She wasn’t responsive to my voice or my soft touch. Her face was pale, her body was limp, her breathing was rhythmic and shallow. Should I call the medics, I wondered, or have her mother carry her out of my office? Luckily, she was my last client for the day, so I had time to figure out what to do with this unresponsive teen. I was seeing dissociation in its extreme form: the body shutting down in a “freeze” position, the way some wild prey respond when threatened by a predator. But what in our session had 17-year-old Trina perceived as “predatory”?
Though there had been a casual conversation about college plans and a boyfriend, there had been no talk of her early sexual abuse memories with a grandfather with whom she no longer had contact. After three years of treating her for dissociative behaviors, including sudden regressions, amnesia, and dazed states, I thought we’d moved beyond such an extreme response to stress on her part.
Trina was demonstrating a “dissociative shutdown,” a symptom often found in children faced with a repeated, frightening event, such as being raped by a caregiver, for which there’s no escape. Over time, this response may generalize to associated thoughts or emotions that can trigger the reaction. Although the child’s body may be immobilized, her mind remains active and can invent solutions, often retreating into an imaginary world, where bad things aren’t happening. With time and practice, the mere thought of needing to escape a situation may trigger a self-induced hypnotic retreat, along with a primitive freeze response.
According to Bruce Perry, senior fellow of the ChildTrauma Academy in Houston, these kinds of episodes are best understood as a dysregulation of the central nervous system’s opioid systems, which have been repeatedly activated by extreme stress. This response then becomes an enduring “trait,” so that small reminders of trauma can stimulate these dramatic alterations in consciousness. Perry points out that medical professionals often are puzzled by this kind of shutdown and may diagnose it as “syncope of unknown origin,” “conversion reactions,” or “catatonia.”
Working with dissociative children and teens can be unnerving for therapists, particularly in view of such extreme symptoms. A basic theoretical understanding of dissociation can demystify even this kind of sudden in-session event. But as important as it is to have a theoretical understanding of what’s happening, a clinician needs a pragmatic, strength-based, problem-solving focus to feel prepared to treat such entrenched dissociative reactions in children and teens.
Most children experiencing dissociation don’t have as little control as Trina did at this juncture. Usually, signs of dissociation can be as subtle as unexpected lapses in attention, momentary avoidance of eye contact with no memory, staring into space for several moments while appearing to be in a daze, or repeated episodes of short-lived spells of apparent fainting. As they move along an intensity spectrum, some young clients may have alterations in identity, with sudden regressions or rage-filled episodes, and little awareness of their behavior.
There’s still little consensus about how dissociation develops in traumatized children, but it’s been linked to disorganized attachment, often characterized by blank looks, avoidant eye gaze, and shifting affect. Frank Putnam, director of the Mayerson Center for Safe and Healthy Children at Cincinnati Children’s Hospital, has theorized that, while most infants learn to shift flexibly between emotional states over time, trauma-based states are marked by inflexibility and impermeability. According to psychologist Silvan Tomkins, children learn to rely on “affect scripts,” sequences of automatic behaviors that help them avoid experiencing such painful affects as fear, shame, or disgust—the kind of deeply disturbing feelings aroused during sexual abuse or other traumatic experiences with caregivers. The traumatized child learns to avoid overwhelming emotional pain through dissociation. As a consequence, these children can fail to develop the basic building blocks of identity and consciousness.
The reversal of dissociative states requires a therapeutic relationship in which the child can feel safe and clearly distinguish between the present environment and the traumatic past, while developing the deep, embodied conviction that the future doesn’t have to mirror what he or she has already been through. From years of experience working with children like Trina, I knew that my job was to help her discover alternatives to her avoidance response, understand and learn to tolerate its triggers, and find ways to override the automatic physiological escape tendency over time.
Handling the Emergency
When I asked Trina’s mother to come into my office, she first gently shook her daughter, saying “Trina, session is over” in a singsongy, motherly tone. No response. In a quiet, hypnotic tone, I suggested to Trina that she’d find herself growing more and more awake, ready to face hard roadblocks in her life. No response. Then Trina’s mother and I decided to call 911. Her mother, apparently accustomed to this strange behavior, was surprisingly calm. When the medics took Trina to an emergency room, I expected that she’d wake up as they transferred her to the stretcher and then the ambulance, but she didn’t.
Two hours later, my cell phone rang. It was Trina. “Dr. Soybean (her playful name for me),” she implored, “Please tell the hospital doctor that I don’t need psychiatric admission, and that I’m not crazy!” As relieved as I was to learn that she’d awakened from her dissociative slumber, I saw a great opportunity to move her forward therapeutically. Whenever my child clients ask me for something, I find a way to ask them to do something in return that will be a therapeutic advance for them. So I asked Trina to come to my office first thing in the morning, and explained that if she could successfully describe what happened right before her dissociative shutdown, she could avoid the hospitalization. If, however, she was unable to uncover the feelings that led to this self-defensive reaction, it would make sense for her to go the hospital after the session. Trina agreed to this.
The next session centered on the kind of “fishing expedition” often required with dissociative patients. Blocked from the feelings that usually help people string together a coherent narrative explaining their experiences, dissociative clients’ responses often appear as mysterious to them as they do to others. Trina remembered that we’d talked about her high-school science project, her ambition to be a biochemist, and a boyfriend she was outgrowing. I suggested that something else in our conversation had awakened her old feelings of being helpless, frozen, and unable to move forward. She acknowledged that was true, but remained mystified about what had triggered the old sense of being trapped.
I asked her to focus on that feeling of being trapped and as Trina got in touch with it, she became agitated and nearly mute. As she struggled, I modeled slow, rhythmic breathing and softly said, “Breathe with me. We’ll get through this together.” She took my cue and followed my slow breathing. “Where are you feeling this in your body I asked?”
“In my chest—it’s tight,” she said.
I used a familiar image to help her counter the sense of constriction in her chest. “Let’s imagine together that you’re out in the woods near your house and breathing the fresh fall air,” I said. We stayed with this image for about five minutes, and then I redirected her.
“Whatever’s happened, we can work together so you can handle it. We can find a solution, no matter how scary the trap feels.” I’ve learned that blocked memory usually returns when the therapist provides safety and confident reassurance that the information is tolerable, so I asked, “If you had to guess who it was about, would you guess your mother, your boyfriend, or your father?” Sometimes “guesses” allow the unconscious mind to express itself.
“I don’t really know,” she said, “but if I had to guess, it would be about my father,” she said.
“Something he did or something he said?” I wondered with her.
“I don’t know,” she said, “but he always says stupid things to me, so he probably did say something.”
“Think about your father saying stupid things, and tell me what you feel,” I said.
“My chest feels tight” she said, “and I feel trapped.”
“You aren’t trapped,” I reassured her. “Your whole life is ahead of you. Every day you’re more and more free. Soon you’ll be 18, and have the freedoms of an adult.” My comment about her future, which she faced with both anticipation and anxiety, was right on target.
“That’s it!” she said, “I remember.”
Trina’s parents were divorced, with joint custody. With a shaking voice, she told me that her father had threatened to withdraw college funding if she didn’t agree to overnight visits at his house, where her early abuse had occurred. She’d visited him willingly over the years when he put no real pressure on her, but the controlling nature of his new demand aroused the hopeless feeling she’d experienced when her grandfather’s abuse had seemed so inescapable. The overwhelming fear she’d experienced the day before seemed to encapsulate a central dilemma faced by all child survivors, now heightened by her approaching transition to adulthood: could she grow up, go to college, and be normal? or was she stuck forever in the traumatic past? It was crucial to find a way to support her belief that she could move on in life and escape the traps of her past.
Now that Trina had explained her dilemma, we began to brainstorm practical solutions, discussing ways she could stand up to her father. Ultimately, she decided she’d like me to serve as an intermediary to help him understand why presenting his demand in this authoritarian way triggered her old symptoms. In a subsequent session, I told him how she experienced his attempt to influence her through his control of her college money. He insisted he hadn’t really intended to withhold the funds, he was only emphasizing to her that he “could.” In a subsequent family session, with my prompting and direction, he promised her he’d pay for college, and that he’d never use this threat again. For her part, Trina promised him she’d visit him as her schedule allowed. She never experienced that degree of dissociative shutdown again.
Over time, Trina learned to believe that the brighter future she dared imagine for herself was possible. Her treatment revolved around learning to combat her automatic tendency to dissociative avoidance and repeated recommitment to her belief in a positive future, whatever challenges she faced in her life. Through her college and postgraduate education, she succeeded, using her skills in affect tolerance, identifying emotional triggers, and self-awareness to navigate dismissive teachers, rude boyfriends, and even the tragic death of a close friend. She stayed in my practice for six years, maturing from a frightened, avoidant girl who had trouble attending school to an aware, insightful survivor.
Today, Trina is an accomplished medical professional, married, with a young child of her own. When asked about her recollections of her early treatment, she says, “Yes, I was a weird kid, but you knew what to do about it.” She quickly changes the subject, but proudly shows me pictures of her new son, who she assures me is developing beautifully, “without dissociation or other wacky stuff.”
By David Crenshaw
Working with extreme forms of dissociation is a demanding and often anxiety-provoking therapeutic challenge. In the face of extreme symptoms that can seem quite bizarre, the therapist must have the experience, skill, and emotional steadiness to communicate both a clear sense of direction and a conviction about what needs to be done. In the morning-after crisis interview with Trina, Joyanna Silberg displays all those qualities as she creates the kind of emotional bond and sense of safety that enables Trina to return to adequate coping. I question, however, whether the same qualities might have been more patiently employed the night before to help Trina avoid her trip to the emergency room.
In crisis moments, seemingly small shifts in language and affect can have major impact. I was struck by the difference in Silberg’s intervention the night of Trina’s dissociative shutdown and her more effective response in the next day’s follow-up session. In the first instance, Silberg describes her response in this way: “In a quiet, hypnotic tone, I suggested to Trina that she’d find herself growing more and more awake, ready to face hard roadblocks in her life.” The following day, Silberg is far more concrete and makes better use of her strong therapeutic alliance with Trina, as clearly conveyed in her instruction, “Breathe with me. We’ll get through this together.” I can’t help but wonder if the ER trip the previous night could have been avoided if Trina had heard something as powerfully reassuring as, “Breathe with me” and “We’ll get through this together.”
In the session the following morning, Silberg, with conviction and evident affect, simply and unequivocally says to Trina, “You aren’t trapped.” It’s then that Trina is empowered to remember the conversation with her father that had triggered her dramatic shutdown. Silberg reinforces her forceful statement with some powerful suggestions, including: “Your whole life is ahead of you. Every day you’re more and more free. Soon you’ll be 18, and have the freedoms of an adult.”
I was puzzled by Silberg’s response to Trina’s call from the ER. She describes Trina’s request to help her avoid hospitalization as an example of a “client ask[ing] me for something.” Silberg explains that in such situations she “find[s] a way to ask [child clients] to do something in return that will be a therapeutic advance for them.” This leads her to ask Trina to come for a session the following morning and identify the exact moment that triggered her “dissociative shutdown.” I didn’t understand the rationale that identifying the exact trigger moment would determine whether or not psychiatric hospitalization was needed. If the therapist is asking the client to come to her office the next day to pinpoint the exact moment of being triggered, surely she believes her patient is capable of outpatient therapy. If the client was unable to identify the exact trigger moment in that session, would that really be an adequate justification of psychiatric hospitalization?
Fortunately, the follow-up session is quite productive, reflecting the skills and strengths of both therapist and client. Ultimately, I think the validation of Silberg’s work with Trina and the quality that’s needed to help clients experiencing extreme symptoms like hers is embedded in the adult Trina’s retrospective comment on what her therapy experience meant to her: “Yes, I was a weird kid, but you knew what to do about it.” Clearly Silberg created the sense of safety, trust, and optimism that made it possible for Trina to move on with her life, despite her early abuse.
I appreciate David Crenshaw’s thoughtful comments. Perhaps I described too quickly the efforts her mother and I made to awaken her the evening before. It was about 45 minutes of intense intervention before her mother and I made the decision to call the medics.
In most outpatient offices, I’d guess, therapists wouldn’t even be able to devote that much time in such an emergency. While it’s certainly possible that I might have hit on the right thing to say if I’d worked on it even longer, my focus at that time was arousing her so that she could safely leave my office, as the behavior occurred at the end of the session. This goal—to have her leave my office—probably came through in my tone and interventions, despite the reassurances that I tried to offer. I was mystified about the exact source of the shutdown, and reassurance alone wasn’t effective. Perhaps unconsciously, Trina was saying that her only safety was in my office, and she couldn’t “leave,” grow up, or achieve adulthood. Thus, my own goal to have her leave my office was incompatible with her goals.
Episodes of unpredictable shutdown, sometimes seen as psychogenic seizures, are sufficient for hospitalization since they can be dangerous. Young people in this state can fall down and hit their heads or not be responsive to the outside world for hours at a time. The question of whether Trina was a treatable inpatient or outpatient was debatable, in that the doctor in the ER thought she was eligible for admission the night before, having witnessed the shutdown state. Had she not been able to use the episode to gain further self-knowledge and increase control, the episode could have been classified as “unpredictable,” and an argument made that this behavior was too dangerous for her to be treated as an outpatient. Realistically, however, had she not been able to get to the bottom of this episode the next day, but seemed to be trying, I most likely would have made another “deal” with her to keep her out of the hospital.
Joyanna Silberg, Ph.D., a consulting psychologist at Sheppard Pratt Health System in Towson, Maryland, was past president of the International Society for the Study of Trauma and Dissociation. She’s the author of the recently released The Child Survivor: Healing Developmental Trauma and Dissociation. Contact: jlsilberg.@aol.com.
David Crenshaw, Ph.D., A.B.P.P., is the clinical director of the Children’s Home of Poughkeepsie (New York) and a faculty associate of Johns Hopkins University. He recently edited Reverence in the Healing Process: Honoring Strengths without Trivializing Suffering. Contact: firstname.lastname@example.org.
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A new calendar inspires many to turn over a new leaf. For some of us, this may mean learning to turn the other cheek. In recent years, the biological benefits of forgiveness have been widely publicized: lower blood pressure and cholesterol, better sleep, and an improved immune system. Psychologically, people who forgive show lower levels of depression, anxiety, and anger, enjoy better relationships, and report higher levels of optimism and happiness. Sounds great, so why is forgiveness so damn difficult?
Frederic Luskin has some interesting thoughts on that subject. As director of the Stanford Forgiveness Project, he’s studied forgiveness for the past 20 years. He authored Forgive for Good: A Proven Prescription for Health and Happiness and has shared his wisdom with survivors in Northern Ireland, as well as those at Ground Zero in Manhattan.
Since he’s an expert on the psychology of forgiveness and on therapeutic pathways to achieving it, we thought the beginning of the year might be an especially good time to hear from him.
RH: How did you become interested in forgiveness?
Luskin: In addition to the pain of being badly hurt by a close friend without having any idea how to deal with it, I needed to find a dissertation topic when I was graduating from Stanford. This was before there was a lot of research about forgiveness. I thought what I learned about getting over my own wounding might have a broader application, and it just seemed like a good opportunity to bring more psychological understanding to something that’s traditionally been such a spiritual concept.
RH: I’m reminded of the Alexander Pope quote: “To err is human; to forgive, divine.” Do we equate forgiveness with spirituality or God more than we do other virtues?
Luskin: I think so, because it’s so difficult. The human tendency is to deliver payback for any hurt that’s been experienced.
RH: The “divine” part of that statement suggests that it requires supernatural strength to forgive.
Luskin: I don’t believe that. I think it takes something more than the essential selfishness that most of us operate out of, but I don’t think it’s divine to understand that you don’t want somebody else to suffer just because you’ve suffered.
RH: As you’ve seen, it’s terribly difficult for a lot of people.
Luskin: That’s part of the reason why the research that we did is so important. Making a connection between enhancing one’s health and forgiveness gives people additional motivation to do something that they might not do otherwise. People may not worry about whether they’re going to heaven, but at least forgiveness reduces their blood pressure and their chance of having a heart attack.
RH: Your work calls into question several beliefs about forgiveness. I’ll toss out a few true-or-false statements here: “Forgiveness means forgetting.”
Luskin: That’s false. It’s actually remembering differently. While lack of forgiveness is remembering something with an edge or a grudge or a sense of injustice, forgiveness means remembering it more benignly, with compassion. It involves some purpose of moving ahead, rather than just being stuck in the past.
RH: “Forgiveness requires repentance from the other.”
Luskin: The fact is that you can forgive someone who’s dead. So it can’t require that.
RH: Isn’t it easier to forgive when the other person is repentant?
Luskin: Certainly, if somebody is really apologetic and takes responsibility—“My bad. I really hurt you. No excuses.” Then forgiveness is easier. It’s not just bad because you got hurt, but I did something wrong.
When someone says, “I’m sorry because you’re hurt,” well, that can make the person who’s been injured feel at fault because they were hurt.
That’s an offensive kind of apology. It’s different when you say: “Boy, I did wrong, independently of whether or not you got hurt. I also see how that wrong has impacted you, and I’m sorry for that.”
So there are two steps—“I did wrong, and that wrong hurt you.” Then the next step is, “Since it’s my responsibility, what can I do to make it better for you?” That’s a true apology, and that makes a real difference.
RH: Is that because it validates the feelings of the victim?
RH: It says, yes, it really was your fault, I don’t have to blame myself or take some of that responsibility. You’re taking it.
Luskin: Well, you still have responsibility for living your life and moving on, but at least that person has said that they’re a significant contributor to the distress and the tears.
RH: Another belief: “Forgiveness is a one-time thing.”
Luskin: No. It’s a process we do over and over. Sometimes you’re reminded of painful situations when you least expect it. Sometimes the person comes back into your life, or you’re just remembering what they did and you have to go through it again.
RH: One final statement: “Forgiveness means everything returns to the way things were.”
Luskin: Sometimes it returns to the way it was, but sometimes you can’t go back. After all, how can you go back if someone close to you has been murdered? Nevertheless, if somebody makes a mistake and they say they’re sorry and ask forgiveness, you can go back to the same type of relationship that you had.
RH: I heard a talk at which you said: “Forgiveness is the experiencing of being at peace right now, no matter what happened five minutes or five years ago.” How is peace related to forgiveness?
Luskin: What is forgiveness except the experience of peace around your own life? It’s acknowledging that you’re OK. Forgiveness is all about people’s perception of their life. If I feel bad, that’s my experience. Just because bad things happen doesn’t mean that I have to behave badly. Understanding that can make a huge difference for many people.
RH: Why do you think we have such a tendency to perpetuate the bad?
Luskin: Part of that is the way our neurology is wired to look for things that are wrong in order to keep us safe. Part of it is the way many cultures foster revenge, retribution, payback, and total self-absorption.
RH: I’ve noticed that victimhood can make people feel like they’re in a position of power, one that they’re reluctant to give up.
Luskin: But feeling resentful and victimized is a highly limited form of power. The price you pay is feeling perpetually uncomfortable and off center. We get angry when life isn’t working; we don’t get angry when life is working.
If you see people who are angry or who are nursing a long-standing grudge, it’s probably because their life isn’t working, and they don’t know what else to do. The whole task of forgiveness comes down to redirecting energy from a preoccupation with helpless resentment to finding a better way to live one’s life.
Ryan Howes, Ph.D., is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs “In Therapy” for Psychology Today. Contact: firstname.lastname@example.org; website: www.ryanhowes.net.
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Do childhood trauma and a chaotic family environment cause adult borderline personality disorder (BPD)? Common clinical wisdom says yes, but new results are leading some researchers to insist that it’s more complicated than that.
Investigators from the Minnesota Twin Family Study, first begun in 1983, collected data about childhood abuse and adult personality from 1,382 pairs of same-sex twins, followed over time from ages 11 to 24. By examining differences in abuse exposure and genetic overlap (whether the twins were identical and thus had the same DNA, or fraternal, and thus had only about 50 percent genetic overlap), the authors, led by Marina Bornovalova of the University of South Florida, concluded that childhood abuse in itself isn’t a direct cause of adult BPD traits. But since childhood abuse is seen so frequently in individuals with BPD (some studies suggest in as much as 90 percent of cases) why the overlap? According to the study, common genetic factors contribute to both childhood abuse and BPD.
The researchers suggest two possible genetically influenced reasons for the connection between childhood abuse and adult BPD. In the first model, called “passive genetic mediation,” children not only inherit genes from their parents, but are raised in an environment that’s an expression of the parents’ own genetic influences. In this model, children inherit genetic tendencies toward aggression, impulsivity, and emotional dysregulation from their parents and are raised by parents who are themselves aggressive, impulsive, and dysregulated. Abuse and BPD are thus different manifestations of the same emotionally dysregulating factors.
In a second, more controversial scenario, known as “evocative genetic mediation,” children who inherit difficult genetic temperaments from their parents tend to behave as moody or impulsive children. Emotionally intense and difficult to raise, these children strain their parents’ own genetically limited coping resources, contributing to parenting failures characterized by childhood abuse and neglect.
If the second scenario sounds like blaming the victim, the authors are quick to point out that their results “don’t support the idea that [childhood abuse] is inevitable, justified, or without harm.” However, their work raises possibly provocative questions about the causes and effects of childhood abuse and adult borderline personality disorder, once again putting science at odds with facile, politically correct perspectives on complex psychological phenomena.
What Causes Borderline Personality Disorder? Journal of Abnormal Psychology, doi: 10.1037/a0028328.
Q: I know that the first session with new clients is crucial, especially when doing brief therapy. How can I make the most of it?
A: Like it or not, many of us are brief therapists by default. Stats tell us that clients go to an average of five to eight therapy sessions, but most of them go only to one, making it essential that we hit the ground running.
We all know the essential tasks of the first session in any kind of therapy: building rapport and a sense of collaboration, assessing and diagnosing, and formulating and offering a preliminary treatment plan. The tasks in brief therapy aren’t different, but they’re done in less time–meaning that therapists need to get to work immediately, and there’s little leeway for mistakes.
I find it useful to think of the first session the way a family physician might when a client shows up with an ailment. Basically, there are four goals to meet: getting on the same page, changing the emotional climate, clarifying the link between problems and personality, and offering a clear treatment plan–and if you miss any one of them, the client probably won’t return.
Getting on the Same Page
It’s useful to set the stage for brief therapy by letting clients know a little about your approach during the first contact–that you think brief, that you focus more on the present than the past, and that you give behavioral homework. You may tell them a little about your experience to convey a sense of your competence. Once they come to the session, like any therapist, you help them feel welcomed and safe. You can do this by listening carefully to their story and being empathic, subtly mirroring their body position or language to help foster rapport, and clarifying their expectations, either to reinforce them or to suggest alternatives.
But you can’t just listen for 50 minutes and then thank them for coming, take out your appointment book, and say, “Same time next week?” Not in the age of Dr. Phil. You must shape the process by offering direction and leadership, not just responses. This gives clients the crucial sense that you know what you’re doing and where you’re going with them.
However, the most important part of getting off on the right foot is what I call “tracking the process like a bloodhound.” This is where it’s easy to get lazy and lose focus. Clients instinctively want to talk content–to dig through their pile of stories and sort through the heap of facts. Of course, to some extent, that’s important, but you want to focus on what you see that clients usually don’t: what’s happening moment-to-moment in the room. Whether you make a comment or an interpretation or provide education, you need to watch closely how the client responds. Make sure you notice the nod of the head or other indicators of solid agreement. If you hear a “Yes, but . . .” or a lukewarm “That makes sense,” or observe eyes glazing over or a frown, don’t move ahead. Stop and address the problem that’s right there in the room: “Hmmm, you’re making a face. It seems like you may see it differently.”
Gently clarify your thinking, connect your thoughts to the clients’ most pressing concern, and make sure they’re in sync with you throughout the session. If they are and you can offer a clear treatment plan, you’re off to a good start. But if not, they’ll balk or seem uncertain about setting up another appointment. Then and there, you need to realize that, somewhere along the line, you fell out of step.
Changing the Emotional Climate
In a first session, clients are expecting something for their time and money: when they walk out, they want to feel differently from how they felt when they walked in. This is what I call changing the emotional climate. Simply listening and being empathic, allowing clients to vent, goes a long way toward accomplishing this. So does education. Talking to clients about the brain physiology of anxiety, for example, or typical family patterns can help normalize their distress and place it in a larger, fixable context. This is what your family doc does when she tells you that you have an infection or that your rash is simple contact dermatitis caused by the new cream you put on your face. You feel better having a label, an explanation, and a palpable sense of your physician’s educated concern.
In brief therapy, though, you need to ramp it up experientially. One of the most effective ways of changing the emotional climate is, again, zeroing in on the ongoing process with the client. You want to pay extremely close attention to the nonverbal communication, to tap the subtle feelings that are just below the surface. When Sara looks hurt, stop the story and focus: “Hold on, Sara, what just happened? You’re looking sad.” If you say this gently, with real sincerity, Sara may be able to drop her defenses and actually begin to tear up or cry. This open and shared vulnerability will help her emotionally bond with you. You can also do this by asking directly about these often softer and less obvious emotions: “What causes you to feel sad? What worries you the most?” Or ask about positive feelings to offset all the focus on negative ones: “When do you feel your best? What are you most proud of?” By asking, you move to a different level in your relationship with a client and change the climate in the room. Even if Sara seems to push your questions away, you’re still letting her know that you’re noticing how she feels and that this is a safe place to talk about difficult things when she’s ready.
While these points may seem fundamental to being a therapist, I’m always surprised when I see clinicians failing to create this powerful shift. They get too caught up in gathering history for assessment to notice these emotional subtleties, or they rationalize that it’s too soon to tap them. But that’s a mistake.
Linking Problems to Personality
The first question I always ask myself is: What keeps this person from solving this problem on his own? Sometimes it’s because clients have situational stress: they just got fired from their job, they have a medical crisis, their kid got busted for drugs. Normally, they can cope, but now there’s just too much on their plate. They need support and help to be able to zero in on the problem. Other times, it’s a matter of skill or lack of it: they have continual financial problems because they really don’t know how to set up a budget, or can’t talk with their partner without triggering conflict or disengagement. Once you help them understand and implement a budget or master the keys to good communication, the problem begins to fade.
Other problems persist, not because they’re rooted in stress or lack of skill, but are intrinsically linked to their personality and coping style. I think of this from the Buddhist standpoint: How you do anything is how you do everything. In fact, this is where some clients are stuck. While they’re worried about the what–the content of their problems–the real source and solution to their current problem, and many of the problems in their lives, lies in the how, their overall response to problems. This is what I call their core dynamic–an expression of their primary childhood ways of coping, such as accommodation, anger, or withdrawal. While these ways may have helped them survive the challenges of their early environment, now, like outdated software, they’re no longer helping them negotiate the more-complex demands of an adult world.
To move out of the 10-year-old’s perspective and better handle the problems in their lives, they need to update their inner software. More traditional approaches might track this down by a long march through the past, but in a brief approach, you can tackle it in the first session by asking how they concretely and specifically cope with current problems on the job or at home. Of course, you may even detect their coping style during the session itself, through their responses to you.
Once I’ve defined their coping style, I often try to link it to their current problem, helping them see the latest manifestation of the same outmoded response. By doing that, I set the stage for their attempt to challenge their early wiring: instead of being good and accommodating, as they’ve always done, the might push back and say what they need; or, instead of spraying anger around the room, they might self-regulate and use their anger as information. I let them know that they can update the software, which will not only fix their current problem, but prevent future ones.
This focus on defining, understanding, and challenging the core dynamic is empowering for clients. The message is that you can help them map out new ways of taking acceptable risks, breaking old patterns, and acting more like the adult they are than the 10-year-old they often feel like.
Offering a Clear Treatment Plan
Finally, like the physician, you need to leave clients with a clear set of next steps. If you decide the client is stuck because of situational stress, talk about ways of navigating this challenge in the scope of their broader lives. If it’s about coping skills, map out what skills you feel would be important for them to learn. If it’s about their core dynamic and ineffective approaches to problems, or a combination of all of the above, let them know what you’re thinking and what they concretely need to do.
Then, as always, track the process and see what happens next. Does this make sense to them? Do they agree? Do they understand how this is all related to their presenting concern? If there’s a sincere and congruent yes, you may give them concrete behavioral homework to help develop new skills or reduce their stress. If there’s hesitation, ambivalence, or accommodation, stop, clarify, or ask questions until you’re clear about what’s going on. Just remember that their resistance isn’t the problem, but a source of valuable, additional information about what the solution might be. As in any other phase of psychotherapy, it’s hard to go wrong if you bear in mind the clinician’s most useful mantra: track the process like a bloodhound!
Robert Taibbi, L.C.S.W., trains nationally and is the author of more than 200 articles and five books, including the forthcoming Therapy Boot Camp: Brief, Action-Oriented Approaches to Anxiety, Anger & Depression. Contact: firstname.lastname@example.org. Tell us what you think about this article by e-mail at email@example.com, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.
Debbie, who’s in her fifties, called: “I’m so upset about my relationship with my daughter. She and I are always in conflict, and my husband agrees this needs to be changed.”
When she came in, she reported feeling sad because she couldn’t enjoy visiting her daughter, an only child who lives nearby. “It’s such a noisy household. The children scream and squabble; there are two of them under the age of 6. I wish my daughter would be more organized and keep them quiet, so I could enjoy being there. I get so tense, I have to leave her home in the middle of a visit.”
I didn’t have a clear strategy, so I asked her to bring her daughter, Emmy, next time. Then the dynamics became clear. Emmy is a high-energy, outgoing, modern, in-your-face 35-year-old woman. Mother Debbie is quiet, somewhat distant, a loner, who needs her space. I was reminded of the movie My Big Fat Greek Wedding. Mom is a lot like the uptight couple who come into the vibrant Greek gathering.
During the hour with Mom and daughter, it became clear that Emmy wanted her mother to change and just enjoy her high-energy household. “Why can’t you be like other grandmothers, and just come in and enjoy the family?” And Mom wanted Emmy to change. “Why can’t you be more organized and quiet, so I can be comfortable with you? I can’t stand all that commotion.”
First, I tried some conventional strategies, like helping them listen nonjudgmentally to each other, but there was no movement in their relationship. I didn’t see any point in seeing them together again, so I asked Debbie to come in alone.
Again, she told me, “It just isn’t me to be like other grandmothers who get on the floor and play with the children and enjoy all the noise. And I like me the way I am. She’s asking me to be someone I’m not.”
I assured her: “You’re fine just as you are, and Emmy is fine the way she is. You just happen to be very different personalities. She’s AM, and you’re FM: she’s rock-and-roll, and you’re chamber music.” She agreed.
“Fortunately, there’s a solution. I’m thinking about Meryl Streep, and how she takes on a different personality for every role, but off-stage, she’s still Meryl Streep: she doesn’t have to change who she is. I wonder if you’d enjoy inventing a role that works well when you’re with Emmy and her family? (Here, I slowed to my hypnotic voice and watched her slip into a trance.) When you open the door to her home, you can see it like a stage. You pause at the door, view the scattered toys, and listen to the active children as part of a stage set. You may find it amusing. You’re Meryl Streep slipping into a role. Your creative inner mind will be alongside your conscious mind, enjoying the flow as you engage with your daughter and your grandchildren in fun ways, and every time you enter that stage, that family stage, you’ll find yourself expanding into your new role in satisfying ways, sometimes surprising yourself, always enjoying your secret strategy. It’s OK to let your husband in on it. Afterward, you and your husband may chuckle about the relaxed grandmother character you’ve created. You’re both director and actor on this stage. Really enjoy surprising them.”
She came out of her trance and exclaimed: “I can do that!” After some additional mental rehearsal, she left in a very good mood. Three days later, my phone rang: “This is Meryl Streep calling. I just earned an Oscar. I spent a whole day with Emmy and her family, and at the end of the day, my husband asked Emmy, “How did your mother do today?” Emmy said: “She did great!”
It was their first pleasant, relaxed day together in many years, a day without tension and conflict. I asked Debbie what she found interesting while playing her new role. She replied, “I felt so calm–very different–calm and comfortable.” ;
A well-deserved Oscar!
A few weeks later, she called to say, “I’m so excited and happy because I entertained my entire high-stress clan, and did my Streep thing, and enjoyed myself!”
A couple of months later, she said, “I’m so glad I did it. Strangely, now I feel more motherly and understanding toward my daughter than ever.”
By Steve Andreas
This is a really lovely example of many different important aspects of change work, and the importance of a careful choice of words.
The first session doesn’t offer a clear direction for intervention, so Ronald Soderquist wisely brings in the daughter, so he can observe them interacting, rather than knowing the daughter only through the filter of the mother’s perceptions and report. Although the interaction becomes much clearer when the daughter joins the mother for the second session, having them both together makes it difficult to intervene usefully.
In that session, it becomes clear that, for both of them, the issue is one of identity, in contrast to behavior. Both want the other to change, and each speaks of this change in terms of being different–in contrast to acting different. The daughter says, “Why can’t you be like other grandmothers,” and the mother says, “Why can’t you be more organized and quiet.” (Most answers to either of those questions would lead only to justifications and rationalizations, neither of which would be useful.)
For most people, being different seems to be much more difficult than doing something different. If you describe a certain behavior as “being different,” most clients will object, as both mother and daughter do in this case, and this is one source of what many therapists describe as “resistance.”
As long as both mother and daughter think of their differences in terms of the other having to be different, not much is possible. Demanding that someone else be different is an ill-formed outcome that gets many of us stuck and frustrated, because while you have at least some choice about your own behavior, you really don’t have any choice about what someone else does. That’s why having them “listen nonjudgmentally to each other” in the second session went nowhere, despite how useful that intervention often is.
But if you describe the same behavior as “doing something different” or “acting different” a client will often be willing to consider it. This distinction between identity and behavior is one that many therapists have never learned, and it’s often a crucially important reframe. In this case, it’s the key understanding that allows the mother to change her behavior and have a new internal response to the chaos of her daughter’s household.
In the third session, the mother states even more blatantly that her understanding of the issue involves her identity, “It just isn’t me to be like other grandmothers. . . . I like me the way I am. She’s asking me to be someone I’m not.” That brief utterance makes six references to her identity and five to her being: isn’t, me, be, I, me, I, am, me, be, I’m.
Soderquist begins his intervention by exquisitely pacing her focus on her identity, assuring her, “You’re fine just as you are,” relieving her of any pressure to change who she is, and implying that her daughter’s attempt to change her isn’t valid. He follows this up immediately with saying, “And Emmy is fine the way she is,” which implies that the mother’s attempts to change her daughter are just as invalid. Since the mother already agrees with the first statement, she has to agree with the second, which only reverses the direction of the logic. Abandoning her attempts to get her daughter to be different closes a door that leads nowhere, and opens a door to a more useful alternative.
To strengthen this understanding, Soderquist first offers a generalization about two of them being different. “You just happen to be very different personalities.” Then he follows this up with two metaphors that express this difference in who they are, “She’s AM, and you’re FM: she’s rock-and-roll, and you’re chamber music.” Both metaphors are drawn from contexts in which differences clearly don’t need to change.
He begins his description of Meryl Streep, and the difference between her self and the roles she plays, with the word, “Fortunately,” a cognitive qualifier that creates an expectation of good things to come. If he’d used a different adverb, such as “unfortunately” or “sadly,” the mother would have had a very different expectation about what he’d say next. Saying “there’s a solution,” further directs her attention away from the problem and builds even more positive expectation.
“I wonder if you’d enjoy inventing a role that works well when you’re with Emmy and her family,” is called an embedded question, a hypnotic linguistic form often used by Virginia Satir, one of the greatest therapists who ever lived. Although it’s a statement, it elicits an internal response as if it were a gentle question, but without demanding an overt response the way most questions do. This invites the mother to consider changing her behavior without any demand that she do so, and with no need to respond verbally.
Notice how different an overt question with the same content would be. “Would you enjoy inventing a role that works well when you’re with Emmy and her family?” would demand a verbal answer, and keep her externally focused on Soderquist, making it harder to turn inward and consider whether she could enjoy doing that. The embedded question focuses her attention on whether she’d enjoy playing a role, implying that she can do it; the question is merely whether she’d enjoy it or not. Before, she demanded that the daughter change; now she’s invited to change her own behavior (while keeping her identity intact)–an enormous shift in attitude that most clients can benefit from.
As she begins to consider this possibility, she’ll naturally become more internal, a perfect time for Soderquist to slow his voice to be more hypnotic and set up the specific cues for her new role play–all in present tense, so that she can rehearse it as if it’s happening at the moment. “When you open the door to her home, you can see it like a stage. You pause at the door, view the scattered toys, and listen to the active children as part of a stage set.”
Then he permissively suggests a response she might have, “You may find it amusing,” and follows with even more detailed suggestions that continue to encourage a rehearsal of new behaviors. “You’re Meryl Streep slipping into a role.” The use of “slipping” implies that it will be easy and effortless. Think how different it would be for her if he’d said “trying to get into role” or “struggling to act differently”! He then goes on to suggest other behaviors, and possible pleasurable responses for her.
When he says, “Your creative inner mind will be alongside your conscious mind,” it implies that the creative mind is unconscious and will assist her. As he goes on to say, “enjoying the flow as you engage with your daughter and your grandchildren in fun ways,” it implies that much of this will occur unconsciously and spontaneously. Notice all the words that make this rehearsal an enticing prospect: enjoying, flow, engage, fun, expanding, satisfying, surprising, enjoying, secret.
A bit later, when Soderquist says, “Afterward, you and your husband may chuckle about the relaxed grandmother character you’ve created,” it invites her to take a future vantage point and look back on what she’s imagined, as if it had already happened, further cementing its reality as something she can do. With all this elegant hypnotic language, it’s not surprising that when she emerges from her trance, she says, “I can do that!”
This entire intervention probably took less than four minutes, showing that when you know what to do–and how to do it–change is easy.
I think Ronald Soderquist deserves an Oscar, too!
Ronald Soderquist, Ph.D., a hypnotherapist and licensed Marriage and Family Therapist, is the director of Westlake Hypnosis in the Los Angeles area. He’s served on the staff of California Lutheran University and other universities and graduate schools. Contact: firstname.lastname@example.org.
Steve Andreas, M.A., has been learning, teaching, and developing personal-change methods for more than 53 years. His books include Virginia Satir: The Patterns of Her Magic; Transforming Your Self; and Six Blind Elephants: Understanding Ourselves and Each Other. His new book is Transforming Negative Self-Talk: Practical, Effective Exercises. Contact: email@example.com.
Tell us what you think about this article by e-mail at firstname.lastname@example.org, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.
Psychologist Philip Zimbardo knows a thing or two about tough guys. In 1971, his notorious Stanford prison experiment, originally planned for two weeks, had to be shut down after only six days when college students acting out roles as prison guards started to play a little too rough with their mock inmates. In 2007, he tried to understand the military abuses at Abu Ghraib prison in his book The Lucifer Effect: Understanding How Good People Turn Evil. Now he turns his attention to a different kind of prisoner: the average American male shackled by the constraints and demands of societal expectations.
In a new eBook titled The Demise of Guys: Why Boys Are Struggling and What We Can Do about It, Zimbardo and his coauthor psychologist Nikita Duncan paint a dire picture of dudes in this country, asserting that boys are increasingly failing to measure up academically, socially, and sexually. The blame, they say, lies with the Internet, television, and video games. According to their view, a new Lost Generation has grown up, addicted to arousal and constantly seeking stimulation and novelty through digital means: “The excessive use of video games and online porn in pursuit of the next thing is creating a generation of risk-averse guys who are unable (and unwilling) to navigate the complexities and risks inherent to real-life relationships, school and employment.” More young men are supposedly languishing in their parents’ basements, aimless, asocial, and out of touch.
The signs of the decline, they say, are everywhere: falling test scores, violent video gaming, and a buxom pornography industry. Zimbardo describes a “social intensity syndrome” in which men are driven to engage in intense, male-dominated social interactions leading to an endorphin rush that the rest of their dull daily lives just can’t match. During a popular TED talk, Zimbardo said “Guys would rather be in a bar with strangers, watching a totally overdressed Aaron Rodgers of the Green Bay Packers, than Jennifer Lopez totally naked in the bedroom.”
Boys aren’t the only ones struggling, suggests psychiatrist Boadie Dunlop, director of the Mood and Anxiety Disorders Program at Emory University. With the economic downturn’s hitting men particularly hard, they’re relying more heavily on women as the primary household earners. While traditionally female-populated fields like healthcare and social services are experiencing burgeoning demand, “manly” occupations like construction and manufacturing are being scaled back and reorganized for greater efficiency. Many men are finding themselves outsourced, obsolete, and out of work. “Compared to women, men attach greater importance to their roles as providers and protectors of their families,” Dunlop says, “and men’s failure to fulfill the role of breadwinner may lead to greater depression and marital conflict.”
Zimbardo and Duncan may be sounding an alarm about masculinity in crisis, but concerns about the death of manhood have been around for decades, if not centuries. Pornography isn’t new, even if it’s now more accessible on the Internet. Many video gamers would protest that gaming is more interpersonally interactive today than ever, and our wired world is used much more for social networking than social detachment. Are entertainment addictions really a more pervasive societal concern for men than rising housing costs and ballooning student loan bills? Is the fact that men are living with their parents longer and postponing marriage and childrearing a sign of “Arma-guy-ddon” or just a smart social adaptation to an economic “man-cession”? Only time will tell.
Manpocalypse: http://www.demiseofguys.com; British Journal of Psychiatry 198, no. 3 (March 2011): 167-68.
By Eleanor Counselman
Q: I’d like to learn more about therapy groups. Can you explain their therapeutic value and what skills are required to run them that are different from those of an individual therapist?
A: After many years as a group therapist, the main distinction I see between individual and group work is that clients tend to talk about relationship problems in individual therapy, whereas they inevitably exhibit them in group therapy. In a group context, a therapist can more easily and directly see what goes wrong interpersonally for a given client. In the presence of others, clients may exhibit isolating patterns, become self-protective, or engage in off-putting behaviors, all too often without even being aware of them.
Dave was a pleasant young man who came to see me for depression and social isolation. He’d suffered several important losses—his wife divorced him and then he lost his job—and was stuck in a stressful family situation of caring for a chronically ill relative. Through individual treatment, he grieved for his losses, and his mood improved; however, he couldn’t seem to develop social relationships, and he remained lonely. Friendships seemed to begin well, but never deepen. Neither he nor I was sure why, as he was bright and, when encouraged, a warm, forthcoming person.
After he joined a group that I lead, however, I began to understand what was holding him back. When other group members candidly shared their thoughts and feelings, he responded with agreeable, but entirely impersonal replies. He shifted the conversation away from any emotional engagement, making the others feel unheard and unacknowledged. For instance, he might respond to a member’s painful story with “I bet things will work out in the end,” or pick up on the least emotional aspect of a situation and inquire further about that.
When I shared this observation, using specific examples from group sessions, he was dumbfounded. His deflecting style was completely automatic behavior, developed years before to protect himself from intrusive and prying parents. But once he recognized it and acknowledged the old, lingering anxieties that he circumvented by not revealing anything about himself, he began to connect more directly with other group members and people outside the group.
Group therapy is a highly effective laboratory in which to practice new behavior and get honest feedback from others. The woman who consistently tells her individual therapist that she never gets her needs met in relationships may discover in group that she behaves in ways that inevitably make sure that others overlook her. The group members will let her know that if she doesn’t speak up, she will be overlooked. Members will ask where she learned how to be overlooked, and will encourage her to take the risk of asking for attention. The “nice guy” who’s always afraid of offending someone can express irritation with another group member and learn that the world hasn’t ended, and that he’s still accepted by the group.
In an effective therapy group, the majority of the work takes place in the room: although members talk about their lives “outside,” the real action is the moment-by-moment back-and-forth among group members. The group leader’s role is to help participants give constructive and honest feedback to each other—sometimes called the “hall of mirrors”—and avoid giving criticism or advice.
Because a well-run group offers a safe, contained space, it can help members try out new behaviors or ways of interacting that they wouldn’t attempt elsewhere. A large part of the leader’s role is to encourage members to try out new behaviors and responses. One group member, Susan, was the daughter of an unpredictable and intrusive mother. She’d learned to protect herself by always being in control, to the point that, in the group, she assigned herself the task of monitoring the process and drawing in silent members, as if she didn’t trust me to be the group leader. In one session, I invited her to experiment with allowing herself to let me be the one in charge. After stepping back during the session, she reported that she was amazed at the level of anxiety she experienced, and the strength of her long-buried yearning to allow herself to depend on someone else. She later said that she felt safer letting me be in control in group than in an individual session, because of the perceived protection of the other “siblings.”
In fact, although prospective members often imagine that the presence of the other members makes group therapy more anxiety-provoking, the opposite is often true. The group can actually support an individual member, especially when there’s a conflict or another issue with the group leader.
I once made a mistake in tallying the bill of a meek, superego-burdened group member. Raised by harsh, perfectionist parents, she’d never before stood up to authority. But with the encouragement of her fellow group members, she was able to tell me that the mistake had made her mad, and that she doubted my competence as a result of my error. She wouldn’t have dared stand up to me in a one-on-one session, but the group support gave her courage.
For group therapy to be effective, any new members should be up to the level of the group. A person who can’t describe what he’s feeling and experiences only body sensations won’t do well with group members who are more fluent in speaking about their emotions, but this same person might do well among people who have difficulty articulating their feelings. The basic requirement of membership in a group is that the client must be able to uphold the particular group agreement or contract, which typically covers attendance requirements, payment, confidentiality, limits on outside contact with group members, termination procedures, and the role of the leader.
Today, there are many varieties of group therapy, including standard interpersonal or psychodynamic therapy groups; open-term or time-limited groups; and CBT, psychodrama, and DBT groups. There are groups for specific populations or themes: men, women, gay, eating-disordered, first-break psychosis, medical illness, social anxiety, mind-body, and, of course, addictions. Naturally there are now cybergroups that make a group experience possible for people living in isolated places.
Groups have many healing qualities, but one of the most important is the basic human support they provide—giving a sense of belonging and group cohesion, factors that are increasingly scarce in our fragmented society. One client, reflecting on what he’d gained from the group as he was terminating therapy, said that what he found hardest to leave was the sense of being part of something—the feeling that the group was always there for him in a basic way. “My life is so much better, and I am so grateful,” he said, “but I’ll just plain miss being here with you guys every Tuesday evening!”
So why isn’t group therapy a more widely used treatment? For one thing, many insurance policies will pay for only a fixed number of visits, so group members who want to continue past the allotted 10 or 20 sessions must pay out of pocket for much of the year. This is a false economy on the part of the insurance companies. Since group sessions are so much less expensive than individual sessions, the reimbursement for a dozen private sessions would pay for the better part of a year of group sessions.
Another issue is client resistance to joining a group. Some clients are afraid they’ll get less attention from the therapist in a group—”I don’t want to share my therapist” is a common refrain. Other reactions include “How can a group of people with problems help me?” or “I can’t imagine telling my problems to strangers” or “What if I don’t like the group—or the group doesn’t like me?”
These concerns are legitimate. It can be scary joining a bunch of strangers, with whom intimate personal stories will be shared, and sometimes it doesn’t work out. I’ve never had a client who didn’t like at least one person in a group, although I’ve had clients who came to feel they weren’t in the right group.
What skills does a good group leader need? One of the most important is the ability to do mental multitasking. You’ll usually be thinking on at least four levels at once: about the individual members, the interpersonal interactions, the group as a whole, and your own internal reactions. Some therapists are not good at this, preferring the more intense focus of individual treatment.
Other clinicians dislike the exposure involved in leading a group. In fact, it is more uncomfortable to make a mistake in front of six or eight of your clients than to make one in the relative privacy of an individual session. I was genuinely embarrassed when I made the billing error with my client. While I knew that what my client did was therapeutic for her, it still stung me, all the more so because it happened in front of an audience—one that was pleased to see me brought down a peg, I might add.
Clinicians without a substantial referral base may find it too difficult to keep their groups filled. It’s demoralizing to have a group dwindle down to two or three members. Some clinicians have formed group-therapy networks to solve this problem, marketing the network and referring to each other’s groups. Involvement in local and national group-therapy associations can help keep group referrals coming too.
Should you just start a group yourself? Definitely not without specific training! The American Group Psychotherapy Association (www.agpa.org) has developed guidelines
for becoming a Certified Group Psychotherapist (CGP), and the parent group and its local affiliates offer many fine training opportunities.
Group therapy can be an excellent treatment for most clients. It’s cost-effective, and in many ways a better mirror of “real life” than individual therapy. Whatever happens in group, you’ll never be bored!
Eleanor Counselman, Ed.D., C.G.P., F.A.G.P.A., is immediate past president of the Northeastern Society for Group Psychotherapy and an assistant professor of psychiatry at Harvard Medical School. She’s published numerous articles on psychotherapy and has a private practice in Belmont, Massachusetts. Contact: EleanorF@Counselman.com. Tell us what you think about this article by e-mail at email@example.com, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine section.
By W. Robert Nay
It’s one thing to help an easily incensed individual learn to manage a too-easily-aroused temper. It’s entirely another thing to help partners in a troubled relationship deal with the kind of anger that gets triggered primarily when they’re with each other. Yet therapists often focus too narrowly on helping individuals manage their personal anger, rather than helping partners reduce the anger that repeatedly arises between them.
In chronically angry couples, differences of opinion rapidly become arguments, which escalate to raised voices, raised blood pressure, and sometimes raised fists. Repeatedly, the anger itself, rather than the initial disagreement, becomes the issue, shooting back and forth, intensifying with each volley. As the emotion rises, and as ordinary inhibitions fall away, the likelihood of verbal abuse and/or physical aggression grows. Aggressive feelings drown out any attempt at addressing the underlying conflicts or problems in the relationship.
Partners riding this merry-go-round of anger almost inevitably blame each other for the problem. Typically, one or both portray the other as having “started it,” ignoring the fact that their conflict occurs within a system of two. The partners pass the anger back and forth like a shared virus.
My Way or the Highway
Adam and Sarah sought my help after what Sarah called “years of fighting over nothing,” which had sapped the life from their marriage. Sarah, 38, told me her anger was triggered only by Adam’s temper. “I’m fine with other people,” she said, adding that the only time she got mad was when she felt Adam had invaded her space. “With him, it’s always ‘my way or the highway.’ He gets extremely loud, intense, and sarcastic when we don’t do what he wants, when he wants it.”
When I asked her how she usually reacted when Adam got angry, she looked embarrassed. “Lately, I’ve been telling him off,” she admitted. “I can’t take any more of his loudness and aggression. Last week, I screamed at him to ‘shut the hell up’ in front of our children. I don’t want to act this way, or for them to turn out like him!” I asked her if she’d be willing to be a part of the treatment, even though she believed Adam’s anger was the main problem. Although she wasn’t sold on this idea, she agreed when I told her that she needed to learn to change the way she reacted to Adam’s anger to help defuse it early, and to feel better herself.
Adam, 41, informed me right away that he’d do anything to save his marriage. He came from a family of shouters, he said, and often listened to his parents argue well into the night. While he’d vowed not to be like them, he found himself all too often “losing it” with Sarah—yelling and saying things he later regretted. But he saw his wife as a big part of the problem: “If she’d just leave me alone when I get stressed out, I wouldn’t get so mad. She needs to learn to back off.” He blamed much of his anger on stress resulting from long hours working for a demanding boss at a large insurance company. By blaming his wife and his work, he externalized his feelings. Like most of my angry clients, deep down, he believed that his anger originated outside himself.
Strategies for Arousal Management
I met with Sarah and Adam individually for three sessions to identify their individual patterns of anger arousal—the physical sensations each experienced when anger was triggered. From there, the focus shifted to specific strategies to derail their arousal pattern before they became so angry that calming thoughts and self-control were difficult or impossible.
In my first individual session with each of them, I asked each one to keep an anger log, recording the situations when anger was experienced, the thoughts or “self-talk” that arose in their minds, their body sensations (tight shoulders, heat in neck and face, jaw tension), and the actions or words they used to express their animosity. The logs and my clarifying questions helped me identify their triggers: the actions or statements that seemed to instigate arousal. As partners become aware of specific triggers, they can “preview” an upcoming encounter to think ahead about how to manage their temper, if it arises.
To assess how each got triggered, I reviewed what I call the “Five S’s”—life factors that contribute to instigating and intensifying anger arousal. These include: inadequate Sleep; ongoing life Stress; not eating properly, or inadequate Sustenance; use of Substances like alcohol, caffeine, or other drugs; and any health issue or Sickness that increases irritability (a bad cold, headache, lower back pain). Adam told me, for example, that he often stayed up until 1:00 a.m. to have some time alone, yet arose at 6:00 a.m., getting only five hours of sleep. He agreed to begin pushing his bedtime sequentially earlier by about 15 minutes a night, to work toward a 10:00 p.m. bedtime. We discussed making the bedroom extra dark to further aid sleep onset.
Adam’s stress level was heightened by his feeling that he had to work late to avoid a threatened layoff. We discussed a variety of coping strategies, including work breaks, a power nap, relaxation techniques, and ways to challenge scary self-talk—”How will I support my family?” “What if I can’t find another job?”—which fueled anxiety and sometimes contributed to insomnia. He told me he often skipped lunch or grabbed a snack from a machine, since he felt he was too busy for a meal. I encouraged him to take at least 30 minutes to eat a healthy lunch to sustain his blood-sugar level, since low blood sugar is related to irritability and general disinhibition.
As for substances, Adam told me he drank lots of caffeinated diet colas at work and had begun consuming two or three glasses of wine each evening as a way of “winding down.” I told him that while we all vary somewhat, even small amounts of alcohol and caffeine tend to be disinhibiting and could fuel anger arousal. We agreed it was best to avoid drinking alcohol during the work week and to limit other drinks to decaf versions and water. Sarah’s Five S’s included drinking wine with Adam in the evenings, as well as frequent headaches, which fueled irritability and negative self-talk. I encouraged her to limit her alcohol consumption and to seek medical guidance for her headaches.
From their anger logs, we identified the first physical sensations of anger arousal. Adam reported that his chest felt tight and his breathing would get heavy. In contrast, Sarah found that her first anger tell was when her jaw felt tight. Both reported that the next phase of anger arousal they noticed was heat in the neck and face. I encouraged them to learn to identify these feelings as signals to begin arousal management.
At this point, I taught both Adam and Sarah to employ an easily remembered protocol for dampening arousal, which I call the Stop method—Stop, Think, Objectify, Plan. The first step to controlling anger is to reduce initial arousal by internally stating the self-instruction to “Stop!” while mentally picturing an image and/or hearing a sound associated with cessation. For example, Adam would imagine a bright, red stop sign and his father’s voice saying “Stop immediately!”
Next, to derail anger escalation, it’s helpful to ask clients to sit down (assuming a physical position the brain associates with safety) and engage in deep, diaphragmatic breathing. Adam and Sarah learned to sit in a fully relaxed position while practicing a version of diaphragmatic breathing and exhaling to a slow, internal count from 10 to 1. The acts of sitting and consciously breathing interrupt angry thoughts, because they focus attention on these tasks. Each was instructed to continue taking relaxing breaths as needed until his or her anger signal diminished.
I then encourage each partner to focus on his or her most upsetting, angry thoughts, which usually sprang from common cognitive distortions. Some examples include: mindreading—”Sarah just loves to get me mad, so she can accuse me of being irrational”; personalizing—”Adam’s fury isn’t about his stress: it’s to put me down!”; overgeneralizing—”Adam can never cool it: he’s always just on the edge of losing it”; and thresholding—”If Sarah corrects me in front of the kids one more time, I know I’m going to lose it.” These distortions trigger fight-or-flight instincts and associated arousal, making it critical to develop the ability to step back and look at the situation through a more objective and calming lens.
After quickly identifying one or two distortions prominent in their thinking, each learned to rebut and replace anger-arousing thoughts with affirming facts. This is called objectifying. I typically teach clients a strategy I call “camera checking” to focus them on the observable facts of the anger-inducing situation. By emphasizing the facts, rather than perceptions colored by resentments, experiences, or faulty beliefs, partners learn to avoid demonizing and personalizing the other’s words and actions. This process diminishes the perceived threat and, typically, leads to an immediate decline in arousal. For example, instead of thinking “She loves to make me mad”—an irrational mindreading of Sarah, Adam was asked to focus on observable statements and actions devoid of interpretation: “The fact is that Sarah is telling me her opinion of how I handled our son Jake. She disagrees with me.” This thought—an objective statement, rather than an attack on the other’s character—sets the stage for a discussion of differences of opinion.
Each partner is encouraged to think of an immediate plan, focusing on the facts of the situation. Having a plan reduces perceived threat by increasing one’s sense of control. Adam’s plan was, “I’ll suggest we table this until I feel less exhausted,” or “I’ll look at her and listen until she expresses her ideas—seeing them as information and not criticisms or put-downs.”
Therapy often involves entirely too much talking about new skills the client should put into place, but not enough rehearsing. Clients often understand well enough what to do when life challenges arise, but often can’t recall and enact new skills in the heat of the moment. Accordingly, new coping behaviors need to be rehearsed enough to be automatic. I spend a full session with each partner, role-playing how to implement the Stop in mock situations of provocation. I model how to use the Stop, and then we reverse roles and have the client use it in the heat of role-plays that enact the most difficult and volatile situations each client can imagine.
Making a Commitment to Change
After Adam and Sarah had experienced applying Stop techniques, I met with them together to put these skills into practice. Adam echoed the doubts of most clients at this juncture: “I still feel that I’m going to lose it when Sarah and I really get into it. How can I remember to do all this stuff when the heat gets turned up?”
To segue into the next phase of our work, I asked them to discuss together the words and actions that had most quickly provoked anger escalation in the past. For Sarah, it was when Adam raised his voice, approached within two feet of her, and told her she was incompetent as a wife and mother (using words like lousy, lazy, and weak) and criticized her in front of the children. Adam responded strongly when Sarah raised her voice, questioned his sanity (“You’re nuts!” “You need help!” “I’m going to have you put away”), refused to speak to him for hours, and threatened divorce. They were encouraged to discuss how they felt when these threatening behaviors were directed at them, while their partner listened without interruption.
I asked each to make a commitment to change, based on what they’d learned in the individual sessions and from each other. Which behaviors were they willing to alter? Which behaviors would they agree to substitute when angry? I helped them be as specific as possible, to ensure well-defined, practical, and measurable goals. Adam agreed that when conflict arose, he’d sit down and use a softer voice, tell Sarah what behaviors he wanted her to alter without resorting to name-calling, and do all this in private. As in other cases, I said that if they wanted to, they could write down and sign their commitments to each other as a contract.
We then spent two full sessions practicing “circuit breaking” to derail anger escalation. Each partner has two potential circuit breakers, warning signals that the system is getting dangerously hot. One, an inner physical feeling signaling anger arousal, originates in the self; the second, the partner’s anger actions, originates in the other. The activation of these circuit breakers signifies the need to shut down the discussion and begin using the Stop method.
The self-originating circuit breaker for Adam included a tightening of his shoulders and chest or warming of his face; his other-originating circuit breaker was when Sarah’s voice became significantly louder or she began criticizing him in front of the children. Sarah’s self-originating circuit breakers included a tightening jaw and a flushed, warm face; her other-originating circuit breaker was when Adam got loud, stood within two arm’s lengths of her, or called her a name.
These four levels of awareness (his and her self-signals and other-signals) warned that arousal was escalating and the action should be ended for as long as needed to employ the Stop techniques, calm down, and reassert control of arousal. As I encouraged them to discuss the hardest, most triggering topics that they could think of while practicing circuit breaking, they began readily to halt and derail their anger, and then redirect themselves back to calmer talking and listening about issues. I demonstrated these strategies for them, so they could practice during two sessions devoted exclusively to rehearsing together how to use circuit breaking.
As Adam and Sarah practiced using Stop with me, they not only became more proficient in derailing their anger arousal, but also less reactive to each other. Just as exposure training reduces anxiety to feared situations, these rehearsals helped them feel less threatened as they learned new ways of responding to old anger triggers. They felt more prepared for the next provocative encounter and more relaxed about how to handle each other’s actions.
A Vision of Relationship
Now that their anger arousal was under control, we could begin to discuss underlying relationship issues during our couples sessions. Through conversations emphasizing I-statements and active listening, I asked each to discuss their vision of how they’d like their lives to be in a year and beyond in major life areas: love and intimacy, friendships, activities/interests, spirituality, intellectual stimulation, family/parenting, financial. Once they each better understood the other’s vision and underlying needs, both could craft more-realistic expectations of their partner and a mutual vision for their relationship, reducing sources of future conflict.
During 10 additional sessions, they practiced using Stop to derail anger arousal that would emerge as they decided how to collaborate on implementing their individual visions and their common goals. For example, Adam wanted more time with his male friends, and Sarah wanted to visit her parents more frequently—something Adam had resisted in the past, which had been a source of arguments. They agreed that on the same weekend at least once a month, they’d fulfill these individual goals, removing a source of conflict. They reported using Stop and circuit breaking with much success at home. By mutually managing their arousal, they reported success in discussing and resolving differences as they worked on satisfying their needs.
This CBT based systemic approach to anger treatment acknowledges that couples inhabit an interdependent relationship, and that treating both of them, regardless of who’s the “angrier,” helps each identify and alter his or her contribution to the problem. Nevertheless, the approach I’m describing is no miracle cure. One partner frequently refuses to participate. When I’m forced to work with one partner alone, I employ the same methods for arousal management described above and use role-plays with me standing in for the partner to allow the client to practice circuit breaking. Safety is always the priority, and I routinely and ongoingly assess the degree of risk if violence is an issue. When the risk is too high, I refer the partners to separate therapists until they become comfortable with joint sessions.
The path to behavior change is often circuitous, and setbacks frequently occur, especially when one or both partners minimize the need to use Stop, rationalizing that “We’ve got this down and don’t need to do all those steps,” or returns to old thinking and actions when one or more of the Five S’s suddenly fuels arousal. Adam began working late and missing evening meals, driving home exhausted and out of sorts—which fueled irritability and rekindled old habits. At those times, it’s especially helpful to assess what exactly has taken place and recommit to new behavior. Thus, “booster” sessions are usually necessary.
Rather than becoming overfocused on the drama of anger or its roots in an individual’s life, it’s crucial to understand anger as part of an ongoing, interdependent system of expressed and unexpressed needs, which ultimately must be addressed in any relationship. Rather than something that must be managed by just one partner, it’s important to see it as being central to the dance of need fulfillment in a couple, and to help both partners learn new steps to convert this often destructive force into fuel for lasting relationship change.
By Ronald Potter-Efron
Robert Nay presents a patient, thoughtful, and practical approach to the difficult task of working with angry couples. He’s quite thorough in his three-phase technique, and recognizes that a major concern in working with such couples is getting them to stick with the therapeutic program long enough to develop new habits of respectful communication. Brain research on neuroplasticity suggests that it takes at least six months of practicing new behavior to create permanent change.
My major critique of Nay’s approach is that it isn’t truly systemic in the classic sense of that term. Rather, he begins by separating the parties and working with them individually for several sessions. In my own work, I try to avoid individual sessions, because all too often, clients use them to share potentially explosive secrets—”I just want you to know that I’m having an affair with my secretary, but don’t tell my wife.” Individual sessions increase clients’ tendency to try to make the therapist their ally against their partner. At a deeper level, I believe that holding separate individual sessions implies that the real issues are individual, rather than systemic.
I prefer to keep the couple together in sessions so that they can focus on how they’re mutually creating their miseries. One approach I use helps couples chart the details of their here-we-go-again arguments—the fights that have occurred so frequently that both parties know all the lines, but still become so emotionally flooded that they seemingly can’t stop these conversations from happening. It’s critical, I believe, for the couple to realize that they’re mutually responsible for these minidramas. Although either partner can derail the scene by refusing to say the lines, these fights in reality usually don’t end until both parties decide to quit. Until that happens, most partners tell me that even when they try not to get sucked in, they quickly return to their habitual roles when their partner plays out the old drama.
It appears to me that, instead of a truly systemic approach, Nay does what I call side-by-side individual work. In essence, his goal is to help each partner inoculate himself or herself from their partner’s provocative words and deeds. His Stop method certainly will help them do exactly that, but I don’t see how it’ll lead to a significant change in the system.
This is most apparent in the individual approach Nay uses to elicit the couple’s sharing of personal visions of a presumably brighter and more constructive future. This attempt to get them out of their current quagmires and help them look ahead to a more positive future is certainly valuable, but, from a pure systemic perspective, I believe that much more emphasis should be placed on having partners craft a mutual vision together—a shared dream that offers a more cooperative direction.
In summary, I’d say that, despite his useful insights into the struggles of angry couples, Nay’s case description offers a side-by-side therapy approach, rather than truly systemic counseling.
I appreciated Ronald Potter-Efron’s perspective that, for lasting change to occur, the couple must continue to rehearse new anger actions and reactions to each other over time, so that they become more automatic, particularly when anger arousal is triggered and old habits rear their heads. However, I was perplexed by his focus on the lack of purity in following a classic approach to working with a couples system of learned interactions.
This case clearly melds cognitive-behavioral methods with couples therapy and communication strategies. The thrust of the case is to move away from the individual-therapy approach to working with both partners, each of whom participates in the dance of anger. I thus agree that we must move beyond a side-by-side approach to anger treatment. After a few individual visits to instruct each partner in the rudiments of managing arousal—a CBT approach that can best be carried out individually—I work with both partners, if possible, to help them collaboratively craft an approach to attaining their individual needs.
As their needs are better fulfilled, anger arousal is likely to be reduced or eliminated. I’ve experienced few problems in making it clear that the goal of treatment is to alter how they manage anger arousal as a couple, not to do parallel, individual therapy. In particular, the circuit-breaking strategy, through which both partners learn to recognize and communicate early on that arousal is escalating, permits them to remain focused on clear communication and resolution of needs, without being derailed by recurrent anger patterns that defeat their best efforts at making necessary relationship changes.
W. Robert Nay, Ph.D., is clinical associate professor at Georgetown University School of Medicine and the author of Taking Charge of Anger: Resolving Conflict, Sustaining Relationships and Communicating Effectively Without Losing Control and Overcoming Anger in Your Relationship: How to Break the Cycle of Arguments, Put-Downs and Stony Silences. Contact: firstname.lastname@example.org; www.wrobertnay.com.
Ronald Potter-Efron, Ph.D., is a clinical psychotherapist, co-owner of First Things First Counseling and Consulting, and director of its Anger Management Center. He’s the author of Rage: A Step-by-Step Guide to Overcoming Explosive Anger. Contact: email@example.com.
By Ryan Howes
Back in the 1970s, Donald Meichenbaum was part of a group of innovators that included Albert Ellis and Aaron Beck. Together they challenged the prevailing behaviorist paradigm, lobbying to have the psychology field recognize the pervasive influence of thoughts and beliefs on observable behavior. Four decades later, the sometimes acerbic Meichenbaum remains an outspoken critic of what he considers unproven therapeutic practices and fads, upholding standards of empirical proof for clinical methods within the field. Now 70 and retired from his professorship at the University of Waterloo in Canada, he’s presently research director of the Melissa Institute for Violence Prevention in Miami, and has a particular interest in ensuring that the combat vets returning from the wars in Afghanistan and Iraq receive the best treatment available. As active as ever and a popular figure on the workshop circuit, he recently talked about conclusions he’s drawn from decades of experience in the field.
RH: My students have an ongoing debate about the nature of therapy, and how much the therapist-client interaction should resemble a real relationship.
MEICHENBAUM: I get hung up with the word “real.” I mean, what’s an “unreal” relationship? Clearly, when we’re talking about therapeutic alliance, we’re talking about a relationship. The therapeutic alliance depends on the degree to which the therapist and the client agree on a set of goals and the means to get to those goals. That alliance necessarily has to do with the affective bond that develops, and the alignment between the client’s view of what’s wrong and how to get help and what the therapist has to offer. If those are in line, then you’re going to get a therapeutic bond, and everything follows from that.
RH: So the relationship needs to be real enough in clients’ lives that they’ll take the process seriously?
MEICHENBAUM: Yeah, and I’m essentially at my therapeutic best when the clients are themselves offering the advice I’d otherwise offer. In other words, I need clients to convince me that what they need is cognitive-behavioral therapy (CBT). So I use a lot of Socratic questioning to draw out people’s own wisdom. I’m a bit like Peter Falk playing Columbo: I try to get people to provide the answers they’re looking for themselves, rather than trying to become their surrogate frontal lobe.
RH: A former client just contacted me after coming home from Afghanistan. He’s had a tough time, and he’d been specifically advised to seek out EMDR treatment for post-traumatic stress disorder. What would you recommend?
MEICHENBAUM: I’ve done battle with the EMDR people so many times that I don’t want to get back into that debate. Rather than thinking that there’s one approach to PTSD that’s across-the-board better than any other, I think it’s more important to look at what’s common among all these procedures, and help people understand that there are a range of methods—besides exposure-based interventions—that can be helpful.
The choice of which method to recommend should be determined by the client’s symptomology. If your client’s main problem is hypervigilance, avoidance behavior, and mistaken beliefs, then some variation of in vivo exposure, where he can tell the narrative and then change the mistaken beliefs, would be acceptable. But if, in fact, his primary concern is guilt—his feelings about killing a buddy in friendly fire or killing others—then the treatment of choice would be a procedure focused on guilt or moral injuries. The field has advanced to a point where we can now tailor interventions to fit more closely the specific nature of the client’s distress, not just the broad category of PTSD.
Researchers Anke Ehlers and David Clark have identified that the major problem that leads to chronic PTSD has to do with biographical memories. Many people need help to incorporate the trauma memory into the larger narrative of their lives. They need help getting a larger perspective.
The other thing that’s now emerging in the literature is that helping people with PTSD isn’t just about getting rid of bad thoughts, but retrieving positive thoughts of what they did to survive. There’s an increasing recognition of the need to incorporate into treatment resilience-engendering, strength-based interventions, such as fostering positive emotions, psychological flexibility, optimism, gratitude, and spirituality. I’ve been involved in developing iPod technology for returning service members (see www.warfighterdiaries.org). These videos can be downloaded onto an iPod and people can listen to these coping stories whenever they want. This project dovetails with the Constructive Narrative approach that I now advocate.
RH: So there’s no one true cure?
MEICHENBAUM: There’s no single model that fits all. I really see myself as an honest broker, so anyone who says I have the cure, like Steven Hayes’s idea that his Acceptance and Commitment Therapy is “The Third Wave”—ACT may work with many people, but it’s not a panacea.
RH: You’ve done research specifically on what constitutes therapeutic expertise or mastery. You’ve written that people need about seven years to become an expert at anything. Is that similar to the 10,000 hours to achieve expert status that Malcolm Gladwell writes about in The Outliers?
MEICHENBAUM: That’s exactly right, we’re using the same data—10,000 hours, or, if you’re a chess player, 50,000. I say it takes seven years for a therapist to become an expert, because that’s how long it takes to see enough patients really shape up. You learn by deliberative practice, learning from your mistakes.
RH: So what can less experienced therapists do to provide good client care while they’re gaining sufficient experience to move to the next level?
MEICHENBAUM: I think it’s a journey. Some people start off a bit ahead of others because they already have core skills, like knowing how to listen, how to reflect, those kinds of things. I think that the main thing is not to be sucked up by the hype that’s associated with certain therapy models—you need to be a critical consumer. It’s also important to find a good mentor and be part of a peer group in which you look closely at each other’s work.
I think that a crucial pathway to expertise in psychotherapy is to have the guts to audiotape or videotape your sessions, and watch them with someone else; we all need that kind of feedback. The other thing is that you should develop a habit of soliciting feedback from your patients. At the end of every session, you should ask them, “Is there anything I said or did, or anything I failed to say or do, that you found particularly helpful or unhelpful?” We all need to regularly do those kinds of dipstick assessments and solicit that kind of feedback. If you’re an athlete and you miss the shot, you get immediate feedback. If you hit the golf ball in the rough, you get immediate feedback. Psychotherapists don’t get that kind of feedback automatically; they have to ask for it.
RH: As one of the founders of CBT, how far do you think it’s come?
MEICHENBAUM: Years ago, the behavioral traditionalists attempted to get all cognitive types kicked out of the American Association of Behavioral Therapy. They tried to make sure that no articles with the word “cognition” appeared in journals like JABA [Journal of Applied Behavior Analysis]. A letter was even circulated specifically identifying people who were bastardizing behavior therapy. Today AABT has changed its name to the American Association of Cognitive Behavior Therapists. One has got to be impressed with that kind of growth.
In addition, there’s an increasing appreciation of the particular factors that make cognitive-behavior therapy effective, like the therapeutic alliance and the whole business of nurturing hope and attending to feelings. So I think CBT has continued to develop and embrace a broader perspective, recognizing that feelings impact thoughts, as well as thoughts impacting feelings.
Finally, I think that there’s a great deal more humility about the limitations of CBT. Recent studies in the area of depression highlight that behavioral activation and helping people get exercise is equally, or more, effective than cognitive therapy. In the area of substance abuse, CBT is no better than other kinds of interventions, like 12-step groups. In fact, in substance-abuse studies using CBT, there’s no evidence that the cognitions have changed, or that the mechanisms of change are in any way linked to the specific CBT procedures. So I think anyone who’s sensitive to the data has to be given pause by how little we still know about what particular mechanisms lead to change.
RH: It’s humbling!
MEICHENBAUM: Sure. I think if you’re honest in this profession, that’s usually the right stance.
Ryan Howes, Ph.D., is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs “In Therapy” for Psychology Today. Contact: rhowes@mind spring.com; www.ryanhowes.net.
With all the recent developments in research, theory, and practice, we have more treatment options to choose from than ever before. Why then do so many practitioners still find client “resistance” a regular companion in their consulting rooms?