Developmental Trauma: Living in the Present As If It Were the Past

My prior articles about psychological trauma discussed how unresolved childhood trauma, also known as developmental trauma, affects traumatized individuals as adults (see my article: Overcoming Trauma: When the Past is in the Present).  In this article, I'm focusing specifically on how developmental trauma often affects clients' relationship with their psychotherapist, especially during the early stage of psychotherapy.

Developmental Trauma: Living in the Present As If It Were the Past

In his paper, Developmental Trauma Disorder, trauma expert Bessel van der Kolk, MD indicated that developmental trauma, which includes abuse and neglect, is probably this country's biggest public health challenge.

He estimated that approximately 3,000,000 children are reported as being abused or neglected per year--and these are only the cases that are reported.  Many cases go unreported, so that number is probably much higher.

According to Dr. van der Kolk, approximately 80% of these cases are the result of abuse and neglect by the children's own parents.  As a result, developmental trauma is a significant problem in this country, and much remains to be done.

Since untreated trauma does not simply go away when children become adults, it's important to understand the impact of trauma (see my article: Untreated Trauma is a Serious Issue With Negative Consequences).

What is Developmental Trauma?
Before going into more clinical material, let's define "developmental trauma."

Developmental trauma occurs in childhood. It causes overwhelming stress for the child, especially when the stress is not alleviated by the parents.  This includes:

• physical abuse
• emotional abuse
• sexual abuse
• physical neglect
• emotional neglect

The dysfunction in the home can include, among other things:

• mental illness
• substance abuse
• domestic violence
• an incarcerated relative
• divorce

Developmental trauma is also called Adverse Childhood Experiences (ACE) and has serious long term health and mental health implications (see ACE Childhood Study).

Since adults, who experienced Adverse Childhood Experiences, were unable to trust their parents, who were supposed to love and protect them as children, it makes sense that they often have problems trusting people in their adult relationships, including their psychotherapist (see my article: Adults Who Were Neglected or Abused as Children Often Have Problems With Trust).

What Are the Clinical Implications in Therapy For Adults With Developmental Trauma?
For adults, who experienced developmental trauma as children, it takes a lot of courage to come to therapy to be emotionally vulnerable enough to work through their trauma (see my article: Starting Therapy to Overcome Untreated Trauma and Developing the Courage to Change).

It's not surprising that these adults often come to therapy with a great deal of ambivalence and mistrust (see my article: Starting Psychotherapy: It's Not Unusual to Feel Anxious or Ambivalent).

Since most trauma-informed psychotherapists recognize these dynamics, they are aware of the importance of trying to establish a trusting relationship with these clients.

It's not unusual for these individuals to go from one psychotherapist to the next as soon as they feel emotionally vulnerable in therapy--especially since they often come to therapy unconsciously anticipating that the therapist will fail them in the same way that their parents failed them.

Their unconscious anticipatory fear that the psychotherapist will fail them in much the same way that their parents failed them usually indicates that they are living in the present as if it were the past.

The following fictional clinical vignette, which represents a common scenario for adults with developmental trauma, illustrates these points:

Fictional Clinical Vignette: Living in the Present As If It Were the Past
Nina

Nina, who was in her mid-30s, began therapy after her relationship with John ended six months after they started dating.

John ended the relationship because of Nina's jealous accusations.  John vehemently denied that he was cheating, but Nina didn't believe him.

Developmental Trauma: Living in the Present As If It Were the Past

Although they got along well during their first three months together, Nina began to suspect that John was cheating after their relationship became more emotionally intimate in their fourth month together.

Even though she saw no direct signs of John's infidelity, her suspicions alone were enough for her to assume that he was cheating, and she was relentless in her accusations.

When she came for her first session with her therapist, Nina expressed regret that she had destroyed her relationship with John with no objective evidence that he was cheating.  In hindsight, she understood her mistake and why John got fed up.

She also explained to her therapist that this was her pattern in relationships--she always assumed that her boyfriend at the time was cheating, even when there were no objective signs of infidelity.

When she came to therapy the following week for her second session, Nina had a completely different take on why her relationship with John ended.

She told her therapist, "All men cheat and since all men cheat, I know that John was cheating on me.  He ended the relationship because I called him on it and he didn't like it."

When her therapist attempted to explore Nina's feelings about the relationship in the current therapy session versus what Nina said in the first session, Nina acknowledged that she had initially said that  she had made a mistake with John.  But she maintained that she was wrong in her first session and what she felt today was the truth, "Men can't be trusted."

Her therapist realized that, although Nina did a 180 degree turnaround from her first therapy session to her second session a week later, she knew that Nina did not meet the clinical criteria for multiple personality disorder or, as it is now called, Dissociative Identity Disorder (DID).

She recognized Nina's turnaround as a matter of shifting self states, which is a dissociative process, but not as dissociative as DID (see my article: How Shifting Self States Can Affect You For Better or Worse).

And, while everyone has shifting self states to some degree, people who are not traumatized usually have barely perceptible shifts as compared to people with unresolved trauma.

So the fact that Nina had a completely different view about the demise of her relationship when she returned to therapy on the second week was understandable considering her history of childhood trauma.

When Nina talked about her childhood, she vacillated between idealizing and denigrating her mother.

When she idealized her mother, Nina thought that her mother could do no wrong.  But when she denigrated her mother, she blamed her mother for not leaving the father, who had a long history of cheating on the mother.  Once again, her therapist understood these shifts as being part of Nina's shifting self states which were emotionally unintegrated.

Nina also had a long history of aborting therapy.  She explained to her current therapist that she had seen 10 therapists in the last two years, and she left each one when she felt that she couldn't trust the therapist (see my article: When Clients Leave Psychotherapy Prematurely).

Based on what Nina told her, her current therapist could see that Nina's pattern was that she left therapy as soon as the therapeutic work intensified and she felt too vulnerable.  Before that, Nina tended to idealize her therapists.  But once the work progressed and came close to her core traumatic issues, Nina became fearful, she developed a mistrust for the therapist and left therapy abruptly.

Forewarned of Nina's pattern in therapy, her therapist knew that there was a real possibility that Nina might abort the current therapy--even if it seemed like she developed a trusting relationship with the therapist before they processed Nina's traumatic experiences.

During most of her therapy sessions, Nina made it clear to her therapist that she understood that her traumatic childhood, including her father's infidelity, impacted her ability to have lasting relationships with men.

Most of the time, she expressed regret for her mistrust and wanted to "...hurry up and get over my trauma, since I'm not getting any younger and I'd like to get married and have children."

Nina sought therapy with her current therapist because the therapist specialized in working with trauma using EMDR Therapy.  Nina wanted to try EMDR therapy because she heard that it tends to work faster than regular talk therapy.

On the days when Nina acknowledged how her childhood history affected her adult relationships, she was in a hurry to get relief from her traumatic symptoms.

But on the days when she came to therapy blaming "all men for being dogs," she disavowed any connection between her childhood history and the demise of her relationships.  Once again, her shifting perspective was due to her shifting self states.

As part of the therapeutic process, Nina's therapist was the "container" for these different self states (see my article: The Holding Environment in Psychotherapy).

She knew that, even when Nina was in a hurry to process her childhood trauma, Nina wasn't ready.  Nina needed to develop internal resources and a greater sense of emotional integration before she would be ready to process her childhood trauma--otherwise, she would be flooded with anxiety and completely overwhelmed by the trauma therapy.

Her therapist also helped Nina to recognize her different self states by doing Ego States therapy (also known as Parts Work therapy) with Nina.  In this type of therapy, the therapist helps the client to get to know each of her shifting self states in order to foster greater emotional integration.

Nina understood most of the time that the internal resourcing and the Ego States therapy was preparation to eventually process her traumatic memories.  But there were times when she came to therapy feeling angry with her therapist for "dragging out the process and not helping me to get over my trauma."

During those times, Nina was ambivalent about her therapist and about the therapy.  Nina feared that she was being "duped" by the therapist and that she shouldn't trust the therapist.  She threatened to leave therapy and accused her therapist of being "no better than all the other therapists that I've had before."

But Nina and her therapist weathered these storms and, most of the time, Nina was able to see that her doubts and mistrust were the result of a particular self state that got triggered when she became anxious about the therapy (see my article: Coping With Trauma: Becoming Aware of Your Emotional Triggers and Expanding Your Window of Tolerance in Therapy).

She could see that what she was experiencing was the result of her traumatic past which she was living out in the present with her therapist.

Along the way, there was enactments in therapy, as there often are with clients who have been traumatized:  There were several sessions in a row where Nina "forgot" to bring a check to pay her therapist, she "forgot" to come to her sessions, and she was annoyed when her therapist held her accountable for her broken appointments.

All of these enactments were unconscious on Nina's part and were part of her dissociative shifting self states.

Most of the time, her therapist did not get caught up in these enactments but, being human, there was one time when she found herself right in the middle of an enactment with Nina: Nina's therapist had to take a couple of weeks off for a medical procedure.  She made a conscious decision not to disclose her medical problem, which was not serious, to Nina because she assessed that Nina was not ready emotionally to handle this disclosure.  She also wanted to preserve her right to privacy by not disclosing her medical problem.

When her therapist told Nina that she had to take a couple of weeks off, Nina exploded.  She was angry because she felt she was being abandoned by her therapist and with only a couple of weeks notice (see my article: Abandonment Issues Can Get Triggered While Your Therapist is Away).

Nina's therapist had little notice from her doctor that she needed this medical procedure, which could not wait, so she couldn't provide Nina with more notice.  But her therapist didn't want to reveal this to Nina because, as previously mentioned, she thought Nina was too emotionally fragile at that point.

Her therapist did the best she could under the circumstances to contain Nina's upset as well as her own feelings of being misunderstood.  But, after two sessions where Nina ranted about the two week break, her therapist told Nina in an angry tone that she would have a backup therapist that could consult during that two week break.

Even though her therapist got caught up in a mutual enactment by talking to Nina in an angry tone, something shifted for Nina where she stopped ranting and realized that she was being unreasonable (see my article: Mutual Enactments in Psychotherapy Between Client and Psychotherapist).

They were able to talk about what had just happened between them, and Nina expressed that, while she didn't like that her therapist spoke to her in an angry tone, she could feel the genuine nature of her therapist's upset and this caused her to "wake up" and see her therapist as a "normal human being" with her own experiences and feelings.  This was a major breakthrough for Nina.

As I mentioned in an earlier article about enactments, there are times when mutual enactments can have a positive effect on the therapy if the therapist is able to repair the rupture between the therapist and client and they come to a new understanding of their therapeutic relationship (see my article: Ruptures and Repairs in Psychotherapy).

Of course, although these enactments can be repaired and advance the therapeutic work, a therapist should never plan an enactment.

Gradually, over time, Nina became much more perceptive of when she was going through a self state shift.  She had developed a much more observing sense of self so that she could step back, even when she was in a mistrustful state, and see, "It's happening again," which made it easier for her to be more objective and shift into a more emotionally balanced state.

Developmental Trauma: Living in the Present As If It Were the Past

As Nina became more emotionally integrated with fewer dramatic self state shifts, she was now ready to process her earlier traumatic experiences using EMDR therapy.

By processing her childhood trauma in therapy, eventually, Nina freed herself from her traumatic history so that she was no longer living in the present as if she were in the past.

Conclusion
Reenacting unresolved childhood trauma is an unconscious process.

These reenactments occur in personal relationships, work relationships, and in the client's relationship with his or her psychotherapist.

There are times when traumatized clients are able to get a glimpse into these reenactments in therapy but, due to the nature of their shifting self states, this new understanding can be tenuous and change back and forth over time until the client becomes more emotionally integrated as a result of the work in therapy.

A skilled trauma-informed psychotherapist understands that clients often go back and forth in their understanding of their problems because the shifting self states are unconscious.

Developing a trusting relationship with a traumatized client is of the utmost importance before any processing of trauma occurs.

The therapist must also help the client to develop the necessary internal resources and coping skills before processing trauma.

Each client is unique as to when he or she feels safe enough in therapy and prepared to do the therapeutic work.

When a client has worked through developmental trauma, s/he is free to live life without constantly reenacting the past.

Getting Help in Therapy
Making the decision to start therapy is an important step which most people don't take lightly, especially people with a history of trauma (see my article: The Benefits of Psychotherapy).

People with developmental trauma often come to therapy after they have had a series of major disappointments or setbacks in their life.

It takes courage to face a painful history of trauma, and most trauma-informed psychotherapists are aware of this and the clinical implications for the client (see my article: How to Choose a Psychotherapist).

If you think you might be living in the present as if it were the past, you owe it to yourself to get help from a licensed trauma-informed mental health professional.

Although the therapeutic work isn't quick or easy, once you have worked through the trauma, you can live a more fulfilling life without the burden of your past.

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).

I have helped many clients to overcome trauma so they could go on to live a more fulfilling life.

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 or email me.

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

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 feeling...by 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
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

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 Past, Understanding 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

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.

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

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 Therapist

Boundary Violations and Sexual Exploitation in Psychotherapy

Psychotherapy and the Positive Transference). 

Your Therapist 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
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. 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).

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