion is exposed. It was but an imagination, given power by our refusal to look at it, with no actual ability to harm our true Self.

This was the freedom that gave Angela the  power to forgive her abusers (there was nothing left to forgive), integrate the personalities (they no longer had a function), and live in a world she now knew to be safe, manageable and, in the end, sometimes even fun.

In writing the book, Angela wanted others to hear the message that facing our fears is the key to freedom, that nothing can rob us of our ability to choose how we respond to life and to declare our right to be who we truly are. With this, we integrate the fractured parts of our own personality and find our own sense of wholeness, completion and fulfillment.

Throughout our work, Angela would repeat to me, “I want to be one of your success stories.” Many times, she felt the way was too difficult, but as I continued to hold a safe place for her, she developed the courage to face her fears one by one, dismantling the entire structure of her constructed “personality” and reclaiming her original innocence and wholeness.

In the end, she discovered that facing her fears made it possible to forgive, not in the sense of merely accepting those who had abused her, but in the much more profound sense of realizing that they, too, were in need of love, and that holding onto her anger and pain simply kept her a perpetual victim of their abuse. Only with this realization was she free to ask for the love she had once known as a little child of 4, and in asking, find that it was, in fact, still available in the world. With this, she was able to integrate that love and become whole again, to replace the path of disintegration into many fragments that she had chosen before. This integration of love, “a love that doesn’t hurt,” awakened a profound sense of spirituality within her. She is now, in fact, one of the most peaceful, loving and spiritual people I know.

 

****

Todd E. Pressman has been a licensed psychologist for the past 32 years. He is the founder and director of Pressman and Associates at Logos Wellness in Voorhees, New Jersey. An author and speaker, he co-wrote The Bicycle Repair Shop: A True Story of Recovery From Multiple Personality Disorder as Told by Patient and Therapist with Angela Fisher, who, during the course of her recovery, felt the need to share her story so that it might be of help to “anyone who wants to get free.” Pressman’s forthcoming book, Deconstructing Anxiety: The Journey From Fear to Fulfillment, will be available in August. Contact him at toddpressman@comcast.net or through toddpressman.com.

 

****

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.