Nancy is beginning to deepen into her story, a frightening and all-too-common rendition of what it's like to live with an alcoholic husband. She cries a little as she relates the details—the shouting matches, the contrite explanations, the fear of telling others about it. Her face is contorted with despair and shock, her voice quavers. When her hand goes to her throat, I feel my heart break a little.
Later, hours after Nancy is gone, I become aware of a tension headache at the base of my skull. As I sit quietly with it, images of this session arise. I realize as I sit there with my pounding head how swept up I'd been by Nancy's hopelessness and fear. I visualize myself listening with my head jutted forward, unsupported by my body. I experiment with this position and, sure enough, when I stick my head out, the headache gets worse. I suspect that I've been unconsciously craning my head forward to hang on to her every word. I've taken on her pain in a very real, very physical way.
We've all experienced what happens when get tied up in our clients' knotted lives. But how do we attune to our clients' experiences and not get knotted up ourselves? Good supervision always helps, and it's a relief to untie some of our own twisted history while we do it. Through supervision, we can discover the common threads between our historical material and that of our clients. It helps us avoid unwittingly weaving our stories into theirs.
But what about my headache? Research has shown that part of what happens in empathy is that we, literally, take on something of what another feels, down to the racing heart, the tight shoulders, and the sinking chest. The key word here is something. If we feel too much of what our clients feel, it can be as if we're imprisoning our bodies in their scenarios.
For therapists then, self-care becomes more than just taking enough time off, balancing our practice, and getting good supervision. It involves getting our bodies back.
One method I use to get my body back is to stretch between sessions, eat and drink a bit, and breathe deeply for a minute or so. I call this freestanding self-care—anything that I do to relieve, renew, or recover outside of the therapeutic encounter. Freestanding self-care extends deeply into our lives through short-term, middle-term, and long-term activities. Short-term examples include my breathing consciously and drinking enough. They happen around the edges of our workday. Middle-term self-care might be yoga classes, long walks with the dog, and regular massage. Long-term self-care could be a restful and playful vacation each August, along with daily meditation. All these behaviors enable us to practice what we preach, keep our bodies from accumulating stress, and model a balanced life for our clients.
But perhaps a more important way to care for myself is to make sure that I don't give away too much of my body in the first place. I call this embedded self-care—actions taken right in a session that keep me grounded within myself, both in the midst of my clients' intense emotions (whether overtly expressed or not) and within my reactions to them. And the key to this form of self-care is how and where I pay attention.
Attention is the currency of therapy—essentially, it's what the client pays for. High-quality, nonjudgmental attention can be a balm directly applied to a client's wounds, which soothes immediately and heals over time. The Zen Buddhist monk Thich Nhat Hanh once said that attention is like water and sunlight for a plant. What we pay attention to grows, and what we don't pay attention to withers. Through this lens, suffering arises from attention being paid to the wrong elements in ourselves, such as shame and self-denigration, and attention being withheld from that which needs to be grown--self-respect and self-reflection.
Attention is both conscious and unconscious, a fact we don't often appreciate. We pay attention to many things in any one moment, filtering out most of it so that only a small percentage reaches conscious awareness. Part of what happens when we fall into our clients' material is that our bodies are registering, processing, and responding to the client beneath our overt, conscious tracking. Giving clients our undivided attention can undermine our ability to help them and exhaust us in the process. We must learn to use our attention effectively on behalf of our clients and our own self-care.
As a graduate-school trainer of counselors, I teach my students via classroom exercises that, to be effective, attention needs to oscillate between several modalities. First, we alternate paying attention to our inside landscape (sensations, emotions, thoughts), then to the outside environment. When we practice purposely getting off-balance by letting one mode fixate, the students have a direct experience of feeling more narcissistic (attention stuck inside) or more codependent (attention stuck outside).
The next oscillation of attention is panoramic-to-narrow. The students and I look at small details in a practice client (perhaps that finger tap on the thigh) and alternate that with looking at the whole field of experience—the client's whole body and even the room itself. When we practice getting locked into narrow focus, obsession starts to brew. If we try locking into wide panorama, where no foreground or background exists, attention deficit can start to feel very real.
The last oscillation has to do with the effort we put into the act of attending. I have my students notice that, at times, our attention is free flowing—we just relax and allow attention to wander of its own accord. In a session, this form of attention can help students pick up aspects of the client they'd otherwise miss. Alternately, we need to control our attention at times, willing it in a certain direction. I tell my students that attention is like a muscle they need to exercise constantly. Controlled attention will help them overcome biases they may have internalized—like paying attention to certain emotions and not others, for instance. Controlled attention will also help them pull out of dysfunctional patterns, like my fixated attention on my client with the alcoholic husband.
Oscillation of attention is the primary way we keep our bodies safe and whole, or get them back when we've given them away. It also enables us to tolerate and even work with intense feeling states in our clients. If I can stay grounded in myself, my sense of safety and self-possession can be an anchor that helps clients to feel supported when exploring high emotional seas.
Using oscillating attention, that first scenario with my client could have gone like this: Nancy begins to cry as she describes her husband's drinking, and as she does so, my head cranes forward as I listen intently. In a few moments, I oscillate in and realize my neck is straining too much and that I'm overly absorbed—I'm not feeling empathy, but feeling exactly the same feelings she's feeling. I take a breath and bring my head back, taking a moment to consciously relax my neck. As I get my body back, I retrieve my own sense of self. Now I can attend to Nancy again in a more helpful manner. As she brings her hand to her throat, I ask her to pay attention to that action, seeing if there's something her hand may be wanting to say to her throat. She begins to stroke her throat softly, and says "Yes, my hand is saying it'll be all right if you talk about this. You'll be okay."
"Yes," I say in reply, "Exactly."
This blog is excerpted from "Caring for the Caregiver," by Christine Caldwell. The full version is available in the July/August 2004 issue, The Body in Psychotherapy: How Far Do We Want to Go?
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Tags: body | body and mind | caregiver | Challenging Cases & Treatment Populations | challenging clients | Countertransference | mind body | Mindfulness | relaxation techniques | self-care | stress | stress anxiety | stress reduction | Transference | transference and countertransference