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Sunday, December 10, 2017

Using Imagery as a Powerful Tool in Trauma Therapy

In prior articles, I discussed how developing internal and external resources are helpful in processing psychological trauma (see my articles: Developing Internal Resources and Coping SkillsCoping Strategies in Mind-Body PsychotherapyThe Therapeutic Benefits of Integrative PsychotherapyUsing Your Imagination as a Powerful Tool For Change, and Understanding Your Shifting Self States).   One of the many resources that I use when doing trauma therapy is imagery, which is the subject of this article.

Using Imagery as a Powerful Tool in Trauma Therapy

As an integrative psychotherapist, I often combine various treatment modalities when it's beneficial to  the individual client.

The key to being able to combine treatment modalities in an integrative psychotherapy is to have a good foundation in a particular type of psychotherapy and professional training in the other modalities.

As I've mentioned in other articles, my original postgraduate training is in psychoanalysis and psychodynamic psychotherapy, and I work in a contemporary, dynamic and interactive way.

After using psychoanalysis and psychodynamic psychotherapy for several years, I could see that it had certain limitations--just as all therapy modalities do.

Although my personal experience in psychoanalysis was very effective in helping me to resolve traumatic experiences, that was nearly 20 years ago, times have changed and most clients don't want to come to therapy for multiple sessions per week for several years as I did.

Once a week psychoanalysis/psychodynamic psychotherapy, which is now the norm, lacks the same intensity as multiple sessions per week.  As a result, the transference/countertransference issues are not as intense, and generally it takes longer in once a week sessions to resolve trauma.

This is what prompted me to study EMDR Therapy, clinical hypnosis and Somatic Experiencing.

For many clients, who don't want to wait years for relief from their traumatic symptoms, these therapy modalities work faster than psychoanalysis/psychodynamic therapy in helping clients to overcome trauma.

This doesn't mean that I don't use my psychodynamic understanding while working with a client.  I still listen and pay attention for the client's unconscious process and transference/countertransference issues as I integrate other forms of therapy.

Before I go into how I use imagery, I want to clarify that the client doesn't need to be good at visualizing to use imagery.

Many clients, who say they can't visualize, are able to get a "felt sense" of images and this is just as useful in therapy.  Other clients who have difficulty visualizing have other senses that work, including an intuitive sense of the image, which can be very powerful.

Using Imagery as a Powerful Tool in Trauma Therapy
Imagery is a powerful resource in psychotherapy, especially when working with psychological trauma.

Imagery comes alive when the therapist helps the client to amplify and enhance the imagery.

The following fictional vignette demonstrates how imagery helps to process trauma:

Nick started therapy because he was having a difficult time asserting himself in his marriage and in his work-related relationships.

Using Imagery as a Powerful Tool in Trauma Therapy

He told his therapist that ever since he was a child, he lacked confidence in himself and this lack of confidence had a profound effect on his life.

In his personal relationships, before he got married, Nick had a hard time asserting himself when he was attracted to a woman.  Throughout college, he had difficulty feeling confident enough to ask women out on a date.  Most of the time, he would go out with women who asked him out.

In his senior year, he met a woman, Jenna, that he really liked. He lacked the self confidence to ask her out, but he soon discovered that she was interested in him when Jenna asked him to go out for dinner.

Jenna was the one who initiated sex and, 10 years later in their marriage, she was still the one who initiated sex and all their activities, including social activities and vacations.  This was causing problems in their relationship because Jenna complained that she was tired of always being the one to take charge.  She wanted him to take charge sometimes.

Nick understood why Jenna was unhappy with his lack of assertiveness, but he didn't know how to change.

Nick was also having problems advancing in his career.  Other people that he trained and who knew less than Nick, were getting promoted into more senior positions because they knew how to advance their ideas and themselves with their superiors.

When Nick discussed his family history with his therapist, he described a neglectful and critical parents.  He was the younger of two sons, and his parents tended to dote on their older son and to ignore or criticize Nick.

They often compared Nick unfavorably to his older brother, John, and generally discouraged Nick.

Over time, Nick felt that he had nothing of value to offer, and he tended to remain quiet while his older brother got all the praise.

He often felt as a child that he was "a mistake" and that his parents didn't really want to have another child.  This was confirmed by his mother in a tactless admission on her part when Nick turned 21 and left home.

Until he began therapy, Nick never associated this critical, neglectful parent with his lack of confidence and assertiveness.  He also never realized that he had been traumatized by these early experiences.

As he discussed this with his therapist, he said this made sense to him, but he asked, "Now that I know this, how can I change it?"

Based on her experience as a trauma therapist, his therapist told Nick that, although his awareness was an important step, it was only the first step.  She recommended that they revisit his memories using imagery as a tool in trauma therapy.

One of Nick's touchstone memories was of his father telling Nick to "Be quiet" when he wanted to tell his family about an award he received at school for a science project.

Not only did his father tell Nick to "Be quiet," he also told him that "No one's interested in hearing about your award." Then his father turned to Nick's older brother, John, and asked him how his day went at school, and both his father and mother listened to John with admiration.

As a result of many similar experiences with his parents, Nick felt "I'm not important" and "I'm powerless."  These feelings remained with him as an adult.

Nick's therapist recommended that they use imagery to go back to that touchstone memory to see how Nick's experience of himself might change if he could imagine himself having a powerful ally in that situation.

At first, Nick couldn't think of anyone to be an ally to rework this memory.  Then, he remembered his science teacher, who recommended Nick for the award and who often complimented him on his work.

His therapist asked Nick to go back into the touchstone memory and to imagine what his science teacher might have said if he had been with Nick when his father told Nick to be quiet.  She asked Nick to describe the scene in the present tense.  She also helped Nick to amplify the imagery so he could experience it more vividly.

Nick closed his eyes and imagined himself back at home with his family.  He also imagined that he invited his science teacher, Mr. Ross, to dinner that night and Mr. Ross was sitting next to Nick when Nick brought up his science award, "Mr. Ross is there sitting next to me.  When he hears my father tell me to be quiet, he interrupts my father and says, 'Now wait a minute--this is a very important award at the school and Nick's science project was by far the best project the school has seen in years.  I can't sit here and allow you to be dismissive of Nick and this wonderful honor.  Nick deserves much better than this.  I don't have children but, boy, if I had a son like Nick, I would never tell him to be quiet.'"

Nick's therapist could see that Nick's demeanor changed as he imagined Mr. Ross standing up for him.  His chin was raised, his posture was more erect and he had a smile on his face.

Then he explains to his therapist, "Both of my parents have always had a lot of respect for teachers, and they liked Mr. Ross so they would listen to him.

Then Nick goes back into his memory, "So, when they hear Mr. Ross say this, both of my parents look embarrassed and they look at me in a different way.  Then, my father says, 'I'm sorry for interrupting you, son.  Tell us more about your award."

Nick's therapist helped Nick to amplify the shift he was experiencing and to anchor that new feeling in his body.

Nick and his psychotherapist did many similar exercises in therapy using imagery for other traumatic touchstone memories.

Using Imagery as a Powerful Tool in Trauma Therapy

Gradually, Nick was able to internalize the feeling that he is a worthwhile and lovable person.  Over time, as he gained more confidence in himself.

To his wife's delight, he took more of an initiative in terms of their sex life and social activities together.

With regard to his career, Nick and his therapist used imagery to rehearse scenes with his manager where Nick would be more assertive in advancing his ideas.  This allowed Nick to present himself and his ideas with increased confidence, which resulted in praise and promotion with a substantial pay increase.

Every client is unique and their needs in therapy are different, which is why it's helpful for therapists to have a number of different modalities to use to help clients to overcome their problems.

Imagery can be a powerful tool in trauma therapy.  It is one of many tools that trauma therapists can use to help clients to transform traumatic experiences.

When clients use imagery in therapy to imagine the help of powerful figures, such as mentors, wise people, nurturing people or whatever type of figure would be helpful, this can help to create new neural networks in the brain that facilitate change.

Using imagery can help clients to see themselves in a different way and allows them to transform their unresolved trauma.

Getting Help in Therapy
If you have unresolved traumatic experiences, rather than continuing to suffer on your own, you could benefit from working with a trauma therapist (see my article: The Benefits of Psychotherapy).

Once you're free of your trauma, you will have a greater sense of well-being and lead a more fulfilling life (see my article: How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individual adults and couples.

I work in an integrative way depending upon the needs of each client.

One of my specialties is helping clients to overcome trauma, and I use many creative therapeutic tools, including imagery.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.

See My Other Articles About Psychological Trauma.

Thursday, December 7, 2017

How Your Shifting Self States Can Affect You For Better or Worse

I have discussed self states in prior articles (see my articles: Understanding the Different Aspects of Yourself That Make You Who You AreParts Work in Therapy: Is a Split Off Part of Yourself Running Your Life?Learning to Nurture Your Inner Child, and Experiencing Your Future Self: The Self You Want to Become.  In this article, I'm focusing on how your self states shift in various ways and how you can use these shifting self states to feel more confident and resilient.

How Shifting Self States Can Affect You For Better or Worse

What Are Shifting Self States?
As I discussed in a prior article, even though people tend to think of themselves as unitary beings, in fact, everyone has a multiplicity of selves or self states.

Self states are on a continuum.  For the purposes of this article, when I refer to self states, I'm not referring to multiple personality disorder or dissociative identity disorder, which is a diagnosis on the far end of the spectrum of self states.  I'm referring to everyone's common experience of different aspects of themselves.

The reason why people aren't usually conscious of these self states is because a particular self state usually predominates at any given time and the other self states tend to recede.

So, the self states tend to shift in a barely perceptible way, and this is a common phenomenon for everyone.

An Example of a Shifting Self State
Andy was feeling confident in himself as he approached the theatre where he was about to audition.  He had practiced his lines with his acting coach, and he really felt he understood the role and how to approach it.  His acting coach told him that this part was made for Andy, and he encouraged Andy to go to the audition.

How Shifting Self States Can Affect You For Better or Worse
But just before he went on stage to recite the lines from the play, Andy remembered the first time that his mother came to see him in a play and how critical she was afterwards.  She told him that his performance was the worst thing she had ever seen and she advised him against an acting career.

Whereas Andy had been walking with his head up, chest out, and whistling a tune before he got to the theatre, when he remembered what his mother said, his demeanor changed to reflect the shift in his self state:  He looked down at the ground, his posture was slightly hunched and all he could think about was that he wasn't going to pass the audition.

Discussion About the Example of a Shifting Self State
In the fictional example above, Andy was feeling confident in himself initially.  He received positive feedback from his acting coach and he felt and projected his confidence.  At that point, Andy was in a particular self state where he felt sure of himself.

But when he thought about the negative comments that his mother made to him, his self state shifted without Andy realizing it.  He no longer felt confident and this was reflected in his inner sense of self as well as in his body language and outer presentation.  This switch in self states was unconscious--it happened outside of Andy's awareness.

How to Use Shifting Self States to Enhance Your Sense of Self
As a trauma therapist, I assist clients with internal and external resourcing as part of the preparation for doing trauma work.

One way to do internal resourcing, which I often use, is called imaginal interweaves as developed by Laurel Parnell, Ph.D. (see my article: Developing a More Resilient Self in Therapy).

Imaginal interweaves are a tool to help clients to feel confident, lovable and other positive aspects by imagining powerful, nurturing and wise figures.  These figures can be people that clients know or they can be from books, movies, TV programs or other fictional characters.  They can also be superheroes if this feels meaningful to the client.

The kind of imaginal interweaves that clients choose depend upon the negative beliefs that they have about themselves.  For example, if they have a particular self state that predominates that makes them feel they're "unlovable," they will choose imaginal interweaves that will help them to feel the opposite--that they're lovable (see my article: Overcoming the Emotional Pain of Feeling Unlovable).

If I'm using EMDR Therapy, I would use this particular modality's bilateral stimulation (eye movements or tapping) to reinforce these imaginal interweaves so that they are amplified for the client (i.e., the client can feel these interweaves as self states within themselves).

Another therapeutic resourcing tool I use before processing psychological trauma is asking clients to remember times when they felt confident (as in the fictional example above where Andy remembered his experience with his acting coach).

Usually, I recommend that clients bring in at least 10 or so positive memories when they felt good about themselves and I use bilateral stimulation to reinforce these self states.

Then, when we're processing the traumatic experience, if the client needs these internal resources because s/he is having difficulty in the processing, we can call upon these imaginal interweaves or positive memories to help the client to shift self states so we can resume processing.

For the person who isn't in therapy, s/he can also become aware of shifting self states.  Admittedly, this isn't easy because the shifts usually happen so imperceptibly.  It will take some time and effort to recall experiences where it happened in the past (as in the fictional example above) and making an effort to recognize it when it occurs in the present.

How Your Shifting Self States Can Affect You For Better or Worse

In his book, Awakening the Dreamer, Philip Bromberg gives an examples of shifting self states. According to Bromberg, researchers did a study using the game "Trivial Pursuit" where they told one group to imagine themselves as professors, and they told the other group to imagine themselves as "soccer hooligans" (the term used in the book) before they answered questions from "Trivial Pursuit."  The group that imagined themselves as professors did far better than the group that imagined themselves as "soccer hooligans."

The participants who imagined themselves to be professors and took on that self state are similar to my fictional example of Andy who initially was confident when his self state was connected to the memory of the encouragement he received from his acting coach.  This self state was reflected in his confident internal sense of self as well as in his overall demeanor.  Similar to the group who thought of themselves as professors, this was Andy's confident self state in that moment.

As I mentioned earlier, this is only the preparation stage of working through trauma in psychotherapy, but it is a powerful part of the work that can help to overcome obstacles when the trauma is being processed in therapy.

Unfortunately, most people tend to unconsciously concentrate on negative images and memories of themselves which shifts them into a negative self state.  But, with practice, you can also learn to focus on positive images and memories.

Self states are usually unconscious and difficult to perceive in the moment.  They're easier to detect retrospectively.

Shifting self states are even more difficult to detect.  However, once you become aware that everyone has shifting self states, you can begin to focus on become sensitized to the particular self state that you're in and how your self states switch.

When you become aware of the shifting self states and realize that you can use your imagination with positive memories from your life or imaginal figures, you can try to switch your self state.

Getting Help in Therapy
There are people who have experienced serious traumatic events in their lives where it has become too difficult to overcome a predominant negative self state.

When this occurs, this is not about a "weakness" or any other type of deficit.  It just means that the traumatic experiences were so overwhelming that they dominate the individual's life and they need to be processed in therapy.

If you are struggling with unresolved trauma, rather than struggling on your own, you could benefit from working with a trauma-informed psychotherapist who can help you to overcome the trauma (see my article: How to Choose a Psychotherapist).

Working through unresolved trauma can free you from your traumatic history so you can lead a more fulfilling life.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individual adults and couples.  

I tend to integrate various forms of therapy depending upon the particular needs of each client (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I have helped many clients to overcome psychological trauma.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.

Tuesday, December 5, 2017

Developmental Trauma: "This is Who I Am" vs "This is What I Do"

Developmental trauma occurs over time starting in childhood (as compared to shock trauma, which is usually an event).  Developmental trauma can occur when young children learn who they are from their parents, who might value certain aspects of the child and not others.  According to Philip Bromberg in his book, Awakening the Dreamer: Clinical Journeys, the aspects of the child that are not validated by the parents, become dissociated "not me" parts of the self and the parts that are valued become, "This is who I am."

Developmental Trauma: "This is Who I Am" vs "This is What I Do"

According to Bromberg, one of the reasons that developmental trauma is significant is that it shapes the child's core self through the attachment patterns that the child develops with the primary caregiver.

In order for the child to maintain a sense of core self as s/he matures, s/he has to preserve the early attachment patterns with the primary caregiver, which includes the aspects of self that were validated to the exclusion of the aspects that weren't.  This pattern continues as the child becomes an adult and  forms new relationships with significant others later in life.

When adults, who have a history of developmental trauma, come to therapy, they often have no awareness of the aspects of themselves that are dissociated due to the early invalidation in their attachment pattern with the primary caregiver.

When they were children, not only did they have to do what the primary caregiver needed them to do, they also had to be who the caregiver needed them to be with regard to the aspects that the caregiver validated.

To help these individuals to become more self reflective and aware that they're continuing to be who their primary caretaker needed them to be and that aspects of themselves have been sacrificed, the therapist helps these clients to see themselves within the enactments in therapy (for more about enactments, see my articles: Mutual Enactments Between the Psychotherapist and the Client in Psychotherapy and Why Your Psychotherapist Can't Be Your Best Friend).

With the increased awareness that develops in psychotherapy, these clients can learn to distinguish "This is who I am" from "This is what I do."

Being able to make this distinction is crucial for these clients to be able to make the changes in themselves that they're hoping to make.

The following fictional clinical vignette illustrates these concepts:

Fictional Vignette:  Developmental Trauma: "This is Who I Am" vs "This is What I Do:"

Ted came to therapy because he was having problems in his relationship with his wife.

Initially, Ted told his therapist that his issues as communication problems with his wife.  He said they frequently argued about money, and his wife saw him as a tightwad.  Although he acknowledged that he could be overly thrifty at times and he wanted to salvage his marriage, he saw his thriftiness as, "This is who I am" and he saw no way to change it.

Developmental Trauma: "This is Who I Am" vs "This is What I Do"
It became apparent, as the therapist listened to his early history, that Ted's mother was also thrifty and she encouraged Ted to do everything he could to save his money.  He told the therapist that his mother praised him for being parsimonious and told him, "You're just like me," which pleased Ted very much as a child.

He also told his therapist a story about how he bought flowers for his third grade teacher with birthday money that he saved.  He loved his teacher and he was thrilled to see how happy she was when he gave her the flowers.

But when he got home and told his mother about it, she scolded him for "wasting" his money.  She told him, "Saving your money is important."

Ted told many similar childhood stories where he was initially elated to give a gift to someone and then he felt ashamed when his mother scolded him and refused to talk to him for the rest of the day when she found out that he used his money to give a gift to someone.

Ted learned early on that if he wanted to remain in his mother's good graces, he would have to conform to her way of thinking.

As an adult, Ted felt he learned a valuable lesson from his mother when he was a child.  But now his wife was complaining because he had such a hard time spending money even when it came to giving birthday gifts to his wife.

Although Ted understood somewhat why his wife was upset, he told his therapist, "My wife wants to change me, but she just doesn't understand that this is who I am."

He was concerned because his wife's birthday was coming up and he was sure that she wanted a gift from him.  He wanted to "keep the peace," so he planned to get her a gift, but he felt he was going against a basic part of himself in order to do it.

His therapist suggested that Ted buy his wife a gift and they could talk about how he felt afterwards.

A week after Ted gave his wife the gift, he came to his therapy session looking upset.  He told his therapist that, even though it was against his basic sense of self, he bought his wife something that she had been hinting about, a makeup mirror in the shape of a shell.  She was so happy that she threw her arms around Ted and kissed him, but Ted felt miserable for going against his sense of self.

Ted's therapist explored Ted's feelings about giving his wife this gift that she really wanted, and Ted told his therapist that he felt he disappointed his mother--even though his mother had been dead for more than 10 years, "My mother would have been angry with me if she was still alive and, even though she's been gone for several years, I feel like I let her down."

Ted's therapist tried to help Ted to remember how he felt as a child when he gave his teacher the flowers and he saw how happy she was.  Ted remembered that he felt happy, but he couldn't separate out this part of the memory from how unhappy his mother was afterwards.

He recalled other childhood memories when he wanted a certain toy or picture book, and his mother discouraged him from having them.  She told him that it would be a waste of money.  After a while, Ted stopped allowing himself from even wanting these things.

Looking back on those memories, Ted knew that his family was upper middle class, so his mother could well afford to buy him these things, so he wondered why his mother discouraged him from wanting toys or books, "At first, it made me feel sad, but then I learned to do without them and not want them any more."

His therapist noted to herself that this was the first time that Ted reflected on his mother's dynamics and how it affected him.

Gradually, over time, Ted became more self reflective and he began to make the distinction between who he is as a person and his behavior.  He realized that, when he was a child, he was too afraid to go against his mother's wishes because she would ignore him when she was displeased.

Resolving Developmental Trauma in Therapy: "This is What I Do and I Can Change."
More importantly, Ted realized in therapy that he was still trying to hold onto his mother's love by behaving the way she wanted him to behave.  It was his way of holding onto her even though she was gone.

As his therapy progressed, Ted realized that he no longer had to behave in a way that would honor the memory of his mother.  And, as he came to terms with this, other aspects of himself that were invalidated by his mother, came alive.

Not only was he more generous with his wife, but he also allowed himself to want and have things again, which was liberating for him.

When aspects of children are invalidated by their primary caregiver, children learn to disavow these aspects.  This is part of developmental trauma.

On an unconscious level, children dissociate these aspects in order to maintain the attachment with the caregiver, which is essential to children's sense of well-being.

This disavowal comes at a great cost to children as they grow up unconsciously dissociating parts of themselves to maintain the attachment.

Children who learn to maintain only the aspects of themselves that are validated by their caregiver and disavow the aspects that are invalidated continue this pattern as adults and believe, "This is who I am."  This makes change difficult for them because they believe that their behavior is intrinsic to who they are.

Developing the necessary self awareness to realize that who they think they are is really not an intrinsic part of themselves and it's really their behavior is usually a gradual process in therapy.

Being able to separate out "who I am" from "what I do" can be a freeing experience because it allows the true self to emerge (see my article:  Becoming Your True Self).

Getting Help in Therapy
If you're having problems changing because you believe that your problematic behavior is part of who you are, you could benefit from seeking help from a licensed psychotherapist (see my article: The Benefits of Psychotherapy).

Self awareness is the first step in making changes

Developing the necessary awareness and insight into ingrained problems is often a gradual process, and a skilled mental health professional can help you in your journey (see my article: How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individual adults and couples (see my article: The Benefits of Integrative Psychotherapy).

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.

See my other articles about Psychotherapy.

Monday, December 4, 2017

Parallel Losses For the Psychotherapist and the Client

Loss and grief are an unfortunate part of life, and it's one of the reasons why many people come to therapy (see my articles: Who Are You After Your Parents Die?,  Grief: The Emotional Impact of Losing Both of Your Parents and Coping With Grief).  There are often times in psychotherapy when the psychotherapist and the client are going through parallel losses.  In fact, this phenomenon occurs more often than most people would think (see my article: The Psychotherapy Session: A Unique Intersubjective Experience).

Parallel Losses For the Psychotherapist and the Client
This parallel process between the psychotherapist and client often benefits the therapeutic work because, through her empathy, the therapist has more to give to the client because she is going through a similar process.

In order for this process to be healing for the client, the therapist must be trained and skilled at being able to experience the client's suffering while, at the same time, dipping into her own experience briefly without getting lost in her experience.  

The psychotherapist's focus must be mainly on the client and, while their experiences might be similar in some ways, the therapist can't assume that the client's experience is exactly the same as the therapist's experience.

From my own experience as a psychotherapist and from what colleagues have told me about their experiences, it's often the case that a client comes to therapy at the same time that a therapist is having a similar experience.

Depending upon the psychotherapist's theoretical orientation, the therapist probably won't share her loss with the client, especially if it will impinge on their work, because the therapy is focused on the client and not the therapist.

There might be times when it is therapeutic for the therapist to share a similar personal experience with the client, but only if it is in the service of furthering their work together.

Let's take a look at how this parallel process between therapist and client shows up in therapy in the following fictional vignette:

Fictional Vignette: Parallel Losses For the Psychotherapist and the Client

Lois began therapy because her mother, who had advanced Alzheimer's, was rapidly decompensating both physically and mentally.  

Parallel Losses For the Psychotherapist and the Client
Her mother began showing signs of dementia about 10 years before.

Until recently, the decline had been slow and her mother still knew Lois and Lois' siblings.  But a month prior to Lois starting therapy, her mother was becoming increasingly confused and no longer recognized Lois and other family members.

The doctor at the skilled nursing facility where Lois' mother lived told Lois and her siblings that her mother's condition was worsening, and they discussed the treatment plan, including advanced directives.

Lois and her mother were close, and it was excruciating for Lois to see her mother deteriorate over time.  Prior to the dementia, her mother had been very sharp and active, so it was especially difficult for Lois to watch the mother she knew slowly disappear.

She found support at an Alzheimer's support group, but she found her visits to see her mother increasingly difficult.

Knowing that her mother's life would soon be coming to an end, Lois knew that she would need more than her support group.  She needed the one-on-one support of a psychotherapist.

From the first therapy session, Lois felt understood and cared about by her therapist (see my article: The Creation of the "Holding Environment" in Therapy).

In addition to helping Lois cope with emotional pain of watching her mother decompensate due to Alzheimer's disease, the therapist also provided Lois with practical information. 

Lois felt fortunate that she found a psychotherapist who was so knowledgeable about loss, grief and the practical issues involved with having a family member who has dementia.

Little did Lois know that her psychotherapist also had a mother who was suffering with advanced Alzheimer's disease, and they were both going through a parallel process.

Lois' therapist wondered if it would be therapeutically beneficial for her to disclose to Lois that she was also going through a similar situation.  But she sensed, based on things that Lois told her, that Lois needed something different from her at this point in time--she needed to feel that her therapist was outside the world of Alzheimer's disease, nursing homes and hospitals.

As a result, her therapist decided that there would be no therapeutic benefit to disclosing her personal situation to Lois, so she kept it to herself.  She didn't want to impinge on Lois' experience.

Even though her therapist didn't disclose her personal situation to Lois, Lois felt that her therapist was present with her in a way that she had never felt before with her other therapists--as if her therapist really understood what Lois was going through--and this was healing for Lois.

Two months before Lois' mother died, her therapist called her to let her know that she would have to cancel their next two appointments because she had a loss in her family.  

When they resumed work together, Lois expressed her condolences to her therapist.  She didn't ask if the person who died was close to her therapist because she already felt overwhelmed by her own emotions.  Sensing that Lois didn't want to know, her therapist didn't divulge that her mother had just died from complications of Alzheimer's.

When Lois got the call from the nursing home that her mother died the night before, she was grief stricken.  All along she was grieving for the changes in her mother.  Somehow, she thought that, since she anticipated her mother's death.  She knew she would be upset, but she didn't think she would be so upset.

After their father died a few years earlier, Lois' siblings looked to her for advice because she was the oldest, and now it was no different with their mother's death.  They looked to her for guidance and emotional support, so Lois was glad to have her weekly therapy sessions so she could get her own emotional support from her therapist.

Lois resumed her therapy sessions a week after her mother died, and she was relieved to feel enveloped in the caring and empathetic environment that her therapist created for her (see my articles: Why is Empathy Important in Psychotherapy? and The Psychotherapist's Empathic Attunement to Unconscious Communication in the Therapy Session).  

Parallel Losses For the Psychotherapist and the Client

She could feel her therapist's attunement to her, and there were times in her sessions when she felt she didn't even need to talk.  It was enough to be there and feel her therapist's empathy.  

Aside from her advanced clinical training and experience, her therapist also had her own therapy that she relied on for her support through the grief process.  

Her therapist had many years of experience helping clients to cope with grief.  As she listened to Lois talk about her feelings, she recognized the parallel experiences between them.  She sensed the similarities as well as the differences in their relationships with their mothers and their experiences of grief.

Just as Lois found these therapy sessions to be healing, her therapist also had an internal experience of how healing these sessions were for herself.

It's not unusual for a psychotherapist and client who are working together in therapy to be having a parallel experience--whether it's about loss, happy experiences, personal relationships or any other experiences.

Most of the time, if the psychotherapist is skilled, experienced and can contain her own experiences with appropriate boundaries, the client can benefit from going through this parallel experience with the therapist--whether the client knows about the parallel experience or not.

There are times when even the most skilled psychotherapists must be aware of their own limitations and not take on certain clients because they are aware that they have a particular emotional vulnerability to whatever the client is going through and the therapy wouldn't be beneficial for the client.  Usually these instances are more the exception than the rule.

The therapist usually makes a decision on a case-by-case basis, depending upon the client's needs and the therapist's comfort level with disclosure, whether or not to disclose her own experience.  For instance, in substance abuse treatment, therapists often reveal their own history with substance abuse because this is an accepted practice in substance abuse treatment.

Psychotherapists' disclosure is a topic where there are many different views.  While the therapist is expected to be genuine and no longer expected to be a "blank screen" with her client, the decision to disclose personal information or not must be viewed in light of whether it would be of therapeutic benefit to the client and not solely for the therapist's benefit.

Getting Help in Therapy
Whether or not to start therapy can be a challenging decision (see my articles: Starting Psychotherapy: It's Not Unusual to Feel Anxious or Ambivalent and Psychotherapy and Beginner's Mind).

Finding a licensed mental health professional who is right for you is a process (see my articles: How to Choose a Psychotherapist).

When you and your psychotherapist are a good match, you can benefit from your work together in ways that might exceed your expectations (see my article: The Benefits of Psychotherapy).

The healing process in therapy can lead to emotional breakthroughs and a more fulfilling life.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individual adults and couples (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.

See my other articles about Psychotherapy: My Articles About Psychotherapy.

Sunday, December 3, 2017

Mutual Enactments Between the Client and the Psychotherapist in Psychotherapy

In a prior article, Why Your Psychotherapist Can't Be Your Friend, I began a discussion about the roles of the psychotherapist and client in therapy, which included the concept of mutual enactments in therapy.  In this article, I will delve deeper into the concept of mutual enactments with a clinical vignette that illustrates these concepts.

Mutual Enactments Between the Client and the Psychotherapist in Psychotherapy

Before I go any further, I think it would be helpful to have a definition of "enactments" in the therapy setting.

Although there are various definitions for enactments, depending upon whether psychotherapists are Classical or contemporary Relational psychotherapists, I prefer the definition given by Fonya Lord Helm in a chapter, "Enactments Leading to Insight for Patient, Therapist and Supervisor" in Enactment: Toward a New Approach to the Therapeutic Relationship edited by Steven J. Ellman and Michael Moskowitz, which is:

"An enactment is any action occurring during the psychotherapy or psychoanalysis that repeats an earlier similar experience or fantasy and communicates nonverbal means in a way that will draw the therapist or analyst into a nonverbal communication" (p. 157).

In the past, the term "acting out" was used instead of "enactments," and this usually referred to the client's impulsive and improper behavior.  Although the emphasis was on the client's acting out behavior, it's also generally understood that psychotherapists can act out as well.

The term "acting out" is used less these days because of its pejorative connotation and also because the behavior is viewed from the psychotherapist's perspective in the type of hierarchical therapy where the therapist is seen as being "neutral" and "abstinent" as opposed to a more contemporary relational view of mutuality between therapist and client.

The contemporary view of enactments is that they are generally unconscious on the part of both the psychotherapist and the client.

In the past, enactments were seen solely as "mistakes" in therapy.  Now enactments are viewed most by therapists as an unavoidable part of therapy.

Whereas the ideal is to strive for no (or few) enactments, from a practical and therapeutic perspective, the reality is that there will be enactments, whether they are big or small and, once they occur, the therapist can discuss these enactments to further the work.

Although the focus in this article is on enactments between psychotherapists and clients, it's important to understand that enactments occur in everyday relationships, including romantic relationships, familial relationships, friendships and work relationships.

At this point, in addition to the vignette I provided in the last article, the following vignette will shed light on this dynamic between therapists and clients.

Fictional Vignette:  Mutual Enactments Between the Client and the Psychotherapist in Psychotherapy:

Liz, who was in her mid-30s, started therapy because she had longstanding problems in romantic relationships.

Although she had no problems meeting men, her problems began once the relationship became serious because she had difficulty trusting men in intimate relationships.

Her lack of trust in these relationships would manifest in her insecurity and jealousy with Liz imagining that her boyfriend at the time was cheating on her--even when she had no objective reason to think this.

When Liz began to feel jealous and insecure, she had difficulty separating her feelings from facts (see my articles:  Overcoming the Insecurity and Jealousy That's Ruining Your Relationship and Discovering That Your Feelings Aren't Facts).

Instead of observing and exploring her feelings with her boyfriend, she behaved as if her feelings were true and accused him of cheating.  She was so caught up in her emotions that she had no awareness that she was projecting her feelings onto the situation.  As far as she was concerned, when she felt her boyfriend was cheating, it must be true.

The pattern was that she would feel overwhelmed with jealousy and insecurity, accuse her boyfriend of cheating, he would be genuinely shocked and then he would try to defend himself against these accusations.

But no amount of denial or proof would dissuade Liz of her convictions that her boyfriend was unfaithful to her.

The more her boyfriend denied cheating and showed her proof, for instance, that he was with male friends at a basketball game, the more convinced Liz was that her boyfriend was lying.  And if her boyfriend refused to respond to her accusations, she also saw that as proof that he was guilty of infidelity.  So, there was no way to resolve this problem.

This is an example of an enactment in an intimate relationship.  It has many of the same qualities as enactments in therapy, which I'll discuss later.

As would be expected, this dynamic tended to erode the positive aspects of the relationship and would soon doom the relationship.  Her then-boyfriend would accuse her of being jealous and controlling, and she was convinced that he was trying to turn the tables on her when he was really the guilty one.

After each relationship was over, Liz had some insight into the fact that her accusations were irrational and she would have regrets.  But, by that time, the situation had gotten so bad that her ex-boyfriend no longer wanted to hear from her--let alone resume the relationship.

Every time Liz began to a new relationship, she vowed to herself that she wouldn't ruin it by making baseless accusations of infidelity.  But when she became jealous and insecure, the feelings were so powerful that she would lose all perspective.

These unconscious feelings overpowered her.   Once these feelings dominated her, she believed them to be true until she was out of the relationship.

When she discussed these dynamics with her therapist, she expressed sincere regret for the heartache that she caused in her boyfriends and herself and a strong desire to stop this behavior.

Mutual Enactments Between the Client and Psychotherapist in Psychotherapy

Her therapist sensed that Liz's regret as well as her sorrow for destroying her relationships. Her therapist was aware that, since this dynamic was unconscious at the time when it occurred, Liz was unable to control it.  She was also aware that Liz lacked the objectivity as well as the verbal skills to address this in her relationship when she was overwhelmed by these feelings.

Her therapist recognized Liz's behavior in her relationships as being enactments.  She also knew that there would probably be enactments in the therapy, and she would need to try to be aware of as they occurred.

Since Liz had been in therapy before, Liz knew that her family history, which was chaotic and dysfunctional, contributed to her inability to sustain romantic relationships.  But knowing this did nothing for her in terms of her enactments in her relationships (see my article: Intellectual Insight Isn't Enough to Change Problems).

From Liz's perspective, her prior experiences with therapy were disappointing.  The pattern was that the therapy would go well at the beginning, and then Liz would realize that she didn't trust the therapist.

Since she was unable to communicate her feelings of mistrust directly to her prior therapists in the past, she aborted therapy without discussing it, and she didn't respond to their outreach calls or letters (see my article: When a Client Leaves Therapy Prematurely).  These abrupt endings to her therapy were also enactments on her part.

After hearing about her previous history in therapy, Liz's therapist was aware that Liz might end this therapy abruptly too if she developed negative feelings towards her (also known as the negative transference).

Her therapist also wondered how much the prior therapists contributed to these enactments because of their own frustration and negative feelings about these dynamics.  She was aware that she would need to be vigilant about her own feelings about their therapy (known as countertransference) to minimize her own unconscious contribution to mutual enactments.

During the first few months, therapy went well.  Liz showed up on time for all her therapy appointments, she was compliant with paying her fee on time, she reflected on their sessions between sessions, and she discussed her reflections at subsequent sessions.

Her therapist enjoyed working with Liz and looked forward to their sessions.  Liz was intelligent and articulate about the issues they discussed, and she even kept a journal between sessions to write down her thoughts (see my articles: The Benefits of Journal Writing Between Therapy Sessions and Journal Writing Helps Relieve Stress and Anxiety).

But a month before her therapist was due to go on vacation for two weeks and she mentioned that she would be away, her therapist noticed an abrupt change in Liz's demeanor.  Whereas normally, Liz was relaxed in session, immediately after her therapist told her about the break, Liz looked tense and suspicious.

Her therapist mentioned her vacation in a month's time at the beginning of the session because she wanted to allow time for them to discuss any feelings that Liz might have about the break.

Her therapist could see from the abrupt change in Liz's demeanor that Liz had a negative reaction to the upcoming break, but Liz refused to talk about it when her therapist asked her about it.

From her silence and refusal to talk, her therapist was aware that she was witnessing an enactment on Liz's part, and she hoped not to get caught in a mutual enactment.

Based on Liz's history of relational problems, her therapist knew that Liz's reaction was probably unconscious on her part and Liz lacked the necessary insight and communication skills to talk about her feelings rather than enacting them in her sullen, uncommunicative behavior.  She knew it would be useless to explain this to Liz at the moment because Liz wasn't receptive to hearing an explanation.

Her therapist was aware that she was on the horns of a dilemma:  Liz was unconsciously trying to control her in the session by not talking and trying to make her feel guilty about leaving Liz (similar to how Liz tried to control her relationships with her former boyfriends).

Her therapist was also aware that, similar to Liz's dynamics with her former boyfriends, if the therapist attempted to encourage Liz to discuss her feelings, Liz would resent her and view her with increased suspicions.  But if she remained silent, Liz would feel that was too emotionally depriving and interpret that to mean that her therapist didn't care.

Ether way, her therapist would be engaging in a mutual enactment so she would have to decide quickly in the moment which course of action would be least disruptive to the therapy and might result in furthering the work.

Her therapist decided to share her dilemma with Liz, "I can see that you have feelings about the upcoming break in our therapy sessions.  I'd like us to be able to talk about that, but just now when I encouraged you to talk, you've remained silent.  I feel myself on the horns of dilemma.  Just like the dynamics in your romantic relationships, on the one hand, if I encourage you to talk, you see that as further proof that I'm doing something wrong and I don't care about you. But if I remain silent, you see that as proof that your feelings aren't important to me and I don't care about you.  Either way, you think I don't care.  Can you see my dilemma?"

Listening to her therapist express her dilemma softened Liz a bit.  She seemed to relax a little, and she nodded her head as if she understood what her therapist meant.

In the past, her therapist had spoken to Liz about what happened to her when she became jealous of her boyfriends as her being caught in a "vortex" of overwhelming emotions.

This idea of being stuck in a vortex came to Liz's mind now, and she told her therapist that she wasn't sure what she was feeling, but she felt as if her emotions were overpowering her.

Recognizing her new ability to even verbalize that she was overwhelmed and caught up by powerful emotions in the here and now represented significant progress for Liz.

Her therapist asked Liz to describe the vortex to her and she said she hoped to be able to help Liz to step out of the vortex.

Liz described feeling like she was in a whirlwind of powerful emotions that threatened to overtake her.  She said it was like being in the middle of a storm and she described those feelings.

Her therapist pointed out that Liz's ability to describe this whirlwind meant that Liz wasn't completely caught up in it--part of her was somewhat objective and could step out of the storm, even if it was momentarily, to observe herself in the storm.

Liz gave a barely perceptible nod to indicate that she agreed that she sensed a shift in her--something she had never experienced in the past.  She was able to say that, she wasn't sure why, but she felt unhappy about her therapist's announcement that they would be taking a break for two weeks when her therapist went on vacation.

Although Liz was unhappy about the upcoming break, she was pleased that she had achieved some objectivity about herself and her feelings by being able to observe herself, and she attributed this to their work together so far and her therapist telling her about the dilemma.

In the sessions that followed, Liz and her therapist continued to deal with Liz's unhappiness about the upcoming break and how abandoned she would feel (see my article: Coping With Trauma: Becoming Aware of Your Emotional Triggers and Old Abandonment Issues Can Get Triggered When Your Psychotherapist is Away).

Gradually, Liz made tentative connections between her feelings about the upcoming break and her distrust of her parents, especially her father, whom she described as a "philanderer" and "a rolling stone" who often disappeared from the household for months at a time (see my article:  Reacting to the Present Based on Your Traumatic Experience of the PastUnderstanding Why You're Affected By Trauma From a Long Time Ago and Overcoming Trauma: When the Past is in the Present).

Liz also made connections between her feelings of abandonment with her boyfriends when she felt jealous and her feelings of abandonment with her father.

With the help of her therapist, she realized that in the past, on an unconscious level, she sabotaged her relationships because she feared being abandoned, and she would rather end the relationship herself than endure the pain of being left (see my articles: Fear of Abandonment: Leaving Your Relationship Because You're Afraid of Being Abandoned and Fear of Abandonment Can Occur Even in a Stable Relationship).

This realization led to Liz's recognition that, on an unconscious level, she behaved similarly with her therapists.  Her fear of being abandoned by her therapists resulted in mistrust and caused her to leave therapy abruptly.

Liz and her current therapist talked about the possibility that Liz might be tempted to leave this therapy, in much the same way that she left her prior therapies, when her therapist went on vacation.

In the past, Liz had never contemplated this possibility prior to leaving therapy.  Instead of talking about her fear of being abandoned by her therapists in the past, she enacted her fear instead by leaving.  Unconsciously, her fear caused her to leave them before they left her.

Liz told her therapist that she didn't want to leave this therapy, but she had a fear that her therapist might not come back.  She knew this fear was irrational, and she discussed this with her therapist, but the feelings were so strong, she didn't know how to keep them from overwhelming her.

Her therapist taught Liz some self soothing techniques to help her to take care of herself (see my article: Self Soothing Techniques to Use When You're Feeling Distressed).

She also encouraged Liz to continue to write in her journal between sessions to have a way to discharge some of these emotions.

In addition, prior to going on vacation for two weeks, her therapist gave Liz the name of a therapist who would be covering her cases in case Liz needed to talk during their two week break.  Then, they confirmed their next appointment in two weeks.

During the two week break, Liz struggled with her fears of abandonment.  She knew that the intensity of these feelings were triggered by her earlier experiences of being abandoned again and again by her father when he went to live with other women for months at a time.

But, even though she recognized the origin of her feelings, she still felt overwhelmed.  She thought about calling the therapist who was on-call while her therapist was away, but she didn't feel comfortable doing this.

Each day Liz's feelings about abandonment got stronger, and she wrote about her feelings in her journal.  She hoped the days would go quickly so she could talk to her therapist about these feelings when her therapist returned.

But on the day when Liz was supposed to return to therapy, she "forgot" to go to her session.  The day came and went without Liz realizing that she missed her appointment.

When Liz came in for her next therapy session, she and her therapist discussed why Liz missed her appointment, which was another enactment.

Liz recognized that she had unconsciously forgot her appointment because she was angry that her therapist was aware and she felt abandoned.

Being able to talk more comfortably about her feelings was further progress for Liz in therapy.

Mutual Enactments Between the Client and Psychotherapist in Psychotherapy

At that point, her therapist recommended that they begin work on the trauma that was being triggered in Liz's relationships and in her therapies, which was her family history, especially her history of being abandoned over and over by her father (see my articles: Healing Old Emotional Childhood Wounds That Are Affecting Current Relationships ).

Liz agreed that it was time that she dealt with the source of her problems.

In the clinical vignette above, both the psychotherapist and client engaged in mutual enactments in the therapy.

Even when the therapist anticipated that there would be enactments, based on Liz's history, she found herself in a dilemma in the therapy where an enactment would be inevitable, and shared her dilemma with the client.

When the therapist shared her dilemma with the client, the therapist attempted to make the unconscious conscious for Liz by putting the dilemma into words rather than just behavior.

Even though Liz wasn't able to discuss the dynamic at that point, she began to become aware of her feelings and how they affected her therapist and the therapy.  This was a major shift for Liz, who had never recognized these dynamics before.

Recognizing a mutual enactment won't necessarily prevent future mutual enactments, as illustrated in the above vignette.

The therapist was aware of the possibility that there would be probably be an enactment on Liz's part after the therapist came back from vacation.

Due of their professional training and their own psychoanalysis, most therapists are more aware of mutual enactments prior to their client's awareness.  But, being human, psychotherapist also engage in enactments from time to time, as illustrated in the vignette.

Many psychotherapists agree that it's not a matter of if they and their clients will occasionally get caught up in enactments--it's more a matter of when.

What's most important is how therapists use these enactments, after they have occurred, to shed light on the unconscious processes that are going on between the therapist and the client. The therapist can then use this new awareness to further the therapeutic work and help the client to make breakthroughs.

Getting Help in Therapy
Mutual enactments are common in relationships of all kinds.

When mutual enactments occur in personal relationships, the people in the relationship often don't have the wherewithal to make these unconscious dynamics conscious, so they continue to engage in enactments which can be damaging to the relationships.

When enactments occur in psychotherapy, they are usually related to the client's earlier personal history.

The behavior related to the enactment will continue to repeat itself until the therapist helps the client to become aware of the enactments and they work on the underlying issues instead of enacting them unconsciously.

If you realize that you continue to engage in destructive patterns in your relationships, you might be enacting unconscious behavior from the past.

Rather than continuing to behave in an unconscious way that has a negative impact on your relationships as well as your sense of self, you could benefit from working with a psychotherapist who is skilled in identifying and working through enactments, including mutual enactments (see my articles: The Benefits of Psychotherapy and How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individuals and couples (see my article: The Benefits of Integrative Psychotherapy).

I have helped many clients to learn to recognize unconscious feelings so they can discuss them and work through them in therapy rather than enacting them.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.

Friday, December 1, 2017

Why Your Psychotherapist Can't Be Your Friend

Many clients who are new to psychotherapy don't understand why they can't have a personal relationship with their psychotherapist.  To clarify this issue, my goal in this article is to address why psychotherapists can't be friends with their clients (see my articles: Psychotherapy and the Erotic Transference: Falling "In Love" With Your TherapistBoundary Violations and Sexual Exploitation in Psychotherapy and Psychotherapy and the Positive Transference).

Why Your Psychotherapist Can't Be Your Friend

Psychotherapists have a code of ethics that they must follow.  One of the items in the code of ethics is that therapists and clients can't become friends outside of the therapy sessions.  The purpose of this stipulation is to protect the client from boundary violations and to protect the therapeutic work that the therapist and client are engaged in.

While it's understandable that clients might have a desire to become friends with their therapist, it's up to the therapist to explore this desire, try to understand how it's connected to the client's problems and history, help the client work through this issue, and maintain a professional boundary.

There are times when psychotherapists get caught up in enactments with their clients.  Enactments are usually unconscious on the part of the client and the therapist and often related to prior personal history that gets played out in the therapy.

Mutual enactments are common and exploration and resolution of these enactments can deepen and enhance the work.

The following fictional vignette is about a case where these issues come up in therapy:

Fictional Vignette: Why Your Psychotherapist Can't Be Your Friend and Understanding Mutual Enactments in Therapy

Jane moved to New York City to start a new job after she completed graduate school.  Although she loved her new job and New York, she felt very lonely on weekends because she didn't know anyone other than her coworkers and they were all married and led busy lives.

She tried various social groups and participated in local events, but she had no luck in forming friendships among the people that she met.  This reinforced a longstanding feeling that she had about herself that she wasn't lovable or good enough for people to want to care about her.

After several months of feeling increasingly lonely, Jane began therapy at a psychotherapy center where they offered sliding scale fees.

After her intake, Jane was assigned to a new woman therapist who was part of the center's training institute, and Jane began attending therapy twice a week.

Jane liked her therapist, Susan, from their first session, which was unusual for Jane.  Usually, she felt shy and awkward when she met someone new, but Susan had a way of helping Jane to be at ease.

Jane looked forward to her therapy sessions on Mondays and Wednesdays.  She liked talking to Susan and felt better afterwards.  But between sessions, Jane still felt lonely.

A few months later, a friend from graduate school, Dee, moved to New York and reconnected with Jane.

Jane and Dee were friends in graduate school and they usually enjoyed each other's company, but now whenever they got together, Jane found her mind wandering back to Susan.  She noticed that she was comparing Dee to Susan and Dee would always fall short.

As time went on and Jane continued to compare Dee unfavorably to Susan in her mind, she spoke to Susan about it in one of their therapy sessions.

Susan was already aware from the way Jane complimented her and how much Jane said she enjoyed their sessions that Jane was idealizing her.  So, she wasn't surprised when Jane told her that she was comparing Dee unfavorably to Susan.

Jane told Susan that she would really like it if they could be friends outside the therapy sessions.  She told Susan that, after all, they were close in age and she suspected that they probably had a lot in common.

Susan listened attentively and then normalized Jane's wish.  She told her that many clients feel this way about their therapists and this was part of an idealizing transference.  She also explained why it was important that they maintain their therapeutic relationship, as opposed to a personal relationship, in order not to cross boundaries and sacrifice their work together.

Why Your Psychotherapist Can't Be Your Friend
On some level, Jane knew that she and Susan couldn't be friends, but she felt hurt and rejected when she heard Susan tell her this.  She told Susan that she didn't think their therapeutic work would be compromised in any way and, in fact, she thought the work might be enhanced if they became friends.

As Jane and Susan continued to explore these issues, Susan talked to her training supervisor about this issue.  Susan was clear that she wasn't going to violate an ethical boundary, but she felt herself defensively pulling away emotionally from Jane, and she was afraid that this would ruin their work together.

Susan and her training supervisor talked about how Susan could remain balanced in her approach with Jane--neither too friendly nor too distant--to maintain a therapeutic rapport with Jane.

During this time, Jane missed a therapy session.  She was aware that the psychotherapy center's policy was to give at least 48 hours notice (unless there was an emergency) and that she would be responsible for the fee if she gave less than 48 hours notice.  But she left a message for Susan an hour before their appointed session time saying that she wasn't feeling up to going to their session that day.

When Jane returned to her next session, Susan asked Jane about the missed session, and Jane responded that she just didn't feel like coming to therapy that day.  She offered no other explanation.

When Susan reminded her about the center's policy about broken appointments, Jane told her that she didn't feel she should be charged for the appointment because she had come to all her other appointments and this was the first appointment that she missed.

Susan sensed that something had gone awry between Jane and her and that it was probably related to their talk about why she and Jane couldn't be friends.

But when she tried to explore this with Jane, Jane said that her missed session had nothing to do with their discussion and she would rather that they "move on" and talk about more important things than continue to talk about her missed session.

Susan knew that Jane's idealizing transference wouldn't last forever and that an idealizing transference often changes to a negative transference since no therapist could live up to the idealization and remain on a pedestal indefinitely.  But she was surprised that this change happened so quickly.

Susan was also concerned that if there was a negative transference that it would interfere with the work, which she wanted to avoid.

As a new therapist and without the benefit of being able to speak with her supervisor beforehand, Susan told Jane that she would overlook the broken appointment fee this time, but if Jane had another broken appointment, she would have to pay the fee.

When Jane left another message the following week indicating that she wasn't coming to their appointment on the same day as the appointment, Susan spoke with her supervisor about it.

During their supervisory session, Susan and her supervisor talked about "enactments" between clients and therapists.  She explained to Susan that, like many therapists, Susan got caught up in an enactment with Jane when she agreed not to charge her for the missed appointment despite the fact that Jane was well aware of the center's policy and had signed an agreement about broken appointments.

Susan's supervisor told Susan that it appeared that Jane wanted to feel "special" in Susan's eyes and if she couldn't be friends with Susan, she might have unconsciously created this situation where she could feel that she was a special client to Susan where Susan would break the rules for her.

The supervisor encouraged Susan to address and explore this issue with Jane and to explain Susan's role in getting caught up in this enactment.  She also told Susan that, based on the center's policy, Susan would have to collect the fees from Jane.

Jane felt embarrassed about her role in the enactment, but she also understood that she was a new therapist, she was still learning, and that even experienced psychotherapists unconsciously get caught up in mutual enactments with therapy clients.

When Jane returned for her next session, she didn't offer a reason for the last cancellation, so Susan brought up the issue and suggested they talk about it.

Initially, Jane was defensive and told Susan that she didn't want to waste her time talking about this when she had other more important things to talk about it, "And, anyway, isn't it my session to talk about anything that I want to talk about?"

Susan explained why they needed to talk about the cancellations and the unpaid fees.  She started by acknowledging that, as a new therapist who wanted their work to go smoothly, she made a mistake allowing Jane to break the rules.

When Jane heard Susan admit to making a mistake, she softened somewhat.  She still liked Susan and she was concerned that she might have gotten Susan "in trouble" with the center (see my article: Ruptures and Repairs in Psychotherapy).

Susan explained that she wasn't in trouble with the center, but she needed to address the mutual enactment that occurred between them so they could understand the meaning of it.

Reluctantly, Jane admitted that she felt hurt and angry when Susan told her that they couldn't be friends, even though Jane was already aware of the rules.  She also admitted that she could have come in for her therapy sessions, but she was annoyed and decided to skip those sessions.

This discussion led to Jane talking about how she always wanted to feel special with her mother, but she was aware that her younger sister was her mother's favorite, which left Jane feeling that she wasn't good enough or lovable enough to be her mother's favorite.

This lead to their talking about why Jane wanted to feel special to Susan.

Although, as a new therapist, Susan initially feared that what started as a negative transference would lead to the demise of the therapy, she now saw that discussing it was key to getting Jane to open up and get to more core issues.

Jane agreed to pay for the missed sessions, and they continued to work on the core issues of her feelings of being unlovable and not good enough (see my article: Overcoming the Emotional Pain of Feeling Unlovable).

The therapeutic relationship is a unique relationship unlike any other because it's focused on you.

It's common for clients to wish to have a personal relationship with their therapist--either a romantic/sexual relationship or a friendship.

It's the therapist's job to recognize these transferential issues, address them in therapy, and maintain a professional boundary.

It's not unusual for clients' transferential experience to change from an idealized transference to a negative transference, especially since no therapist remains on a pedestal indefinitely.

Addressing transference issues and mutual enactments, if handled well by the therapist, can enhance the therapy by helping the client to address the core underlying issues.

Getting Help in Therapy
If you're feeling stuck in your life, you could benefit from working with a skilled psychotherapist who can help you to overcome your problems (see my article: The Benefits of Psychotherapy).

There are also times when you and your therapist can get stuck in mutual enactments, including boundary violations, when you could benefit from a consultation with another therapist.

Rather than struggling on your own, you could work through your problems with an experienced therapist who has the skills and knowledge to help you overcome your obstacles (see my article: Choosing a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist with over 20 years of experience who works with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.