Newsletter Archives

  • August 01, 2011 12:39 PM | Anonymous
    by Elizabeth Doherty Thomas

    The gap between your love of this field and your ability to swallow the concepts of marketing may be remarkably vast. They seem to conflict: helping others versus helping yourself. Therapy is a private, confidential relationship behind closed doors and marketing is getting out there in a big way, drawing attention to yourself. If you get a little sick to your stomach, you're normal! Let's attempt, however, to reframe marketing in a way that feels authentic and maybe even inspiring. To be completely blunt, too many people are desperate for what you can offer and the only way to help them is to market yourself.

    The Social Justice Approach to Understanding Marketing

    How many dollars and how many people were involved in forming you from childhood through graduate school and into your license? Even private schools get tax breaks because we believe, as a nation, that education is improving your life, which improves society. Maybe your spouse worked two jobs while you went to school, or your kids didn't get as much parental attention as you had to hit the books. Now imagine all that work for naught. The very people you so desperately know you can help aren't finding you. All the time, supervision, authors who wrote those textbooks, family that sacrificed, everyone put so much energy into helping you advance, and now you're going to hide behind your couch claiming it's selfish or wrong to market?

    Systems Theory Requires Being in The "System!"

    People often mistake advertising with marketing. Advertising is the passive bus stop bench, the printed ad, appearing randomly in front of a variety of people who aren't asking for your services. Marketing, however, is being, quite literally, in the marketplace, or in the "systems" your ideal client hangs out in. If you work with children, the systems you market to are schools, daycares, parent groups, maybe hospitals. Maybe you serve artists, in which case you figure out all the places they natural congregate. I like to think of your ideal client as a bee that likes to buzz around fellow bees. Where are they doing this? That is the system you need to buzz around as a professional able to help with their pains and problems. They aren't wandering office park hallways, learning what the letters LMFT mean, opening doors to see if you're sitting in a chair waiting for them.

    Helping Those Who Can't Pay

    We care deeply about helping people but we also have student loan debt, mortgages, and with a masters or Ph.D., deserve to afford the occasional overpriced coffee, right? A cool feature of marketing is you actually offer high quality, high value information, for FREE. You focus on getting the wisdom in your head out to people who want to hear it. The more people know, like, and trust you in your community (by way of low-cost barriers like free e-books, or talks to groups of people you serve, etc) word spreads that you are a nice, likeable, trustworthy source of help and healing. Then money leaves their wallet, you fill your practice, and all the while you don't have to feel like a greasy salesperson hawking Ginsu knives for $19.95.

    There are many moving parts and pieces to marketing but the great news is therapy, by it's very nature, has an inherent draw to people. Anytime you get frustrated or question the challenges of marketing, be humbled by people who are trying to make a living selling one dollar items, requiring thousands of customers, huge inventory, lots of customer service, and convincing people of the need for the tiny widget.

    Elizabeth Doherty Thomas is starting graduate school in the fall to be an MFT. Since 2005 she has been helping connect therapists with clients seeking their help online via two therapy directories and her consulting work. Visit her website for free marketing help and inspiration, www.ElizabethDohertyThomas.com.

  • June 01, 2011 12:40 PM | Anonymous
    By Theresa L. Cangelosi

    As a somatic psychotherapist, I have always used a body- based approach in my practice. When working with clients who have experienced trauma I have learned that a mind-body approach is crucial. Freud defined trauma as a break in the barrier that protects from over stimulation and leads to a feeling of helplessness.

    When an event is too stimulating to be contained, we become overwhelmed, our lower brain structures organize our survival responses and our nervous system becomes disorganized. Our nervous systems can get stuck and we could look manic and hypervigilant, we can feel numb and vacant, or we can switch back-and forth between those extremes, which can look like bi-polar disorder.

    This extreme range of symptoms is indicative of a disregulated nervous system in need of stabilization. When we experience a shock, there can be a break from earth, self, and others. In stabilization we look for re-reconnection to our natural self and our community.

    The "break" that Freud mentioned could be any incident that we perceive as life threatening, such as a car accident or a rupture in attachment with our caregivers. Early developmental shock or trauma can underlie acute and chronic trauma, and be an indicator of who will develop PTSD.

    Whether it is developmental or shock trauma, the approach is the same. A bodymind approach to trauma is necessary to address the disregulation in the brain regions that have been overwhelmed and are struggling to regain balance and stability. It is helpful for practitioners to understand the neuro-physiology of this disregulation, and in turn educate and empower clients to be aware of their natural ability to regain integrity.

    Fortunately, most of the ways we help our fellow humans who have experienced a traumatic event comes naturally to us. We have all experienced how a hand on our back can comfort us when we are grief stricken, how speaking to someone who has been injured and letting them know we are going to stay with them can do wonders. Helping someone stay present, aware of self and eventually connected with others can be the difference in someone developing PTSD or coming out of the acute stress and recovering.

    Current neuro-physiology teaches us about the sympathetic and parasympathetic nervous systems, so we don't have to wonder why what we do naturally works. Knowing how the nervous system is affected by trauma helps us to respond with an intention to stabilize. It is important to know where the nervous system is stuck, so we know what would bring it into a natural rhythm, and how the nervous system will respond.

    In her course called Trauma First Aide(TM) Training, Geneie Everett, Ph.D. says, "you have to know what you're looking at, to know what you're looking for". Learning the symptoms of the sympathetic and parasympathetic nervous systems is a very helpful skill set in preventing and treating trauma.

    When our life or bodily integrity is threatened, it is a normal and adaptive response to fight or flee to protect ourselves. This natural stress response allows us to use our sympathetic nervous system to respond in the most successful way possible and then to return to a normal level of functioning once the threat is gone. About 80% of the population can experience high levels of activation, acute trauma, and not develop PTSD, chronic trauma. Of course it is best to help anyone stabilize soon after a trauma, so the chances of developing the wide array of symptoms, associated with PTSD, both emotional and physiological, will be greatly diminished.

    After an overwhelming event, clients could be in an acute or chronic stage of trauma and find that they are stuck in any combination of the stress responses: flight, fight or freeze. Our presence and voice engaging them can help the client become self aware and grounded . As we help the client find a place in their body where they tolerate feeling sensation, they experience the natural rhythm of their reciprocal nervous system The fragmentation can come together and give a sense of integrity. The manic energy of a fiercely wagging foot can slow down with guidance from a practitioner who knows the nervous system, and the client can experience their motion attempting regulation. Once their motion is slowed to a tolerable range of experience, they could feel the internal rhythmic rocking and then a full breath. Knowing the nervous system helps us all to listen to the body calling us back to the present where we are connected, whole and safe.

    Learning about the nervous system gives both client and therapist another way to understand the language of the instinctive part of us that knows how to protect us and return us to our natural integrity and resilience. It is our sensory brain that is organized for survival during and after a traumatic experience. Since the cognitive functions of the neocortex are the areas of our brains that become disorganized by the overwhelm of trauma, we as therapists who treat traumatized clients need to know how to read the sensory messages of our lower brain structures related to breathing, circulation, digestion, reproduction, flight/fight response and unconscious control. When these life sustaining functions are stable, our nervous systems can return to their inherent wisdom and natural rhythm.


    Theresa L. Cangelosi, M.A., SEP is a Somatic Psychotherapist and Somatic Experiencing ™ Therapist in private practice for 18 years in San Francisco. She was part of the team that taught Trauma First Aide ™ to first responders in New Orleans after Hurricane Katrina and currently is a teacher with Trauma First Aide Associates. Find Theresa online at www.tlcangelosi.com.

    This article first appeared in the January February 2011 edition of the Newsletter of San Francisco CAMFT.

  • May 20, 2011 12:44 PM | Anonymous
    By Holly Holmes-Meredith

    In order to thrive and grow into our potentials, we all have basic needs that must be met consistently. The most basic needs are for food, safety and shelter. Other important needs are for loving attention, a sense of belonging, stimulation through learning and play, structure and boundaries, age appropriate responsibilities, respect, freedom to express oneself, to be heard, and creative outlets.

    As children if we do not have these needs met, or they are met erratically or inconsistently, we develop defenses and strategies to compensate. These strategies may help us cope and survive when we are young, but as we get older, these defenses, behaviors, perceptions and ways of being with ourselves and our world often become liabilities. Many common issues that clients want to work on in hypnotherapy are linked to these childhood patterns that limit.

    Karen's parents divorced when she was eight years old. After her father moved out, her mother had care of three kids and took on a full time job to make ends meet. Karen lost the full time attention of her mother and her father at the same time. As the oldest child, Karen took on the responsibility of caretaking of her brother and baby sister and doing many chores around the house when her mom was at work. Even though there was the support of baby sitters and neighbors who provided after school child care, Karen became the second parent to her siblings. Her time to be a child was over.

    Karen was commended by all for being so grown up and responsible. She was such a good girl for helping her mom and for taking care of her brother and sister. And she was so dependable that by the time she was thirteen, her mother allowed Karen to be the after school babysitter, prepare dinner and do the chores without much supervision.

    The family maintained some stability. The basic needs were met. But Karen had many childhood needs that seemed to disappear when her father left: the need for age appropriate responsibilities and the freedom to be a kid.

    At 32, Karen comes for hypnotherapy wanting to work on her symptoms of co-dependence that are the result of her childhood family dynamics. Her symptoms are burnout, compulsive dependability, an excessive need to take care of others, anger, stress, and many unsatisfying relationships where she gives and gives and still doesn't have her needs met. She yearns for change.

    In Karen's hypnotherapy inner child work is the focus.

    It is imperative that the client has access to a positive inner resource that can function as a inner parent before the client engages in inner child work because in a regressed state the client's inner child needs to have an appropriate and loving re-parenting experience that will restructure the past events and create new inner child responses. There are several ways to gather resources. A client can meet her higher Self in hypnosis and cultivate a relationship with this inner wisdom as a re-parenting resource, or the client may do some inner family work where the client's actual parents are transformed into more self-actualized, consistent, appropriate and resourceful "inner parents" who can support the inner child. Another option, especially for a client who has had severe childhood trauma and neglect, is to access a positive archetype of a parent. With the inner parent in place and available in these hypnotic restructuring processes the inner child finally has her needs met intrapsychically; it is as if the inner child is freed from the frozen patterns and childhood perceptions so that she can finally begin to feel whole and free again.

    The state of consciousness accessed in hypnosis is elastic: there is no limitation to linear lime or space. The hypnotic re-patterning can lighten or undo the energetic patterns of childhood that are creating the present life difficulties and the hypnotic re-parenting and corrective emotional experiences can create new inner patterns and responses that are accessed in present time. And because hypnotic consciousness is holographic, with ongoing work, the new patterns and experiences eventually generalize and replace the old perceptions, patterns, and behaviors. Inner child work creates lasting change.

    In Karen's inner child work she accesses her higher Self as a resource for an available, wise and responsive inner parent. She dialogues with the higher Self to build trust and a loving inner relationship prior to doing any childhood regression work. She has homework between sessions to make on-going contact with her higher Self as a way to continue to build trust and familiarity with her inner wisdom. When she feels comfortable knowing that her higher Self will be with her, responsive, and consistently available, we begin the childhood regression work to support the transformation and healing of her inner child.

    Commonly the hypnotic regression back to childhood events is facilitated through a technique called the Affect Somatic Linguistic Bridge. In this technique the client chooses a specific troubling issue that is current in her life and goes into the issue through body sensations, emotions and words that represent the experience. By suggesting that these current life effects are amplified, they become the bridge back in time to the childhood events.

    When using this technique, Karen feels an emptiness in her stomach and a heaviness in her shoulders. She expresses that the emotions are abandonment and feeling responsible for her siblings. Her words are, "It is up to me. I have to do it myself." She feels this huge burden and her tears begin to flow.

    Karen regresses to eight years of age. She is alone in the house with her siblings after school when her newly divorced mom is at work. She is cooking popcorn for an after school snack. Smoke fills the hallway and the fire alarm goes off. She pulls the pan off the stove, grabs her baby sister and screams for her brother to get out of the house. After the smoke clears, Karen discovers that the house is safe. She scours the burnt pan and airs out the house. She doesn't tell her mother about the incident because she wants her mom to think she is responsible and a big girl. Every time her mom comes home she tells Karen what a big girl she is, how responsible she is, and how she can trust her to help with the house and the kids. This special attention from her mom feels wonderful. Karen thinks that telling her mom about the smoke and burned popcorn may not only make her mom mad, but it may also stop her mom from giving her attention and praise that fills up the empty place inside. Karen covers up her fear and the feelings of pressure to do things responsibly and correctly so she can continue to get approval from her mom. Getting approval for what she does is the main way Karen feels love from her mother. Karen's developing co-dependent patterns are reinforced each time she denies her feelings or her needs and takes care of the house or her siblings for her mother's approval. Because Karen's needs aren't met freely and directly for her efforts, she begins to resent her siblings.

    In the hypnotic re-parenting of the eight year old, Karen's higher Self takes charge of the popcorn incident and gets the three kids to safety and then, as the adult, she accesses the problem and deals with it. Her higher Self talks to Karen and tells her that she is lovable for simply being who she is, not for what she does. Her higher Self attends to Karen's needs to be a child and have free time and play time. Time to be a kid. The higher Self spends time with Karen nurturing her, and being present with her. Karen begins to relax and let go of the compulsion to have to do to be worthy and lovable.

    After several inner child sessions Karen notices that she is beginning to set boundaries for herself and nurture herself more. She begins to practice meeting her own needs first. And when she gives to others, she begins to give from a place of fullness rather than from a place of needing approval or acknowledgement from others. She feels more relaxed and more energy and joy. Her transformation continues as she learns how to attend to, love and support her inner child.

    By accessing holographic consciousness in hypnosis and working with the inner child, we can heal places where our psychological development was arrested because of unmet needs. By accessing the beyond time and space elasticity of hypnotic consciousness, and engaging in inner child work, it is not too late to have a happy childhood.

    Note: The client Karen is fictional, but an accurate representation of what a typical co-dependent client would go through in hypnotherapy focusing on inner child work.

    Holly Holmes-Meredith, Doctor of Ministry, Licensed Marriage Family Therapist, Board Certified Clinical Hypnotherapist, Clinical Director, HCH An Institute for Hypnotherapy and Psychospiritual Trainings

    Visit Holly Holmes-Meredith's page on East Bay Therapist
  • May 19, 2011 12:46 PM | Anonymous
    By Pete Walker

    1. Introduction

    This article highlights the prodigious role that emotional neglect plays in childhood trauma, and how it alone can create Complex PTSD. It begins by extensively examining the processes of denial and minimization that blunt our awareness about childhood trauma. Denial is first explored in relationship to abuse, especially verbal and emotional abuse, which then sets the stage for a more complete explication of the trauma of emotional neglect.

    Denial about the deleterious effects of childhood abandonment seriously delimits our ability to recover. Continuous emotional neglect turns the child's psyche into a quagmire of emptiness, fear and shame - a quagmire that she will, as an adult, frequently flashback into until she understands and works through the wretchedness of her childhood. Without such understanding, her crucial, unmet needs for safe and comforting, human connection will continue to cause her an enormous amount of unnecessary suffering.

    2. Denial and minimization

    Recovery from PTSD correlates with an individual's ability to understand on deep impactful levels how derelict her parents' were in their duty to nurture and protect her. The individual needs to get that emotional flashbacks are direct messages from her child-self about how seriously her parents hurt and injured her. As denial is significantly deconstructed, the recoveree feels genuine compassion for the child she was. This in turn motivates her to engage the healing process of identifying and addressing the specific wounds of her childhood. Over time she becomes aware of her specific abandonment picture and the pattern of physical, spiritual, verbal and emotional abuse and/or neglect that she experienced. [Chapter 8 of my book, The Tao of Fully Feeling, provides guidelines for assessing your particular pattern].

    Confronting denial is no small task. Children so need to believe that their parents love and care for them, that they will deny and minimize away evidence of the most egregious neglect and abuse. De-minimization is a crucial aspect of confronting denial. It is the process by which the individual deconstructs the defense of making light of his childhood trauma. The lifelong process of de-minimizing the impact of childhood trauma is like peeling a very slippery and caustic onion. The outer layer for some is the stark physical evidence of abuse, e.g., sexual abuse or excessive corporal punishment. In a perversely ironic way, my parents' physical abuse of me as a child was a blessing for it was so blatant that my attempts to suppress, rationalize, make light of and laugh it off lost their power in adolescence, and I was able to see my father for the bully that he was. [Seeing my defensively idealized mother's abusiveness came much later].

    Identifying my father's behavior as abusive eventually helped me become aware of less dramatic aspects of my parents' oppression, and I subsequently discovered the verbal and emotional abuse layer of the onion of my childhood abandonment.

    3. Verbal and Emotional Abuse

    The fact that verbal and emotional abuse can be traumatic is lost on many childhood trauma victims. Many never learn to validate its crippling effects. They never accurately assign current time suffering to it. Attempts to acknowledge it are typically blindsided with thoughts that it was nothing compared to kids who were repeatedly beaten - who had it worse. Yet for me, and many of my clients, verbal and emotional abuse was much more injurious than our physical abuse.

    Being ongoingly assaulted with critical words systematically destroys innate self-esteem and replaces it with a prevailing consciousness of toxic self-criticism. Even worse, words that are emotionally poisoned with contempt [a deadly cocktail of intimidation and disgust] infuse the child with fear and toxic shame respectively. Fear and shame condition him to refrain from asking for attention, from expressing himself in ways that draw attention, and before long from seeking any kind of help or connection at all.

    Unrelenting criticism, especially when it is ground in with parental rage and scorn, is so injurious that it changes the structure of the child's brain.

    Here is a theoretical model of this. Repeated messages of disdain are internalized and adopted by the child, who repeats them over and over to himself. Incessant repetitions result in the construction of thick neural pathways of self-hate and self-disgust. Over time a self-hate response attaches to more and more of the child's cognitions, feelings and behaviors. Eventually, any inclination toward authentic or vulnerable self-expression activates internal neural networks of self-loathing. The child is forced to exist in a crippling state of self-attack, which eventually becomes equivalent to a state of full-fledged self-abandonment. The ability to support or nurture himself or take his own side in anyway is decimated. With ongoing parental reinforcement, these neural pathways expand into a large complex network that becomes an Inner Critic that dominates mental activity. This critic elaborates myriad programs of self-rejecting perfectionism and paints the psyche with the endangerment scenarios that I describe in my articles on Shrinking The Critic. Until these programs are effectively deconstructed, the individual typically lives in varying degrees of emotional flashback much of the time. 1

    The verbal and emotional layer of the abuse onion has myriad sub-layers of minimization which must be confronted in the long difficult disengagement of one's identity from the toxic critic. I have heard clients jokingly repeat numerous versions of this over and over: I know I'm hard on myself, but if I don't constantly kick my own ass, I'll be more of a loser than I already am.

    A childhood rife with verbal and emotional abuse often creates an identification with the critic that is so pervasive, that it is as if the critic is the whole identity. Disidentification from the critic is the fight of a lifetime, and for a long time there is a great pull to collapse back into the old habit of self-blame. Ironically this self-hate can constellate around the self-judgment that one is especially defective because she cannot simply banish the critic. [Typical toxic, all-or-none thinking from the critic]. Sadly, many survivors give up before recognizing the myriad subtle ways the critic tortures them. Yet, there is no more noble recovery battle than that which gradually frees the psyche from critic dominance. Until this happens to a significant degree, there is minimal development of the healthy, user-friendly ego.

    Let us look now at how emotional neglect alone creates a psyche-dominating Critic.

    4. Emotional Neglect: The Core Wound in Complex PTSD

    Minimization about the debilitating consequences of a childhood rife with emotional neglect is at the core of the PTSD denial onion. Our recovery efforts are impeded until we understand how much of our suffering constellates around early emotional abandonment - around the great emptiness that springs from the dearth of parental loving interest and engagement, and around the harrowing experience of being small and powerless while growing up in a world where there is no-one who's got your back. Many survivors never get to discover and work through the wounds that correlate with this level, because they over-assign their suffering to overt abuse and never get to the core issue of emotional abandonment. As stated above, this is especially true when they dismissively compare their trauma to those who were abused more noticeably and more dramatically. [This is particularly ironic in light of the fact that some individuals can suffer a modicum of active abuse without developing PTSD, if there is one caretaker who does not emotionally neglect them].

    Traumatic emotional neglect occurs when a child does not have a single parent or caretaker to whom she can turn in times of need or danger, and when she does not have anyone for an extended period of time who is a relatively consistent source of comfort and protection. Growing up emotionally neglected is like nearly dying of thirst just outside the fenced off fountain of a parent's kindness and interest. Emotional neglect makes children feel worthless, unlovable and excruciatingly empty, with a hunger that gnaws deeply at the center of their being, leaving them starving for human warmth and comfort - a hunger that often morphs over time into an insatiable appetite for substances and/or addictive processes. [I find it noteworthy that denial processes about early abandonment often morph later in life to the minimizing operations that some survivors use to rationalize their substance and process addictions. While addictions are often understandable, misplaced attempts to regulate painful emotional flashbacks, they become increasingly self-destructive when an individual is old enough to learn a healthier flashback management regimen. Accordingly, excessive eating, spending, drinking, drugging, sexing, working or dissociating, are not only desperate attempts to distract from inner pain, but also counterproductive efforts to attain an ersatz form of human comfort and soothing. And while many recoverees eventually come to see their substance or process addictions as problematic, many also minimize their deleterious effects and jokingly dismiss their need to end or reduce their reliance on them.]

    5. The Evolutionary Basis of Attachment Needs

    The human brain evolved during the Hunter-Gatherer era that represents 99.8% of our time on this planet. Children's vulnerability to predators caused them to evolve an intense, instinctual fear response to being left alone without protection. Fear hard-wired in the child as a healthy response to separation from a protective adult, and linked automatically to the fight response so that the infant and toddler would automatically cry angrily for attention, help, cessation of abandonment - even at the briefest loss of contact with parental figures. Beasts of prey only needed seconds to snatch away the unprotected child.

    In present time dysfunctional families, many parents disdain children for needing their attention. Even the most well-intentioned can seriously neglect the child by subscribing to the egregious 20th century 'wisdom': Kids need quality time -not quantity.

    When children experience long periods of being powerless to obtain needed connection with a parent, they become increasingly anxious, upset and depressed. Over time their dominant experience of self is so replete with emotional pain and so unmanageable that that they have to dissociate, act out [aggression against others] or act in [aggression against the self] to distract from it. The situation of the abandoned child further deteriorates as an extended absence of warmth and protection gives rise to the cancerous growth of the inner critic as described above. The child projects his hope for being accepted onto inner demands of self-perfection. By the time the child is becoming self-reflective, cognitions start to arise that sound like this: I'm so despicable, worthless, unlovable, ugly; maybe my parents would love me if I could make myself like those perfect kids I see on TV.

    In this way, the child becomes hyperaware of imperfections and strives to become flawless. Eventually she roots out the ultimate flaw - the mortal sin of wanting or asking for her parents' time or energy. Intrinsic to this process is noticing - more and more hypervigilantly - how parents turn their back or become angry or disgusted whenever she needs anything, whether it be attention, listening, interest, or affection.

    Emotional neglect, alone, causes children to abandon themselves, and to give up on the formation of a self. They do so to preserve an illusion of connection with the parent and to protect themselves from the danger of losing that tenuous connection. This typically requires a great deal of self-abdication, i.e., the forfeiture of self-esteem, self-confidence, self-care, self-interest, self-protection. Moreover, ever-developing endangerment programs proliferate in the critic as the child learns that he cannot ask the dangerous parent to protect him from outside world dangers and injustices. His only recourse is to become hyperaware and on constant look out for things that may go wrong, and the list of such possibilities becomes endless, especially when they are graphically illustrated and overemphasized on the television. Consciousness eventually becomes overwhelmed with the processes of drasticizing and catastrophizing- the processes by which the child constantly rehearses dreaded and dreadful scenarios in a vain attempt to prepare himself for the worst. This is the process by which Complex PTSD with its overdeveloped stress and toxic shame programs sets in and becomes triggerable by a plethora of normally innocuous stimuli. Most notable of these stimuli are other people, especially unknown people or people even vaguely reminiscent of the parents. Over time, the critic comes to assume that other people are dangerous and automatically triggers the fight/flight/freeze/fawn response [ See my article: The Four F's: A Trauma Typology] whenever a stranger or unproven other comes into view. This process becomes the social phobia that is frequently a symptom of complex PTSD.

    6. Abandonment Stultifies Emotional and Relational Intelligence

    Emotional intelligence and its cohort, relational intelligence, never get to develop, and children never learn that a relationship with a healthy person can become an irreplaceable source of comfort and enrichment. Moreover, the appropriate management of the normal emotions that recurrently arise in significant relationships is never modeled for them. Emotional intelligence about the healthy and functional aspects of anger, sadness, and fear lies fallow. Moreover the receptor sites for receiving love and caring from others often lay dormant and undeveloped. Emotionally abandoned children often devolve into experiencing all people as dangerous, no matter how benign or generous they may in fact be. Anyone can automatically trigger the grown-up child into the deeply grooved patterns of perfectionism and endangerment engendered by their parents. Love coming their way reverberates threateningly on a subliminal level. If, from their perspective, they momentarily trick someone into seeing them as loveable, they fear that this forbidden prize will surely be taken away the minute their social perfectionism fails and unmasks some normal flaw or foible.

    As with physical abuse, effective work on the wounds of verbal and emotional abuse can sometimes open the door to de-minimizing the awful impact of emotional neglect. I sometimes feel the most for my clients who were only neglected, because without the hard core evidence - the remembering and de-minimizing of the impact of abuse - they find it extremely difficult to connect their non-existent self-esteem, their frequent flashbacks, and their recurring reenactments of impoverished relationships, to their childhood emotional abandonment. I repeatedly regret that I did not know what I know now about this kind of neglect when I wrote my book and over-focused on the role of abuse in childhood trauma. It is so hard to convey this to a client whose critic minimizes and shames them for their plight by comparing them unfavorably to me: I didn't have it anywhere near as bad as you. My mother never hit me!

    How ironic that this typically invokes a feeling-sense in me that by far the worst thing that happened to me, by far, was growing up so emotionally abandoned. In fact, it was not until I learned to assign the pain of numerous current time emotional flashbacks to the abject loneliness of my childhood, that I was able to work effectively on the repetition compulsion that kept me vacillating between long periods of isolation and relationships that were never safe enough to reveal my whole self. It is important to emphasize here that real intimacy, and the healing comfort it alone can bestow, depends on showing up in times of vulnerability - and eventually, and most especially, in the flashbacked-times of feeling trapped in the fear, shame and depression of the abandonment melange.

    In this vein, I had to painstakingly practice for years showing up in my pain and abstaining from my childhood default positions of running or hiding or camouflaging with substances whenever I was in the grips of the fear, shame or depression of the abandonment melange. How else would I ever have learned that I was loveable and acceptable in all aspects of my experience, not just in the social perfectionism of my people-pleasing codependence?

    And of course, like most survivors, I was ignorant at first that I was experiencing the emotional pain of the abandonment melange; how could I help but conceal it? Yet, even after considerable de-minimization of my childhood abuse/neglect picture, I still remained convinced for a long time that everyone but my therapist [who in deep flashbacks, I also recurrently distrusted] would find me abhorrent if I presented myself authentically in such condition. Gratefully, sufficient positive experiences with my therapist eventually emboldened me to bring my authentic vulnerability to other select and gradually proven relationships, where I found the acceptance, safety and support that, previously, I would not have even known to wish for.

    It is important to note the limitations of the analogy of the onion. Effective recovery does typically involve working at various levels at the same time. De-minimization is a lifetime process, and remembering a crucial instance of being abused or neglected may occasionally impact us even more deeply on subsequent remembering as we more fully apprehend the hurt of particularly destructive parental betrayals. One such occasion left me reeling with the certain knowledge that getting hit felt preferable to being abandoned for long hours outside my depressed mother's locked bedroom door. I have known about the latter for quite some time now, and yet writing about it brings up some new bittersweet tears. For me, my ongoing work with the layers of the denial onion still sometimes has a bittersweet quality to it - bitter because abandonment was the worst thing that happened to me, especially as it happened over and over again at such a young and normally needy age - and sweet because these tears validate the truth of this recollection - and sweet, in gratitude, because I do now regularly experience good enough love and safety in relationship - and now bitter again because I can still emotionally flashback to that bereft state of feeling stranded from the comfort of others, even occasionally from my wife and son and inner circle-friends - and then sweet again because, ongoingly, the frequency, duration and intensity of these flashbacks decreases as I increasingly master the use of the tools I describe in my article, Emotional Flashback Management. I am also blessed to see this same progress in various of my long term clients who work with this model.

    7. The Neuroplasticity of the Brain

    I am so heartened to know about all the new neuroscience research that proves the neuroplasticity of the brain, i.e., that the brain can grow and change throughout our life: old self-destructive neural pathways can be diminished and new healthier ones grown. [A General Theory of Love by Thomas Lewis inspiringly explicates this fact]. The critic can indeed literally be shrunk via long-term, frequent and dedicated use of the thought-stopping, thought-substitution and thought-correction practices I describe in my articles on the critic. This is especially true when these techniques are empowered by the grieving processes I describe in my book, The Tao of Fully Feeling, and in an article, Grieving and Complex PTSD, that I will post on my website around the end of 2010.

    There is also growing evidence that recovery from Complex PTSD is reflected in the narrative a person tells about her life. The degree of recovery matches the degree to which a survivor's story is complete, coherent , emotionally congruent and told from a self-sympathetic perspective. In my experience, deep level recovery is often reflected in a narrative that places emotional neglect at the core of the understanding of what one has suffered and what one continues to deal with. It is a very empowering accomplishment to really get the profound significance of childhood emotional neglect - to realize in the moment how a flashback into bewilderment, panic, toxic shame, helplessness, and hopelessness is an emotional reliving of the dominant emotional tone of one's childhood reality. Like nothing else, this can generate self-compassion for one's child-self and one's present-time self, kick-starting the process of resolving any given flashback. This also assuages emotional neglect by providing the self with the essential missed childhood experience of receiving empathy in painful emotional states instead of contempt or abandonment. This, in turn, proves that there has been significant deconstruction of the learned, unconscious habit of pervasive self-abandonment.


    1 [In viewing Richard Davidson's research along side that of Susan Vaughan's, I have come to believe that the Critic forms in the right prefrontal cortex of the brain. Davidson's research {What does the prefrontal cortex do in affect, Biological Psychology 67, 2004, pp219-233} shows that people with a predominant negative outlook have greater pre-frontal right brain activation than those with a positive outlook whose left prefrontal cortex activation dominates; moreover Vaughan's MRIs with people in flashback [The Talking Cure] shows intense right hemisphere stimulation during flashbacks with a dearth of left hemisphere activation.]


    Pete Walker, M.A., MFT, is a licensed Marriage and Family Psychotherapist with degrees in Social Work and Counseling Psychology. He has been working as a counselor, lecturer, writer and group leader for 30 years, and as a trainer, supervisor and consultant of other therapists for 15 years. He holds certificates in supervision from the California Association of Marriage and Family Therapists (CAMFT) and the Psychotherapy Institute in Berkeley.

    Visit Pete Walker's page on East Bay Therapist

  • May 17, 2011 12:48 PM | Anonymous
    By Cybele Lolley

    Last summer, in late July 2009, I learned that my partners employer was planning on moving the company to a new location so he could be by the ocean and surf. This move was happening in February 2010. We were instantly filled with resistance, rebellion and anger. How could he do that to us, and our comfortable happy world! We reactively went into 'quit and get another job' mode.

    With the economy as it was last summer, there were few to no jobs out there, especially in her field. There also was the issues of potential LHFLO-last hired first laid off. At least with the current job position she had job security and great ongoing growth. My practice was sufficient, but not enough to sustain us both if she quit and became unemployed. Within a short period of time we knew we had to follow the company.

    This decision caused much anguish. I was loosing all that I had created and used as my professional and personal foundation. I needed to leave my supervisor position, my practice, my networking pool and my support community. My social friendships, my spiritual community and my comforting outlets were not going to be as easily available. My ego identification of 'I' wasn't happy! 'I' had 6 more months to live as 'I' had been living for many years. Influenced by my years working in the hospice and grief field, I was very aware of it all ending, dying. On top of that, I felt great responsibility to do this ending with the least harm possible to my clients for they too may have many internal conflicts with this outcome.

    I needed to center and prepare myself before I told my clients. I tried to do this quickly, but it took two months. Holding the news at times felt like a guilty secret eating me up. I scripted personalized wording over and over as to what I would say to each client. I took the time to find how to say the news in a least painful way, to know what I was willing to disclose, and to ready for difficult questioning and reactions. I was grateful for having this grounding time. All clients, including those I had ended with within the year, were told in early October, with only four months remaining. My decision to notify recent terminated clients was based on addressing my unavailability for future services at a non-crisis time.

    When other clinicians asked about my process, I referred to this time as 'breaking up with 20 relationships at the same time, one after another, not because they weren't loved or their work was complete, but because I was moving away.' As a way to manage this great emotional difficulty, my mind would create sarcastic humor by remembering popular 'break-up' songs such as Breaking up is Hard to Do, Another One Bites the Dust, and 50 Ways to Leave Your Lover. This technique kept me open, lighter and available.

    The therapeutic relationship we had developed through continual brave vulnerability, devoted repairs and tender caressing was ending, was dying. Each client had their own reactions to this painful news so attentive sensitivity and adaptability were required on my part. I had a client point out to me that I was making a 'selfish choice' repetitively and it was a great challenge to not move into justifying my position since it felt like I had little or no choice. Another client wanted to complete her therapy 'to do' list for all the issues she skirted around for years. A couple clients didn't want to be reminded of our little time left and pulled back relationally and behaviorally. One client even terminated early to take control of our situation. However, the majority of my clients stayed until the end, coming back consistently even though they knew it would be difficult. They stayed with their internal process and our relationship ending. Even though I know they were getting their own needs met with returning and staying present with their process, this choice also offered me the treasured gift of care. We could also call it affection or even love.

    I worked hard at staying aware when my stuff was too much in the room. There was no way possible to not have my stuff in the room. Although this is an ideal thought, it isn't a human reality. Since we physically share the same space, I believe we are always in the room to some degree. One client, at one point, needed reassurance that my stuff wouldn't infringe on her process, which scared both of us. As a clinician who tends to utilize consistent boundaries around self-disclosure and containment, I felt horrified that I could cause such great damage, and professional failure, if this occurred. My only response was that I would try my best. My clients were aware of my own struggle with our ending. Even though I did do my very best to contain my stuff, I was more transparent then ever before. I cried with some and shared mutual anxieties about not knowing what was next with others.

    This was such a beautiful time and such a painful time, each adding to the quality of the other. This was a transcending time. It reminded me of sitting with those who are aware they have limited time left alive due to illness. There's often a vivid and heightened sensory awareness during this time. I watched my clients and myself 'see' my physical office space with new eyes. I noticed myself looking deeply into my clients' faces and eyes as an attempt to imprint them into my memory. I caught myself breathing with them to share the same breath rhythm. Holding the compassionate space for my clients to feel all that they felt - angry, hurt, loved, rejected, abandoned, special, important, meaningful, etc. was both rewarding and challenging. To support my ability to stay open to their pain, I utilized my mindfulness practice and healing beliefs as grounding sources with all the grief emotions in the sessions.

    Overall I was aware that I could not 'fix' the situation just as a doctor can't fix a dying patient, but I tried anyway at times as an attempt to ease my guilt around taking ultimate control of our work and leaving them. One of my most challenging clients, also deeply cherished, repetitively called out my attempts to 'fix' the situation. One time she humorously naming my referring efforts as 'passing her on to a rebound'. I was shocked and hurt by her perspective of this 'therapeutic' tool regularly used in our field as equivalent to a romantic rebound. I perceived her response as her resistance and lack of understanding of the 'benefit' in this standard. Over time, I got her point. I was attempting to pass her on to someone she could latch on to with the hope that it would ease her pain and meet her needs when I'm gone, even if it was under the temporary umbrella of 'grief counseling'. My client desired to grieve and process our relational death without professional help. I wonder if maybe her desire wasn't 'resistance', but the desire to rely on her emotional strength developed in our work as her grieving and healing foundation. I may never know, or not know for a few years.

    I know that referring is good legal and ethical practice for not abandoning our clients and referrals to other professionals is an important practice. I gave thought-out, specific referring clinician information to all my clients. With that said, I appreciate how my client's perspective has broadened my perspective. It's deepened my understanding that our go-to referral intervention has limits. I'm now more aware that offering referral may not be for a client's sake, but may be for ours alone. Referring helps ease our guilt of abandoning them, which is what we are doing when we leave them. Referring may also be a way we seek continual contact with our clients as the next therapist may get a release to talk to us. Allowing these possibilities to be a true shifts the focus from the client being resistant to recognizing that I, the clinician, have consultation/support needs. The final work then focuses on honoring and supporting the clients plan to do the grief work outside of the therapy structure.

    Getting consultation and support during this process was essential for me to stay present with the intensity of the experience. I continue to be so grateful for my consultation colleagues and fellow supervisors for their ability to hold space for my expressed pains, worries and doubts about doing a good-enough job facilitating these breakups. With most of my attention going outward towards packing up my home and closing up my personal and professional relationships, it was healing to have safe and comfortable spaces to grieve, to be scared and to find grounding strength through their trust for my abilities as a clinician.

    I've thought of this termination experience often over these months. I've noticed my critical mind finding things I could have done better to maybe ease the mutual pain more. Then I remember a piece of wisdom share with me long ago. The degree of pain we feel is in relationship to the degree of attachment we have. Some may read this and disagree, and that's okay. From this place I know I did the best job I could with an extremely challenging task. I was deeply attached to my clients because they mattered to me. I cared about them. I loved them. My heart embraced them as they shared vulnerabilities with me, strived to improve their lives, and struggled to say good-bye.

    As I prepare to close this article, my final thought is towards impermanence. This closing for me has been a symbolic practice death. I chose to use it as a holistic unfolding and releasing, using Stephen Levine's A Year To Live as a spiritual guide. At some point we all will go through this task of closing a practice, or someone close to you will need to do it for you. This may be a voluntary decision like my move or retirement, or involuntary due to illness or death. All things have a birth and a death, a beginning and an end. Currently, I'm in the groundless transitional space between endings and beginnings, the Bardo, the Great Void. I focus on the gifts in my present as I my rebirth, and reincarnation, begins- strengthening my health with beach walks, finding spiritual community & comforting outlets, and saying 'Yes' to auspicious manifestations, like writing this article.
  • May 16, 2011 12:50 PM | Anonymous
    By Graeme Daniels

    (This article first appeared in the July/August 2008 issue of East Bay Therapist)

    A problem of misunderstanding? In some settings I've heard the term "process" used with at least three different meanings, two of which are clinical. The first meaning is administrative, and systemic, as in process of a business-model. Process as in procedure, I've observed, is what one colleague (with tongue firmly in cheek) called "a molasses-like movement of ideas or action within a hierarchical system like, say, a hospital, or an agency." That's what people mean when they refer to a "process unfolding."

    The second meaning refers to the internal work of an individual's therapy, with therapeutic assistance being that of a catalyst: the client is "processing" material, drawn out by a probing facilitator. The last meaning, that which is most relevant to any discussion of a system's communication, or certainly to any discussion of group therapy, is one which carries the least shared understanding, and incurs the most resistance.

    Perhaps it's an issue of application. The process of group therapy that I'm referring to is the relational information that passes between group members, versus the content–that is, the explicit words spoken, the substantive issues, and the arguments advanced (Yalom, 1995). In this context, process refers to a meta-communication between members, sometimes conveyed non-verbally.

    In my role as group therapist, I am constantly on alert for these moments of multi-layered communication, and as a supervisor, I am frequently urging other therapists-in-training to observe patterns of process, and to orient their groups–in plainspoken terms -- to the value of learning from such exchanges. Reflecting upon these roles, group therapist and supervisor (of, predominantly, group therapy), I begin to notice an interesting array of resistances to the process orientation. It calls to mind an article by a Murray Bowen acolyte, Michael Kerr, entitled: "An Obstacle to 'hearing' Bowen Theory". In it, he wrote of the negative reactions of students when observing the Bowen theory in practical application. Likewise, I repeatedly observe the squirming in chairs, and the quiet sniff of distaste, when faced with the prospect of making process comments in groups.

    Thinking more broadly, maybe the issue is one of assimilation into systems. When speaking of the contrast between outpatient groups with members of equal circumstances, and those wherein one member of a family is admitted to an inpatient unit and another participates on an outpatient basis, I draw attention to the relative intensity of the latter groups. They don't go home together, I succinctly conclude; there's no shared drive home in which individuals might recriminate one another for things said in the just finished group meeting. The difference is important, I assert. And so, there is a system beyond the present system to be concerned with. Group therapy, especially of a process-oriented approach, contends with this vast exterior system on a constant basis. I'm referring to social norms, family norms, the norms that state, for example, that commenting upon the manner of communication (especially of strangers), is rude, or at least disorienting.

    Consider the following question, posed by a therapist to a new group with a homogeneous set of problems, composed of psychologically-minded members: "Does anyone in the group have any feedback for what's happening between John and Sarah?" (I shall deliberately exclude the content). Such a statement may be calling for group members to comment upon how the exchange illuminates the relationship, though the question's open-ended nature easily allows group members to choose a content-oriented response instead.

    More than likely, members would select from the following options: a review of the information provided by the two members, giving advice or otherwise attempting to problem-solve for one or the other; offering acceptance, mirroring, or a declaration of shared experience. Even in groups of motivated members, who have been screened for group therapy, and oriented to the norms of the group process, comments upon meta-communication are often withheld, or else left to the group therapist to reveal.

    "That's your job," I once heard a group member say. That terse reply suggests clues to the resistance to process, a matter expanded upon in Mathew Miles' essay, "On Naming the Here & Now". In it, he writes that "here & now" comments, those references to immediate events in a group that form the nuts and bolts of the process orientation, recall the childhood experience of being controlled and criticized. We remember being told to look at people when we're speaking to them, to stop interrupting, and to take our hands out of our pockets. If group therapy is to recreate this old experience, or even to just provide echoes of it, then it would be infantilizing. Furthermore, Miles writes, such a focus would intensify self-consciousness, and render a discussion of communication more complex, if not overwhelming.

    A content focus is, therefore, safer and easier. Of course, group therapy is intended to do more than merely draw attention to, or even correct, all manner of verbal and non-verbal behaviors. What distinguishes the here & now focus from this disconcerting social template, is what Yalom refers to as the second tier of the here & now focus, that of process illumination. This is the dimension that provides examination, and understanding. Ultimately, it calls on members to follow the track of their exchanges, reflect upon them, and draw a non-judgmental learning experience as to how they relate to others.

    All of which becomes more fascinating when thinking of groups with adolescents, or groups with so-called "low functioning" populations. Consider some of the terms or ideas already used or referenced in this article: hierarchy, self-consciousness, infantilizing, problem-solving, group safety. The reader can begin to gain an idea as to why certain populations would resist process-orientation, or else why mental health professionals would resist it on their behalf.

    Recall Wilfed Bion's three basic assumptions of group life. The first basic assumption is one he called dependence. In a basic dependent group, one notices the group searching for an oracle or a deity, from which all security, nourishment, and direction come (Bion, 1961). Especially in hospitals, where little, if any, orientation is provided as to group therapy, we can imagine why adolescents would readily adhere to hierarchies and depend upon a leader, but why they might also bristle at a therapist that constantly drew attention to their mannerisms, or syntax, assuming a critical intent on the part of the therapist?

    We can also understand why highly anxious individuals, accessing treatment in order, primarily, to relieve symptoms, might be disoriented by a therapeutic approach that, for example, re-directs questions away from the facilitator, but rather towards the group, and which constantly seeks to decentralize the group tasks. This approach places implicit responsibility upon the group to self-activate. This question of client/patient, or group responsibility for change versus therapist responsibility for the process (here, as in procedure) of change, is one which all therapists must address, repeatedly. The meaning of the "that's your job" rebuke is to resist shared responsibility.

    And yet moments of spontaneity and individuation do occur, even if they are cast as indicators of a resistant pathology. This is particularly true in adolescent groups, and there is some irony here, as it is adult facilitators who, as often as not, resist the process orientation. Consider the following brief exchange:

    Client: (upon receiving a series of facilitator questions) "I feel like you're cross-examining me!"

    Therapist: "But do you see the point I was trying to make?"

    Client: "I don't care. These questions are stupid."

    Therapist: "Remember, this process is not about me."

    The adolescent client in this instance has made, in effect, a process comment, one which the therapist has ignored. In speaking to many group therapists about this kind of exchange, I've come across a few interesting pretexts for why the therapist would choose this tact. First of all, that the group's primary task may have been that of addressing problem behaviors, with special attention to attendant defensive thinking. The process comment in the above scenario was deemed a deflection, a defensive maneuver by the group member, and so a process exploration, one that was interpretative, but not directive, would have been misguided.

    Secondly, many group therapists rightfully concern themselves with group safety, and so err on the side of containment of affect. Indulging process may lead to an escalation, a stirring of high anxiety, or scapegoating, with problematic implications for the later stability of the hospital unit, or else that previously indicated ride home.

    "I was concerned that the group may become overwhelmed", said one facilitator, explaining why she consistently deferred on making process interventions. She'd actually begun the group with the glib pronouncement that the group's main purpose was to explore patterns of communication, but as the group progressed, the term "communication skills" replaced 'explore", and so a more didactic intent became apparent. This was perhaps recognized by the assembled adolescents, whose largely passive participation betrayed an unconvinced air.

    Perhaps it's a question of priorities, or of assessment. It's undoubtedly true that some clients are sufficiently dysfunctional (either in terms of ego boundaries, or else cognitive ability), that the process-oriented approach is too disorienting. Imagine a highly anxious group member, whose internalization of even the most carefully neutral of interpretations evokes a panicked inference of criticism, if not accusation. Although, one might argue that even this individual might benefit, ultimately, from hearing different perspectives upon communication.

    Furthermore, group dynamics take place within a broader context, no matter how hard they try to create self-containment (no outside relationships as a group rule, for example). Groups in hospital settings cannot realistically contain contact outside of group meetings, they cannot eliminate the lack of cohesion borne of high turnover, or ignore that destabilizing consequences of group disorientation; and they cannot easily take neutral stances towards the varying types of self-destructive behaviors that are often the presenting reasons for therapy.

    I think it's really a matter of integrating the process-oriented approach, rather than dismissing it as contrary to the priorities of, say, behavior modification, or symptom reduction. In my work with adolescents, in particular, I observe a strain of conservatism that leads to a quasi-parental dynamic between client and clinician. It's been interesting to notice that in certain modalities (art therapy, and drama therapy) some of the inhibiting qualities of regular talk therapy are diminished. Self-consciousness is often reduced, for example, if disguised in a character.

    Furthermore, I've noticed the symbolic disguise of art and drama allows for a practice of process illumination that might otherwise feel too intense, too real. The explicit disclosure of true thoughts and feelings is often perceived as too threatening by adolescents. When loss of esteem, or rejection, is at stake, truth is a risk, and its disclosure requires a sensitive development of trust. Adolescents often defend against this risk by projecting the dilemma onto adults, particularly parents: "I want to gain their trust".

    A more thorough depiction of group dynamics with adolescents is provided by Pressman, Kymissis, and Hauben's 2001 article: "Group Psychotherapy for Adolescents Comorbid for Substance Abuse and Psychiatric Problems: A Relational Constructionist Approach" In this description of a combined day treatment and high school program, the authors posit several observations about adolescents in treatment:

    • that adolescents construct acceptance and personal meaning through role-defined, non-hierarchical relations;
    • that conflict resolution involves the emergence of overwhelming feelings that comorbid adolescents cannot control;
    • that they may require extended orientation to group therapy, and may initially engage groups in a rebellious fashion;
    • that the primary challenge for the patients is to learn self-control and trust of others;
    • finally, and most crucially, that negative countertransference can be avoided when staff members do not feel intense responsibility and need for control.

    The program structure and pattern of interventions reflect many of these baseline assumptions. The hierarchy of the program is decentralized, for example, de-emphasizing a "charismatic" leader, and instead implementing a multidisciplinary team. This tended to mitigate rebellious action. Empathy as a leading intervention, is emphasized, allowing space to de-pathologize patient behavior. Staff would empathize with the adolescents' resistance to treatment, rather than coaching a premature cohesiveness. Empathy with parents' distress replaced collusion with the need for punitive, rigid responses designed to influence negative behaviors.

    In the article, examples are given of aggressive gestures, horseplay, sexual innuendos between patients and staff, that are met with largely interpretive response (only the example of the aggressive gesture led to a patient being removed from group); ultimately, that example, also was treated with an interpretive response, rather than a strictly directive intervention.

    Above all, while not strictly identical to a process-orientation, the above-described model presents two provocative challenges that speak directly to what is, perhaps, a systemic resistance to process:

    1. That the ability for adolescents to express angry feelings is more important than maintaining strict unit order, and
    2. That a lack of strict adherence to subject matter of the group allows staff to keep abreast of the adolescents' thoughts and feelings.

    The first time someone walked out of a group I was facilitating, I felt in my heart that I'd done something wrong. That action, combined with the group's subsequent blaming of the departed individual (I was briefly relieved, but ultimately confused), seemed to violate some ill-defined notion of leadership.

    In this article, I've reviewed what I've observed as the resistance to a process-orientation, within a variety of different attention to group therapy with adolescents. I've implicitly advocated for a style of group facilitation that challenges order, hierarchy, even what some may term safety, and in doing so entered that ambiguous space wherein client/patient and therapist responsibility is negotiated. Once again.

    References

    Kerr, Michael E., MD (1991) "An Obstacle to 'Hearing' Bowen". Family Center Report, Volume 12, No. 4.

    Pressman, Mary A., MD, Kymiss, Paul, MD, Hauben, Richard, C.A.C (2001) "Group Psychotherapy for Adolescents Comorbid for Substance Abuse and Psychiatric Problems: A Relational Constructionist Approach". International Journal of Group Psychotherapy, 51(2).

    Yalom, Irvin (1995) The Theory and Practice of Group Psychotherapy. Fourth Edition. Basic books

    Miles, Mathew (1970) "On Naming the Here and Now" unpublished essay, Colombia University.

    The Theory and Practice of Group Psychotherapy. Fourth Edition. Basic books

    Bion, Wilfred (1961) "Experiences in groups and other papers" New York: Basic books.

    "Disorders of Self, New Therapeutic Horizons" (1995) Edited by James F. Masterson, MD, and Ralph Klein, MD. Brunner/Mazel, Inc.


    About the Author

    Graeme Daniels has been facilitating support groups and psycho-educational groups for over twelve years. He currently leads men's support groups at the Impulse Treatment Center in Lafayette, California. In collaboration with founder/owner Don Mathews, MFT, the groups address issues of sex addiction and couples' relationships. Graeme is also currently the supervisor of the intern program at Thunder Road Adolescent Treatment Center in Oakland, California, which specializes in substance abuse issues. Meanwhile, he is also in private practice in Pleasant Hill and has worked with adults, couples, adolescents, and families dealing with substance abuse as well as sex addiction.

    Visit Graeme Daniels page on this Website.

  • May 15, 2011 12:55 PM | Anonymous
    By Graeme Daniels

    This article is presented in three parts. Part 1 Part 2 Part 3

    Some time ago I worked with a father and son who were struggling to communicate regarding the son's substance use. The son, Eddie, 18, had been living with his father, Mike, for two years, following his parents' divorce six years earlier. Eddie had begun using drugs (notably alcohol and marijuana) at age 14, and exhibiting defiant behaviors at home and at school. After Eddie completed a ten-week outpatient treatment intervention, father and son were referred to me for therapy.

    Eddie presented as motivated to change his behavior, but was consumed with anger about his father's distrust of him. "He never believes anything I say", he'd complain, to which the father would retort, "You don't give me reason to." Both Mike and Eddie agreed that they wanted to regain mutual trust, but they were locked in a cycle of mutual blame.

    Mike occasionally pretended to trust his son in order to de-escalate conflict, but ended up disillusioned whenever Eddie relapsed. Eddie ended up guilt-ridden. I asked the father and the son to each take responsibility for their own thinking, feeling, and solutions and to set a realistic foundation for the rebuilding of trust.

    Eddie and I focused on identifying his problematic thinking, and redefining his ideas about risk-taking. He was aware of the risks associated with drug use: Eddie had been both arrested and suspended from school for intoxication- related offenses. When asked about the risks associated with sobriety, and the acceptance of his father's house rules, he struggled with feelings of resentment and was unable to imagine how his life might change for the better. Gradually, Eddie acknowledged the fears that lay under his resentment: abstaining from drug use might lead to loneliness and loss of friendships; accepting his father's rules meant losing his freedom and the adult image he craved.

    On a deeper level, Eddie's distrust of his father stemmed from the divorce of six years earlier, when Eddie's life was thrust into turmoil, his parents' needs seemed to take priority over his own.

    In reframing trust-building as a task for Eddie as well as for his father, I was able to persuade Eddie to accept a series of agreements that included (1) submitting to urinalysis testing at his father's request and (2) accepting material consequences (withholding of money, for example) whenever he relapsed. Having good intentions would not mitigate the consequences; if Eddie reached a "contact high" from someone else's use, or received a positive drug test result after unwittingly tasting a drink that was "spiked," the consequence would remain the same. When Eddie bristled: "That's not fair," I reminded him that his body and brain would respond the same to exposure to a drug regardless of his notions of fairness.

    A second series of agreements presented a particular challenge to Mike. In conjoint therapy, Mike spoke of his feelings of guilt as a parent. His inconsistent parenting and controlling tendencies: name-calling, impulsive imposing of consequences, and distancing interpretations of his son's behavior ("I think you use to escape from your feelings!") masked a deep feeling that he and his ex-wife had let Eddie down. I suggested to Mike that he seemed as impulsive and conflicted as his son and that his behaviors were inadvertently reinforcing his son's negative behaviors.

    I worked with Mike to focus on consistently and calmly following through on realistic limitsetting. Trust could not be based on an anxious belief in his son's latest promise, only to be followed by blame. Father and son were to commit to eliminate bargaining over the fairness of consequences of the son's drug use: the relapse of a friend, the father's controlling behavior, or other stressors, could no longer justify relapse. Further, each committed to seek out separate support systems for the processing or venting their feelings, so that they could avoid directing judgements at each other.

    These agreements allowed for father and son to understand that trust is a bond that develops and evolves through ongoing attention and care, not something to be taken for granted. They allowed father and son to navigate past mutual blame, and made space for each to sit with their uncertainty and discomfort - without resorting to substance use on the part of the son, or rigidity on the part of the father.

    Over the course of therapy, there were relapses on either side. Eddie often tested his father's curfews, demands for phone "check-ins," and chore assignments; he used drugs on numerous occasions, and generally manifested his contempt for Mike's parenting. Mike gave frequent voice to frustration, often characterizing his son's relapses as a form of betrayal. As time passed, the structure provided by agreements allowed father and son to explore and change their values, and challenge the beliefs that perpetuate thecycle of drug addiction.

    Mike and Eddie terminated therapy after about a year. At that time, Eddie had been clean for 90 days and wanted to focus more on twelvestep work. Mike has sent me Christmas cards the last three years, and Eddie has contacted me as well. Their relationship, though not perfect, has improved. Eddie has grown to see the connection between being truthful and gaining trust and is invested in truthfulness as a value for himself. Mike is more willing to take responsibility for his feelings of guilt and inadequacy, instead of externalizing them or blaming his son. Ultimately, Eddie moved out of his father's house. Without the intensity of cohabitation, Eddie is more able to pursue the tasks of individuation, and Mike the task of letting go.

    References

    Gorski, T. (1989) Passages Through Recovery: An Action Plan for Preventing Relapse. Hazleton: Center City, Minnesota

    Miller, M.& Bakalar, JD. "The adolescent brain: Beyond raging hormones." The Harvard Mental Health Letter, July 2005, 22(1).

    About the Author

    Graeme Daniels has been facilitating support groups and psycho-educational groups for over twelve years. He currently leads men's support groups at the Impulse Treatment Center in Lafayette, California. In collaboration with founder/owner Don Mathews, MFT, the groups address issues of sex addiction and couples' relationships. Graeme is also currently the supervisor of the intern program at Thunder Road Adolescent Treatment Center in Oakland, California, which specializes in substance abuse issues. Meanwhile, he is also in private practice in Pleasant Hill and has worked with adults, couples, adolescents, and families dealing with substance abuse as well as sex addiction.

    Visit Graeme Daniels page on this Website.
  • May 14, 2011 12:59 PM | Anonymous
    By Graeme Daniels

    This article is presented in three parts. Part 1 Part 2 Part 3

    "For those who self-identify as addicts, addiction (or dependency) is a state of being, and not a matter of choice."

    As a result of this thinking, as well as other misconceptions, what is communicated to the struggling user is often inappropriate, if not counterproductive: misguided attempts to control use or narrow goals centered around the tangible effects (legal, medical, or occupational) of drug use. "Getting my life under control by getting my drinking under control" is a potentially dangerous fallacy. What is missing is an attention to emotional changes that distort thinking, and ultimately change relationships.

    Terry Gorski, in Passages Through Recovery (1989), describes a "post acute withdrawal" phase, a time of emotional and behavioral changes that lingers twelve to eighteen months into a period of abstinence. Recovery programs refer to analogous concepts - "dry drunk" periods, or "white knuckling."

    Long after the last drink has been taken, recovering addicts may have problems thinking clearly, be prone to irritability and conflict, sleep restlessly, feel vulnerable and even believe that they are going crazy.

    Many addicts state that a primary goal in therapy is to regain the trust of their loved ones - parents and spouses who have become indignant towards their lying, secrecy, and manipulation. But they often become frustrated because they fail to recognize that the task of regaining trust is a reciprocal one. The mental and spiritual aspects of the disease create a negative relational cycle.

    The user lies, the loved one colludes with the lie. The user pretends they are clean or blames their drug use on others; the loved one agrees to believe them. The addict says "let me handle it" or "I've got it under control" as a way of avoiding scrutiny; the loved ones back off. They subscribe to the myth that the addict can and will control their use.

    This denial of reality leads users back into the cycle of use, and loved ones into despair. Provocative questions to addict clients often include: "Do you trust them enough to tell them the truth?"; "Do you trust them enough to allow for their questions?"- and especially for youth - "Do you trust them (your parents) enough to accept their limit-setting, to allow them to parent, and to allow yourself to be a kid?" The purpose is to reframe the task of regaining trust for users and their families, because the greater challenge is not that of users gaining the trust of would-be helpers, but, rather, that of helpers gaining the trust of users.

    The following is a summary of important messages for substance users and families:

    1. Mental and behavioral effects of drug use are not confined to an intoxication syndrome.
    2. Risk-taking needs to be redefined in emotional terms; the courage to be honest and accept limitations replacing the false bravery of self-destructive behavior.
    3. The "they like me better when I'm high" effect: When we confuse the negative effects of intoxication with those of withdrawal, we unwittingly reinforce drug use.
    4. The development of maturity is arrested by regular drug use. This statement is not a value judgement about a person's selfhood but, rather, a truth about biological development.
    5. The mental and emotional fallout of addiction continues long after usage stops.
    6. The trust wound between substance users and their families is a mutual one.

  • May 12, 2011 1:03 PM | Anonymous
    By Graeme Daniels

    This article is presented in three parts. Part 1 Part 2 Part 3

    When confronting issues of substance use, professional opinions as to what constitutes use, abuse, or dependency, as well as notions of prevention, often compete with the ideas of individuals and families, and those of the culture at large.
    Graeme Daniels

    Recently, a client who proclaimed himself an addict looking to abstain from drugs, asserted: "I wanna quit drugs, I just wanna' drink from now on." The misconception that drugs exclude alcohol is an example of a distorted--but all too pervasive--belief. Similarly, clients often believe that the consequences of drug use are confined to the period of intoxication, and do not extend beyond that time.

    As therapists working with such clients, we must confront these distorted belief systems before we can clarify treatment goals. In this article, I will discuss some important ideas pertaining to substance use, and present interventions that are substantive and practical.

    Distorted Beliefs about Addiction

    Inverted notions about risk-taking: Our beliefs can help us or they can mislead us. Negative beliefs about self, for example, can form the psychological fuel of an escalating substance dependency. Conversely, a positive self-image can inspire self-care. But in the inverted universe of substance abuse, definitions/ideas of positive self-image and positive self-care are turned upside down. For example, when speaking to adolescents, I often comment that an emotional and behavioral change that occurs relatively early in drug use is that of increased risk-taking and impulsivity. Drugs are dangerous, I add, not to mention illegal and largely forbidden. There is generally a respectful agreement on this point, but I also note when my clients seem unmoved. After all, I can see them thinking, risk-taking is manly, risk-taking is good.

    The willingness to take risks garners esteem within a peer group and creates a false sense of heroism within the young person. This twist of thinking has significant implications; under social pressure, what we commonly think of as self-destructive risk-taking is perceived by our adolescent clients as courageous.

    How can we "coopt" the positive value attached to risk-taking and turn it right side up again? I believe that the key lies in redefining risk in emotional terms: It takes courage to risk being honest with others, to stand strong in the face of peer pressure and dare to accept limitations, protect our safety, and adhere to conventional behavior.

    Negative reinforcement for intoxication: Drugs are intoxicating because they promise an instant way to alter our feelings. Seconds, minutes, perhaps an hour, is all that is necessary to achieve a desired effect, and the message to our central nervous systems is clear: you do not have to wait to change how you feel. When asked what is attractive about the mood and mindaltering experience, addicts will first give some familiar responses: drugs allow for disinhibition, increase confidence or relaxation, and create a feeling of elation where there was anxiety before. But deeper exploration reveals more: As feelings change, so, too, do the user's perceptions: responses to stressors are intensified, confidence turns into entitlement, and the user, filled with false confidence, misreads social cues and perceives social approval where there is none.

    Withdrawal brings with it even more distorted thinking. The absence of the intoxicating high feels punishing to the suffering addict. But what is he being punished for? For using? Or for not using? For the absence of the drug in his system, or for its presence? After all, the best way to eliminate the suffering of withdrawal is with further intoxication. The addict comes to the wrong conclusion: he believes he is being punished for not using, not for using. Onlookers may reinforce these conclusions by reacting more aversively to the negative effects of withdrawal than to the negative effects of intoxication. Consider the logic of what I might term the "they like me better when I'm high" effect: When intoxicated, a user may be relaxed, more confident, and more sociable. When not intoxicated, they may be irritable, complaining, anxious, and lethargic. Whom do we want to be around?

    The "think before you act" fallacy: Science has come to understand that drug use inhibits maturity, and that addiction has more to do with biology than with character. According to a recent article in the Harvard Mental Health Newsletter: "Human brain circuitry is not mature until the early 20s. Among the last connections to be fully established are the links between the prefrontal cortex, seat of judgement and problem solving, and the emotional centers in the limbic system.

    These links are critical for emotional learning and high level self-regulation." The implications of this research are that youth is particularly vulnerable to addiction. Though we may want them to "think before they act," research teaches us that the integration of thinking and feeling, that ability to distinguish between what we think is important (i.e. a craving state), and what is really important, is a matter of development and time. Teenage brains are simply not yet developed enough to make these distinctions. Drug use then further inhibits this development, because it undercuts one of the cornerstone tasks of maturation, namely, the practice of patience and the tolerance of discomfort.

    Social norms are complicit with drug use. Advertising associates alcohol and tobacco use with sex, popularity and fun, and creates an environment in which immediate gratification is a commodity. Society reinforces the "life lessons" of addiction: the belief that impulsivity, intense experiences, and quick relief from bad feelings are the important goals and not dealing with, and learning from, the ups and downs of life. The sober experience of life is implicitly devalued, and not using, not being high or intense, is defined as "square."

    The myth of responsible drinking: "Drink responsibly," the ads and commercials warn us. Although many can and will obey the limits, many others will struggle, fail, and suffer the consequences - legal, occupational, relational - that accompany abuse. Still others cannot even engage in the struggle. Mainstream society either misunderstands, or plainly rejects, those for whom the very term "drink responsibly" is a contradiction.

    We are still a long way from grasping the notion now understood by the medical establishment, and best articulated by the twelve-step community: that for those who self-identify as addicts, addiction (or dependency) is a state of being, and not a matter of choice.

    Next: Part 2, The Emotional Work of Recovery
  • May 10, 2011 1:11 PM | Anonymous
    By Joan Gold

    Joan Gold As Sexual Addiction becomes more frequently recognized as a diagnostic label, sex addicts are more easily identified and referred for treatment. Addiction being a family disease, the more sex addicts referred for treatment, the more it becomes apparent that there is an entirely new group of co-addicts that urgently require attention. The partners and spouses of sex addicts, while sharing many similarities with partners/spouses of alcoholics, gamblers, et al., have many unique characteristics that significantly impact treatment failure or success.

    I came to Impulse Treatment Center (ITC) in Walnut Creek, CA in March of 2008, having worked for several years as an intern with addicts and co-addicts of the more traditional variety. The ITC treatment model involves assessing the couple (frequently the initial treatment unit), then referring the partners to their own individual treatment groups. Couples therapy is usually, although not always, delayed until individual treatment has had a chance to create change.

    Over the past year, I have learned a lot about the struggles my co-addict clients must overcome in order to have their pain recognized, their needs addressed, and their path towards wholeness and healing begun.

    It is important to note that while sexual addiction is by no means gender-limited, at this time it is primarily heterosexual men who present for treatment at ITC. According to Carnes, the ratio of sex addicts presenting for treatment in general is the same as alcoholism and gambling, approximately three men for every one woman. (Carnes, 2002, p.13). I look forward to a time where this treatment group becomes more widely diversified; ITC has not, to date, been able to put together a group of women sex addicts. Currently I work exclusively with women as coaddicts.

    Partners/spouses of sex addicts see themselves as victims and they almost always present for treatment in crisis; sexual betrayal has either recently become known, or known in a way that allows its full significance to be felt. I see a lot of hysterical, raging and/or collapsed women in my office as I assess them for appropriateness for my groups. Many of these women are in shock. For a large percentage, this is the first time they have put their outrage/loss/betrayal into words. Sometimes they don't have the words. Most of them have no support system, or they feel their support system cannot tolerate the knowledge that "the perfect husband" isn't perfect after all.

    These women may have been holding into their lonely knowledge for days, months or years. Their language is halting, gutteral; their affect tearful, their bodies rigid, their attitudes careen between vindictive and confused. Upon further exploration, rarely do their stories of "the perfect marriage until the day I found the credit card receipts/the secret email account/the police report/the VD diagnosis" hold up. "What made this marriage so otherwise perfect?" I ask them. "Where did your feelings of being loved and valued come from?"

    It is tempting to keep the empathy and support going forever, easy to join these women in their almost hypnotic recounting of family tragedy and virtue betrayed. If the therapy, group or individual, is to be effective however, it is crucial that the crisis be managed, and, once stabilized, that the client be helped to transition into a role where she becomes able to take an active part in identifying her piece of the addiction puzzle.

    This is different than "blaming the victim" and one of the primary reasons that group therapy is the treatment of choice for co-addiction. If I have done my psycho education around sexual addiction correctly, the women will soon understand that their partners' addiction and/or recovery is neither their fault nor their responsibility. Their husbands or boyfriends did not become sex addicts because of anything the clients did or didn't do, however the reason the client was able to sustain what she thought of as an "intimate relationship" with someone not available for real intimacy is an important point of exploration.


    It is noteworthy that many of the women I see at ITC have been
    with their partners for two and three decades.



    It is noteworthy that many of the women I see at ITC have been with their partners for two and three decades. Others report serial relationships with sex addicts, unwittingly married two and three times to different sexually impulsive men. These are my true allies in the group process, the women whose lives demonstrate that it isn't about being victims after all. They weren't "done wrong" by "bad men" through an accidental quirk of fate. What drew them into the same relationship over and over again? What felt so familiar that it overrode any sense of something not quite right? How did these women distract themselves from their loneliness, justify the lack of attention, learn to live with the sense of themselves as forever needy and unfulfilled?

    It is the hardest part of my work as a therapist to develop the understanding that whether a woman decides to leave her relationship, or stay and see what can be salvaged, this "crisis" is her opportunity to look at her own role in maintaining a system of secrets and lies. This is the most challenging initial task of therapy and once navigated and the work begun, this is the most common place of ongoing resistance.

    It is helpful to have my clients read Patrick Carnes' work on sexual addiction, in which he reports that sex addicts and co-addicts come from strikingly similar backgrounds: "families that are both rigid and disengaged," with "addicted or multiply addicted family members," where "relationships that are controlling and emotionally unsatisfying create comfort in that they are familiar." (Carnes, 1992, p.145-6)

    Partners/spouses of sex addicts share many of the consequences of sexual addiction -- financial, health, family, career -- but most especially they share the shame. (Carnes, 1992, p. 147).

    Over and over I hear women say, "If only he were an alcoholic" or "if only he were a gambler." They would prefer their husbands be addicted to cocaine rather than to call-girls, they tell me, because what cocaine offers is clear. It is not a fantasy wife or girlfriend. "Cocaine doesn't make you wonder where you fell short."

    Sex addiction impacts partners at the deepest level of self. That is why an early intervention is an invitation to the women to take a look at who they are apart from the addict. Eating disorders, drug and alcohol dependence; childhood physical, emotional and/or sexual abuse figure large in many of these women's personal histories.

    Again, the psycho education piece is crucial here in helping to reduce shame and suspend judgment, allowing the clients to develop empathy, first for themselves and, eventually (if the relationship is to endure) for their partner as well.

    My goal in treatment is to shift the focus of the group off the sex addict and onto the woman herself. This can be an ongoing dance; if the sex addict partner is untreated, there is the ongoing impact of his projection and denial. If in treatment, the normal ups and downs of the recovery process are a constant invitation to judgment and blame. Two points I continually stress with my clients whose partners are in treatment: (1) sexual addiction, as all addiction, is a highly relapsable disorder and (2) the recovery process is a long slow journey. How are you going to take care of yourself while he is doing his work?

    Most of the women I work with have some question in mind about whether they should stay in the relationship, or leave. I help them give themselves the time to really think through their options rather than end the relationship in a reactive state.

    This is all complicated by centuries of cultural bias which makes it difficult to even believe in the concept of sexual addiction as a "real" diagnosis. Medical professionals, and even some therapists who have not been educated in the sex addiction model, unwittingly perpetrate the stereotype of "This is the way men are." I have worked with a number of women who have undergone years of couples therapy in which sex addiction was never named or addressed, but rather characterized as a problem of communication or temperament; one woman, for example, found herself labeled "uptight" in objecting to her husband's use of internet porn.

    On the rare occasion when a group member leaves and a new member is added, each woman is asked to retell the story of what brought her into the group. Many of the women object to the retelling. They tell me how each time they repeat their story, it's like ripping the scab off a wound they desperately want to heal. I remind them that addiction flourishes in vagueness and obfuscation. True healing will only be found in the raw, unembellished truth.

    Other women, who don't object to retelling the story per se, are worried that if they keep their "bad" feelings alive this way, they will never be able to arrive at forgiveness. Like the addict, they have gotten forgiving confused with forgetting. They will have the opportunity to forgive, I tell the women, down the road somewhere should they wish to do so. The job in early treatment is not forgiveness. Betrayal and loss by an intimate partner needs to be fully felt and processed before it can be forgiven. Premature attempts at forgiving/forgetting are just another form of the addict/co-addict cycle of denial.

    In addition to telling and retelling the story, early group work involves psycho education around the issues of sexual addiction, co-addiction and addictive family systems; training in mindfulness in order to be able to identify and name feelings; and identification with other group members to help reduce shame and experience real intimacy.

    Middle stage group work involves increasing tolerance for feelings, and learning to let feelings inform actions. Exploration of childhood loss/trauma also begin here. I have found the loss of self that results from those early woundings is what allows the women to remain in psuedo-intimate and disrespectful relationships, believing it is all they deserve.

    Late stage group work includes acknowledging the changing sense of self, exploring the power and freedom afforded by being able to set boundaries, separating "kindness" from "enabling," rethinking relationship roles and rules, and building personal resources and support systems.



    For more information about the Spouses/Partners of Sex Addicts Program at Impulse Treatment Center, please contact Joan Gold at (925) 2806700 or (510) 418-2387. For more information about ITC's treatment programs for sex addicts, go to www.sexaddicttreatment.net

    Joan Gold is an MFT Intern supervised by Don Mathews, MFT, Director of Impulse Treatment Center. She is a 2005 graduate of JFK University, with an MA in Counseling Psychology (Transpersonal Specialization). She has completed her hours towards licensure and is currently in the process of sitting for her licensing exams.

    Visit Joan Gold's page on East Bay Therapist



    References


    Carnes, Patrick (1982) Don't Call it Love
    Carnes, Patrick (2002) Clinical Management of Sexual Addiction
 

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