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Lewis Carroll chose to close his renowned work Through The Looking Glass with a poem. One stanza reads:

Long has paled that sunny sky:
Echoes fade and memories die:
Autumn frosts have slain July.

Buddhist note that as we walk our path through life that suffering is inevitable, the root of all suffering is attachment and that everyone, everything changes.

In his book The Forgiving Self psychologist Robert Karen Ph.D. notes that “all lives are rent with losses from the very beginning.” The list of authors addressing this fact is very, very long. Elizabeth Kubler-Ross’ classic book On Death and Dying introduced many of us to the four stages of grief.

Yet often, in our office we fail to recognize or acknowledge the more frequent losses both we and our clients experience. They are ubiquitous. They may be as simple as closing our eyes and going to sleep at the end of the day, closing a conversation on the telephone, bidding farewell to a friend when we drop them off at the airport. Or a client may end therapy before we thought it was the “right” time, a spouse or close friend may announce that they are ending their relationship with us and death comes to all living things, including each of us.

We have many options for dealing with these endings. Ernst Becker’s Pulitzer Prize winning book Denial Of Death addresses this at length. Drawing from the science of fractals, each ending can be understood as a mirror or recapitulation of previous endings we have experienced. How have we been impacted by previous endings? How have we previously related to or understood endings? Do I believe and/or participate in ending rituals such as a football player’s dance in the end zone, jubilation after a sports event, a wedding, a funeral? What about an after-life or reincarnation?

Back in my office am I, as James Masterson writes, the “guardian of the real self” of my client? Can I, do I attend with compassion and curiosity to my client’s ending experiences: the end of the session, the ending of a job, loss of sight, hearing, dexterity, agile and creative thinking, the loss of hope, loss of resources? How do I deal with such endings in my own life? Do I have a well from which I can draw compassion, curiosity and patience? Does my narcissism weave fantasies into apparent realities: that I will not die, that not winning the lottery or catching the big fish was not a disappointment? Does my depression keep me enmseshed in my losses and endings?

Do I have to have an answer? Perhaps “don’t know mind” and “bare attention” warrant exploration. Have autumn’s frosts slain July or have I given it that meaning? And so what meaning do I give to a client’s report of an ending? Do I notice at all, mine or yours?

©Copyright 2009 Dennis Thoennes, Ph.D., ABPP.  All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Dennis and/or see his GoodTherapy.org Profile

One of the leading principles of modern positive therapy practices is the lending of one’s own skills and support to another, and the seeking of harmonious and effective support networks for those going through difficult times emotionally and mentally. For most mental health professionals, it’s a joy to be of service to clients, whether it’s extending a favor or working towards the gift of mental well-being. But a new study has revealed that some people, especially in times of distress, are averted to gifts and favors, particularly for the sense of social obligation that these things carry.

The research, carried out by Jean-Sébastien Marcoux at HEC Montreal, was a long-term effort conducted over the course of ten years, and presents an impressive array of subjects and circumstances. Marcoux focused his data gathering on a certain situation in which we are frequently both distressed and involved in an activity where favors and gift-giving are common: moving. The researcher pointed out that while not all moving experiences are negative, most are stressful by their very nature, and a large percentage are necessitated by unsettling events such as a divorce, the loss of a job, or death. In these stressful situations, Marcoux found that people tend to decline offers of help and exhibit an aversion to gifts, often because they don’t wish to experience the social pressure and sense of obligation involved.

The research has many implications for related markets, as the reluctance to receive products and services as favors leads to the need to purchase these items directly. But the findings are important for therapy, as well; the notion that offering more when clients are upset or feeling indebted may not be the best practice.

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The song says, “Sorry seems to be the hardest word.” Well… that depends. There is a bounty of research that tells us about the impact of trauma such as mugging, rape, burglary, war, genocide etc. No doubt such activities inflict pain and leave scars. What is too often missed are the scars that are not there. That might well be because this scar is the imprint of neglect.

Alan Schore Ph.D. has done a masterful job of educating us about the neuropsychobiological effects of interpersonal relationships including the dyadic regulation of affect. Right there on the screen, evident for anyone looking is (or could be) an FMRI (functional magnetic resonance image) that shows us a person’s brain. We can see differences between the prefrontal orbital cortex of a person raised with a healthy degree and manner of attunement and one who had less than that. This is evident in many of the children found in Romanian orphanages or those here in the US. One such orphanage was depicted in the movie Cider House Rules.

There is a long and storied history of the tough, silent guy, the “John Wayne” type. The difference though, between that silent type and the adult we might see in our office, the adult who grew up neglected and unattuned to, is that the former is more likely to care about other people, society and relationships. The adult who was profoundly neglected as a child is more likely to display a generalized indifference, disconnection from others and a diffuse visceral reaction and feeling unrelated to others and thus feel, think and behave like a stranger in a strange land. This has many of the hallmarks of depression: anhedonia, isolation, poor self care, and lack of future plans and ambitions. We might see these symptoms.

To some therapists this person may appear to be in need of social skills training or direction and encouragement to get involved in life activities such as gardening, exercise or a drumming circle, or an antidepressant. The benefits of these treatments are most likely to be short lived or prove insufficient. The lyrics in Elton John’s song ask these questions “What have I got to do to make you love me? What have I got to do to make you care?”

In my experience it is essential to get a good and thorough history of this client, particularly of their first ten years. Did she have significant people in her life that she believed really cared about her, whom she could rely on? When questioning, be sure to get specific examples. Don’t let the truth languish in ambiguities. This client may protest, “Yeah, I was well fed, went to good schools.” This client may avoid self-reflection eschewing the “pity pot” and quickly point to others who “had it worse”. As much as this client rejects the therapist’s inroads to contact he also wants exactly that.

I have found that this client is not playing games but profoundly doesn’t know how to connect and very likely doesn’t know how to articulate that. I have found that asking her (or him) to make a collage that shows me that feeling or to bring in a poem or song lyrics or recordings helps bridge into that diffuse visceral reality.

This client can be tremendously challenging to a therapist because if the therapist has had a childhood of good enough attunement this client is speaking, at a gut level, a very different language than the therapist. Therapy with such a client can lead the therapist to think he/she is “following a rabbit down a rabbit hole” or indulging the client’s pathology. In this therapy the therapist may confront some of his/her own darkest, scariest, loneliest and unexplored areas of psyche.

In the Odyssey, Odysseus encountered a sign when he arrived at the river Styx, “Abandon hope all ye who enter here”. Though paradoxical, I believe this may be the most curative therapy for this client, this victim of neglect. It’s not about being drug down a rabbit hole or joining them in a pity party. It rather is a profound respect for the client in his greatest fear and deepest reality. It is as though the client asks the therapist, “What have I got to do to be heard?” “Can you see me? Tolerate me? Hear me? Attune to me? And, when you can hear me, tolerate, and attune, my reality takes on texture, dimension and we have connection.” This connection can be a means of developing new neuronal pathways, hope and engagement. Not just in the abstract but here and now with us.

As the client recognizes this deep loneliness he may come to a very deep sadness and grief. The therapist being present and attuned provides the client the experience of being real. Being real means I exist, you exist. This is mirroring. As the client unwraps these undeveloped or exiled parts of himself and sees that the therapist sees and cares, the neglect of the past begins to be transformed and the client gains the tangible experience of attuned engagement.

During this therapy process the therapist must be very sensitive to signs of a client’s self abuse, addiction behavior or suicidality. During this process the client is venturing into truly terrifying territory. It’s as though the client is using the therapist as a ladder into the deep, dark, terrifying cavern of his psyche. The therapist needs a good support system and to be familiar with his own demons and dragons in order to see and support the client and not join him in the decent. Signs of therapeutic gain may include the therapist’s recognition that the client comprehends he is being seen, heard, therapeutic rapport, as well as signs the client is taking care of themselves and connecting with others. These signs may include more socially appropriate dressing, friendships and meetings with peers, interest in activities, and improved appetite.

This is a big part of what makes the life of the psychologist so taxing, so difficult and so rewarding. Each of our clients, in some way, invites us to meet parts of ourselves as we meet. Hence, the dyadic discovery of the Real Self is at hand.

©Copyright 2009 Dennis Thoennes, Ph.D., ABPP All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Dennis and/or see his GoodTherapy.org Profile

Click here to contact Dennis and/or see his GoodTherapy.org Profile

It is customary for a therapist to facilitate a client’s thinking and feeling “outside the box”, to “wake up and smell the coffee”. Therapists want to assist clients to release the constraints of what is “customary” or “normal” for them and explore the world of thoughts and feelings that have been taboo or off limits. The other end of the spectrum is also, sometimes, the therapeutic focus i.e. learning to self regulate and develop the skills for expressing feelings such as anger in socially appropriate, non-abusive ways. Certainly there are clients who need such therapeutic assistance.

I remember a colleague commenting “I make it very clear to each and every one of my clients that I will not be sexual with them and that my office is not a place for expressing rage and anger.” Sometimes, in some situations, for some clients such clear and definite boundaries are appropriate or necessary.

Years ago I had a television set with rabbit ears for an antenna. The signal was often blurred and I would get headaches as my eyes tried to reconcile the blurred images. It often is the distress of blurred boundaries and tangled experiences that brings people to therapy.

Some states credentialing requirements or guidelines or those of some professional groups may require a therapist to include in his or her office policy very clear language about, for example, sexual boundaries. Heeding such directives or advice may be legally necessary and professionally appropriate. In the intricacies and dynamic processes of the therapy session what was printed in an office policy is likely to fade out of awareness for the client. If a therapist recognizes that a client is having romantic or sexual feelings for the therapist it would not be appropriate for the therapist to kindle the client’s affections for the therapist. In the interest of properly tending professional boundaries, throwing the proverbial bucket of cold water on the client may be “safe” but counter therapeutic.

Perhaps the client has a history of not just well contained but repressed feelings. As the client’s trust and rapport with the therapist builds these feelings may begin to manifest. Some client’s have learned the best defense is a good offense. Being offensive, in spades, may be both their safe haven and a primary consternation. A skilled and well-resourced therapist may help the client to open to an interior universe of terror, constriction, avoidance and denial. That the client may have very angry, romantic or sexual feelings for the therapist may be an opening for the therapist into the client’s interior miasma. If the therapist is brave and skilled enough he/she may help the client discover exiled parts of themselves that can become elements of a robust, vibrant and healthy person.

I remember a senior colleague comment that “All relationships have a sexual element. When we go to our office we can’t exclude it as though it were a set of car keys we forgot or a puppy we left at a kennel.” So if sex is always here, is always a part of every relationship, perhaps it would serve us well to be aware of it and make wise choices about it. Can we do this if sexuality is not allowed into the therapeutic relationship? If or when a client manifests angry, sexual or romantic feelings for the therapist an opportunity may be presenting itself to help the client learn to manage the complex realities of relationships. Can I, do I help the client learn to differentiate caring, being emotionally vulnerable and seen in a compassionate way from a romantic or sexual advance, interest or activity? Is it not the therapist’s responsibility to help the client learn that being seen and known emotionally is safe, that being compassionate, curious and committed to their healing and the emergence of their real self (see J. Masterson) is part of a healing, loving and vibrant relationship and not grooming and exploitation?

Skilled therapists we’ve heard of, known, been trained by, therapists such as Virginia Satir, Carl Rogers, and Jay Haley showed us that it was at this moment of authentic connection that deep, rich healing can happen. Current researchers such as Alan Schore (The Neurobiology of Affect Regulation) have shown us that self awareness and self image have their roots in the dyadic relationship of infant and parent. Martin Buber, decades before, wrote of the relationship of two people as the calling of one another into being. What “I” of the client do I evoke and what “you” in me is evoked by my client? It may be when my hands feel clammy, my mouth is dry, and my sphincters cramp that I have an opportunity present. An opportunity is present for healing, actually helping the client move from the darkness of shame, trepidation and anger to the light and vitality of being here and now in a connected and healthy way.

If a client manifests an element of sexual or romantic interest in me or is angry toward me and I respond with clear, strong language marking distinct boundaries and propriety I may feel safe and that I’ve taught the client an important lesson. But, have I helped them find and develop their Real Self and navigate the tidewaters of intrapersonal and interpersonal dynamics? The recognition and maintenance of clear boundaries and skilled and compassionate address of a client’s sexual, romantic or angry feelings toward their therapist are a client’s right and the therapist’s responsibility. The work of luminaries preceding us serves not only as an example of their remarkable skills both as a person and as a therapist but also they beckon us along the same path. They call us into being in our fullness. They encourage us to leave the refuge of absolutes and engage in the vibrant, dynamic processes of living now. John Zinn called it “full castrophe living”. Will you?

The record of therapist sexual impropriety with clients is testament that prohibition (by itself) is insufficient or ineffectual and it is essential that therapists gain further training and consultation regarding these matters. James Masterson teaches that the therapist is the “guardian of the client’s Real Self”. I believe he is speaking of the same core reality that has been elucidated by therapists, researchers, poets and philosophers including Martin Buber and Alan Schore.

William Stafford, the late poet laureate of Oregon closed his poem “A Ritual To Read To Each Other” with these lines:

Tho’ we could fool each other we should consider-
lest the parade of our mutual lives get lost in the dark-
for it is important that awake people remain awake
or a breaking line may discourage everyone back to sleep.
The signals we give, yes, no or maybe,
they should be clear
for the darkness around us is deep

©Copyright 2009 Dennis Thoennes, Ph.D., ABPP All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Dennis and/or see his GoodTherapy.org Profile

Click here to contact Dennis and/or see his GoodTherapy.org Profile

Recently a client described an icy meltdown she and her husband had with one another. This is not an uncommon event in the lives of couples I see. I noticed I began to consider a variety of therapeutic frames I could utilize and directions I could take to facilitate the client’s self exploration and find a way to understand such a difficulty and find acceptable alternatives. Then something else happened.

I noticed I am much more familiar with this “icy meltdown” experience than I’d care to admit. I so often fall short of the expectations I have of myself as husband, human and therapist. Then I recalled a line I heard in a workshop conducted by Stephen Levine, “Have mercy. Have mercy.” Pema Chodron also addresses this in her book “The Wisdom Of No Escape”.

We are all so human, so incomplete, so flawed and often have such high expectations of ourselves and others. This can set the stage for a life of unmet expectations and a long and painful traverse of life. Certainly there are instances where we cut ourselves or others too much slack.

Often we want so much from others and ourselves. What would “have mercy” actually look like. It could mean compassion for myself and others. I realize that I want to help my clients be free of suffering and to be happy. Sometimes this is a noble veneer covering my desire to have my clients think highly of me and refer people to me so I can have the prestige, the income, the life I fantasize.

Perhaps in the moment when my client tells me of her woe I could simply listen with a compassionate heart, not rush to fix or change her or relieve her of her misery. Bowlby spoke of being with a client “without hope and without expectation”. Surprisingly, when I can do this I may find my attention is less distracted with my endeavor to be the effective, wonderful and successful therapist. I may realize own familiarity with my client’s pain and frustration. I may be able to be more fully present with my client and in so doing she may learn that pain isn’t always something to fix, avoid or run away from.

So often I and my clients, perhaps you also try desperately to make life work, make it look like “it should”. I may have developed an ideal, an idea of the way it should be, a template. Richard Schwartz (IFS) identifies this as “false self”. Our reaction is often to get so down about life and/or ourselves when our experience of ourselves or the other doesn’t fit our template. Then we think there’s something wrong with “life”. Perhaps we’re working like the proverbial “hammer mechanic”, to make “life” fit our template. It may be wise to recognize simply this is life happening.

This is not despair, about giving up, about enduring abuse. It’s about intruding on our addiction to pleasure, having life work out the way I (ego) want.

When we do this we may feel just as miserable as before. And just perhaps grief, acceptance and serenity may be dawning.

©Copyright 2008 Dennis Thoennes, Ph.D., ABPP All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Dennis and/or see his GoodTherapy.org Profile