Progress in Psychotherapy Isn't Linear

Clients who are new to psychotherapy often don't know what to expect, which is why it's important for psychotherapists to provide psychoeducation about how psychotherapy works (see my article: Why It's Important For Psychotherapists to Provide Clients With Psychoeducation About How Psychotherapy Works).  One important aspect of psychotherapy to understand is that progress in therapy usually isn't linear, which is the topic of this article.

Progress in Psychotherapy Isn't Linear

Defining the Presenting Problem: Understanding Big T and Small T Trauma
It's understandable that clients want to see that they're making progress in therapy, especially if they've been suffering with longstanding problems.

When a client is in therapy, it's important for the client and the psychotherapist to understand the nature of the presenting problem.  That makes it easier to set therapy goals and to measure progress in treatment.  This might take a while to reveal itself as the client comes to therapy and gives the therapist information about the history of the problem and how it's affecting her now.

Usually, the narrower the problem, the easier it is to make progress and resolve the problem in therapy.  For instance, if a client comes to therapy after she has been robbed and, prior to the robbery everything was basically going well with no history of prior trauma, this is a simpler case than someone who comes to therapy with longstanding unresolved trauma from childhood (also known as developmental trauma).

Saying that it's a simpler case is in no way meant to minimize the traumatic experience of being robbed.  But compared to an adult client with a long history of being abused and neglected as a child, it's a less complex case.

With regard to definitions of trauma, the unresolved developmental trauma would be considered a "Big T trauma" and the one-time traumatic event, like getting robbed, where there was no prior trauma, is considered a "Small T trauma" (see my article: Big T and Small T Trauma).

For Small T trauma, the goals are usually more narrowly defined. These might include: The client being able to walk down the same street where she was robbed without fear or being able to leave the house without fear.  If someone who was robbed is very frightened, this is important and it might seem daunting.  But relative to Big T trauma, the scope is narrower.

For Big T trauma, the goals are more complex and might be multi-layered.  For instance, a client who was abused and neglected as a child might be fearful of experiencing his feelings.  He might have constricted affect and not even understand his feelings because he had to protect himself as a child so he wouldn't feel so vulnerable.  This, in turn, usually leads to problems in adult relationships.  So, you can see that Big T trauma is more complex, and there will be layers of trauma to work on.

Understanding the scope of the problem involves exploration.  For instance, a client might begin therapy by saying that she has a problem communicating with others.  This is, of course, a very general definition of a problem, and the psychotherapist would need to ask questions to make it more specific:  Does she have problems talking to everyone or only people at work?  Is the problem related to a medical issue or is it a psychological issue or both?  When did the problem start?  How does the client experience this problem?  How is this problem affecting the client internally and interpersonally?  And so on.

As the client and psychotherapist explore these questions and the history of the problem, they might discover that the problem is longstanding and the client cannot remember a time when she didn't have this problem, even as a child.

As they continue to explore this issue, they might discover that the problem is pervasive in all areas of the client's life.  The client reveals that all possible medical issues have been ruled out and the client's doctor recommended that the client seek psychological help.  Furthermore, the client reveals that whenever she has to speak, whether it's one-on-one or in a group, she becomes panicky and she has had a few panic attacks recently.

It soon becomes clear that the client's problem talking to others is a symptom of a much larger problem, and her anxiety is related to longstanding unresolved trauma.  As a result, the problem is much more complex than the client originally thought.  This sounds like Big T trauma, and it will require further exploration to discover the root of the problem.

In contrast to Big T trauma, if a client came to therapy and says she has problems speaking up at staff meetings ever since her boss humiliated her in a prior staff meeting, but she never had this problem before, she never has this problem in any other situation, and there is no developmental trauma, this is probably a Small T trauma.  It's not multi-layered like Big T trauma, and the goals in therapy would probably be narrower and more easily achieved.

The Circular Nature of Progress in Therapy
Even when a client has had a significant breakthrough in therapy in a prior therapy session, he might come in the next week experiencing many of the same problem that he did before the breakthrough.

You might ask:  "Why is this?"

Well, there are many reasons.  One reason is that many clients need at least a few "Aha!" moments in therapy in order for breakthroughs to stick.

Another reason is that, even when a client really wants to make progress in therapy and resolve his problems, there is almost always ambivalence and some anxiety about changing.  For many clients, the "devil" (or problem) they know is easier to deal with than the "devil" they don't know (change) (see my article: Starting Psychotherapy: It's Not Unusual to Feel Anxious or Ambivalent).

Many clients will tell their therapists that they are fearful of who they would be if they didn't have a longstanding problem because they've had the problem for so long, and they've learned to identify with their problem as if it's a part of themselves.

As a result, a client might have to go over the same material several times or more before the change "holds" and remains.  They might have to circle back many times to rework the same or various aspects of the same problem.  Along the way, other aspects of the issues they're struggling with might come to the surface in order to get worked through.

This is one of the main reasons why progress isn't usually linear.  Most of the time it's circular:  Two steps forward and one step back.

For people who are in recovery for addiction, one of the first things that they learn in recovery is that relapse is part of the process.  Many clients new to recovery will hear this and say that they have made a firm commitment to their recovery and they will never relapse.  But being human means that clients often do go back a step or two before they can go forward.

It's no different for most other problems that people come to therapy to resolve.  And the more complex the problem, the more likely that progress will be circular and not linear.

Conclusion
Most clients who are new to psychotherapy expect that their progress will be a linear progression, like a straight arrow, where they keep making progress and never backslide.  But this is rarely the case, especially if their problems are longstanding and complex.

Understanding the problem, the problem's history, how it affects the client now, and so on, is important to setting therapy goals.  The simpler the problem, the easier it will be to resolve, so Small T trauma is less complex than Big T trauma and will be more readily resolved, all other things being equal.

Sometimes, the client either doesn't know what the problem is or thinks the problem is narrower than it is.  As the client and psychotherapist explore the problem, they can define the problem better to understand if it is a new problem which is narrow in scope or if it is a multi-layered problem with a long history, which makes it much more complex.

Assuming that clients come to therapy on a regular basis and they are working with a skilled psychotherapist, most clients' progress is circular rather than linear--two steps forward and one step back.  The more complex the problem, the more likely that clients will occasionally have setbacks (see my article:  Setbacks Are a Normal Part of Psychotherapy on the Road to Healing).  This is human nature.

For more complex problems, if there is progress, it can usually be seen over time by comparing how clients were when they first started therapy to how they are feeling, thinking and behaving now.

With regard to making progress in therapy, knowing what to expect in terms of this going forward/occasionally going backward dynamic helps clients to have reasonable expectations of themselves and their therapy.

Getting Help in Therapy
Making a decision to change and asking for help in therapy are courageous initial step (see my article: Developing the Courage to Change).

If you have been struggling with unresolved problems, you owe it to yourself to get help from a licensed mental health professional (see my article: The Benefits of Psychotherapy).

A skilled psychotherapist can help you to overcome your problems so that you can live a more fulfilling life, free from the history of your problems (see my article: How to Choose a Psychotherapist).

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

I work 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 (917) 742-2624 during business hours or email me.

EMDR Therapy for "Big T" and "Smaller t" Trauma

As a New York City psychotherapist who is an EMDR therapist, I see clients for EMDR treatment for both "Big T" and "Smaller t" trauma. I will clarify what I mean by "Big T" and "Smaller t" trauma below.

What is EMDR?
First, as I have written about in earlier posts, I want to reiterate that EMDR (Eye Movement Desensitization and Reprocessing) is a form of psychotherapy which has been found to be effective for healing trauma. Francine Shapiro, Ph.D., who is a psychologist, developed EMDR in the late 1980s.

EMDR Therapy For "Big T" and "Smaller t" Trauma

Since that time, EMDR has been one of the most well-researched forms of psychotherapy for posttraumatic stress disorder (PTSD) and other types of trauma. It has been recognized as a safe and effective form of treatment by the Veteran's Administration, the American Psychiatric Association, the International Society for Traumatic Stress Studies, the Israeli National Council for Mental Health and the United Kingdom Department of Health, among other mental health organizations.

EMDR uses bilateral stimulation of the right and left brain hemispheres (through eye movements, alternate taping, bilateral music, and other similar methods) to activate the brain's "information processing system" to heal trauma.

When we are overcome by experiences that produce overwhelming emotional and physical reactions, often, our minds are unable to process these experiences.

Under certain circumstances, which are unique to each person, these overwhelming experiences can produce adverse reactions, like debilitating depression, anxiety and other psychological difficulties. EMDR allows clients to reprocess these experiences, allowing us to get to the root of these emotional processes, and usually produces a long-term cure.

EMDR therapists, who have advanced training, know how to work with clients in a way so that they are not overwhelmed with the EMDR reprocessing. Each client's experience is unique.

Generally speaking, high levels of emotional reaction tend to dissipate with EMDR treatment. Also, an experienced EMDR therapist makes sure that clients are well prepared for EMDR processing before the actual processing begins by working with clients to develop internal resources (coping skills) to deal with any uncomfortable reactions that might take place during the reprocessing of emotional trauma.

What is the Difference Between "Big T" and "Smaller t" Trauma?
EMDR is usually associated with what is referred to in psychological literature as "Big T" trauma. However, it seems that it is less well known that EMDR is usually very effective for "Smaller t" trauma as well.

"Big T" Trauma
When we refer to "Big T" trauma, we are usually referring to trauma that occurs during war or natural disaster, rape, kidnapping, physical attack, and other similar types of trauma. These types of trauma are usually so overwhelming for most people that they are unable to cope.

An example, of this is the Vietnam or Iraqi veteran who has witnessed atrocities during war and who comes home, relives these atrocities through flashbacks, where it adversely affects his or her ability to function in every day life.

Another example of "Big T" trauma is when a woman who has been raped continues to have nightmares about the rape; she ruminates about what happened, reliving the event over and over again in her mind.

She might be too afraid to start new relationships or to even go outside.

Generally, "Smaller t" trauma is trauma that is more subtle than "Big T" trauma.

An example of "Smaller t" trauma can occur when we're children and we witness events that are upsetting and overwhelming to us because our child-like minds are unable to understand or process these events.

An example of a "Smaller t" trauma could be when a child witnesses loud arguments between his parents and he fears that they are going to get a divorce. As a child under these circumstances, it's normal to be concerned about his safety and well-being. After all, he worries about what will become of him and who's going to take care of him if his parents are not together.

These kinds of experiences can leave a mark on a child's psyche, leaving him vulnerable to feeling anxious, depressed, or insecure later on in life.

There are many other everyday examples of "Smaller t" trauma that people often don't recognize at the time when they're occurring. The emotional damage that has been done often does not show up until later on in life. Sometimes the events that led up to these problems later on are apparent and, other times, they're not. Either way, EMDR is usually an effective form of therapy to overcome the effects of "Smaller t" trauma.

Since most literature focuses on "Big T" trauma like PTSD, I would like to focus on "Smaller t" trauma in this post to illustrate its effects and how EMDR can help. The following vignette is a composite of many cases with all identifying information changed to protect confidentiality:

John:
When John first came to treatment, he was in his late 30s. He worked as an attorney in a large corporate law firm. Like most attorneys in his law firm, John hoped to become a partner one day in his firm.

Generally, he liked corporate law and enjoyed working with his clients. However, he felt very anxious around his boss because his boss was a bully. Whenever his boss felt that John fell below what was considered an acceptable rate of "billable hours," he berated him in the most demeaning way.

John understood the importance of "billable hours" and knew what was expected of him. He felt that, overall, he was a knowledgeable and capable attorney. However, whenever his boss berated him, John felt emotionally paralyzed.

John felt his confidence plummet and he would ruminate for days about whatever his boss told him. His colleagues experienced the same bullying from the boss and, although they were concerned about it, they were not as affected by it as John.

John recognized this and he knew he needed to get help or his boss's tirades continued to be detrimental to him. He realized that his reaction to his boss's comments were out of proportion to the current situation.

The First Phase of EMDR Treatment: During the first phase of EMDR treatment with John, I obtained a detailed history from John about his background. From his family history, I learned that John's father was very much like his boss. He was hypercritical of John and often berated him, leaving him feeling like he could never please his father. If John came home with a report card with all A's and one B, John's father focused on the "B" and berated him for not getting an "A" in that subject, leaving John to feel badly about himself.

Developing Coping Skills: During that initial phase of treatment, I also helped him to develop basic coping skills. Since he didn't do anything to manage his stress, John began working out and going to yoga class. I also taught John to meditate.

In addition, we developed internal resources that he could use during EMDR processing. For instance, John learned to think about and visualize certain "protective" figures from his life (his grandfather, a kind uncle, his nurturing older sister, as well as a lifelong friend and confidant). Through EMDR processing, we worked to help John to internalize these protective figures in such a way that he could "call on them" (essentially, remember, visualize and sense them) when he felt emotional distress either in the psychotherapy session or outside. Just using these internal resources whenever he had to deal with his difficult boss helped John tremendously.

EMDR Processing: During the next phase of treatment, John chose a particular incident that occurred at work with his boss and we began to process that incident using EMDR eye movements. 

Before the processing, John rated this incident as a "9" out of a possible 10 in terms of how emotionally disturbing it was to him (with 0 being no disturbance and10 being the highest level of disturbance). So, overall, it started out as being very disturbing to him. 

However, as we continued to do EMDR processing, the incident became less and less disturbing. It gradually went down to a 5 for John. He felt relieved, compared to how he felt originally, but it was still disturbing. Further processing of that incident did not decrease John's level of disturbance.

When Processing of Trauma Gets Blocked: When the level of processing gets "blocked" (meaning that it stays at a certain level of disturbance and it won't go down to 0 or 1), it generally means there is underlying trauma that is feeding into the current situation and is making it more emotionally charged than it might normally be. Having already obtained John's family background, I was aware that John's relationship as a boy with his father was probably feeding into his current problems and activating his emotional response.

The Difference Between EMDR and Regular Talk Therapy for Trauma: If we were doing regular talk therapy, we might have discussed John's relationship with his father and how if affected him now.

It probably would have been enlightening to John but, usually, this would only remain as an intellectual insight. In other words, it's interesting and informative to know, but it doesn't produce any change. And therein lies the problem with regular talk therapy and trauma.

In addition to my EMDR training, I'm also trained as a psychoanalyst, so I understand and value psychodynamic treatment for most problems. However, when it comes to trauma, regular talk therapy is often limited in terms of resolving and healing trauma.

Processing the Earlier Trauma that Triggers the Current Trauma: So, knowing that there were probably earlier memories that were feeding into and triggering John's emotional reaction to his current situation, we did what is known in EMDR as a "float back."

During a "float back," the client thinks back to an earlier time when he might have experienced these same feelings. An experienced EMDR therapist might have a sense of what those memories might be, but he or she doesn't make any suggestions about them. The EMDR therapist allows the client to come up with whatever he or she remembers or senses.

In John's case, his earliest memory of feeling the same way as he did in his current situation was when his father berated him during Little League practice. According to John, he struck out each time that he was up at the plate during a big game with a rival team.

Afterwards, he was feeling bad enough, but when his father yelled at him in front of his team mates and the other parents, John was mortified. John rated his level of disturbance as being a "10" for this memory. Gradually, as we continued to process the memory with EMDR, his level of disturbance went down to a "0." When it went down to 0, he, of course, remembered the memory with all of the details, but he no longer felt disturbed by it.

Resolution of the Trauma: After we processed this earlier memory, which was emblematic of his experiences with his father, we went back to the current situation with his boss. As is usually the case, having reprocessed the earlier "Smaller t" trauma produced a "0" in terms of John's level of emotional experience in the current situation.

John was really surprised and greatly relieved. He was able to go back to work, deal with his boss, and when his boss saw that he could no longer intimidate John the way he used to, he stopped ranting at him and chose to bully another more vulnerable attorney instead.

EMDR Follow Up: When John checked in with me several months later, he told me that the results of our work continued to hold. He also said that his self esteem was now higher than it ever had been and his boss told him that he was on track to become a partner, which made John feel very happy.

The above vignette is one brief example that demonstrates how EMDR can work. Everyone's experience of EMDR is unique.

EMDR is an effective treatment for dealing with trauma, and it is usually faster than regular talk therapy.

Getting Help in EMDR Therapy
If you have unresolved trauma, you could benefit from working with an experienced EMDR therapist who is a licensed psychotherapist.

About Me
I am a New York City licensed psychotherapist and EMDR therapist.

I work with individual adults and couples.

I have helped many clients resolve both "Big T" and "Smaller t" trauma.

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

To set up a consultation, call me at (917) 742-2624 during business hours or email me.