Tag Archives: therapeutic alliance

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.

 

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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

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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.

 

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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.

 

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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.

 

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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.

 

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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.

 

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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.

 

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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.

Remembering Martin Buber and the I–Thou in counseling

By Matthew Martin and Eric W. Cowan May 8, 2019

Counseling research designed to measure therapeutic efficacy has increasingly focused on empirically validated methods and interventions. On the other hand, counselors have long understood the therapeutic relationship to be the most powerful meta-intervention for fostering client change and transformation. Carl Rogers’ No. 1 rule — that the counselor and client must be in psychological contact — is the precondition for all therapeutic movement. As counselors, we must “be someone with” rather than “do something to” the client.

However, the interpersonal process that occurs between counselor and client is difficult to quantify because it possesses intangible qualities that slip through the fingers of measurement and scientific scrutiny. The relationship between counselor and client seems to transcend any particular intervention strategy. The maxim “it is the relationship itself that heals” is an organizing principle to which most counselors subscribe and yet still sometimes forget. In the search for empirically validated methods, are we in danger of losing touch with what matters most in counseling?

Another consideration is the cultural shift that has altered how people communicate, with interpersonal contact becoming increasingly digitized, objectified and packaged in virtual platforms. Will the next generation of counselors still give primacy to the sense of “presence” in the therapeutic relationship that is the heart of counseling? From our perspective, it seems that a counselor’s enhanced capacity for meaningful interpersonal contact is more important than ever.

Philosopher Martin Buber detailed the qualities that characterize a real “encounter,” or I–Thou meeting, between two people. His ideas remain as relevant today as when they helped to shape the humanistic movement in psychology and counseling.

The I-Thou encounter

According to Buber, an interpersonal encounter contains wonderful potential that far exceeds two separate people in conversation. This potential becomes apparent when two people actively and authentically engage each other in the here and now and truly “show up” to one another. In this encounter, a new relational dimension that Buber termed “the between” becomes manifest. When this between dimension exists, the relationship becomes greater than the individual contributions of those involved. This type of meeting is what Buber described as an I–Thou relationship.

The I–Thou relationship is characterized by mutuality, directness, presentness, intensity and ineffability. Buber described the between as a bold leap into the experience of the other while simultaneously being transparent, present and accessible. He used the term “inclusion” to describe this heightened form of empathy. It is a far cry from the now-familiar scene of a group of friends sitting around a table at a restaurant, all gazing into their smartphones.

Buber saw the meeting between I and Thou as the most important aspect of human experience because it is in relationship that we become fully human. When one meets another as Thou, the uniqueness and separateness of the other is acknowledged without obscuring the relatedness or common humanness that is shared. Buber contrasted this I–Thou relationship with an I–It relationship, in which the other person is experienced as an object to be influenced or used — a means to an end. Regrettably, the I–It relationship requires little explanation for anyone living in a cultural frame of absent-mindedness and technological materialism.

The world of I–It can be coherent and ordered — even efficient — but it lacks the essential elements of human connection and wholeness that characterize the I–Thou encounter. The I–It attitude is increasingly depersonalizing and alienating as it becomes structuralized in human institutions. When an extreme I–It attitude becomes embedded in cultural patterns and human interactions, the result is greater objectification of others, exploitation of people and resources, and forms of prejudice that obscure the common humanity that unites us.

Although Buber saw the I–It as an essential pole of human existence, he thought humanity was losing its ability to orient toward the Thou. He emphasized the important balance required between the two poles if humanity was to survive the dangers inherent in the possibility of mutual destruction.

Counselors view the client–counselor relationship as the foundation of all therapeutic growth because it is fundamentally affirming of human connection, validation and participation. In our own small sphere of influence, we are a force for promoting a more compassionate and humanized world. Counselors should keep this in mind even as we strive toward greater technical organization and efficiency within a mental health “service delivery system” that is not entirely compatible with our broader aims.

To exist is to be in relation

Buber rightly understood that human development occurs in a relational context. Human beings are highly social creatures who need love and care from others to survive through infancy and beyond. An absence of these relational needs almost always leads to psychological injury.

Buber called this deep participation with, and acceptance of, another’s essential being “confirmation.” He believed that one’s innate capacity to confirm others, and to be confirmed in one’s own uniqueness by others, is the source of our humanity. The innate subjectivity that unfolds within every human being can begin to be actualized only when it is accurately mirrored in the eyes of another. Confirmation is at the heart of the I–Thou meeting, of human flourishing and of counseling.

Confirmation is similar to the concept of not imposing “conditions of worth” in the relationship. However, confirmation goes a step further by acknowledging the person’s potentialities — what one may become. For example, a child experiences the tension between growth and fear along each step of the developmental path. The parent can either accept the child’s reluctance in the moment or encourage the child to take the leap. At all ages, human thriving is found in these continual moments of confirmation of potentiality from person to person. As a client struggles with making the “growth choice” or the “fear choice,” the counselor invites the client to greater participation, yet expects to bump into the old fears that make such participation fraught for the client.

Unfortunately, we aren’t always as mindful and present as we’d like to be with others, and we ourselves have not been affirmed in the eyes of others as often as we would like. Even the best of us can fall into an I–It orientation with the world, failing to see the other person at all. Buber believed that these “missed meetings” were the ultimate failure of human relationships and resulted in us losing a part of ourselves.

We all desire to be confirmed in our uniqueness, but when we realize that confirmation is not going to happen, we seem to sacrifice true confirmation for mere approval in hopes of preserving our attachment to others. We cultivate the ability to “seem” a certain way to others to elicit approval, but such approval does nothing to nourish our “being.” A person would rather be confirmed in that which he or she is not than chance the possibility of not being accepted at all.

Unfortunately, this “seeming” mask tends to get stuck, and as one hides one’s being in fear, the possibility of an I–Thou relationship is lost. As Buber cautioned, “To yield to seeming is man’s essential cowardice, to resist it is his essential courage.” When the I of the I–Thou relationship is sacrificed for the It orientation of abstracted relation, authentic human growth and connection are lost, and the I begins to wither away.

Healing through meeting

How can we as counselors foster and model I–Thou relationships with our clients and help them avoid the temptation of “seeming” like someone they are not? Buber thought the answer could be found in a process of active imagination that he termed “inclusion.” In this process, the barriers and constrictions that prevent one from being fully present to an I–Thou encounter indicate where the work is to be done. In what ways must the client stay hidden from others and protect his or her own inner thoughts, feelings and fantasies?

In inclusion, one imagines what another person is feeling, thinking and experiencing while standing in relation to them as a Thou. Rogers’ concept of empathy and Buber’s concept of inclusion are similar (in fact, the two of them debated about it). However, inclusion places greater emphasis on the unique subjectivity of the person attempting to understand the other.

The attempt at understanding the subjective inner world of the person is not a one-way street because the counselor must account for his or her own influence upon the client as both participants come into psychological contact. The I–Thou is a relational event that is co-created; it does not fully reside in one participant or the other. The counselor’s ability to mine the riches of the present encounter and wonder “what is happening between us in the immediate moment” expresses Buber’s notion of inclusion.

We as counselors have the ability to confirm our clients through the process of inclusion, providing them with a relationship that can heal the wounds of their past missed meetings. We must stand in relation to our clients as an I to a Thou to successfully inspire them to move from a “seeming” stance to one of greater authentic participation and “being.”

Although empirical methods and interventions are critical in guiding our understanding of best practices, we must not forget that the single most predictive variable in whether counseling is effective is the client’s experience of the counseling relationship itself. Clients deserve to be seen as a Thou. As Buber once said, “In spite of all similarities, every living situation has, like a newborn child, a new face that has never been before and will never come again. It demands of you a reaction that cannot be prepared beforehand. It demands nothing of what is past. It demands presence, responsibility; it demands you.”

Every moment is an opportunity for “healing through meeting.”

 

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Matthew Martin is a graduate of James Madison University’s clinical mental health counseling master’s program. He is currently completing his residency in counseling at the university’s counseling center. Contact him at matthewmartin.rva@gmail.com.

Eric W. Cowan is a professor in the Department of Counseling and Graduate Psychology at James Madison University. He is the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship. Contact him at cowanwe@jmu.edu.

 

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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.

 

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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.