Psychotherapy Essentials to Go Achieving Psychotherapy Effectiveness

PSYCHOTHERAPYESSENTIALSTOGO

AchievingPsychotherapyEffectivenessMolynLeszcz

ClarePain

JonHunter

RobertMaunder

PaulaRavitz

SERIESEDITORS:PaulaRavitzandRobertMaunder

W.W.NORTON&COMPANY

NewYork|London

ANORTONPROFESSIONALBOOK

Contents

Acknowledgments

SeriesIntroduction

1IntroductiontoAchievingPsychotherapyEffectiveness

2LearningObjectives

3CommonFactorsandtheImportanceofRelationships

4DevelopingaSharedUnderstandingofaClient’sRelationalWorld

5EngagingintheProcessofTherapy

6AccountingforTrauma

7FinalThoughtsGlossary

LessonPlans

Quiz

AppendixA:Role-PlayTranscripts

AppendixB:PracticeReminderSummary

AppendixC:AnswerKey

AppendixD:TherapistWorksheet:AssessingandReflectingonCommunication

AppendixE:RecommendedReadings

References

PracticeReminderCard

OTHERTITLESINTHESERIESINCLUDE:

CognitiveBehavioralTherapyforDepressionMarkFefergrad&AriZaretsky

CognitiveBehavioralTherapyforAnxietyMarkFefergrad&PeggyRichter

InterpersonalPsychotherapyforDepressionPaulaRavitz,PriyaWatson,&SophieGrigoriadis

MotivationalInterviewingforConcurrentDisordersWayneSkinner&CarolynneCooper

DialecticalBehaviorTherapyforEmotionDysregulationShelleyMcMainandCarmenWiebe

MolynLeszcz

Forallwhohavetaughtme.

ClarePain

Dedicatedtoallthosewhoworktohealfromtraumaticexperiences.

JonHunter

Formykids,whohavetaughtmesomuch.

RobertMaunder

ForMomandDad.

PaulaRavitz

Formyfamily.

SeriesIntroduction

Psychotherapyworks.Meta-analysesdemonstratethatpsychotherapyreducesthesymptomsandimpactofthementaldisordersthatmostcommonlyinterferewithpeople’slives,includingdepression,anxiety,andtheextraordinarychallengesthatemergefromconcurrentaddictions,mentalillnesses,andpersonalitydisorders.Theconsensustreatmentguidelinesthatprovideclinicianswithevidence-baseddirectionfortreatingdepression,anxiety,andothermentaldisordersrecommendpsychotherapy,sometimesasafirstlineoftreatment.

Atthesametime,practicingeffectivepsychotherapyisverychallenging.Foronething,treatmentguidelinesrecommendspecificmodalitiesofpsychotherapyforspecificdisorders,suchasInterpersonalPsychotherapy(IPT)fordepression,CognitiveBehavioralTherapy(CBT)fordepressionoranxiety,MotivationalInterviewing(MI)formentalhealthissuesandsubstanceabusedisorders,andDialecticalBehaviorTherapy(DBT)forborderlinepersonalitydisorder.Therapistsworkingatthefrontlinesofmentalhealthcareseealloftheseproblems,butacquiringextensivesupervision,training,andcertificationinanyoneofthesemodalitiesiscostlyandchallenging,andbeinganexpertinalltypesofpsychotherapyisvirtuallyimpossible.Howcanafront-linetherapistusethecoreskillsofdifferentmodalitiesofpsychotherapyeffectivelytohelphisorherclientsovercomethedebilitatingeffectsofmentalillness?

PsychotherapyEssentialstoGorespondstothechallengethattherapistswhoarenot(yet)expertsfaceinacquiringthecoreskillsofpsychotherapy.Itisdesignedtobeusefulforbothnewtherapistsandthosewhoaremoreexperiencedbutwanttolearnthecoretechniquesofdifferenttypesofpsychotherapy.Italsoisarefreshercourseonthetechniquesthatexperiencedtherapistsarealreadyfamiliarwithandcanbeusedforteachingcounselingtechniquestohealthworkers.

Thisprojectemergedinresponsetotheneedsofmentalhealthcareworkerswhowerefacingextraordinarychallenges.Workingincommunityclinicsinremote,underservicedareas,theseclinicianswereunabletoprovidepsychotherapytotheirclientsbecausetheyhadminimalpsychotherapytrainingandlimitedmeansofacquiringit.Caseloadswereoftenheavyandresourcesforreferringclientstopsychotherapistswereextremelylimited.Theseclinicianswantedtobutwereunabletousepsychotherapeutictechniquestohelptheirclientswhoweresufferingfromdepression,anxiety,andconcurrentdisorders.Needlesstosay,itwasnotfeasibleforthesehealthworkerstoobtainthetraining,observation,andone-to-onesupervisionthatarerequiredtobecomeexpertsinspecificmodalitiesofpsychotherapy.Surely,therewasabetteralternativethanprovidingnopsychotherapyatall!

Drawingonthewealthofexpertiseofthecontributingauthorsinthisseries,whoareallfacultyorstaffathospitalsaffiliatedwiththeUniversityofToronto,wecreatedthemanualsandvideosthatareatthecoreofthePsychotherapyEssentialstoGomaterialsaswellasalloftheaccompanyinglessonplansinordertomeettheneedsofcliniciansand

theirclients.Themanuals,videosandlessonplansworked.Wetestedthematerialsthatwedevelopedwithhealthcareworkersofseveraldisciplinesandlevelsofexperience—fromthecaseworkersincommunitymentalhealthcareclinicswhoseneedsinitiatedtheprojectandtomedicalstudents,nurses,familymedicineandpsychiatryresidents,andsocialworkers.Theirknowledgeincreased,theyusedthetechniquesthattheyhadlearned,andtheyreportedthattheyhadbecomemoreconfidentandeffectiveclinicians,evenwithdifficultclients.Evenseasonedtherapistsbenefitedfrombrushinguponthespecifictherapyprotocols.

ThefirstfivebooksandDVDsofthePsychotherapyEssentialstoGoseriesteachtheskillsofMotivationalInterviewing,CognitiveBehavioralTherapy(foranxietyandfordepression),DialecticalBehaviorTherapy,andInterpersonalPsychotherapy.Thesematerialsarenotintendedtoreplacefulltrainingintheseevidence-supportedpsychotherapeuticmodels;rather,theyintroduceanddemonstratetechniquesthatcliniciansandstudentscanintegrateintotheircareofpeoplewithcommonmentalhealthproblems.

ThissixthbookanditsaccompanyingDVDaddresspsychotherapyeffectivenessacrosseverymodalityoftherapy.Regardlessofwhichtypeofpsychotherapyatherapistprovides,doingpsychotherapyrequirestherapiststobeflexibleandresponsivetotheirclients.Alsotherapistsandclientsmustformandsustainastrongworkingrelationship:thetherapeuticalliance.Ineverymodalityofpsychotherapy,agoodtherapeuticallianceleadstogoodclinicaloutcomes.Withsomeclientsthechallengesencounteredinformingandmaintaininganallianceprovideawindowontheinterpersonaldifficultiesthatruninterferenceinsomeoftheirotherimportantrelationships.Thisbookonpsychotherapyeffectivenesssynthesizesthemostimportantcommonfactorsofpsychotherapiesandprovidesatherapistwithanapproachtounderstandingandmanagingchallengestoestablishingandmaintainingatherapeuticalliance.

Learningpsychotherapymeanschanginghowyoubehaveasaclinician—andchanginghabitualbehaviorisnotoriouslydifficult.Learningnewprofessionalbehaviortakestimeandpractice—youneedtoexperienceanewwayofbehaving;itisn’tenoughtoreadaboutitorhearaboutit.Experientiallearningismosteffectivewhenitincludesdemonstration,modeling,andpractice.Foreachbookintheseries,wesuggestthatyoufirstwatchtheDVD,thenreadtheaccompanyingtext,andthenfollowtheinstructionsinthelessonplanstopracticeandconsolidateyourlearning.Takethequizbeforestartingthisprocessinordertoassessyourknowledgeandyourneeds,andthentakeitagainafterhavingcompletedallofthelessons,inordertoassessyourprogress.Afterward,usethesummarycardofpracticeremindersinyourdailyclinicalwork.

Forthoseinterestedinmoretraining,furtherreadingandclinicalsupervisionarerecommended.WehopethatthetechniquespresentedintheseintroductoryPsychotherapyEssentialstoGomaterialswillexpandyourclinicalrepertoireandwillimproveyourcompetenceandconfidenceinworkingwithclientswithmentalhealthproblems.

Notesaboutlanguage.First,thosewhoprovidecareandtreatmentforpeoplewithmentalhealthproblems,andindividualswhoreceivethatcare,preferawiderangeof

namesforthoseroles,andsomehavestrongfeelingsabouttheirpreferences.Forthesakeofconsistency,throughoutthisserieswerefertotheformerindividualsas“therapists”(occasionallyoptingfor“clinicians”forthesakeofsomevarietyofexpression)andthelatteras“clients.”Wedothisinspiteofthefactthatsomemodalitiesofpsychotherapyareexplicitaboutwhichtermsarepreferable.Wehopethesearereadtobetheinclusiveandnonprescriptivechoicesthatareintended.Second,thegenderofthetherapistsandclientswearediscussingisirrelevant.Wehaveadoptedtheconventionofreferringtothetherapistasfemaleandherclientasmale,forthesakeofeconomyoflanguage.Whendiscussingdevelopmentalprocesses,thechildwehaveinmindistheonewhowillgrowupintoaclient,sowehavegenerallymadehimmaleaswellforconsistency.Whendiscussingachildandhisorherprimarycare-provider,wecalltheadultinthatroleaparent,acknowledgingthatthereareotherswhoalsoservetheparentingrole.

PaulaRavitzandBobMaunder

PSYCHOTHERAPYESSENTIALSTOGO

AchievingPsychotherapyEffectiveness

1::IntroductiontoAchievingPsychotherapyEffectiveness

EachofthepreviousbooksinthePsychotherapyEssentialstoGoseriesisderivedfromaspecifictypeofpsychotherapythatisdescribedinamanualandsupportedbyevidence.Thisbookisalittledifferent.Justlikeitspredecessors,itisgroundedinevidence-supportedpsychotherapypractices;however,unliketheotherinstallmentsofthisseries,AchievingPsychotherapyEffectivenessdoesnotdescribeaparticularmodality.Instead,wefocusontheories,principles,andpracticesthatimprovetheeffectivenessofalmostanytypeofpsychotherapy.Weprovideananswertothisquestion:Whatcanimproveatherapist’seffectiveness?

Theauthorscometothisquestionfromdifferentdomainsofexpertise,fromInterpersonalPsychotherapy,grouppsychotherapy,andpsychotherapeuticapproachestotraumaandtoadaptingtoseriousillness.Differenttypesofpracticeledustofavordifferentmodelsofpsychotherapy,buteachofusturnstoevidencetodeterminetheelementsofourworkthataremostvaluableandmostimportanttoteachandreinforce.Theevidenceleadsustoagreeontheessentialingredientsthatarecommontoeffectivepsychotherapiesofeverytype,andthisbookprovidesaworkingsynthesisofthoseingredients.AchievingPsychotherapyEffectivenessendeavorstohelpyoutobecomethemosteffectivepsychotherapistthatyoucan,regardlessofthemodelofpsychotherapythatyoupractice.

2::LearningObjectives

Thefollowingobjectiveswillhelpyoutofocusyourlearningasyoureadthetext,viewtheDVD,andcompletethelessonplans.

Attheendofthisbook,wehopethatyouwillbeabletoachievethesegoals:

1.Listthetherapists’qualitiesthatcanpromoteatherapeuticalliance.

2.Developanunderstandingwithyourclientsaboutrelationshipsthatshapedtheirinternalworkingmodels,patternsofattachment,andinterpersonalpulls.

3.Recognizethepotentialimpactofunresolvedtraumaandlearnhowandwhentoaskaboutit.

4.Understandtherisksandchallengesthatcanleadtonegativepsychotherapyoutcomes,includingtransference-countertransferencedynamics.

5.Recognizeandusealliancestrainsastherapeuticopportunities.

6.Expandyourreflectivecapacityandtherapeuticrepertoirebyusingmentalizingandmetacommunication.

3::CommonFactorsandtheImportanceofRelationships

OneofthekeyprinciplesofthePsychotherapyEssentialstoGoseriesistoidentifyandrecommendpracticesthathavethestrongestevidenceforcontributingtoeffectivepsychotherapy.Followingthisprinciple,AchievingPsychotherapyEffectivenessbeginswithfindingthatthereismuchmorethatdistinguisheseffectivefromineffectivetherapiststhanthatwhichdistinguishestheeffectivenessofdifferentmodelsoftherapy(Barthetal.,2013).Thebesttherapistsaffordtheirclientstwicethelikelihoodofimprovementandhalfthelikelihoodofdeterioratingcomparedtolesseffectivetherapists(Baldwin&Imel,2013),whereasthedifferenceineffectivenessbetweendifferentmodelsoftherapyismuchlessdramatic.Whiletraininginanevidence-basedmodeloftherapyisimportant,LuborskyparaphrasesthedodobirdinAliceinWonderlandtoconcludethat“allmodelshavewonandalldeserveprizes”(Luborskyetal.,2013).Therefore,thecentralfocusofAchievingPsychotherapyEffectivenessistoguideatherapistregardinghowbesttouseherselfasatherapeuticagent—whichistosayweemphasizetheevidence-basedpsychotherapistmorethanevidence-basedpsychotherapies.

THECOMMONFACTORSOFPSYCHOTHERAPYTheevidenceaboutwhatdeterminespsychotherapyoutcomessuggeststhatthegreatestimpactisduetofactorsthatarecommontoallmodelsofpsychotherapy,includingastrongtherapeuticalliance,empathyandcollectingclientfeedback,consensusaboutgoals,collaboration,positiveregard,therapistgenuineness,andatherapist’sabilitytoadapttoherclientandtomanagethetensionsandstrongemotionsthatariseintherapy(Norcross&Lambert,2011;Norcross&Wampold,2011).Eachcontributiontoimprovementthatismadebyspecifictechniquesofparticulartherapies,attitudesthataclientbringsintotherapy(suchasmotivation),changesthatoccurintheclient’slifethatareentirelyoutsideoftherapy,andtherapistcharacteristicsisimportantbuthasasmallereffect.

Byattendingtotheessentialcommonfactors,effectivepsychotherapistsestablishwhatWampold(2001)describesasa“healingcontext.”Inthisbookweemphasizethatmanyofthesegoalsdependonthetherapist’sabilitytounderstandaclient’srelationalworld,tomentalize1,and,inturn,tocommunicatemeaningfully.

THECENTRALITYOFRELATIONSHIPEffectivepsychotherapyoccurswithinatherapeuticrelationshipthatisco-constructedbytherapistandclient,arelationshipinwhichbothindividualsreiterativelyaffecteachother.Whateverproblemsbringaclientintotherapy,thebenefitsofpsychotherapywillemergefromanewrelationshipexperiencethatempowershimtogrow,develop,andhealinternaldeficits,despiteoftenreflexivelyreenactingproblematic,familiarrelationaldynamicsduringtherapy.Wepresentanumberoftechniquesandprinciplesthatcanbeeasilyintegratedwithinvariousmodelsoftreatmenttoimproveoutcomes.Whilethisguidebookemphasizesonespecificcontext—situationsinwhichthetherapeuticrelationshipbecomesstrained—thecoreskillsweteachareusefulinalltherapeuticcontexts.Theseskillsarementalizing,metacommunication,andattentiontointerpersonaldynamics.

ADilemmaofPsychotherapyPeoplecometopsychotherapyformanyreasons,oftensimplyforreliefoftheburdenofsymptomsofdepressionoranxiety;theyoftendonotidentifythemselvesashavingdifficultiesinrelationships.Nonetheless,theroleoftherelationshipiscentraltothepracticeofeffectivepsychotherapy,andrelationaldynamics,especiallybetweentherapistandclient,arealwaysimportant.Theproblemsthataclientidentifiesmayhaveemergedbecauseofunderlyingrelationshipproblems(suchasconflict,loss,orloneliness),ortheymayacttointerferewithcurrentrelationships.Inanycase,psychotherapyaimstotreattheseproblemsusingthepowerofahealingrelationship,whichwillinevitablybeshapedbytheproblemsthataclienthasbroughttotherapy.

Althoughmostclientswouldnotarticulateitinthisway,itishelpfultostartwiththeassumptionthatformingarelationshipwithatherapistpresentsaclientwithadilemma.Heapproachesthisnewrelationshipwithbothhopeanddread—dreadthattherapyisgoingtobearepetitionofpreviousrelationshipsthatfailed,orinwhichhewasshamed,punished,orrejected.Therapybecomespartoftheclient’sproblemifitre-createsthisold,familiarpatternofrelating.Butclientsalsohaveahope—thatthistimeitwillbedifferent;

thatatherapistwillhelpthemhealandrecover(Leszcz&Malat,2011;Mitchell,1993).Thechallengeoftherapyistobeginarelationshipthatcouldgointhatnegativedirection(becomethe“sameoldthing”)andinsteadturnitintoaconstructiveandreparativerelationship.Inthatsense,therapyiseitherpartoftheproblemorpartofthesolution.Inordertomaximizetheoddsthattherapywillcontributetothesolution,atherapistmustremainflexibleandattuned,eveninthefaceofevocativeinterpersonalforces,andbeabletomoveintoanoptimaltherapeuticposturethatisshapedbytheneedsoftheclient.

ANAPPROACHTOPSYCHOTHERAPEUTICEFFECTIVENESSOurapproachtoachievingpsychotherapyeffectivenessfollowsasequencethatisfirmlyrootedinanunderstandingofthepowerofrelationshipdynamics.First,weattendtothefoundationofthetherapeuticrelationship,whichisthetherapeuticalliance.Second,wedeepenourempathicconnectionbyunderstandingtheclient’srelationalworldandfindingconstructivewaystocommunicatethatunderstanding(Elliott,Bohart,Watson,&Greenberg,2011).Wedothisbylearningabouthisearlyattachmentrelationships(there-and-then),hiscurrentrelationships(there-and-now),andthedynamicsoftransferenceandcountertransferencewithinthetherapeuticrelationship(here-and-now).Third,welearnabouttherepetitivepatternsofunhappy,self-fulfillingsequencesthatmayrecurintheclient’slife(theseexperiencesofthedreaded“sameoldthing”arealsoreferredtoasmaladaptiveloops)andattendtohowwe,astherapists,mayinadvertentlybe“hooked”intothesepatternswhileinthetherapeuticrelationship.Fourth,werecognizetherapeuticopportunitiestothenget“unhooked,”usingtechniquessuchasmentalizingandmetacommunicationtorepairstrainsinthetherapeuticallianceandpromotenewwaysofunderstandingandexperiencingrelationships.Oneofthemostpowerfulskillsofaneffectivepsychotherapististhecapacitytobe“present”enoughwithinthealliancetobecomehookedintointeractionsthatriskreinforcingherclient’sunhappyoldpatterns(notmerelyattendingtothetechnicalaspectsofadherencetoamodelofpsychotherapy),tothennoticeandappreciatewhatisbeingre-createdandgetunhookedbyaddressingthepatternsinanonblamingfashion(Hill&Knox,2009).Finally,weexaminetheimpactoftrauma,whichissocommonandinfluencestherapysomarkedlythateverytherapistmusttakeitintoaccount.

ANAPPROACHTOPSYCHOTHERAPYEFFECTIVENESS

Buildastrong,positivetherapeuticalliance

Developasharedunderstandingofaclient’srelationalworld

•Earlyattachmentrelationships

•Currentrelationships

•Transferenceandcountertransference

Identifyself-fulfillingpropheciesthatreinforcepathogenicbeliefs(maladative

loops)

Whenbehaviorallyoremotionallyhooked.getunhooked

•Mentalizing

•Metacommunication

Taketheimpactoftraumaintoaccount

THETHERAPEUTICRELATIONSHIPANDTHETHERAPEUTICALLIANCEThetherapeuticrelationshipstartswithelementsthatarefundamentalinreasonableperson-to-personinteractions,suchasrespectanddecencyand,withthetherapist’sdemonstrationofpresencethroughpsychologicalavailability,empathy,responsiveness,andinterest(Viederman,1999).However,thetherapeuticrelationshipalsohasspecificelementsthatrequiredeeperdiscussion:thetherapeuticalliance,transference,andcountertransference.

Theevidenceisstrongthatthetherapeuticalliance—asexperiencedbytheclient—isasignificantpredictorofpositiveoutcomeacrossalltreatments(Horvath,DelRe,Fluckiger,&Symonds,2011;Martin,Garske,&Davis,2000).Thetherapeuticallianceisthegroundinwhichtherapytakesroot,soaneffectivetherapistneedstoestablishanallianceasthefirstfocusofanypsychotherapy.Inparticular,themoreshecangainconsensuswithherclientsaboutthegoalsandtasksoftreatment,themoreeffectivetreatmentwillbe.

Aneffectivetherapistbuildsthealliancebyengaginginacollaborationinwhichshetreatstherapyasajointundertaking(Horvathetal.,2011).Theheartofthisworkishercapacitytobuildrapport,remainingalerttoactionsthathinderaffiliationbetweenaclientandhistherapist.Themostsubstantialofthesebarriersaretherapistbehaviorsthatconvey

judgment,blame,shame,orinterpersonalcontrol.Ontheotherhand,atherapeuticrelationshipgoesbeyondmeresupport.Inordertoachievethegoalsthatatherapistandclienthavenegotiated(suchasalleviatingsymptomsandproblems),thereisaninevitablebalancebetweenvalidationoracceptanceofaclient“justasheis”andpromotingchange.Itisimportantthatatherapist’scommitmenttobesupportive,empathic,andengageddoesnotblockherfromchallengingtheclient’smaladaptivebehaviors,suchassubstanceabuse,thatcontributetopoorfunctioningandimpedepositivechange.Oneofthekeyskillsrequiredtopromotechangeistofindpalatablewaystosayunpalatablethings.

Toagreewithaclientaboutgoals,atherapistneedstounderstandhiscoreconcerns.Sheworkstofindawaytomakesenseoftheseconcernstogetherwithhim,usingwordsandconceptsthataremutuallyaccessible.Theoryandtechnicallanguageshouldbeavoidedbecauseitmayinadvertentlydistanceatherapistfromherclientorleadtoafalsesenseofagreement.

Finally,butcrucially,atherapistmustremainattentivetotheboundariesofethicalpractice.Shemustalwaysmakechoicesintheserviceofadvancingherclient’sinterests.Seetheboxentitled“ATherapist’sResponsibilities”foraverybriefoverview(toreflectontheethicsofpracticingpsychotherapyinmoredepth,seePope&Vasquez,2010).

ATHERAPIST’SRESPONSIBILITIES

Psychotherapyrequiresaprofessionalrelationship,whichplacesfiduciarydutyandresponsibilitiesonatherapistbeyondthoserequiredinotherkindsofrelationships.

Allofthesuggestionsinthisbookaretobeappliedwithinthefollowingframeworkofethicaltherapy:

•Atherapistmustbeadequatelytrained(and/orsupervised)tobecompetentinthetreatmentthatheorsheprovides.

•Atherapistmustconformtotheprofessionalandethicalstandardsofhisorherprofession.

•Atherapistmustremaincognizantoftheimbalanceofpowerthatisinherentinthetherapyrelationship.Forminganyotherkindsofrelationshipswithaclient,suchassocial,sexual,orfinancialrelationshipscontravenesatherapist’sfiduciaryandethicalduties.

•Whenconsideringcrossingaboundary,suchaswhenatherapistconsidersgreaterself-disclosurethanistypical,atherapistmustassessifthischoiceisintheserviceofherclient’sgoalsratherthanherown.

1Thisbookintegratesconceptsfromseveralpsychologicaltheoriesandschoolsofpsychotherapy.Wehavebeenjudiciousinalsoadoptingtechnicaltermsfromthesesources,inanefforttoavoidthelackofclaritythatcomesfromjargon.Nonetheless,psychotherapyisaspecializedtaskthatrequiressomespeciallanguage.Whentechnicaltermsarefirstintroduced,theyappearinitalicsandaredefinedintheglossaryattheendofthisvolume.

4::DevelopingaSharedUnderstandingofaClient’sRelationalWorld

Inadditiontolearningfromaclientaboutwhateversymptoms,struggles,orproblemsbroughthimintotreatment,therearethreekindsofinformationaboutrelationshipsthatcanbeusedtounderstandaclient’srelationalworld.First,atherapistcangatherinformationaboutherclient’sdevelopmentalhistory,suchashowheinteractedwithmembersofhisfamilyoforiginandtheeventsthatcontributedtoresilienceortoproblemsinchildhoodandyouth.Second,atherapistcanunderstandherclient’scurrentrelationships,suchaswithhisspouseorromanticpartner.Third,aneffectivetherapistlooksataspectsofthetherapeuticrelationshipitself,particularlythetransferencerelationship.Itmaynotalwaysbenecessarytoinvestigateeachoftheseareasinthesamedepthforeveryclient,buttheyarecomplementarywaysoflearningabouthisrelationalworld.Wenowlookateachsourceofrelationshipinformationinturn.

RELATIONSHIPSINACLIENT’SDEVELOPMENTALHISTORYWeunderstandaperson’searliestrelationshipsbyusingattachmenttheory,whichstipulatesthataclient’sexperienceinimportantdevelopmentalrelationships,especiallywithhisprimarycareprovidersorparents,haslefthimwithasetofexpectationsbothaboutwhatwillhappenincloserelationshipsandhowbesttorespondtoothers.Thisinternalworkingmodel,developedinresponsetothousandsofinteractionswithhis

caregivers,determineshowheunderstandshimselfinrelationshiptoothers(Bowlby,1969).Onecouldcallthisacognitiveschemaaboutwhatonecanexpectfromoneselfandfromothers.Itisn’tthelabelthatisimportant;itistheideathatone’sexperienceofrelationshipsshapesone’ssubsequentexpectationsandbehaviors.

AValidatingEnvironmentMostfundamentally,achildiscriticallydependentonhiscaregivers’abilitytotakehisinnerlifeseriously—meaningthathisparentunderstandshimtobeadevelopingindividualwithamindofhisown.Ifhisparentstreathimasanindividualwithhisowndesires,hopes,opinions,intentions,preferences,ambitions,andfantasies,hewilldevelopthecapacitytoreflectonandunderstandmentalstates,andhewillseehisinnerlifeandtheinnerlivesofothersassalientandimportant.Theabilitytoreflectinthiswayiswhatismeantbythecapacitytomentalize.Theparentalqualitiesthatpromotethisdevelopment(avalidatingenvironment)notonlypromotementalizingandempathywithothers,butalsofacilitateachild’sdevelopingresiliencetoadversity,abilitytotoleratefrustrationandsuffering,andcapacitytoadapttotheneedsofthepresent(Fonagy&Bateman,2008;Lyons-Ruth&Jacobvitz,2008).Thevalidatingenvironmentprovidedbyagood-enoughparent(Winnicott,1971)providestheconditionsthatenableachildtodevelopasecurebase.Forachild,asenseofhavingasecurebasemeansbeingabletotakehisorherownphysicalandpsychologicalsafetyforgranted.Asecurebaseprovidesconfidence,fromwhichhecancomfortablyexplorehisworldindependently,confidentthathecanreturntothesafehavenofhisparent’ssolaceandprotectionwhensomethingfrightenshim(Bowlby,1969).Thereisacloseanalogyintherapy,whereatherapist’ssupportofasafeandpredictabletherapeuticenvironmentactsasasecurebasefromwhichaclientcanexplorehisinnerworld,thedynamicsofhisrelationships,andsolutionstoproblems.

QUALITIESOFAVALIDATINGPARENTALENVIRONMENT

•Primarycaregiverswho

•takeachild’sinnerlifeseriously

•understandthatachildisaseparateindividual

•are“goodenough”

•responsive,caring,andcurious,butnotperfect

•attemptto“read”achild’ssignalsandrespondappropriately

•respondtofearwithprotection

•respondtoinjurywithcomfort

•respondtoautonomywithrespect

•respondtoachievementwithpride

Foravarietyofreasons,suchastheirownexperienceswithaparent’sinaccessibilityduetodepression,poverty,deficitsinsocialsupport,substanceabuseortraumatization,somecaregiversfailtovalidatetheinnerlifeoftheirchildren.Aninvalidatingcaregivermayreject,ignore,mock,orotherwiseminimizeanddisavowachild’semotionalreactionsandinnerexperience.Inthisenvironment,achildbecomesconfusedandmistrustfulofhisownemotionsandresponsesand(likehisparent)failstodeveloptheskillsnecessarytorecognize,clarify,orcarefullydiscriminatebetweenthevariouscontentsofhisinnerworld.Lackingacomfortablecuriosityabouthisinnerlife,hispsychologicaldevelopmentsuffers.Achildwhogrowsupinsuchanenvironmentispronetofeelinginsecureandtohavinganinternalworkingmodelthatperpetuatesnegativeexpectationsofhimselfandothers.Whensuchamodelisusedtopredict,makesenseof,andrespondtothebehaviorofothersincurrentrelationships(whetherornot“referringtothemodel”isconscious),itusuallyleadstoproblems.

InfantandChildhoodAttachmentAttachmentbehaviorsarethewaysinwhichachildsignalsneedtohisparentwhenhefeelsfrightened.Childrencometodifferinthebehaviorsthattheyfavorasresponsestofearwhenparents’responsestotheirchildren’sstrategiesrewardorextinguishparticularfear-basedbehaviors.Theinternalworkingmodelguidesattachmentbehaviorsbyencodingthebestunderstandingthatisavailabletoachildaboutwhattoexpectfromhisparentandhowtorespond.Thus,whenachildwithsecureattachmentisfrightened,heshowsdistressandtriestogetclosetoaparent,basedonhisexperiencethathisparentrespondsreliablyandeffectivelytohisneedforcomfortandprotection.Theirtimeinphysicalcontactwitheachotherworks;thechildfindssolaceandisreadytoexploreagainshortlyafterthethreatisgone.Anotherchildmayhavelearnedtoactivateattachmentsignalsveryquicklywhenevenmildlydistressed.Thischildishypervigilantfortheavailabilityofothers,andhisexpressionsofneedaremoreeasilytriggeredandmoreintense.Alternatively,attachmentbehaviorsmaybecomerelativelydeactivated,withmutedexpressionsofdistressandarelativelackofinterestin,ordevaluationof,thepresenceofothers(Ainsworth,Blehar,Waters,&Wall,1978;Shaver&Mikulincer,2002).Oncereinforcedandestablishedintheinternalworkingmodel,theseattachmentbehaviorstendtopersistintoadulthoodandoftenunderliepersistentdifficultiesinrelationships,producingsufferingandinterferingwithcoping.Thisiswhythesebehaviorsareimportantfortherapiststounderstand.

Ifatherapistwantstogetabetterimpressionofthequalitiesoftheenvironmentinwhichaclientgrewupin,shecanaskaboutdevelopmentalrelationships(usingquestionslikethosefoundintheboxentitled“ExploringaClient’sDevelopmentalRelationships”)andtailorthequestionstotheindividual’scircumstances,beingcuriousabouthowparticulareventsfeltandwhattheymeanttotheclient.Ofcourse,askingaboutaclient’schildhoodrelationalenvironmentdoesnottellatherapisthisattachmentstyle—butitdoesallowherclienttosharewithherhisunderstandingofwhathewasadaptingtowhenhewasgrowingup.Thewayhetalksabouttheseexperienceswillalsogivehercluesabouthowhehasmanagedthatadaptation—Isheoverwhelmedwithemotion?Doeshedismisstheimportanceoftheseexperiences?Ishediscombobulatedandvague,orishesuccinct,clear,andthoughtful?(Hesse,2008).

EXPLORINGACLIENT’SDEVELOPMENTALRELATIONSHIPS—THEREANDTHEN

Whenyouwereupsetasachild,whatwouldyoudo?

Whatmadeyouhappyorexcitedasachild?

Howdidyourespondtobeingseparatedfromyourparents?

Howdidyoumanagewhenyoufeltrejected?

Wereyoueverfrightenedofyourparents?

Whatdidyoulikebestaboutyourmomordad(orwhoeverraisedtheclient)?

Pleasedescribeyourrelationshipwithyourmomordad(orwhoeverraised

theclient).

Pleasegivemesomeexamplesfromyourlifethatwillbringthosedescriptionstolife.

PATTERNSINACLIENT’SCURRENTRELATIONSHIPSItisalsoimportanttoreviewaclient’scurrentrelationshipstolookformaladaptivepatterns(especiallyifheisunabletoseetherecurrentpatternsortheirlinkstoearlierrelationships).Onceagain,attachmenttheorygivesusanefficientlensthroughwhichtoexamineourclients’relationships.

AdultAttachmentAdultsusetheirinternalworkingmodelofexpectationsandassumptionsaboutthemselvesinrelationtootherstorelateinwaysthatarefairlyconsistentovertime.Identifyingthesepatternsinpsychotherapystartswithobservingaclient’sexpressionsofdistress,observinghisattitudestowardclosenessandintimacy,listeningtothewaysandwordsheusesinordertospeakabouttheseissues,andthenmakinginferencesabouttheassumptionsencodedinhisinternalworkingmodel.

Secureattachmentisthepatterninwhichtheattachmentsystemworksmostsuccessfullytofacilitateflexibleandmutuallysatisfyingreciprocalrelationshipsandeffectiveaffectregulation.Importantly,secureattachmentisalsocharacterizedbyawell-developedcapacitytomentalize.Manypeoplewhoseproblemsbringthemtopsychotherapyhaveoneofthreetypesofinsecureattachment.

Preoccupiedinsecureattachmentischaracterizedbyahyperactivatedattachmentsystemwithexcessiveexpressionsofdistress,intensehelpseeking,anexpectationofpainfulrejectionorabandonment,andintenseanxietyaboutbeingalone.Itcanbeinferredthatapreoccupiedindividualhasaninternalworkingmodelbuiltonassumptionsofpersonalfragilityandunworthinessandabeliefthatotherswillrespondtothatunworthinesswithinconsistentattentionorabandonment.

Indismissinginsecureattachment,theoppositebehaviorisobserved.Feelingsofinsecurityinrelationshipsaredefendedagainstbyavoidingintimacyandmutingexpressionsofvulnerability;closerelationshipsaredevaluedandhelpisnotsought(norevenapparentlyneeded,ifonejudgesfromoutwardappearancesonly).Onecaninferaninternalworkingmodelinwhichothersarethreateninganddisappointing,andoptimalsecuritydependsonself-relianceandself-containment.

Finally,aninternalworkingmodelthatcombinesnegativeexpectationsofothers(asrejecting,frightened,frightening,shaming,ordisappointing)andoneself(asfragileorunworthy)resultsinconflictingaffectiveandinterpersonalstrategies,suchassaying“I’mfine”whileconveyingtheoppositenonverbally.Itisasthoughtheclientisreachingoutforhelpand,atthesametime,fearingthepersonwhosehelptheyareseeking.Thisirresolvabledilemmaandmixedmessagingleaveapersonstuckinanuntenablebind.

Thisstateofdisorganizedinsecureattachmentisoneofpainfulisolation,neitherfeelingokayonone’sownnorabletoseeksupportfromothers.2

ThePullofInterpersonalBehaviorAsecond,alliedmodelforunderstandingcurrentrelationshipsisrepresentedbytheinterpersonalcircumplex,articulatedbyKiesler(1996).Theinterpersonalcircumplexprovidesaframeworkforunderstandingmanyrelationalbehaviorsandproblems.Similartoattachmenttheory,thecircumplexdescribesuniversalbehaviorsthatarenottheresultofmentalillnessbutdoleadtocommoninterpersonalproblems.Thecircumplexusesdimensionsofrelationshipforcesplottedontotwoindependentaxestodescribethewaysinwhichpeopleinteract.Theinterpersonalcircumplexclarifieshowaperson’sinterpersonalbehaviorhelpsdeterminethekindofinterpersonalresponsethatheorshepullsfromanotherperson.Thismodelcomplementsthevalueofunderstandingaclient’sinternalworkingmodelbyfocusingattentiononhowhisinterpersonalbehaviorbecomesaforcethatinadvertentlyinfluencesthebehaviorofothers—settingupafamiliarsequenceofinteractions,whichmaybeproblematicenoughforustoidentifythemasmaladaptiveloops.

Theverticalaxisofthecircumplexrepresentstheroleofpowerinrelationships,withextremesofdominanceatthenorthpoleandsubmissionatthesouthpole.Thehorizontalaxisreferstotheroleofaffiliation,orhowcloseapersonlikestobewithothers.Ithastheextremesofcold,distant,orhostilebehaviorinthewestandwarm,friendly,oraffiliativebehaviorintheeast.Interpersonalbehaviorcombinesbothaxes—forexample,aclientcanbehostileandsubmissiveatthesametimeasoccursinangrywithdrawal,apatternthatlivesinthesouthwestquadrant.Alternativelyapersonmightseekaffiliationthroughsubmission,whichoccursinpreoccupiedattachmentandismappedinthesoutheastquadrant.

Ingeneral,interactionsamongpeoplefollowtworules.First,affiliationtendstopull

foramatchingresponse.Ifaclientisfriendly,othersarelikelytowanttobefriendlyback,whereasifsomebodyisdisengagedorhostile,itfeelsnaturaltootherstokeeptheirdistance.Second,powerrelationshipstendtobereciprocal,sothatwhenaclientactsinadominantway,theotherperson,perhapshistherapist,mayfeelapulltorespondwithsubmission(e.g.,tofeeldisempoweredorsilenced).Similarly,aclientwhoissubmissivetendstounintentionallyelicitdominatingresponsesfromothers,suchasexertingcontrol.3Whenthesedynamicinterpersonalpullsarerigidandextreme,theytendtoperpetuateinterpersonalproblemsinself-fulfillingmaladaptiveloops(discussedfurtherbelow).

INTERPERSONAL“PULLS”INTHECIRCUMPLEX

Attitudesandbehaviorsonthepowerdimensionusuallypullforanopposite,reciprocalresponse

•Dominanceusuallypullsforasubmissiveresponse

•Submissionusuallypullsforadominantresponse

Attitudesandbehaviorsontheaffiliationdimensionconsistentlypullforamatching,complementaryresponse

•Friendlinesspullsforafriendlyresponse

•Coldnessorhostilitypullsforacoldorhostileresponse

Thesepatternshelpatherapisttounderstandhowotherpeoplereacttoherclient.Theyalsohelpatherapisttoappreciatehowherowntendenciestobehavewithaclientlineupwiththebehaviorthathisapproachtopowerandaffiliationtendstopullfromothers.Usingthisunderstandingfromtheinterpersonalcircumplexallowsatherapisttomonitorifsheiseitherrepeatingpreviousproblematicinteractionsorprovidinganew,therapeuticexperience.Asshebecomesattentivetothesepatterns,atherapistcanchoosetointentionallyresistthepulls,forthegoodofthetherapy.Forexample,maintaininganaffiliativeresponsetoaclientwhenhisbehaviorpullsfordisengagementmayhelphimtobreakoutofthesedistancingpatternsanddiscovernewwaysofbeingclosetoothers.Thetherapist’saimshouldbetorecognizethepattern,identifythepull,andthenusethatknowledgetoavoidrepeatinganundesirableinteraction,sometimesbysimplycommentingonthepatternwithoutjudgment.Whenatherapistrespondsinwaysthatdisconfirmherclient’sexpectations,itallowsthembothtoprocesswhatishappeningwithoutblameorshame.

TheseinterpersonaldynamicscanbeobservedintheexamplesoftherapyportrayedintheDVD.JoelWalkerishostileanddominant,apresentationthatisoff-puttingandwouldtypicallypullatherapistwhoisnotattentivetothedynamicintoanunhelpfulpositionofangrydisengagement.KatherineMarksisbothdisengaged(fromthetherapistandherself)anddisempowered,whichwilltypicallypullhertherapisttowardadistancingandoverlycontrollingstance.

Oftenitisnotuntilthetherapisthasinadvertentlyreactedtothepullthatshecan

recognizewhatishappening.Thishastheadvantageforthetherapistofanexperientialunderstanding—andfromthisexperiencethetherapistcanconsiderhowshewillintentionallytrytoresisttheproblematicpullonthenextoccasionitoccursandthenhelptheclienttobegintochange.Ifthepullappearstobetypicalofinterpersonalproblematicinteractionsoutsideofthetherapyrelationship,thiscanprovideapowerfultherapeuticopportunity.Gettinghookedbytheseinterpersonalpullsandthengettingunhookedareimportantcomponentsoftherapistengagementthatwillbeaddressedfurtherbelow.

TRANSFERENCEANDCOUNTERTRANSFERENCEThethirdsourceofinformationaboutaclient’srelationshippatternsemergesduringthetherapyitself.Transferencereferstothe(sometimesunconscious)expectations,attitudes,andfeelingsthataclientdirectstowardhistherapistthatarebasedmoreonhispastexperienceswithothers(encodedintheinternalworkingmodel)thanonwhatishappeninginthepresenttherapeuticrelationship.Countertransferencereferstothecorresponding(sometimesunconscious)expectations,attitudes,andfeelingsthatatherapistexperienceswiththeclient.Countertransferencefeelingsmayincludepersonal,idiosyncraticreactionsofthetherapist’sbutoftenresultfromtheclient’sinterpersonalpullsusingtheinterpersonalcircumplexthatwedescribedabove.

TRANSFERENCE

Transferencecanbeevidentearlyintherapy.

Recognizingtransferencepatternshelpsatherapistunderstandaclient’sbasicpatternsofrelating.

Transferencehasanimpactonatherapist.Sheeitherreactstotransferencewithherowncountertransference,orsherespondswithamorethoughtfultherapeuticintervention.

Transferenceandcountertransferenceneednottakemanysessionstodevelop;theycanmanifestquickly.Recognizingatransferencepatterncanhelpatherapisttounderstandandworkwithaclient,especiallywhenatherapistincludesinthatunderstandingthereactionsthatshehastoherclient’stransference.Buthowcanonerecognizeaclient’spatternoftransferenceandone’sowncountertransference?

Onewaytotuneintoaclient’stransferenceistoobservetheemotionsandinterpersonalbehaviorsthatheexpressesmostcommonlyintherapy.Empiricalresearchsuggeststhatthesewilloftenconformtooneoffivecommonpatterns.First,theclientcanreactinasecure,engagedworkingrelationship,whichprovokeslittledifficulty.However,thepatternisusuallymorechallenging.Aclientmaymanifestapatternofbeing

predominantlyangry,anxious,avoidant,orsexualintherelationship(Bradley,Heim,&Westen,2005).Insecureattachmentisverycommonamongpeoplewhoseekpsychotherapy,andthereisaclosecorrespondencebetweensomeofthesetransferencepatternsandattachmentstyles,particularlythesecure,avoidant,andanxiouspatterns.

Countertransferencealsotendstofollowafewcommonpatterns.4Atherapistmayfeelthatshewantstogothatextramileforaclient,shemaywishthatshehadnevertakentheclienton,orshemayfeelunusuallyboredorannoyedduringtherapysessions(seethenextboxformoreexamples).Eachpatternprovidesimportantinformationabouthowherclientcanaffectothersbecausethetherapist’sreactionisoftensimilartoreactionsfromotherpeopleinherclient’slife.

COMMONPATTERNSOFEMOTIONALEXPRESSIONANDBEHAVIORTHATCANBEATTRIBUTEDTOTRANSFERENCE

•Secureandengaged

•Angryorentitled

•Anxiousandpreoccupied

•Avoidant

•Sexualized

COUNTERTRANSFERENCEISIMPORTANTINFORMATION

Yourcountertransference

•maybesimilartoresponsesbysignificantpeopleinthepatient’slife

•caninformyourunderstandingofthepatient’sinterpersonalproblems

•Recognitionofcountertransferencecanguidefurtherintervention

Thus,countertransferencemayprovideanothertypeofinformationabouttheinterpersonalinteractionsthataclientinadvertentlycreates(andthatcanleadtotheself-fulfillingprophecyofmaladaptiveloops,whichhebothdreadsandexpects).Forexample,ifatherapistisfeelingboredwithaclient,itmaywellbethatotherpeoplefeelboredwithhimaswellanddisengagefromfurtherinteraction.Others’disengagementreinforcesthisclient’slonelinessinhissufferinganddepriveshimofanopportunityforhelpfulsocialsupport.Understandingthesecluestodifficultiesandfindingaconstructive,nonblaming,empathicwayofexploringthemwithaclientcanprovideanewandpowerfullytherapeuticexperience(Betan,Heim,Zittel,&Westen,2005).

COMMONCOUNTERTRANSFERENCETHOUGHTSANDFEELINGS

Countertransferencethoughtsandfeelingsareinevitable.However,problemsariseifatherapistactsoncountertransference,withoutreflectingfirst.

Imaginehowdifferentatherapywouldbeifyouactedononeofthesecommonreactions:

•IwishIhadnevertakenthisclienton.

•Ifeeloverwhelmed.Ithinkthispersonwoulddobetterwithsomeoneelse.

•Thisclientismyfavorite.

•Iwanttodisclosemoreaboutmyselfandgotheextramileforthisperson.

•Ifeelattractedtothisclient.

•Ifeelbored,annoyed,andwatchtheclock.

•Iwanttoprotectornurturethispatient;Ifeelangryatpeopleintheirlife.

•Ifeelunappreciated,devalued,andfeeltheurgetocriticize.

GettingaDeeperUnderstandingofTransferenceDynamicsThenexttask,afterbuildinganallianceandbeingabletodescribeaclient’schiefcomplaintsandrecurrentstrugglesinrelationships,istogetadeeperunderstandingoftherelationaldifficultiesthatinterferewithhisgoals.Ausefulwaytoconceptualizetransferenceindynamictermsstartsfromthepremisethatalthoughclientsentertherapyformanyreasons—oftensimplyforreliefofsymptoms—thedynamicsoftransferencearisefromthecombinationofdreadthatoldrelationalpatternswillberepeatedalongsidethehopeforsomethingnewandbetter.Inordertoachievethelatter,aclientmustfirstremovetheobstaclestoresilienceorgrowththattypicallyresultfromdifficultearlylifeexperiences(Shedler,2010).

Inparticular,earlylifeexperiencesmayleadtotheformationofpathogenicbeliefsabouttheselfandothers—skewedexpectationsthatareencodedinaninsecureinternalworkingmodel.Thesebeliefscreateproblemssuchasself-doubt,self-loathing,distrust,fearofcloseness,feelingsofguiltandexcessiveresponsibilityforothers,shame,anddifficultieswithangerorassertiveness(Sammet,Leichsenring,Schauenburg,&Andreas,2007;Weiss,1993).Pathogenicbeliefsalsoshapeanindividual’sinterpersonalbehaviors(Shedler,2010).Thesebehaviorscanleadtoamaladaptiveloopinwhichexpectationsguideinteractions,whichcreateexperiencesthatreinforcetheexpectation—arepetitionthatispainfulanddestructive.Forinstance,apersonwhoanticipatesrejectionorshamefromothersmayprotecthimselfbywithdrawingprematurelyfrominteractions,whichincreasestheoddsofactualrejectionandconfirmsthepathogenicbeliefthatnoonewants

tobewithhim.Thissamepersonmightalsodismissthevalueoftherapy—essentiallytestingifhistherapistwillrespondintherejectingorshamingwaythathisbeliefspredict.Inpsychotherapy,weaimtomodifytheloopsothattheoutcomeismoreadaptiveandfunctional.

Pathogenicbeliefsarethefirststepinasequenceofmentalactivityandinterpersonalbehaviorsthattogethercanbeunderstoodasadescriptionoftheclient’sprimaryrelationaldifficulties.Beliefsthatareformedasclientstrytomakesenseofupsettinganddisappointingexperiencesinearlyrelationshipsguideinterpersonalbehavior.Moreaccuratelyinthecontextofpsychotherapy,old,familiar,destructivepatternsareinternalizedaspathogenicbeliefs—andleadtomisunderstandingcurrentcircumstances,andactinginawaythatleadstointerpersonalproblems(Strupp&Binder,1984).Thisisthe“loop.”Atherapistcangetasenseofthepathogenicbeliefs,andthebehavioralpatternstheycreate(andwhichwillplayoutinaclient’srelationshipsandinthetransference),byusingallthreesourcesofrelationshipdata:bytalkingaboutpastexperience(there-and-then);exploringcurrentrelationalepisodes(there-and-now);andpayingverycloseattentiontowhatgetsevokedwithinthetherapeuticencounter(here-and-now)(Luborsky,Popp,Luborsky,&Mark,1994).Forexample,aclient’spathogenicbeliefaboutbeingunworthywillinfluencehimtoexperiencehimselfasbeingnotvalued

orbeingcriticizedbythetherapist.Alternatively,aclientwiththatbeliefmayseektomasterthenegativeexpectationsbyturningthetablesonthetherapist(pushingheraway),dealingwithhisfearofshameandhumiliationbyshamingandhumiliatingthetherapist.Insuchaffectivelyloadedinteractions,itisespeciallyimportantforatherapisttopaycarefulattentiontoherowncountertransferenceand,infact,towelcomeitasusefuldataaboutwhatherclientmighthaveinhismindwhenheactswithhostility(orsubmission)towardher.

Bylookingforloopsofmisunderstandingandrepetitiveanddestructiveinterpersonalexperiences(especiallyhere-and-nowwithinthetransferenceandcountertransference),onecanunderstandaclientmoredeeply,whichinturnfostersmoreaccuratetherapistempathy.Aswewillsee,oneofthecommonwaysinwhichthetherapeuticalliancecanbestrainedorrupturediswhentreatmentinadvertentlyreconfirmstheclient’spathogenicbeliefsandreinforcesamaladaptiverelationalloop.Thatiswhentherapycanreinforcetheclient’sproblemratherthanprovidingasolution.Beingattentivetosuchloopscanhelpatherapisttosteerherclienttowardanewexperienceofrelationships.

2Thenomenclatureofadultattachmentpatternsdiffersindifferenttheoreticalmodels.Amorecompleteexplicationcanbefoundelsewhere(Maunder&Hunter,2012;Ravitz,Maunderetal.2010)alongwitharationaleforcombiningmodels.3Affiliativebehaviorveryconsistentlypullsforamatchingresponse.Responsesonthedimensionofpower,however,arenotalwaysreciprocal.Dominancethatiswarmoraffiliativeismorelikelytopullforasubmissiveresponsethandominancethatisdisengaged.Sometimesthelatterchallenge(asisillustratedbyJoelintheDVD)elicitsanequallyhostileresponse.4Wearefocusingonaspectsofcountertransferencethataredirectlyrelatedtowhatishappeningwithinthetherapeuticrelationshipandarecluestodifficultiesintheclient’sotherrelationships.However,thetherapist’spersonalityandinterpersonalsensitivities(whichexistirrespectiveoftheclientwithwhomsheisworking)canalsobeproblematic.Therapistswhotendtohavepooroutcomesshouldseekconsultationandrecognizetheirpotentialcontributions(Gabbard,1995).Collectingclientfeedbackabouttheirexperienceoftherapy,progress,andtheallianceisalsorecommended(Norcross&Wampold,2011).

5::EngagingintheProcessofTherapy

Effectivepsychotherapyisnotalwayssmoothsailing.Inevitablechallengesarisewhenatherapistlacksunderstandingorempathyorwhenshegetspulledintopositionsthatreplicatetheproblemandarenotpartofthesolution.Ideally,aneffectivetherapistfocusesonwhatishappeningbetweenherandherclientinamoment-to-momentfashion.Whileitiseasytofocusoncontent—thenarrativethatisunfolding—aneffectivetherapistknowsthatthedynamicsandprocessofthatinterchangeareevenmoreimportant.Theprocesstellsherwhatishappeningrightnow,inthemoment,notinthepast.Attendingtotheprocessstartswhensheaskstheessentialquestionofwhysomethingishappeninginthiswayatthismoment.Isshebeingexperiencedassomeonehelpful,empathic,andattuned?Oristhetherapistbeingexperiencedassomeonedismissive,rejecting,orcritical?Istherapybeingexperiencedbytheclientasenablinghimtofeelbetterovertime,ornot?Therapistscannotknowandmustnotassumetheyknowwhatisinthemindsoftheirclients,buttheycangentlyexplorethesekindsofquestionsinordertogetclientfeedbackthatimprovestheirunderstandingovertime.

Whentherapistsfeelchallengedorstressed,theirresponsescanbecomeunhelpfultothepatientandharmfultothetherapeuticrelationship.Becauseitishardtothink,beempathic,ormentalizewhenunderstress,therapistscanbecomehostile,antagonistic,defensive,orwithdrawninsteadofpausingtoreflectonamoreconstructiveresponse.Forinstance,acommonreactiontoaclientshamingoneistoreflexivelyshameback,andfewtherapistactionsaremoredamagingthanblamingordiminishingaclient(Kraus,Castonguay,Boswell,Nordberg,&Hayes,2011).Soaneffectivetherapistpaysalotofattentiontorecognizingandattendingtostrainsinthetherapeuticalliancewhentheyoccur.Becauseeverytherapyexperiencebecomesstrainedattimesandbecauseitisverylikelytooccurinthecontextofaclient’stypicalmaladaptiveinteractions,effectivetherapistsalwayskeepaneyeoutforevidenceofstrain.Isthisclientavoidingtalkingaboutarecentdifficultsession?Feelinglesshopeful?Moredemoralized?Lessmotivated?Morewithdrawn?Guarded?Doeshehavelessaccesstohisemotions?Isheavoidingormissingsessions?Hashebecomeflatteringandsubmissive?Often,ifwecaninterceptthesethreatstotheallianceearlywecanmakeverygoodtherapeuticuseofthem.Becausetheyoccurpreciselyatmomentsofinteractionthataremostemotionallyloadedforaclient,therapyislikelytotakeoneoranotherdirectionasaresultofhowatherapistdealswiththem;strainsinthealliancecanbeanopportunityforlearningandgrowth.Effectivetherapistsaresensitivetothatprocessandusetheirawarenesstopreventreinforcingaclient’stypicalmisunderstandingofothers’intentions,beliefs,andfeelings.

Tofullyengageinpsychotherapy,aneffectivetherapistneedstohavearangeofwaysinwhichsheusesherselftherapeuticallytoexpressconcernandunderstanding,andto

exploreandcommunicateabouttheprocessesthatreverberatebackandforthbetweenherselfandherclient.Sheneedstobegenuinelyinvolvedwiththetreatment—notsittingapartfromtheclient,sotospeak,butsittingwithhimanddemonstrating,bothinwhatshesaysandwhatshedoes,thatshereallymeanstobethereandwishestounderstand.Aneffectivetherapistshowsthatsheisnotgoingtoavoiddealingwithhotissuessuchasemotionallyoverwhelmingproblems,negativetransference,ortherapeuticimpassesbutthatshewillexplorethemwiththeclientinawaythatisengaged,respectful,andbearstheclient’sgoalsinmind.Mostimportantly,aneffectivetherapistdemonstratesthatshewillnotaddtotheburdenofshame,blame,orfaultthattheclientisalreadycarrying.Laterinthechapter,wediscussthetechniquesofmentalizingandmetacommunication,whichassistatherapistindealingwiththesehotissues.

TEARANDREPAIR:GETTINGHOOKEDANDGETTINGUNHOOKEDAwell-constructedandmaintainedalliancecontainsthetherapeuticprocessandkeepstheclientandtherapistengagedwithoneanotherthroughtheinevitableemotionalandrelationaloscillationsthatoccurintherapyandcreatestrain.Repairingthesestrainsiscriticaltosuccess;theiroccurrenceneednotunderminetheeffectivenessofpsychotherapy.Onthecontrary,strainsinthetherapeuticallianceareimportantopportunitiesforrecognizingtogetherwhathasgoneawryandhowitcaninformboththerapistandclientabouthowproblemsoccurinrelationshipsoutsideoftherapy.HillandKnox(2009)refertothetearandrepairofthetherapeuticrelationshiptounderscorethefactthattensions,disagreements,anddivergencewilloccurandthatthesearetherapeuticopportunities,butonlyifrecognizedassuch(Safran,Muran,&Eubanks-Carter,2011).

TEARANDREPAIR

Astrainedtherapeuticrelationshipoccurswhentensions,disagreements,divergence,andhurtfeelingsbetweentherapistandclientinterferewiththetherapeuticalliance.

Astrainedalliancecanberepairedandisanopportunityforaclientto

•Grow

•Seehimselfascapableofattainingagoodrelationship

•Experienceothersasemotionallyavailable

Inordertoturnastrainintoanopportunityforgrowthanddevelopment,atherapistneedstobecloseenoughtotheencountertofeelitsemotionalimpact,thatis,togethooked.However,shealsoneedstoretainthecapacitytoreflectandstepback,thatis,getunhooked,inordertoprovideatherapeuticresponsethatprocessestheexperiencewiththeclientratherthanenactingareactionthatconfirmsaclient’spathogenicbelief(Kiesler,1996;Leszcz&Malat,2011).Atherapistisaidedintheseinteractionsbyrecognizinghercountertransferenceandtheinterpersonalpullsevokedinherbyherclient,inaccordance

withtheinterpersonalcircumplexmodel.Beingsufficientlyengagedwiththeclientallowsonetofeelthepull(togethooked)buthavingaframeworktounderstandinterpersonalpatternsintherapyallowsonetodisengageandreflect(tounhook).Ifthetherapistisabletogenerateatherapeuticresponsethatisnovelfortheclientitmaydisconfirmhispathogenicbelief.Ofcoursethisinsightisdeepenedthroughsubsequentcommunication,jointexploration,and,mostimportantly,theexperienceofthetherapistasdifferentthanexpected.Thisexperientialconfirmationoftheclient’swishformorefulfillingrelationshipssetsafoundationforsafeexplorationandgrowthinthetherapy.

Itisnevercertaintoatherapist,inadvance,ifaparticularchoiceofwordsoractionwillbetherapeutic.Shejudgesthisfromtheclient’sfeedbackandresponse.Evidenceofbenefitisseenwhentheclientbecomesmoreemboldenedemotionally,moreself-referential,morereflective,morethoughtfulaboutwhatisgoingoninhisinnerworldandinthemindsofothers,andwhenhegainsmoreaccesstomemoriesofearlylifeeventsthathaveshapedtheoriginalpathogenicbeliefs(Weiss,1993).If,however,thetherapistbecomeshookedandsubmitstoherclient’sinterpersonalpullsinwaysthatcomplementthem,disconfirmationdoesnotoccur.Atthosetimestheclientbecomescaughtagaininhismaladaptiveloop,andherevertstohistypicalpatternsof,forexample,silence,defensiveness,oraggression.Thusonecanjudgethetherapeuticimpactofinterventionsbytheresponsestheyproduce.Whenindoubt,checkinandinquire—thisprovidesaquickopportunityforrealignmentifatherapistisnotprovidingthebenefitthatsheintends.

Gettinghookeddescribestheexperienceofatherapistbecomingdrawnintoreactingintheoldrelationalpatternsthatthepatientinadvertentlypullsfor(e.g.,ontheinterpersonalcircumplex).Thisisnotwrong;itisalmostinevitableingoodtherapiesinwhichthetherapistisreallyconnectedtotheclient.However,thetrickforaneffectivetherapististobeawarewhenthisishappeningsothatshecangetunhooked(Choi-Kain&Gunderson,2008).Unhookingrequiresthetherapisttoobserveherselfgettingunhelpfullycaughtupintheclient’srepetitiverelationalpattern,andshecanusethisasdatatoassisttheclientinbecomingmoreawareofit.Atherapistcangetunhookedbyreflectingontheprocessoftherapywiththeuseofmentalizingandmetacommunication.Althoughtheseusuallygohandinhand,wewilladdressthemoneatatime.

UNHOOKINGWITHMENTALIZINGReflectingontheprocessoftherapyisaformofmentalizing,whichisapowerfultherapeutictoolforpromotinggrowth,development,andresilience.Perhapsthemoststraightforwarddefinitionofmentalizingforourpurposesisthatitis“acapacitytoreflectonone’sownmindandthemindofothers.”Althoughmentalizingisimplicit(i.e.,unconscious)inmanyinterpersonalinteractions,ineffectivepsychotherapythetherapistmentalizesexplicitlyinordertohelptheclientovercomedeficitsinhisorherowncapacitytomentalize.

Mentalizinginvolvesappreciatingthatpeoplehavedifferentmentalstates,suchasbeliefs,desires,intentions,andemotionsthatguidetheirbehaviors.Understandingthe

presenceofthesestatesofmindinoneselfandothersclarifieswhypeoplebehaveinthewaystheydo.Anindividualwithstrongmentalizingcapacitycanappreciate,forinstance,thatsomeonewhofeelsthreatenedwillactdifferentlythanhewouldifhefeltsafe,thatwhatonewishesforwon’tnecessarilyoccurandthathowonelooksmightbedifferentfromhowonefeels.Ultimatelyonecanneverknowwhatisinanother’smind,butonecanmakeareasonableguessastohowanotherpersonisfeelingandexplorewithhimorhertoconfirmormodifytheguess.Mentalizingisaformofreflectionthatallowsustoappreciateourownandothers’intentionsasdifferentfromtheirbehaviors,andwecaninturnappreciatethenuanceofinteractions.

Mentalizingisacrucialcomponentofourmentallife,andaneffectivepsychotherapist“multitasks”aboutmentalizing.First,sheseesitasameansofunderstandingaclient’sdifficulty—appreciatingthatearlyadversityhasimpairedhiscapacitytoaccuratelymentalizeabouthisownmindandwhatisgoingoninthemindsofothers.Second,aneffectivetherapistemploysmentalizingasatherapeutictechnique,modelingreflectionbywonderingoutloudaboutherclient’smentalstate,forexample,ortheinnerlifeofapersoninananecdotetheclientrelates.Third,mentalizingisaskillaclientcanacquire,whichwillhelphimtoavoidhischaracteristicmaladaptiveloops.Whenaclientcanimprovehiscapacitytomentalize,hetakesamajorsteptowardresilienceandwell-being.Fourth,aneffectivetherapistisawareofherinnerexperiencesandpostulatesaboutherclient’sinnerexperiencesinordertoremainreflectiveandmovethetherapyforward.

UsingMentalizingtoUnderstandaClientWeearlierdescribedparentalcharacteristicsthatprovideachildwithavalidatingenvironment.Fundamentally,avalidatingparentappreciatesthetypeandintensityofachild’semotionalsignalsandisabletoconsiderpossiblereasonsforthemandconveyanexplanationofthechild’sinternalstatethatmakessensetohim,aswellasconveyingasenseofadultcontainmentormasteryofthestate.Thisprocessofreflecting,containing,andalleviatingfosterssecureattachmentandachild’scapacitytomentalize(Fonagy&Target,1997).Thesesameactivitiesofsupportandvalidationthroughreflecting,containing,andalleviatingarealsousefulforpsychotherapists,especiallywhenrespondingtoclientswhofeelinsecureinthepsychotherapeuticrelationship.

Growingupinaninvalidatingenvironmentleadsanindividualtoaninsecurepatternofattachmentanddifficultywithmentalizing.Thisdifficultycomesinseveralforms.Forexample,mentalizingcanbe“stuck”inanearlydevelopmentalphase,suchaswhenapersonassumesthattheeffectofanactisthesameasitsmotivation—“ifyoumakemeangry,itmustbebecauseyouwantedtomakemeangry.”Alternatively,mentalizingcanbechronicallydistortedbyrigidexpectationsofwhatothersarelikelytothink.Mentalizingcanevenbe“turnedoff”byachildwhen,forexample,hiscapacitytounderstandhisabusiveperpetrator’smindrevealshisabuser’shatred(orotherterrifyingintent).“Turningmentalizingoff”canbeunderstood(atleasthypothetically)asadeterminationthatitisbetternottoknowwhatothersthink,ifitistoofrighteningtobeawareoftheirthoughtsoronehasnopowertoprotestorleave(Choi-Kain&Gunderson,2008).

Aclientwithadismissingattachmentstylemayhaveexperiencedaparentwhowassopersistentlyunavailablethatthechild’sabilitytounderstandhismindwasundernourished,leadinghimtoceasetryingtounderstandhisownfeelingsandmotivationsorthoseofothers.Alternatively,aclientwithpreoccupiedattachmentmayhavefoundhisparent’smindtobeinconsistentlyavailableorattentive,whichcontributedtoamodeofmentalizingthatwasoverlyfocusedonfindingcluesaboutchangesinhisparent’smentalstate.Thischildbecameexquisitelyattentivetowhatothersmaythinkandfeel—watchingforwindowsofavailabilityandanticipatingdisappointmentorrejection.Itismerelyasubstitutionofoneterminologyforanothertosaythataninsecureadultwhomaintainsthesebiasesofperceptionandattributionhaspathogenicbeliefsabouthimselfandothers,whichputshimatadisadvantageininterpersonalrelationships.Asapsychotherapyclient,hewillrevealhisbiasedexpectationsviaproblemsinhiscurrentcloserelationshipsandbyhistransferencetothetherapist.

UsingMentalizingasaTherapeuticTechniqueTherearemanyforcesatworkinatherapeuticconversation,layeredwithinthedialogue.Whentheselayersfeelconfusing,mentalizingcaninformatherapistabouthowtoact.Forstarters,thelinkbetweensecureattachmentandeffectivementalizingisausefulguidebecauseitsuggeststhatprovidingasecuretherapeuticbaseisapreconditionfortheexplorationthatpsychotherapyrequires.Inattemptingtocreatethatsecuretherapeuticbase,aneffectivetherapistworksatbeing“goodenough”inappreciatingandattendingtoherclient’sdistress.Thisisapositionthatallowshertoacthelpfully,withoutbeingtooinhibitedbytryingtofindaperfectresponse.5Shetriestomaintainbothcuriosityaboutwhatisinherclient’smindandhumilityaboutthelimitsofherabilitytotrulyunderstandhim.Ofcourse,aneffectivetherapistalsoappliesthereflectivefunctiontoherself—mentalizingisfundamentallyinteractional,soapsychotherapistneedstoreflectonherownstateofmindaswellasherclient’sduringpsychotherapy—anattitudethatpredisposeshertoidentifyingandcatchingcountertransferencereactionsearlyandbeingabletofindthereflectivespaceinwhichtounhookfromimpasses.Aclientdevelopsasecurebasewithapsychotherapistsotheclientcanreturnandfeelsteadiedwithintheirrelationshipwhendistressedbytherapeuticexploration.Theeffectofprovidingthesefunctionsistohelpaclientdevelopmoreeffectivestrategiestoself-regulatehisdistress.

MENTALIZINGSTRATEGIES

Thinkingaboutthoughtsandfeelings

•Yourownandothers’

Helpingaclienttomentalizewellhelpshimorhertoappreciatethat

•Othershavemanydifferentbeliefs,understandings,andintentions

•Aperson’simpactisnotalwayswhatheorsheintends

•Sometimespeoplefeelonewayandactanotherway

Helpingaclienttoregulatehisemotionsmoreeffectivelyrequiresattendingtohislevelofarousal.Whenanyofusisinteractingwithanother,thereisarangeofoptimalarousal—azoneinwhichwearealert,attentive,andengagedwithoutbeingoverwhelmedorwithdrawn.Clientswholiveinstatesofinsecurity(andevenmoresoforthosewhohaveexperiencedtrauma)areoftentoohighlyaroused(thehypervigilanceandoverstimulationoffear)ortoounaroused(thenumbing,avoiding,anddissociationthatdefendagainstfear).Reflectioncannotoccureffectivelyineitherofthosestates,sothetherapistmustworkwiththeclienttohelphimtoreturntotheoptimalzoneofarousal(Ogden,Minton,&Pain,2006).Overtime,thetherapisthelpsaclienttowidenthisoptimalzoneand“makeroom”fortheextentofarousalthataccompaniesallofhisorheremotions.Effectivetherapistsaccomplishthisgoalbyusinginterpersonalstrategiessuchasprovidingsupportandvalidation,maintainingpresence,andbeingconsistent.Bymentalizingandpromotingaclient’scapacitytomentalizeitisreasonabletoexpectaclientwillreducenonmentalizingbehaviors,suchascuttingorbingingonfood,inordertoregulatehisemotions.

Oncethetherapeuticrelationshipissufficientlystable,atherapistcanemphasizeseveralmentalizingstrategies.Thesecanhelpaclientmanageemotionsmoreeffectively,gentlypromoteunderstandingofhimselfandothers,andincreasehisabilitytoconstructacoherentnarrativeabouthimself.Thisinturnhelpsaclienttohaveaclearersenseofhowhislifeandproblemshaveevolved,agreaterempathytowardhimselfandothers,anenhancedabilitytofunctioninhiscurrentcircumstances,andthecapacitytoexpresshimselfeffectively.

Twousefulmentalizingstrategiesaremodelingandcontrarymoves.Atherapistmodelsmentalizingbyadoptinga“notknowing”therapeuticstance,exhibitingcuriosityaboutherclient’sinnerworld(andherown)bylabelingaffectandbycommunicatingaboutinternalstatessuchasemotions,wishes,andvulnerabilities.Modelingbringsmentalizingaliveinthehere-and-now.Itisoftenhelpfultowonderaloudaboutintentions—eitherthoseoftheclientorofanotherpersonwithwhomhehasinteracted.Questionssuchas“Whatdoyouthinkhewastryingtodo?”or“Icanseethatmadeyouangry,butwhydoyouthinkitdid?”requestamentalizingresponse.Whatdidthatotherpersonhaveinmind?Wastheirobjectiveorimaginedintentequivalenttotheoutcome?

Acontrarymoveisaninvitationtoaclienttomovehisattentionbetweendifferingperspectivesoraspectsofexperience.Onecanaskquestionsintendedtomoveaclient’sattentionbetweenthoughtsandfeelings,betweenthinkingaboutoneselfandthinkingaboutothers,betweenafocusonaninternalversusanexternalperspective,orfromastanceofcertaintytooneofgreaterdoubt.Forinstance,aclientmaybecaughtinnonreflectiveruminationthatisfocusedonanoverlyintellectualanalysisofaninteraction.Thecontrarymoveistoencouragetheclienttolookatthesameissuefromtheperspectiveoftheemotionsofthepeopleinvolved.Similarly,iftheclientisfocusingonlyonhimself,onecanencouragehimtoconsidertheperspectiveofanotherperson.

MENTALIZINGTECHNIQUES

Modelmentalizingofself

•Communicationofmentalstates

•Reflectiononmentalstates

•Wonderingaboutintentions

Usea“not-knowing”stance

Usecontrarymoves

Collaborateincreatingacoherentnarrative

Thetimingofatherapist’srequesttoherclienttoseeaninteractionfromtheother’spointofviewisimportant,anditisbestutilizedwhencombinedwithempathywithinatherapeuticalliance.Ifperspective-takingquestionsareaskedtooearlyon,aclientmaythinkthetherapistisnotawareofhisdifficultiesoristakingthesideoftheother.Thisislikelytoreinforceaclient’spathogenicbelief.

CASEEXAMPLE:HELPINGACLIENTTOMENTALIZE

Bypracticingandmodelingmentalizing,atherapisthelpsaclienttoacquirethiscapacityforhimself.Whenaneffectivetherapistthinksoutloud,forexample,sheinvitesherclienttodothesameforhimself.Itisalsohelpfultoacknowledgewhenitisapparentthataclientismentalizing,ortopausetheprocessandrewindwhenheisnot.

Aclientwhosecapacitytomentalizehadincreasedoveracourseofpsychotherapywasdescribinganexperienceinacoherentmanner.Hisnarrativehadacleartimeline,hecommunicatedhowhefelteffectively,andhecommunicatedhisunderstandingoftheotherpeopleintheseencounters.Whenheshiftedtodescribeaninteractionwithhisbrother,however,hisnarrativebecameincoherent.Henolongerusedcompletesentences,losteyecontactwiththetherapist,andbegantotalkaboutdetailsthatwerebesidethepoint.Ratherthanfocusingonthecontentofthedisputebetweensiblingshewasdescribing,histherapistchosetoidentifyforhimthechangeinhisstateofmindandmodeofcommunicationthatshehadobserved.Sheconveyedthatshefelt“lost”inthemoment,andsheaskedhimto“rewind”towhenhestoppedbeingcoherent.Shenotedthathehadlosttrackofhisthoughtswhenshewastalkingaboutrelationshipsthatcarriedalotofbaggageforhim.Thissimpleobservationbroughthimbacktothehere-and-nowofthetherapy.Inresponse,theclientdescribedtheextentoftheunderlyinganxietythatheexperiencedwhenspeakingabouthisbrother.Thisreturntomentalizingabouthimselfallowedhimtoexperiencehisincoherenceasalapse(duetothefamilialtensionsthatwerestillabletodiscombobulatehim)ratherthanasalackofprogress.Thetherapistcongratulatedhimforhissuccessindealingwithnonfamilyissues,andsheidentifiedthe

challengesthatremainedwithinthefamily.Thetherapeuticconversationthenmovedontoreflectontensionswithhisolderbrother.Mentalizingenabledhimtorestorehisabilitytothinkclearlyandhebegantospontaneouslygenerateideasforwaystoapproachananticipatedfutureinteraction.

RemainingReflectiveIfthereareaspectsofherownlife,betheyhistoricalorcurrent,whichareactivatedbyaclient,theresultingcountertransferencecanderailthetherapyunlessshereflectsuponthesethings.Amentalizingperspectivecanbeprofoundlyusefulforclarifyingavagueandunsettlingcountertransference.Questionsinformedbymentalizingcangoalongwaytowardexplicatingwhyatherapistfeelsacertainwaywithacertainclient.Forexample,atherapistmaywonder“WhydoIfeelthisparticularkindofdiscomfortwiththisclient?,”“Whodoesthisclientseemeas?,”“WhodoesthisclientthinkIseethemas?,“Whodoesthisclientremindmeof?,”or“Whatdoesthisclientthinkmyintentionwas?”Anotherbarriertolearningaboutaclient’swishesandintentoccurswhenatherapistimposes(ofteninadvertently)anassumedgoalonthepsychotherapy—suchaswantingherclient(orassumingthatherclientwants)tostaymarriedortoregainemployment.

Finally,atherapist’sabilitytomentalizecanbechallengedwhenaclient’sinternalworkingmodelprescribesasetofexpectationsaboutothersandhowheshouldbehaveinrelationships.Adismissingindividual,forinstance,mayassumethatotherswillbeunavailableandthereforeacttoincreaseinterpersonaldistance.Ifatherapistdoesnotreflect,shemayinadvertently“accepttheinvitation”andworkwiththisclientinanemotionallydisengagedanalysisofproblems.Suchanapproachwouldservetoreinforcethemaladaptivelooptowhichitgivesrise,ratherthanchallengeit,andwouldnothelptheclienttochange.Similarly,apreoccupiedclientwhosignalshisattachmentneedsexcessivelymaypullhistherapistinto“crisismode,”leadingtoaffectivelyoverchargedinteractionsandafailuretomaintainappropriateboundaries.Withoutreflection,atherapistslipsintore-engagingwithamaladaptiveloop,ratherthanprovidingatherapeuticallydisconfirminginteraction—andshebecomespartofareenactmentoftheprobleminsteadofbeingpartofatherapeuticprocessthatpromotesthediscoveryofsolutions.

UNHOOKINGWITHMETACOMMUNICATION:TURNINGIMPASSETOOPPORTUNITYOnewaytoturnanimpasseintoatherapeuticopportunityistocollaborativelyreflectonwhathastranspired.Thisallowsatherapistandclienttothinktogetherandtrytounderstandwhythisishappeninginthiswayatthispointintime.Assumingwecannotforcertainknowwhatisinthemindoftheclient,thisisanimportantquestionforthetherapisttofirstaskherself.Inposingthisquestiontoherself,atherapistcreatesreflectivespace,whichreducesherreactivityandallowshertothinkaboutthepotentialmeaningandimpactofthisexperience.Ofcourse,aneffectivetherapistdoesnotstopatposingthis

questiontoherselfandreflectingonitsanswer;shealsofindstherightwayandmomentinwhichtoenlisttheclientinthereflection.Sheseekstofindpalatablewaysofdiscussingunpalatablethings.Astherapists,wemustbeabletospeakaboutwhatwethinkisrelevant,inwaysthatareasnoninjuriousaspossible,thataretimedwell,andthatallowustoalignourimpactandourtherapeuticintent(Yalom&Leszcz,2005).

METACOMMUNICATION

Judicioustherapisttransparencyor“thinkingoutloud”

•Blendsassertivenesswithtentativeness

Collaborativereflectiononwhathasjusttranspired

•Whyisthishappeninginthiswayrightnow?

Effectivemeta-communication

•Isusedtofurtheratherapeuticgoal

•Isrelevantandwelltimed

•Isnoninjurious,validating,andilluminating

•Hasanimpactontheclientthatalignswiththerapeuticintent

Metacommunicationiscommunicatingaboutcommunication(Kiesler,1996;Safranetal.,2011;Wachtel,2011).Thetherapist’scapacitytoemploymetacommunicationtoworkwithmomentsoftensioninthetherapeuticallianceisattheheartofeffectivetherapeuticwork.Itallowshertocapitalizeonstrainsintheallianceandpreventsimpassesandstalematesfrombecomingentrenched.Atherapistemploysmetacommunicationatthesepointsbecausesheismindfulthatimpassesintherapyoftenoccurwhenaninteractionisreinforcingapathogenicbeliefratherthandisconfirmingit.Metacommunicationmayinvolvejudicioustherapisttransparencyor“thinkingoutloud,”aswhenthetherapistselectivelysharesherownemotionalreactiontoachargedtherapeuticmomentinordertoopenexplorationandfosterreflection.Whenshedoesthis,sheismindfulnottoassumethatsheknowswhythetensionsoremotionsareemergingorwhatmightbeinherclient’smind.Insteadsheassumesverylittle,adoptingamannerthatisbothstraightforwardandtentative.Duringthisprocess,itisimportantthatatherapistremainfocusedonvalidatingratherthanblamingherclient.Astherapistsgainmoreexperiencetheybecomemorecomfortablewithjudiciousself-disclosure(e.g.,transparentcommunicationaboutwhatisoccurringinthehere-and-nowofthetherapeuticinteractions)andrecognizethatitispossibletodeepentheirconnectionwithclientswithoutfallingdowntheslipperyslopeofboundaryviolationsandheightenedclientdependence.Thisskillisattheheartofmaximizingone’suseofselfasatherapeutictool.

CASEEXAMPLES:MENTALIZINGANDGETTINGUNHOOKEDWITHMETACOMMUNICATIONANDJUDICIOUSSELF-DISCLOSURE

InDr.Pain’sinteractioninthefirstroleplaywithKatherineMarks(seeDVD),thetherapistdirectlyaddressesherobservationofachangeinthequalityofherinteractionwithherclient.

Dr.Pain:I’mgettingafeelingthat,aswe’vebeentalking,insteadoffindingawaytotalktoeachotheraboutthethingsthatpuzzleyou,oryou’dliketoexplore,theoppositeishappening.IfeellikeI’minadvertentlysortofchasingyououtoftheroom.Thatsomehow,whatbeganasaverytentativecuriosityisnowmovingtowardfeelinglessengagedhere.Howhaveyoufeltinthelastwhilesincewebeganthissession?

Inthiscommentthetherapistdrawsonherexperienceofcountertransferencewhensheuseshersenseoffeelinglessengagedasdata.Shementalizesaboutherownshiftfromcuriositytodisengagement,andsheasksKatherinetoreflectonherownexperienceinthehere-and-now.RevealingherownexperienceandalsoaskingKatherinetoreflectfostermentalizing.Atthesametime,Dr.Painacceptsresponsibilityfortheroleshemayinadvertentlyhaveplayedinthisshift.Byputtingherfeelingintowords,Dr.PainusesmetacommunicationtoexplorethefluctuatingpullsofengagementbetweenKatherineandher.

Katherine:Whatever,whateverhappenshereisnotgoingtomakeanydifference.That’ssortofhowitfeelstomebecauseIcan’tbe,Ican’tbehelped.Ijust,youknow,it’sallfine,it’sallgood,Ijustcan’tbehelped.

Katherine’sresponseistorevealapathogenicbeliefthatshecannotbehelped,whichmayunderlieherdistancingandsubmissivestance.Katherine’sexpressionofthisbeliefprovidesanopportunitytounderstandherexperienceandtoavoidthemaladaptiveloopthatwouldoccurifthetherapistbecamelessengagedandthusreinforcedKatherine’sexpectation.

InDr.Leszcz’sinteractionduringthefirstroleplaywithJoelWalker(seeDVD),heexperiencestensioninthetherapeuticalliancewhenJoelbecomesactivatedinanangry,dismissivestate.

Joel(interrupting):I’mnotsomewackocreep,right,youknow,that’snot,there’snothinglikethatgoingon,okay?There’snothinguntowardhappeninginmyfamilyhome,okay?Let’smakethatabsolutelyclear.

Dr.Leszczchoosestoprocessthistensioninthehere-and-nowofthetherapeuticrelationship,askingtheclienttomentalizewhatmaybeinDr.Leszcz’smind.

Dr.Leszcz:Doyouthinkthat’swhatI’mthinking?

Joel:Idon’tknowwhatyou’rethinking.ButI’mnot,I’mnotgonnaletyouaskthatquestion.Okay,just,endofstory.

Dr.Leszcz:IcantellyouwhatI’mthinking.

Dr.Leszczproceedswithtentativeandjudiciousself-disclosure.Hetriesto

resistthehostilepullofJoel’sconfrontationtoprovideanexperiencethatdisconfirmsJoel’sfearofbeingjudgedandcriticized.HementalizeswithJoelbyempathicallyconveyinghispreliminaryunderstandingofwhatmaybeinJoel’smind.

Dr.Leszcz:I’mthinkingthatyou’reprettyangry,prettythreatened,prettyunhappy,andsofarexperiencingmeaspartoftheproblemandthat,thatmaybe….I’dstillliketoseewhatelseisgoingonsoIcanseeifIcannotbepartoftheproblem.

5Thismayaccountforwhytherapistswhoareveryself-criticalareoftenlesseffective—theydemandtoomuchfromthemselvesandtheirinevitabledisappointmentcontaminatesthetherapeuticrelationship(Henry,Strupp,Butler,Schacht,&Binder,1993).

6::TakingAccountofTrauma

Traumaticexperiencesinchildhoodorlaterlifeareextremelycommonamongpeoplewhoseekpsychotherapy.Asaresult,effectivepsychotherapistsmusttaketraumaintoaccount,andtheyuseideasandtechniquesthatassistclientstosettleandresolvesymptomsarisingfromunresolvedpasttraumaticexperiences.Katharine’sDVDsectionscapturesomeoftheideasthatunderpinourapproachtoassistintheresolutionoftraumaticexperiences,andtheseportionsoftheDVDcanbeviewedwhilereadingthissection.

Traumaisubiquitousandisespeciallycommonamongpeopletreatedformentalhealthproblems(e.g.,seeFriedmanetal.,2002;Neria,Bromet,Sievers,Lavelle,&Fochtmann,2002;Saxeetal.,1993).Becausetheseindividualsareusuallydiagnosedwithdisordersotherthanposttraumaticstressdisorder(PTSD),theroleofatraumaticpastandhowitcontinuestoaffectthepresentoftengolargelyunrecognizedbytheseclientsandtheirtherapists.Thisoversightandthereasonsforitarecentraltoanunderstandingofthecomplexityoftrauma.

Aclient’sfailuretorecognizeanassociationbetweenpasttraumaticeventsandcurrentsymptomsandproblemscanbeunderstoodtobetheresultofpsychologicaldefenses.Thepresentemotionaldistressis“unlinked”fromitscausesasawaytoavoidandtrytomanagewhatisoftenaverydysregulatedemotionallifecreatedbythepasttrauma.Althoughthisdisconnectionbetweenthememoryoftraumaandcurrentsymptomsandproblemsisinsomewaysaneffectivedefense,itnonethelessbecomespartoftheproblemofunresolvedtrauma—yetanotherexampleofapatterncreatedbyaclienttohelpthemwithdistress,whichturnsouttobemaladaptive.

Fortherapists,theroleoftraumaisoftenunderrecognizedindisordersotherthanPTSD.IfaclientdoesnothaveclearPTSDsymptoms,therapistsmayassumethatpasttraumasarenotactivelycontributingtotheclient’scurrentdistress.However,PTSDisactuallyanunusualoutcomeofpsychologicaltrauma.Inanurban,nonclinicalpopulation,Kesslerandcolleagues(1995)foundthatwhereas60%ofpeoplehadexperiencedalife-threateningevent,theprevalenceofPTSDwasonly5%to10%.Therefore,mostpeople’sdistressfollowingatraumaticexperiencesettlesdownwithinafewweeksandtheyregainorretaintheirusualabilitytofunction.Forthosewhosesymptomsdonotresolve,depressionisamorecommonconsequenceoftraumathanPTSD(Galeaetal.,2002).

Theessenceofatraumaticeventisthatitprovokesaprofoundlyaversivestateoffearorterror.Thesestatesarediscerniblebytheirconsequences:excessivearousal,intrusivememories,andavoidanceofremindersandmemories.Ifthesesymptomsfailtoresolve,othersymptomsmayariseandbecomemoreprominent.Theseincludelow-grade,chronicdepression,oftencombinedwithperiodsofgeneralizedanxiety,panic,oranger.

Furthermore,traumatizedindividualsoftenrespondtothesubstantialemotionaldysregulationthattheyexperiencewithbehavioralmeasuresintendedtoreducetheintensityoftheiremotions,suchasdrugandalcoholuse,self-injury,andotherhigh-riskbehaviors.Suchclientsoftenalsohavemedicallyunexplainedsymptoms,amnesias,dissociativeexperiences,animpoverishedrelationallife,andadeeplynegativeself-image.Thisbroadrangeofchronicsymptoms,deficits,andimpairedfunctiondisguisesthelinkbetweentheeventsthatgeneratedthefearandaclient’sreactiontothem.

BEINGATTUNEDTOTRAUMA

Traumaisprofoundlyaversiveandleadsto

•Excessivearousal,intrusivememories,andavoidance

•Depression,anxiety,andanger

•Problemsregulatingfeelings

•Medicalsymptoms

•Memorygapsanddissociation

•Relationshipproblems

Furthercomplicatingmatters,thefactthatatherapistdoesnotrecognizetherolethatunderlyingtraumaisplayinginherclient’sproblemsisusuallyalignedwiththewaysthattheclientdefendshimselfagainstthinkingabouthispast.Anindividualinthisstateisnotinaposition(yet)toconsiderthebenefitsofreflectingonandintegratinghisexperienceoftraumaintoanarrativeorautobiographicalaccountofhislife—hecannotyetmentalizeabouthisexperience.

Ofcourse,notallclientswithmixed,chronicpsychiatricsymptomshaveexperiencedtrauma.However,becausetheprevalenceoftraumaticexperienceissohighamongpeoplewithmentalillness,traumasymptomsoftenco-occuralongsidevirtuallyallothermentalhealthdisorders.Itiseasytooverlooktraumasymptoms,forinstance,inaclientwithadisease,suchasschizophrenia,thatisveryclearlynottheconsequenceoftrauma.

AstherapistsweneedtoguardagainsteitherassumingthateveryonewhoexperiencestraumawilldevelopPTSD,orfailingtoconsiderthepotentialroleoftraumawhenconfrontedwithaclientwhohasacomplexgroupofsymptomsandproblems.Inthisway,wecanavoidbecomingunwittingco-conspirators,whohelpclientshidefromtheirterrifyingpastsandallowtheirunsuccessfulanddysfunctionalavoidantadaptationstocontinue.Insuchasituation,effectivetherapyencouragesboththetherapistandclienttoconsideridentifyingandexploringtherelationshipbetweenthepastandtheproblemsofthepresent,withtheassumptionthatfindingawaytousefullyaddressaclient’sunresolvedexperienceswillreducehissufferingandimprovehiscurrentandfuturequalityoflife.

PATHSTOUNRESOLVEDTRAUMA

Whydosomepeoplefailtorecoverfromtraumaticexperiences?Whydotheyremaindistressed,losefunction,anddeveloppsychiatricdisorders?Therearetwoproposedroutestochronic,unresolvedtraumaticsymptoms.Thefirstrouteisthatpreviouslywell-adjustedadultsmaynotbeabletoresolvethecumulativeimpactofmultipletraumaticexperiences,asisseeninmembersofthemilitarywhoaredeployedtoofrequently(Klineetal.,2010).Thecombinationofrecurrentexposure,alackofsupport,andinadequatetimetorecovercaneventuallyoverwhelmanindividual’sresilienceandproducesymptomsanddysfunction.Thesecondrouteisfoundintraumasurvivorswhohavehadaninvalidatingchildhood(Linehan,1993).Ofnote,mostclientswhoarechronicallysymptomaticaftertraumahaveexperiencedmanytraumaeventsaswellasachildhoodinachronicallyinvalidatingenvironment.

Achildraisedinaninvalidatingenvironmentisill-preparedforsubsequenttraumaticexperiences.Theinvalidationmeansthathehashadlittlepracticeatknowinghisownstrongemotionsandrespondingtothemwithcompassion.Whensuchapersonisexposedtoaterrifyingevent,heisunabletounderstandortoleratehisresponseandbecomessymptomatic.Similarly,heisnotabletoaccuratelyidentifyothers’emotionalcommunications,whichmakesitconsiderablymoredifficulttorecognizeoracceptcompassionandassistancefromothers.Furthermore,ifthetraumaoccurredwithinhishomewithcaregiverswhowerefrightening,frightened,orwereunableorunavailabletooffersolaceandprotection,thetraumaticexperiencesbecomeinextricablyjoinedtotheexperienceofinvalidation.6

ASKINGABOUTTRAUMAThefirstwayoftakingtraumaintoaccountwithanewclientistoaskabouttraumaticeventsinhislife.Thisshouldusuallybedoneduringtheinitialassessmentbutcanalsobedonelaterintreatment.Askinggentlyandappropriatelyaboutadultorchildhoodexperiencesthatwerefrighteningisusuallyagoodplacetobegin,regardlessofaperson’sdiagnosisorsymptoms.

ASKINGABOUTTRAUMA

Askinggentlyandappropriatelyismoreamatteroftoneandtimingthanofchoosingperfectwords;uselanguagethatisfamiliarandcomfortabletoyourclient.

Samplequestions:

•Hasanythinghappenedtoyouthatfrightenedyouagreatdeal?

•Doyouthinkyouhavegottenoverit?

•Hasanyonephysicallyorsexuallyhurtyouasanadult?Asachild?

•Idon’twanttodistressyouwiththesequestionsbutIthinkthatitmighthelpustofigureoutwhatyou’resufferingwithrightnow.Doyouagree?

Iftheclientisbecomingoverwhelmed,slowdowntheprocess:

•Switchfromenquirytoempathicvalidation,or

•Acknowledgethetimeisnotrightandchangethesubject

Sometimesaclientbecomeslesscoherentwhenhespeaksoftraumaticevents,reportingtheseeventswithoutanyemotionalcolororseemingtobetoooverwhelmedwithemotiontoarticulatetheirexperience.Asaclientattemptstodescribeatraumaticexperiencethesyntaxofhislanguagemaychangetobecomelessclear,suchthathenolongerusesorderlyconnectedsentences,forinstance(seethecaseexample“HelpingaClienttoMentalize”).Thisincoherenceisahintthattraumaticmemoriesarenotyetadequatelyincorporatedwithinhisautobiographicalnarrative.

UNDERSTANDINGTRAUMATICEXPERIENCESANDPROMOTINGACCEPTANCEANDINTEGRATIONHearingthefactsofthetraumaticeventdoesnot,initself,tellatherapistwhatisdisturbingherclient.Indeed,hearingtheclientreporthistraumaticexperiencescandistanceatherapistbecauseofherownreactiontoit.Forexample,especiallyattimesofemotionalintensity,itiseasyforatherapisttofallintothetrapofassumingthatsheknowsorfeelsthesameastheclient,effectivelysubstitutingherownreactionforherclient’s.Althoughunderstandable,whenthisoccurstheclient’sownexperienceandanycluestothemeaningthetraumahadforhimbecomelost.Toavoidthis,thetherapistneedstokeeptheclientcentrallyinherattention;itistheclient’sexperiencethatmustremainthetherapist’sfocus.Inthiswayhereffortstomentalizeabouttheclient’sexperiencewillfacilitateusefulunderstandingabouttheaspectsoftheeventsthatweretoofrighteningordifficultfortheclienttoresolve.Understandingtheeventwithintheindividual’suniquepersonalhistoryhintsatthemeaningthatitholdsforhimandwhyhehasnotresolvedtheexperienceandrecovered.Aneffectivetherapistnotesherownreactionstoaclient’straumastory(hercountertransference)butholdstheminmindasuseful,potentialinsightsintothepatient’sexperience—distinctfromherclient’sexperienceandthemeaningheattributestoit.

ASSESSINGIFTRAUMAISRESOLVED

Isthepastdisturbingexperiencefrequentlyontheclient’smind?

Whomhastheclienttoldabouttheevents?

Whatisitliketellingyounow?

Howmuchhastheclientintergratedtraumaticmemoriesintohisorherlifestory?

Isthelanguagethataclientusestodescribethetroublingeventsasymbolic,linguisticdescriptionthattakesitsaudienceintoaccount?

Inassessingtraumaticexperiences,aneffectivetherapistaskstheclientifthepastdisturbingexperiencefeelsrelativelyresolvedorwhetheritisonhismindalotofthe

time,and,ifso,howmuchofthetime.Whomhashetoldabouttheeventsandwhatisitliketellingthetherapistnow?Atherapistobserveshowmuchtheclienthasintegratedhispastintothestoryhetellsabouthislife.Shenoticesthefluencyorlackofitthataclientusestodescribethetroublingevents:isitasymbolic,linguisticallysophisticateddescriptionthattakesitsaudienceintoaccount?Forexample,canhetellhistherapistoneaccountofhissexualassault,hisfamilydoctoranotherequallytrueaccount,andhisnewromanticpartneranother—eachtailoredtothespecificrelationshipsinvolved?Tobeabletoadaptanarrativeabouttraumatodifferentcircumstancesandlistenerswhilemaintainingitsaccuracyisastrongindicatorofasuccessfulpsychologicalresolutionofthememories(andagoodcapacitytomentalize).Oristhestoryonlyaccessiblewhentriggeredbyambientremindersthatleavetheclientstrugglingwithapastexperiencethatseemstosuddenlyhappenagainasthoughforthefirsttime,experiencednotaslanguagebutwiththesenses?Thelattersituationindicatesthatthetraumaisunresolved.

Allenstatesthattheaimofhelpingaclientresolvehispastisto“makesense”ofit,tohavethecapacitytoreflectuponthepastwithinthesafetyofthetherapeuticallianceandtodevelopacompassionateattitudetowardhimself(Allen,2013).ContrarytoformalguidelinesforthetreatmentofPTSD,whichrecommendthataclientbe“desensitized”tohisorhertrauma(Foa,Keane,Friedman,&Cohen,2014),wesuggesta“softer”goal—topromoteacceptanceandintegrationofthetraumaticexperiencesintoaclient’slife.Indeed,foraclientwithacomplexmultisymptompresentation,desensitizationisnotappropriateorhelpfuluntilsubstantialstabilityhasbeenachieved(Herman,1992).

WorkingtoRecognizeandResolvetheExperienceofBetrayalWhenItIsExperiencedinTherapyOneofthereasonsforattendingspecificallytounresolvedtraumaticexperienceisthatclientswhohavesufferedbothtraumaandinvalidatingchildhoodenvironmentsconsistentlyhavedifficultyformingatrustingrelationshipwithothers,includingatherapist.Tounderstandthis,considertheenvironmentinwhichsuchexperiencesoccur.Overwhelminglyfrighteningexperiencesarenotnecessarilypsychologicallytoxic—unlessthevictimsarealsoabandonedintheprocess(orafterward)bythepeopleintheirliveswhomtheycountonforprotectionandsecurity.Thetherapistinadvertentlyandunconsciouslyremindstheclientofthepersonwhoshouldhavehelpedhimduringorafterhistraumaticexperience,butdidn’t.Consciousorunconsciousmemoriesofthisbetrayalemergewhentheclienttalksorthinksaboutthetraumaintherapy.Foraclientinthissituationthecombinationoftraumaandbetrayalisexperiencedasbeingindivisible.Ratherthanrecognizingthathisparents,caregivers,orotherlovedadultsfailedhim,aclientinthissituationhasdevelopedthepowerfulhabitofblaminghimself.Hisemotionsoffearorterrorhavebeenreplacedbyhelplessnessandshame,self-blame,self-hatred,andmistrust.Whenthispotentcombinationemergesinthetherapeuticrelationship(intransferenceandcountertransference),itprovidesboththerapistandclientwiththeopportunitytounderstandtogetherwhattheclientneededtorecoverbutlacked.

Aslongasatraumaticeventisonlyknowableasasensoryexperience—aphysicalre-

livingtriggeredbycurrentevents—aclientremainsvulnerabletobeing“hijacked”andcognitivelydisorganizedbyhispast.Forsuchaclient,inordertochangethecriticalandderogatoryself-judgmentthatpreventshimfromthinkingcompassionatelyabouthisownpast,heneedstheexperienceofaninterestedandnoncoerciveclinicianwhoiscapableofforming,andmaintaining,atherapeuticrelationship:adjustingherparticipationintherelationshipmomentbymomenttomodulatehislevelofarousal;tosupportgoodjudgment;andtomodelmentalizingbyhelpingtoexploreanddifferentiatethoughts,emotions,andsomaticexperiences.Inthisway,aneffectivetherapisthelpsherclienttolinkemotionswithcausesandtodistinguishresponsesfrompresenteventsfromreactionstothepast.

6Felittiandcolleagues(1998)havedemonstratedthatadultswhowereexposedtodifferenttypesofchildhoodadversity(includingphysicaltrauma,sexualtrauma,neglect,livingwithafamilymemberwithmentalillnessoraddictions,andotherformsofadversity)areatagreaterriskformentalhealthproblemsaswellashavinghigherphysicalmorbidityandmortality.Forexample,aboyexposedtosixormoretypesofadversityhasa46-foldgreaterlikelihoodoflaterbecominganinjectiondruguserthanaboywhoisnotexposedtothesetypesofadversity.Needlesstosay,exposuretochildhoodadversityisalsolinkedtodeficitsinmentalizinganddifficultyusingrelationshipseffectivelytoregulatestrongemotions.

7::FinalThoughts

Whichfactorsdistinguishmoreeffectivefromlesseffectivetherapists(Norcross,2011;VanWagoner,Gelso,Hayes,&Diemer,1991)?Theevidencetellsusthateffectivetherapistsmaintainagoodrelationalpresence.Theymanifestwarmthandanauthenticinterestintheirclients.Theyhavecapacityforreflectionandtheyrefrainfromreactingautomatically.Whentheygethookedintonegativecountertransferentialresponses,theycanusethemasanopportunitytostepbackandreflectonthemaladaptiveloopthatistemporarilybeingreinforcedorrepeatedwithinthecontextoftreatment.Theyseethenegativeexperiencetheyhavewithaclientasanopportunityforrepair—anopportunitythattheyseektocapitalizeonthroughmentalizingandmetacommunication.Effectivetherapistsemphasizetheadaptivenatureoftheirclients’effortsratherthanfindingfault,blaming,orshaming.Theyfindtherightbalancebetweenaffiliationandcontrol,avoidingtheunproductiveextremesofovercontrolanddisengagement.Effectivetherapistsalsokeepinmindthattraumaisendemicandthatitsimpactcanmanifestinemotionaldysregulationandrelationshipproblems.Theyareabletokeepthetraumaperspectiveinmindastheyworkwiththeclient’sdeclaredchiefcomplaint.Importantly,therapistswhoareeffectivearemindfulofthepowerimbalanceintreatmentandthewayinwhichjudgmentandhostilitycanbeexperienced,evenifunintended.

Atherapist’spersonalcharacteristicsalsohaveaneffect.Therapistswithanxiousattachmentstylesareoftentooeagertowintheirclients’endorsementtomaintainobjectivityandmayhavedifficultyendingtherapy.Aperfectionisttherapist’snegativeself-assessmentcanleadhertobetoodemandingofherself.Inturnthiscanspilloverintothetreatment,imbuingitwithasenseofharshjudgment.Anobsessivetherapist’sinflexibleadherencetoatreatmentmodeloftenleadshertooverlookthinkingaboutprocess,orbeingabletorevisetherapeuticresponsivenesswithaless“adherenttothemodel”butamoreresponsivealternativeapproach(Castonguay,Boswell,Constantino,Goldfried,&Hill,2010;Krausetal.,2011).

Effectivetherapistsdonotassumethattheirtherapeuticintentionautomaticallypredictstheeffectontheclient,butratherwillinquirehowtheclientisexperiencingwhatishappeningintherapy(Hill&Knox,2009).Thisisasimportantinprocessingnegativeexperiencesasitisinprocessingpositiveexperiences.Weoftenneglecttheimportanceofprocessingthepositiveandcelebratoryelementsoftherapy,whichcanbeofgreatvalueindistinguishingpastfrompresent.Itispreciselythisjointsharedexplorationthatconsolidateslearningandtherapeuticgainsandprovidestheexperientialdisconfirmationofnegativeexpectationsthatclientsoftenneedfortherapytowork.

Finally,effectivetherapistsaremindfuloftheirfiduciaryresponsibilitieswithregardtoboundaries.Theyrecognizethatsituationsinwhichtheyplacetheirneedsaheadoftheir

clientsareneveracceptable.

Atherapistcanbehighlyeffective—regardlessofthespecificmodalityofpsychotherapythatsheuses—byattendingtoprocessandusingthetherapeuticrelationshipasameansofprovidingherclientwithexperiencesthatinterruptthemaladaptiveinterpersonalcyclesthathehasbroughtintotherapy.Bydoingthis,aspectsoftraumaticexperiencesareintegratedandtheclientcandevelopandbecomemoreresilientwhilecreatinganewrelationalmatrix.

Althoughnotwocoursesofeffectivetherapyareexactlythesame,andeverysessionpresentstherapeuticchoicesinwhichthereisnoobviousrightorwrongcourse,aneffectivetherapistcannonethelessbeguidedbyevidence-basedprinciples.Inthisbookwedescribedasequencethatservesasaguide(althoughnotarecipe)foreffectivepsychotherapyinalmostanymodalityandthatpromotestherapeuticbehaviorassociatedwithbeinganeffective,evidence-basedtherapist.

Inparticularwehaveemphasizedtheprocessesinvolvedinturningtherapeuticmomentsofimpasseortensionintoopportunitiesforchange.Theelementsofatherapeuticrelationshipwiththemostrobustevidenceforeffectiveness—astrongtherapeuticalliance,therapistempathy,andcollectingclientfeedback—allcanbeenhancedthroughuseofmentalizingandadynamic,relationallyinformedunderstanding.

Glossary

Attachmentbehaviorreferstoactionstakenbyapersonwhenarealorimpliedthreatactivateshisorherattachmentsystem—theactionsaredirectedtowardobtainingahelpfulresponsefromthepersontowhomtheyareattached(e.g.,parentorromanticpartner).Attachmentbehaviormayincludeexpressingdistress(inordertoattractacare-providingresponse),seekingproximitytotheother,ordistancingtheotheremotionallyoractually(inordertoavoidnegativeconsequencesofexpressingdistress).

Attachmenttheoryisawayofunderstandingcloserelationships.Infantattachmentdescribescertainaspectsoftherelationshipofaninfanttoanadultwhoparentshimorher.Attachmenttheoryfocusesontheinterpersonaldynamicsoffeelingthreatenedbyadirectthreatorbytheimpliedthreatofseparation.Thesedynamicsincludetheinfant’sexpressionofdistressorseekingofproximitytoaparent,theparent’sresponsetotheinfant,andtheeffectsofaparent’sresponseontheinfant.Adultattachmenttheorydescribesanalogousdynamicsthatoccurbetweenadultswhodependoneachotheremotionally,especiallyromanticpartners.

Contrarymovesareatechniqueemployedbyatherapisttopromotementalizing.Thetherapistoffersacommentorquestionthatinvitestheclienttoconsideradifferentperspective(e.g.,thoughtsratherthanfeelingsorviceversa),anexternalversusaninternalperspective,oranotherperson’spointofview.

Countertransferencereferstoaspectsofthetherapist’sinnerthoughtsandfeelingsduringtherapywithaclient.Expertsdisagreeastowhichaspectsofatherapist’sthoughtsandfeelingsarecountertransferenceandwhicharenot.Thenarrower,classicalviewisthatcountertransferenceismostlyorentirelyunconsciousandconstitutesatherapist’sreactionstotheclient’stransference.Inthisbookwetakeabroaderview,includingallaspectsofthetherapist’s(typicallyautomatic)reactionstoaparticularclientthatareatleastsomewhatdifferentfromwhatheorshemightusuallythinkorfeelwhenworkingwithotherclients.

Dismissingattachmentisapatternofinsecureadultattachmentinwhichexpressionsofdistressorinterpersonalneedaremuted,self-relianceishighlyvalued,intimacyanddependenceareavoided,andintimate,committedrelationshipsarerelativelydevalued.

Disorganizedattachmentisapatternofinsecureattachment.Inadults,disorganizedattachmentisrecognizedwhenapersondisplayssignsthatpotentiallytraumaticattachmentevents(e.g.,abuse,ordeathofaparent)areunresolved.Clinically,disorganizedattachmentissometimesaccompaniedbyconflictingattachmentbehavior(e.g.,experiencingsimultaneousurgestobothseekandavoidclosecontact).

Thetermgood-enoughparentwascoinedbyDonaldWinnicott.Itreferstoaparent

whoprovidesavalidatingenvironmentandemphasizesthatthisdoesnotrequireexpertiseorperfection.

Here-and-nowreferstorelationshipprocessesthatoccurwithinthetherapeuticrelationshipandare,therefore,maximallyavailableforobservationandinquiry.

Theinternalworkingmodelisacognitive-affectiveschemathatservestopredictlikelyoutcomesofattachment-relatedevents.Basedonearlyinteractions(especiallywithparents),theinternalworkingmodelispositedbyattachmenttheory,whichencodesexpectedoutcomesofattachmentinteractions(e.g.,rejectionorprotection)

Theinterpersonalcircumplexisadiagramthathelpstounderstandhowoneperson’sbehaviorinfluencesanotherperson’sresponse.Thecircumplexincludestwoaxes,whichrepresenttwowaysinwhichpeopleinteract.Thefirstaxisisaboutdominance,whichrangesbetweenactinginawaythatissubmissiveandactinginawaythatisdominantofothers.Thesecondaxisisaboutaffiliationandrangesbetweenactingtoincreaseclosenesstoothersandactingtoincreasedistancefromothers.Becausethesetwoaxesareindependentofeachother,interpersonalbehaviorcanbedescribedasacombinationofaperson’spositionontheaxisofdominanceandthisperson’spositionontheaxisofaffiliation.

Interpersonalpullsareforcesthatoccurbetweenpeopleaccordingtothepositionoftheirbehaviorontheinterpersonalcircumplex.Forexample,oneperson’sdominantbehaviorinfluencesanotherpersontobesubmissive(dominancepullsforitsopposite).Ontheotherhand,oneperson’sfriendlybehaviorpullsforanotherpersontoalsobefriendly(affiliationpullsforamatchingresponse).

Amaladaptiveloopisacircularprocessinwhichaperson’sexpectationofhowheorshewillbetreatedbyothersleadstobehaviorthatunintentionallyelicitsaresponsefromanotherpersonthatconfirmsthebelief.Itisaspecifictypeofself-fulfillingprophecy.Forinstance,apersonwhoanticipatesrejectionorshamefromothersmayprotecthimselfbywithdrawingprematurelyfrominteractions,whichincreasestheoddsofactualrejectionandconfirmsthepathogenicbeliefthatnoonewantstobewithhim.

Mentalizingreferstoasetofcognitiveprocessesthatallowapersontoobserveandthinkabouthisorherownthoughtsandfeelings,andtoimaginewhatsomeoneelseisthinkingorfeeling.Mentalizingimpliesthatapersoniscuriousaboutthoughtsandfeelings,reflectsonthem,andlooksforindicationsthathisorherideasaboutthoughtsandfeelingsneedtobemodifiedattimes.

Metacommunicationiscommunicatingaboutcommunication.Inpsychotherapy,metacommunicationmayenrichthecontextofcommunication(e.g.,thinkingoutloud,tosharetheemotionalcontextofcommunication)ormaybeusedtoclarifywhatisexpressed(e.g.,byexplicitlyattendingtobothverbalandnonverbalexpression).

Atherapistengagesinmodelingbybehavinginawaythataclientcanemulate.Atherapistwhodisplaysacuriousandreflectivestancetowardhisorherownthoughts

andfeelings,forexample,demonstratestheskillofreflectivethoughtforaclientwhotendsnottobereflective.

Pathogenicbeliefsarebeliefsaboutothers’thoughtsandfeelingswhoseaccuracyisunquestionedanduntested(andare,therefore,ofteninaccurate),suchthatbehaviorbasedonthosebeliefstendstoelicitundesirableresponsesfromothers.Whenthoseundesirableresponsesreinforcethebelief,theself-reinforcingcycleiscalledamaladaptiveloop(seeabove).

Preoccupiedattachmentisapatternofinsecureattachmentinwhichexpressionsofdistressorinterpersonalneedareamplified,needsforacceptanceanddependenceareprominent,andindividualagencytomaintainandrepairrelationshipsisineffectiveorabsent.

Presenceisacharacteristicofeffectivetherapiststhatreferstoacompositeofvaluabletraitsandbehaviors:availability,responsiveness,empathy,interest,genuineness,andpositiveregard.

Theprocess(noun)isthewayinwhichsomethingintherapyhappens,ratherthanthenarrativecontentofthething.Forexample,theprocessinonemomentoftherapymightbethattheclientistellingastorywhilethetherapistlistenscarefullyandreflectsonthestory.Thisprocesscanbedescribedwithoutreferringtothenarrativecontentofthestory.

Toprocess(verb)intherapyreferstoworkingsomethingthrough:understandingit,breakingitintoitscomponentparts,placingitincontext,andtestinguntestedassumptionsaboutit.Inthisway,atherapistandclientmightprocessamomentoftensionormiscommunicationtofullyunderstandwhathappenedandresolveanyremainingconflict.

Secureattachmentisapatternofattachmentinwhichintimateandreciprocalrelationshipsarevaluedandactivelymaintained,expressionsofdistressorinterpersonalneedareflexibleandproportionatetocircumstances,andindividualagencytorepairrelationshiprupturesiseffective.

Inchildhoodattachment,securebaseisthenameofafunctionthataparentservesforachildwhentheparent’spresenceisadependablesourceofcomfortandconfidence.Theparent,underthesecircumstances,servesasabasefromwhichthechildcanexploreindependentlyandtowhichheorshecanreturnwhendistressed.

Self-disclosureinpsychotherapyreferstoatherapistcommunicatingpersonalinformation.Self-disclosureispotentiallyharmfulwhenitservesthetherapist’sneedsratherthantheclient’sneeds,andsoitmustbeusedcautiouslywithadequatethoughtaboutbothwhatisbeingexpressedanditsvalueinadvancingtherapeuticgoals.

Therapeuticalliancereferstothecollaborativeworkingrelationshipbetweenatherapistandclient.Itincorporatesattitudesofmutualtrustandrespect,sharedgoals,andanimplicitcontracttoworktogetherintherolesoftherapistandclient.

There-and-nowreferstorelationshipprocessesthatoccurwithincontemporaryrelationshipsoutsideoftherapy,suchasbetweenaclientandhisorherspouseorfriend.

There-and-thenreferstorelationshipprocessesthatoccurredwithinpastrelationships,suchaschildhoodrelationshipsbetweenaclientandhisorherparents.

Transferencereferstoaspectsoftheclient’sinnerthoughtsandfeelings.Expertsdisagreeastowhichaspectsofaclient’sthoughtsandfeelingsaretransferenceandwhicharenot.Thenarrower,classicalviewisthattransferenceismostlyorentirelyunconsciousandconstitutesaclient’sreactionstothetherapistthatarebasedentirelyonexperiencesinearlierrelationshipsandfantasiesaboutthoserelationships,especiallychildhoodrelationshipswithparents.Inthisbookwetakeabroaderview,includingallaspectsoftheclient’sautomaticreactionstothetherapist.

Avalidatingenvironmentisoneinwhichachild’scaregiversacknowledgeandrespecthisorherdesires,hopes,opinions,intentions,preferences,ambitions,andfantasies.Validationdoesnotimplyconstantpraiseoracceptance(e.g.,ofmisbehavior),butitdoesimplythatthechild’scaregiversconsiderthechild’sinnerlifetobeimportantandthattheywanttounderstanditandempathize.

LessonPlans

(SeeAppendixCforanswers.)

LESSONPLAN#1EstablishinganAllianceandUnderstandingoftheClient

Thefirststepsofpsychotherapy,regardlessoftreatmentmodality,aretoestablishanallianceandapreliminarysharedunderstandingwiththeclientaboutthedifficultiesthatbringhimtoseekhelpandthetreatmentgoals.ReviewChapters1–4andanswerthefollowingquestions.

1.Whatarethequalitiesofatherapistthatcanimprovetherapeuticalliances?

2.Gettinganunderstandingofaclient’sgoalsfortherapyisimportant.Sometimesclientshavedifficultyansweringdirectquestionsaboutwhatbringsthemtotreatment,whytheyaresuffering,orexactlywhattheyhaveasachiefcomplaint.Whatareexamplesofindirectwaystoaskabouttreatmentgoals?

3.Whatsourcesofdatacanbeusedtounderstandaclient’srelationalproblemsandsuffering?

4.Practicingpsychotherapyrequiresthetherapistandclienttobecomebothobserversandparticipantsintheirpresentexperiences.Thisincludesbeingawareofmoment-to-momentchangesinemotionalstatesornarrativecoherenceduringsessions.Howcanthishelpaclienttochangeunderlyingpathogenicbeliefsthatperpetuatedifficultiesinrelationships?

5.Describetransferenceandcountertransferenceandwhytheyareimportantinpsychotherapy.

6.ADULTATTACHMENT:Fillinthefollowingtabletocharacterizedifferingfeaturesofthehistories,behaviors,andinterpersonalconsequencesofadultattachmentstyles.

SECURE PREOCCUPIED DISMISSING DISORGANIZED

Careproviders’characteristics

Attachmentbehaviors

Others’experiencesofthisperson

7.THEINTERPERSONALCIRCUMPLEX:Wherewouldyouplaceeachoftheclientsonthetapeddemonstrationsontheinterpersonalcircumplex,andwhatwouldyoupredictregardinginterpersonalpullsonandresponsesfromothers?

HOMEWORK:Ittakespracticetobecomeattunedtoprocesselementsinpsychotherapyasmarkersoftherapeuticopportunitiesandasdatatobetterunderstandaclient.Reflectingontherapeuticprocessesretrospectively,youcaneventuallydeveloptheabilitytodoitinrealtime,duringasession.UsetheAssessingandReflectingonCommunicationworksheet(AppendixD).Withyourclients,learnmoreabouttheirrelationshipsinthepastandpresent,keepinginmindtheimpactoftrauma.Begintonoticeaffectivelychargedordifficult-to-respond-tomomentsoftensioninasessionandtrytotrackyourownandyourclient’sinnerexperiences(feelings,thoughts)duringthesemoments(includingcountertransferenceandtransference).Usetheattachmentandcircumplexframeworkstoinformandmakesenseofyourunderstandingofclients,takingintoaccountyourknowledgeoftheirearlylivesandcurrentrelationships,alongwithyourexperiencewithinthetherapeuticalliance.

LESSONPLAN#2Tear-and-RepairProcesses:UsingMentalizingandMetacommunication

Applyingarelationalframeworktoclinicalpracticehelpstherapiststounderstandhowearlylifeexperiencesshapecurrentrelationshipdifficulties.Opportunitiesemergewithinthetherapeuticalliancethatcandisconfirmaclient’spathogenicbeliefs(whicharenegativeexpectationsofothersencodedinaninternalworkingmodel).Thislessonreviewshowatherapistcanunderstandcountertransferencereactionsoralliancetensionsasdata,resistdistancinginterpersonalpulls,andusetherapeutictechniquesofmentalizingandmetacommunication.ReviewChapter5,readthetranscripts,andwatchtheroleplaysontheDVDbetweenJoelWalkerandDr.Leszcz.Thenanswerthefollowingquestions.

1.Describementalizingandlistwaystouseitwithaclient.

2.Describemetacommunicationandhowitcanbetherapeuticallyusedduringmomentsoftensioninthealliance.

3.Aneffectivetherapistalternatesbetweenexploring,activelylistening,validating,clarifyingfactualdata,andconfrontingclientsonmaladaptivebehaviors(especiallybehaviorsthatraisesafetyconcerns).Whatarethesignsthatindicateatherapistshouldsloworpauseexplorationinfavorofprovidingvalidationandsupport?

4.Describedifferingwaysinwhichatherapist’sabilitytoremainreflectiveand

therapeutically“present”canbechallengedbyaclientwhoisdismissingversusaclientwhoispreoccupiedinhisattachmentstyle?

5.Whatshouldatherapistdowhentherearesafetyconcerns?

6.BelowisanexcerptofcommunicationbetweenJoelWalkerandDr.Leszczthatbeginswithadifficult,challengingmoment.Considerthissequenceasamaladaptiveloop.Usingtheinterpersonalcircumplexandtransference/countertransferencedynamics,howcanyouunderstandthisinteraction?

THECOMMUNICATION/INTERACTION

T:Istillneedtogetasenseofwhyyourwifefeelssheneedstousethatleverage[ofaccesstoyourdaughter]togetyoutodosomethingortobedifferentortochangesomething.IneedtounderstandthatifIcan.

C:(interruptsangrily):I’mnotsomewackocreep,right,youknow,that’snot,there’snothinglikethatgoingon,okay?There’snothinguntowardhappeninginmyfamilyhome,okay?Let’smakethatabsolutelyclear.

T:Doyouthinkthat’swhatI’mthinking?

C:Idon’tknowwhatyou’rethinking.ButI’mnot,I’mnotgonnaletyouaskthatquestion.Okay,just,endofstory.

T:IcantellyouwhatI’mthinking.I’mthinkingthatyou’reprettyangry,prettythreatened,prettyunhappy,andsofarexperiencingmeaspartoftheproblemandthat,thatmaybe….I’dstillliketoseewhatelseisgoingonsoIcanseeifIcannotbepartoftheproblem.

T:IcantellyouwhatI’mthinking.I’mthinkingthatyou’reprettyangry,prettythreatened,prettyunhappy,andsofarexperiencingmeaspartoftheproblemandthat,thatmaybe….I’dstillliketoseewhatelseisgoingonsoIcanseeifIcannotbepartoftheproblem.

C:Well,theydon’twanttobearoundme.Sarahdoesn’tanyway.

T:“Peopledon’twanttobewithyou.”Thatgeneratessomefeelingsforyourightnowandthatwouldbeprettypainful,Iwouldimagine.

C:Youknowwhat,it’spainfulifyouwanttobewiththem.

T:Whatwe’retalkingaboutobviouslytouchesalotoffeelingforyou….DoyouthinkwhenSarahasksyou,orevenwhenIaskyouhowyou’refeelingthatthere’s,thatitmightbecomingfromaplaceofinterestorconcern?

C:Whatconcernthough,youknow?Whatconcern?Youknow?Youtellme“whatareyoufeeling,”Imean,howdoIknowyou’renotsayingtome“what’swrongwithyou?”Right?

T:Isthatwhatyouhear?“What’syourproblem?”Irealizethisisveryhardforyou.

C:Idon’tknow,ah,Idon’tknow.Youknow,dowehavetotalkaboutthis,Imean….YouaskmetotellyouwhatI’mfeeling,right?Sarahasksmetoo,“what’sgoingon,whatareyoufeeling,”whatever,it’slike,it’s,it’s“whyareyouthewaythatyouare?”That’sbehindeveryquestion,there’ssomethingwrongwithyou.“Why?”

7.Therearemanyrightwaystorespondtherapeuticallytoamomentofstrain.Affectandemotionaremarkersoftherapeuticopportunity.Continuingwiththesession,describehowthetherapistrespondstothisaffectivelychargednodalmoment?

8.Asimportantasitistorecognizeandworkwithcountertransferenceandinterpersonalpullstoguidetherapeuticprocesses,itisalsoimportanttoregisterevidenceoftherapeuticbenefit.Describethreekindsofimprovementthataclientmayreportordisplaythatwouldbeevidenceofbenefit.

HOMEWORK:Tryusingmentalizingand,whereappropriate,metacommunicationtoexpandyourrangeofengagingintheprocessoftherapy.Techniquesfrombothapproachescanbeintegratedintoyourworkwithclients,regardlessofthespecificmodalityyouuse.

Ittakespracticetobecomeawareofprocesselementsinpsychotherapyasmarkersoftherapeuticopportunitiesandasdatatobetterunderstandaclient.Reflectingontherapeuticprocessesretrospectivelyhelpstherapiststodeveloptheabilitytodoitinrealtime,duringasession.Continuetomakeuseofthetherapistworksheet(AppendixD)toidentifyaffectivelychargedordifficult-to-respond-tomomentsoftensioninasessionandnoticewaystoidentifythiskindofmoment:theclient’swords?youremotionalresponse?theclient’sfacialexpression?youroryourclient’sbodylanguage?Reflectontheinnerexperiences(feelings,thoughts)ofyouandyourclient(includingcountertransference).Usethetheoriesdiscussedinthisbooktoorganizeyourunderstandingoftheclientinthesemoments,aswellastheprocessesofandchangesthatoccuroveracourseoftherapy.Beattunedtoimpactsofyourresponsivenessandcommunicationwiththeclient.

LESSONPLAN#3TakingTraumainAccount

BothclientsontheDVDandtranscribedsessionshavehistoriesoftrauma.ThislessonontakingtraumaintoaccountfocusesonKatherineMarksandherworkinpsychotherapywithDr.Pain.

ReviewChapter6ontraumaaswellasthetranscriptsandDVDsegmentsofKatherine’ssessionswithDr.Pain.Rememberthatthesecondroleplayissession#6;inthepriorsessionKatherinehadspokenaboutherexperienceofbeingrapedwhenshewas14yearsoldandthebetrayalofbeingabandonedbyadultswhofailedtoprotectorhelpherafterward.

1.Whichemotionisconsideredtobeatthecoreoftrauma?

2.Whataresomeoftheclinicalphenomenathatcanalertustothepossiblepresenceof

aninvalidatingchildhood?Whichcaregiverscouldnotprovideadequatesafetyandreassurance?

3.Howcommonistrauma?Howmighttraumaaffecthealth?Howmighttraumaaffectrelationships?

4.Whendoesatherapistscreenfortrauma?

5.Howistraumaassessed?

6.Listfivequestionsthatatherapistcouldusetoaskabouttrauma.

7.Describetwowaysofunderstandingwhysomepeoplefailtorecoverfromtraumaticexperiencesandsufferfromchronic,unresolvedtraumaticsymptoms.

8.Moment-to-momentattunementtomentalstatesandfeelingsbyusingmentalizingaidsatherapeutichealingprocess.Reflectonthefollowingtwosegments.Howdoyouunderstandtheclient’sambivalenceaboutengagingintreatmentinthefirstsegment?

THECOMMUNICATION/INTERACTIONFROMSESSION#3

C:I’mjustnotthatinteresting,right?Imean,it’sjust,Ihavenothingreallygoingon,there’snothingreallywrong,there’snothingreallythematter,it’sjust…

T:Sorrytointerrupt,I’mjustwondering…Ihearwhatyou’resayingandIcanseethatyou’renotinacutedistress,ifthat’swhatyoumean,butit’salmostlikeyoudaren’thopeforsomethingandmaybetellmeifI’minthewrongballpark,butitfeelslikeyouwouldliketo,somehow,hopeorexperiencesomethingtoreflecton,toseewhat’smissing.

C:Yeah,butIdon’tknowhowtogetthere.

T:I’mgettingafeelingthat,aswe’vebeentalking,insteadoffindingawaytotalktoeachotheraboutthethingsthatpuzzleyou,oryou’dliketoexplore,theoppositeishappening.IfeellikeI’minadvertentlysortofchasingyououtoftheroom.Thatsomehow,whatbeganasaverytentativecuriosityisnowmovingtowardfeelinglessengagedhere.Howhaveyoufeltinthelastwhilesincewebeganthissession?

C:Whatever,whateverhappenshereisnotgoingtomakeanydifference.That’ssortofhowitfeelstomebecauseIcan’tbe,Ican’tbehelped.Ijust,youknow,it’sallfine,it’sallgood,Ijustcan’tbehelped.

T:Thatsoundslikeyou’refeelingupset.Canyoustaywiththatfeelingandtalkfromitalittlebit?

THECOMMUNICATION/INTERACTIONFROMSESSION#6

T:Andtheweekend’sirritability…

C:Right.Right.Yeah.

T:What?

C:Well,I’m,Imean,Iguesspartofmeisbeginningtoseethatitwasn’tjustmyfault.Thatotherpeoplecouldhavesteppedintohelpmeinwaysthattheydidn’t.Um,butIstillputmyselfinharm’swaysothere’sthisthinggoingon.Istill,Iwasstillthestupidpersonwhoputmyselfintothesituationso…

T:Sothere’sonetendencytotakethatkindofblameandthenthere’sthisotherkindoftendencytosayasyoujustdid,theycouldhavebeenmorehelp.Andthere’sthatsortofirritableexperienceovertheweekend.SoI’mwonderingifthatkindof[thinkingthat]“it’smyfault”[andthensubsequentlythinking],“wellactually,Iwas14”…

C:Yeah,um,andtheforgivenessofthat,right?Theforgivenessoftheparentswhoweren’tthere.Theforgivenessofthefriends,who,youknow,didn’tthinkitwasanybigdeal,right?So,Ijustforgave,Ijust,youknow,itwasmyfaultandyouknowhowcouldtheyunderstand?AndIthinkifIwere,ifithappenedtomydaughter,ifithappenedtomykids,Iwouldbe,right,I’dbe.

T:What?

C:Well,I’dberightthereforthem.I’dberightthere.Imean.

T:Youwouldn’tblamethem?

C:No,Imean,no.So,again,I’mstucktryingtofigureouthowtothinkaboutthis.Imean,itfeelslikeit’ssortofnewinformation.

T:Whichpartisnew?

C:Thefactthattherecouldhavebeenmorehelp.Therecouldhavebeenadifferentresponse.

T:Canyouthinkoutloudaboutthat?

C:Well,youknow,I’vefeltlikedamagedgoods.Foryears,Ifeellikedamagedgoods…

T:Whatdoesthatfeellike?

C:ItfeelslikeI’mconstantlyneedingtoapologizeandtomakeupforandtodotherightthingbyandtodomorethanand—it’sexhausting[T:Umhum].It’sexhausting.

9.Describehowtherapeutictechniquesofmentalizingormetacommunicationareemployedintheabovetwosegments.

HOMEWORK:Rememberinghowcommontraumaisinclinicalpopulations,whenassessingnewclientsremembertoaskabouttrauma.Watchforsignsofdisorganizationandmomentsofnarrativeincoherence.Workwithinzonesofoptimalarousal;whenneeded,slowdownexplorationinfavorofsupportoruseacontrarymovebyshiftingthefocus.Rememberhowahistoryofunresolvedtraumamightaffectaninternalworking

modelandexpectationsofothersthatwereadaptiveinpast,butnotnecessarilyadaptiveortrueinthepresent.Treatingtraumaisnotabout“findingoutthetruth”ortryingtomakeupfortheclient’spast.Insteadthetherapisthasthepossibilityofbeingwiththeclientandfacilitatingherorhismoment-to-momentexperienceofbeingabletotalk,think,remember,feel,andstaygroundedinthepresentwiththeother(thetherapist).Thiscapacitycandevelopandtendstoputthepastintothepast,disconfirmingoldfearsandreplacingthemwithgreaterconfidenceaboutthefuture.

LESSONPLAN#4UnderstandingandWorkingTherapeuticallywithClients

Thiscase-basedlessonwillhelptoconsolidateprinciplesandtechniquesthatimproveyourpsychotherapyeffectiveness.Usearelationship-focusedunderstandingtomakeclinicallyreasonedtherapeuticresponsesinthefollowingcases.Employmetacommunicationandmentalizingresponsesthatareguidedbyyourunderstandingofattachment,interpersonalpulls,transference/countertransferencedynamics,andtheimpactoftrauma.

Case#1

Danielleisawomaninherearly50swhorecentlydiscoveredthatherbreastcancer,treatedtwoyearspreviously,hasspread.Sheisanarticulatewomanwhohasnopasthistoryofpsychiatricillness.Shelivesaloneandiscurrentlyonsickleavefromherlong-standingworkasaprimaryschoolteacher.Sheisanactivememberofherchurchcommunity.Heroncologistnoticedthatshewasdepressedandtearfulthroughoutherlastvisitandhadsuggestedthatitcouldbehelpfultospeakwithatherapistduringthisstressfultimeofbeingtreatedforcancer.Thetherapistwasaskedtoseehertoprovidecounselingsupport.

Daniellehadherfirstchemotherapytreatmenttwoweeksago.Aclosefriendofferedtospendthenightwithherfollowingthattreatment,butDaniellerefused.ByeveningDaniellehadhadseveralboutsofnauseaandvomitingandwasfeelingpoorlyphysicallyandsomewhataloneintheworld.Neverthelessshecalledherfriendandtoldhershewasalright.Thetherapistasksherwhyshedeclinedherfriend’shelp.Danielleanswers,“IhadthisideaIwouldbebetteroffonmyown.”Followingthatverydifficultnight,shehadcalledherfriendinthemorningtobedriventotheemergencyroom,wheresherequiredintensivemedicaltreatment.

1.WhatisyoursenseofDanielle’sattachmentstylebasedonthisbriefvignette?Whatotherinformationwoulditbehelpfulforthetherapisttoknowinordertoenhanceherunderstandingoftheclient’smaladaptiveloopsandinternalworkingmodel?

WhenDaniellespeaksaboutherdevelopmentalrelationshipsandearlychildhood,shesaysthatsheneverknewherfatherbecauseshegrewupwithasinglemother.Hermotherwasaregisterednurseintheirremote,ruralcommunity.Daniellesaysshewas

ahighlyrespectedwoman,“thestrongsilenttype.”Althoughothersinthecommunitywenttohermotherforadvice,Danielleherselftendednottogotohermotherbecauseshefoundhertobetoobusyandemotionallyunresponsive.Instead,whensheneededemotionalsupport,Danielleturnedtotwopeersandthemotherofoneofthosepeers,whowasamoreresponsiveandavailableindividual.AsDanielledescribesherrelationshipwithhermother,thetherapistcomments,“LetmeseeifI’munderstanding.Itsoundslikeyourmotherwasagoodcitizenwhohelpedmanypeople,butyoulookedforemotionalsupportelsewherebecauseshewasn’tsoavailabletoyou?”Danielledoesn’tdirectlyanswerthequestion,butbecomestearfulandsays,“Thereissomethingaboutbeingtakencareof.”Shethenelaboratesthatshedeclinespeople’soffersofhelpbecauseshefeelscrowdedandexposedasifshewerethecenterofattention,preferringtoslipintotheshadows.Afewmomentslater,referringtopeoplethatareprayingforherandherillnessshesays,“I’mnotjustsad,I’mscaredtobeloved….Idon’tknowwhattodowiththat,Iwanttorunaway.”

2.Usingprinciplesofmentalizing,howmightthetherapistrespondatthismoment?

Case#2

Miltonisa40-year-oldunmarriedfatheroftwoadultchildrenwhowasraisedbyothersinhisextendedfamily.Heisestrangedfrombothofhisparentsandneverknewthemwell.Hewasreferredtopsychotherapybyhisfamilyphysicianforhelpwithchronicdepression.Hehasanextensivehistoryoftrauma,includingchaoticearlylifecircumstances,sexualabusebyafamilymember,andabruptseparationsfromcareproviders.Healsohasahistoryofpoly-substancedependence.Followingparticipationinanaddictionstreatmentprogram,Miltonisintheearlystageofrecovery,attendinggroupstopreventrelapse.

Thisweekheaskshistherapisttofilloutareportthathasbeenrequestedasaresultofanassault.Sheissurprised.Althoughshewasawareofhischildhoodsexualabuse,shedidn’tknowthathehadbeenassaultedasanadult.Miltonhadn’ttoldthetherapistabouttheassault,althoughinanearliersessionhehadvaguelyalludedtostressthathesaidhedidn’twishtospeakof.InthissessionMiltonbecomesangry,statinghecan’tbelievethatshehasn’tunderstoodthefullstoryfromthesnippetshehasmentioned.Hesaysthathesometimesfeelstheassailant’shandsaroundhisneckinflashbacks.Hehasnightmaresoftheassaultandtellshistherapistthattheassailanthadthreatenedtokillhim.Shesays,“Okay,nowtherearesomethingsaboutthetraumathatarebeginningtostringtogether.”Miltonbecomestearfulandthetherapistregistershischangeinaffectfromangertosadness,andsays,“It’sbeenatoughyearanditisawfultohavetoremembertheassaultsothatIcanfilloutareportforyou.“SheexperiencesMiltonasmorepresentintheroomwithherashereplies,“Yeah,Idon’tliketothinkaboutthisstuff.”

3.Takingtraumaintoaccount,whatdoyouthinkabouttheclient’searlierreluctancetodiscloseordiscussdetailsoftherecentassault,andthetherapist’snotpushingto

pursuethis?

4.Usingmetacommunicationandmentalizing,howmightthetherapistrespondtothismomentofstraininthetherapeuticalliance?

Case#3

A42-year-oldnarcissisticprofessionalwithahistoryofgeneralizedanxietyarrivesforhisappointmentwithhistherapist.Theclienthadearlierdescribedgrowingupwithamotherwhosedemandsonhimwereunrelenting,inconsistent,andunpredictable,oftenleavinghimfeelingangry,isolated,andoverwhelmed.Thetherapistarrivesafewminuteslate,thenneedstotakeanurgentcallthatdelaysthebeginningofthesessionby15minutes.Uponbringingtheclientintotheoffice,thetherapistapologizesandaskshowtheclientexperiencedthewait.Theclientsays,“Whenyouwereafewminuteslate,itdidn’tbothermebecausethathappens,butthenwhenyouwentintoyourofficeanddidn’tcomeouttogetmeimmediately,Istartedtogetangrierandangrierthinkingthatyouweredoingsomethingelseinsteadofcomingtoseeme.Ilookedattheclockandpromisedmyselfthatifyouweren’toutin10minutes,Iwouldleaveandyoucouldgotohellifyouthoughtyouwouldgetpaidforthemissedsession.”Thetherapistresponds,“I’mgladthatyou’restillhereandthatwearemeeting.I’dliketotalkwithyouaboutwhatyouthoughtaboutandwhatyouwentthroughinordertoactuallystayandallowustomeet.”Theclientsaysthatashebegantothinkaboutleavinginangerandwasbecomingmoreupset,hetookamomenttoreflectandsaidtohimselfthistherapisthasbeengenerallyprettyconsiderateandresponsive,butsometimesthingshappen.Hechosetogivethetherapistthebenefitofthedoubtandstay.

5.Howmightthetherapistusemetacommunicationtodealwithanactionthathasbeenfrustratingtoaclientandthenbegintoprocesstheeventwithinthehere-and-nowofthesession?

6.Inthiscase,howmightaninternalworkingmodelformedearlyinlifeaffecttheclient’scurrentexpectationsinrelationships?Howdoestheclient’scapacitytomentalizerelatetotheseexpectations?

Case#4

Cherylisa37-year-oldbusinesswomanwholiveswithherfiancé.Shehasstruggledwithchronicdepressiondatingbacktoheradolescence.Shebecamedepressedaftertheacrimoniousbreakupofherparents’marriagethatfollowedthediscoverythatshehadbeensexuallyassaultedbyheruncleasachild.Thesymptomsofdepressionhaveremittedoverthepastyearofpsychotherapy,whichhasusedamentalizing-basedapproachinwhichshehasmostlydiscussedcurrentaspectsofherexperienceandattimesreflectedonherpasttraumas.Shehasdevelopedmoreappreciationandcompassiontowardherselfasayoungpersonwhosufferedthesexualassaultsandthenthedissolutionofherhome.

Lastmonth,shedisclosedthedetailsofthesexualassaultstoherfiancéwitharesultantpositiveexperienceoffeelingunderstoodandcaredfor.Thiswasthefirsttimeshehadtoldanyoneotherthanhertherapist.Lastweekshetoldhertherapistwhensheandherfiancéwentforpremaritalcounselingfromtheirpastor,shecalmlymentionedthesexualassaults.Shefeltabletosharethiscomponentofherexperiencewiththepastor,becauseshefeltitwasimportantto“getitonthetable.”

7.WhatdoyouthinkaboutCheryl’sbeingabletotalkaboutthesexualassaultwithbothherfiancéandtheircounselor?

HOMEWORK:Inthisbook,youlearnedtopayattentiontoyourclients’earlyattachmentrelationships(there-and-then),currentrelationships(there-and-now),andthepresentdynamicsoftransferenceandcountertransferencewithinthetherapeuticrelationship(here-and-now).Youhavelearnedtorecognizethepotentialimpactofunresolvedtraumaandtobeattentivetorepetitivepatternsofunhappy,self-fulfillingsequencesthatmayrecurthroughmaladaptiveloops,includinghowyou,asatherapist,mayinadvertentlybehookedintothesepatternsinthetherapeuticrelationship.

Asafinalhomeworkassignment,useAppendicesBandDtoreflectonyourclientsandbeintouchwithallcomponentsofyourexperienceofthem:yourthoughts,youremotions,yourassociations,andyourinteractions.Considerthetherapeuticalliancesyouhavewithyourclients,boththestrengthsandthetensionsthatoccur.Deepenyourempathicconnectionsbyusingyourownexperiencestounderstandyourclients’relationalworlds.Considerconstructivewaystocommunicatethisunderstandingwithclients.Identifytherapeuticopportunitiestousementalizingandmetacommunicationwithinanoptimalzoneofarousaltorepairstrainsintherapeuticalliancesandpromotenewwaysofunderstandingandexperiencingrelationships.

Quiz

(SeeAppendixCforanswers.)

1.Thetherapeuticalliance:

a.Islessimportantthanthetherapeuticmodelwithregardtotheoutcomeofthepsychotherapyprocess.

b.Representselementsoftheclient-therapistrelationshiprelatedmainlytotransferenceandcountertransference.

c.Isbothaspecificandcommonfactor,becausethealliancemustbeestablishedwithinthespecificmodelapplied.

d.Whenruptured,cannotberepaired.

e.Intheclient’sassessmentislessimportantthanthetherapist’sassessmentofthetherapeuticalliance.

2.Approachesandconsiderationstorepairtherapeuticalliancerupturesinclude:

a.Usingcontentsolutionstoprocessproblems.

b.Understandingstrainsintheallianceasopportunitiestodisconfirmpathogenicbeliefs.

c.Neverviewingtreatmentaspartoftheproblembutpartofthesolution.

d.Redoublingthefrequencyofinterpretationsorattendingtocognitivedistortions.

e.Focusingmoreoninsightthanrelationalexperiencesbecauserelationshipsarelessimportant.

3.Whichofthefollowingstatementsisfalse?

Metacommunication:

a.Itinvolvescommunicationaboutmeta-analyticresearch.

b.Itinvolvesbothidentifyingandmakinguseoftheclient’sinterpersonal“pulls,”patterns,andimpact.

c.Ithasthepotentialtointerruptthe“maladaptivetransactioncycle.”

d.Itinvolvesexplorationandcommunicationaboutovertandcovertcommunicationanditsovertandcovertinterpersonalimpacts.

e.Itcaninvolvethetherapeuticuseofcountertransference.

4.AllofthefollowingelementspromoteastrongtherapeuticallianceEXCEPT:

a.Competenceinmanagingemotionalstrain

b.Sympathy

c.Positiveregard

d.Genuineness

e.Responsiveness

5.Pooroutcomesinpsychotherapymay:

a.Beduetotheimpactofthetherapist’sself-doubt,anger,oravoidanceofchallengingclients.

b.Berelatedtoanincompleteorinaccurateassessment.

c.Reflecttherapistcontributionsrelatedtoaninflexiblerelianceonaparticulartechnique.

d.Beduetosubtlehostilityordisingenuousempathyfromthetherapist.

e.Alloftheabove

6.Transference

a.Isonlyevidentlaterinacourseofpsychotherapy.

b.Shouldneveraffectatherapist.

c.Isdiagnosedaccordingtoaclient’sDSMorICDdiagnosis.

d.Haspatternsthatincludebeingpredominantlyangry,anxious,avoidant,orsexualized.

e.Isunrelatedtoattachmentstyle.

7.Countertransference:

a.Canbeunderstoodasunconsciousandsometimesovertattitudesandfeelingsthatthetherapistcarriestowardtheclient.

b.Mayinterferewithoptimalunderstandingandresponsivenesstotheclient.

c.Maycontributetooptimalunderstandingandresponsivenessasavaluablesourceofclinicaldata.

d.Isa“jointcreation”ofboththeclientandtherapist.

e.Alloftheabove

8.Regardingethicalpracticeandresponsibilitiesinpsychotherapy,allthefollowingstatementsaretrueEXCEPT:

a.Boundariesprotecttheframeandintegrityofthetreatment.

b.Boundariesareintendedtoreinforcepowerimbalancesbetweenthetherapistandclient.

c.Boundariesareessentialtomaintainaspartofthetherapist’sfiduciaryandethicalresponsibilities.

d.Atherapistmustconformtothepracticestandardsofhisorherprofessionandbe

trainedand/orsupervisedtobecompetentinthetreatmentprovided.

e.Therapistsareheldtoprofessionalstandardsofobjectivescrutinywithrespecttomanagingboundaries.

9.Todevelopasharedunderstandingofaclient’srelationalworld,itishelpfultolearnabout:

a.Developmentalhistoryandrelationships

b.Currentsignificantrelationships

c.Unresolvedtrauma

d.Aspectsofthehere-and-nowtherapeuticrelationshipsuchastransference

e.Alloftheabove

10.Thecircumplexdescribesinterpersonalimpactsorpullsthatcontributetothemaladaptivetransactioncycle.Whichofthefollowingstatementsistrue?

a.Thereisareciprocal,oppositeresponsetointerpersonalexpressionsofaffiliation.

b.Anexampleofthereactiontoa“hostile-dominant”interpersonalpullistorespondwithcomplianceandfriendliness.

c.Clientsmayinadvertentlyworsenrelationshipsthroughtheinterpersonalpullstheygenerate.

d.Metacommunicationisineffectiveatbreakingthemaladaptivetransactioncycle.

e.Maladaptivecyclesonlyapplytopersonality-disorderedclients.

11.Foratherapisttounderstandaclient’sinternalworkingmodelandattachmentstyle,inferencescanbemadefromobservationsaboutallEXCEPT:

a.Aclient’sexpressionsofdistress

b.Attitudestowardclosenessandintimacy

c.Expectationsofresponsesfromothersintimesofneed

d.Socioeconomicstatus

e.Helpseeking

12.Achild’sattachmentstyle:

a.Emergesasthebestadaptationtoacomplexenvironmentandisencodedinaninternalworkingmodel.

b.Isinfluencedbysocialstressors,resources,socialsupports,andqualitiesofparenting.

c.Shapesexpectationsofothers’responsiveness.

d.Affectsresilience.

e.Alloftheabove

13.Avalidatingenvironmentinearlychildhoodpromotesthedevelopmentofattachmentsecurityandisfosteredbyparentsorprimarycaregiverswho:

a.Focusmainlyonthechild’sachievements.

b.Areperfectlyresponsive,spending100%ofthetimebeingfocusedonthechild.

c.Viewthechildnotasaseparatebeing,butasanextensionofthemselves.

d.Respondtothechild’sfearsoastorestoreasenseofsafetytothechild.

e.Disavowthechild’semotionalreactions.

14.Adultattachmentstyles:

a.Canbedividedintosecureandinsecuretypes.

b.Canbedividedintoorganizedanddisorganizedtypes.

c.Reflecttheinternalworkingmodeloftheindividual.

d.Helpthetherapistunderstandtheclient’ssenseofhimselforherselfandtrustofothers.

e.Alloftheabove

15.Whichattachmentstyleischaracterizedby“dialed-up”attachmentbehaviorswithamplifiedexpressionsofdistress,intensehelpseeking,anexpectationofrejectionorabandonment,andanxietyaboutbeingalone?

a.Secure

b.Preoccupied

c.Dismissing

d.Disorganized

e.Noneoftheabove

16.AllofthefollowingaretrueEXCEPT:

a.Unresolvedtraumaunderliesinsecureordisorganizedattachmentpatternsofrelating.

b.UnresolvedtraumaalwaysleadstoPTSD.

c.Unresolvedtraumaisassociatedwithmentalizingdeficits.

d.Unresolvedtraumaaffectsaclient’sself-esteem.

e.Unresolvedtraumamakesitmoredifficulttoformtrustingrelationships.

17.ThesequelaeofunresolvedtraumaincludeallEXCEPT:

a.Emotionaldysregulation

b.Substanceabuse

c.Medicallyexplainedsymptoms

d.Impulsivity

e.Relationshipproblems

18.MentalizingtechniquesincludeallEXCEPT:

a.Usinga“knowing”stancetomakeinterpretations

b.Usingcontrarymoveswithshiftingfocusofexplorationbetweenthoughts-feelings,experiences,andperspectives(internal-external,self-other).

c.Modelingmentalizing

d.Encouragingtheclienttothinkandtomakesenseofhisexperiences.

e.Beingreflective

19.Thetear-and-repaircycleinpsychotherapy:

a.Makesuseofalliancetensionsastherapeuticopportunities.

b.Usescountertransferenceandmetacommunication.

c.Providespotentialdataaroundaclient’srelationalpulls.

d.Requiresthetherapisttoberesponsiveratherthanreactive.

e.Alloftheabove

Jacobisa45-year-oldsinglemanwhoisemployedasanofficetemp.Heoftenleavesworkwithfatigue,stomachupset,andgeneralizedbodypain.Nospecificcausehasbeenfoundforhisphysicalcomplaints.

Jacob’sprimarycareprovidertendstowincewhenhecomesforanappointment;Jacobisalwaysupsetandneedy,andthefamilydoctor,havingrunoutofthingstorecommend,feelsfrustratedandineffective.Hereferredhimforpsychotherapyforanxiety,andheexplainedtoJacobthatpsychotherapycouldbehelpfulifhissymptomsarerelatedtostress.

Jacob’spsychotherapisthaslearnedthathisdevelopmentalyearswerechaoticandscary.Hewasraisedbyasinglemotherwhohadanunreliableincomeandoftenblamedthechildrenfortheirrelianceonher.Jacob’smotherdevelopeddiabeteswhenJacobwas12,andsheoftencomplainedthatitwasbecauseofthestressinherlife.

AfterseveralpsychotherapysessionsJacobremainshighlydistressed.Hedescribeshisphysicalandpsychologicalsymptomstothetherapistinadesperatetoneofvoice,shiftingfromonecomplainttothenextwithoutanyapparentrationale.Thetherapistfeelshopelessandoverwhelmedandnotatallsurehowtohelphim.ThetherapiststartstothinkabouthowtotransferJacob’scaretoanothertherapist.

20.WhatisyourinitialimpressionofJacob’sattachmentpattern?

a.Secure

b.Preoccupied

c.Dismissing

d.Disorganized

e.Maladaptive

21.Basedontheinformationyouhave,wherewouldyoumapJacobontheinterpersonalcircumplexandwhatresponseswouldyouexpecthimtopullfromothers?

a.Hostile/disengaged-Dominant(northwest),pullingfordisengagingdominancefromothers.

b.Hostile/disengaged-Submissive(southwest),pullingfordisengagingsubmissivenessfromothers.

c.Affiliative/friendly-Dominant(northeast),pullingforaffiliativesubmissivenessfromothers.

d.Affiliative/friendly-Submissive(southeast),pullingforaffiliativedominancefromothers.

e.Noneoftheabove

Maryisa28-year-oldgraduatestudentseekingpsychotherapyforchronicstrugglesinrelationships.Duringtheinitialsession,sheoftenlaughsandissarcastic,statingsheknowswhyshestrugglesandexpectsthatpsychotherapywillnothelp.Towardtheendofthefirstsession,shementionsthatshebelievesshehasneverknownwhatitistofeelhappy.

22.WhatisyourinitialimpressionofMary’sattachmentpatternofrelating?

a.Secure

b.Preoccupied

c.Dismissing

d.Disorganized

e.Invalidated

23.Basedontheinformationyouhave,wherewouldyoumapMaryontotheinterpersonalcircumplexandwhatresponseswouldyouexpecthertopullfromothers?

a.Hostile/disengaged-Dominant(northwest),pullingfordisengagingdominancefromothers.

b.Hostile/disengaged-Submissive(southwest),pullingfordisengagingsubmissivenessfromothers.

c.Affiliative/friendly-Dominant(northeast),pullingforaffiliativesubmissivenessfromothers.

d.Affiliative/friendly-Submissiveness(southeast),pullingforaffiliativedominancefromothers.

e.Noneoftheabove

24.ImportantaspectsofthetherapeuticalliancetobeawareofincludeallEXCEPT:

a.Collaborativeagreementonthegoalsoftherapy.

b.Attendingtotherelationshipbetweenthetherapistandclient

c.Consideringthenegativeexpectationsoftreatment.

d.Theclient’sabilitytobepsychologicallyminded.

e.Therelationshipwiththetherapistasatemplatefortheclient’sdifficulties.

25.Characteristicsoftheexemplarypsychotherapistasperceivedbycolleagueshavebeendescribedasincluding:

a.Capacitytobereflectiveratherthanreactive.

b.Genuineinterest,caring,andcommitment.

c.Empathiccapacityandconceptualability.

d.Self-awarenesswiththecapacitytocontainanxietyandrecognizelimitsandfit.

e.Alloftheabove

AppendixA:Role-PlayTranscripts

(RefertotheenclosedDVDforthefullvideo.)

ROLEPLAY#1:JoelWalkerandDr.LeszczEstablishingatherapeuticallianceandexploringpsychotherapygoals

Inthisroleplayofthefirstsession,weareintroducedtoJoel,whoisclearlyanunwillingparticipantintheprocessofpsychotherapy.

C:YouknowIwasreferredhere,right?Thisisnotmygambit.I’mnotthrowingmyselfatyourfeet.

T:AndI’mgoingtoaskyousomequestions—[C(interrupts):Okay,yup,fine,sure,fine].Hopefullythiswillbeusefultoyou[C(interrupts):Okay].Alright?Appreciatethat.

T:Tellmewhyyourfamilydoctorisrecommendingthis.Whatyourunderstandingis?

[Elicitingtheclient’sperspective]

C:Well,I’mnotamindreaderImean,Idon’tknowwhathe’sthinking,but,Imean,he’ssayingtome,like,Idon’tthinkit’sasmuchaboutwhathe’sthinkingasitisaboutwhatmywife’sthinking.

T:Uhhuh.

C:So,youknow,Ithinkshe’sbehindthismorethananything,sothat’s,that’swhereI’mstuck[T:Umhum].Right?So,youknow,Imean.Yeah,that’sjustwhereI’mstuck.It’slesshimthanitismywife.

T:Isee.

C:So,soI’mhere.Takingupyourvaluabletime.LikeIendupbeingtheguywhohasto,hasto,ah,youknow.Anyway,soyouknow,Imean,doyourworst.Iknowwhat’scoming.

T:Youknowwhat’scoming.

C:Yeah.

T:Tellmewhatyouthinkiscoming.

[Exploringexpectationsinthehere-and-now]

C:Well,youknow,you’regonna,you’regonnaaskmeaboutmychildhoodandstuffandthenyou’regonnatellmewhyI’msomessedup.Andyouknow,Ijustkeepworking,andah,andmaybewehumorsomepeopleandmywifesoftensupabitaboutsomethingsthatsheshouldchilloutabout.

T:So,inmeetingwithmethere’ssomethinginthisforalotofpeoplebutnotforyou.

T:So,ifyouweretomoveonfromwhereyouarerightnow,Joel[C:yeah],Joel,what

wouldthatlooklike?Whatwouldthatbelikeforyouinyourlife?Howwouldyoubefeelingdifferently?

[Exploringtreatmentgoals]

C:HowwouldIbefeelingdifferent?It’snotaboutfeelingdifferent,it’sabouttakingcareofotherpeoplewho,whogathertheseopinionsbecauseperiodicallypeoplepointtheirfingersatmeandsay,youknow,loser,soyougodothis.

T:You’vemadeacoupleofcommentsaboutyourselfthatyouattributetootherpeopleaboutbeingaloser—what’shappenedrecentlythatthishascometoahead?

C:(Exhaling)Look,thesituation,whatI’mtalkingaboutisthat,um,mywifegavemethebootrecently—soIcouldjustleaveandIcouldjustleaveitallbehind,Idon’treallywanttodothat.Mywifealsohasourdaughter.Soshekindofgetstocalltheshots.

T:Andyourdaughter’sa,abigpieceofthisforyou.What’syourdaughter’sname?

C:Charlotte.She’sthree.

T:Sopartofwhatbringsyouhereistryingtogetsomethingbackon,ontherailssothatyoucancontinuetoseeCharlotte.

[Validatingthechiefconcern]

C:Well,that’sthepowershe’sgot,doctor.Imean,shecansay,well,youknow,Imean,youdothis,youdothat,oryoudon’tgettoseeCharlotte.Andyouknow,IcouldarguethatbecauseI’mherdad[T:Right].ButImeanwecouldarguetothepointwherewe’regoingtocourtandhowmuchtimeandmoneyisthatgoingtowaste?

T:Sure,sure.WhyisyourwifeblockingyoufromseeingCharlotteatthismoment?

C:She’snotsomuchblockingme,shewon’tletme,ah,seeheronherownbutyouknowthere’snoreasonforit.It’sapowermove.MydaughterandIhaveafinerelationship.IalwaysdoeverythingIcanformydaughter—whereversheis,she’snotgonnahavethesamehousethat,that,Igrewupin.She’sjustnotgonnahavethat.

T:Right.

C:And,andso,it’sapowermove.’Causeyouknowshe,mywife,um[pause],mywife,um,mywifeknowsthatshecan,shecancontrolmethatway.

T:SoyourwiferecognizesbecauseofyourattachmenttoCharlotte,shecanusethatforleverage.

[Expressingempathy]

C:[continues]…sothat’s,youknow,that’swhyI’mhere.

T:Istillneedtogetasenseofwhyyourwifefeelssheneedstousethatleveragetogetyoutodosomethingortobedifferentortochangesomething.IneedtounderstandthatifIcan.

[Usinganot-knowingstancetochallenge]

T:Theremaybevalue…

[C(interrupts):I’mnotsomewackocreep,right,youknow,that’snot,there’snothinglikethatgoingon,okay?There’snothinguntowardhappeninginmyfamilyhome,okay?Let’smakethatabsolutelyclear.]

T:Doyouthinkthat’swhatI’mthinking?

[Usingmetacommunicationtoprocessthealliancetension]

C:Idon’tknowwhatyou’rethinking.ButI’mnot,I’mnotgonnaletyouaskthatquestion.Okay,just,endofstory.

T:IcantellyouwhatI’mthinking.I’mthinkingthatyou’reprettyangry,prettythreatened,prettyunhappy,andsofarexperiencingmeaspartoftheproblemandthat,thatmaybe…I’dstillliketoseewhatelseisgoingonsoIcanseeifIcannotbepartoftheproblem.

[Silence]

T:Soifit’salrightwithyou,Joel,I’mgoingtocontinuetoaskyousomequestions.

C:I’mtryingtotellyoueverythingIknow.

T:WhatdoyouthinkSarahwantstobedifferentinhowyouarethatledhertosay“you’releavingandyoucan’tseeCharlotteuntilyougetsomehelp”?

[Askingtheclienttomentalize]

C:Youknow,Ijustthinkthatmaybewhatshewantsisadifferentguy.

T:Areyoudifferentthanyou’vebeenrecently?Havetherebeensomechangesgoingonforyou?

C:Changes?No,well,youknowI’vebeenworking;I’vebeenworkingalot.

T:Haveyoubeenfeelingmoreangry,moreupset?

C:I’malwaysunderpressure.

T:Yeah,whatkindofpressure?

C:Ihaveabusinessjob.Ihavetoperformandsometimesit’stense.Andthat’sjustthewayitis.

T:Whatdoyoudo,Joel?

C:Icontrol,ah,Icontrolinventoryforadepartmentstore,alltheinventory.Wedothebuying,wedothechoosing,wegetittothestores,sothere’salotofdecisionstobemade.There’sadozenpeopleunderme.

T:Andthisisatough,toughclimateforthatkindofbusiness.

[Expressingempathy]

C:Yeah,itisnotgettinganyeasier,yeah.

C:Imean,youknow,youjusthavetodowhateveryouhavetodosometimes.Sometimes

youhaveto,ah,sometimesyouhavetousethewhip.

T:Thewhip.

C:Yeah.

T:Atwork.

C:Yeah.Notliterally,I’mbeingmetaphorical.

T:Iunderstoodthat.Buttellmewhatusingthewhipmightlooklikeatwork.

C:Ah,somepeople,youneedtogetupintheirgrillabit,youknow.Justdependsonwhoitis.Youhavetopushtheirbuttons,sometimesyouhavetodothat,youknow.It’snotpersonal;youjustgottomeetyourtargets.

T:Haveyoubeenusingthewhipmorerecently?

C:More?Idon’tknow.

T:Howaboutathome?

[Exploringsafetyconcerns]

C:Ihaven’tbeenhomeinsixmonths.

T:Beforethat,sayayearago.

C:Idon’tusethewhipwithmydaughter.

T:That’simportantforyoutoconveytome.

[Usingmetacommunicationtobuildapositivealliance]

C:Well,okay.It’sthetruth.Like,Imean,mydaughterisnot,mydaughterisnotlikethesepeoplewhoworkwithme,youknow?

T:Thatmakessense,Iunderstandthat.Um,butI’minterestedinyouruseofthe,ofthatmetaphor,thewhip.

C:It’sjustthefirstthingthatcameintomyhead.

T:That’sokay;I’mnotfindingfaultwithitatall.I’mjustcuriousaboutitsuse,aboutthemeaningtoyou.I’lltellyouwhatI’mthinking:whenyou’reunderpressureyouputpressureonpeoplearoundyou.

T:Andwith,withCharlotte,itsoundslikethat’sarelationshipthere’smuchlessconcern.Youwanttoseeher[C(interrupts):It’snotaboutthat].Yeah,it’snotaboutthat,whatisitabout?

C:It’snotabusinessrelationship.LikeImean,it’s,it’s,itwas,afamily,right?LikeevenwithSarah,I’mnottakingthatstuffhome,we’retryingtohavealittlesocietyinthehouse,whichisafamily.

T:Iseehowimportantitisforyou,Joel,topreservethatfamily,andyourrelationshipwithCharlotte.HowimportantisitforyoutopreserveyourrelationshipwithSarah?

C:ifitwerejustaboutCharlotte,I’dprobablybetalkingtoalawyerrightnow.

T:SoyoualsowanttopreservetherelationshipwithSarah?

C:Well,Ido,Idon’tknow.Maybethat’spieinthesky,Idon’tknow.

T:Well,hardtoknowatthismoment,butit’simportantinformationforyoutosharewithme.

T:Howareyoufeelingrightnow,Joel,aswe’retalking?

[Seekingclientfeedback]

C:Well,I’mfeeling,atthismoment,I’mfeelingabitantsy.

T:Antsyaboutwhat?

C:It’s,ah,well,youknow,ImeanIdon’tspendalotofdays,youknow,shootingthebreezeaboutmypersonallifewithpeople.Youknow?

T:I’msureit’snotaneasythingforyoutodo.

C:Well[sighs],maybenot.

T:CertainlywhenyoucameinIpickedupalotof,ah,alotofangerandsomeantagonismaboutbeinghere.

[Metacommunicatingtorepairthealliancetension]

C:Look,man,youcanpileonwiththatstuffallyouwant;Imeanthefactisthatitwasnotmychoice.

T:Yeah,Iunderstandthat.WhydidyousayIcouldpileonwiththat?DoyoufeellikeI’mpilingonwhenImakethatcomment?

C:Well,youknow,likeantagonistic,angry,givemethelaundrylistof,youknow,whateverdespicablethingsyou’reseeinginme.There’snooneelsehere;youcanmakemefeelhoweveryouwant,goahead.

T:I’mnotfeelinganythingakintodespicable.LetmetellyouwhatI’mpickingup.Letmerunitbyyou,Joel,andtellmewhatyouthink.Ithinkyou’reunderalotofpressure,Ithinkyou’refeelingalotofapprehensionaboutimportantrelationshipsinyourlife.Youmadeaveryimportantcommentthatwedidn’tfocusonearlierabout“youwanttomakesurethatCharlottegrowsupinadifferentkindofhomethantheoneyougrewupin.”Myhunchisthatwhenyouusethemetaphorofcrackingthewhip,thatyoumightknowmoreaboutwhatit’slikeonbothsidesofthat.

C:Yeah.

T:AndyouwanttomakesurethatyouprotectCharlottefromwhatyougrewupwith.IknowI’mstretchingherebecauseIdon’thavealotofinformationbutI’mbasingthatuponsomeofthethingsyou’resayingandalsohowI’mfeelingwithyou.

C:Look,whatevermypastis,ismypast.And,um,it’sover,I’mnotinterestedreallyin,ah,inrelivingitandthepeoplewhowereinstrumentalinthatpast.Youknow.Theydon’tmatter,thethingthatmatters,isthat,ah,Charlottegetstoexistinadifferentreality.

T:Exactly.AndIthinkmaybewehavefoundsomecommonground.Youdon’twanttorelivethepast…

C:No.

T:…andIdon’twantyoutorelivethepast,andmyconcernisthatsomethingsareputtingpressureonyou.You’veusedlanguageindescribinghowyouthinkI’mthinkingaboutyou—thatleadsmetobelievethatyouexpectmetobecriticalandattackingandI’mnotfeelingthatway.I’mawareofyourangerbutI’mmorecuriousaboutitthan,ah,angrywithit.I’mhopingwecanhaveanopportunitytocontinuetotalkaboutthattogether.

[Questioningthepathogenicbeliefaboutothers’judgment]

C:[Sigh]Idon’tknow.I’malittleconfused.LikeIjust,ah,like…[sigh]

T:Howwouldyoufeel,Joel,aboutcomingbacktoseemeasecondtime?Sowecantalkalittlebitmoreaboutthis?

C:Yeah,IguessIcould.

T:Okay,Iwould,Iwouldbepleasedifyouweretochoosetodothat.

T:Joel,we’regonnaneedtowinddowninjustafewminutesbutIwantedtogiveyousomefeedbackbeforeweendandhopefullymakeaplanfornextsteps.I’mhopingthatIcanbehelpfultoyouandthatmeetingtogetherwouldbeuseful.ButletmegiveyoualsoalittlemoreinformationaboutwhatIthinkwemightbeabletofocuson.Andletmeknowhowthissitswithyou.Atonelevel,there’ssomeantagonism,andmaybeevensomehurtthatliesbeneaththat.ButIalsowasawarethattherewereanumberofpointswhereyoutouchedonsomerealtenderness,especiallyaroundCharlotteandmaybeevenaboutSarahandmyreadingisthatsomething’sgettingintheway,andthattalking,workingintherapy,mightbehelpfultoyou.Yousaidearlierthat’sit’sveryimportantforyoutomakesureCharlottegrowsupinadifferenthomethanthehomeyougrewupin…

[Developingasharedunderstanding]

C:Yup.

T:Ah,andsometimesdespitepeople’sbestefforts,ah,thepastcreepsupintothepresent.

C:NotwithCharlotte.

T:That’sgood.Ah,howdoyoufeelabouttheprospectofmeetingagain?

C:YouknowI,Idon’tknow,Imean,ah,beforecominginhereIwouldn’thaveimaginedthat,ah,soIsupposethatmeansnowIcanimagineit.

ROLEPLAY#2:KatherineMarksandDr.PainEstablishingatherapeuticallianceandexploringpsychotherapygoals

ThisisKatherine’sthirdpsychotherapysession.Inthetwosessionsthatprecededthis,ahistorywasgathered.Katherinewouldliketherapybutshe’sambivalent.Shewouldliketohopebutcannot,andshemightevennothavemuchofasenseofwhatshewants.Duringthissegmentthetherapisttriestoclarifytheclient’sgoals.

C:Umhum,soum,reallyitwasmyfriendwho,ah,suggestedthatIcomeandtalktoyou.

T:Whydidshethinkitwouldbehelpful?

C:Idon’tknow[laughing].I’mnotsure.I’mnotsure.ButIthought,sure,I’llgotalktosomeone,Iguess,sortofexplorewhat’sgoingon.

T:Toexplorewhat’sgoingon,okay.Thatsoundsgood.Whatwouldyouliketoexplore?

[Askingaboutchiefconcernsintheclient’swords]

C:Idon’tknow,uh,IguessIfeelalittlebitlost,Idon’tknow….It’slikethingsarehappeningaroundme,Idon’tknowhowtoexplainit.

T:WouldithelpifIaskedyouwhat,ifeverythingwentwellifweworkedtogether,whatwouldbedifferentifwehadasuccessfultherapy?[C:Uhhuh]Whatwouldchange,whatwouldfeeldifferent?

C:[Chuckles]Um,mylife,Imean,youknowmy,mywholelifewouldchange.

T:Yourwholelifewouldchange?Whatwouldchange?

[Exploringtreatmentgoals]

C:Um,Idon’tknowwhetherit’s,um,aneasinessaboutthingsorthere’s…

T:Insidethingswouldfeeleasier?

C:Uhhuh.Um,Idon’tevenknowactuallywhatImeanbythat,um.Idon’tknow.

T:Maybeit’sdifficulttoimaginewhatthingsyou’dliketofeelchangeinsideyoubutsomethingseemstohaveappealedtoyou.Anditseemstobeaninsidething.Yourwholelifewouldbedifferentbutyou’dfeeleasierinside[C:Uhhuh].Areyoufeelingthatrightnowaswesitandtalk?

[Exploringinthehere-and-now]

C:Ifeelreallylostactually.I’mnotquitesure.

T:Lost,okay.Andwhatdoeslostfeellike?

[Encouragingreflection]

C:Sortof,hmmm,notknowingwhichwaytogo,notknowinghowtomakedecisionsaboutthings,um,I,notknowingwhatIwanttodo,iftherewasanythingIwantedtodo.Idon’twantanything.Ihaveno,um,needofanything.That’sthefeeling,I’m

feelingquitedisengaged,sortof…I’mjustnotthatinteresting,right?Imean,it’sjust,Ihavenothingreallygoingon,there’snothingreallywrong,there’snothingreallythematter,it’sjust…

T:Sorrytointerrupt,I’mjustwondering….Ihearwhatyou’resayingandIcanseethatyou’renotinacutedistress,ifthat’swhatyoumean,butit’salmostlikeyoudaren’thopeforsomethingandmaybetellmeifI’minthewrongballpark,butitfeelslikeyouwouldliketo,somehow,hopeorexperiencesomethingtoreflecton,toseewhat’smissing.

[Returningtofocusontreatmentgoals]

C:Yeah,butIdon’tknowhowtogetthere.

T:I’mgettingafeelingthat,aswe’vebeentalking,insteadoffindingawaytotalktoeachotheraboutthethingsthatpuzzleyou,orthatyou’dliketoexplore,theoppositeishappening.IfeellikeI’minadvertentlysortofchasingyououtoftheroom.Thatsomehow,whatbeganasaverytentativecuriosity,isnowmovingtowardfeelinglessengagedhere.Howhaveyoufeltinthelastwhilesincewebeganthissession?

[Metacommunicatingoninterpersonalpulls]

C:Whatever,whateverhappenshereisnotgoingtomakeanydifference.That’ssortofhowitfeelstomebecauseIcan’tbe,Ican’tbehelped.Ijust,youknow,it’sallfine,it’sallgood,Ijustcan’tbehelped.

T:Thatsoundslikeyou’refeelingupset.Canyoustaywiththatfeelingandtalkfromitalittlebit?

[Encouragingmentalizingofafeeling]

C:Ah,it’swayeasiertonotknowthantoknowthatyoucan’tbehelped,Iguess,Idon’tknow.[tearful]

T:Itmakesyoucry?

C:I,uhhh,Ijustfeellikea,Ifeellikealostcause,I’malostcause,right[crying]?

T:Youknow,Inoticedyou’vestoppedlookingatmecompletely.

[Reflectingonbehaviorinthehere-and-now]

C:Idon’tknow,Idon’tknow.[sighing]Uh,I,Idon’twanttobeseenlikethis,Iguess,Idon’twanttobeseenlikeIneedhelporthatIcan’tgethelporthatI,youknow…

T:Butyou’rehere.

C:ButI’mhere.[Sighs]Ireallyhavenothingtocomplainabout.Right?

T:Itseemstomethatthere’sasortofwavelikemovementhere.Youcomeinwithalittletinyglimmerofhope;you’dliketofeeleasierinsideandwhenwestarttotalk,it’slikeyouwithdrawandIaskyouaboutthatandthere’sthehopeagain.

[Mentalizingabouttheclient’sinternalexperiences]

C:Uhhuh

T:Withtears,withrealworrythatyoucan’tbehelped,thatit’snotgoingtowork.[C:Uhhuh].Isthatawholenewsetofexperiencesforyousincethechildrenleft?Oristhispartofwhatyouhave,youlivewith?

C:Thisisold.

T:Thisisold?What’sold?

[Usinganot-knowingstance]

C:Um,awholebunchofthings,Iguess,um,feelingthatIbetterjusttakecareofmyself.Um,it’snotquitethat,um,Ireally,justreallynothingbig,it’sjustthatIdon’t,Idon’tthinkthatanybodycanreallyhelpme.ItjustfeelslikeI’mwhining;IfeellikeI’mwhining.

T:Youfeellikeyou’rewhining?Ifeellikethere’salmostakindofanurge,adesiretoaskforasortofhelpinghand.There’ssomethingthatyoufeelwouldbenefitfromabitofhelpatthistimebutitfeelslikequiteadangerousthingforyoutoconsider.You’resupposedtobeself-reliantcompletely.Tobeseentoneedabitofassistanceorsupportwouldbeasignof,woulditmakeyoufeelvulnerable,orwoulditbeasignofweakness?

C:Umm,I’mnotsureitwouldbethere,Iguess.

T:You’renotsurethatthehelpinghandwouldbethere?[C:Yes].Okay.

C:Soitwouldjustbewayeasiernottoask.

T:Sowhat’sthedangerofasking?Here.

[Processinginthehere-and-now]

C:Ofallthedangers[sigh],Iguessitwouldbeamiss;youknowwe’dmisseachother,youwouldmiss.

T:Soyou’daskforhelpandIwouldsortof…

C:Thinkitwassomethingelseandthen…

T:Okay,okay.WhatwouldImiss?

C:WhatI’mreallytryingtosay.

T:AmImissingitnow?

C:Idon’t,youknow,thisis,Imean,I’mnotsosurewhatI’mtryingtosaysoIcan’tputthatpressureonyou,Imean.

T:It’sjustawelloffeelingsthat’sjustunderthesurface.Canyousaysomething,whatyou’refeelingthatseemstobubblerightup?

[Encouragingmentalizingoffeelings]

C:What,Idon’tknowwhatyouwantmetosay[crying].Idon’tknowwhatyouwantme

tosay.Idon’tknowwhattosay…

T:Thefeelingsjustsortofebbawayandyou’renotquitesurewhat’shappening?Sohowisthissofar?Mysenseisyou’reriskingalittleherebyhelpingmeunderstandthisebbandflowofwishingtoreachoutandthenbeingquitenervousandwithdrawing.

C:Umhum.Itfeels,um,it’snotwhatIexpected,tosaytheleast.Itfeelsrisky,itfeelsodd…

T:Odd?

[Usinganot-knowingstance]

C:Odd,becauseIdon’t,Ididn’tknowIwasgoingtodothis,cryorfeelanythingreally.

T:Soyousurprisedyourselfalittlebit.

C:Umhum[sniffling].Umhum.

T:TheclearestthingI’veheardisthatthedangerisifyoureachoutyourhandforsomehelp,Imightmissit;misstheentirepoint.Missyou,mis-communicate.

C:Itislike,um,asyou’respeakingit’slike,ah,themissingislikeaperformance,it’slikeIdoaverygoodperformanceofallthethingsthatIdoinmylife.Andsopeoplerespondtothat.I’mgood,youknow?I’magoodwife;I’magoodmother,andmissingsomehow.Butit’snotanybody’sfault.

T:Soyou’reverygoodathelpingotherpeople.Growingyourchildrenup,beingawifetoyourhusband,beingaworker,andnowthechildren,don’tneedyouasmuchorasintenselyastheyhavedoneforthelastcoupleofdecades.Itseemsthatthis,thisperformanceaspectorthis“somethingmissingfeeling”comesuptoyourattentionabitmore.

C:Butthenagain,like,youknow,Ithink,amIjustwhining?AmIjust,whycan’tI,whycan’tIletpeopleknowwhatIwantordon’twant?

T:Whycan’tyouletpeopleknowwhat?Well,yousortofhavehere,haveyou?Haveyoutoldmewhatyouwanthere?

C:Yeah…

T:Well,let’smakesureI’veunderstoodthat.Whatwouldyoulikehere?

[Seekingclientfeedback]

C:Iguesstoreconnecttosomethingortogetclarityaboutsomethinginsideofmethatjust,I,Iguessitjustfeels,missing.

T:Right,right.Sothat’swhatyou’dlike.AndthedangeristhatIwon’tgetitandyouwillthenbeforcedintoasortofperformanceofgoodpatientor…[C:Uhhuh.]“Thankyouverymuch,doctor,thatwaslovely”orwhatevertheperformancewouldbe?

C:Icandothatreallywell.

T:Well,I,Ihearthat,yeah.Itcomestomymindthatforyouitseemstobedangerousto

say,“Something’smissingI’mnotclear,IthinkIcouldfeelawholelotdifferent.”Yousaidyourlifewouldbeentirelydifferentiftherapyweresomehowtohitthespot.Butit’sabitdangeroustobeabletobeawareofthosethings?

C:Ortoaskforthem.Imean,whatifI’mnotworthit?I’mnotworthit,right?I’mnot…

T:Youshouldn’twanttohavemorebecauseyou’renotworthit?

[Questioningthepathogenicbeliefoflowself-worth]

C:Well,itfeelslikeitwouldbeeasyenoughforsomeonetojustbrushmeoff,just…

C:Orit’stoomuchtroubleor,justno.

T:No?

C:Justno.

T:So,gosh,thatmustbequiteariskif“no”comestomind.Yousaidthiswasn’tquiteasyouhadexpected.Yousaidyousortofsurprisedyourselfwithtearsandfeelingscloserthanyouimaginedperhaps?Andhowbraveitistocomehereandexpectano,orhalfexpectano.

C:Uhhuh.

T:IcanseethethoughtsbutIcan’t…

C:…hearthem.

T:Itsoundedlikethat,ah,whatwereyou…

C:It’saninterestingidea.I’dneverthoughtaboutbraveryinthatrespect.

T:Youdon’tthinkofyourselfascourageous?Incominghere,uncertain,ambivalent,puttingwhatyou’dlikeonthetable,askingforsomehelp?

C:Imean,Iguessthelastquestionthenis,amIhelpable?Like,canIbehelped?

T:Whatdoyouthink?Tellme…there’ssomethingaboutthewayyou’reaskingmethatquestion.

[Usinganot-knowingstanceinsteadofreassuring]

C:Well,I,atthispointIknowIwanttobehelped.Um,whichisnotwhatIcameinwithreally.I’mnotsure;itmaybebiggerthananyonecanhelpmewith.Itmaybeabigproblem,itmaybe…unsolvable.Youknow,I’mtryingtogetapictureofwhat,what,Ican’tgetapictureofwhatitisthatI,thathelplookslike.

T:Ithoughtforamomentyouweregoingtoaskmedirectly,willyouhelpme,andthenwe…

C:[laughing]

T:AndIthought,well,thatwouldbe,thatwouldbe…

C:Verybrave.

[Demonstrating“presence”withpositiveregard]

T:Wonderful.Yeah,thatwouldbeterrificifyouasked.Imeanitwouldseemtometobesomethingyouactuallywanttodo,notparticularlyperformance-related.

ROLEPLAY#3:JoelWalkerandDr.LeszczUsingcountertransference,mentalizing,andmetacommunication

We’regoingtolooknowatsession2betweenJoelandhistherapist.Joelhasdifficultyrelatingandexpressingemotions,buthegeneratesstrongfeelingsinthetherapist.Thetherapistfeelsunderattack.HefeelstheneedtoprovehimselfandwantsJoeltoseehimaspartofsomethinghelpfulratherthanasashaming,humiliating,orcrushingforce.That’sapowerfulmotifinJoel’slife.ThefactthatthisthemeisbroughtintothesessionischallengingbutgreatnewsbecauseitmeansJoelandthetherapistareclosetoJoel’scoreconcerns.

T:Morning,Joel.Goodtoseeyouagain.There’salotthatIwanttoaskyouaboutbutbeforeIdothatIwanttoaskyouhowyoufeltaboutthelastmeetingandaboutcomingbacktotoday’smeeting.

[Seekingclientfeedback]

C:Ithoughtaboutit.YouknowitwasdifferentthanIexpectedsoitwasokaytocomebackforsure.

T:Canyoutellmethewaysinwhichitwasdifferentthanwhatyouexpected?

C:I,IknowIdidn’treallyfeellikeabagofshittalkingaboutallthisstuff,right?Ah,andah,andIguessthatwasdifferentthanIexpected.Iguess,youknow,withtheresponsethatyouhadwas,Iguess,differentthanIexpected.

T:Yeah,Iwanttothinkaboutthat,IwanttolearnmoreaboutthatbutI’mgladthatitfeltdifferentinapositivewayfromwhatyouexpected.Thatphrasethatyouuse,“abagofshit,”isthathowyou’vebeenfeeling?

[Askingaboutconcernsusingtheclient’swords]

C:SometimesIdo.SometimesIdo.

T:Canyoutellmeaboutthat?

C:It’sjustsomethingallmylifethat’shappened.Imean,Idon’texpectthattochangereally.

T:Yousaidallyourlife?Goingbacktowhen?

C:Well,youknow,likeallmylife,right?Youknow?Whenisitsomethingyoucanchangeandwhatisjustacharactertrait,right?Youknow,you’rejustthatguy,right?I’mthatguyandthat’showIgettofeel,that’sall.

T:Howdoyouthinkyoucomeacross?

[Encouragingreflectiononinterpersonalimpact]

C:Well,Idon’tknow.ItrynottocomeacrossatallwhenI’mfeelinglikethat.Youknowsometimesyou’rearoundpeoplewhenyou’refeelingthatway.Lotoftimesit’sthemthat’smakingyoufeelthatway.Or,whatever,but,youknow,it’dbebetterjustto,justtotryandshutthehellupandgetthroughit.

T:Uhhuh.Sojustkindofshutdown,keepyourheaddown;justtrytogetthroughit.

C:Hey,ifyoucandoit,that’swhatyoudo.

T:Whathappensifyoucan’t?

C:Well,Idon’tknow,Idon’tknow.Youknowit’dbenicetobetheinvisiblemanforafewminutesbutIcan’tdothat,so,youknow…Well,it’shardwhenyourwifekicksyououtofthehouse.

T:Whatwouldyourwifesay—Iknowthis,you’regoingtotellme“askSarah”—butsinceSarahisnothere,whatwouldSarahsayaboutthisidentificationassomebodypeoplewanttogetawayfrom?

[Exploringinterpersonalpulls]

C:Idon’tknow!She’dprobablysay,“Ican’ttalktoyouwhenyou’relikethis.”

T:Ican’ttalktoyouwhenyou’relike[C:Yeah!]thisbecauseofwhat?

C:That’sthepartyou’dhavetoaskherabout,um,…look,I’llbehonestwithyou,there’sapartofmethatsaysthat’sjustfinebecauseIdon’twanttotalkrightnow,youknow?So,so,youknow,backoff.

T:Whenyousay“rightnow,”you’retalkingaboutrightnowherewithyouandme?Oratthispointintimeinyourlife.

[Exploringthehere-and-nowalliancetension]

C:It’sbeginningtobeabitofboth.Imean,whatdoyouwantmetosay?

T:Well,there’snothingthatIparticularlywantyoutosay.WhatI’mthinkingisthatyou’vecarriedaroundafeelingofbeingworthlessandsomebodypeoplewanttogetawayfrom.Andthat’satoughwaytogothroughlifeandI’mconcernedthatyou’vebeenfeelingmorethatwayrecently.Andthatitmaybemakingittoughforyoutobewithpeople—eventhepeoplethatyouwanttobewith.

[Mentalizingabouttheclient’sexperienceswithothers]

C:It’snottoughformetobearoundthepeoplethatIcareabout,it’s,ah,it’stoughforthemtobearoundme.That’swhatIget.

T:Thatit’stoughforthemtobearoundyou?

C:Well,theydon’twanttobearoundme.Sarahdoesn’tanyway.

T:“Peopledon’twanttobewithyou.”Thatgeneratessomefeelingsforyourightnowandthatwouldbeprettypainful,Iwouldimagine.

[Expressingempathy]

C:Youknowwhat,it’spainfulifyouwanttobewiththem.

T:Yeah.

T:Whatwe’retalkingaboutobviouslytouchesalotoffeelingforyou.CanIaskyou,

Joel,totrytotracksomeoftheemotionofwhatyou’reintouchwithrightnow?

[Exploringhere-and-nowfeelings]

C:Trackit?

T:Yeah,payattentiontoit,commentonit,describeit.

C:Idon’tknow.It’sjust,it’sjust,that,ah,that…it’slikewhenSarahwouldsay“tellmewhatyou’refeeling,tellmewhatyou’refeeling.”Andyouknow,itjust,andIwould,youknow,it’sjust,like,“whatdoyouwantfromme?!”Idon’tknow…I’msorry,I’msorry,I’msorry,Ijust…

T:You’resorryaboutwhat?

C:Idon’tknow,like,like,what…

T:IthinkyouletmeintosomethingreallyimportantrightnowandI’mgratefultoyouforthat,becauseI’maskingyoutodosomethingthatsoundslikeSarahhasaskedyoutodothatisveryhardforyoutodo,andthatistotrytotalkabouthowyouarefeelingwhenyou’refeelingreallybadlyaboutyourself.AndIthinkthathowyourespondtothat,ifthisisakindofwindowintothat—what’shappeningwithyouandme—isthatyougetangry,andthenyoufeelregretful.Andyoukindofjustcollapseinonyourself.Anditdoes,Ithink,asyou’vearticulated,leadpeopleyouwanttobecloseto,leadthemtowanttowithdrawfromyou.

[Metacommunicatingaboutmaladaptiveloops]

T:DoyouthinkwhenSarahasksyou,orevenwhenIaskyouhowyou’refeelingthatitmightbecomingfromaplaceofinterestorconcern?

[Challengingpathogenicbeliefsbyaskingtheclienttomentalize]

[Silence]

C:Whatconcernthough,youknow?Whatconcern?Youknow?Youtellme“whatareyoufeeling,”Imean,howdoIknowyou’renotsayingtome“what’swrongwithyou?”Right?

T:Isthatwhatyouhear?“What’syourproblem?”Irealizethisisveryhardforyou.

C:Idon’tknow,ah,Idon’tknow.Youknow,dowehavetotalkaboutthis?Imean…YouaskmetotellyouwhatI’mfeeling,right?Sarahasksmetoo,“what’sgoingon,whatareyoufeeling,”whatever,it’s,like,it’s,it’s,“Whyareyouthewaythatyouare?”That’sbehindeveryquestion,there’ssomethingwrongwithyou.“Why?”

T:You’veidentifiedsomeveryimportantthingsthatIthinkwarrantourattention.Youfeelverybadlyaboutyourselfanditsoundslikeit’sbeengoingonforalongtime.Idon’tknowthefulldimensionofwhythatis,howthathascometobe.ButwhatIhearinyourrelationshipwithSarahandwhatIfeelhereisthatit’shardforyoutofeelsupportedandyou’remuchmorelikelytofeelcriticizedandI’mawareevenwhenI’msayingthattoyou,itmayfeelforyoulikeI’mpilingon.Ireallyamnot,it’sreallynotwhatIintend[C:Right].Itsoundstomelikeyouhavebeenreallyquitealoneforalong

time.Thatanykindofoverturesomebodymakestowardyou,eveniftheyarecomingfromapositionofcaringaboutyou,feelslikethey’regoingtoexposeyoutomorecriticism.

[Metacommunicatingtoseekasharedunderstanding]

C:Okay.

T:ItwouldbehelpfulformetoknowifwhatI’msayingtoyoufeelslikeit’sintherightballpark?

C:Youknow,maybeitis,Idon’tknow.LikeImean,it’s,likemyperspectiveisdifferentthanyours’cuzyou’re,you’relookingatitfromoutside,right?SoyouknowIgetto,Igettofightformyselfright?That’smyperspective.

T:Feelsforyoulikeyou’vebeendoingalotoffightingforyourself.

C:Ihaveto.

T:Youhaveto.Good.

C:Doesn’teverybody?

T:Ithinkyou’vehadtodoalotmorefightingthanalotofpeople.Well,that’swhatIhopewe’llbeabletotalkabouttogether.

ROLEPLAY#4:KatherineMarksandDr.PainUsingcountertransference,mentalizing,andmetacommunication

ThisfollowingsegmentisfromKatherine’ssixththerapysession.Inthesessionthatprecededthis,Katherinehadrecalleddetailsofherrapeatage14,aswellasthefailureofpeoplearoundhertohelpheratthetime.Wecanhypothesizethatherfamilywereunable,unwilling,oruncertainofhowtoassistherthroughthattime.ThisfailuremayberelatedtoKatherinecomingtofeelundeservingofhelpandunabletoconnectdeeplywithherselforothers.

T:Howwasthelastsession?Anythoughts,feelings,reflections?

[Checkingforfeedback]

C:Youknow,thesessionitselfisabitofabluractually.Um,yeah.But,ontheweekendfollowingthat,um,Iwasbothexhausted—justexhausted—andsortof,um,Iwouldn’tsaydepressedbutsortofreallyirritable,justsnappy,just,youknow,nothingisrightiswhatitfeelslike.

T:Doyouthinkyou’rerelatingthattothesessionalittlebit?

C:Ican’t,yeah;Ican’trememberfeelingthatwaybeforeactually.

T:Feelingsnappy,irritable?

[Mentalizingfeelings]

C:Yeah.

T:Okay.Sodoyouremember…Iagreewithyou…Ineverkindofrememberwordforwordwhatwesay,butI’mjustwonderingifthereisawayinthatthatsnappinessorirritabilityrelatestohowyou’redoingintherapy,let’ssay,orgenerallyhowthingsfeel.

C:Um.Idon’tknowhowtoanswerthat.Iguess,youknow,I…IguessI’mfindingoutnewinformation.I’mfindingoutmoreaboutmyself,whyI’mfeelingwhatI’mfeeling.Butthat’ssortof,Ithink,tellingyouwhatyouwanttohear.Idon’tactually,right,so…

T:Wereyouperforming?

[Seekingasharedunderstanding]

C:Iwas.Sorry,um,yeah,sothey’rehardactually.Thesesessionsarehardforme.Yeah,andIguessyouknow,thelastone,itdefinitelyfeltconnectedtothesession,thatIreallyjustwantedtolayinbedallweekend.That’swhatIwantedtodo.

T:Andthat’ssortofrelatedto…Youknow,letmetellyouwhatIremember.BecauseIrememberformeit,feltlikeabitofamarkerbecauseyoufairlyspontaneouslyrelatedthisperformancemodeasyou’vedescribedwithasensethattherecouldbemorebutyou’renotquitesureifyou’reentitledtofeelbetter,performless,andlivemoreorbemore.Youkindofrelatedthattotherapethatyou’vealwaysremembered,Ithink,

whenyouwere14.Andasyousaidlasttimequiteclearly,thatthatwasoneofthelasttimesyouremembertryingtoreachoutforhelp,inthemonthssubsequenttotherape.Thatyouwouldhavelikedsomemoresupport.You’dhavelikedtohavepeoplehelpyou,yourfamilybethereabitmoreforyou.Andyettodayyou’renotquitesure…whenIjogyourmemorydoesthatcomebackabit?

[Modelingmentalizingandlinkingtraumatopresentexperience]

C:It,itdoes.It’smuchclearerwhenyourelayitbacktomethanIthinkmyexperienceofit.Um,it,yeah,becauseit’s…myexperienceofit,especiallyduringthemonthsafterwardswasthatitwassomethingthatIdid.Right?Thatitwasmyfault.Ihadputmyselfinharm’sway.Thatwasthephrase,“Iputmyselfinharm’sway,whatwasIthinking?”Yeah,toget,um,my,bothmyparentsto,yeah…Notexactly,sono,theywerecompletelyincapableof,of,ah,beingthere,understandingtheeffectthatithadonme.That’swhereweendeduplastweek.Theywerecompletelyincapableofunderstandingtheeffectthishadonme.Right.

T:Andtheweekend’sirritability…

[Encouragingmentalizingoffeelings]

C:Right.Right.Yeah.

T:What?

C:Well,I’m,Imean,Iguesspartofmeisbeginningtoseethatitwasn’tjustmyfault.Thatotherpeoplecouldhavesteppedintohelpmeinwaysthattheydidn’t.Um,but,Istillputmyselfinharm’swaysothere’sthisthinggoingon.Istill,Iwasstillthestupidpersonwhoputmyselfintothesituationso…

T:Sothere’sonetendencytotakethatkindofblameandthenthere’sthisotherkindoftendencytosayasyoujustdid,theycouldhavebeenmorehelp.Andthere’sthatsortofirritableexperienceovertheweekend.SoI’mwonderingifthatkindof“it’smyfault,”“well,actually,Iwas14.”

C:Yeah,um,andtheforgivenessofthat,right?Theforgivenessoftheparentswhoweren’tthere.Theforgivenessofthefriends,who,youknow,didn’tthinkitwasanybigdeal,right?So,Ijustforgave,Ijust,youknow,itwasmyfaultandyouknowhowcouldtheyunderstand?AndIthinkifIwere,ifithappenedtomydaughter,ifithappenedtomykids,Iwouldbe,right,I’dbe…

T:What?

C:Well,I’dberightthereforthem.I’dberightthere.Imean.

T:Youwouldn’tblamethem.

[Validatingthattraumavictimsarenotatfault]

C:No,Imean,no.Soagain,I’mstucktryingtofigureouthowtothinkaboutthis.Imean,itfeelslikeit’ssortofnewinformation.

T:Whichpartisnew?

C:Thefactthattherecouldhavebeenmorehelp.Therecouldhavebeenadifferentresponse.Hmm…

T:Canyouthinkoutloudaboutthat?

C:Well,youknow,I’vefeltlikedamagedgoods.Foryears,Ifeellikedamagedgoods.ImeanI’m…

T:Whatdoesthatfeellike?

C:ItfeelslikeI’mconstantlyneedingtoapologizeandtomakeupforandtodotherightthingbyandtodomorethanand—it’sexhausting[T:Uhhuh].It’sexhausting.

T:Andthenewinformationis…isitfromourvantagepointasadultwomen,wewouldn’t,wecouldn’tpossiblyimaginehowa14-year-oldwouldputherselfinharm’sway.

C:No,andyouknowthekindof…becausemymother’snotawful.Likeshe’s,she’sanempathicperson.But,withyouknow,somanydifferentpeople,um,andthenjusttohavethatabsence.Itwasreallylikethat,right?“Whatdidyoudo,howcouldthishavehappened?”Youknow,almost“howcouldyouhavedonethistous?”whichislike…ButnowIreallydon’tknowwhattodowiththisinformationbecausereallyitjustpissesmeoffnowmorethanIcanevenimagine,um.Probablymorethanpissesmeoffbut,youknow,Idon’tknowwhattodowithit.

T:Do?

C:Withthisinformation,withthiswaythatI’mfeeling,with,thatit’snotokay.It’snotokay.

T:What’snotokay?

C:Thattherewasnoonethere.

T:Howdidyoumanage?

[Contrarymove:Shiftingfocusfrominternalexperiencetobehavior]

C:[Sighing]Um,Ijust,Iwascompletelydeadinside.Iwasjustsortofnumb.Ididreallywellinschool.IdideverythingthatIwassupposedtodo.

So,allthispastweekend,Iwasjustexhausted.Iwasexhausted,right.AndIwasjustfeelinglikeIdidn’twanttodoanything.AllIwantedtodowaslayinbed,really.Andnoonewasgoingtoletmedothat.Ihadneighborswhowerecalling,Ihadmyhusbandtryingtogetmetomakedinnerforhim,Ihad,youknow,mymothercallingaboutmydad.Anditwaslike“justleavemealone,leavemealone.”SoImanagedtobackthemalloff.Idon’tknowhowIdiditactuallybutImanagedtobackthemalloffandstayinbedfortheentireweekend.Ifeltreally,Idon’tknow,indulgent,butitwasgreat![Laughter]Itwaslikereallygreat.Iwas,youknow,andIcan’tremember…I’veneverdonethatbefore.Yeah,I,yeah,mymotherwasshocked.Shewas,like,Iwasverycurt,Iwasjustverycurt.AndI’mnevercurtwithher,right,becauseshe’sso,she’stheperfectmother.SoIjustsaid,“Notnow,I’mbusy.”“Whatareyoudoing?”

“I’mlayinginbed,”youknow,“gotalktoDadyourself,Ican’t,Ican’tsolvethisforyou.”AndI,thatwasit.Hungup.

T:Andwhatwasthatlike?

[Mentalizingofpositiveemotions]

C:Itwasreally,itwasreallyfun.Itwasreallyfun.

T:Whatdidyoudoinbed?

C:Iread.[Laughter]IreadallthebooksthatsitbesidemybedandIneverevergettoreadbecauseIjustnevergettoreadthem.Ijustread,Ididnothing,really.Imean,Ijustread,itwasgreat.

T:Icanfeelit.

[Modelingmentalizing]

C:Itwas![Laughter]Itwasgreat.Justtodonothing,foranyone.Todonothingforanyone.Igotuptogotothebathroom,thatwasit.Thatwasit!Andmaybegetsometoast.Butthatwasit.Like,Imean,honestly,forgetit,likemyhusbandwasinshock,hethoughtIwasreallysick.

T:Hewasworriedaboutyou?

C:Hewasworried.Hewasworried.Itdidn’tstophimfromaskingmetomakedinnerbuthewasworriedaboutme.ButIdidn’tmakehimdinner.SomaybeIdon’tknow.

T:Wow.

C:Iknow.Itwasgood.

T:Itwasgood.

C:I’llhavetodothatagain!It’sverygood.

T:Sohowdoesthatrelatetoourworkhere?Tellmeaboutthat.We’vecomeonabitofajourneyandnowsuddenlywe’relaughingbecauseyoudecidedtogoonstrike.

[Metacommunicatingaboutthehere-and-now]

C:Right.

T:Orgoonareadingbinge[C:Areadingstrike].Yes.Sohowareyoudoing?

C:Ifeellighter.IfeellighterthanIdid,absolutely.IfeelwaylighterthanIdidlastsession.Um,Ifeelmore,Idon’tknow…morelikeme?Morelike,yeah.

T:Feelstomelikethere’smoreofyouintheroom.IfeellikeI’mnotsortofrunningaroundsomehowchasingyouor…itfeelslikeyou’rerightthereandwecanconnectinaway.

C:Yeah,andIdon’t,Idon’t,Idon’tfeellikeI’mperforming.Thatwasonethingforsure.IdidnotfeellikeIwasperformingthisweekend.Ishouldn’thavebeenthisexhausted.Performanceisexhausting,right,nottherealthing[T:Yes,yes].Thisdoesn’t,thisfeels

energizing,Iguess,Imean,it’snotexhausting.

AppendixB:PracticeReminderSummary

(RefertotheenclosedPracticeReminderCard.)

AchievingPsychotherapyEffectiveness:AHealingContext

Therapistqualitiesandcharacteristicsthatpromoteatherapeuticalliance

Empathy,Responsiveness,Interest,Rapport,PositiveRegard,Genuineness,andtheabilitytomanagestrainandrepairtensionswithinthealliance

RELATIONSHIPS:Developasharedunderstandingoftheclient’srelationshipsthatshapedhisorherinternalworkingmodel,attachmentpatternsofrelating,interpersonalpulls,pathogenicbeliefs,andmaladaptiveloops.

Enquireaboutanddiscover:

•Developmental,earlylife,significantrelationships(e.g.,withcareproviders)

•Whatwererelationshipslikewhentheclientwasyounger?

•Howwereupsettingfeelingsmanagedinthefamily?

•Whatwerespecificrelationships,suchaswithaparent,like?

•Towhatextentwasthehomeenvironmentfrighteningandchaotic,orstableandreliable?

•Currentrelationships,todiscoversocialsupportsalongwithinadvertentinterpersonalpulls

•Noteextremesofdisengaging,distancingversusaffiliative,enmeshed;dominantversussubmissive,passive

•Rememberthatinterpersonalpullsareopposinginthedimensionofpower,andcomplementaryinthedimensionofaffiliation

•Historyofunresolvedtrauma,itscomplexsequelae,andfeelingsofunderlyingfear

•Theexperienceofthetherapeuticalliance(e.g.,interpersonalpulls,transference/countertransference)

ATTACHMENTPATTERNSOFRELATING

Secure Preoccupied Dismissing Disorganized

Careproviders’characteristics

Goodenough Inconsistentlyresponsive

Mostlyunresponsive

Frighteningorfrightened

Attachmentbehaviors Fullrangeandflexible

Dialedup Dialeddown Unclassifiable,fluctuatesunpredictably

Others’experienceofthisperson

Trustworthy,reliable

Overwhelming,needy

Distant,aloof Discombobulating

ATear-and-RepairPsychotherapyProcess

Becloseenoughtotheclienttoriskgettinghookedintomaladaptiveloops,whileretainingthereflectivecapacitytousethosemomentstherapeutically.Seektoprovideexperientialdisconfirmationofpathogenicbeliefsandexpectations(e.g.,ofharm,negativejudgment,disinterest)byrespondinginwaysthatchallengemaladaptiveloopsandfosterapositivesenseofselfwithempathy.Emphasizetheadaptivenatureofyourclient’sefforts.Beattunedtointerpersonalconsequences,thetransference/countertransferencedynamic,andtrauma.

ANAPPROACHTOPSYCHOTHERAPYEFFECTIVENESS

Buildastrong,positivetherapeuticalliance

Developasharedunderstandingofaclient’srelationalworld

•Earlyattachmentrelationships

•Currentrelationships

•Transferenceandcountertransference

Identifyself-fulfillingpropheciesthatreinforcepathogenicbeliefs(maladativeloops)

Whenbehaviorallyoremotionallyhooked.getunhooked

Mentalizing

Metacommunication

Taketheimpactoftraumaintoaccount

Mentalizing

Thinkingaboutthoughtsandfeelings—yourownandothers’.Mentalizinghelpsclientstoappreciatethatothershavemanydifferentbeliefs,understandings,andintentions;aperson’simpactisnotalwayswhattheyintend;andsometimespeoplefeelonewayandactanotherway.

Modelmentalizing

•Reflectonmentalstates

•Communicateaboutmentalstates

•Wonderaboutintentions

Usea“not-knowing”stance

•Beopenandcuriousaboutwhatisinyourandothers’minds

Usecontrarymoves

•Askquestionstovaryfocusbetweenthinking,feeling,andfromdifferingperspectives(e.g.,self/other,internal/external)

Collaborateincreatingacoherentnarrative

Metacommunication

Therapistandclientthinktogethertounderstandandrepairamomentoftensionasashareddilemma,withoutassumingparallelswithotherrelationships.

Withnoninjurious,validating,therapeuticintent:

•Acceptresponsibilityforcontributingtothetension.

•Highlightthatweaffecteachother;modelreflection.

•Exploretheclient’sexperienceofthehere-and-now.

•Becuriousaboutstatesofmind.

•Reflectcollaboratively:Whyisthishappeninginthiswayrightnow?

•Judiciously,tentatively,andreflectively:

•Thinkoutloudaboutsubjectiveperspectives

•Seekunderstanding

•Shareemotionalreactions

Remembertheimpactofunresolvedtrauma

Unresolvedtraumacanunderlieexcessivearousal,intrusivememories,avoidance,depression,anxiety,anger,problemsinregulatingemotions,medicallyunexplainedsymptoms,memorygaps,dissociation,self-harmbehaviors,substanceabuse,andrelationshipproblems.

•Arethedisturbingtraumaticexperiencesontheclient’smindfrequently?

•Istheclientreflectiveaboutthetrauma?

•Whomhastheclienttoldabouttheevents?

•Whatisitliketellingyounow?

•Howmuchhastheclientintegratedtraumaticmemoriesintohisorherlifestory?

AppendixC:AnswerKey

LESSONPLAN#11.Thequalitiesofatherapistthatcanimprovetherapeuticalliancesincludeaccurateempathy,rapport,psychologicalavailability,positiveregard,responsiveness,interest,genuineness,andtheabilitytorecognizeandrepairalliancestrains.

2.Examplesofindirectwaystoaskabouttreatmentgoalsincludeaskingquestionssuchasthefollowing:Ifthiswastohelpyou,iftherapywassuccessful,whatwouldthatlooklike?Whatwouldthatbelikeforyouinyourlife?Howwouldyoufeeldifferently?Howwouldworkoryourrelationshipsbedifferent,orhowyoufeeldifferentlyaboutyourself?Ifwecouldlookahead6monthsfromnow,whatwouldbedifferentforyou?Ifaskingquestionslikethesedoesnotyieldacleargoal,asanextstepthetherapistmighthavetotentativelysuggestwhatsheunderstandsthegoalmightbe.Todothis,thetherapistcansynthesizeinformationandofferahypothesisaboutthetreatmentgoalandthenseekfeedbacktoensuretheworkiscollaborative.

3.Thetherapistconsidersmultiplesourcesofdatainordertoinformanunderstandingofaclient’srelationalproblemsandsuffering.Theseincludeearlylifeandcurrentsignificantrelationships,historyoftrauma,relationalepisodes,andthehere-and-nowmomentsofinteractingwithinthetherapeuticrelationship.Takingalltheseintoaccount,atherapistcangleanasenseoftheclient’sattachmentstyle,pathogenicbeliefs,andinterpersonalpulls.

4.Awarenessofmoment-to-momentchangesinemotionalstatesornarrativecoherenceduringsessionscanhelpaclienttochangeunderlyingpathogenicbeliefsthatperpetuatedifficultiesinrelationships.Affectivelychargedmomentsservetomarkmaterialtofurtherexploreandprocess.Itistherapeuticallyproductivetowonderaboutandexplorewhyatopic,person,recollection,orsomethingaboutaninteractionleadsaclienttobecomeirritable,overwhelmed,discombobulated,ordisengaged.These“tipoftheiceberg”reactionsareessentialtoexamine.Intheprocessofexplorationwithinasafetherapeuticmilieu,aclientcanmakelinkstounderlyingpathogenicbeliefsortounresolvedtraumaticexperiences.Maladaptiveinterpersonalbehavioralloopsmayappearduringmomentsoftensionordisconnectioninthetherapywhentheclientexpectsthetherapisttorespondasothershaveintheirsignificantearlyrelationships.Whenthisoccurs,itisatherapeuticopportunityforrepairinwhichtheclientcanlearnexperientiallythatwhatwastrueinthepast,isnotnecessarilytrueinthepresentorinfutureinteractions.Aclient’sexperienceofatherapistasresponsive,caring,genuine,andinterestedcreatesahealingcontextinwhichtobereflectiveratherthanreactive.Thispermitstheclienttobemoreemotionallyregulated,moreinsightfulintohisorherimpacts,andmoreawareofhisorherinterpersonal,behavioralchoices.Insightgleanedfromtherapeuticprocessinginthehere-and-nowstrengthensself-confidenceandbuildsamorepositive

self-image,whichovertimeimprovescurrentrelationships,thushelpingtochangeunderlyingbeliefsandresolvemaladaptive,self-perpetuatingproblematicloops.

5.Transferenceandcountertransferenceareimportantinpsychotherapy.Transferencereferstothesometimesunconsciousexpectations,attitudes,andfeelingsthataclientdirectstowardhistherapistthatarebasedmoreonhispastexperienceswithothers(encodedintheinternalworkingmodel)thanonwhatishappeninginthepresenttherapeuticrelationship.Countertransferencereferstothecorrespondingexpectations,attitudes,andfeelings,whicharealsosometimesunconscious,thatatherapistexperiencestowardtheclient.Countertransferencemayprovideanothertypeofinformationabouttheinterpersonalpullsthatleadtomisunderstandingsbetweenaclientandothers.Whentherapistsfeelchallengedorstressed,andhavestrongnegativecountertransference,theirresponsescanbeharmfultothetherapeuticrelationship.Becauseitishardtothink,beempathic,ormentalizeunderstress,therapistscanbecomehostile,antagonistic,defensive,orwithdrawnwheninthegripofastrongcountertransferencefeeling,insteadofpausingtoreflectonamoreconstructiveresponse.Understandingthesehere-and-nowdynamiccluestodifficultiesinmomentsofalliancestrain,andfindingaconstructive,nonblaming,empathicwayofexploringthemwithaclientcanprovideapowerfultherapeuticexperience.

6.Thefollowingtablecharacterizesimportantfeaturesofthehistories,behaviors,andinterpersonalimpactsofadultattachmentstyles.

Secure Preoccupied Dismissing Disorganized

Careproviders’characteristics

Goodenough Inconsistentlyresponsive

Mostlyunresponsive

Frighteningorfrightened

Attachmentbehaviors Fullrangeandflexible

Dialedup Dialeddown Unclassifiable,fluctuatesunpredictably

Others’experienceofthisperson

Trustworthy,reliable

Overwhelming,needy

Distant,aloof Discombobulating

7.THEINTERPERSONALCIRCUMPLEX:Wherewouldyouplaceeachoftheclientsonthetapeddemonstrationsontheinterpersonalcircumplex,andwhatwouldyoupredictregardinginterpersonalpullson,andresponsesfrom,others?Theclientsportrayedintheroleplaysbothexpectlittleofothers,andtheyareemotionallydistant,butindifferentways.WhereasJoelcomesacrossasantagonisticandadversarial,expectingcriticismorharmfromothers,Katherinecomesacrossascompliantanduncertain,expectingothersnottobeinterestedortocare.Itishelpfultounderstanddistancinginterpersonalimpactsonothers,includingthetherapist.

Joelmapsontothehostiledominant(northwest)quadrantofthecircumplex.Hisdistancingandoverpoweringbehaviorevokeshostilityandwithdrawalfromothers(i.e.,theyfeelpulledtowardhostilityandwithdrawal).Thus,Joel

mayinadvertentlyevokewhathedreads:ahostileresponseinwhichtheotherpersonbecomesinterpersonallydistant.Awareofthesepulls,thetherapistintentionallyresistsbyremainingproximallyaffiliatedandactive.

Thisisanexampleinwhichbehavioronthedimensionofpowerpullsforamatching,hostileresponseratherthanpullingforitsopposite.(Dominancethatiswarmoraffiliativeismorelikelytopullforasubmissiveresponse.)

Katherinemapsontothesouthwestquadrantofthecircumplex,beingdisempoweredanddisengaged.AlthoughsheisnotovertlyadversariallikeJoel,sheisnonethelessdistancing.Inthefaceofhersenseofpowerlessness,otherswillbepulledtorespondbybeingoverlyactive(andthisunderestimationofhercapacityforself-efficacywouldleadthemtoact“for”her,whichwouldservetoperpetuateherdisempoweredstance).Onthehorizontal,affiliativeaxis,althoughsheisnothostile,Katherineisdisengaging,holdingnoexpectationsofothersasbeinginterestedorhelpful.Notehowsheoftentellsthetherapistthatshedoesn’tthinksheneedshelp.Thissetsupthepossibilityofthetherapistsimplyagreeingandoverlookingherstruggles.Therefore,theresponsethatKatherine’sbehaviorpullsforwouldinadvertentlyevokearecapitulationofanearlyexperienceofbeingoverlookedinatimeofneedanddistress.

LESSONPLAN#21.Mentalizingisaprocessofreflectingonwhatisinone’sownmindandthemindsofothers.Whenwementalizeweunderstandthatintentionsaren’tvisibleandmaycontradictactions.Mentalizingcanbeusedinpsychotherapytreatmentinthefollowingways.

a.Atherapistcanmentalizetounderstandaclient’sdifficulty.Thismaybeespeciallyimportantwhenearlyadversityimpairsaclient’scapacitytoaccuratelymentalize

abouthisownmindandaboutthemindsofothers.

b.Atherapistcanmodelmentalizingtofosteraclient’sreflectivethinkingandcommunicationofmentalstates.

b.Atherapistcanuseanot-knowingstancebyshowinghumilityaboutherlimitedabilitytotrulyunderstandaclientandbyexhibitingcuriosityaboutaclient’sinnerworld.

b.Atherapistcanusecontrarymovesbystrategicallyshiftingaclient’sattentiontodifferingaspectsofexperienceordifferentperspectives.Contrarymovesareespeciallyusefulwhenaclientisinaruminative,nonmentalizingstateofmind,overlyfocusedononeoftheextremesofthedimensionsof(1)thoughtversusemotions;(2)innerversusexternalexperiences;(3)self-focusedversusother-focused.

b.Atherapistcanusementalizingasameanstocollaborativelycreateacoherentnarrative,tofostergreaterself-awareness.

b.Mentalizingisalsoagoaloftreatmentbecausementalizingisaskillthatcanbeacquiredtobuildresilienceandwell-being.

2.Metacommunicationisatherapist’scommunicationabouttheprocessesofcommunicationthatoccurbetweenthetherapistandclient.Itisusedtounderstandamomentoftensionasashareddilemma,withoutassumingparallelswithotherrelationships.Thetherapistspeaksabouthersubjectiveperspectiveandawareness,andsheexplorestheclient’sexperienceinthehere-and-now,withcuriosityaboutinternalstatesofmind.Thetherapistacceptsresponsibilityforhisorherownunwittingcontributiontotensions,whichservestoemphasizethewaysweaffecteachother,andmodelsamentalizing,reflectivestancefortheclient.Duringthisprocessitisimportantthatatherapistfocusonvalidatingratherthanblamingtheclient.Appliedwithtactandcare,metacommunicationcanbeusedasaninterventiontohelpclientstounderstandandchangetheirroleintheinterpersonalpatternsthatcontributetosuffering.

3.Atherapistcanbeattunedtoanumberofsignalstosloworpauseexploration.Indicatorsofaneedtoslow,pause,orchangetacticsincludeaclientbeingextremelydisengaged,dissociating,or,attheotherextreme,beingoverlyaroused,andaffectivelydysregulated.Thisisespeciallyimportantforclientswithinsecureattachment,inordertofosterareflectiveprocess.Helpingaclienttoregulatehisemotionsrequiresattendingtohislevelofarousal.Thereisarangeofoptimalarousal—azoneinwhichwearealert,attentive,andengagedwithoutbeingoverwhelmedorwithdrawn.Clientswhohaveexperiencedtraumaareoftentoohighlyaroused(thehypervigilanceandoverstimulationoffear)ortoounaroused(thenumbing,avoiding,anddissociationthatdefendagainstfear).Reflectioncannotoccureffectivelyineitherofthosestates,sothetherapistmustworkwiththeclienttohelphimtoreturntoamoreflexiblestate,inwhichexplorationandtherapeuticprocessingcanoccur.Overtime,thetherapisthelpsaclienttowidentheoptimalzoneand“makeroom”forthe

extentofarousalthataccompaniesallofhisemotions.Effectivetherapistsaccomplishthisgoalbyusinginterpersonalstrategiessuchassupportandvalidation,maintainingpresence,andconsistencyinthetherapy.

Inthesemomentsinwhichaclientisoveraroused,ordisengaged,atherapistcanshiftfromexplorationtovalidation,orshecanfocusmomentarilyonanothersubject,lettingtheclientknowthatsheisdoingthistoprovideamomenttoregaincomposure.Atherapistcansubsequentlyusemetacommunication,withcuriosityandreflection,tomakeitclearthatsomethingshifted.Withanot-knowingmentalizingstance,shecancheckinwiththeclientandseekfeedback,askingtheclienthowheisdoingandwhetherthetherapistmayhaveinadvertentlydoneorsaidsomethingthataffectedtheirtherapeuticprocessinanegativeway.Alternatively,contrarymovescanbeusedtoreestablishatherapeuticprocesswhenthetherapistishookedintofeelinglikewithdrawing,controlling,oractingonacountertransferencereaction,suchasarguingwithoropposingtheclient.Itcanbehelpfultorewindtothemomentwhenthecountertransferencefeelingsbeganandthenrestorementalizingprocessesbyusingacontrarymove.

4.Atherapist’sabilitytoremainreflectiveandtherapeutically“present”canbechallengedbyclientswhoareinsecureintheirattachmentstyle.Aclient’sinternalworkingmodel,whichprescribesasetofexpectationsaboutothersandhowheshouldbehaveinrelationships,maychallengeatherapist’sabilitytomentalizeandcanincreasethepotentialforreenactmentofamaladaptiveloop.Adismissingindividualmayassumethatotherswillbeunavailableandthereforemayacttoincreaseinterpersonaldistance.Ifatherapistdoesnotreflect,shemayinadvertently“accepttheinvitation”andworkwiththisclientinanemotionallydisengagedanalysisofproblems.Suchanapproachwouldservetoreinforcethemaladaptivelooptowhichitgivesrise,ratherthanchallengeit,andwouldnothelptheclienttochange.Similarly,apreoccupiedclientwhosignalshisattachmentneedsexcessivelymaypullhistherapistinto“crisismode,”leadingtoaffectivelyoverchargedinteractionsandafailuretomaintainappropriateboundaries.Withawarenessofthesedynamics,atherapistcanprovideatherapeuticinteractionthatdisconfirmspathogenicbeliefsandpromotes

understanding,self-compassion,andself-efficacywiththediscoveryofsolutions.

5.SAFETYCONCERNS:Whenatherapistisconcernedabouttheriskofself-harmorharmtoothers,includingcircumstancesofdomesticviolence,itisimportanttoaskquestionstoclarifyfacts,actions,andintentions.Avoidancecangeneratemoretensionandunease.Whentherearehighlevelsofconcernaroundsafetyrisk,involveorconsultwithothermentalhealthspecialistsregardinginterventionsthatensurethesafetyofall(e.g.,activatingreferraltoemergencyservicesornotifyingchildren’saidservices).Domesticviolenceiscommonandmustbeassessedandmonitored.Atherapistactivateshelpwhennecessary,suchascomingupwithsafeexitplansandoptionsforalternativehousing,orinvolvingsocialservicesandthepolice.AnexampleofaskingquestionsaroundsafetyriskisillustratedinthetranscribedroleplaywhenDr.LeszczseekstoclarifyJoel’smentionof“thewhip”byinquiringaboutbothworkandhome.

6.SomeoftheinteractionsbetweenJoelandDr.Leszczillustrateamaladaptiveloopusingtheinterpersonalcircumplexandtransference/countertransferencedynamicstoaidinunderstanding.Joelanticipatesthathewillbejudgedorcriticized,andherespondswithdefensive,hostile,anddismissivebehavior.Thisattitudewouldevokeadistancing(andpotentiallyhostile)countertransferencereactioninthetherapist.Thisisanexampleofamomentof“tear”thatcansubsequentlybeusedforthetherapeuticprocessingof“repair.”Thestraininthetherapeuticallianceisrepairedbyprocessingtheinteractionwithareflective,engaged,andaffiliativestance.Tocounterthepullofahostileanddisengagedcountertransferenceresponse,thetherapistunderstandsitasdata.Usingthisinformation,heseekstoreducetheclient’ssenseofvulnerabilitybybeingtransparentandexpressinganintentiontoremainengaged.

7.Therearemanyrightwaystorespondtherapeuticallytoamomentofstrain.Affectandemotionaremarkersoftherapeuticopportunity.Inthissequencethetherapistusesmetacommunicationandmentalizingtoaddresstensionsinthealliance.Thetherapistrespondstothisaffectivelychargednodalmomentbyaskingtheclienttomentalizeaboutwhatmaybeinthetherapist’smind,tryingtoresistthehostilepulloftheclient’sangrydistancing.Mentalizingwiththeclient,hecounterstheclient’sexpectationofcriticism.Inthisprocessingofthealliancestrain,maladaptiveloopsandunderlyingpainfulpathogenicbeliefsoftheinternalworkingmodelarerevealedwithinthehere-and-nowofthesession.Thisopensupimportantcorestrugglesforfurtherexploration.

8.Asimportantasitistorecognizeandworkwithcountertransferenceandinterpersonalpullstoguidetherapeuticprocesses,itisalsoimportanttoregisterevidenceoftherapeuticbenefit.Herearethreekindsofimprovementaclientmayreportordisplaythatwouldbeevidenceofbenefit:

a.Thepresentingcomplaintsofsymptomsordistresswilllessenorremit.

b.Theclientwillreportimprovedoverallfunctioning,inhisrelationships,work,orotheraspectsofhislife.

c.Theclientwillbemoreemotionallyemboldened,present,reflective,and

thoughtfulaboutwhatisgoingoninhisinnerworldandinthemindsofothers,withgoodnarrativecoherenceaboutself-referentialpastexperiences.

LESSONPLAN#31.Whichemotionisconsideredtobeatthecoreoftrauma?Fear.Itistraumaticforpeopletobebothterrifiedandtrapped.Itisalsoterrifyingtofeelaloneinatimeofgreatfearandneed—whetherornotoneisactuallyalone.

2.Clinicalphenomenathatcanalertustothepossiblepresenceofaninvalidatingchildhood,orcaregiverswhocouldnotprovideadequatesafetyandreassurance,includeemotionaldysregulation;impulsivity;relationshipproblems;narrativeincoherence;andsubstanceabuse.

3.Howcommonistrauma?Howmighttraumaaffecthealth?Howmighttraumaaffectrelationships?Studiessuggestthatupto60%ofclientsinoutpatientmentalhealthcaresettings,andasmanyas90%ofinpatientpsychiatricpatientshaveexperiencedatleastonetraumaticevent.Traumaaffectsthementalandphysicalhealthofanaffectedindividualinmultipleways,includinghighersymptomratesandpoorerfunction.Commonpsychologicalproblemsareaffectdysregulation,self-harm;mood,anxiety,personality,substance,anddissociativedisorders;andmedicallyunexplainedsymptoms.Poorerphysicalhealthinvolvesahigherriskofearlymorbidityandmortalityandapoorerhealthself-evaluation.Ahistoryofneglectorabusecanunderlieinsecureordisorganizedattachmentpatternsofrelatingandmentalizingdeficits,whichcanaffectaclient’sself-esteem,abilitytoformtrustingrelationships,andqualityoflife.

4.Whendoesatherapistscreenfortrauma?Traumaisassessedwitheveryclient,atthetimeoftheinitialassessmentandduringthecourseoftherapy.

5.Howistraumaassessed?Traumaisassessedinmanyways.Initiallytraumaisassessedbygentlebutdirectquestionsaboutexperiencesinwhichaclienthasbeenveryfrightened.Atherapistalsoobserveshowaclientdescribeshisorherrelationshipsandexperiences.Narrativeincoherence,includingveryvagueoroverlyinclusivedescriptions,cansignalanuntoldhistoryofabuseorneglect.Ifaclientbecomesoverlyaroused,overwhelmed,orhasanincongruentlackofaffectinthemidstofspeakingaboutunresolvedtraumaticexperiences,thetherapistcanrecognizeempathicallythattheclientisdistressedandsuggestheswitchthesubjecttoanareaoflessstresstohelptheclientregainhisemotionalbalance.Traumaexpertsdescribethezoneofoptimalarousal,whichcanbequitenarrowforclientssufferingfromunresolvedtraumaticexperiences;theyareconsequentlyeitherhyper-orhypo-arousedwhentryingtotalkabouttheirexperienceinanassessment.

6.Questionsthatatherapistcouldusetoaskabouttrauma:

a.Whomhaveyoutoldabouttheevents?

b.Whatwastheirreaction?

c.Whatisitliketellingmenow?

d.Howoftenisthetraumaonyourmind?

e.Whereareyouwithregardtohealingthisdifficultexperience?

7.Therearedifferingwaysofunderstandingwhysomepeoplefailtorecoverfromtraumaticexperiencesandsufferfromchronic,unresolvedtraumaticsymptoms.

a.Therecanbeacumulativeimpactofrecurrentexposuretotraumaticexperiences,asisseeninmembersofthemilitarywhoaredeployedtoofrequentlywithalackofsupportandinadequatetimetorecover.

b.Traumasurvivorswithahistoryofaninvalidatingchildhoodenvironmentcombinedwithanexperienceofmultipletraumaticeventscanalsohavechronicpsychiatricsymptoms,poorfunctioning,andinterpersonaldifficulties.Aninvalidatingchildhoodmakesitconsiderablymoredifficulttorecognizeoracceptcompassionandassistancefromothers.Furthermore,iftraumaoccurswithinachild’shomewithcaregiverswhoarefrightening,frightened,orunableorunavailabletooffersolaceandprotection,thetraumaticexperiencesbecomeinextricablyjoinedtotheexperienceofinvalidation.

8.Moment-to-momentattunementtomentalstatesandfeelingsbyusingmentalizingaidsinthetherapeutichealingprocessandunderstandingofaclient.MakingsenseofKatherine’stentativenessinthefirstsessionistricky.Initiallyshemakesagoodargumentforwhysheshouldn’tbeintherapyandthetherapistmaybepulledintobeinginagreementwithher.Katherinewouldliketherapybutmayfeelthatshe’sdamagedandhaslowself-esteem;thussheisnotabletoexpressorbeintouchwithherneedandwishforhelp.Shewouldliketohopebutshecannotbecauseshefeelsthatshehasnorighttohope.Thetraumaticrapecombinedwiththebetrayalsheexperiencedwhenherparentsdidnotrespondortaketheassaultseriouslyconvergedtoshapealowexpectationofothers.Thiscomestolifeinherambivalenceaboutbeingattunedtoherowninternalfeelingsorthoughts.

9.Byemployingmentalizingandmetacommunication,thetherapistexploresanawarenessofanddiscussionoftheimpactsofearlylifeexperiences,includingtheresponsesofotherswhoshapedtheclient’ssenseofself.Thetherapisttriestofocusonboththecurrentandpresentexperiencesoftheclientwithmoment-to-momentattunement,fosteringreflectionwithinazoneofoptimalarousal,usinganot-knowingstance,andencouragingmentalizingbytheclientaboutherown14-year-oldselffromthevantagepointofthepresent.Thetherapistthenhelpshertomakelinks—toseethatlifeexperienceshaveanimpactonhersenseofselfandonhercognitiveexplanationsandideasaboutherselfaswellasonemotionalstates.

LESSONPLAN#41.WhatisyoursenseofDanielle’sattachmentstylebasedonthebriefvignette?Basedontheclient’sself-relianceandreluctancetoexpecthelpfromothers,herattachmentappearstobedismissing.Inlightofthis,thetherapistwilllistenforsignsofavoidance

thatmaynotbeadaptiveinthesecurrentcircumstances,inwhichDanielleneedshelpfromothers.

Whatotherinformationwoulditbehelpfulforthetherapisttoknowinordertoenhanceherunderstandingoftheclient’smaladaptiveloopsandinternalworkingmodel?Aswell,hertherapistcaninquireaboutconfidantes,closerelationships,andDanielle’srelationshipswithcareprovidersearlierinherlife,explainingthatlearningaboutpastrelationshipsisoftenhelpfulforunderstandingcurrentstrugglesinrelationships.Examplesofhelpfulquestionsincludethefollowing:Whatwererelationshipslikeforyouwhenyouwereyounger?Howwereupsettingfeelingsmanagedinyourfamily?Howwereyoudisciplined?Tellmeaboutyourrelationshipwithyourfatheroryourmother?Whatwereyourmotherandfatherlike?Whenyouwereafraid,whodidyougoto?Whatwasyourhomeenvironmentlike(e.g.,frighteningandchaotic,orstableandreliable)?

Inthecaseofdismissingattachment,thereisoftenacareproviderwhowasconsistentlyunresponsive.Adismissingclienttypicallytendstobeself-reliantandself-sufficientincurrentrelationships,toexpectlittleofothers,andtobehaveinwaysthatcreateinterpersonaldistance,asDanielledoeswhensheturnsdownherfriend’sofferofhelp.

ThetherapistmayalsobealerttoevidencethatDanielleisdistancingherselfinthehere-and-nowofthetherapeuticrelationship.

2.Usingprinciplesofmentalizing,howmightthetherapistrespondatthismoment?ThetherapistcanmodelmentalizingbyofferingwhatisinhermindinresponsetoDanielletellingheraboutherexperience.Shemayalsoofferavalidating,empathicreflectionaboutwhatsheimaginesDanielleisexperiencinginternally.Forexample,shecouldsay,“Icouldbeoffhere,butIhavethesenseofyoubeingsimultaneously

thisscaredchildwhofeelsshecannotreachout,andanadultwhoinfacthasquiteadeepcapacitytocopewiththedifficultcircumstancesoflivingwithcancer.”

Alternatively,shecanuseacontrarymoveandshiftfocustofostermentalizing.BecauseDanielle’sfocusissituatedinternallyinastateofemotion(feelingsadandscared),thetherapistcouldaskheraquestionthatshiftsherfocustoanexternalperspectiveandaskabouthersenseofwhatmightbeinthemindsofthoseotherswhoareofferingtohelpandtoprayforher.Forexample,“Whatdoyoumakeoftheparishioners’wishingtohelpyou?”Recognizingherlegitimateneedsandthecaringintentionsofsomeofherfriendsmayleadtoagreateracceptanceofherownsenseofvulnerability.

Athirdoptionwouldbetomentalizeaboutthethoughtsandfeelingsofthosewhotrytoofferhelp.“Iwonderwhatitfeelslikeforafriendwhooffershelpwhenyouareunabletoreceiveit.Maybeyouhavebeeninthatpositionandcanrememberwhatitfeltliketoberefused?”Daniellemayrecognizethatitcanbehurtfulandupsettingwhenaclosefriendinneedkeepsafriendatbay.Thesurprisingrecognitionmaypromoteafreshlookatwhysheiscompassionatetoothersbutdeniesthemthechancetobecompassionatetoher.

3.Takingtraumaintoaccount,whatdoyouthinkaboutMilton’searlierreluctancetodiscloseordiscussdetailsofarecentassault,aswellasthetherapist’snotpushingtopursuethis?

Thisclienthasanearlyhistoryoftraumacoupledwitharecenttraumaticevent.Unresolvedtraumacanbefragmentingtoaclient’scoherencewhenunderstress.ByrespectingMilton’swishtoavoidthetopicatfirst,thetherapistavoidspromptingtooearlyadisclosurebyMilton,whichcouldberetraumatizingifitistooforcefuland

mistimed.However,inretrospect,thetherapistmayhavebeenabletohelpMiltontospeakmoreabouttheassault.Thiscanusuallybedonebyexplainingtheneedtotheclient,emphasizingthattakingitslowlyandstayinggrounded(i.e.,withinazoneofoptimalarousal)mayallowhimtoshareafewfacts.Inthisway,thetherapistcouldhelphimthinkaboutthetraumatherapeutically.

Whenthereisahistoryofacuteorchronictrauma,itisespeciallyimportanttokeeptheimpactsoftraumainmind,asdescribedinchapter5.Thereisoftenatensionbetweenopposites.Forinstance,theclientturnstothetherapisttohelpresolvehisdistressandatthesametimeexperiencesthetherapistasfailinghim,aspreviouskeypeopleinhislifehad.Thetherapistalsohastobeawareofinterpersonalpullstoeitherrescuetheclient,ortodistanceherselffromhim.Theremaybeothercountertransferencereactionstotheclient’spainfulaffectsaswell.Thetherapistmayfeelhookedintoadistancinginterpersonalpullandmaybeconfusedbytheclient’slossofnarrativecoherencewhenhespeaksaboutthetrauma.Usingthisknowledge,thetherapistcanusementalizingtounderstandthesedilemmasandtopromoterepairandreengagementintherapeuticprocessing.

4.Usingmetacommunicationandmentalizing,howmightthetherapistrespondtothismomentofstraininthetherapeuticalliance?Thetherapistcanspeakabouthersubjectiveperspectiveandawareness,acceptingresponsibilityforherowncontributiontothemisunderstandingbysayingsomethinglike,“Idon’tmeantoupsetyou.Youareright.Ihadn’tunderstoodthatyouhadbeenassaultedasanadult.Perhapsyouwantedmetoknowwithouthavingtogointoit.Itsoundslikeitwasprettyfrightening.Iwishtohelp,andIknowyouneedmetofilloutthisreportandwe’llgettothis.ButI’mtryingtosortoutwhatmayhavehappenedbetweenus.Whydoyouthinkwedidn’ttalkaboutthismore?Whatdoyouthinkhappened?”Then,shecanexploretheclient’sexperienceinthehere-and-now,withcuriosityabouthisinternalstateofmindandappreciationofhisfearanddistress—“Aswe’retalkingaboutthis,Iwanttocheckinwithyou.Howareyoufeeling?Doyoufeelsafeinthisroom?Whatareyouthinking?”Thismodelsamentalizing,reflectivestanceforthe

client.Thiscanhelptorepairthealliancetension,provideexperientialdisconfirmationofhisnegativeexpectationsofothers,andmovetowardincreasinghiscapacityforinteractingwithreflectionandawareness.

5.Howmightthetherapistusemetacommunicationtodealwithanactionthathasbeenfrustratingtoaclient,inordertobegintoprocesstheeventwithinthehere-and-nowofthesession?Thetherapistcanusemetacommunicationtotalkaboutthemomentofstraininthetherapeuticalliance.Shecanasktheclientiftheycantalkaboutwhathappenedandhisreactions.Firstapologizingforthelateness,shecanconveythatsheisgladthattheclientstayedandtheycaninfactmeet.Thenshecanbegintoexplore:forexample,“Let’shavealookathowmydelayinseeingyoumadeyoufeelandwhattheimpactofthatisonourrelationship.”

Metacommunicationprinciplesguidethetherapisttoexpressempathy,identifythemomentofchange,andacknowledgehisorherroleinamomentoftension,apologizingifappropriateformissingsomethingorupsettingtheclient.Acollaborativediscussionoffeelings,suchasanger,andimpactswithinthehere-and-nowcanaidintherapeuticprocessing.Developingamutualunderstandingofanalliancetearparadoxicallycreatesanopportunityforrepairthatcanhelpaclientfeelvalidatedandrespected,emotionallyregulated,calmer,andreflectivewithinthesafetyofthealliance,ratherthanreenactingamaladaptiveloop.

6.Inthiscase,howmightaninternalworkingmodelformedearlyinlifeaffecttheclient’scurrentexpectationsinrelationships?Howdoestheclient’scapacitytomentalizerelatetotheseexpectations?Aninternalworkingmodelcanmisleadclientstoexpectpeopletobehaveorrespondascareprovidersdidearlierinlife.Thisclientmayexpectotherstobeunresponsiveanddemanding,reactingtotheirownconcernsinsteadofhavinghiminmind.Deficitsinhisabilitytomentalizemakeitdifficultforhimtoappreciatethatothersmaywellhavedifferentbeliefs,understandings,andintentionsthanheexpects.Ashedevelopshisabilitytomentalize,hecancometorealizethataperson’simpactisnotalwayswhatisintended.Thinkingaboutandimaginingwhatisinthemindofsomebodyelseandoneselfisatthecoreofmentalizing.

7.Whatdoyouthinkaboutthisclientbeingabletotalkaboutthesexualassaultwithbothherfiancéandtheircounselor?Thisclientistakingtheriskofsharingthefactshewassexuallyassaultedasachildwiththosewhoareclosetoher.Sheseemstowantherfiancéandpastortoknowmoreaboutwhosheis.Perhapspriortotherapyshe

wouldhaveexpectedherrelationshipstofallapartasherparents’marriagedidwhenhersexualassaultwasrevealed.Sheisattemptingtoincludeandultimatelyintegrateherpastintoherautobiographicalnarrative.Herabilitytoadaptherstoryoftraumatodifferentcircumstancesandlistenersisanindicatorofasuccessfulpsychologicalresolutionofthetraumaticmemories(andagoodcapacitytomentalize).Itwouldbehelpfulinthiscasetoprocessthispositivestepandcelebratorymomentintherapy,acknowledgingherabilitytoshareherexperienceofassaultasrepresentativeofhertherapeuticgains.

MultipleChoiceQuizAnswerKey1.c.Thetherapeuticallianceisbothaspecificandcommonfactor,becausethealliancemustbeestablishedwithinthespecificmodelapplied.

2.b.Approachesandconsiderationstorepairtherapeuticalliancerupturesincludeunderstandingstrainsintheallianceasopportunitiestodisconfirmpathogenicbeliefs.

3.a.Thefollowingstatementaboutmetacommunicationisfalse:Metacommunicationinvolvescommunicationaboutmeta-analyticresearch.

4.b.Sympathy

5.e.Pooroutcomesinpsychotherapymay:

•Beduetotheimpactofthetherapist’sself-doubt,anger,oravoidanceofchallengingclients.

•Berelatedtoanincompleteorinaccurateassessment

•Reflecttherapistcontributionsrelatedtoaninflexiblerelianceonaparticulartechnique.

•Beduetosubtlehostilityordisingenuousempathyfromthetherapist.

6.d.Transferencepatternsincludebeingpredominantlyangry,anxious,avoidant,orsexualized.

7.e.Countertransference:

•Canbeunderstoodasunconsciousandsometimesovertattitudesandfeelingsthatthetherapistcarriestowardtheclient.

•Mayinterferewithoptimalunderstandingandresponsivenesstotheclient.

•Maycontributetooptimalunderstandingandresponsivenessasavaluablesourceofclinicaldata.

•Isa“jointcreation”ofboththeclientandtherapist.

8.b.Regardingethicalpracticeandresponsibilitiesinpsychotherapy,thefollowingstatementisfalse:

•Boundariesareintendedtoreinforcepowerimbalancesbetweenthetherapistandclient.

9.e.Todevelopasharedunderstandingofaclient’srelationalworld,itishelpfultolearnabout:

•Developmentalhistoryandrelationships

•Currentsignificantrelationships

•Unresolvedtrauma

•Aspectsofthehere-and-nowtherapeuticrelationshipsuchastransference

10.c.Thecircumplexdescribesinterpersonalimpactsorpullsthatcontributetothemaladaptivetransactioncycle.Clientsmayinadvertentlyworsenrelationshipsthroughtheinterpersonalpullstheygenerate.

11.d.Foratherapisttounderstandaclient’sinternalworkingmodelandattachmentstyle,inferencescanbemadefromobservationsaboutallEXCEPTsocioeconomicstatus.

12.e.Achild’sattachmentstyle:

•Emergesasthebestadaptationtoacomplexenvironmentandisencodedinaninternalworkingmodel.

•Isinfluencedbysocialstressors,resources,socialsupports,andqualitiesofparenting.

•Shapesexpectationsofothers’responsiveness.

•Affectsresilience.

13.d.Avalidatingenvironmentinearlychildhoodpromotesthedevelopmentofattachmentsecurityandisfosteredbyparentsorprimarycaregiverswhorespondtothechild’sfearsoastorestoreasenseofsafetytothechild.

14.e.Adultattachmentstyles:

•Canbedividedintosecureandinsecuretypes.

•Canbedividedintoorganizedanddisorganizedtypes.

•Reflecttheinternalworkingmodeloftheindividual.

•Helpthetherapistunderstandtheclient’ssenseofhimselforherselfandtrustofothers.

15.b.Whichattachmentstyleischaracterizedby“dialed-up”attachmentbehaviorswithamplifiedexpressionsofdistress,intensehelpseeking,anexpectationofrejectionorabandonment,andanxietyaboutbeingalone?Preoccupied.

16.b.AllofthefollowingaretrueEXCEPT:unresolvedtraumaalwaysleadstoPTSD.

17.c.ThesequelaeofunresolvedtraumaincludeallEXCEPT:medicallyexplainedsymptoms.

18.a.MentalizingtechniquesincludeallEXCEPT:usinga“knowing”stancetomakeinterpretations.

19.e.Thetear-and-repaircycleinpsychotherapy:

•Makesuseofalliancetensionsastherapeuticopportunities

•Usescountertransferenceandmetacommunication

•Providespotentialdataaroundaclient’srelationalpulls

•Requiresthetherapisttoberesponsiveratherthanreactive

20.b.WhatisyourinitialimpressionofJacob’sattachmentpattern?Preoccupied.

21.d.Basedontheinformationyouhave,wherewouldyoumapJacobontheinterpersonalcircumplexandwhatresponseswouldyouexpecthimtopullfromothers?

•Affiliative/friendly-Submissive(southeast),pullingforaffiliativedominancefromothers

22.c.WhatisyourinitialimpressionofMary’sattachmentpatternofrelating?

•Dismissing

23.a.Basedontheinformationyouhave,wherewouldyoumapMaryontotheinterpersonalcircumplexandwhatresponseswouldyouexpecthertopullfromothers?

•Hostile/disengaged-Dominant(northwest),pullingfordisengagingdominancefromothers

24.d.ImportantaspectsofthetherapeuticalliancetobeawareofincludeallEXCEPTtheclient’sabilitytobepsychologicallyminded.

25.e.Characteristicsoftheexemplarypsychotherapistasperceivedbycolleagueshavebeendescribedasincluding:

•Capacitytobereflectiveratherthanreactive

•Genuineinterest,caring,andcommitment

•Empathiccapacityandconceptualability

•Self-awarenesswiththecapacitytocontainanxietyandrecognizelimitsandfit

AppendixD:TherapistWorksheet:AssessingandReflectingonCommunication

WHATWASTHECOMMUNICATION/INTERACTION?

Whatisyourunderstandingoftheclient’sexperienceandfeelingsinthatinteraction?

Whatcountertransferenceorpullsdidyoufeel?

Howdoesthisfitwithyourunderstandingoftheclient(attachment,interpersonalpullsonthecircumplex,historyofunresolvedtrauma)orpathogenicbeliefsencodedinaninsecureinternalworkingmodelthatwaspreviouslyadaptive?

Understandingthisinteractioninthisway,howwouldyouplantorespondifamomentlikethiswasrepeated?*

Inapsychotherapysession,ifamomentofinteractionfelttenseorwasdifficulttorespondto,usetheabovetoreflectonyourin-sessionexperiences,responses,interpersonalpulls,andunderstanding.

Secure Preoccupied Dismissing Disorganized

Careproviders’characteristics

Attachmentbehaviors

Others’experienceofthisperson

*Aimtoclinicallyrespondinwaysthat(1)validateaclient’sfeelings(i.e.,sadness,anger,fear,anxiety,worry,disappointment,orfrustration);(2)areexpressedwithgenuineinterest,empathy,andpositiveregard;and(3)donotmakeaclientfeeloverwhelmedordefensive(i.e.negated,dismissed,criticized,judged,invalidated,interrupted).

AppendixE:RecommendedReading

Tofurtherexploreevidence-basedaspectsofpsychotherapy,attachment,theinterpersonalcircumplex,mentalizing,metacommunication,andtheimpactoftrauma,readtheseauthoritativeworks.

Allen,J.G.,Fonagy,P.,&Bateman,A.(2008).Mentalizinginclinicalpractice.Arlington,VA:AmericanPsychiatricPublishing.

Bateman,A.W.,&Fonagy,P.(2012).HandbookofMentalizinginMentalHealthPractice.Washington,DC:AmericanPsychiatricPublishing,Inc.

Bowlby,J.(1969).Attachmentandloss:Vol.1:Attachment.NewYork,NY:BasicBooks.

Fonagy,P.,Gergely,G.,Jurist,E.,&Target,M.(2005).Affectregulation,mentalization,andthedevelopmentoftheself.NewYork,NY:OtherPress.

Kiesler,D.J.(1996).Contemporaryinterpersonaltheoryandresearch.NewYork,NY:JohnWileyandSons.

Lanius,R.A.,Vermetten,E.,&Pain,C.(2010).TheImpactofEarlyLifeTraumaonHealthandDisease:TheHiddenEpidemic.Cambridge,UK:CambridgeUniversityPress.

Mikulincer,M.,&Shaver,P.R.(2007).Attachmentinadulthood:Structure,dynamics,andchange.NewYork,NY:Guilford.

Norcross,J.C.(2011).Psychotherapythatworks:Evidence-basedresponsiveness(2nded.).NewYork,NY:OxfordPress.

Safran,J.D.,&Muran,J.C.(2000).Negotiatingthetherapeuticalliance:Arelationaltreatmentguide.NewYork,NY:Guilford.

vanderKolk,B.A.,MacFarlane,A.C.,&Weisaeth,L.(1996).Traumaticstress:Theeffectsofoverwhelmingexperienceonmind,bodyandsociety.NewYork.NY:Guilford.

Weiss,J.(1993).Howpsychotherapyworks:Processandtechniques.NewYork,NY:Guilford.

Acknowledgments

ProducingPsychotherapyEssentialstoGohasdependedonandbenefitedfromthesupportandexpertiseofmanypeople.Wewishtoacknowledgeandthankthemanyexpertswhoprovidedthefoundationsonwhichtheapproachdescribedinthisbookwasbuilt:PeterFonagy,AnthonyW.Bateman,JonG.Allen,EphiBetan,JeremyD.Safran,J.ChristopherMuran,BesselvanderKolk,RuthLanius,JohnBowlby,DonaldJ.Kiesler,andJohnC.Norcross.WearegratefultotheOntarioMinistryofHealthandLong-TermCarewhoprovidedfundingtotheeducationaloutreachpilotprojectteamoftheNorthernPsychiatricOutreachProgramattheCentreforAddictionandMentalHealth(CAMH);NancyMcNaughton,WayneWard,andtheUniversityofTorontoStandardizedPatientProgram;RobertSwensonandRobertG.CookeandtheOntarioPsychiatricOutreachProgram;theUniversityofTorontoDepartmentofPsychiatry;theMountSinaiHospitalDepartmentofPsychiatry;theMountSinaiPsychotherapyInstitute;theMorganFirestonePsychotherapyChair;ScottMitchellandtheCanadianMentalHealthAssociation’snorthernOntariobranchexecutivedirectorsandhealthcareworkers.Wealsowishtothankalltheactorswhobroughtthematerialtolife,TomandReetMaeandJoryLyonsofMaeStudios,andConnieKim,aswellasAndreaCostella-DawsonfromW.W.Nortonforherpersistence,help,andsupportoftheseries.

References

Ainsworth,M.,Blehar,M.,Waters,E.,&Wall,S.(1978).Patternsofattachment:ApsychologicalstudyoftheStrangeSituation.Hillsdale,NJ:LawrenceErlbaumAssociates.

Allen,J.G.(2013).Restoringmentalizinginattachmentrelationships:Treatingtraumawithplainoldtherapy.Washington,DC:AmericanPsychiatricPublishing.

Baldwin,S.A.,&Imel,Z.E.(2013).Therapisteffects:Findingsandmethods.InM.J.Lambert(Ed.),BerginandGarfield’shandbookofpsychotherapyandbehaviorchange(6thed.).NewYork,NY:JohnWileyandSons.

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Index

Pagenumberslistedcorrespondtotheprinteditionofthisbook.Youcanuseyourdevice’ssearchfunctiontolocateparticulartermsinthetext

[Pagenumbersinitalicrefertoillustrationsorboxedtext.]

Aacceptance

ofclient,12

oftraumaticexperience,61

affectandemotion

client’sself-regulatorycapacity,44–45,144–145

effectsofinvalidatingexperienceinchildhood,18–19

identifyingtransference,28,29

affiliation

ininterpersonalcircumplex,24–25,135

therapeuticgoals,63–64

alleviating,42

anxiousattachmentstyle,64

arousal

paceoftherapyandclient’slevelof,144–145

therapeuticgoals,44–45

traumasymptoms,54–55,150–151

attachment

adultmanifestationofchildhoodexperiences,22–23

assessmentof,9,20–21,153–154

developmentalsignificanceof,16,19–20,135

attachment(continued)

informationofinternalworkingmodel,19,20

insecureformsof,22–23,42–43,134,142

quizquestions,95–97,98–100,160–161

secure,22,134,142

theory,67

intherapeuticrelationships,41–42

therapist’sanxiousstyle,64

Bbeingpresent,9–10,35

betrayalintrauma,61–62

Cchange

acceptanceofclientand,12

commonfactorsofpsychotherapy,6

disconfirmingclient’spathogenicbeliefsfor,38–39

effectiveuseofstrainsintherapeuticalliancefor,37–38,148–149

goalsfortraumatherapy,61

signsofimprovement,149

therapeuticallianceasmechanismof,7,140–141

therapistqualitiesasmechanismof,5–6

circumplexmodel

pullsin,25,25

purposeof,23–24,69

quizquestions,95,98–100,162

structure,24,24–25,69,135

therapeuticusesof,25–27,38–38,74–75,142–143

client’srelationalworld

assessingcurrentpatternsin,21–27,134,140

developmentalhistoryof,16–21,133–134,140,153

formationofpathogenicbeliefsand,31–34

quizquestions,94,160

scopeofassessmentof,15–16,16

therapeuticsignificanceof,6,8

seealsoattachment;circumplexmodel;interpersonaldynamics

cognitiveschema,16–17

communication

fordiscussingtherapeuticgoals,11–12

therapist’sskills,6

seealsometacommunication

confidence,17

containing,42

contrarymoves,136–137

defined,46,68

therapeuticusesof,46,144,146

countertransference

inassessingclient’straumaexperience,59–60

associatedthoughtsandfeelings,30

clinicalsignificanceof,29,29–30,48

defined,27,68,141

interpersonalcircumplexand,27

quizquestions,93–94,159

recognizing,28–29

role-playtranscripts,121–132

therapeuticprocessingof,48,141–142,148,149

D

depression,traumaand,54,55

desensitization,61

development

assessingclienthistory,15,16–21,21

attachmenttheoryof,16–17,135

ofinsecureattachments,42–43

withinvalidatingcaregiver,18–19,42

invalidatingchildhoodastraumariskfactor,57

obstaclestomentalizingability,42

ofpathogenicbeliefs,31–34

invalidatingenvironment,17–18,41–42,96

dismissinginsecureattachment,22–23,42,68,134,142,153–154

disorganizedattachment,23,68,134,142

domesticviolence,147–149

Eeffectivepsychotherapy

coreskillsfor,7

cross-modalityprinciplesof,1–2,6

determinantsof,6,7

learningobjectivesfor,3–4

obstaclesto,35–37

sequentialapproachto,9–10,66,136

therapistqualitiesasdeterminantof,5–6,63–66

emotionalself-regulation

paceoftherapyandclient’scapacityfor,144–145

therapeuticgoalsandstrategiesfor,44–45

empathy

developmentof,inchildhood,17

insequentialapproachtoeffectivepsychotherapy,9

aspsychotherapyoutcomefactor,6

ethicalpractice

quizquestions,94,160

safetyconcerns,147–149

therapist’sresponsibilities,13,13,65

evidence-basedpractice,5–6,66

Ffear,astraumaoutcome,55,149

feedback,client,6,39,109,118,121,126

Ggenuineness,therapist,6

goals,therapy

communicationabout,12–13,139–140

aspsychotherapyoutcomefactor,6

role-playtranscripts,12–13,139–140

good-enoughparent,17,68

good-enoughtherapist,43

Hhealingcontext,6

here-and-now,9,33–34,68

role-playtranscriptsexploring,104,114,115,117,123,124,132

hookingandunhooking,9–10,27,38–40,49–50,51–52,63,136

Iinternalworkingmodel

attachmentexperienceindevelopmentof,16,18–19,20,22–23,135

defined,16–17,68–69

interpersonalcircumplexmodeland,23–24

mentalizingcapacityand,48–49,157–158

pathogenicbeliefsin,31

quizquestions,95

interpersonaldynamics

circumplexmodel,23–27,38–39,69,74–75,95,135,142–143

quizquestions,94–95,160

therapist’sattentionto,ascoreskill,7

seealsoclient’srelationalworld;therapeuticalliance

Llessonplans

establishingalliance,73–75

tear-and-repairprocesses,76–79

therapeuticprocess,83–90

traumaconsiderationsintherapy,79–83

Mmaladaptiveloops

assessment,33–34

attachmentexperienceindevelopmentof,19–20

challengingclient’s,12,136

clinicalsignificanceof,9

defined,9,69

interpersonalcircumplexmodelof,23–24

pathogenicbeliefsinformationof,31–33,32

reflectiontopreventengagementwith,48–49

seealsohookingandunhooking

mentalizing

benefitsof,40–41,136

caseexamplesof,47,51–52,121–132

client’sinternalworkingmodelaschallengeto,48–49,157–158

clinicalsignificanceof,6,7,9,41

defined,40,69–70,144

developmentofcapacityfor,17,41–43

lessonplan,76–79

modeling,45–46,136,144

toprocessalliancetension,156

quizquestions,97–98,161

therapeuticusesof,41,43–46,46,144,146,152,154–155,400

metacommunication

ascoreskillforeffectivepsychotherapy,7

defined,50,70,137,145

goalsof,137–138

lessonplan,76–79

toprocessalliancetension,156–157

quizquestions,92,159

role-playtranscripts,121–132

therapeuticusesof,9,50,145,152

modeling

defined,70

ofmentalizing,45–46,136,144

Nnot-knowingstance,46,52,136,144,146

inrole-playtranscripts,106,116,117,120

Ppathogenicbeliefs

clinicalsignificanceof,31–34

defined,70

disconfirming,intherapy,38–39

exploringandprocessing,140–141

formationof,31,32

perfectionisttherapists,64

positiveexperiences,64–65

positiveregard,therapist’s,6

posttraumaticstressdisorder,53–54,61.seealsotrauma

powerrelationships

ininterpersonalcircumplex,24,25,135

preoccupiedattachment,22,42–43,70,134,142

presence,therapist’s,9–10,63,70,146–147

process,therapy,35–37,70,75,79

processing,therapeutic,26,52,64–65,70–71

pullofinterpersonalbehavior,25,25–27,69,142–143,149

Qquizquestions

assessment,98–100

attachmentrelationships,160–161

attachmentstyle,95–97

circumplexmodelofinterpersonalbehavior,162

client’srelationalworld,94–95,160

ethicalpractice,94

internalworkingmodel,95

mentalizing,97–98,161

metacommunication,92,159

tear-and-repairprocesses,98,161

therapeuticalliance,91–93,101,159

transferenceandcountertransference,93–94,159

trauma,97,161

validatingenvironment,161

Rreflection

toavoidengagementinmaladaptiveloop,48–49

challengestotherapist’scapacityfor,146–147

collaborative,49–50

asqualityofeffectivetherapists,63

therapeuticusesof,42,43–44

resilience,17

Ssafetyconcerns,147–149

secureattachment,19,22,71,134

securebasefordevelopment,17–19,22,43–44,71

self-blame,client,61–62

self-disclosure,50,71

self-fulfillingprophecies,9,10,32.seealsomaladaptiveloops,136

shaming

intherapy,36

traumaexperienceand,62

Ttear-and-repairprocesses,37–38,38,76–79,98,136,148,156–157,161

therapeuticalliance

beingpresentwithin,9–10

building,11–12,12,73–75

client’sapprehensiononenteringinto,8

clinicalsignificanceof,6,7,8,9,11,66,159

collaborativereflectionin,49–50

defined,71

effectiveuseofstrainsin,4,9,36–38,50,148–149,156–157

gettinghookedandunhookedin,9,27,38–40,49–50,51–52,63,136

goalsettingand,12–13

interpersonalcircumplexmodelforevaluating,26–27

mentalizingtoprocesstensionin,52

quizquestions,91–93,101,159

role-playtranscripts,103–120

safeenvironmentfor,17–18,43–44

strategiesforrepairing,9–10,148

therapeuticrelationshipand,10–11

therapistqualitiesandskillsforbuilding,8–9,37,133,139

therapiststressaschallengeto,36

therapisttransparencyin,50

seealsocountertransference;tear-and-repairprocesses

therapeuticrelationship

betrayalintraumaand,61–62

tearandrepairof,38

therapeuticallianceand,10–11

fortraumatreatment,62

seealsotherapeuticalliance

therapistqualities

adaptabilitytoissuesarisingintherapy,6

beingpresentwithinalliance,9–10

coreskillsforeffectivepsychotherapy,7

determinantsofeffectivepsychotherapy,5–6,63–66

exemplary,101,162

genuineness,6

judicioustransparency,50

obstaclestoeffectivepractice,64

professionalresponsibilities,13

topromotetherapeuticalliance,133,139

forpromotingtherapeuticalliance,8–9,37

there-and-now,9,33,71

there-and-then,9,33,71

tolerancetofrustration,17

transference

clinicalsignificanceof,27,28,31

defined,27,71–72,141

mentalizingperspectivetoexamine,48

quizquestions,93,159

recognizing,28,29

therapeuticprocessingof,9,31

transparency,therapist,50

trauma

assessment,58–59,60–61,138,150–151

characteristicsofunresolved,60–61

clinicalsignificanceof,53,55–56,64,138,149–150

implicationsfortherapy,79–83

invalidatingchildhoodandriskof,57

obstaclestorecoveryfrom,151

overcomingexperienceofbetrayalin,61–62

pathstounresolved,56–58

posttraumaticstressdisorderand,54

quizquestions,97,161

recognizingexistenceandeffectsof,53–54,56

symptoms,54–55,55,149

therapeuticrelationshipfortreatmentof,62,155–156

therapistreactiontoclient’saccountof,59–60

treatmentgoals,61

Vvalidatingenvironment,17–19,41–42,57,72

quizquestions,96,161

ADVANCEPRAISE“Anextraordinarilylucidandhelpfuldiscussionofthetenetsandtechniquesofpsychotherapy.Thepresentationdrawsoncurrentresearchandthecasepresentationsarenotonlygrippingbutalsostuddedwithbriefcleardiscussionsofthereasonsforeachtherapistcomment.Asuperbtrainingmanualfortherapists.”

—IrvinYalom,ProfessorEmeritus,StanfordUniversityandauthorof“The

GiftofTherapy”“Atlast!Hereisthatrarity,abookthatactuallytellsyouhowtodothejobofpsychotherapy—layingoutthedetailedworkingsofformingatherapeuticalliance,deepeningemotionalengagement,tactfullytacklingtrauma,andtransformingtherapist-clientrelationshipstrainintotherapeuticopportunity.Theaccessible,learning-orientedformat,withextensiveannotatedextractsfromtherapysessions,provideidealteachingmaterialforallmentalhealthprofessionals.Simplewithoutbeingsimplistic,demystifyingwhileacknowledgingcomplexity,readableandreliable,energizingyetevidence-based,itisdestinedforaplaceineverytherapist’sandwould-betherapist’sbackpack.”

—JeremyHolmes,MD,FRCPsych,SchoolofPsychology,UniversityofExeter,UK

MolynLeszcz,MD,FRCPC,DFAGPA,isProfessorandChair(Interim)attheDepartmentofPsychiatry,UniversityofTorontoandthePsychiatrist-in-ChiefatMountSinaiHospital.Hisacademicandclinicalworkhasfocusedonbroadeningtheapplicationofpsychotherapywithinpsychiatry.Dr.LeszczisaDistinguishedFellowoftheAmericanGroupPsychotherapyAssociationandco-chairedtheirSciencetoServicesTaskForceleadingtopublicationofClinicalPracticeGuidelinesforGroupPsychotherapy.WithIrvinYalom,heco-authoredthe5theditionoftheTheoryandPracticeofGroupPsychotherapy(2005).Hisresearchhasfocusedongrouppsychotherapy.ClarePainMD,MSc,FRCPC,DSc(Hons),isAssociateProfessorattheDepartmentofPsychiatry,UniversityofToronto,DirectorofthePsychologicalTraumaProgramatMountSinaiHospital,ConsultantattheCanadianCenterforVictimsofTorture,Co-projectdirectoroftheTorontoAddisAbabaPsychiatryProjectandCoordinatoroftheUniversityofToronto-AddisAbabaCollaborationProgram.Herclinicalfocusisontheassessmentandtreatmentofpatients,includingrefugees,whocontinuetosufferfromtheeffectsofpsychologicaltrauma.

JonathanHunter,MD,FRCPC,isAssociateProfessorattheUniversityofToronto,whereheheadstheDivisionofConsultation-LiaisonPsychiatry.HeisHeadofPsychosocialServicesintheMarvelleKofflerBreastCentreatMountSinaiHospitalandafoundingmemberoftheCollaborativeMentalHealthcareNetworkoftheOntarioCollegeofFamilyPhysicians.Hisclinicalandresearchinterestsincludethepsychiatricandpsychotherapeuticcareofcancerpatients,theroleofearlylifeexperienceandattachmentinadaptationtodisease,andtheimportanceofmentalizingintreatment.

RobertMaunder,MD,FRCPC,isProfessorattheDepartmentofPsychiatry,UniversityofTorontoandHeadofResearchatMountSinaiHospital’sDepartmentofPsychiatry.Hisprimaryresearchinterestisintheroleofinterpersonalattachmentinhealth.

PaulaRavitzMD,FRCPC,isAssociateProfessorandAssociateDirectorofthePsychotherapies,HealthHumanities&EducationScholarshipDivisionintheDepartmentofPsychiatryattheUniversityofTorontoandMountSinaiHospitalMorganFirestonePsychotherapyChair.Heracademicfocusisonthepractice,teaching,dissemination,andresearchofevidence-supportedpsychotherapytreatmentsinmentalhealthcare.

PRACTICEREMINDERCARD

ACHIEVINGPSYCHOTHERAPYEFFECTIVENESS

Therapistqualities&characteristicsthatpromoteatherapeuticalliance:

empathy,responsiveness,interest,rapport,positiveregard,genuineness,&theabilitytomanagestrainandrepairtensionswithin

thealliance

Developasharedunderstandingofaclient’srelationalworld-Earlyattachmentrelationships

-Currentrelationships-Transferenceandcountertransference

IdentifymaladaptiveloopsthatreinforcepathogenicbeliefsMAPPINGINTERPERSONALPULLSONTHEAXESOF

THEINTERPERSONALCIRCUMPLEX

Anattachmentstyleemergesasthebestadaptationtoacomplexenvironmentandisencodedineachindividual’sinternalworking

modelATTACHMENTPATTERNSOFRELATING

Secure Preoccupied Dismissing Disorganized

Care-providers’characteristics

Goodenough Inconsistentlyresponsive

Mostlyunresponsive

Frighteningorfrightened

Attachmentbehaviors Fullrangeandflexible

Dialedup Dialeddown Unclassifiable,fluctuatesunpredictably

Others’experienceofthisperson

Trustworthy,reliable

Overwhelming,needy

Distant,aloof Discombobulating

ATear&RepairPsychotherapyProcess

Respondempathically,challengingmaladaptiveloopsandfosterapositivesenseofself.Disconfirmpathogenicbeliefsandexpectationsabouttheselfandothers(e.g.ofharmornegativejudgment).

Metacommunication:torepairanalliancetension•Acceptresponsibilityforcontributingtothetension,highlightinghowweaffecteachother.

•Exploretheclient’sexperienceinthehere-and-now.

•Collaborativelyreflectonwhythisishappeninginthiswayrightnow,thinking“outloud”aboutsubjectiveperspectivesandemotionalreactions.

Mentalizing:toappreciatethatothershavedifferentbeliefs,understandings,andintentions;thataperson’simpactisnotalwayswhattheyintend;andthatpeoplecanfeelonewayandactanother.

•Collaborateincreatingacoherentnarrative.

•Modelmentalizing.Communicateaboutmentalstates.Wonderaboutintentions.

•Usea“not-knowing”stance.Beopenandcuriousaboutwhatisinyourandothers’minds.

•Usecontrarymoves.Varyfocusbetweenthinking/feeling,self/other,internal/external.

Unresolvedtraumacanunderlieproblemswithrelationships,regulatingemotions,medicallyunexplainedsymptoms,memorygaps,dissociation,self-harm,andsubstanceabuse.

•Arethedisturbingtraumaticexperiencesontheclient’smindfrequently?

•Howmuchhastheclientintegratedtraumaticmemoriesintohisorherlifestory?

•Istheclientreflectiveaboutthetrauma?

•Whohastheclienttold&what’sitliketellingyounow?

Copyright©2015byPaulaRavitz,RobertMaunder,MolynLeszcz,ClarePain,andJonHunter

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TheLibraryofCongresshascatalogedtheprintededitionasfollows:

Ravitz,Paula,author.

Achievingpsychotherapyeffectiveness/PaulaRavitz,RobertMaunder,MolynLeszcz,ClarePain,JonHunter.—Firstedition.

p.;cm.—(Psychotherapyessentialstogo)

“ANortonProfessionalBook.”

Includesbibliographicalreferencesandindex.

ISBN978-0-393-70826-4(paperback)

I.Maunder,Bob(BobG.),author.II.Leszcz,Molyn,1952-,author.III.Pain,Clare,author.IV.Hunter,Jon,1958-,author.V.Title.VI.Series:Psychotherapyessentialstogo.

[DNLM:1.Psychotherapy—methods—Handbooks.2.Psychotherapy—methods—ProblemsandExercises.3.ClinicalCompetence—Handbooks.4.ClinicalCompetence—ProblemsandExercises.5.MentalDisorders—therapy—Handbooks.6.MentalDisorders—therapy—ProblemsandExercises.7.Professional-PatientRelations—Handbooks.8.Professional-PatientRelations—ProblemsandExercises.9.PsychotherapeuticProcesses—Handbooks.10.PsychotherapeuticProcesses—ProblemsandExercises.11.TreatmentOutcome—Handbooks.12.TreatmentOutcome—ProblemsandExercises.WM34]

RC480.5

616.89’14—dc23

2014027699

ISBN:978-0-393-70826-4(pbk.)

ISBN:978-0-393-70999-5(e-book)

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