The Importance of the Therapeutic Relationship

Until the past several decades, psychotherapists believed they were a blank canvas onto which their patients projected all their unresolved issues from their childhood and their internal relational experiences with their parents. Nowadays, we believe that there is a close, real relationship between the patient and therapist that develops over time and may become the most important agent for change in the patient’s treatment. Both the patient and therapist bring to the relationship their own unconscious past relational patterns that originated in early childhood experiences, often between them and their parents.

It is crucial that the therapist monitor the nuanced interactions and enactments that occur over the course of the therapy. The danger in not paying close attention to the shifts between them and their patients could lead to serious negative consequences, such as repeating unhealthy relational patterns or driving the patient out of treatment. I recently encountered one example of such an enactment in my practice. Twice I mistakenly got the time wrong for one patient and I either had booked someone else during his time slot or I forgot to come to my office to see him. If I wasn’t monitoring the shifts in our relationship, I may have dismissed this as a simple error on my part instead of an interaction between us, and it could have well marked the end of his therapy. Luckily I was aware of how unusual this behavior was, as I have never mistaken a patient’s time slot in my 20 years of practice. This signaled to me that there must be an enactment between us that tells us something essential about the patient’s relational experience in the world. Sure enough, after exploring this together, we discovered his experience of feeling like an afterthought to his parents and friends most of his life. Instead of driving him away from treatment, this enactment elucidated something important about this patient’s relational dynamics and became an essential part of his healing.

I sometimes think that if a patient and I focus on nothing else but the twists and turns in our relationship, we still might be engaged in the vital process of therapeutic action that enables the patient to make long-lasting positive changes to his or her life. This relationship is unique in that I am a part of it, unlike all other relationships that I only hear about through the lens of their point of view. I can help patients come to understand deep-rooted relational patterns and have a positive experience of a relationship that might be unlike any other past or current relationships they have ever experienced. Such a healthy relationship can be a “corrective emotional experience” that can have everlasting changes for the patient.

The Role of Meditation Practice In Psychotherapy

In recent years I have begun implementing meditation practice during the first ten minutes of a session with some of my patients. The choice whether to meditate or not is always at the discretion of the patient. The purpose of such practice is to help bring awareness to one’s internal world in the present moment. This encompasses improving one’s attunement to emotions and physical sensations that can be detected in the body. I have found that many people are initially uncomfortable being with themselves in the here-and-now, and thus they flee being in the present and resort to living in the past or future, allowing their thoughts to distract them from what is right before them.

Most people do not need my help accessing their thoughts; they can fairly readily identify what they are thinking. It can be a different matter when they are trying to identify what they are feeling. When an emotion is intensely felt, it is likelier that the individual will notice it and be able to describe it. One is more apt to recognize that she is enraged than to recognize that she is mildly annoyed. But if we believe that all people have thoughts, feelings, and physical sensations at every moment, whether we are aware of it or not, then we can begin to see how difficult it can be for many people to access feelings when felt to a lesser degree. This concept that people have thoughts, feelings, and physical sensations at every moment is similar to breathing. Once an individual is encouraged to focus on his breathing, he usually can do so easily. We are all breathing at every moment but often we are not paying attention to our breathing. The same applies for thoughts, feelings, and physical sensations. Some people may find identifying and accessing physical sensations challenging. Still more may struggle to identify and stay with their feelings. Trauma survivors in particular may struggle in this way, given that one of the ways they learned to cope with the trauma they experienced was to numb themselves and dissociate from their internal world. This serves a protective function. As adults many of these individuals have difficulty knowing what they are experiencing when it comes to emotions and physical sensations.

Meditation seems to assist people in building their awareness of what is happening internally. Furthermore, it can help people learn to stay in the present moment and tolerate inhabiting their own internal world without feeling threatened by unpleasant emotions. I’ve witnessed people who initially had trouble sitting still because they were so anxious learn to relax into a ten minute meditation practice and open themselves up to the present. With most patients we start and end the meditation practice with four deep breathing inhalations and exhalations. This seems to help people relax and prepare themselves for the meditation. During the meditation itself, patients are instructed to focus on something simple, such as their breath, that they can keep returning to when their minds start to wander. They simply can notice and be curious about the thought that distracted them and then return to their breathing. With some patients, it is preferred to scan the body from head to toe during the meditation as a way to tune into what is happening internally. By conducting a body scan, one might become aware of tension and other physical sensations that are being held in various body parts. Another option is to draw one’s awareness to the sounds around them, both near and far. I invite my patients to focus on their breathing or to do a body scan, however, because these are ways to increase awareness of one’s internal space, whereas sound brings the individual to something that exists outside of them. Over time, most patients tell me that they have found that the meditation helps them be more aware of what is going on inside them, both with emotions and with physical sensations, and these skills can transfer to the their lives apart from the meditation. For the purpose of developing these skills during psychotherapy, I find that the term “awareness building” rather than “meditation” may be a better fit. People can get confused by what is meant by meditation practice. When we agree that we are working on improving their awareness of their feelings and body sensations, they can best understand how such practice can be of value to them. After the ten minutes, I find it useful to briefly discuss how the patient experienced the exercise and what she became aware of during the time. I also attend to whether starting with this practice has a positive shift for the remainder of the session and can help the patient feel more present and connected to me while engaged in the therapeutic endeavor.

Suicide Survivors

The term "suicide survivor" is unfamiliar to most people. They assume it refers to people who have attempted suicide themselves; in fact, it refers to people who have lost someone to suicide. Whether it is a family member, partner, friend, patient or colleague, losing someone to suicide is incredibly challenging to those who are left behind to grieve. It is a far more complicated type of death that may take a longer time to grieve and can stir up a variety of feelings such as sadness, shock, anger, and guilt. Many survivors feel very isolated, experiencing that those around them cannot understand what they are going through. Also, there is a stigma attached to suicide that often causes people to keep this information a secret. 

Working with suicide survivors is one area I specialize in, although many patients come to me for other reasons and it often isn't until much later in their treatment that I learn they've lost someone to suicide. The impact of this loss can be tremendous. We need to take into consideration the specific relationship to the patient. Losing a friend or sibling is quite different than losing a parent. Losing someone the patient had a close, loving attachment to is different than losing someone where the bond was more fraught. We also want to pay attention to the method of suicide and the patient's unique experience around the death. For instance, the trauma of a survivor who witnessed or discovered the person who committed suicide varies from that of those who were distanced from this immediate visual and auditory trauma. The experience of someone who had a loved one who had previous attempts or threatened suicide for years varies from that of the patient who was completely caught off guard by the loss of one whose death was spontaneous or unexpected. A health care provider who loses a patient to suicide may experience a particular type of guilt, as their colleagues or the institution they work for may consciously or unconsciously fault them for the death. 

As you might imagine, this is a very complex topic that has so many variables that one may have never even considered. In working with survivors, I try hard to not make any assumptions about their experiences. I allow for the space and time for them to tell their story and express their feelings about their loss. Many of my patients have described how I am the first person they talked to at length about their loss because of their shame and their experience of feeling misunderstood by others. I sometimes will encourage survivors to seek out a support group where they can hear other survivors tell their stories so that they can feel less alone with their grief. 

One good resource for more information is The American Foundation for Suicide Prevention, which has information that can be useful for suicide survivors: https://afsp.org/ 

The Relational Nature of Shame

In the play (and movie) Proof, the character Hal asks, "How embarrassing is it if I say last night was wonderful?," to which Catherine responds, "It's only embarrassing if I don't agree." This is a great example of illustrating how shame is relational in nature. As Catherine points out, Hal's question might have been met with a variety of reactions. If Catherine were to respond, for instance, by saying she wishes it hadn't happened, Hal might experience shame about what he said and may even regret that they spent the night together. But Catherine agrees with him, they kiss, and he is elated. Without our even realizing it, our experiences of shame are often closely tied to other people's reactions. The key component to hold onto from this illustration is that one may say or do the exact same thing yet have a completely different self-experience based on the reaction of the other.

From a very early age, children may develop positive or negative self-experiences based on how the people closest to them (parents, siblings, peers, teachers) respond to them. If a young boy is expressing excitement and vitality about what he is doing, for instance, his father might respond by mirroring the boy's enthusiasm and encouraging him to engage in the activity. This could lead to the boy developing a healthy sense of himself and his own agency in the world. If the father, on the other hand, were to respond by telling the boy to knock it off, then the boy is likely to believe that what he was doing displeases his father and is wrong. Often, the reaction of the other is much subtler. In this example, the father might simply give a lukewarm response, ignore the boy, or register discomfort on his face. These more nuanced, less apparent reactions can be incredibly impressionable on a child's sense of self. Even if it is not conscious, the boy might come to learn that expressing his vitality is something to be ashamed of, and this might continue to be confirmed by subsequent, similar experiences. Once the boy reaches adolescence and adulthood, a lifetime of such experiences may have led him to squelch his own excitement and dampen his vitality.

I find that by helping patients understand how closely linked their shame is to the reactions of others, it helps them to shift how they view their past experiences. Others' reactions could lead either to greater acceptance or greater shame about the part of self in question. If a female patient comes to learn that her shame about her appearance is tied to comments and reactions she has gotten from other people throughout her life and to images that our society has held up as an ideal, she might begin to reevaluate her own beliefs and self-perception. In this way, having the awareness of just how powerful is the relational nature of shame, one might be better positioned to change one's own deeply held views and challenge distorted beliefs about oneself. 

Mourning Losses

When we think about mourning losses we usually think of grieving a loved one who died or perhaps grieving the end of a relationship. Yet, much of the work of psychotherapy involves mourning losses that are less transparent - losses that can be traced back to childhood. This is the type of mourning that I wish to address in this blog post.

Most adult behavior has its origins in our early childhood experiences. We may unconsciously cling to relational patterns and beliefs that stem from the earliest years of our lives. Oftentimes, the reason we do this is to avoid incredibly painful feelings that may arise and engulf us when we allow ourselves to fully access these experiences. To recognize that one's parent was never able to love and accept them unconditionally, that this parent may never apologize for abuse or injuries they've inflicted, that the parent may never change and one may never have the mother or father they have always longed for and needed, that they will never be truly vindicated for the traumas they have endured - to come to terms with such losses is to open oneself up to tremendous grief. People may spend the majority of their lives engaging in all sorts of behaviors that are attempts to stave off such mourning.

Continued avoidance of mourning unresolved losses from our past comes at a devastating cost. People may suffer from depression, anxiety, and any number of other mental illnesses. They may experience chronic pain and health concerns, abuse substances, repeat unhealthy relationship patterns, and find themselves having ongoing difficulties at work and in their social lives. Even worse, they may inflict the same injuries that they suffered onto their partners and children. 

We can understand how not allowing oneself to mourn the death of a loved one can impede one's healing; we may allow ourselves and encourage others to take whatever time is needed to fully grieve, being gentle in the knowing that mourning can take various forms and evoke a gamut of emotions.  The same concept applies to mourning losses that are much more deeply buried. If working through these losses in therapy didn't have the potential to help an individual achieve greater self-awareness, profound healing, more satisfying relationships and one's personal life goals, then there would be absolutely no good reason to ask our patients to undergo a process which has the potential to stir up such pain. Still, I know of no other way to make long-lasting fundamental positive change. There's a corny saying in the business (alright, there are several) that you have to go through it to get through it. I think this expression is rather apt when it comes to this topic of mourning losses from one's childhood.

Communicating with Text Messages; Don't Text While Driving!

I wonder how many therapy sessions have been spent focusing on the heated arguments that patients have had via text messages. People will engage in lengthy back and forth conversations with their significant other, family or friends that could last for hours. In all the countless times that patients have told me about or shared with me these strings of texts, never once has it gone well.

I believe that texting serves a valuable function, such as coordinating plans, locating each other when you are meeting up, scheduling an appointment, or sending a short "thinking of you" or a funny message with the requisite emoji. Other than in these instances, I find that attempting to have a serious conversation over text messaging is not fruitful. Ditto for Facebook, social media, and possibly even email. These mediums of communication are simply too apt for misunderstanding and an exacerbation of anger and hurt feelings. 

Something gets lost when you don't see or hear the person you are speaking with. Non-verbal communication and tone of voice give us such important information about the other person. We can learn a great deal from someone's body language and the way they sound that is much more comprehensive than you could possibly get from just reading the words that were sent to you. In the absence of such data, people are likely to "mind-read" and interpret the other person's intentions without having access to all the crucial information they would need to truly understand what is being conveyed.

It seems to me that people feel freed up to express difficult thoughts and feelings when there is some distance between them and the person they are talking to. This indirect means of communication may feel easier for many than to talk directly to the other person about how one feels or what one believes. It may be easier to yell at a stranger who cut you off in traffic when you are safely hidden inside the comfort of your car. But when you are face to face with the person who has upset you, that is often another story. Yet, direct and honest dialogue is undoubtedly the most effective means of communication and conflict resolution. 

I encourage patients to learn and practice direct communication skills. I empathize with how scary this can feel for people, but I help teach them that ultimately it is more empowering, healthy, and mature and will usually yield the most positive outcomes. Most of us did not grow up learning how to communicate effectively. In school we took algebra, social studies, and biology but we probably did not take classes in feelings, relationships, conflict management, and communication skills-the things we will benefit from knowing for the rest of our lives. But adults can still learn these skills. Some people may feel pulled into the drama or comfort of shooting off an unfiltered text message or long missive via Facebook, perhaps as a way to discharge one's discomfort with the feelings they are experiencing, but I would strongly suggest that taking time to think and sit with one's feelings rather than impulsively engaging in these behaviors is likely to benefit everyone in the end.

Acting Out Behaviors

In my last blog post I addressed the "acting in" behaviors of depression and anxiety. Here I would like to focus on "acting out" behaviors that people turn to in an attempt to manage uncomfortable internal emotional states. There are many ways that people may "act out," such as putting substances (alcohol, prescription and recreational drugs, nicotine, or food) in their bodies to "self-medicate," overworking, gambling, working out excessively, obsessively turning to plastic surgery for cosmetic changes, excessive shopping, binge watching tv, spending hours playing video games, or engaging in risky and/or excessive sexual activities. When these types of behaviors are being used to unconsciously (or perhaps consciously) manage one's feelings, it probably means that the individual is choosing to flee from living in the present moment or the "here-and-now" to avoid fully inhabiting and experiencing one's feelings.

Cognitive behavioral therapists would focus on these behaviors directly and work on helping their patients learn ways to change the behaviors. Psychodynamic or psychoanalytic therapists like myself view these behaviors as symptoms or coping mechanisms that the patients employ because they might be the most adaptive ways they have learned to regulate the unacceptable, scary, or threatening feelings that are buried beneath. Rather than focus so directly on these symptoms, we believe that if we can help patients access and express the underlying unresolved feelings and come to understand how they are internally organized in relation to their emotions and unconscious processes, then over time people can learn healthier, more effective ways to manage their internal worlds. As a patient does so, we find that the unhealthy symptoms start to dissipate because there in no longer such a strong need to rely on archaic defense mechanisms that served a purpose at one time but now are more likely to be hindering an individual's progress.

A behavior is always a choice (even when it may not feel like a choice); feelings are not. If we subscribe to the belief that most people are well-intended and would choose the healthiest methods available to them, then we can come to see inexplicably harmful behaviors as adaptive attempts to manage difficult internal states. When people are able to learn alternate ways to manage these internal states, they are apt to choose the healthier options. When people learn that they needn't fear nor judge their feelings and begin to practice ways to tolerate, effectively manage, and perhaps even embrace their emotions, then they are better positioned to fill their tool boxes with the most healthy and effective tools. 

The Insidious Nature of Shame

The topic of shame intersects with my previous blog posts and is an incredibly important issue I wish to address. It is unclear as to whether or not shame is truly an emotion like anger, sadness, and joy; I don't imagine that animals other than humans are plagued by it. Nonetheless, shame is pervasive in the world of human beings. Unlike guilt, which is the experience of feeling bad about something you have done or not done, shame is feeling bad about a part of oneself, a part of self that one believes is wrong, unacceptable, or ugly. For example, people may feel shame about their appearance, their sexual orientation, or their ethnicity. Like guilt, shame serves no healthy function and is usually inhibiting people from accepting themselves and living fully authentic lives. 

We are taught to feel ashamed of parts of ourselves from an early age. If our parents, our peers, and our friends and acquaintances believe that something about us is wrong, then the likelihood is that we will believe that what others are saying or thinking about us must be true. We develop in relation to others. If the circles of influence we are most closely surrounded by believe one thing, we are likely to be swayed in the same direction. Thus, young boys and girls who are surrounded by people who believe that boys should not exhibit feminine traits and girls should not exhibit masculine traits will feel shame around their own feminine or masculine parts of self. Teenage girls and boys who grow up in a world where they are taught that having same-sex feelings is wrong will likely develop shame if they are experiencing sexual attractions to people of the same sex. For the fortunate ones who are taught from a young age that there is nothing shameful about normal, human parts of self, these children may grow up accepting the parts of themselves that others learned were shameful. 

In my work as a psychotherapist, I have found that in order to move from a place of shame to a place of acceptance, an individual needs to connect to his or her anger toward the people, institutions, and societies that have perpetuated the myths that have led to the shame in the first place. Keeping with the example of someone who grows up feeling shame about having same-sex feelings, in order to progress from shame to acceptance, one must redirect the anger that is turned against oneself to its proper target(s), the people responsible for the shaming. I use the example of same-sex feelings here, but this concept applies to any parts of one's self of which one has learned to be ashamed. My last post was about the healthy emotion of anger. Here is another way in which anger is essential to the formation of a healthy, authentic self. In psychotherapy, patients have an opportunity to explore the parts of themselves that have caused them shame and learn to access the underlying healthy anger they feel about having been taught the false lessons that any parts of their true selves are bad, ugly, wrong, or shameful.