Knowing When to Push

I was doing a workshop in the Midwest and, as is often the case when I travel, I spent a great deal of time with the person who organized the training. We ate meals together. We talked. We became fast friends. Over dinner one night, she shared a story about her life—one that stuck with me for years and would affect my life and work in profound ways.

A vivacious, single, 35-year-old woman, Sally had a passion for running. One day, the unimaginable happened: when she returned to her apartment after a run, the door closed behind her and there stood a man in a ski mask with a knife in his hand. Sally quickly told herself that she might get raped but would somehow survive the ordeal. And in fact, that’s precisely what happened.

The rapist ordered her to remove her clothes and have intercourse with him as he held a knife to her throat. She complied. Then, when he was more focused on his orgasm than her, she escaped and ran across the street to a neighbor’s house. When the police arrived, she matter-of-factly relayed what had happened. After listening to her report, the police officer said, “Lady, I don’t get it. You were just raped at knifepoint and you’re telling me the story so calmly. How is that possible?”

Sally looked the police officer straight in the eye and without a moment’s hesitation replied, “You don’t think that I’m going to let 15 minutes with that fucker ruin my life, do you?”

Sally’s reaction took my breath away. I wanted to stand up and applaud. I wanted to scream, “Yes!” I was in absolute awe of her strength and fortitude. Sally became my new hero.

She had no post-traumatic stress disorder (PTSD), no nightmares, no sexual hang-ups, no depression, no anxiety. She needed no therapy. Nothing. Her rape did have one lasting effect, however. For years, she volunteered at rape crisis centers to help other women who’d been through similar experiences.

Despite my fascination with Sally’s courageous response, I distinctly recall wondering, “How could Sally have triumphed over adversity so quickly, so masterfully, so completely—without therapy? Was she in denial?”

The answer was no. Sally wasn’t a “survivor” or a “rape victim.” Sally was thriving. Here’s what I learned that day: knowing what’s happened in people’s lives is a lot less helpful than knowing the meaning they’ve ascribed to their experiences. It’s what people tell themselves about their trials and tribulations that dictate how they respond, react, and recover.

But how many therapists would’ve honestly believed Sally’s response to be possible? How many of us would’ve worried about possible relapse rather than cheer her on? Wouldn’t we be haunted by fears of delayed PTSD or that her resilience would be short-lived?

As therapists, we’re taught to take in-depth psychosocial histories. And when we learn that clients have experienced tough childhoods, sexual or emotional abuse, or significant losses, we often make immediate assumptions about their current struggles and the kind of treatment they require. In many ways, the information we gather about problematic pasts biases and blinds us. Because we’re empathetic to the challenges certain clients have endured, we’re less likely to nudge them beyond their comfort zones. After all, we wouldn’t want to trigger them.

However, we do our clients a great disservice when we think we grasp who they are simply because we’ve gathered some facts about their lives. Human beings are far too complex to assume that we know how any single person assimilates his or her experiences. But since having assumptions that influence our work with clients is unavoidable, why not assume resilience? Why not trust people’s abilities to rebound from adversity? Why not focus on their resources, rather than look for pathology under every rock?

Marie and Justin

Recently, memories of Sally came rushing back to me when I began work with Marie and Justin, a couple in their 40’s who came to Boulder to do a two-day intensive with me because their marriage was in deep trouble. I quickly learned that their two children, ages 12 and 14, were the light of their lives. Marie was an attorney—outgoing, likable, with a lot of friends and a busy social life. Justin, on the other hand, worked as physicist and was a self-proclaimed “nerd.” He loved being with his wife and kids, but had little need for anyone else.

When I asked about the purpose of our meeting and what they were hoping to accomplish in our two days together, I learned they hadn’t had sex in 12 years. Overall, they loved each other, collaborated in everything they did, and enjoyed each other’s company. The problem was that Justin no longer wanted to be in a sexless marriage. He was ready to get out and wasted no time in telling me about his deep sense of hurt and rejection due to Marie’s unwillingness to be responsive to any of his sexual advances. He sobbed loudly and uncontrollably as he spoke about it.

Although he’d told Marie of his pain and frustration in the past, it wasn’t until their intensive with me that he truly let his guard down and the floodgates opened. Marie was obviously touched by Justin’s outpouring of emotions. She knew that her actions had been hurting him, but she had no clue as to the intensity of his pain and felt guilty to be the cause of such unhappiness. I asked Justin to explain more about his feelings.

“I can’t live like this anymore,” he cried. “I adore Marie, but the pain I feel lying in bed next to her each night is unbearable. When I think about my life without her, I don’t assume that I’ll be happy or find someone else. I just know that I can’t live with this rejection anymore. I’d rather die. I have to leave if nothing changes.”

In turn, Marie told me that she definitely wanted to save her marriage. She couldn’t fathom a life without her best friend and partner, and said she wasn’t going to let that happen.

“So what needs to happen for the two of you to become sexual again?” I asked.

Marie responded that she didn’t even like sex. If it were just up to her, she wouldn’t have sex again. She wished that Justin would just focus on how great the rest of their marriage was and not worry so much about sex. But she now realized that wasn’t going to happen. Still, Marie wasn’t convinced she should have to do something she really wasn’t up for doing.

Of course, her reluctance to have sex made me curious about her past sexual history, both with Justin and prior to their marriage. She admitted that she’d slept with many men when she was in college and attributed it to the fact she’d been sexually abused for two years when she was a preteen. When she talked about the events surrounding the abuse, the devastating details of her childhood slowly emerged. Her biological father had abandoned the family when she was small. Although the man her mother quickly remarried was physically abusive to her brothers and sexually abusive to her and her younger sister, her mother never spoke up or tried to protect them from him. Marie repeatedly vowed not to be like her mother.

Eventually, when the authorities caught wind of the abuse, Marie and her sister were taken out of their home and placed in a horrendous foster home. She considered returning home, but her mother refused to believe her story about the abuse. Marie found her biological father, who begrudgingly allowed her to live with him and his wife until she graduated from high school. Then she was on her own.

She managed to string together loans to get herself through college and law school. Afterward, she held down increasingly responsible and lucrative positions, becoming successful and respected in her field. But a low-grade depression followed her around. Despite her success, Marie knew there was something wrong with her marriage. And now things were coming to a head.

If Marie truly wanted to save her marriage, I realized, she was going to have to become proactive in revitalizing her sexual relationship, regardless of her abusive background. Justin simply wasn’t going to stay otherwise.

At this point, I asked whether Marie had gotten help for the abuse and learned that, in fact, she had. They’d gone to therapy together for four years, and she went individually to work on the abuse issues for a year and a half. Although they liked their therapist, after five and a half years, sex was still off the table.

Justin said that the therapist would occasionally suggest exercises, such as sensate focus, that would get them touching again. But since Marie was never in the mood for sex and the therapist didn’t want to push her, they never did the exercises. Justin felt that therapy was one-sided, reinforcing Marie’s feelings about sex, which even made Justin question whether he was being selfish.

Marie admitted that the year-and-a-half focus on the abuse did little to help her let go of the past. In fact, she found it counterproductive to rehash the details of the abuse and her feelings about her childhood. She just didn’t know what else to do. Eventually, since nothing was changing, they tried a new therapist, who, in the first session, suggested that they just get naked and take a shower together. They never went back to him.

I understood at once that moving too fast would be a therapeutic deal-breaker. So how could I help them save their marriage, and balance being sensitive to Marie’s turbulent past while not allowing it to define her or the possibilities for her future?

Tough Love

It seemed clear to me that by focusing on Marie’s fragility, Marie’s previous therapist failed to challenge her in a way that might have opened the way for positive change in her marriage. The more the therapist treated her with kid gloves, the more Marie saw herself as incapable of becoming sexual again. I decided it was time for tough love.

Once I sensed that Marie felt comfortable with me, I leveled with her. “You know, I’m on your side,” I said. “I want what you want for your marriage. I think you have an incredible relationship and I hope Justin stays. But in order for that to happen, you’re going to have to do something concrete about your sexual relationship. Otherwise, he’s going to leave. He means it.”

“I know,” she said. “That’s why I’m here. But I’m not ready to have sex. Not even close. I just don’t feel like it. And it’s hard for me to think about doing something I don’t feel like doing.”

Then I said, “You told me a number of times that you don’t want to be weak like your mother, that you don’t want to just go along with something because you feel you have to. You want to be strong and take a stand. In some ways,” I continued, “I think you’ve made a point of standing your ground with Justin because it makes you feel like you’re saying no to something you haven’t wanted to do. Standing your ground is a good thing. But I find it curious that you’ve been saying no to the man who worships the ground you walk on and who you loves you endlessly, rather than saying no to the man who deserves it—your stepfather.”

Marie looked puzzled.

“You see,” I explained, “you could say no to your stepfather by not allowing him to have a hold on your life anymore, by freeing yourself from the emotional shackles you’ve been weighed down by all these years. Don’t allow him to jeopardize the loving marriage you have with Justin.” And then I told her Sally’s story.

At the end of the story, Marie said in a quiet tone, “But Michele, Sally was a grown woman at the time. She could make that decision. I was just a child.”

“You’re right,” I replied. “You made the only decision you could’ve made at the time. You were a kid. You were dependent on your parents. You trusted the adults in your life. That was terrible. But you’re not a kid anymore and you can make a different decision now.”

For the first time in the session, her eyes filled with tears. “You’re right,” she whispered.

Then we got down to business. “What’s the smallest change Marie could make that would make a difference to you?” I asked Justin.

Marie spoke first. “I have lots of ideas,” she said. “I could go to bed at the same time he does. I could sleep naked for the first time in years. We could cuddle several times a week in bed. We could kiss. She also suggested watching television, reading together, and snuggling. Marie offered to initiate all these actions. She wanted Justin to feel wanted.

Justin still had his sights on intercourse and other, more sexual behaviors, but saw this as a great first step. He agreed to approach his goal to be more sexually active in stages. Marie was relieved about that and understood the importance of being committed to continued progress.

Then, as I would with any other couple wanting to improve their sexual relationship, we began talking about the real nitty gritty, the nuts and bolts of what turns each of them on. Since it had been so long since they were physical, they had to stretch a bit to remember. They also said that they’d never had an open conversation about sex before. Although Marie had experienced orgasms in the past, they were somewhat erratic. She was uncomfortable coaching Justin to “get it right,” but he told her that he really wants to hear what feels good to her. So they both agreed to institute a regular time to talk openly and honestly about their reactions to the touching they were about to experience.

Toward the end of our time together, Justin expressed his fear that Marie’s willingness to become more physical wasn’t going to last. And what happened next was the perfect ending for our two days together: Marie expressed deep sorrow for having put Justin’s feelings aside for so long and promised that this would be a real turning point in their marriage. She even talked about looking forward to the time when she would be ready to make love again. She promised him things would be different. They hugged.

Within five days of them leaving my office, I received two emails from Marie letting me know that things were on track. The last one included a selfie of the two of them, grinning from ear to ear.

It’s been six months since I met with Marie and Justin, and I’ve done numerous follow-up telephone calls with them. They continue to be increasingly physically affectionate and have had sex three times.

Marie has been surprised and relieved to find that touching has been pleasant. She’s feeling good about pushing herself through her fears and about the positive ripple effect in her relationship. Justin is pleased, but also eager to find ways to become increasingly sexual.

I know that my work with Marie and Justin isn’t over. But I also know that my belief in Marie’s ability to change made it easier for her to believe in herself. As a rookie therapist, I’m not sure I would’ve had the courage to push her the way I did. In fact, even as a veteran therapist, I must admit that I was ambivalent about challenging her. But when I thought about the urgency of their situation and the fact that the laser focus on her past never really helped much, I decided to trust my instincts that she could handle it.

I’m just grateful that Sally was in the room with me that day. But truth be told, she’s never too far away.

Case Commentary

By Mary Jo Barrett

Weiner-Davis begins by telling us the story of Sally, a survivor of a violent rape, who was able to do for herself exactly what good treatment for PTSD tries to accomplish. Apparently unencumbered by a history of developmental trauma, Sally went beyond the normal fight/flight/freeze response after her terrifying ordeal, and mobilized her resources to move on with her life. Using Sally’s experience as a kind of inspiration, Weiner-Davis weaves empathy and challenge into her work with Marie and Justin to help them make meaning of their difficulties, focus their resources, and integrate their trauma story in a way that helps quickly shift some of the rigid, long-term patterns in their relationship.

Creating a therapeutic relationship in which clients feel enough comfort and safety to be as effectively challenged as they are by Weiner-Davis in this case often takes a great deal of time, skill, and patience. Here, Weiner-Davis makes it appear almost effortless. Without minimizing her clinical skill and savvy, I’d point out a possible factor in this case, one that’s often overlooked in discussing the work of well-known clinicians like Weiner-Davis, the author of many popular books, a TED Talk speaker, and a frequent guest on Oprah and other TV talk shows. The factor is this: a highly regarded clinician’s reputation can give therapy a head start and enhance the possibility of making a quick emotional connection and achieving a positive outcome.

As Weiner-Davis describes it, “Once I sensed that Marie felt comfortable with me, I leveled with her,” determining early on that Marie’s previous therapist hadn’t done enough to challenge her. But a therapist without Weiner-Davis’s credentials might well have had a much more difficult time creating that context of comfort.

As someone who’s written about trauma for three decades and has had some measure of media exposure, I recognize that clients often come to me more ready to attach than they would with a therapist with less public presence. Clients’ readiness to trust me and give me the benefit of the doubt isn’t necessarily because they know I’m such a terrific clinician. They come to me with the expectation that since I’ve written books and have credibility in the professional community, even if I challenge them and make them a bit uncomfortable, I know what I’m doing and the outcome will be positive.

In this age of the Internet, my assumption is that Marie and Justin were well aware of Weiner-Davis’s reputation as a popular author and a “divorce buster” before they set out to work with her, and that her reputation was a factor in their trust and lack of reluctance to her challenging approach with them. This isn’t to say that her reputation was the only factor; she clearly knows a lot about the principles of effective trauma treatment and her skills as a clinician are masterful. Yet before we feel inadequate reading about such an efficient case, we need to bear in mind the crucial importance of client expectations in determining success in psychotherapy.

Author Response

I appreciate Mary Jo Barrett’s thoughtful case commentary. In truth, I can’t say I disagree with her premise that my reputation may play a key role in increasing clients’ receptiveness to my suggestions and their expectations about change.

In the last few years, I’ve become particularly interested in the power of the placebo effect in medicine and therapy—the ways in which healthcare providers can intentionally increase people’s beliefs that change is inevitable. In fact, countless patients have freed themselves of life-threatening illnesses when they’ve collaborated with doctors who’ve instilled positive expectations about outcomes. Conversely, there’s something called the nocebo effect, which refers to negative beliefs or expectations that make negative outcomes likelier.

I’m convinced that when clients seek our help, they’re often desperate for answers to questions like “How bad off am I?” or “How long will this last?” or “Will I ever be ok?” or “What are my chances for improvement?” And then, depending on our responses, their beliefs about the possibility for change become more deeply entrenched. We have great influence over the level of hope our clients have when they walk out our doors.

This ability to influence is inherent in our jobs as therapists. Clients believe we have answers, or they wouldn’t come to us, nor would they pay us. Although I wholeheartedly agree that bestselling books and Oprah appearances don’t hurt one’s credibility, I’m convinced that every person reading this article has the leverage either to help clients discover and capitalize on internal resources, or unintentionally to induce self-doubt. Making sure they’re doing the former is a therapeutic skill, and it can be learned. It’s not magic.