Transcript: Episode 283
282: Therapeutic Relationship, Part 2
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[Short piano piece is played, lasting about 20 seconds]
In this episode, we continue our earlier discussion of Courtois and Ford's chapter from Complex PTSD. Courtois and Ford said, “Empathic strain results from those interpersonal events in psychotherapy that weaken, injure, or force beyond reasonable limits the therapeutic response to the client. Countertransference processes are only one source of empathic strain. Yet we believe that in the treatment of PTSD, countertransference responses are perhaps the primary cause of treatment failure. Empathic errors, misunderstanding or misinterpretation of the client's intended or actual communication can occur as a result of countertransference that is from the therapist own personal history, the nature of the client's trauma history, institutional factors such as lack of support, and countertransference can lead a therapist to confuse empathy with sympathy by over identifying with, and attempting to rescue, or becoming over involved with a corresponding loss of professional boundaries, or an assumption that the client is too damaged or fragile to be able to change or to heal, and that the therapist must therefore rescue or provide. On the other hand, too little empathy, in contrast, results in therapists disinterest, disengagement, distancing, or withdraw, non-response, evasion and even aggression.”
I can't tell you how many times in my own history, or in the history of others that I have either worked with or consulted on, where there… I mean, there are cases, of course, where people have not enough boundaries and terrible things happen. Those kinds of things always show up on the news. What no one talks about is the opposite. Where boundaries are too rigid, or therapists are just too tired, or not engaged enough, so that not enough empathy is offered. And that can look like everything from refusing to work with parts, to forcing a specific treatment goal, to abandoning a client in pain because they're not getting over it fast enough, or they won't engage soon enough, when that withdraw or hesitation or shut down is absolutely part of the communication and a valid response to what they are experiencing. And when that is dismissed, or ignored, or not tended to, or not responded to, it becomes a kind of victim blaming, or a kind of gaslighting of where the therapist is saying, “you're doing this wrong, or “we have to do this my way,” or “you need to be doing this and this and this.” There are times for those kinds of conversations. But when those conversations are replacing empathy, because the therapist doesn't want to do their part of the work, that's not okay. A therapist cannot get so flustered by a client's presentation or the clients issues that it comes to the point of the therapist feeling or expressing directly or indirectly, frustration that the client is not getting better yet, or the client is not progressing as they should, or as fast as they should, or as quickly as they should, or in the way that they should. Because if they are not progressing, then what the therapist is doing is not being helpful. And the therapist first needs to change before the client can change. That's why the client is paying them.
They can get consultation. They can get further support. There's all kinds of things a therapist can do. But it's not the clients responsibility to do that part of the work for the therapist. That makes them the rescuer instead of a therapist being the rescuer. And all of that, either way, is acting out relational trauma. And one of the earliest ways to see that this is happening is that there starts to be a loop. And I don't mean like flashback intrusions, or getting stuck on a certain issue that is difficult to get out. But this relational loop where the client tries to do something, or express something, or share something, and the therapist responds in a particular way, or doesn't respond more likely, and so the client retreats, because that wasn't safe. There was misattunement. That's a rupture, you guys. And then the client tries again, and the same thing happens and they retreat again.
So sometimes, I know that like borderlines get stereotyped for this push and pull. But there can be a push and pull going on that is relational in nature, because of how the therapist is responding, that is not behavioral on the client. And then punishing the client for that behavior that is really on the part of the therapist, that's DARVO. That is domestic violence. That is that is the deny, attack, reverse offender and victim, which becomes gaslighting in the therapeutic relationship. And that's not okay. That is actual harm. That is abuse of the client, even if the therapist is good in lots of other ways, or really good at holding presence. When they've dismissed the client, when they Gaslight, the client, when they cause harm in these ways, that is one more layer of abuse that that client is dealing with.
And they may be so vulnerable, that it takes them a long time to figure out what's going on, to get out of this situation, to leave therapy. And if this shame builds up faster than they are able to process or figure out what's going on and they internalize that, that's when we get back to the high risk of suicidality. Because that's what it feels like, “this is not going to get better. It is my fault that it's going wrong.” And there is this despair because of what Laura Brown calls ‘the death of hope’. And that is when we have suicides. That is when we have premature treatment termination—people quitting therapy. I am not, I don't have data on this. But if I were giving anecdotal, I would say 95% of suicides, and 98% of people quitting therapy are because of this happening. This is huge. And it's important and we need to do better. It's not okay to hurt our people in these ways.
And in more neutral contacts. It's what we went through trying to make friends over the last year and understanding that clears out of, okay, this isn't actually me doing friendship wrong. You know what? It turns out, I'm actually a decent friend. I just had to find people who also wanted to be friends with me at the same time as I wanted to be friends with them. And so sorting out who those people are is the same thing as sorting out who those therapists are. You need a therapist who wants to help you at the same time as you also want help, who is able and willing to do the work at the same time as you are able and willing to do the work.
It's also true in marriage relationships. It's also in true with those of us who have been through religious abuse. Which is a whole different podcast episode that we need to talk about. But trying to find a faith tradition and an expression of your faith that is also healthy for you, is a big deal when you grew up with relational trauma.
Courtois and Ford said, “if the therapist erred, he or she needs to honestly own the behavior and apologize for the mistake, however, not from a position of abject shame.” So you can't shame your client and also apologize to them when you mess up. ruptures happen, but they need to be repaired. And if you're shaming your client as part of your apology, it doesn't count as an apology, and again, acts out the same relational trauma they've already been through. Courtois and Ford, “a sincere acknowledgement and apology can go a long way in modeling a new way of being in a relationship, one that is based on communication and mutual respect.”
I was once in therapy with that particular therapist for four years before realizing that they were very judgmental about a particular area of our life that was a really huge and important piece to us. And because that got shut down, that was such a big misattunement and such a rupture, that it nearly cost that relationship. And if that were tended to, we could have gotten through it or around it, or made a decision about if we could proceed with therapy or not when that was such a big area that was important to us. But it was not tended to at all, even though we tried over and over again to approach the subject. It was such a blind spot to the therapist, that it ultimately destroyed our therapeutic experience. And so it became part of like a long list of bad therapy experiences. When once again, we really hoped, “Oh, this time it will be different this time it will be different.” Which feels like that whole domestic violence cycle again, after growing up with relational trauma, right? That's how triggering it can be.
Courtois and Ford's say, “the goal is to assist the client in developing an earned secure style by providing a safe base in therapy from which to explore him or herself and others. The treatment relationship is at once technique, a relational bond and a container. It provides modeling of relational response and containment for the client that promotes an expanded repertoire of feelings and expression.” So then they talk about attachment styles a little bit, which obviously matters in therapy. Yay, Peter. Good job, Peter. They, these, these matter, attachment matters, especially with trauma. So thank you Peter Barach for linking that.
But Courtois and Ford talk about it in the context specifically of the therapeutic relationship. So let's look at that. With secure attachment, quote, “they are less immediately and globally mistrustful of others have a relatively healthy family and support system, have a generally positive self-concept and sense of self-worth, tend to be aware of, and in touch with, their emotions have access to positive and negative memories, and tend to have positive and straightforward views of caregivers and authority figures, and to be able to relate fairly well to them.”
So you guys after everything we have learned in the last year, and I'm talking about the pandemic and how that was so politicized, and the protests and learning about lived experience and why that matters. I honestly don't think I will ever again seek out a treatment, seek out treatment from a therapist who is a healthy person with secure attachment. Because at this point, I honestly have learned that they do not understand me. They don't know how to respond to me. They can have different skills and strengths that are fantastic. I am glad there are healthy people in the world. But the rate of misattunement is so high where they are literally baffled by me because they don't understand where I'm coming from. It’s too difficult. I am too tired and too fatigued by having to try to express myself to someone who does not understand what it's like to be in that place, that it's not worth my time in therapy anymore. I feel like it is not, like, it wastes my time, so that I am there in therapy, educating the therapist instead of getting therapy. And I'm just not going to do that anymore. That doesn't mean I want a therapist with bad boundaries, or a therapist who doesn't know how to take care of themselves. There's, it doesn't have to be that. But we're going to talk about that. But when someone has lived through hard things, knows how to disclose about that in appropriate ways—not where I get the details or sessions become about you, but to where I can tell you understand the struggle—there’s attunement in that. And that builds relationship. It doesn't keep you so far separated from me that, like, we're in the pandemic glass wall between us, right? It unites us together with you having good boundaries, and you having your work done. And you modeling what earned secure attachment looks like, which is the thing. And we'll talk about that in a minute. But that's what has become most comfortable to me. And it has become a place where I can go to therapy and relax, and collapse. Not in a shutdown kind of way. But in a sit down and breathe while still showing up kind of way. Because my therapist already understands where I'm coming from. And there is already attunement in place. Even though our stories are completely different.
So what I'm sharing is that we have found a therapist who has complex trauma herself. I don't need any details of what that means to her. And I'm not sharing any more details on the podcast. But what I'm sharing is that we have chosen a therapist, specifically who already understands, because I can't go through any more experiences of being shamed for my response to what I went through, which is not my fault. And that's not okay. And I don't think I will survive another experience like that. And so this is a critical change that we have learned over the last year that I think is making all the difference in the world. My therapist, to be clear, has never once said, “this is what my complex trauma looks like,” or “this is what my symptoms are,” or “this is what I went through.” Like her boundaries are excellent. She's very careful about consent. She's very careful about boundaries. She's very careful about keeping me safe. But I know she knows what complex trauma is. And I know she has her own therapist. And I know what she does to take—well I don't know what she does to take care of herself—I know that she takes care of herself. You know why? Because we tended to it in the relationship. Our relationship was safe enough that I could literally ask the question, “do you have a therapist? Do you take care of yourself? How will I not trigger you? How can I share da da da da?” These were conversations we could actually have, where I asked questions of my therapist, were never before in therapy have I felt it was okay to ask any question, much less about my therapist. And so this is an example of good boundaries, but also a relationship where we can have conversations about these things. And it has made all the difference in the world.
Because without that, what happens is what Courtois and Ford say, quote, “if they express needs, and these were not responded to, they would be devastated and would blame themselves rather than the person who responded poorly and disappointed them.” Which goes back to what Chefetz calls the ‘attackment’ that parents, or therapists, by virtue of their own unresolved history, behave in ways that are unpredictable and inconsistent, frightened by their own stuff or frightening the clients or their children. The parent is at once the source of needed attachment and the source of abuse in pain. Which leaves the child or the client highly physically and emotionally dysregulated and shame bound, seeing themselves in negative ways, sincerely believing that they were deserving of this abuse and that neglect.
You guys, that's such a painful place to be. And if I have really made enough progress in therapy over the years, to say, “it's not okay to be treated that way,” then I also have to seek out a therapist who doesn't treat me that way. To where I don't leave therapy feeling like I've just been abused again. To where someone, I mean, I have to do my own work. I'm responsible for that. And I want someone who can hold presence with me or is not going to shy away from my pain, who's strong enough to deal with that and to be present with me and that. But I also need that pain responded to and tended to, because that's why it's still there is because it hasn't been yet. So it doesn't matter how many secrets I cough up if we just leave them on the table. I don't need to regurgitate just for the sake of regurgitating, I don't need to sit there waiting for permission to exist. If you are really saying what happened to me was not okay. And that the responsibility of these secrets are not mine. Then I want to put them down instead of carrying them around. And I want to walk away, because they're not mine. And then I want to be tended to, and cared for, and responded to. Not just still be alone with nothing. And that's the difference. I can't just pretend that nothing ever happened. I already am really good at dissociating, I could pretend that nothing ever happened without also being abandoned by my therapist.
So if I'm going to lay these things down, or if I'm going to share parts of myself, I need to be responded to and tended to, because I exist. And I have the right to interact with others. And I am empowered to say, “this is what I need. To be treated like a human being.” And Courtois and Ford say the therapy relationship is the therapy.
That's all I want to share from this chapter. But it's so powerful, and it impacts every area of life.
And where we have come to is that we are married to Nathan, not just because he is kind, but also because he is responsive. And we have changed our parenting so that we are not just trying to be present with them, or teaching them lessons that they need to learn in concrete ways that they are able to process, but also that we respond to and tend to their pain, and their stories and their communications as they learn how. And it means that we have actually come out of the pandemic with more friends than we went into the pandemic with because we have learned how to try to connect with others, even while our skill set for friendship is still raw and messy and new. But it's responding to and tending to that matters. And sometimes that's not always possible. Like we have two friends who are very good at being both present and responsive. But they also know our previous therapists and so because of those boundaries, that just has to be off limits. And so it shuts down a huge part of our life, which is just heartbreaking. But that's how we can navigate that.
But because of those experiences of being tended to and responded to, we have also been able to do the work, or at least start the work, of building other friendships as well. We’ve been friends with Peter now for two years? Three years? That's a long time. And he is responsive and tends to and we can share with him and he can share with us. And, and, other friends that we have met that have been colleagues who have become friends over the last year or two. And now we're making new friends with other people who have DID and are also clinicians. And that has been a powerful experience. And learning that it's okay that we need that tended to, and being with that group, meeting on a regular basis. And practicing, sharing, practicing taking turns, practicing listening and being present with and tending to, and also practicing receiving that. You guys, it's been so good for us. There are friends who we met through the podcast, who have stayed in touch with us, or who we have connected with and respond to us. And we are trying to learn to respond to them. These different friendships, you guys, are so new to us. And our skills are still so few. And yet those relationships feel solid. And now a year after the pandemic started we have more friends than we've ever had in our life. And not that we need 100 billion friends, I'm not talking about that. But closeness and intimacy with other people where when we are in crisis, or just having a good day, or thinking about something that's difficult and just need to bounce something off, or just vent something, like these normal things. We have choices where that goes.
So it's okay and not a crisis anymore that we have two really precious friends that we can't talk to about therapy anymore. Because we have these friends over here where we can talk about that. And so learning to broaden our friendships or our relationships has helped us find a new kind of stability. And having a different kind of therapist who is responsive in a different kind of way, helping us address things and tend to things instead of just leaving them out there where we're acting out our abuse again. That has made us strong in the comfort that we receive from that tending to. And having had not just bad therapy experiences in the past, but also good therapy experiences, knowing that those things matter. Like you know what I really miss from the pandemic is the sand tray, for example. You guys, the sand tray was kind of cool in lots of ways. Like there were things that we could get out. And so now we can paint. And we can use words, because we got a taste of what that experience was. And we can take that and keep the good. Or like our previous therapist that was so good with presence. Like she set the bar high. And we're not going to be with a therapist ever again that cannot just be present at that level. Like she set the bar high for this is what good therapy looks like. And we need more of that. And so we know what to look for now.
So even though we've been through hard things, or different experiences that were difficult relationally, we've learned what we need. And we are learning through that to tend to it ourselves. And that can have good boundaries. I'm going to use Peter again because he is a safe friend. And I just feel like this is an okay thing to share. Peter and I can message random things to each other all the time, right? But there are times where I'm saying “oh my goodness, this is what's happening da da da da.” And because I'm a deaf person, it comes out through text. I don't automatically pick up the phone. I'm learning to pick up the phone. My two safe friends, actually, I'm practicing with them. So a shout out to them because they have been good safe people and I'm learning to use the phone with them. And that has never happened before. So that's huge. The DID therapists that I am getting close to—we meet every week by Zoom. And so I'm getting practice at video where that has always been very difficult for me. But poor Peter, like, I'll just send an essay to his phone because that's, that's just, comes out like I just, “da da da da”. And sometimes we will talk back and forth or banter back and forth, or just you know, like friendship things, right? But other times Peter will say, “Hey, I'm getting ready to go into a session, so I can't reply right now.” Because he has boundaries. But you guys, that's just information. It doesn't hurt me when he says that. It's just communicating, “I will still tend to you, but I have to go do this right now.” But you know what? He still tends to it. Later when he's done with doing his sessions or whatever, then he comes back and we finish our conversation. And there are times one of my friends has lots of cases with her job, right? And so like, I understand that, because I have cases, my clients, right? And will say, “Hey, can you go for a walk today?” “No, because I've got a lot of cases I have to do.” Like I get that. And those are good boundaries. And for me, those kinds of healthy boundaries as part of a relationship matter a lot. Because if you can set those healthy boundaries, then I know that your yes really is a yes because your no means no. Does that make sense?
And so these same things that build a healthy relationship in therapy, even though your therapist is not your parent, and your therapist is not your friend, those same lessons in the relationship that you learn, you get to carry with you. And so, there are so many people in my life now that offer me the grace and the space, as they say, to practice these things and learn them in healthy ways that are really, really fantastic. And I just want to point that out. Because we have come through a difficult year, where our feelings were big, the pandemic seemed endless—and maybe it still does in some ways—politics were brutal. There was so much negativity in so many ways, with what was going on with politics, and people taking sides and all of this divisive nastiness. And because we were going through our own issues, we were in such a dark place. And all of that is valid to have to deal with. But I also just want to acknowledge when we have a good day, and when we're okay.
And these things that we learn in the therapeutic relationship, need to be able to contain all of that. Need to be able to respond to all of that. When things are hard. When things are good. When it's difficult to engage. When there is a withdraw or a retreat because there are warning flags going off or alarm bells going off. You guys that's just the amygdala, you don't have to hate on him. It's not an offensive thing. Listen to your amygdala. Teach your amygdala what's okay and what's not. We can be present with all of these pieces, and engaged as people, and still have healthy boundaries. And learning how to do that has changed our life considerably. So that literally yesterday, last night, we spent seven hours on Zoom with friends, slept all night—which has never happened before except for after therapy—and woke up feeling happy. And with that kind of strength we wrote our fairy tale for therapy, the first part of it, and did some painting and had some rest. And we'll go to therapy tomorrow and engage in that process again. And that becomes that upward cycle in a good way, instead of that escalating downward spiral. And it's huge. It changes everything for the person. Being a good therapist isn't just about skills. It's about caring for yourself. It's about having safe people in your own life and when you don't, doing the work to first get safe, and then to find other safe people. And being not just present in people's pain, but responsive to them as people. That's what it means to be a good therapist.
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Thank you for joining us for System Speak – a podcast about dissociative identity disorder. This podcast is available on any podcast player and on systemspeak.org. If you would like to know more of our story, our memoir, If Tears Were Prayers, is now available at systemspeakbooks.com. Thank you for listening.