The following psychotherapy session begins with an established client with whom I have worked for over a year, with whom the above interventions were instrumental. At this time, our selves-at-best are online, which enables us to traverse self-at-worst conditioning while remaining in communication. Underlying her avoidant strategy are layers of protectiveness covering profound hurt. Despite the fact that we have established trust between us, when the attachment system is activated, doubt emerges. This session started with her acknowledgement of feeling safe. As the session unfolded, she encountered an early memory of being with her father that conveyed her longing as a little girl and yet how frightened she was of doing the wrong thing that would bring him to reject her. Sadness emerged, and she was baffled and confused. This session reveals the power of the internal working model and the force of the injunction against opening up. This section was chosen to illustrate the harsh messages that drive avoidant defenses and how the patient’s perception of safety changes on a momentary basis.
PT: If I had had one person, one adult who had been kind, loving …? Or somebody to just ask me who I was or what I thought about… [Her longing emerges – transformance]
TH: Well that’s kind of what I feel like I want to do right now… I’m really loving getting to know who you are and what you thought about – so important… what happens when I say that? What’s it like for you to know that I want to know you, what you think about, feel about? [I offer my interest in her and then I check for her experience of me as therapist – checking her receptive capacity.]
PT: I think I’m not convinced anybody really wants to know who I am? It’s hard for me to really believe that. [Origins for the development of the avoidant strategy]
TH: It’s hard for you to believe that I want to know you? [Amplifying by making it explicit in our relationship]
TH: What happens when you look at me? When I say I want to know you? [Make the relational experiential.] What do you see in my eyes?
PT: You’re all blurry, I can’t see without my glasses – that helps. (Laughs) [Humor regulates anxiety.]
TH: it does help… okay in this blurry state – [staying with her] what do you see through the blur? [I join her with laughter and still keep the focus.]
PT: I can.
TH: What do you see?
PT: I don’t doubt your sincerity. I just don’t believe that anybody really wants to know me. [Fixed invariant patterning]
TH: You don’t believe and that comes from way inside, right? And so when you see me, you don’t doubt my sincerity, what does happen? [I acknowledge her belief and encourage her to explore the here and now with me.]
PT: Well I have a whole defense, “she doesn’t really want to know, that she’s, this is part of the therapy…”
TH: These are all the thoughts, but what happens with your eyes, when your eyes are seeing my eyes? [Bypassing the defense, staying with the direct relational experience]
PT: My eyes tell me that you are truly here; truly looking at me, really want to know…
TH: and how, what’s that like to… [I wish I had said yes, and affirmed first before metaprocessing.]
PT: that’s hard for me to trust
TH: It’s hard for you to trust (hand motioning inside) How far in can that go? [I go with the receptivity that emerges when she names her eyes so that I can tell I am truly here]
PT: (sigh) I think it can go in, I think if I can just relax…
TH: Try out how that can go – [Make it experiential.] try out relaxing just see how much you can take in.
TH: To take in that I care about you and I want to know you. [This might have over amped the charge.]
TH: What happens, let’s take it slow and see what happens this time.
PT: (deep breath)
TH: That’s a deep breath [Moment–to-moment tracking, always important to notice]
PT: There’s something that really is – it’s like a block. It’s like it doesn’t just sink in.
[This is self-at-best talking about self-at worst.
TH: Do you know where that block comes from?
PT: um, umm
TH: see if you can see…where that block comes from. [I want to know if she can she make the link.]
PT: I think it just comes from being disappointed in the past – so just like “Don’t do that again!” (spoken in harsh tone)
TH: right (mirrors her hand gesture which shows a firm marking a boundary between self and other)
PT: DON’T do that.
TH: DON’T. (Echoes the harsh tone)
PT: DON’T let that in again.
TH: DON’T. (Repeats mirroring hand gesture – Pt. is nodding) That’s it… [Affirming her and amplifying her expression of her internal working model]
PT: Don’t be stupid. Don’t (hand firmly presses her leg now) you know? Don’t believe that somebody is really interested in you. [Procedural learning]
TH: Ohhh, (big sigh) How painful, right, to believe and be disappointed… that makes good sense – that you wouldn’t let in what’s here – cuz of the past disappointments. [Explicit empathy with the defense]
PT: yeah (cries a bit)
TH: Just let that through – see what that’s like to recognize. Stay with me, what are you getting? What’s happening?
PT: (sniffs, looking down and away)
TH: How do you feel right now as you are noticing this? [I am checking her window of tolerance.]
PT: umm (nodding) I think a lot. It’s so hard for me to go into my feelings cuz I think a lot….. [Increased self awareness of her defense]
TH: Stay with me – together we can help sort this out. [And she just did go into her feelings.]
PT: I’ve always been that self sufficient, didn’t need anybody, developed my own thoughts. Even turned away a lot of relationships, you know, don’t get too close… [Click of recognition… describes the cost of the avoidant strategy, which this work is asking her to notice, to reconsider and to try something different]
[Once we penetrate the defense, feelings emerge that register the pain and the loneliness – the disappointment is wired together with the defense, which appeared in full force.]
With an avoidant patient, I want to heighten the relational action tendencies, whether it is relating to themselves or to others. Their ability to make use of the therapist, as another who can be an accompanying and a caring presence, is what is called for to develop receptive affective capacity, to truly undo the aloneness and impact of being rejected, dismissed, and objectified This has everything to do with connection. I believe that in order to be connected to another, I must be connected to myself. So, as I help this patient tune into her own internal world of thought, feeling and customary behaviors, this opens the patient’s capacity to reflect on her own self, both the longing and the dread. This unfurling brings us to an adaptive action that translates into opening curiosity with more space for understanding rather than reactivity. In this moment the balance shifts to revealing herself in the presence of the therapist.
PT: I try to get myself to figure out what I’m feeling. [Transformance glimmer]
PT: I always feel like “Don’t set yourself up for disappointment, I just come back to that over and over.
TH: Right, so that’s (points to her head) you learned that, that is hardwired in you, right?
TH: That was your motto as a kid, and something today – what about if you put that right next [to each other] (shows both hands) “Don’t set yourself up for disappointment and “what have we been working with today?” What do you get if you put them together? [Psycho–ed in a mood of conspiratorial exploration, then metaprocessing]
PT: (big Sigh) That’s a tough one. Because I want to believe that I can trust you, and other people, that they can give me what I need, but that’s just not there (chokes up)
TH: you know what’s there? There’s feelings…(gently noticing) that still need to come out cause the thing is they’re getting in the way…of your taking this in… [I am staying with what is happening and lend my trust that if feelings are emerging, they deserve to be felt.]
TH: Your feelings are really about all that hurt. [It’s as if I am introducing her to her feelings with my understanding and acceptance.] What’s happening right now?
PT: It’s a grief that makes me sad that I can’t get that in my life. It makes me sad, it makes me…
TH: The grief is about you couldn’t get that in your life, you didn’t get that in your life…from the person that you wanted it with, so this is that little girl in you that just couldn’t get what you needed… [Psycho-ed about mourning the self, with empathy]
PT: (looking down and away)
TH: Stay with me, what are you feeling? Stay with this.
PT: You know it’s hard because when I was a kid to need my dad or my mom in my family was just considered horrible, what’s wrong with you? [The significant events of her early life experience now reveal her prevalent attitude in her current life.]
TH: So come here for a second, I want to check in with you. How is it to be here with me? [The deactivating strategy pulls at her. I see she is slipping out of the present with me, and sinking into shame.]
PT: (stays in eye contact)
TH: Cause I feel like I so want to go with you to these places. [Therapist’s explicit use of self to undo aloneness and counter the old experience]
PT: (gaze averts and looks around)
TH: Cause you don’t have to feel alone.
PT: I don’t feel alone.
PT: I really feel like you’re right there with me… I really do. [I have to admit this feels like a surprise and a relief.]
Step-by-step, sometimes forwards and sometimes backwards, we forge ahead. From here I am able to ask the patient if we can take this accompaniment back to the little girl in her. This opens a doorway into an imaginal world that she occupied alone as a little girl. Only now she takes me with her out into the fields she explored as a little girl, and imagines me taking her hand and walking alongside her. We are constructing a more trusting relationship by ferreting out the stops of the internal working model and challenging the procedural learning with our present here and now experience.
With ambivalent patients the focal goal of treatment is to develop self-action tendencies, to strengthen the sense of self and self-efficacy. These are a) becoming aware of one’s own needs, b) learning how to express them, and c) being willing to stand up for one’s self (Fosha, 2000). To this I would add, that the preoccupied patient needs to learn what exactly belongs to them and falls under the responsibility of their own self-purview. In order to achieve this, much differentiation needs to take place, between self and other, thought and feeling, past and present. The therapist may need to take deliberate steps to slow down the ambivalent patient, to penetrate their wall of words, and to help them to identify how their emotions are driven by their anxiety-ridden thoughts (emotionality).
Differentiate between Self and Other
I want to help the ambivalent patient differentiate between self and other. With preoccupation, the boundary between self and other is often confused, leaving a poor sense of what belongs to whom. Boundary confusion is part of the composite of the preoccupied state. An important aspect of treatment is to present opportunities for ambivalent patients to distinguish what’s happening inside themselves from what is happening with another person. In the preoccupied state of mind, the tendency to predict and project what is to come in the future is mostly fear and anxiety driven, based on things that happened in the past. I want to help these patients become conscious of and able to discern their own visceral, body-based feelings from their perseverations about others’ perceptions and intentions. I want to do so with compassion and understanding that hyper activating to get the attention of the other developed as a strategy to do the best to cope with their primary attachment relationship.
Dyadic Regulation and Self-regulatory Skills
At the start I am often focused on anxiety regulation and looking for ways to help my patients redirect their attention to self-care. As therapist, I attempt to step in as an other who can slow the torrent of words with containment, summarization, or wondering, so I can make contact and let them know I hear them. I want to help my patient find calm as we shape their emphasis to respond to their own self-experience. Teaching grounding, self-regulation skills and breathing practices help patients learn ways to attend to their own activation and recognize signals of anxiety in themselves. The more anxiety is regulated, the closer patients can get to their own self, and tend to actual glimmers of core affect and self-knowledge.
To do this, therapists must be able to regulate their own anxiety, especially in the presence of someone with permeable boundaries and heightened anxiety. Like flying on an airplane with small children, the therapist must put the oxygen mask on their own self first. By noticing and regulating my own and the patient’s anxiety, I model self–care and consideration.
Discern between Thought and Feeling, and Empathize with Core Affect
With more capacity to regulate anxiety, the more likely it is that one can access core affective experience. However, sometimes focusing on emotion leads to heightened arousal. It is so important to teach such patients to discern between thought and feeling. In preoccupied states, patients are sometimes overwrought and don’t really know what happened that led to their current level of distress. Many patients believe they are sharing feelings when they say, “I feel that he… doesn’t love me anymore, is going to fire me, is going to leave me.” Therapists must check the accuracy of feeling words vs. thinking words and teach patients the difference. With some patients it can be very helpful to name the categorical emotions of sadness, anger, fear, joy, disgust and surprise. Some appreciate having a list that gives examples of mild, moderate and intense feeling words. The intention is to help these patients to notice such thought streams and to redirect their attention to their body-based experience. From here, we focus on the somatic edge of core affect and help the patient to stay with what crests and falls, surges and wanes, arises and dissipates. No matter how small or large the wave of affect, we want to help our patient learn to recognize how affect moves, so that then we can reflect on these emotional experiences. As we face these moments together in our present relationship, the relevant historical memories can come to mind in a clearer way and we can link the current trigger with its early life disturbance or trauma.
Build Receptive Affective Capacity
Although ambivalent patients tend to be externally focused and reliant on others, they actually need considerable help to take in soothing and care. Early experiences of abandonment or lack of consistent attention by self-absorbed caregivers have left a significant dearth of trust that anyone would want to be there for them. In response to gestures of care, there can often be significant doubt in the sincerity of the motivating intention behind them. In more extreme cases, stubborn bouts of angry resistance deflect such offers and exemplify defenses against relatedness and defenses against emotion, all in one.
When the therapist provides contact and care with stability and predictability, the hyper activating strategy can begin to ease, as the patient can begin to internalize that the therapist gets them. And yet, ambivalence may show up when the therapist checks for the receptive capacity. For example, when the therapist offers support and withness to undo aloneness and follows up with a relational intervention such as “Can you feel me with you?” The ambivalent’s initial response may be a “maybe” or weak “yes.” Possibly followed by an explanation, “But then I will always have to do this entirely by myself.” Or “That’s only here, can I take you home with me?”
The dual-prong goal is to have both. I want to help patients notice what they can receive, and to notice what happens when the patient can’t take in anymore. This usually means that an early attachment strategy is activated, and something needs holding and to be known. When the therapist can meet such a place with interest and steady attention, we are overlaying a new experience of receptivity on an old experience of “something missing.” When ambivalent patients receive this quality of care reliably, they can begin to saturate in the new experience and let it become part of how they realize they feel met and soothed. The mechanism is for this absorption to sink in so that they can begin to take seriously their need for connection from the inside. I am always delighted when patients tell me how they had a conversation with me in their head during the week, or how they thought of me when they knew they needed to calm down. This is clearly a transitional experience that leads to the capacity to self-regulate.
Gain Access to the Self behind the Wall of Words
Here, the therapist needs to filter through the rapidly erected defensive screens: the wall of words, to select for momentary, emergent glimmers of self. The therapist must catch what is quickly batted away, before it is doubted and obscured with familiar thoughts—protective deflections woven to conceal what would threaten the status quo. I want to interrupt the patient’s rapid movement past self-discovery by joining in, slowing them down and reflecting their own words. In this way, I insist that patients realize that I hear what they say and that they must listen to what they are saying. Often we can catch the spark of an emerging self. We focus and care for these embers of self, in present time and space, and see how fears of abandonment perpetuate when one ignores their own self. When they can turn this around by listening for inner movement and stirrings, they can find the parts of themselves that have been alone and untended. I was working with a woman who located such a young aspect of herself, and through our meeting she realized that she never knew soothing was possible. In giving up that possibility, she had left a part of herself behind. As we come into contact with this part, a whole new level of self-empowerment emerges, and with that arise realizations and important self-knowledge.
Amplify Glimmers of Transformance: Containment, Self-soothing, Self-knowing; Support Internal Guidance
When working with someone who relies on a hyper activating, preoccupied strategy, first, I want to make sure they know their call for attention is being received. Then I am on the lookout for signals of self-direction. I want to highlight and emphasize this potent indicator of transformance-at-work to maximize the development of inner knowing and guidance.
We enter the following segment of a psychotherapy session at the point where the patient is discussing how she had reached out to me when I was out of town, as an alternative to calling her husband with whom she was having difficulty. Instead of calling him repeatedly and insistently, she drew upon self-care materials we had discussed. Even though I wasn’t immediately available, she was able to make use of the call, a friend and self-compassion tapes.
PT: What I would’ve done, had I not received that and been able to take it in… is to bother
S…to try and get regulated…I would’ve gone to him in irritation and frustration and
wanting him to kind of soothe me…and it would’ve been just impossible. [Other-reliant
Th: Wow. So even though I texted you a few hours from the time you texted me, it was
still soon enough? [Reaching out to me was a new behavior, which she found stabilizing]
PT: Yeah…cause I went out dinner and a movie with a friend and then I came home…
Th: Ohhh (eyes wide, pitch rises)
PT: And so I had that in my…[She is starting to reflect.] well I could kind of freak out and
throw a fit and get passive aggressive and angry and all those things I do to get him to
regulate [me]…or maybe I’ll try listening…cause maybe it’s not about what he can do for me
but what can I do for myself [She is discerning what is within her own boundary.]
in this moment of just feeling so undone (eyes squint). [This anxiety is hers to care for.]
Th: (nods, eyes wide) Wow!
PT: That was kind of cool! [mastery – a marker of State Three]
Th: Yeah…feel into what you just said and what you just organized…. oh my gosh!
[metaprocessing and deepening this new experience
PT: (eyes closed) I organized…I made use of something that I hadn’t done before in a really
conscious way…made a decision…a cross point [a new self action behavior] (looks at Th)
…There was a crossroad. I could’ve easily gone the way I usually go or…
Th: And…The way you articulated it to me…can I say it back to you?
Th: Cause you said…I could come undone and throw a fit to get S’s attention and
instead of doing that I thought maybe there was another way I could help myself. [I want
to reflect her own words back to her for integrating and deepening.]
Th: So you went from trying to like (hands gesture in swirling motion as chaos) to do the
preoccupied dance to get momma’s attention…instead of doing that thing, you went into
some self-soothing with a little help (points to self). [Psycho-ed and reminding her I was
involved in her getting what she needed]
PT: Yeah…I was able to go to sleep a little later… [That she was able to go to sleep
suggests that her nervous system was in balance.]
This next section shows a bit of the recursive nature of working with the preoccupied strategy. During this part of the session we are reviewing what happened and speaking to it from different angles, all the while sorting out the new from the old, deepening integration, and valuing this new direction of incorporating new choices into the patient’s repertoire.
Th: Well even that sounds like…given the choices you were giving yourself, you took the high road.
PT: Yeah…felt more embodied or something. More like an adult-to-adult self.
Th: Wow. Self-guiding?
PT: Self-guiding. I’m like, what is it gonna do to wake him up or whatever…so (exhales).
Th: Yeah…how are you feeling as you’re saying this?
PT: Well I want to stay with the good feeling but then I just keep getting distracted by how
irritated I was at him…so I don’t want to do that because that kind of undoes my good thing.
Th: Maybe compartmentalize it a little bit? Like, you could tell me how irritated you are
at him in a little while…we can make space for that (hands make sweeping gesture to the
side) in time. [bypass the defensive hyper-activating] AND…There’s something, a new
way of listening to yourself, reaching out, asking for help, turning back towards yourself,
giving yourself a new solution and taking it and then afterwards, still feeling some
resentment and deciding to sleep on it instead of act that out…[As we metaprocess, there
is a need to sort out the new behavior from the old, and to affirm her decision and
her choice to act on the new, despite feeling activated.]
PT: (gazing intently at Th) Right…
Th: So making more healthy choices from a guiding adult place in yourself.
PT: Yeah…that’s a big deal.
Th: This feels worthy of really (hands encompass a large imaginary ball) acknowledging
and holding (CL mimics holding gesture)…embrace.
Th: And then yourself be with that. That you’ve done something so layered of a new way
of getting yourself calm. [affirming her capacity to self-regulate]
PT: It did feel really good. Like I feel my heart kind of racing in thinking about it…it was exciting…something really empowering about it…like [brings energizing vitality affects]
PT: I’m gonna go and soothe myself…just putting the focus on myself and really getting that
I can relax myself…can you relax yourself? [Doubt emerges – did I just do what I did?]
Th: It looks like it. [affirming]
PT: It felt like part soothe but also part calm down, soothing feels more for like when you’re
hurting or wounded…I wasn’t in that place…I was more in the wound up, agitated place.
I can walk myself down the tree. That was cool to be able to do that. But now I also feel
Th: Walk yourself down the tree…that’s really cool that you could do that. [Emphasize the
self adaptive action and positive choice.]
Th: Cause this is the direction…this is right. I don’t want to be judgmental about it, but at
the same time I want to say (palms up in receiving gesture) this is like…how do I say this
without being judgmental (brow furrows) but I want to acknowledge this. [I am realizing
that the direction she is naming is self-righting– and yet at this moment I feel shy
to be taking such a strong stand.]
PT: You say…this is powerful. [Here – she affirms me… dyadic regulation works both
Th: I feel proud of you…that’s what it is… [Now that I am more regulated, I know what
I am feeling.] I feel proud of you and I hear you feeling empowered…and I feel proud of
you for taking the high road…
PT: Yeah…thank you.
Th: For taking new chances.
PT: I just hope it doesn’t mean that I have to that all by myself all the time. [Here the old
anxiety surges: “Does self-regulation mean I have to be solitary from here on out?”]
Th: But I want to remind you that you didn’t do it all by yourself cause you did it with me.
[I remind her that we have been working together towards this possibility
PT: Oh yeah…I asked you.
Th: That’s what’s really cool.
PT: Oh yeah…I reached out to you and then you gave me this connection…and then I
connected to that connection and then it connected back to me. Somehow, it’s like you
passed the ball to me and it’s mine and then whatever I do next is I’m by myself. [She
recalls the pathway and how it worked between us, which helps her to receive my
response to her more deeply. Although note the ending fear-thought, “I’m by myself.”]
Th: For that bit…and this is like a work in progress.
Th: These are important building blocks…
PT: Yeah…it’s step 1 of a multi-layered process. It’s a beginning.
Th: We don’t know what the end of the story is yet. [We are co-creating a narrative.]
PT: Cause yeah…I really felt…I put the headphones on and I listened to it and I really did
climb down the tree. I really settled down and I really got out of that (hands make swirling
gesture around head)…you know, it’s a frantic…I want to make him pay attention to me…
make him make me feel better and make him…whatever it is that makes that go away…no
going there (hand stretches out to side) and going somewhere else…I really feel like I was
delaying…in DBT, they call that opposite action…it’s a very cognitive approach…this feels
more like an intra-relational thing with you but then with myself so it feels deeper than
Th: (hands pressed together then sweep apart) rather than delaying, that’s like stalling out
and in a way…it’s like (hands press together) you bring something to me…I bring it back…
There’s a sharing and a giving and a taking… [I reinforce our coordinated efforts
PT: Cause I wasn’t coming to you…I’m trying to understand how might I do with you what
I do with other people…you know? I have a feeling I am mostly self-reliant…more
avoidant…but with Sean, I’m disorganized…
Th: With a pre-occupied edge…it’s the anxious attachment.
PT: So I get really clingy and demanding or manipulative. I’ll get inside of those places and
I don’t feel I do that with you. Like it’s contained and clean… [differentiating her
self-at-best behavior with me]
Th: Well, that makes sense because this is my job. What I mean to say is my job is to help
you feel in a balanced way with me… [building a secure base between us]
Th: To feel safe enough to ask for help so you don’t have to clamor for my attention…
PT: (eyes wide) Right…
Th: Cause I want to give it to you. I’m here for you and you trust me enough now that even
if I’m not responding in like (clicks fingers) immediately… [making the implicit explicit]
PT: Right…cause that could be a trigger for some people…if I were in that state…just say I
wasn’t in a relationship with him…and I texted you and didn’t get a response back right
away, I could see getting activated and then acting that out, like Hello? (mimics anger)
Where are you? I could see myself doing that… [She is comparing self-at worst behavior
to this self-at best behavior.]
PT: But I don’t do that…
Th: So instead, maybe there’s a little delay…go to dinner…go to a movie…and by the time
you get back…oh, she’s here…she’s back like I’m back…
Th: I’m online, she’s online.
PT: So the hope is that maybe I can do THIS…. it’s a both/and kind of thing…with myself
and then in relationship with others, right? [Core state, recognizing what she is doing
with me and wanting that to extend that to others.]
Th: I see what you’re seeing as what I would hope for…what I actually feel very excited
PT: It’s both not as scary as I thought it would be and terrifying. More terrifying than I
thought it could be. (smiles at Th, who returns her smile) Cause it’s a balance beam
feeling…of learning something new and I’m all…AHHH! I spook myself out.
Th: But you’re not spooking as much.
Th: You’re not spooking like falling…it’s the tremulous place…. [State Three: The energy
of the new experience…]
PT: Yeah…it’s tremulous.
Th: So it’s enough new that you’re doing something different but enough safety that you
can bear it. [window of tolerance]
PT: I can bear it and kind of modulate…cause that’s where I guess I’m at…a feel like really
Ph.D. level attachment work (smiles).
Th: (smiles) Ph.D. attachment work…and then I was thinking Ph.D. level self-care?
PT: So true…and I’ve been making my food and grocery shopping and cooking my meals and I’m shocked at how much time and energy it takes…[developing self-care]
Undo Psychic Equivalence
When preoccupied patients begin to understand themselves, they often register how their inner critic and maladaptive self perceptions were actually formed by the offensive labels bestowed on them by others, which is what we can see in the following example. When Fonagy identifies psychic equivalence as the internal and the external world being equated, he states that the self-agent is submerged. In the preoccupied strategy, the sense of self has been forsaken by the lack of other reflection and understanding by the caregivers. I notice and help the patient learn to recognize that although bad things happened to him or her, these experiences do not have to define their identity. When the patient begins to get some separation between self and “bad experience,” the self can start to realize the impact of such experiences and begin to process the emotion, and in this case the deep mourning for the self, with regard to that experience.
PT: What is true is that I am realizing that I am enough. The more I realize that I am enough, I don’t feel needy. [huge shift towards self-efficacy]
Th: So what’s this when your hands go like this? (mirroring the way she wraps her arms around herself) [unpacking the movement channel]
PT: I feel me. I’m holding myself. I’m here for me. [self-soothing, containment]
PT: The more I understand myself and my story…and it’s easy to see where they came from having the family that I had and actually being told that I wasn’t enough and that I better get it together…I was made to feel like I was broken. [procedural learning]
Th: you always got the message you were broken. [subtle distinction that this was a message of being broken]
PT: As much as I didn’t want to believe that, and didn’t really feel like I did, it took over me…that message was drove into me and it was like I couldn’t resist it. It took over [She receives this message, an example of psychic equivalence.]
Th: Such a thing that you got this message that you’re this…you’re broken and then you can’t separate out your self from this message. [boundary confusion]
PT: Yeah, you believe it. I can clearly see how I became the way I did. (voice filling with tears) How I acted as if I was broken and needed someone to love me make me feel special.
Th: Right now what are you feeling, just let it through.
PT: I feel sad for my little self that lived this way. [We enter a big wave of grieving for self.]
PT: I feel sad for my little self that lived this way. [grieving for self]
Th: Just let yourself feel this wave cause it’s a deep one.
Th; Breathe into that [I wait for breath as signal of wave passing through.]
PT: Yeah. (tears, reaches for Kleenex… then sobs emerge…)
Th: Just let it through…
PT: There’s a sadness …. A grieving feeling… To have suffered so much in my life…so I’m really getting to understand myself and see my stories and know now where they came from. [mourning the self] They’re not really me. [self-righting online]
Desirable Mobilization: Self-Action Tendencies
In contrast to helping someone with avoidant strategies to develop relational-action tendencies: the capacity to receive and feel with and for others, someone who is preoccupied and other-focused needs to develop self-action tendencies. Cultivating a sense of self is crucial. Connecting to the inner little one who felt abandoned is key. There is ambivalence to receiving comfort, for fear it will leave or not be available. In helping patients to both internalize my constancy and build a relationship with their younger aspects of self, this wheel-spinning drama to be cared for can begin to slow down with the presence of self-to-self connection. (Lamagna & Gleiser, 2007; Lamagna, 2011).
In beginning to discuss treating disorganization resulting from unresolved trauma, a few noteworthy topics and important considerations must be mentioned. Further descriptions of classification systems have grown out of adult romantic attachment research (Bartholomew & Horowitz, 1991; Bartholomew & Shaver, 1998; Shaver & Fraley, 2000). Bartholomew devised the following two-dimensional model that incorporates the categories of models of self and models of other. (See Figure 4).
Figure 4 The two-dimensional model of individual differences in adult attachment
(Shaver & Fraley, 2000).
This model emphasizes the poles of anxiety and avoidance, as they most closely resemble the manifest items used to measure the four attachment styles. (Shaver & Fraley, 2000) A fuller discussion here is beyond the scope of this paper, but I include this model for its significant contribution to the growing field of attachment research. In a nutshell, this system looks at how our attachment representations can move from one person to another across the dimensions of the above quadrant. It acknowledges how people have many different attachment schemas, which change according to anxiety and avoidance, which may be activated depending on the level of support or non-support in a given relationship (Mikulincer, 2015).
While I have written this paper with the stark classifications of each attachment style in mind, I also must say that in clinical practice when interventions land, and the defense structures loosen, the attachment strategy can change. This can happen with a patient who is using an avoidant strategy. What the above model shows is that as anxiety is heightened, the dismissing avoidant may move across the sphere to the place of fearful avoidant, which is analogous to disorganization.
In the transcript working with the avoidant patient, when I leaned into the here and now of our relationship, the patient’s old schema of being disappointed and hurt came in strong. An important part of clinical work is that therapists must be ready to navigate at a moment’s notice. A successful intervention can surprise a patient. When the structures that once held an underdeveloped self intact loosen their grip, previously warded-off affect, memory, realizations arrive and make their presence known and felt. This can be disquieting and even disorganizing for patients.
In working with disorganization, the goal of treatment is to build the patient’s capacity to be with self (and parts of self), at the same time as being with another and over time building safety and trust. Many times, when patients come into treatment with unresolved trauma, they don’t have a clear picture of what really happened to them. While the need to survive was so strong, many times just what they were surviving is out of conscious awareness. Perhaps they have memories of mean or neglectful caregivers, but not the related emotional affects. Perhaps they have strong emotional triggers and upwellings that seem out of proportion to their current life experience, yet no clear understanding that makes sense to them. The patient needs help to locate evidence of what happened, and sometimes he or she can benefit when the trauma can be named. The work is to find and get to know it, and then to build connection between dissociated aspects of self and the core self, to feel genuine emotions and link them to specific memories, to release the adaptive action of categorical emotions, to resolve hauntings from the past, and, finally, to restore the capacity to engage and relate with self and other in present time and space.
Find and Engage Resources
Building resources can require constructing a safe place and/or person, for the patient to go to when the threat of overwhelm looms. When affective experience arrives, I welcome being with the patient and helping them to receive my attention and care so that we can build both tolerance of being seen and felt by another and tolerance of feeling and being one’s own self. It is necessary to understand that individuals who have been traumatized often have relegated parts of themselves into compartments, and stepped outside of these places to go on living. These ways create distinct ego states, which can be confusing and aggravating to loved ones, to whom such changes feel like whim or willful deception.
Regulate and Build Tolerance and Capacity for Emotions
I want to help the person to feel safe, to feel connected to self or to understand something more. These interventions with someone who is disorganized are really aimed towards building the capacity to experience what is happening in the present moment. Distinguishing what is happening here and now from feeling memories that intrude from past trauma and hurt, helps a person to realize what they need to care for themselves, while they learn to process unresolved emotional experiences. This empowers them to expand self-care as well as their relationships with others. This work is geared toward helping the patient regulate emotion and thus, we need to titrate this work within a window of tolerance. It is important here to notice and attend to the markers of dissociation and shame, the dorsal vagal slump of shutting down (Porges, 2009.) I want to help the patient become curious about these processes so that with caring we can build links between the parts that are disconnected and the triggers that set alarms in motion.
Empathize with Dilemmas
What can sometimes appear and be quite challenging for therapist occurs when patients arrive, often in an agitated state, and want help to make some kind of decision. I remember a female patient who would have a problem with her boyfriend and come into session in a dysregulated state, insisting that this is the end—that she no longer can stay in the relationship. The following week she would arrive and all memory of this “decision” seemed to have vanished. I began to see that when such agitation presented, while there was a desire to leave, there was also a longing to stay. I learned to empathize with the dilemma when she is up against such contradictions inside of herself, challenged by her own blind spots and activations.
Sometimes patients seem to be engaged in activities of both of doing and undoing, where on the one hand they are working with much creative effort, they simultaneously thwart themselves by acts of self-sabotage. There appears a back and forth inability to settle into a coherent strategy; to choose one direction may mean leaving behind another. It is important to find a way to hold both, to make room to find the logic beneath the surface. What makes sense may reveal the disorganizing challenges of an earlier life situation. In the simplest way, I am trying to shift from a focus of either/or to both/and. To consider that with disorganization two contradictory circuits are activated at the same time – our work is to develop compassion for such deep dilemmas and hold the possibility that the present day relationships don’t have to operate at such a cost or that no one has to stay in ones that do.
Trauma Does Not Define the Person
In healing deep trauma, there needs to be a distinction between the self of the person and the events that happened to them. Ultimately, instead of needing to split off an unlovable, untrusting part of self, one can make sense of the fact that some mean and awful events took place that hurt. And now, the self doesn’t have to dissociate to bear the unbearable, but rather their capacity to feel and deal can grow. The present–day self can get sturdy enough to withstand the storms of past trials and tribulations, to allow in the memories and associated feelings about what happened, in the presence of love and care, from self-to-self and person-to-person. This to me is integration: that what had once disappeared from awareness can now be found, and even understood with care and tender holding. When someone has a young part of self that stores memories of being mistreated, it makes sense that they mistrust (and even mistreat) others out of reaction. Therefore, the focus of therapy is to heal the splits between trust and mistrust, moving towards an integrated self that can navigate their experiences in the context of a current relationship.
The therapist can take interest and selectively inquire into these chasms of long lost, undeveloped, misaligned aspects of self. At times patients with deep hurt have turned against themselves and have very strong disgust, dislike, even hate towards their younger more vulnerable parts of self. Building interest and connection can take a long time, and the therapist in this situation needs to proceed with the dilemma of holding both, the part that is in reaction to younger self and the younger self who has been banished. Such forays, with an intention to stay regulated enough, can build trust in the value of becoming acquainted and curious about what can be discovered and learned from these dissociated parts and integrated into aspects of self. When this happens, there is a making sense that often has a calming impact and relieves the pressure of confusion and deep insecurity.
Amplify Glimmers of Transformance: Safety, Links between Traumatic History, Current Experience and Dissociated Affects
In working with such disorganization, I want to create links between traumatic history, current experience and dissociated parts. When I am able to hold disparate pieces in mind and then reflect them back to my patient, I function as their pre-frontal cortex, serving the mentalizing function. I’m really trying to witness and make meaning and share meaning as it’s coming to me as a way to build safety, and to help the patient make sense of their own experiences. In treatment, I have found the dilemma of contradictory emotions so helpful to identify—the window of tolerance so important to expand—links between what happened then and what is triggered now, so important to make.