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, PhD, 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 United States. 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 10 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 by Dennis Thoennes, PhD, ABPP. All Rights Reserved. Permission to publish granted to GoodTherapy.org.
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