This publication is protected by copyright law and a single copy of the textbook “ Skilled Empathy”
may be downloaded from this website if used exclusively for personal participation and
registration in the CM Home Study Course and for non-commercial use only, and that all
copyright notes are kept and the publication is not altered.
SKILLED EMPATHY
Creating Safety
Through Therapeutic
Attachment
Laura E. Gollnick, M.S., M.F.T.
SKILLED EMPATHY
SKILLED EMPATHY
Creating Safety
Through Therapeutic
Attachment
Creating Safety
Through Therapeutic
Attachment
1st Edition
1st Edition
Laura E. Gollnick, M.S., M.F.T.
Laura E. Gollnick, M.S., M.F.T.
Wellness Plus
2945 Stonehill Drive
Altadena, CA 91001
(626) 794-9260
iii
Wellness Plus
2945 Stonehill Drive
Altadena, CA 91001
(626) 794-9260
iii
Copyright  2004, Laura E. Gollnick
With the EXCEPTION NOTED BELOW, all rights reserved.
No part of this publication may be reproduced, stored in a
retrieval system or transmitted in any form or by any means:
electronic, electrostatic, magnetic tape, mechanical, photocopying, or recording, without the permission, in writing, of
the publisher.
EXCEPTION: The publisher grants to individual purchasers
nonassignable permission to reproduce the forms, questionnaires, or scripts in the Appendices for clinical use with their
clients and has included them on a CD inside the back cover.
First Edition
First Printing - April 2004
Second Printing - August 2004
Third Printing - August 2005
Fourth Printing - December 2005
Fifth Printing - March 2006
Sixth Printing - July 2006
ISBN 0-9746157-0-6
Wellness Plus
Printed in the United States of America
iv
Credits
Credits
Front Cover
Image  2003 www.clipart.com.
Chapter 1
Pages 15, 18-19, from Kenneth S. Pope & Laura Brown (1996). Recovered Memories of Abuse:
Assessment, Therapy, Forensics. Washington, DC: American Psychological Association. Copyright 1996 by the American Psychological Association. Adapted with permission.
Chapter 1
Pages 31-36, adapted by permission from Office Policies & General Information Agreement for
Psychotherapy Services, as published in Clinical Forms. Copyright 2002 by Ofer Zur, Ph.D.,
www.drzur.com or (707)935-0655.
Front Cover
Image  2003 www.clipart.com.
Chapter 1
Pages 15, 18-19, from Kenneth S. Pope & Laura Brown (1996). Recovered Memories of Abuse:
Assessment, Therapy, Forensics. Washington, DC: American Psychological Association. Copyright 1996 by the American Psychological Association. Adapted with permission.
Chapter 1
Pages 31-36, adapted by permission from Office Policies & General Information Agreement for
Psychotherapy Services, as published in Clinical Forms. Copyright 2002 by Ofer Zur, Ph.D.,
www.drzur.com or (707)935-0655.
Chapter 2
Pages 47, 59 excerpted from George S. Everly, Jr. & Jeffrey M. Lating (Eds.), (1995), Psychotraumatology: Key Papers and Core Concepts in Post-Traumatic Stress. New York: Plenum
Press. Reprinted by permission of Plenum Press.
Chapter 2
Appendix A, pages 71-73, copied with permission from New Harbinger Publications, Oakland,
CA, Tracy Alderman, The Scarred Soul: Understanding & Ending Self-Inflicted Violence.
www.newharbinger.com.
Chapter 2
Page 59, from Shame and Pride: Affect, Sex, and the Birth of the Self by Donald L. Nathanson.
Copyright  1992 by Donald L. Nathanson. Used by permission of W. W. Norton & Company,
Inc.
Chapter 2
Pages 47, 59 excerpted from George S. Everly, Jr. & Jeffrey M. Lating (Eds.), (1995), Psychotraumatology: Key Papers and Core Concepts in Post-Traumatic Stress. New York: Plenum
Press. Reprinted by permission of Plenum Press.
Chapter 2
Appendix A, pages 71-73, copied with permission from New Harbinger Publications, Oakland,
CA, Tracy Alderman, The Scarred Soul: Understanding & Ending Self-Inflicted Violence.
www.newharbinger.com.
Chapter 2
Page 59, from Shame and Pride: Affect, Sex, and the Birth of the Self b y Donald L. Nathanson.
Copyright  1992 by Donald L. Nathanson. Used by permission of W. W. Norton & Company,
Inc.
Chapter 3
Page 84, excerpted from George S. Everly, Jr. & Jeffrey M. Lating (Eds.), (1995), Psychotraumatology: Key Papers and Core Concepts in Post-Traumatic Stress. New York: Plenum Press.
Reprinted by permission of Plenum Press.
Chapter 4
Pages 115-117, from Why Marriages Succeed or Fail: What You Can Learn from the Breakthrough Research to Make Your Marriage Last by John Gottman, Ph.D. with Nan Silver. Copyright  1994 by John Gottman. By permission of Simon & Schuster Adult Publishing Group. All
rights reserved.
Chapter 4
Appendix A, page 133, adapted from Judith V. Jordan & Cate Dooley (2001). Relational Practice
in Action: A Group Manual. Wellesley, MA: Stone Center Publications, Wellesley College.
Chapter 4
Appendix A, page 134, from Shame and Pride: Affect, Sex, and the Birth of the Self by Donald L.
Nathanson. Copyright  1992 by Donald L. Nathanson. Used by permission of W. W. Norton &
Company, Inc.
Chapter 3
Page 84, excerpted from George S. Everly, Jr. & Jeffrey M. Lating (Eds.), (1995), Psychotraumatology: Key Papers and Core Concepts in Post-Traumatic Stress. New York: Plenum Press.
Reprinted by permission of Plenum Press.
Chapter 4
Pages 115-117, from Why Marriages Succeed or Fail: What You Can Learn from the Breakthrough Research to Make Your Marriage Last by John Gottman, Ph.D. with Nan Silver. Copyright  1994 by John Gottman. By permission of Simon & Schuster Adult Publishing Group. All
rights reserved.
Chapter 4
Appendix A, page 133, adapted from Judith V. Jordan & Cate Dooley (2001). Relational Practice
in Action: A Group Manual. Wellesley, MA: Stone Center Publications, Wellesley College.
Chapter 4
Appendix A, page 134, from Shame and Pride: Affect, Sex, and the Birth of the Self b y Donald L.
Nathanson. Copyright  1992 by Donald L. Nathanson. Used by permission of W. W. Norton &
Company, Inc.
v
v
Chapter 6
Page 209, from Judith V. Jordan & Cate Dooley (2001), Relational Practice in Action: A Group
Manual. Wellesley, MA: Stone Center Publications, Wellesley College.
Chapter 6
Pages 210-211, from Jean Baker Miller & Irene Pierce Stiver, The Healing Connection: How
Women Form Relationships in Therapy and in Life. Boston: Beacon Press. Reprinted by permission.
Chapter 6
Page 210, excerpted from George S. Everly, Jr. & Jeffrey M. Lating (Eds.). (1995), Psychotraumatology: Key Papers and Core Concepts in Post-Traumatic Stress. New York: Plenum Press.
Reprinted by permission of Plenum Press.
Chapter 7
Pages 229, 235-236, 239, from Healing the Incest Wound: Adult Survivors in Therapy by Christine A. Courtois. Copyright  1988 by Christine A. Courtois. Used by permission of W. W.
Norton & Company, Inc.
Chapter 7
Pages 204-244, from B.G. Braun (1988) The BASK (behavior, affect, sensation, knowledge)
model of dissociation. Dissociation, 1(2), and B.G. Braun (1988) The BASK Model of Dissociation: Treatment. Dissociation, 1(1). Reprinted by permission of the Ridgeview Institute.
Chapter 8
Pages 262-264, from Kenneth S. Pope & Laura Brown (1996). Recovered Memories of Abuse:
Assessment, Therapy, Forensics. Washington, DC: American Psychological Association. Copyright 1996 by the American Psychological Association. Adapted with permission.
Chapter 9
Pages 278-279, 283-286, from Edmund W. L. Smith, Pauline Rose Clance & Suzanne Imes
(Eds.), (1998), Touch in Psychotherapy: Theory, Research, and Practice. New York: Guilford
Publications, Inc. Reprinted by permission.
Chapter 10
Pages 305-306, Copyright 1995 From Compassion Fatigue: Coping with Secondary Traumatic
Stress Disorder in Those Who Treat the Traumatized by Charles Figley. Reproduced by permission of Routledge/Taylor & Francis Books, Inc.
Chapter 10
Pages 305-308, 310-314, from Trauma and the Therapist by Laurie Anne Pearlman and Karen W.
Saakvitne. Copyright  1995 by Laurie A. Pearlman and Karen W. Saakvitne. Used by permission of W. W. Norton & Company, Inc.
Chapter 11
Pages 330-332, from Preparing Your Clients and Yourself for the Unexpected: Therapeutic Illness, Retirement and Death, by Ann Steiner, www.psychotherapistresources.com Copyright 
2002 by PsychotherapistResources.com. Used by permission of Ann Steiner, Ph.D.
Chapter 6
Page 209, from Judith V. Jordan & Cate Dooley (2001), Relational Practice in Action: A Group
Manual. Wellesley, MA: Stone Center Publications, Wellesley College.
Chapter 6
Pages 210-211, from Jean Baker Miller & Irene Pierce Stiver, The Healing Connection: How
Women Form Relationships in Therapy and in Life. Boston: Beacon Press. Reprinted by permission.
Chapter 6
Page 210, excerpted from George S. Everly, Jr. & Jeffrey M. Lating (Eds.). (1995), Psychotraumatology: Key Papers and Core Concepts in Post-Traumatic Stress. New York: Plenum Press.
Reprinted by permission of Plenum Press.
Chapter 7
Pages 229, 235-236, 239, from Healing the Incest Wound: Adult Survivors in Therapy by Christine A. Courtois. Copyright  1988 by Christine A. Courtois. Used by permission of W. W.
Norton & Company, Inc.
Chapter 7
Pages 204-244, from B.G. Braun (1988) The BASK (behavior, affect, sensation, knowledge)
model of dissociation. Dissociation, 1(2), and B.G. Braun (1988) The BASK Model of Dissociation: Treatment. Dissociation, 1(1). Reprinted by permission of the Ridgeview Institute.
Chapter 8
Pages 262-264, from Kenneth S. Pope & Laura Brown (1996). Recovered Memories of Abuse:
Assessment, Therapy, Forensics. Washington, DC: American Psychological Association. Copyright 1996 by the American Psychological Association. Adapted with permission.
Chapter 9
Pages 278-279, 283-286, from Edmund W. L. Smith, Pauline Rose Clance & Suzanne Imes
(Eds.), (1998), Touch in Psychotherapy: Theory, Research, and Practice. New York: Guilford
Publications, Inc. Reprinted by permission.
Chapter 10
Pages 305-306, Copyright 1995 From Compassion Fatigue: Coping with Secondary Traumatic
Stress Disorder in Those Who Treat the Traumatized by Charles Figley. Reproduced by permission of Routledge/Taylor & Francis Books, Inc.
Chapter 10
Pages 305-308, 310-314, from Trauma and the Therapist by Laurie Anne Pearlman and Karen W.
Saakvitne. Copyright  1995 by Laurie A. Pearlman and Karen W. Saakvitne. Used by permission of W. W. Norton & Company, Inc.
Chapter 11
Pages 330-332, from Preparing Your Clients and Yourself for the Unexpected: Therapeutic Illness, Retirement and Death, by Ann Steiner, www.psychotherapistresources.com Copyright 
2002 by PsychotherapistResources.com. Used by permission of Ann Steiner, Ph.D.
vi
vi
Foreword
Foreword
It took me a long time to realize that safety was of primary importance to the clinical relationship.
It took me a long time to realize that safety was of primary importance to the clinical relationship.
I had responded to unsafe situations as a client by leaving the therapist or as a therapist by losing
I had responded to unsafe situations as a client by leaving the therapist or as a therapist by losing
the client when I failed to be able to create a safe environment. It was only after years of practice
the client when I failed to be able to create a safe environment. It was only after years of practice
that I began to conceive of those withdrawals as due to a lack of safety. I know now that the client’s
that I began to conceive of those withdrawals as due to a lack of safety. I know now that the client’s
feeling of safety, no matter how labeled, is a crucial element of effective treatment.
feeling of safety, no matter how labeled, is a crucial element of effective treatment.
Some clients have the where-with-all to feel relatively safe quite easily, but many do not. In order
Some clients have the where-with-all to feel relatively safe quite easily, but many do not. In order
to build the type of relationship necessary for effective therapy, therapists must develop the skills
to build the type of relationship necessary for effective therapy, therapists must develop the skills
to work with those who have difficulty trusting others. Recognizing the clues that tell the therapist
to work with those who have difficulty trusting others. Recognizing the clues that tell the therapist
that the client is not feeling safe is also of great importance. Laura Gollnick has provided both be-
that the client is not feeling safe is also of great importance. Laura Gollnick has provided both be-
ginners in the field and more experienced therapists with a guidebook that will allow them to de-
ginners in the field and more experienced therapists with a guidebook that will allow them to de-
velop the necessary skills to create safety or to refine the skills they have so that they are better able
velop the necessary skills to create safety or to refine the skills they have so that they are better able
to serve their clients. She has brought together a wealth of information that covers a topic that is
to serve their clients. She has brought together a wealth of information that covers a topic that is
rarely addressed by itself. This effort is a very worthwhile contribution to the field of psychother-
rarely addressed by itself. This effort is a very worthwhile contribution to the field of psychother-
apy that will be of value to many, many therapists.
apy that will be of value to many, many therapists.
Sheryn T. Scott, Ph.D.
Associate Professor
Director of Clinical Training
Azusa Pacific University
Sheryn T. Scott, Ph.D.
Associate Professor
Director of Clinical Training
Azusa Pacific University
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Preface
Preface
HOW TO USE THIS MANUAL
HOW TO USE THIS MANUAL
Becoming a good therapist can be a challenging and exciting experience. A great deal has been
written about being empathic and respectful. Outside of reflective listening, little information is
available about what can be specifically done to create an environment that is safe for clients to
explore their issues. It is often difficult to know where to gain the knowledge of the actual nuts and
bolts of relating to clients and helping them to grow. I hope this manual is a place to begin that journey. Some people learn best from examples and clearly outlined procedures, and others learn best
through a more cognitive or conceptual format. I have tried to offer information in such a way that
both types of clinicians can find ways to increase the safety in the work that they do.
Becoming a good therapist can be a challenging and exciting experience. A great deal has been
written about being empathic and respectful. Outside of reflective listening, little information is
available about what can be specifically done to create an environment that is safe for clients to
explore their issues. It is often difficult to know where to gain the knowledge of the actual nuts and
bolts of relating to clients and helping them to grow. I hope this manual is a place to begin that journey. Some people learn best from examples and clearly outlined procedures, and others learn best
through a more cognitive or conceptual format. I have tried to offer information in such a way that
both types of clinicians can find ways to increase the safety in the work that they do.
This manual was not meant to be all inclusive regarding every topic a therapist might need to deal
with in therapy. I have not addressed safety issues around domestic violence, bereavement, death
and dying, and chronic illness. However, the tools that are described are applicable to many of the
topics you will deal with as a therapist. Also, this work is designed primarily for adults. Couple
work is alluded to in examples and sample dialogues but is not addressed in any specific way
though safety is important to couple work.
This manual was not meant to be all inclusive regarding every topic a therapist might need to deal
with in therapy. I have not addressed safety issues around domestic violence, bereavement, death
and dying, and chronic illness. However, the tools that are described are applicable to many of the
topics you will deal with as a therapist. Also, this work is designed primarily for adults. Couple
work is alluded to in examples and sample dialogues but is not addressed in any specific way
though safety is important to couple work.
There are many valuable theoretical orientations that help us to understand how and why clients
are the way they are. However, I have chosen to provide only minimal theoretical orientation here.
What I have included is material that I think is basic to understanding certain aspects of the treatment relationship such as a brief summary of Attachment Theory. In addition, I discuss some theoretical ways of understanding interactions that I teach to clients, for example, the Drama Triangle
from Transactional Analysis.
There are many valuable theoretical orientations that help us to understand how and why clients
are the way they are. However, I have chosen to provide only minimal theoretical orientation here.
What I have included is material that I think is basic to understanding certain aspects of the treatment relationship such as a brief summary of Attachment Theory. In addition, I discuss some theoretical ways of understanding interactions that I teach to clients, for example, the Drama Triangle
from Transactional Analysis.
The chapters need not be read sequentially. Some of the chapters are free standing so that you can
choose which chapter best meets your needs at any one time. Thus, I have repeated certain information as it relates to the topic of that particular chapter or within sections of a chapter to avoid
having to flip back and forth from one section or chapter to another to find the relevant material.
The chapters need not be read sequentially. Some of the chapters are free standing so that you can
choose which chapter best meets your needs at any one time. Thus, I have repeated certain information as it relates to the topic of that particular chapter or within sections of a chapter to avoid
having to flip back and forth from one section or chapter to another to find the relevant material.
Throughout the manual, clinical examples have been provided to illustrate the concepts presented.
The intent of this manual is to be a starter kit for new therapists and to provide experienced therapists with ways to enhance their practice.
Throughout the manual, clinical examples have been provided to illustrate the concepts presented.
The intent of this manual is to be a starter kit for new therapists and to provide experienced therapists with ways to enhance their practice.
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No therapist’s practice is complete without a drawer full of forms. Many of the forms that I have
found to be useful are included in this manual as Appendices and in electronic form on a CD inside
the back cover. Other appendices have been included to give the therapist tools to supplement the
material in the chapters (i.e., questionnaires, scripts, background information).
Feel free to reproduce any of the forms, questionnaires, or scripts for use with your clients as
indicated in the copyright notice.
No therapist’s practice is complete without a drawer full of forms. Many of the forms that I have
found to be useful are included in this manual as Appendices and in electronic form on a CD inside
the back cover. Other appendices have been included to give the therapist tools to supplement the
material in the chapters (i.e., questionnaires, scripts, background information).
Feel free to reproduce any of the forms, questionnaires, or scripts for use with your clients as
indicated in the copyright notice.
Chapter One sets the stage for creating safety through the therapeutic attachment. It emphasizes the
importance of the initial telephone contact and the initial session in the developing of safety between the client and the therapist. This chapter provides a format for gathering an extensive amount
of information so that a comprehensive history can be taken resulting in a more accurate diagnosis
and effective treatment.
Chapter One sets the stage for creating safety through the therapeutic attachment. It emphasizes the
importance of the initial telephone contact and the initial session in the developing of safety between the client and the therapist. This chapter provides a format for gathering an extensive amount
of information so that a comprehensive history can be taken resulting in a more accurate diagnosis
and effective treatment.
Chapter Two complements the first chapter by assessing how safe the client is in the present. It provides a format to assess the safety and stability of the client’s physical self-care, whether or not
there are self-harming behaviors present and the level of safety and stability that exists at an environmental level. Exploring the client’s interpersonal history conveys that safety needs to permeate
all the therapeutic work as well as the client’s outside relationships.
Chapter Two complements the first chapter by assessing how safe the client is in the present. It provides a format to assess the safety and stability of the client’s physical self-care, whether or not
there are self-harming behaviors present and the level of safety and stability that exists at an environmental level. Exploring the client’s interpersonal history conveys that safety needs to permeate
all the therapeutic work as well as the client’s outside relationships.
Chapter Three discusses several important treatment issues (i.e., boundaries, contracts, phone containment) that need to be carefully considered to keep both the client and the therapist safe. Also
discussed is what happens in between sessions. These concerns are the nuts and bolts that keep the
therapeutic relationship healthy. There is a far greater level of safety when each of these treatment
issues is carefully put into place. For many clients the therapeutic relationship may be the first
healthy attachment they experience.
Chapter Three discusses several important treatment issues (i.e., boundaries, contracts, phone containment) that need to be carefully considered to keep both the client and the therapist safe. Also
discussed is what happens in between sessions. These concerns are the nuts and bolts that keep the
therapeutic relationship healthy. There is a far greater level of safety when each of these treatment
issues is carefully put into place. For many clients the therapeutic relationship may be the first
healthy attachment they experience.
Chapter Four emphasizes the need for the therapist to be sensitive and empathic to the client’s feelings, both spoken and unspoken. It gives practical tools in a number of areas such as expanding the
client’s affect, identifying recurring themes, dealing with uncomfortable feelings, and covering up
feelings with anger. Shame-based feelings are addressed as they impact both the client and the therapeutic relationship. Another important area that is relevant to creating safety is how therapists
may block themselves from dealing with clients’ feelings and the effect this has on the relationship.
This chapter offers several basic exercises that can be used to teach clients about feelings and how
to use these feelings to take care of themselves.
Chapter Four emphasizes the need for the therapist to be sensitive and empathic to the client’s feelings, both spoken and unspoken. It gives practical tools in a number of areas such as expanding the
client’s affect, identifying recurring themes, dealing with uncomfortable feelings, and covering up
feelings with anger. Shame-based feelings are addressed as they impact both the client and the therapeutic relationship. Another important area that is relevant to creating safety is how therapists
may block themselves from dealing with clients’ feelings and the effect this has on the relationship.
This chapter offers several basic exercises that can be used to teach clients about feelings and how
to use these feelings to take care of themselves.
Chapter Five strongly suggests the need for therapists to convey to clients that comforting and
soothing themselves is important. Those clients with trauma or abuse histories are especially in
need of these skills, though they may have difficulty in learning or incorporating them. This chapter
provides a very practical guide to teaching clients the process of relaxation accompanied by the
relevant information about how the nervous system functions. The concept of creating a safe place
within themselves is also discussed. Several self-soothing exercises are provided to help clients
create safety.
Chapter Five strongly suggests the need for therapists to convey to clients that comforting and
soothing themselves is important. Those clients with trauma or abuse histories are especially in
need of these skills, though they may have difficulty in learning or incorporating them. This chapter
provides a very practical guide to teaching clients the process of relaxation accompanied by the
relevant information about how the nervous system functions. The concept of creating a safe place
within themselves is also discussed. Several self-soothing exercises are provided to help clients
create safety.
Chapter Six addresses issues of trust. Identifying those childhood ruptures of trust that their clients
have experienced can help therapists to enhance safety within the therapeutic relationship. Therapists need to understand how their own pattern of attachment may affect the therapeutic relationship in positive or negative ways as well. The concept of self is discussed as a way of helping
Chapter Six addresses issues of trust. Identifying those childhood ruptures of trust that their clients
have experienced can help therapists to enhance safety within the therapeutic relationship. Therapists need to understand how their own pattern of attachment may affect the therapeutic relationship in positive or negative ways as well. The concept of self is discussed as a way of helping
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clients define and understand the effect that ruptures of trust may have had on them. A number of
exercises are offered to strengthen the client’s support system.
clients define and understand the effect that ruptures of trust may have had on them. A number of
exercises are offered to strengthen the client’s support system.
Chapter Seven discusses the special issues concerning the maintenance of safety when dealing with
past trauma. It identifies the three symptom clusters of PTSD which are intrusiveness, avoidance
and numbing, and hyperarousal. There is further discussion of what these symptoms look like in
the client’s life and some ways of working with them. Some indications of dissociation are discussed. This chapter suggests ways to teach clients about the dissociative process.
Chapter Seven discusses the special issues concerning the maintenance of safety when dealing with
past trauma. It identifies the three symptom clusters of PTSD which are intrusiveness, avoidance
and numbing, and hyperarousal. There is further discussion of what these symptoms look like in
the client’s life and some ways of working with them. Some indications of dissociation are discussed. This chapter suggests ways to teach clients about the dissociative process.
Chapter Eight complements Chapter Seven as it uses the knowledge contained therein to enable
clients who have trauma or abuse in their background to heal.This chapter emphasizes maintaining
safety while exploring the trauma or abuse. How integrative memory work and reconnecting with
self and others is interwoven throughout the healing work is explained. This chapter also discusses
memory issues and the controversy that exists around recovered memories which is useful to understand when doing integrative memory work.
Chapter Eight complements Chapter Seven as it uses the knowledge contained therein to enable
clients who have trauma or abuse in their background to heal.This chapter emphasizes maintaining
safety while exploring the trauma or abuse. How integrative memory work and reconnecting with
self and others is interwoven throughout the healing work is explained. This chapter also discusses
memory issues and the controversy that exists around recovered memories which is useful to understand when doing integrative memory work.
Chapter Nine offers a rationale for the therapeutic use of touch which, when utilized appropriately,
can help some clients to heal. When newborns and infants experience trauma or neglect, they learn
that the universe is not a safe place. Preverbal or subcortical messages are stored in the musculature
of the body. This chapter discusses the subject of touch and whether or not its use may be appropriate. It offers a number of practical suggestions that can be used with clients.
Chapter Nine offers a rationale for the therapeutic use of touch which, when utilized appropriately,
can help some clients to heal. When newborns and infants experience trauma or neglect, they learn
that the universe is not a safe place. Preverbal or subcortical messages are stored in the musculature
of the body. This chapter discusses the subject of touch and whether or not its use may be appropriate. It offers a number of practical suggestions that can be used with clients.
Chapter Ten suggests ways that therapists can help prevent burnout and vicarious traumatization
which are natural results of clinical work. Therapists are encouraged to utilize a number of strategies at both a work-related and personal level for dealing with vicarious traumatization. Exercises
are provided to help therapists explore their own history of safety and identify what keeps them
from caring for themselves. This chapter is most likely to be overlooked in an effort to learn
the new skills presented. I encourage you not to do this!
Chapter Ten suggests ways that therapists can help prevent burnout and vicarious traumatization
which are natural results of clinical work. Therapists are encouraged to utilize a number of strategies at both a work-related and personal level for dealing with vicarious traumatization. Exercises
are provided to help therapists explore their own history of safety and identify what keeps them
from caring for themselves. This chapter is most likely to be overlooked in an effort to learn
the new skills presented. I encourage you not to do this!
Chapter Eleven is about the process of closure. Clients and therapists are frequently left with a
sense of unfinished business regardless of the therapeutic relationship when there is no closure.
The experience of saying goodbye often necessitates a grieving process for both the therapist and
the client. Clients have a tendency to avoid bringing the relationship to a close unless actively supported by the therapist in this process. Closure is a way of affirming and celebrating the growth of
the client. This chapter provides therapists with a number of exercises that could be utilized as well
as sample follow-up letters that could be sent to clients.
Chapter Eleven is about the process of closure. Clients and therapists are frequently left with a
sense of unfinished business regardless of the therapeutic relationship when there is no closure.
The experience of saying goodbye often necessitates a grieving process for both the therapist and
the client. Clients have a tendency to avoid bringing the relationship to a close unless actively supported by the therapist in this process. Closure is a way of affirming and celebrating the growth of
the client. This chapter provides therapists with a number of exercises that could be utilized as well
as sample follow-up letters that could be sent to clients.
I would suggest that therapists go on the world wide web for more in depth information on the topics presented here. The web is also a good resource for clients who need to locate community referrals.
I would suggest that therapists go on the world wide web for more in depth information on the topics presented here. The web is also a good resource for clients who need to locate community referrals.
MY JOURNEY
MY JOURNEY
The concept of safety has always been important to me as a person and has been interwoven
through my work as a therapist.
The concept of safety has always been important to me as a person and has been interwoven
through my work as a therapist.
About ten years ago I approached Dr. Sheryn Scott with an outline for a workshop on creating safety with deeply wounded clients. As the outline got fleshed out, I became excited about teaching
About ten years ago I approached Dr. Sheryn Scott with an outline for a workshop on creating safety with deeply wounded clients. As the outline got fleshed out, I became excited about teaching
x
x
this topic to beginning therapists. After reviewing the literature I realized that safety, though generally alluded to, was not emphasized as a topic by most authors. I was thrilled when I discovered
books that discussed safety in some depth. Laura Davis has a chapter on safety in The Courage to
Heal Workbook. Judith Herman discusses safety in Trauma and Recovery. Whitfield, Briere, and
Hunter, among others, address safety in their books on trauma and abuse. However, extensive practical applications that address the issue of helping clients to feel safe in therapy are less frequently
found.
this topic to beginning therapists. After reviewing the literature I realized that safety, though generally alluded to, was not emphasized as a topic by most authors. I was thrilled when I discovered
books that discussed safety in some depth. Laura Davis has a chapter on safety in The Courage to
Heal Workbook. Judith Herman discusses safety in Trauma and Recovery. Whitfield, Briere, and
Hunter, among others, address safety in their books on trauma and abuse. However, extensive practical applications that address the issue of helping clients to feel safe in therapy are less frequently
found.
Using this theme, I taught workshops in a number of settings, provided supervision, and presented
talks in graduate level classes. About three years ago I realized that I had enough material to write
a manual about creating safety with deeply wounded clients. It soon became obvious that safety
was a topic that needed to be addressed with all clients, not just those with trauma or abuse in their
background. At this point my intent changed to writing a practical, “how to” manual for beginning
therapists on ways to create safety through the therapeutic attachment—thus the title.
Using this theme, I taught workshops in a number of settings, provided supervision, and presented
talks in graduate level classes. About three years ago I realized that I had enough material to write
a manual about creating safety with deeply wounded clients. It soon became obvious that safety
was a topic that needed to be addressed with all clients, not just those with trauma or abuse in their
background. At this point my intent changed to writing a practical, “how to” manual for beginning
therapists on ways to create safety through the therapeutic attachment—thus the title.
Writing this manual has taken three and one half years. I am a right-brained, feeling-oriented, psychodynamic therapist who has always hated to write. I have agonized over a great deal of the writing, but I could never let it go. The writing had a momentum of its own and demanded that it be
written. The passion for this topic and the incredible editorial support from Dr. Scott carried me
through a great deal of self-doubt.
Writing this manual has taken three and one half years. I am a right-brained, feeling-oriented, psychodynamic therapist who has always hated to write. I have agonized over a great deal of the writing, but I could never let it go. The writing had a momentum of its own and demanded that it be
written. The passion for this topic and the incredible editorial support from Dr. Scott carried me
through a great deal of self-doubt.
My hope is that this manual will meet a need in the field. It is a way of giving back what was so
generously given to me throughout my own healing journey in therapy as well as in the supervision
and training that I sought.
My hope is that this manual will meet a need in the field. It is a way of giving back what was so
generously given to me throughout my own healing journey in therapy as well as in the supervision
and training that I sought.
Laura Gollnick
Altadena, CA
March, 2004
Laura Gollnick
Altadena, CA
March, 2004
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Acknowledgements
Acknowledgements
Writing this manual would have been impossible without personal and professional support. Many
individuals, knowingly and unknowingly, have contributed to this journey over the years. I offer
my appreciation for their support and caring. I want to personally thank some individuals for their
efforts and contributions.
Writing this manual would have been impossible without personal and professional support. Many
individuals, knowingly and unknowingly, have contributed to this journey over the years. I offer
my appreciation for their support and caring. I want to personally thank some individuals for their
efforts and contributions.
My beloved husband, Daniel, has loved me and always believed in my capacity to become. Without
his ongoing emotional support I would never have claimed this dream. As an accomplished, selfpublished author he taught me how to use the computer and resolved the many technical problems
I frequently encountered. He did the formatting and indexing for this book on the computer. Ultimately, he took responsibility for putting this manual into book form so that it could be printed.
Truly, this has been an act of love, since he continued to operate his own business at the same time.
My beloved husband, Daniel, has loved me and always believed in my capacity to become. Without
his ongoing emotional support I would never have claimed this dream. As an accomplished, selfpublished author he taught me how to use the computer and resolved the many technical problems
I frequently encountered. He did the formatting and indexing for this book on the computer. Ultimately, he took responsibility for putting this manual into book form so that it could be printed.
Truly, this has been an act of love, since he continued to operate his own business at the same time.
My lovely daughter, fine son-in-law, and two precious grandchildren, are a cherished part of my
family support system. My hope is that I can support each of them in claiming their dreams.
My lovely daughter, fine son-in-law, and two precious grandchildren, are a cherished part of my
family support system. My hope is that I can support each of them in claiming their dreams.
Over the years, my dear friend Elinor Johnson has provided me with a place of sanctuary where I
could feel safe, mothered, and intellectually stretched.
Over the years, my dear friend Elinor Johnson has provided me with a place of sanctuary where I
could feel safe, mothered, and intellectually stretched.
Kenneth Clements, L.C.S.W., therapist, mentor, and colleague, unfolded the meaning of healing
for me, both at an emotional and spiritual level. He believed in the importance of writing this manual on safety.
Kenneth Clements, L.C.S.W., therapist, mentor, and colleague, unfolded the meaning of healing
for me, both at an emotional and spiritual level. He believed in the importance of writing this manual on safety.
Cecily Solari, a dear friend throughout the years, put in many hours transcribing the tapes from my
workshop on safety. This script provided a text to begin writing this manual. I owe a note of thanks
to J. J., who was sure this manual would be a success.
Cecily Solari, a dear friend throughout the years, put in many hours transcribing the tapes from my
workshop on safety. This script provided a text to begin writing this manual. I owe a note of thanks
to J. J., who was sure this manual would be a success.
I am deeply grateful for my beloved friends and colleagues, Jan Kuzmic and Gabrilla Hoeglund.
We have laughed and cried together as we supported each other over the many years of our association. My life is much richer because of them. They have listened and believed in me these past
three and a half years.
I am deeply grateful for my beloved friends and colleagues, Jan Kuzmic and Gabrilla Hoeglund.
We have laughed and cried together as we supported each other over the many years of our association. My life is much richer because of them. They have listened and believed in me these past
three and a half years.
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Sheryn Scott, Ph.D., Director of Clinical Training at Azusa Pacific University, supported me in so
many ways in the area of safety and trauma as my therapist, supervisor, and colleague. She taught
me a great deal about safety, attachment, and shame. The mentoring process began twenty years
ago while I was still an intern and has continued to the present day. She mentored me with a graciousness of spirit while giving freely of her knowledge and expertise. Many times she helped me
conceptualize so that I could supervise, teach, and then do this writing from a clinical standpoint.
I would never have written this manual without her ongoing editing and emotional support.
Sheryn Scott, Ph.D., Director of Clinical Training at Azusa Pacific University, supported me in so
many ways in the area of safety and trauma as my therapist, supervisor, and colleague. She taught
me a great deal about safety, attachment, and shame. The mentoring process began twenty years
ago while I was still an intern and has continued to the present day. She mentored me with a graciousness of spirit while giving freely of her knowledge and expertise. Many times she helped me
conceptualize so that I could supervise, teach, and then do this writing from a clinical standpoint.
I would never have written this manual without her ongoing editing and emotional support.
Lynne Fisher, M.A., a doctoral student in Clinical Psychology at Azusa Pacific University carefully
read and reviewed the manual as to its relevance for therapists in training. I was so excited to see
her response to this material!
Lynne Fisher, M.A., a doctoral student in Clinical Psychology at Azusa Pacific University carefully
read and reviewed the manual as to its relevance for therapists in training. I was so excited to see
her response to this material!
Stephanie Miyake, M.A., M.F.T., Director, M.A. Program in Clinical Psychology, Department of
Graduate Psychology at Azusa Pacific University did a wonderful job of editing. She suggested
some excellent changes in formatting which made the manual look more professional. All those
little red marks translated into better language usage and punctuation. I was very touched by her
enthusiastic response to the content, even though I was experiencing burnout at the time.
Stephanie Miyake, M.A., M.F.T., Director, M.A. Program in Clinical Psychology, Department of
Graduate Psychology at Azusa Pacific University did a wonderful job of editing. She suggested
some excellent changes in formatting which made the manual look more professional. All those
little red marks translated into better language usage and punctuation. I was very touched by her
enthusiastic response to the content, even though I was experiencing burnout at the time.
Donald Nathanson, M.D., Executive Director, The Silvan S. Tomkins Institute, Clinical Professor
of Psychiatry and Human Behavior, Jefferson Medical College contributed significantly to the final
version. I appreciate Dr. Nathanson’s wonderful support, his input concerning the title, and his willingness to endorse this manual. In response to my asking permission to use his copyrighted material, he offered to evaluate the final draft. He was exceptionally generous with his time on each
occasion that we interacted.
Donald Nathanson, M.D., Executive Director, The Silvan S. Tomkins Institute, Clinical Professor
of Psychiatry and Human Behavior, Jefferson Medical College contributed significantly to the final
version. I appreciate Dr. Nathanson’s wonderful support, his input concerning the title, and his willingness to endorse this manual. In response to my asking permission to use his copyrighted material, he offered to evaluate the final draft. He was exceptionally generous with his time on each
occasion that we interacted.
I also want to thank all the many individuals and couples I have had the opportunity to work with
as clients. Their struggles and courage to heal are to be commended. They taught me how to be
present and the importance of the concept of safety in the therapeutic attachment.
I also want to thank all the many individuals and couples I have had the opportunity to work with
as clients. Their struggles and courage to heal are to be commended. They taught me how to be
present and the importance of the concept of safety in the therapeutic attachment.
I would like to dedicate this material to survivors of abuse and trauma who take their healing journey and to those who assist them.
I would like to dedicate this material to survivors of abuse and trauma who take their healing journey and to those who assist them.
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Table of Contents
Table of Contents
Credits - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - v
Credits - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - v
Foreword - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -vii
Foreword - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -vii
Preface - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - viii
Preface - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - viii
Acknowledgments - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -xii
Acknowledgments - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -xii
1. Establishing Guidelines for a Climate of Safety in Early Sessions - - - - - Appendix A - Client Consent Form - - - - - - - - - - - - - - - - - - - Appendix B - Client Preliminary Interview Form - - - - - - - - - - - - Appendix C - Consent for Bilateral Release of Confidential Information-
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1. Establishing Guidelines for a Climate of Safety in Early Sessions - - - - - Appendix A - Client Consent Form - - - - - - - - - - - - - - - - - - - Appendix B - Client Preliminary Interview Form - - - - - - - - - - - - Appendix C - Consent for Bilateral Release of Confidential Information-
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2. Exploring the Current Level of Safety - - - - - - - - - - - - - - Appendix A - Self-Inflicted Violence Narrative - - - - - - - Appendix B - Self-Inflicted Violence Questionnaire - - - - Appendix C - Interpersonal History of Safety Questionnaire -
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-75
-79
2. Exploring the Current Level of Safety - - - - - - - - - - - - - - Appendix A - Self-Inflicted Violence Narrative - - - - - - - Appendix B - Self-Inflicted Violence Questionnaire - - - - Appendix C - Interpersonal History of Safety Questionnaire -
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-79
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3. Initial Treatment Issues Around Safety- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -83
Appendix A - Brief Therapy - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -99
Appendix B - Treatment Planning Made Easy - - - - - - - - - - - - - - - - - - - - - - 103
3. Initial Treatment Issues Around Safety- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -83
Appendix A - Brief Therapy - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -99
Appendix B - Treatment Planning Made Easy - - - - - - - - - - - - - - - - - - - - - - 103
4. Learning to Identify Basic Feelings and Needs Around Those Feelings- - - - - - - - - - - - 109
Appendix A - Recognizing and Responding to Feelings of Shame and Guilt - - - - - - 131
Appendix B - History of Basic Feelings Questionnaire- - - - - - - - - - - - - - - - - - 139
4. Learning to Identify Basic Feelings and Needs Around Those Feelings- - - - - - - - - - - - 109
Appendix A - Recognizing and Responding to Feelings of Shame and Guilt - - - - - - 131
Appendix B - History of Basic Feelings Questionnaire- - - - - - - - - - - - - - - - - - 139
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5. Teaching Self-Soothing Techniques to Create Safety within the Client
Appendix A - General Tension Record - - - - - - - - - - - - - Appendix B - Tensing and Relaxing Muscle Group Exercises - Appendix C - Deep Muscle Relaxation Script- - - - - - - - - - Appendix D - Creating a Safe Place Script - - - - - - - - - - - Appendix E - Self-Soothing Activities List - - - - - - - - - - - -
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5. Teaching Self-Soothing Techniques to Create Safety within the Client
Appendix A - General Tension Record - - - - - - - - - - - - - Appendix B - Tensing and Relaxing Muscle Group Exercises - Appendix C - Deep Muscle Relaxation Script- - - - - - - - - - Appendix D - Creating a Safe Place Script - - - - - - - - - - - Appendix E - Self-Soothing Activities List - - - - - - - - - - - -
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6. Exploring and Addressing Trust Issues to Increase Safety - - - - - - - - - - - - - - - - - - - 203
6. Exploring and Addressing Trust Issues to Increase Safety - - - - - - - - - - - - - - - - - - - 203
7. Maintaining Safety While Dealing with Trauma - Initial Stages- - - - - - - - - - - - - - - - - - 225
Appendix A - Repeated Victimization- - - - - - - - - - - - - - - - - - - - - - - - - - - - 255
7. Maintaining Safety While Dealing with Trauma - Initial Stages- - - - - - - - - - - - - - - - - - 225
Appendix A - Repeated Victimization- - - - - - - - - - - - - - - - - - - - - - - - - - - - 255
8. Maintaining Safety While Dealing with Trauma - Advanced Stages - - - - - - - - - - - - - - - 259
8. Maintaining Safety While Dealing with Trauma - Advanced Stages - - - - - - - - - - - - - - - 259
9. Using Touch to Increase Safety - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 277
Appendix A - Client Consent Form for the Use of Touch- - - - - - - - - - - - - - - - - - 295
Appendix B - History of Touch Questionnaire - - - - - - - - - - - - - - - - - - - - - - - 299
9. Using Touch to Increase Safety - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 277
Appendix A - Client Consent Form for the Use of Touch- - - - - - - - - - - - - - - - - - 295
Appendix B - History of Touch Questionnaire - - - - - - - - - - - - - - - - - - - - - - - 299
10. Encouraging Safety for the Therapist to Help Prevent Burnout and Vicarious Traumatization 303
10. Encouraging Safety for the Therapist to Help Prevent Burnout and Vicarious Traumatization 303
11. Creating Safety Throughout the Process of Closure - - - - - - - - - - - - - - - - - - - - - - 321
11. Creating Safety Throughout the Process of Closure - - - - - - - - - - - - - - - - - - - - - - 321
Bibliography - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 347
Bibliography - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 347
Subject Index - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 361
Subject Index - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 361
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1
1
1
Establishing Guidelines for a
Climate of Safety in Early
Sessions
Establishing Guidelines for a
Climate of Safety in Early
Sessions
Chapter Outline
Chapter Outline
A. Initial Contact
A. Initial Contact
B. Initial Session
B. Initial Session
C. Clinical Practice Issues
C. Clinical Practice Issues
D. History-Taking
D. History-Taking
1. Basic Information
1. Basic Information
2. Medical History
2. Medical History
3. Loss and Trauma
3. Loss and Trauma
4. Psychological History
4. Psychological History
5. Substance Abuse
5. Substance Abuse
6. Physical Abuse
6. Physical Abuse
7. Verbal or Emotional Abuse
7. Verbal or Emotional Abuse
8. Sexual Abuse
8. Sexual Abuse
E. Assessing for Frequently Seen Diagnoses
E. Assessing for Frequently Seen Diagnoses
1. Depressive History
1. Depressive History
2. Anxiety History
2. Anxiety History
3. Posttraumatic Stress History
3. Posttraumatic Stress History
1
2
2
Establishing Guidelines for a Climate of
Safety in Early Sessions
Establishing Guidelines for a Climate of
Safety in Early Sessions
From the moment you come together in the room with clients, the theme of safety needs to
be woven and rewoven like a beautiful tapestry. The development of safety is not a single
event. It is a way of being with clients, checking in with them, creating safety between them
and you and inside of themselves, so that they can begin to trust themselves, begin to trust
others, and begin to heal. Research shows that brain chemistry can change when this occurs. It is not a sequential process.You can never know enough about creating safety in the
room because each client is different. It is done in bits and pieces when it fits. It might take
months. It often takes years.You are always building on what you have done before.
From the moment you come together in the room with clients, the theme of safety needs to
be woven and rewoven like a beautiful tapestry. The development of safety is not a single
event. It is a way of being with clients, checking in with them, creating safety between them
and you and inside of themselves, so that they can begin to trust themselves, begin to trust
others, and begin to heal. Research shows that brain chemistry can change when this occurs. It is not a sequential process.You can never know enough about creating safety in the
room because each client is different. It is done in bits and pieces when it fits. It might take
months. It often takes years.You are always building on what you have done before.
INITIAL CONTACT
INITIAL CONTACT
Therapy really begins (or ends) with the first telephone contact. The initial assessment
about whether clients are an appropriate fit for each other is done over the phone prior to
the first session. It is usually preferable to keep the phone conversation brief, but it is very
helpful to assess in a general sense whether or not you can provide the services a client is
requesting. Two very basic pieces of information are needed:
• Who is the client?
• How has the client defined the problem?
Therapy really begins (or ends) with the first telephone contact. The initial assessment
about whether clients are an appropriate fit for each other is done over the phone prior to
the first session. It is usually preferable to keep the phone conversation brief, but it is very
helpful to assess in a general sense whether or not you can provide the services a client is
requesting. Two very basic pieces of information are needed:
• Who is the client?
• How has the client defined the problem?
Example
Example
A therapist gets a call from a woman who says her husband is drinking a lot.
She tells the therapist that she wants to make an appointment for herself and
see if the therapist can help her husband.
A therapist gets a call from a woman who says her husband is drinking a lot.
She tells the therapist that she wants to make an appointment for herself and
see if the therapist can help her husband.
You then need to self-assess:
• Do I want to treat someone who is potentially abusing substances?
• Am I willing to see couples?
• Do I have adequate training in these areas?
• Do I want to accept a client presenting in this particular way (i.e., one person calling
and complaining about the other)?
You then need to self-assess:
• Do I want to treat someone who is potentially abusing substances?
• Am I willing to see couples?
• Do I have adequate training in these areas?
• Do I want to accept a client presenting in this particular way (i.e., one person calling
and complaining about the other)?
Example
Example
A therapist gets a phone call from a mother asking to have her 5-year-old child
seen by the therapist.
A therapist gets a phone call from a mother asking to have her 5-year-old child
seen by the therapist.
You then need to self-assess:
• Am I willing to see children?
• Am I willing to see a family?
You then need to self-assess:
• Am I willing to see children?
• Am I willing to see a family?
3
• Am I willing to see couples?
• Do I have training working with children, couples, or families?
3
• Am I willing to see couples?
• Do I have training working with children, couples, or families?
It is also important to assess if clients are in your fee range, thereby helping to determine
whether or not you choose to see them in treatment. It is helpful to keep a list of therapists
you trust (and agencies) with their particular skills and fee range so that you can make appropriate referrals when necessary.
It is also important to assess if clients are in your fee range, thereby helping to determine
whether or not you choose to see them in treatment. It is helpful to keep a list of therapists
you trust (and agencies) with their particular skills and fee range so that you can make appropriate referrals when necessary.
Note: Many therapists in training work for agencies who may take responsibility for determining the suitability of a referral in terms of fees, skill level, etc. However, your initial phone
contact still will set the tone of your relationship and deserves special care.
Note: Many therapists in training work for agencies who may take responsibility for determining the suitability of a referral in terms of fees, skill level, etc. However, your initial phone
contact still will set the tone of your relationship and deserves special care.
INITIAL SESSION
INITIAL SESSION
The primary goal of the initial session is to form a relationship with the client(s). While I
obtain a lot of information about clients, I also reflect feelings when they are expressed, and
I may need to just be with them if they are very emotional. I use this session to address what
brings them to therapy at this time, what they want out of therapy, concerns they might have
about seeing a therapist, and to begin to gather a history. I will briefly mention a number of
the things I do and give you some techniques that I believe will be useful to you. The material presented herein is primarily my actual words to clients. Feel free to duplicate or modify according to your own style.
The primary goal of the initial session is to form a relationship with the client(s). While I
obtain a lot of information about clients, I also reflect feelings when they are expressed, and
I may need to just be with them if they are very emotional. I use this session to address what
brings them to therapy at this time, what they want out of therapy, concerns they might have
about seeing a therapist, and to begin to gather a history. I will briefly mention a number of
the things I do and give you some techniques that I believe will be useful to you. The material presented herein is primarily my actual words to clients. Feel free to duplicate or modify according to your own style.
I give strokes for coming to the initial session. I do this with every client that walks in the
door. I say the following to clients:
I give strokes for coming to the initial session. I do this with every client that walks in the
door. I say the following to clients:
I grew up believing that to reach out and ask for help was a sign of weakness. What I have learned along the way is that those people who reach out
for help make changes in their lives and their lives work better for them. I
hope that you give yourself some strokes for being here today and for reaching out and asking for something for you.
I grew up believing that to reach out and ask for help was a sign of weakness. What I have learned along the way is that those people who reach out
for help make changes in their lives and their lives work better for them. I
hope that you give yourself some strokes for being here today and for reaching out and asking for something for you.
I check in with what the client is feeling by asking the following kinds of questions.
• I am wondering how it feels to be here?
• Are there any good feelings?
• Are there any anxious feelings?
• Are there any scared feelings?
I check in with what the client is feeling by asking the following kinds of questions.
• I am wondering how it feels to be here?
• Are there any good feelings?
• Are there any anxious feelings?
• Are there any scared feelings?
I am looking especially for what those anxious, scared feelings are. Sometimes there is a
sense of excitement about beginning the therapy process. Frequently, there are anxious or
fearful feelings that need to be expressed. I also want to acknowledge to them that whatever
they feel is okay. Sometimes men are more afraid and sometimes women. I then tell them
what the rest of the session will look like.
I am looking especially for what those anxious, scared feelings are. Sometimes there is a
sense of excitement about beginning the therapy process. Frequently, there are anxious or
fearful feelings that need to be expressed. I also want to acknowledge to them that whatever
they feel is okay. Sometimes men are more afraid and sometimes women. I then tell them
what the rest of the session will look like.
I will be taking a brief history which will take a lot of the session. The history-taking helps me to get an understanding of your family system. I may
need further history, but I will do that in other sessions. Then, we will spend
some time talking about what you want out of being here. Later in this session I will tell you what I see as issues. At the close of the session we will
talk about how it felt to be here.
I will be taking a brief history which will take a lot of the session. The history-taking helps me to get an understanding of your family system. I may
need further history, but I will do that in other sessions. Then, we will spend
some time talking about what you want out of being here. Later in this session I will tell you what I see as issues. At the close of the session we will
talk about how it felt to be here.
4
4
After taking the brief history, I check in to see how they are feeling. I usually say something
like the following:
After taking the brief history, I check in to see how they are feeling. I usually say something
like the following:
I am aware that a number of the questions I asked you during the historytaking are intrusive in nature and may have been uncomfortable for you.
How are you feeling at this point?
I am aware that a number of the questions I asked you during the historytaking are intrusive in nature and may have been uncomfortable for you.
How are you feeling at this point?
Acknowledging their possible discomfort seems to be helpful in creating safety between us.
I then move on by asking clients the following kinds of questions:
• What do you want out of being here?
• What do you want to change?
• What has brought you at this time?
• Why now?
Acknowledging their possible discomfort seems to be helpful in creating safety between us.
I then move on by asking clients the following kinds of questions:
• What do you want out of being here?
• What do you want to change?
• What has brought you at this time?
• Why now?
What clients want to change in their life becomes the basis for a contract between us and
defines the future direction of the work. I ask them to put their goals in behavioral terms.
Clients are not accustomed to thinking in behavioral terms. Doing this allows them to measure whether or not they have accomplished the behavioral changes for themselves.
What clients want to change in their life becomes the basis for a contract between us and
defines the future direction of the work. I ask them to put their goals in behavioral terms.
Clients are not accustomed to thinking in behavioral terms. Doing this allows them to measure whether or not they have accomplished the behavioral changes for themselves.
Note: It is necessary for clients to focus the contract on something they can change rather
than something someone else needs to change. It is also important to develop goals that
spell out new behaviors they will start doing rather than the behaviors they want to stop.
Note: It is necessary for clients to focus the contract on something they can change rather
than something someone else needs to change. It is also important to develop goals that
spell out new behaviors they will start doing rather than the behaviors they want to stop.
Example
Example
Client: “I want my husband to be more loving toward me.”
Therapist: “What specifically would you need from your husband to feel like he
was more loving?”
Client: “I don’t know.”
Therapist: “It sounds like you are unclear about what you need from your husband. It seems like you are wanting your husband to change. It is important to
get clear about what you want. The only person we really have the power to
change is ourselves so it is important for us to focus on what you want to make
different or change.”
Client: “I want my husband to be more loving toward me.”
Therapist: “What specifically would you need from your husband to feel like he
was more loving?”
Client: “I don’t know.”
Therapist: “It sounds like you are unclear about what you need from your husband. It seems like you are wanting your husband to change. It is important to
get clear about what you want. The only person we really have the power to
change is ourselves so it is important for us to focus on what you want to make
different or change.”
Example
Example
Client: “I want to feel better about myself.”
Therapist: “What would that look like? Give me two things you would be doing
differently if you felt better about yourself.”
Client: “I want to start putting my own needs first.”
Therapist: “What would you be doing if you were putting your needs first?”
Client: “I would leave my office at 5:OO pm.”
Therapist: “What else would you be doing to feel better about yourself?”
Client: “I’d like to be able to ask for what I need in my relationship.”
Therapist: “What do you need to ask for that would make you feel better about
yourself and put your own needs first?”
Client: “I would ask my husband to help with the housecleaning each week.”
Client: “I want to feel better about myself.”
Therapist: “What would that look like? Give me two things you would be doing
differently if you felt better about yourself.”
Client: “I want to start putting my own needs first.”
Therapist: “What would you be doing if you were putting your needs first?”
Client: “I would leave my office at 5:OO pm.”
Therapist: “What else would you be doing to feel better about yourself?”
Client: “I’d like to be able to ask for what I need in my relationship.”
Therapist: “What do you need to ask for that would make you feel better about
yourself and put your own needs first?”
Client: “I would ask my husband to help with the housecleaning each week.”
I summarize whatever goals clients have said they want to work on.
I summarize whatever goals clients have said they want to work on.
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Note: Clients may state that they want to work on healing the abuse or trauma in their life.
However, clients who are not emotionally stable cannot safely open up abuse or trauma issues.
Note: Clients may state that they want to work on healing the abuse or trauma in their life.
However, clients who are not emotionally stable cannot safely open up abuse or trauma issues.
I may share with clients the issues that I am aware of from the history-taking I did with
them. Usually, the goals they want for themselves and the clinical history are interrelated.
To give you a sense of the type of responses I give, I have provided the following sample
statements:
It makes sense to me that you keep finding relationships where you are
abused and controlled since your father was physically abusive to you as a
child. Abuse is a form of abandonment, and it leaves a child with difficulty
in self-care. When people have been victimized as children, they sometimes
find others who may victimize them.
or
I can see that it was really hard for you to come today because the people
in your life haven’t always been trustworthy. When your husband left you,
it may have made you feel like you did when your father died.
I may share with clients the issues that I am aware of from the history-taking I did with
them. Usually, the goals they want for themselves and the clinical history are interrelated.
To give you a sense of the type of responses I give, I have provided the following sample
statements:
It makes sense to me that you keep finding relationships where you are
abused and controlled since your father was physically abusive to you as a
child. Abuse is a form of abandonment, and it leaves a child with difficulty
in self-care. When people have been victimized as children, they sometimes
find others who may victimize them.
or
I can see that it was really hard for you to come today because the people
in your life haven’t always been trustworthy. When your husband left you,
it may have made you feel like you did when your father died.
I usually ask if they have any questions that they want to ask me about my education, training, or license. Clients often have questions that they are reluctant to ask. I rarely have clients ask me intrusive questions. If a question feels intrusive to me, I explore the meaning
of it with the client. What is intrusive to one therapist may not be to another. It is important
to be aware of your own comfort level in any self-disclosure.
I usually ask if they have any questions that they want to ask me about my education, training, or license. Clients often have questions that they are reluctant to ask. I rarely have clients ask me intrusive questions. If a question feels intrusive to me, I explore the meaning
of it with the client. What is intrusive to one therapist may not be to another. It is important
to be aware of your own comfort level in any self-disclosure.
At the close of the session, I spend a few minutes exploring what it was like for the clients
to be here. Asking them helps me to begin to understand how they think and feel about what
we have done together. I believe this process creates a greater level of safety between us. I
ask these kinds of questions of all my clients:
• How did it feel to be here?
• What felt good?
• What did not feel good?
• What was helpful?
• What was not helpful?
At the close of the session, I spend a few minutes exploring what it was like for the clients
to be here. Asking them helps me to begin to understand how they think and feel about what
we have done together. I believe this process creates a greater level of safety between us. I
ask these kinds of questions of all my clients:
• How did it feel to be here?
• What felt good?
• What did not feel good?
• What was helpful?
• What was not helpful?
As a therapist, I want to feel confident that a client falls within my training and scope of
practice. I need to assess whether or not I can offer the level of containment that may be
needed and maintain my own safety level. I need to think about my caseload in terms of
numbers as well as the intensity of the work I am doing. One or two suicidal clients requires
a great deal of containment. If you are currently over burdened in your personal life, you
may want to consider referring the client to a colleague.
As a therapist, I want to feel confident that a client falls within my training and scope of
practice. I need to assess whether or not I can offer the level of containment that may be
needed and maintain my own safety level. I need to think about my case
caseload
loadin
interms
termsof
of
numbers as well as the intensity of the work I am doing. One or two suicidal clients requires
a great deal of containment. If you are currently over burdened in your personal life, you
may want to consider referring the client to a colleague.
Example
Example
The therapist's husband has just been diagnosed with cancer. She may not
choose to see couples at this time.
The therapist's husband has just been diagnosed with cancer. She may not
choose to see couples at this time.
Example
Example
A newly licensed therapist is working in her personal therapy on sexual abuse
issues. She may be very uncomfortable working with a perpetrator of abuse or
abuse survivors.
A newly licensed therapist is working in her personal therapy on sexual abuse
issues. She may be very uncomfortable working with a perpetrator of abuse or
abuse survivors.
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I ask clients whether they want to begin working together in therapy or if they would like
to think about it. Some clients choose to not commit at this time, and I briefly explore this
decision by asking if there is any particular reason that they are willing to share with me? I
honor their decision and offer two referrals if they want them. They may tell me that they
are making appointments with several therapists to see which one feels like a good fit. I affirm that decision and let them know that if they decide they want to make a commitment
with me, I would welcome their call. If I am not comfortable seeing them, for whatever reason, then I tell them in a way that minimizes shaming them.
I ask clients whether they want to begin working together in therapy or if they would like
to think about it. Some clients choose to not commit at this time, and I briefly explore this
decision by asking if there is any particular reason that they are willing to share with me? I
honor their decision and offer two referrals if they want them. They may tell me that they
are making appointments with several therapists to see which one feels like a good fit. I affirm that decision and let them know that if they decide they want to make a commitment
with me, I would welcome their call. If I am not comfortable seeing them, for whatever reason, then I tell them in a way that minimizes shaming them.
Example
Example
A client calls for an appointment and states that she is actively suicidal. If my
practice is full or there are issues in my life that make it necessary for me to limit
my clientele to persons who can contain well on their own, I say the following
over the phone: “I want you to have what you need that will help you to heal.
I believe that you need a great deal of support, with sessions at least 2 times a
week and possibly phone contact. I am only working 2 days a week and would
not be able to give you that caring support. However, I can give you some referrals, because I want you to get the help that you need.”
A client calls for an appointment and states that she is actively suicidal. If my
practice is full or there are issues in my life that make it necessary for me to limit
my clientele to persons who can contain well on their own, I say the following
over the phone: “I want you to have what you need that will help you to heal.
I believe that you need a great deal of support, with sessions at least 2 times a
week and possibly phone contact. I am only working 2 days a week and would
not be able to give you that caring support. However, I can give you some referrals, because I want you to get the help that you need.”
Note: Containment means the ability for individuals to manage their emotions reasonably
well while performing whatever tasks are necessary for adequate self-care, fulfilling tasks at
work, and/or caring for home or family needs without doing injury to themselves.
Note: Containment means the ability for individuals to manage their emotions reasonably
well while performing whatever tasks are necessary for adequate self-care, fulfilling tasks at
work, and/or caring for home or family needs without doing injury to themselves.
CLINICAL PRACTICE ISSUES
CLINICAL PRACTICE ISSUES
There are a number of practical issues that therapists must deal with that concern what is
sometimes called practice management. Among these are limits of confidentiality, reporting issues, and informed consent for treatment.
There are a number of practical issues that therapists must deal with that concern what is
sometimes called practice management. Among these are limits of confidentiality, reporting issues, and informed consent for treatment.
It is necessary to consult the laws in your own state regarding confidentiality; reporting
physical, sexual, emotional abuse of children; elder abuse; and working with minors. It is
important that you share with clients that you are a mandated reporter and must comply
with reporting abuse as required in your state. In California you do not need client permission to make these reports. When you are required to report, you cannot maintain confidentiality for the client. Be clear about what you can and cannot offer to minors and their
parents in terms of confidentiality. Good sources of information are the state professional
association’s legal counsel for Marriage and Family Therapists, Licensed Clinical Social
Workers, and Clinical Psychologists. Attending frequent legal and ethical workshops is
useful to keep abreast of the laws of our profession. Obtaining ongoing supervision is additionally very helpful.
It is necessary to consult the laws in your own state regarding confidentiality; reporting
physical, sexual, emotional abuse of children; elder abuse; and working with minors. It is
important that you share with clients that you are a mandated reporter and must comply
with reporting abuse as required in your state. In California you do not need client permission to make these reports. When you are required to report, you cannot maintain confidentiality for the client. Be clear about what you can and cannot offer to minors and their
parents in terms of confidentiality. Good sources of information are the state professional
association’s legal counsel for Marriage and Family Therapists, Licensed Clinical Social
Workers, and Clinical Psychologists. Attending frequent legal and ethical workshops is
useful to keep abreast of the laws of our profession. Obtaining ongoing supervision is additionally very helpful.
Acquiring informed consent for treatment is essential for several reasons. It creates safety
for both the client and the therapist, because boundaries are an integral part of informed
consent. Clients have the right to consent or refuse treatment so they need to have enough
information about policies, procedures, and theoretical orientation to make an informed decision. Having this statement in writing helps therapists and clients avoid misunderstandings. Lastly, it helps therapists develop and clarify their policies and procedures, which is
a sound business practice. Obtaining a client’s consent for treatment without providing adequate information can result in the client taking legal action against the therapist for failing
to provide adequate information about the treatment to be offered. Informed consent should
be reintroduced and examined carefully in the following situations:
Acquiring informed consent for treatment is essential for several reasons. It creates safety
for both the client and the therapist, because boundaries are an integral part of informed
consent. Clients have the right to consent or refuse treatment so they need to have enough
information about policies, procedures, and theoretical orientation to make an informed decision. Having this statement in writing helps therapists and clients avoid misunderstandings. Lastly, it helps therapists develop and clarify their policies and procedures, which is
a sound business practice. Obtaining a client’s consent for treatment without providing adequate information can result in the client taking legal action against the therapist for failing
to provide adequate information about the treatment to be offered. Informed consent should
be reintroduced and examined carefully in the following situations:
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7
• when there is a major change in the approach to treatment
• when there is a major change in the approach to treatment
• when a client comes back into therapy after a prolonged absence
• when a client comes back into therapy after a prolonged absence
• when a new technique is introduced
• when a new technique is introduced
When these periodic informed consent discussions occur, they should be documented in the
client’s file as to when and why they took place, the nature and date of the conversation and
the client’s response.
When these periodic informed consent discussions occur, they should be documented in the
client’s file as to when and why they took place, the nature and date of the conversation and
the client’s response.
Therapists have a duty to obtain informed consent of clients prior to treatment even though
it may not be required by law. Clients have the right to make decisions regarding both their
mental health treatment and medical treatment. Therapists should give clients a client consent form before commencing treatment. This form is basically a policy statement that is
signed and dated by both you and the client and spells out responsibilities of the client and
therapist. (See the Client Consent Form, Appendix A, this chapter.) One way of doing this
is to have clients come 15 minutes early for the initial session. In the reception area, ask
them to complete a simple intake form or the Client Preliminary Interview Form (see Appendix B, this chapter) and to carefully read the Client Consent Form. Review the Client
Consent Form with the clients at the beginning of the initial session before any history-taking begins. Go over each section of the form to be sure that clients understand what they
are signing. I ask clients if they have any questions. If they are comfortable with what they
have read, I ask them to sign their name and date it. I do the same. I then give them a copy
and I keep the other in their file.
Therapists have a duty to obtain informed consent of clients prior to treatment even though
it may not be required by law. Clients have the right to make decisions regarding both their
mental health treatment and medical treatment. Therapists should give clients a client consent form before commencing treatment. This form is basically a policy statement that is
signed and dated by both you and the client and spells out responsibilities of the client and
therapist. (See the Client Consent Form, Appendix A, this chapter.) One way of doing this
is to have clients come 15 minutes early for the initial session. In the reception area, ask
them to complete a simple intake form or the Client Preliminary Interview Form (see Appendix B, this chapter) and to carefully read the Client Consent Form. Review the Client
Consent Form with the clients at the beginning of the initial session before any history-taking begins. Go over each section of the form to be sure that clients understand what they
are signing. I ask clients if they have any questions. If they are comfortable with what they
have read, I ask them to sign their name and date it. I do the same. I then give them a copy
and I keep the other in their file.
Another way of handling informed consent is to give the Client Consent Form to clients at
the beginning of the first session, asking them to read it carefully. Then go over each section
to be sure they understand what it says and answer any questions they may have. Finally,
have them sign and date the form as mentioned above.
Another way of handling informed consent is to give the Client Consent Form to clients at
the beginning of the first session, asking them to read it carefully. Then go over each section
to be sure they understand what it says and answer any questions they may have. Finally,
have them sign and date the form as mentioned above.
For your convenience, I have provided a form titled Consent for Bilateral Release of
Confidential Information (see Appendix C, this chapter). This form, or its equivalent is
used whenever you are going to be consulting with another professional about the case.
This is also true if you are needing to obtain records from previous therapists, schools, or
physicians.
For your convenience, I have provided a form titled Consent for Bilateral Release of
Confidential Information (see Appendix C, this chapter). This form, or its equivalent is
used whenever you are going to be consulting with another professional about the case.
This is also true if you are needing to obtain records from previous therapists, schools, or
physicians.
HISTORY-TAKING
HISTORY-TAKING
Some history-taking forms are quite extensive and if you use one of this type, you can have
clients complete it prior to the first session. Some work sites provide extensive personal history questionnaires, or you can expand on the Client Preliminary Interview Form previously mentioned and create your own. I prefer taking their history in session, so I can assess
the feeling state of clients as they share their history with me. I can also pick up additional
background information which is often valuable to the therapeutic work.
Some history-taking forms are quite extensive and if you use one of this type, you can have
clients complete it prior to the first session. Some work sites provide extensive personal history questionnaires, or you can expand on the Client Preliminary Interview Form previously mentioned and create your own. I prefer taking their history in session, so I can assess
the feeling state of clients as they share their history with me. I can also pick up additional
background information which is often valuable to the therapeutic work.
By taking a careful history, you get to enter your clients’ world and get a sense of what it
was like for them to be a child, a teenager, a young adult, etc. in their family system. The
history helps to assess their level of safety (or lack of it) that was present in their childhood.
This level of safety often strongly correlates with their present level. History-taking helps
to assess the current level of woundedness, and clients are comforted when you see or at
least get a glimpse of what life has been like for them. It conveys that you care and begins
to strengthen the therapeutic attachment between you.
By taking a careful history, you get to enter your clients’ world and get a sense of what it
was like for them to be a child, a teenager, a young adult, etc. in their family system. The
history helps to assess their level of safety (or lack of it) that was present in their childhood.
This level of safety often strongly correlates with their present level. History-taking helps
to assess the current level of woundedness, and clients are comforted when you see or at
least get a glimpse of what life has been like for them. It conveys that you care and begins
to strengthen the therapeutic attachment between you.
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8
History-taking often defines a direction for the healing work. Based on their presenting
problems or symptoms, clients’ history tells you how they got to where they are now and
then ties into what they want to change in their life.
Example
History-taking often defines a direction for the healing work. Based on their presenting
problems or symptoms, clients’ history tells you how they got to where they are now and
then ties into what they want to change in their life.
Example
The client had a history of being physically and emotionally abused by her father, and she had parented her mother. At the close of the history-taking, the
therapist validated the client by saying to her the following: “Since neither of
your parents were emotionally available to you, I can understand how you have
found yourself in abusive relationships and have attracted people to care for
who are not emotionally available to you.”
The client had a history of being physically and emotionally abused by her father, and she had parented her mother. At the close of the history-taking, the
therapist validated the client by saying to her the following: “Since neither of
your parents were emotionally available to you, I can understand how you have
found yourself in abusive relationships and have attracted people to care for
who are not emotionally available to you.”
I do a careful history-taking that may take more than one session. I frequently negotiate an
hour and a half for the initial session. Many therapists may not have the liberty of doing
more than a 45 or 50 minute hour, and additional sessions may be necessary to achieve an
adequate history. I encourage you to get clients’ history at the beginning of therapy, because it allows you to quickly assess the level of safety that is present in their life. Doing a
careful history also provides safety for the therapist. It helps to determine what treatment is
needed and whether you can or choose to provide it.
I do a careful history-taking that may take more than one session. I frequently negotiate an
hour and a half for the initial session. Many therapists may not have the liberty of doing
more than a 45 or 50 minute hour, and additional sessions may be necessary to achieve an
adequate history. I encourage you to get clients’ history at the beginning of therapy, because it allows you to quickly assess the level of safety that is present in their life. Doing a
careful history also provides safety for the therapist. It helps to determine what treatment is
needed and whether you can or choose to provide it.
Example
Example
A young woman came for the initial session of therapy. The therapist quickly
assessed that the client was suicidal and needed to be seen 2-3 times a week
and/or possibly have daily phone check-in. The therapist was limiting his practice to 2 days a week due to his physical problems. Treating the client would not
be in the best interests of either therapist or client. Both the client and therapist
had lack of safety issues. The therapist would have violated his own boundaries
in seeing the client. The client would not have gotten the level of support she
needed to healthfully maintain herself.
A young woman came for the initial session of therapy. The therapist quickly
assessed that the client was suicidal and needed to be seen 2-3 times a week
and/or possibly have daily phone check-in. The therapist was limiting his practice to 2 days a week due to his physical problems. Treating the client would not
be in the best interests of either therapist or client. Both the client and therapist
had lack of safety issues. The therapist would have violated his own boundaries
in seeing the client. The client would not have gotten the level of support she
needed to healthfully maintain herself.
History-taking is always balanced with how safe the client is with you at any given moment. There are times when history-taking must be set aside and soothing the client must
take precedence. Some situations where it might be necessary to stop the history-taking include when clients are becoming very anxious and agitated, touching strong feelings, or
have shut down.
History-taking is always balanced with how safe the client is with you at any given moment. There are times when history-taking must be set aside and soothing the client must
take precedence. Some situations where it might be necessary to stop the history-taking include when clients are becoming very anxious and agitated, touching strong feelings, or
have shut down.
I begin by asking all clients the following:
I begin by asking all clients the following:
BASIC INFORMATION
BASIC INFORMATION
• Name, address, phone number
• Birth date, age
• Marital status (previous marriages, divorces)
• Significant other
• Status of relationship
• Children, stepchildren
• Workplace, job title, phone number, address
• How far have you gone in school? (less shame if asked in this way)
• Siblings and/or step siblings in birth order including client
• Education, occupations of parents and siblings
• Name, address, phone number
• Birth date, age
• Marital status (previous marriages, divorces)
• Significant other
• Status of relationship
• Children, stepchildren
• Workplace, job title, phone number, address
• How far have you gone in school? (less shame if asked in this way)
• Siblings and/or step siblings in birth order including client
• Education, occupations of parents and siblings
9
• Religious preference (practicing or not)
• Loss of sibling and the effect on parents, family, and client
MEDICAL HISTORY
• Do you have any medical problems?
• Are you taking any medications? For what condition(s)?
• Are you taking any over-the-counter medications? For what condition(s)?
• When was your last physical examination? (if more than one year, I recommend getting one)
• What is the name and phone number of your primary physician?
• Do you have any difficulties maintaining your weight?
9
• Religious preference (practicing or not)
• Loss of sibling and the effect on parents, family, and client
MEDICAL HISTORY
• Do you have any medical problems?
• Are you taking any medications? For what condition(s)?
• Are you taking any over-the-counter medications? For what condition(s)?
• When was your last physical examination? (if more than one year, I recommend getting one)
• What is the name and phone number of your primary physician?
• Do you have any difficulties maintaining your weight?
LOSS AND TRAUMA
LOSS AND TRAUMA
Not all of the following categories of loss apply to all clients. I choose those categories that
appear to be relevant at the time of the initial session.
Not all of the following categories of loss apply to all clients. I choose those categories that
appear to be relevant at the time of the initial session.
Adoption
• How old were you when you were adopted?
• When did you become aware that you were adopted?
• How did your parents handle it?
• What feelings got evoked by having this knowledge?
• What is the status of your relationship with your adopted parents?
• What feelings do you have about your adopted parents?
• Do you know your birth parents?
• What is the status of your relationship with your birth parents?
• What feelings do you have about your birth parents?
Adoption
• How old were you when you were adopted?
• When did you become aware that you were adopted?
• How did your parents handle it?
• What feelings got evoked by having this knowledge?
• What is the status of your relationship with your adopted parents?
• What feelings do you have about your adopted parents?
• Do you know your birth parents?
• What is the status of your relationship with your birth parents?
• What feelings do you have about your birth parents?
Abortion
• Have you had any abortions? How many?
• Under what circumstances did you have an abortion?
• What feelings did you have about the abortion when it occurred?
• What are your current feelings about the abortion?
• Have you allowed yourself to do any grieving about the abortion?
Abortion
• Have you had any abortions? How many?
• Under what circumstances did you have an abortion?
• What feelings did you have about the abortion when it occurred?
• What are your current feelings about the abortion?
• Have you allowed yourself to do any grieving about the abortion?
Miscarriages or Infertility
• Have you had any miscarriages? How many? When?
• What feelings did you experience?
• Have you experienced any problems around infertility?
• What were the problems?
Miscarriages or Infertility
• Have you had any miscarriages? How many? When?
• What feelings did you experience?
• Have you experienced any problems around infertility?
• What were the problems?
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• When did they occur?
• What feeling did you experience?
• When did they occur?
• What feeling did you experience?
Significant Loss
• Did you lose a parent or sibling before you were 18 years old?
• Are there any major losses in your life that you would like me to know about?
Significant Loss
• Did you lose a parent or sibling before you were 18 years old?
• Are there any major losses in your life that you would like me to know about?
Traumatic Events
• Were there any traumatic events in your family of origin?
• Are there any traumatic events in your family now that would be helpful for me to
know about?
Traumatic Events
• Were there any traumatic events in your family of origin?
• Are there any traumatic events in your family now that would be helpful for me to
know about?
PSYCHOLOGICAL HISTORY
PSYCHOLOGICAL HISTORY
Clients may have worked with multiple therapists. Some of the therapists that clients have
seen will not seem important. Often there are one or two therapists that have made a significant impact. By asking about each therapist, I am able to ascertain whether or not clients
have had any positive experiences. It may be important to get a signed release and send for
previous clinical records. (See Appendix C, this chapter.) I usually ask the following kinds
of questions:
• Have you ever been in therapy?
• If you remember, what are the names of your previous therapists?
• What issue(s) did you work on?
• What time span and/or age did you see the therapist?
• Was it a positive or negative experience?
• What feelings did you have about this experience?
• Have you ever been hospitalized psychiatrically? When? How long?
• What was the diagnosis?
• What was the outcome?
• Was it a positive or negative experience?
• Were there other hospitalizations? (I again ask the same questions.)
• Are you willing to give me permission to obtain those records if I feel it would be
helpful?
Clients may have worked with multiple therapists. Some of the therapists that clients have
seen will not seem important. Often there are one or two therapists that have made a significant impact. By asking about each therapist, I am able to ascertain whether or not clients
have had any positive experiences. It may be important to get a signed release and send for
previous clinical records. (See Appendix C, this chapter.) I usually ask the following kinds
of questions:
• Have you ever been in therapy?
• If you remember, what are the names of your previous therapists?
• What issue(s) did you work on?
• What time span and/or age did you see the therapist?
• Was it a positive or negative experience?
• What feelings did you have about this experience?
• Have you ever been hospitalized psychiatrically? When? How long?
• What was the diagnosis?
• What was the outcome?
• Was it a positive or negative experience?
• Were there other hospitalizations? (I again ask the same questions.)
• Are you willing to give me permission to obtain those records if I feel it would be
helpful?
Note: It is important to note the response very carefully. Is the client open or very guarded?
Note: It is important to note the response very carefully. Is the client open or very guarded?
SUBSTANCE ABUSE
SUBSTANCE ABUSE
Drugs and alcohol are often used together. When either/or is the case, a careful evaluation
should be done to determine if the person sees it as a problem and whether or not there is
motivation to change any addictive behavior. This evaluation is useful to determine whether or not this is a good time to initiate treatment.
Drugs and alcohol are often used together. When either/or is the case, a careful evaluation
should be done to determine if the person sees it as a problem and whether or not there is
motivation to change any addictive behavior. This evaluation is useful to determine whether or not this is a good time to initiate treatment.
When clients have a history of early childhood substance abuse, some developmental tasks
are not completed and emotional development gets arrested. These tasks may still need to
When clients have a history of early childhood substance abuse, some developmental tasks
are not completed and emotional development gets arrested. These tasks may still need to
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be accomplished in adulthood and may affect clients in several ways:
• inability to establish healthy relationships
• inability to self-soothe in healthy ways
• inability to trust their own feelings and capabilities, etc.
be accomplished in adulthood and may affect clients in several ways:
• inability to establish healthy relationships
• inability to self-soothe in healthy ways
• inability to trust their own feelings and capabilities, etc.
When drug or alcohol abuse is present, a depressive history should be immediately taken
to ascertain the level of depression that may be present. (See Depressive History, this chapter and Suicidality, Chapter 2.) It has been well established that alcohol acts as a depressant.
The whole addictive cycle is often a way of running from the hole in one’s soul or shame.
Addictive behavior keeps clients from dealing with the pain in their life. If there is a high
level of depression, an antidepressant medication can be the beginning of aid in treating the
substance abuse. Referral for a medical evaluation is important when this is the case.
When drug or alcohol abuse is present, a depressive history should be immediately taken
to ascertain the level of depression that may be present. (See Depressive History, this chapter and Suicidality, Chapter 2.) It has been well established that alcohol acts as a depressant.
The whole addictive cycle is often a way of running from the hole in one’s soul or shame.
Addictive behavior keeps clients from dealing with the pain in their life. If there is a high
level of depression, an antidepressant medication can be the beginning of aid in treating the
substance abuse. Referral for a medical evaluation is important when this is the case.
Often, clients who are highly anxious or depressed are addicted to miscellaneous substances such as nicotine, caffeine, or sugar. All these substances are much more acceptable and
may not be seen as a problem. I have found clients using as much as 6-12 cups of caffeine
a day of coffee, large amounts of sodas with caffeine (Mountain Dew, Pepsi, Coca Cola),
or drinks like Red Bull.
Often, clients who are highly anxious or depressed are addicted to miscellaneous substances such as nicotine, caffeine, or sugar. All these substances are much more acceptable and
may not be seen as a problem. I have found clients using as much as 6-12 cups of caffeine
a day of coffee, large amounts of sodas with caffeine (Mountain Dew, Pepsi, Coca Cola),
or drinks like Red Bull.
One issue to consider when substance abuse is present is the potential for others to be endangered by clients’ actions (i.e., drinking and driving, pregnancy, child care). Consequently, substance abuse could trigger a need for a child abuse report.
One issue to consider when substance abuse is present is the potential for others to be endangered by clients’ actions (i.e., drinking and driving, pregnancy, child care). Consequently, substance abuse could trigger a need for a child abuse report.
Exploration of Substance Abuse
Exploration of Substance Abuse
If I determine that there is a history of substance abuse in a client’s family of origin, I address
this by asking the appropriate questions as noted in each section that follows (i.e., drug usage, alcohol usage). Then I ask more in-depth questions about the client’s usage of that particular substance and briefly check for the use of other substances.
If I determine that there is a history of substance abuse in a client’s family of origin, I address
this by asking the appropriate questions as noted in each section that follows (i.e., drug usage, alcohol usage). Then I ask more in-depth questions about the client’s usage of that particular substance and briefly check for the use of other substances.
Drug Usage
Drug Usage
It is important to check for the use of street drugs and for the misuse of prescription drugs.
Also, it is important to check on the possible misuse of over-the-counter drugs. I do not recommend asking clients, “Do you have a drug problem?” Clients using substances addictively are often not aware or are in so much denial that they are not able to answer honestly.
I begin by asking:
• Was there any drug use in your family of origin?
It is important to check for the use of street drugs and for the misuse of prescription drugs.
Also, it is important to check on the possible misuse of over-the-counter drugs. I do not recommend asking clients, “Do you have a drug problem?” Clients using substances addictively are often not aware or are in so much denial that they are not able to answer honestly.
I begin by asking:
• Was there any drug use in your family of origin?
If the answer is affirmative, I then ask the following questions, when appropriate, about
each family member in turn starting with the parents or caretakers and then siblings.
• Did either of your parents, caretakers, or siblings use drugs?
• Which drugs were used? How much? How often?
If the answer is affirmative, I then ask the following questions, when appropriate, about
each family member in turn starting with the parents or caretakers and then siblings.
• Did either of your parents, caretakers, or siblings use drugs?
• Which drugs were used? How much? How often?
Note: It is important to assess whether drugs were used once a day, twice a day, once a
week, twice a week, only on weekends, all weekend, once a month, twice a month, or etc.?
This assessment helps to determine the level of addiction.
• Do you remember or know of a time when no drugs were used?
• Are drugs still being used? How much? How often?
• Do you see it as a problem? In what way?
Note: It is important to assess whether drugs were used once a day, twice a day, once a
week, twice a week, only on weekends, all weekend, once a month, twice a month, or etc.?
This assessment helps to determine the level of addiction.
• Do you remember or know of a time when no drugs were used?
• Are drugs still being used? How much? How often?
• Do you see it as a problem? In what way?
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• How did your parents’, caretakers’, or siblings’ problem affect you?
• How did it affect your relationship with them?
• How did your parents’, caretakers’, or siblings’ problem affect you?
• How did it affect your relationship with them?
I ask clients:
• Is there any drug use by your significant other or your children?
I ask clients:
• Is there any drug use by your significant other or your children?
If the answer is affirmative, I ask any of the preceding questions as they seem appropriate.
If the answer is affirmative, I ask any of the preceding questions as they seem appropriate.
I then ask clients:
• Did you ever use drugs?
• What drugs were used? How much? How often?
• When did you begin using?
I then ask clients:
• Did you ever use drugs?
• What drugs were used? How much? How often?
• When did you begin using?
Note: It can be helpful to ask about drug usage in different periods of a client's life such as
childhood, teenage, 20-30, 30-40, 40-60.
• Were there periods of time when you did not use?
• What was different during those times?
• Are you still using? How much? How often?
• What setting and/or time of day do you use?
• Do you use alone or with others?
• Do you see your use as a problem?
• Does your significant other see it as a problem? In what way?
• Does your family see it as a problem? In what way?
• How has the drug affected you?
• How has it affected your relationships?
• Is this something you want to change?
• What would that change look like?
Note: It can be helpful to ask about drug usage in different periods of a client's life such as
childhood, teenage, 20-30, 30-40, 40-60.
• Were there periods of time when you did not use?
• What was different during those times?
• Are you still using? How much? How often?
• What setting and/or time of day do you use?
• Do you use alone or with others?
• Do you see your use as a problem?
• Does your significant other see it as a problem? In what way?
• Does your family see it as a problem? In what way?
• How has the drug affected you?
• How has it affected your relationships?
• Is this something you want to change?
• What would that change look like?
Some clients become addicted to doctor prescribed pain-killing drugs that have been given
for an illness. An addiction in this category may lead to becoming addicted to other substances. This area is often overlooked in history-taking. Asking the following questions
helps rule out the possibility of addictions to prescribed drugs:
• Have you ever had prescriptions for pain-killing drugs that you have had to use longer than 3 months? Which ones?
• Why were they prescribed?
• How long did you use them?
• What effect did they have on you?
• Did you come to feel that you had to have these drugs even when you were not in
severe pain?
• Do you feel the need to have these drugs now?
• How did you break the addiction?
Some clients become addicted to doctor prescribed pain-killing drugs that have been given
for an illness. An addiction in this category may lead to becoming addicted to other substances. This area is often overlooked in history-taking. Asking the following questions
helps rule out the possibility of addictions to prescribed drugs:
• Have you ever had prescriptions for pain-killing drugs that you have had to use longer than 3 months? Which ones?
• Why were they prescribed?
• How long did you use them?
• What effect did they have on you?
• Did you come to feel that you had to have these drugs even when you were not in
severe pain?
• Do you feel the need to have these drugs now?
• How did you break the addiction?
Note: You may wish to refer to the questions in the previous section about the client’s drug
abuse as seems appropriate.
Note: You may wish to refer to the questions in the previous section about the client’s drug
abuse as seems appropriate.
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Alcohol Usage
Alcohol Usage
I do not recommend asking clients, “Do you have a drinking problem?” Clients using substances addictively are either not aware or are in so much denial that they are not able to
answer honestly. I begin by asking:
• Was there any alcohol use in your family of origin?
I do not recommend asking clients, “Do you have a drinking problem?” Clients using substances addictively are either not aware or are in so much denial that they are not able to
answer honestly. I begin by asking:
• Was there any alcohol use in your family of origin?
If the answer is affirmative, I then ask the following questions as seems appropriate about
each family member in turn starting with the parents, caretakers, and then siblings.
• Did either of your parents, caretakers, or siblings drink?
• How much was drunk?
If the answer is affirmative, I then ask the following questions as seems appropriate about
each family member in turn starting with the parents, caretakers, and then siblings.
• Did either of your parents, caretakers, or siblings drink?
• How much was drunk?
Note: It is important to assess how much alcohol is being used at a time, such as 2-3 glasses an evening, at a meal, a 6-pack per night. This information helps to assess the level of
addiction that is present.
Note: It is important to assess how much alcohol is being used at a time, such as 2-3 glasses an evening, at a meal, a 6-pack per night. This information helps to assess the level of
addiction that is present.
• How big were the glasses?
• What form of alcohol was drunk?
• Were there any other substances drunk? (beer, vodka, wine)
• How often did the drinking occur?
Note: It is important to assess whether alcohol is used daily, once a week, twice a week,
weekends, all weekend, once a month, twice a month, once a year, or etc. This assessment
helps to determine the present level of addiction.
• Do you remember or know of a time when no alcohol was used?
• Is alcohol still being used? How much?
• Do you see it as a problem?
• Was it a problem for you growing up?
• How did this problem affect you?
• How did it affect your relationships?
• How big were the glasses?
• What form of alcohol was drunk?
• Were there any other substances drunk? (beer, vodka, wine)
• How often did the drinking occur?
Note: It is important to assess whether alcohol is used daily, once a week, twice a week,
weekends, all weekend, once a month, twice a month, once a year, or etc. This assessment
helps to determine the present level of addiction.
• Do you remember or know of a time when no alcohol was used?
• Is alcohol still being used? How much?
• Do you see it as a problem?
• Was it a problem for you growing up?
• How did this problem affect you?
• How did it affect your relationships?
I ask clients the following:
• Is there any alcohol use by your significant other or your children?
I ask clients the following:
• Is there any alcohol use by your significant other or your children?
If the answer is affirmative I ask any of the previous questions that may seem appropriate.
If the answer is affirmative I ask any of the previous questions that may seem appropriate.
I then ask:
• Did you ever use alcohol growing up?
• What did you use? How much? How often?
• Did you use anything else?
• When did you begin using?
I then ask:
• Did you ever use alcohol growing up?
• What did you use? How much? How often?
• Did you use anything else?
• When did you begin using?
Note: It can be helpful to ask about alcohol usage in different periods of a client's life such
as childhood, teenage, 20-30, 30-40, 40-60.
• Were there periods of time when you did not use?
• What was different during those times?
Note: It can be helpful to ask about alcohol usage in different periods of a client's life such
as childhood, teenage, 20-30, 30-40, 40-60.
• Were there periods of time when you did not use?
• What was different during those times?
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• Are you still using? How much? How often?
• What setting and/or time of day are you using?
• Do you drink alone or with others?
• Do you see drinking as a problem for you?
• Does your significant other see it as a problem? In what way?
• Does your family see it as a problem? In what way?
• How has drinking affected you?
• How has drinking affected your relationships?
• Is this something you want to change?
• What would that change look like?
I ask how it felt to have me ask these questions. I explore any discomfort briefly.
• Are you still using? How much? How often?
• What setting and/or time of day are you using?
• Do you drink alone or with others?
• Do you see drinking as a problem for you?
• Does your significant other see it as a problem? In what way?
• Does your family see it as a problem? In what way?
• How has drinking affected you?
• How has drinking affected your relationships?
• Is this something you want to change?
• What would that change look like?
I ask how it felt to have me ask these questions. I explore any discomfort briefly.
Sample Dialogue
Sample Dialogue
If a client tells me that they use alcohol I would approach this in a curious manner by engaging in the following dialogue:
Therapist: “What do you drink?”
Client: “I'm only drinking beer.” (Clients often feel that beer does not count as
alcohol usage so it is not seen as problematic).
Therapist: “So how much are you drinking?”
Client: “2-3 cans.”
Therapist: “In what kind of time frame do you drink this amount? Is it an hour,
2-3 hours, or what?”
Client: “I drink 2-3 cans an evening.”
Therapist: “Do you do this daily, once a week, twice a week?”
Client: “I usually do this during the week.”
Therapist: “What do you do on the weekends?”
Client: “I usually go through a 6-pack each on Saturday and Sunday.”
Therapist: “Do you drink anything else besides beer?”
Client: “No.”
Therapist: “Do you think that you have a problem with alcohol?”
Client: “Not really. I’ve always drunk about the same amount.”
If a client tells me that they use alcohol I would approach this in a curious manner by engaging in the following dialogue:
Therapist: “What do you drink?”
Client: “I'm only drinking beer.” (Clients often feel that beer does not count as
alcohol usage so it is not seen as problematic).
Therapist: “So how much are you drinking?”
Client: “2-3 cans.”
Therapist: “In what kind of time frame do you drink this amount? Is it an hour,
2-3 hours, or what?”
Client: “I drink 2-3 cans an evening.”
Therapist: “Do you do this daily, once a week, twice a week?”
Client: “I usually do this during the week.”
Therapist: “What do you do on the weekends?”
Client: “I usually go through a 6-pack each on Saturday and Sunday.”
Therapist: “Do you drink anything else besides beer?”
Client: “No.”
Therapist: “Do you think that you have a problem with alcohol?”
Client: “Not really. I’ve always drunk about the same amount.”
Sample Dialogue
Sample Dialogue
If a client tells me that they use wine, vodka or whiskey I would usually approach this by engaging in the following dialogue:
Therapist: “How much are you drinking?”
Client: “I probably drink 3-4 glasses of wine.”
Therapist: “So how big are the glasses? Are they this big, smaller, larger?”
Client: “They are about this big, maybe 8-10 oz.”
Therapist: “In what time frame do you drink this amount? Is it over an hour,
2-3 hours or several hours?”
Client: “It’s probably over 2-3 hours in the evening.”
Therapist: “Do you do this daily, once a week, twice a week?”
Client: “I pretty much do this every day.”
Therapist: “Do you drink anything else?”
Client: “That’s pretty much it. Wine is all I drink.”
If a client tells me that they use wine, vodka or whiskey I would usually approach this by engaging in the following dialogue:
Therapist: “How much are you drinking?”
Client: “I probably drink 3-4 glasses of wine.”
Therapist: “So how big are the glasses? Are they this big, smaller, larger?”
Client: “They are about this big, maybe 8-10 oz.”
Therapist: “In what time frame do you drink this amount? Is it over an hour,
2-3 hours or several hours?”
Client: “It’s probably over 2-3 hours in the evening.”
Therapist: “Do you do this daily, once a week, twice a week?”
Client: “I pretty much do this every day.”
Therapist: “Do you drink anything else?”
Client: “That’s pretty much it. Wine is all I drink.”
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Note: The Department of Motor Vehicles in California puts out the following guideline when
driving under the influence (DUI)
• 10 oz. beer = 1 drink
• 4 oz. wine = 1 drink
• 1 1--4- oz. vodka, whiskey = 1drink
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Note: The Department of Motor Vehicles in California puts out the following guideline when
driving under the influence (DUI)
• 10 oz. beer = 1 drink
• 4 oz. wine = 1 drink
• 1 1--4- oz. vodka, whiskey = 1drink
If more than this amount is consumed in an hour, the person may show signs of intoxication.
If more than this amount is consumed in an hour, the person may show signs of intoxication.
Further questions I ask if I see serious alcohol abuse include:
• Have you ever had any DUIs for alcohol abuse? How many? When?
• Have you ever been arrested for alcohol abuse? What happened?
• Have you ever gone through alcohol rehabilitation?
• What was the outcome of that rehabilitation?
Further questions I ask if I see serious alcohol abuse include:
• Have you ever had any DUIs for alcohol abuse? How many? When?
• Have you ever been arrested for alcohol abuse? What happened?
• Have you ever gone through alcohol rehabilitation?
• What was the outcome of that rehabilitation?
PHYSICAL ABUSE
PHYSICAL ABUSE
Sometimes therapists are not comfortable asking about physical abuse. When therapists do
not ask, clients do not tell. Often clients do not even realize that they have been abused.
Pope and Brown (1996) note that a number of research studies suggest that most people do
not volunteer abuse histories to the clinician. In citing additional research, Pope and Brown
note, “When hospitalized inpatients were not directly asked, information about childhood
or adult physical or sexual abuse was rarely volunteered; however when direct questions
were asked, more than three-quarters of the hundred patients queried reported at least one
of these types of abuse in their histories” (p.158). It is unethical not to ask.
Sometimes therapists are not comfortable asking about physical abuse. When therapists do
not ask, clients do not tell. Often clients do not even realize that they have been abused.
Pope and Brown (1996) note that a number of research studies suggest that most people do
not volunteer abuse histories to the clinician. In citing additional research, Pope and Brown
note, “When hospitalized inpatients were not directly asked, information about childhood
or adult physical or sexual abuse was rarely volunteered; however when direct questions
were asked, more than three-quarters of the hundred patients queried reported at least one
of these types of abuse in their histories” (p.158). It is unethical not to ask.
It is helpful for therapists to put questions about abuse in behavioral terms. Therapists begin
to gently convey that certain behaviors are unacceptable and unhealthy. These questions
help lift the denial about abuse that many clients have.
It is helpful for therapists to put questions about abuse in behavioral terms. Therapists begin
to gently convey that certain behaviors are unacceptable and unhealthy. These questions
help lift the denial about abuse that many clients have.
When assessing for physical abuse, some questions that may be useful are:
When assessing for physical abuse, some questions that may be useful are:
• When you did something that your parents did not like, what did they do?
• When you did something that your parents did not like, what did they do?
• How was discipline handled in your home or in your family?
• How was discipline handled in your home or in your family?
• What did your mother or father do when they were angry with you?
• What did your mother or father do when they were angry with you?
• Was the same thing done to your siblings?
• Was the same thing done to your siblings?
• How was discipline handled with your siblings?
• How was discipline handled with your siblings?
• Were there any children who were not disciplined?
• Were there any children who were not disciplined?
• Were there any children who were disciplined more or less than others?
• Were there any children who were disciplined more or less than others?
• Were you ever hit? With what?
• Were you ever hit? With what?
• Were you hit with anything else?
• Were you hit with anything else?
• Did it leave welts or bruises?
• Did it leave welts or bruises?
If there are positive answers to any of the last three questions some follow-up questions are:
If there are positive answers to any of the last three questions some follow-up questions are:
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• Who hit you? How much? How often?
• At what ages were you hit?
• What was that like for you?
• Who hit you? How much? How often?
• At what ages were you hit?
• What was that like for you?
When extensive abuse has occurred, it is appropriate to ask further questions at a later time
and these include:
• Did you ever receive bruises, cuts, welts, burns, broken bones, etc.?
• Did you ever require medical attention?
• What was used to hit you? (stick, switch, hand, fist, foot)
• Were you ever thrown or punched?
• Were objects ever thrown at you?
• Was hot water or a hot object used to discipline you?
• Were you ever kicked as part of discipline?
• Were you ever grabbed by the throat and choked?
• Were you ever tied up?
When extensive abuse has occurred, it is appropriate to ask further questions at a later time
and these include:
• Did you ever receive bruises, cuts, welts, burns, broken bones, etc.?
• Did you ever require medical attention?
• What was used to hit you? (stick, switch, hand, fist, foot)
• Were you ever thrown or punched?
• Were objects ever thrown at you?
• Was hot water or a hot object used to discipline you?
• Were you ever kicked as part of discipline?
• Were you ever grabbed by the throat and choked?
• Were you ever tied up?
In a later session, some advanced questions to further assess the impact of physical abuse
include:
• What decisions did you make about yourself as a result of what was done to you
physically?
• What decision did you make about others?
• What decisions did you make about how the universe would treat or provide for you?
In a later session, some advanced questions to further assess the impact of physical abuse
include:
• What decisions did you make about yourself as a result of what was done to you
physically?
• What decision did you make about others?
• What decisions did you make about how the universe would treat or provide for you?
Sample Responses
Sample Responses
“I decided there was something wrong with me.”
“I didn't deserve to be treated well.”
“I was bad.”
“I couldn't trust that others would treat me well.”
“I expect others to abandon me or abuse me.”
“I can't be safe with you.”
“I cannot expect good things in my life.”
“I am not loved and accepted.”
“There is no God.”
“I am not worthy of being loved.”
“I decided there was something wrong with me.”
“I didn't deserve to be treated well.”
“I was bad.”
“I couldn't trust that others would treat me well.”
“I expect others to abandon me or abuse me.”
“I can't be safe with you.”
“I cannot expect good things in my life.”
“I am not loved and accepted.”
“There is no God.”
“I am not worthy of being loved.”
Additional questions that are designed to elicit feelings from the client include:
• As you talk about what happened to you physically, what feelings (mad, sad, glad,
scared) come up for you?
• Are there any other words for your feelings?
• What are you feeling in your body as we talk about what happened to you?
• Where in your body do you feel these feelings?
Additional questions that are designed to elicit feelings from the client include:
• As you talk about what happened to you physically, what feelings (mad, sad, glad,
scared) come up for you?
• Are there any other words for your feelings?
• What are you feeling in your body as we talk about what happened to you?
• Where in your body do you feel these feelings?
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• Do you have some words for these feelings?
• If your body could speak, what would it say?
17
• Do you have some words for these feelings?
• If your body could speak, what would it say?
It is important to determine whether or not there is any domestic violence in the family of
origin. The following questions might be asked:
• Did your mother and father use physical force with each other?
• What did that look like?
• Did your father use physical force with your mother? How often?
• Did your mother use physical force with your father? How often?
• Were there any injuries that required hospitalization?
• Were you present when the abuse took place?
• What was that like for you?
It is important to determine whether or not there is any domestic violence in the family of
origin. The following questions might be asked:
• Did your mother and father use physical force with each other?
• What did that look like?
• Did your father use physical force with your mother? How often?
• Did your mother use physical force with your father? How often?
• Were there any injuries that required hospitalization?
• Were you present when the abuse took place?
• What was that like for you?
Note: Though physical force is more often used by men on women, women physically abuse
their mates as well.
Note: Though physical force is more often used by men on women, women physically abuse
their mates as well.
VERBAL OR EMOTIONAL ABUSE
VERBAL OR EMOTIONAL ABUSE
It is important for therapists to convey their interest in their clients’ family history by being
inquisitive about it without putting labels on it. Some verbally or emotionally abusive behaviors are considered normal in many families. Asking questions in this fashion is an attempt to get under the clients’ defenses. It also conveys that these behaviors are not okay.
Sometimes it takes years before clients realize that what they experienced was abusive in
nature. So, it is important that questions are put in behavioral terms when asking about verbal or emotional abuse. As appropriate, any of the following questions might be asked:
• Did your mother and father ever get angry with you?
• What did they do when they were angry with you?
• Did they ever yell or scream at you?
• What kinds of things were said when they yelled or screamed at you?
• Was there teasing that felt bad to you?
• What kinds of things were said when they teased you?
• How often did it happen?
• Were they drinking or using drugs during these times?
• Did they do these behaviors to your siblings?
• How often did it happen?
• Was there any child who was not treated this way?
• What was it like for you to experience this treatment?
It is important for therapists to convey their interest in their clients’ family history by being
inquisitive about it without putting labels on it. Some verbally or emotionally abusive behaviors are considered normal in many families. Asking questions in this fashion is an attempt to get under the clients’ defenses. It also conveys that these behaviors are not okay.
Sometimes it takes years before clients realize that what they experienced was abusive in
nature. So, it is important that questions are put in behavioral terms when asking about verbal or emotional abuse. As appropriate, any of the following questions might be asked:
• Did your mother and father ever get angry with you?
• What did they do when they were angry with you?
• Did they ever yell or scream at you?
• What kinds of things were said when they yelled or screamed at you?
• Was there teasing that felt bad to you?
• What kinds of things were said when they teased you?
• How often did it happen?
• Were they drinking or using drugs during these times?
• Did they do these behaviors to your siblings?
• How often did it happen?
• Was there any child who was not treated this way?
• What was it like for you to experience this treatment?
It is important to determine whether or not there was any verbal or emotional abuse in the
family of origin. The following kinds of questions might be asked:
• Did your mother and father get angry with each other?
• What did your parents do when they were angry with each other?
It is important to determine whether or not there was any verbal or emotional abuse in the
family of origin. The following kinds of questions might be asked:
• Did your mother and father get angry with each other?
• What did your parents do when they were angry with each other?
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• Did they yell or scream?
• What kinds of things were said when they yelled or screamed at each other?
• Was there teasing of each other that felt bad to you?
• What kinds of things were said when the teasing felt bad to you?
• How often did it happen?
• Were they drinking or using drugs at those times?
• What was it like for you to experience this behavior?
• Did they yell or scream?
• What kinds of things were said when they yelled or screamed at each other?
• Was there teasing of each other that felt bad to you?
• What kinds of things were said when the teasing felt bad to you?
• How often did it happen?
• Were they drinking or using drugs at those times?
• What was it like for you to experience this behavior?
In a later session some additional questions to further assess the impact of verbal or emotional abuse include:
• What decisions did you make about you as a result of experiencing the verbal and/or
emotional behaviors?
• What decisions did you make about others?
• What decisions did you make about how the universe would treat or provide for you?
In a later session some additional questions to further assess the impact of verbal or emotional abuse include:
• What decisions did you make about you as a result of experiencing the verbal and/or
emotional behaviors?
• What decisions did you make about others?
• What decisions did
didyou
youmake
makeabout
abouthow
howthe
theuniverse
universewould
wouldtreat
treator
orprovide
providefor
foryou?
you?
SEXUAL ABUSE
SEXUAL ABUSE
Note: Before asking questions regarding potential sexual abuse, refer to Controversy About
Memory, Chapter 8.
Note: Before asking questions regarding potential sexual abuse, refer to Controversy About
Memory, Chapter 8.
Though the following statement was used in the section on physical abuse, I strongly believe that it also needs to be carefully emphasized here as well. Some therapists are uncomfortable asking about sexual abuse. When therapists do not ask, clients do not tell. Often
clients do not even realize that they have been sexually abused. Pope and Brown (1996)
note that a number of research studies suggest that most people do not volunteer abuse histories to the clinician. In citing additional research, Pope & Brown further note, “When hospitalized inpatients were not directly asked, information about childhood or adult physical
or sexual abuse was rarely volunteered. When direct questions were asked, more than threequarters of the hundred patients reported at least one of these types of abuse in their histories” (p.158). It is unethical to not ask.
Though the following statement was used in the section on physical abuse, I strongly believe that it also needs to be carefully emphasized here as well. Some therapists are uncomfortable asking about sexual abuse. When therapists do not ask, clients do not tell. Often
clients do not even realize that they have been sexually abused. Pope and Brown (1996)
note that a number of research studies suggest that most people do not volunteer abuse histories to the clinician. In citing additional research, Pope & Brown further note, “When hospitalized inpatients were not directly asked, information about childhood or adult physical
or sexual abuse was rarely volunteered. When direct questions were asked, more than threequarters of the hundred patients reported at least one of these types of abuse in their histories” (p.158). It is unethical to not ask.
It is usually difficult for clients to answer questions concerning a history of childhood sexual abuse. There can be a great deal of pain and/or shame when sexual abuse has occurred.
In initial history-taking, I try to ascertain if there was sexual abuse and who the perpetrators
were. It is important to ask for the behavioral examples that tell about the events that have
happened. When inquiring about sexual abuse, I ask in one of the following ways:
• Has there ever been a time when someone touched you in a way that made you feel
uncomfortable or asked or forced you to touch them in a way that did not feel comfortable to you? In childhood? In adulthood?
It is usually difficult for clients to answer questions concerning a history of childhood sexual abuse. There can be a great deal of pain and/or shame when sexual abuse has occurred.
In initial history-taking, I try to ascertain if there was sexual abuse and who the perpetrators
were. It is important to ask for the behavioral examples that tell about the events that have
happened. When inquiring about sexual abuse, I ask in one of the following ways:
• Has there ever been a time when someone touched you in a way that made you feel
uncomfortable or asked or forced you to touch them in a way that did not feel comfortable to you? In childhood? In adulthood?
Note: This question is likely to identify more serious kinds of sexual abuse.
Note: This question is likely to identify more serious kinds of sexual abuse.
When asking about sexual abuse, Pope and Brown (1996) suggest asking for behavioral descriptors in the following manner:
• Have you had any experiences in childhood that you found sexually inappropriate,
uncomfortable, or frightening? This question would apply to adulthood as well.
When asking about sexual abuse, Pope and Brown (1996) suggest asking for behavioral descriptors in the following manner:
• Have you had any experiences in childhood that you found sexually inappropriate,
uncomfortable, or frightening? This question would apply to adulthood as well.
Note: This question may be useful to identify inappropriate sexualization such as a lack of
observance of privacy boundaries in the home, sexual innuendos, etc.
Note: This question may be useful to identify inappropriate sexualization such as a lack of
observance of privacy boundaries in the home, sexual innuendos, etc.
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Example
Example
During an initial history-taking session, a female client was asked if she had
been sexually abused, and she answered negatively. Some time later as treatment progressed the client shared that over several years her stepbrother had
manually fondled her genitals. She told her therapist that she thought she had
not been sexually abused since there had not been any penetration. Often clients will not know what constitutes sexual abuse. Had the therapist asked her
if she had ever had an experience in childhood that she found sexually inappropriate, uncomfortable, or frightening, it is likely the client would have answered
affirmatively. A more accurate history would have been obtained in the initial
sessions.
During an initial history-taking session, a female client was asked if she had
been sexually abused, and she answered negatively. Some time later as treatment progressed the client shared that over several years her stepbrother had
manually fondled her genitals. She told her therapist that she thought she had
not been sexually abused since there had not been any penetration. Often clients will not know what constitutes sexual abuse. Had the therapist asked her
if she had ever had an experience in childhood that she found sexually inappropriate, uncomfortable, or frightening, it is likely the client would have answered
affirmatively. A more accurate history would have been obtained in the initial
sessions.
It is important that the questions about sexual abuse are not suggestive in nature. Implying
that sexual abuse has taken place because a client reports a certain series of symptoms is
unethical and could result in later legal difficulties. If a client chooses to go to court, it could
discredit the testimony.
It is important that the questions about sexual abuse are not suggestive in nature. Implying
that sexual abuse has taken place because a client reports a certain series of symptoms is
unethical and could result in later legal difficulties. If a client chooses to go to court, it could
discredit the testimony.
Assuming that clients have acknowledged a sexual abuse history, my initial conversation
about this topic might include a reflective, empathic statement about their pain and/or their
difficulty in sharing this subject matter such as the following:
Assuming that clients have acknowledged a sexual abuse history, my initial conversation
about this topic might include a reflective, empathic statement about their pain and/or their
difficulty in sharing this subject matter such as the following:
Sample Responses
Sample Responses
“I can see that there is a great deal of pain when you talk about having been
sexually abused.”
“It is really painful for you to tell me about having been sexually abused.”
“Thank you for trusting me enough to share this with me.”
“Thank you for your willingness to share this with me.”
“I want you to know that no matter what you believe, it wasn’t your fault.”
“I can see that there is a great deal of pain when you talk about having been
sexually abused.”
“It is really painful for you to tell me about having been sexually abused.”
“Thank you for trusting me enough to share this with me.”
“Thank you for your willingness to share this with me.”
“I want you to know that no matter what you believe, it wasn’t your fault.”
If the abuse has not been previously explored, it might be asked about in one of these ways:
• How is the sexual abuse currently affecting your life?
• What effect do you see the abuse having on your life in the present?
If the abuse has not been previously explored, it might be asked about in one of these ways:
• How is the sexual abuse currently affecting your life?
• What effect do you see the abuse having on your life in the present?
If I assess that a client is feeling safe to continue talking about this topic, I may ask for some
general information about the incident(s) of sexual abuse such as the following questions.
At this point I am looking for brief answers to my questions. This is not a time to ask clients
to go into great detail even if they voluntarily do so.
If IIassess
assessthat
thataaclient
clientisisfeeling
feelingsafe
safeto
tocontinue
continuetalking
talkingabout
aboutthis
thistopic,
topic,IImay
mayask
askfor
forsome
some
general information about the incident(s) of sexual abuse such as the following questions.
At this point I am looking for brief answers to my questions. This is not a time to ask clients
to go into great detail even if they voluntarily do so.
What was done to you?
• Who did these behaviors?
• Was it done once or multiple times?
• Was this the only person?
• Who were the other persons?
What was done to you?
• Who did these behaviors?
• Was it done once or multiple times?
• Was this the only person?
• Who were the other persons?
Many clients enter therapy for reasons other than sexual abuse. They may not see the sexual
abuse as having affected them or being connected to the issue that they have come to work
Many clients enter therapy for reasons other than sexual abuse. They may not see the sexual
abuse as having affected them or being connected to the issue that they have come to work
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on. Sometimes clients come into therapy with sexual abuse as their main focus. However,
even with this clientele, I do not spend a lot of time in initial history-taking asking them
detailed questions about the abuse. The goal is always to create a climate of safety for clients. During the initial history-taking, trust has not been established. The therapeutic attachment has just begun to establish itself and is still very fragile. When detail is pushed
for, a client’s boundaries may be violated due to a lack of safety. Clients with abuse histories need a therapist who can create a climate of safety through healthy containment and
setting appropriate boundaries. Once I have asked these questions, I move on to the next
area of history-taking.
on. Sometimes clients come into therapy with sexual abuse as their main focus. However,
even with this clientele, I do not spend a lot of time in initial history-taking asking them
detailed questions about the abuse. The goal is always to create a climate of safety for clients. During the initial history-taking, trust has not been established. The therapeutic attachment has just begun to establish itself and is still very fragile. When detail is pushed
for, a client’s boundaries may be violated due to a lack of safety. Clients with abuse histories need a therapist who can create a climate of safety through healthy containment and
setting appropriate boundaries. Once I have asked these questions, I move on to the next
area of history-taking.
Note: I have purposely made this section very short to illustrate the brevity of my historytaking, particularly in this area. Asking questions regarding sexual abuse must always be
balanced with the need to create a climate of safety for our clients.
Note: I have purposely made this section very short to illustrate the brevity of my historytaking, particularly in this area. Asking questions regarding sexual abuse must always be
balanced with the need to create a climate of safety for our clients.
ASSESSING FOR FREQUENTLY SEEN DIAGNOSES
ASSESSING FOR FREQUENTLY SEEN DIAGNOSES
I am including assessment for depression, anxiety, and trauma. I find that most of my clients exhibit symptoms of depression or anxiety, at least initially. Thus, I have included in
this section questions that I frequently may need to ask as part of history-taking. This manual assumes a working knowledge of how to use the DSM-IV-TR (2000) and the material
contained therein. I have also included Posttraumatic Stress Disorder (PTSD), which actually includes symptoms from both of these diagnoses. PTSD has been used as a diagnosis
with increasing frequency in recent years as therapists have come to realize how many situations cause a person to feel threatened. In addition it is important to understand the use
of psychotropic medications. A book you may find helpful is the Clinical Handbook of Psychotropic Drugs by Bezchlibnyk-Butler and Jeffries. (See References.)
I am including assessment for depression, anxiety, and trauma. I find that most of my clients exhibit symptoms of depression or anxiety, at least initially. Thus, I have included in
this section questions that I frequently may need to ask as part of history-taking. This manual assumes a working knowledge of how to use the DSM-IV-TR (2000) and the material
contained therein. I have also included Posttraumatic Stress Disorder (PTSD), which actually includes symptoms from both of these diagnoses. PTSD has been used as a diagnosis
with increasing frequency in recent years as therapists have come to realize how many situations cause a person to feel threatened. In addition it is important to understand the use
of psychotropic medications. A book you may find helpful is the Clinical Handbook of Psychotropic Drugs by Bezchlibnyk-Butler and Jeffries. (See References.)
DEPRESSIVE HISTORY
DEPRESSIVE HISTORY
It is important to assess clients for depression. Clients may not be aware that they are depressed. When clients have experienced depression all of their life, it becomes the norm.
Frequently, there is a genetic predisposition for depression in their family of origin. It is
useful to take a family history concerning depression to ascertain if this is the case. It is
helpful for clients to understand that their feelings may be due to a chemical imbalance. It
is important to help educate clients regarding the variety of tools, including medications,
that can be used to help them to manage these symptoms more effectively.
It is important to assess clients for depression. Clients may not be aware that they are depressed. When clients have experienced depression all of their life, it becomes the norm.
Frequently, there is a genetic predisposition for depression in their family of origin. It is
useful to take a family history concerning depression to ascertain if this is the case. It is
helpful for clients to understand that their feelings may be due to a chemical imbalance. It
is important to help educate clients regarding the variety of tools, including medications,
that can be used to help them to manage these symptoms more effectively.
Note: There is overlap between the symptoms for Major Depressive Disorder and PTSD in
the DSM-IV-TR (2000). Positive answers on one diagnosis may warrant checking out the
other diagnosis.
Note: There is overlap between the symptoms for Major Depressive Disorder and PTSD in
the DSM-IV-TR (2000). Positive answers on one diagnosis may warrant checking out the
other diagnosis.
Major Depressive Disorder
Major Depressive Disorder
depressed mood most of the day
diminished interest or pleasure in all or almost all activities
diminished ability to concentrate
insomnia or hypersomnia
recurrent thoughts of death
Posttraumatic Stress Disorder
markedly diminished interest or participation in significant activities
feelings of detachment or estrangement from others
restricted range of affect
sense of foreshortened future
depressed mood most of the day
diminished interest or pleasure in all or almost all activities
diminished ability to concentrate
insomnia or hypersomnia
recurrent thoughts of death
Posttraumatic Stress Disorder
markedly diminished interest or participation in significant activities
feelings of detachment or estrangement from others
restricted range of affect
sense of foreshortened future
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difficulty falling asleep
difficulty concentrating
I use Major Depressive Disorder from the DSM-IV-TR (2000) as my guide to assess clients
for depression. Three other useful instruments are the Beck Depression Inventory-II (BDIII), (1996), the Beck Hopelessness Inventory (BHI), (1978), and the Beck Scale for Suicide
Ideation (BSS), (1991). These are short self-report assessment tools that can be given to clients and then evaluated with them. (See References, this chapter.) I prefer to do my exploration with clients as I can better assess the feeling state that accompanies their responses
to my questions. The DSM-IV-TR, (2000) can be utilized to form questions concerning the
symptoms the clients may be experiencing:
• Are you depressed most of the day, nearly every day?
• Is there anything that interests you or gives you pleasure?
• What are your sleeping and eating patterns like?
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difficulty falling asleep
difficulty concentrating
I use Major Depressive Disorder from the DSM-IV-TR (2000) as my guide to assess clients
for depression. Three other useful instruments are the Beck Depression Inventory-II (BDIII), (1996), the Beck Hopelessness Inventory (BHI), (1978), and the Beck Scale for Suicide
Ideation (BSS), (1991). These are short self-report assessment tools that can be given to clients and then evaluated with them. (See References, this chapter.) I prefer to do my exploration with clients as I can better assess the feeling state that accompanies their responses
to my questions. The DSM-IV-TR, (2000) can be utilized to form questions concerning the
symptoms the clients may be experiencing:
• Are you depressed most of the day, nearly every day?
• Is there anything that interests you or gives you pleasure?
• What are your sleeping and eating patterns like?
Note: When assessing for suicidality, please refer to Suicidality, Chapter 2 under Looking
for Self-Harming Behaviors for further questions. I use Major Depressive Disorder as given
in the DSM-IV-TR (2000) as my guide when taking a depressive history, and then I check
out the other diagnoses under mood disorders as seems appropriate.
Note: When assessing for suicidality, please refer to Suicidality, Chapter 2 under Looking
for Self-Harming Behaviors for further questions. I use Major Depressive Disorder as given
in the DSM-IV-TR (2000) as my guide when taking a depressive history, and then I check
out the other diagnoses under mood disorders as seems appropriate.
After determining a current level of depression it is often helpful to further assess the client’s history of depressive symptoms at various ages such as childhood, teenage, 20-30, 3040, 40-60. It may be helpful to read through other diagnoses under mood disorders to ascertain which, if any, diagnosis is accurate for the client.
After determining a current level of depression it is often helpful to further assess the client’s history of depressive symptoms at various ages such as childhood, teenage, 20-30, 3040, 40-60. It may be helpful to read through other diagnoses under mood disorders to ascertain which, if any, diagnosis is accurate for the client.
Note: When assessing for depression, it is often helpful to recommend a physical exam to
rule out hypothyroidism (which is often seen as part of postpartum depression), mitral valve
prolapse, anemia, or other medical problems.
Note: When assessing for depression, it is often helpful to recommend a physical exam to
rule out hypothyroidism (which is often seen as part of postpartum depression), mitral valve
prolapse, anemia, or other medical problems.
When clients have abuse in their history, we often see the following mood disorder diagnoses:
Major Depressive Disorder
Dysthymia
Cyclothymia
Bipolar II
When clients have abuse in their history, we often see the following mood disorder diagnoses:
Major Depressive Disorder
Dysthymia
Cyclothymia
Bipolar II
Note: A careful diagnosis is important for purposes of treatment. The DSM-IV-TR (2000) in
Appendix A has Decision Trees for Differential Diagnosis that may be helpful in determining
a diagnosis. Without medication, it may be difficult for treatment to proceed.
Note: A careful diagnosis is important for purposes of treatment. The DSM-IV-TR (2000) in
Appendix A has Decision Trees for Differential Diagnosis that may be helpful in determining
a diagnosis. Without medication, it may be difficult for treatment to proceed.
ANXIETY HISTORY
ANXIETY HISTORY
If there is reason to believe a client may be experiencing anxiety, I recommend an anxiety
history be taken. Sometimes clients are not aware that they are experiencing anxiety or that
their anxiety level is high. For those clients who have experienced anxiety all of their lives,
it becomes the norm. Frequently, there is a genetic predisposition for anxiety in their family
of origin. It is often useful to take a family history to ascertain if this is the case. It is helpful
for clients to understand that their feelings may be due to a chemical imbalance. It is important to help educate clients regarding the variety of tools, including medications, that
can help them manage their symptoms more effectively.
If there is reason to believe a client may be experiencing anxiety, I recommend an anxiety
history be taken. Sometimes clients are not aware that they are experiencing anxiety or that
their anxiety level is high. For those clients who have experienced anxiety all of their lives,
it becomes the norm. Frequently, there is a genetic predisposition for anxiety in their family
of origin. It is often useful to take a family history to ascertain if this is the case. It is helpful
for clients to understand that their feelings may be due to a chemical imbalance. It is important to help educate clients regarding the variety of tools, including medications, that
can help them manage their symptoms more effectively.
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I use Generalized Anxiety Disorder from the DSM-IV-TR (2000) as my guide to assess clients for anxiety. The Beck Anxiety (BAI), (1990, 1993) is also available. This is a short
self-report assessment tool that can be given to clients and then evaluated with them. (See
References, this chapter.) I prefer to do my exploration with clients as I can better assess
the feeling state that accompanies their responses to my questions. The DSM-IV-TR (2000)
can be utilized to form questions concerning the symptoms the clients may be experiencing:
• Do you find yourself feeling anxious or worrying a lot?
• Are you feeling restless, keyed up, or on edge?
• Are you feeling irritable?
I use Generalized Anxiety Disorder from the DSM-IV-TR (2000) as my guide to assess clients for anxiety. The Beck Anxiety (BAI), (1990, 1993) is also available. This is a short
self-report assessment tool that can be given to clients and then evaluated with them. (See
References, this chapter.) I prefer to do my exploration with clients as I can better assess
the feeling state that accompanies their responses to my questions. The DSM-IV-TR (2000)
can be utilized to form questions concerning the symptoms the clients may be experiencing:
• Do you find yourself feeling anxious or worrying a lot?
• Are you feeling restless, keyed up, or on edge?
• Are you feeling irritable?
If clients present with trauma or abuse in their history, I may assess them for Posttraumatic
Stress Disorder (PTSD). Please note that there is an overlap between the symptoms for
Generalized Anxiety Disorder, Major Depressive Disorder and PTSD in the DSM-IV-TR
(2000). Positive answers on one diagnosis may warrant checking out the other diagnoses.
If clients present with trauma or abuse in their history, I may assess them for Posttraumatic
Stress Disorder (PTSD). Please note that there is an overlap between the symptoms for
Generalized Anxiety Disorder, Major Depressive Disorder and PTSD in the DSM-IV-TR
(2000). Positive answers on one diagnosis may warrant checking out the other diagnoses.
Generalized Anxiety Disorder
Generalized Anxiety Disorder
being easily fatigued
difficulty concentrating or going blank
muscle tension (see hypervigilance under PTSD)
sleep disturbance
Major Depressive Disorder
insomnia or hypersomnia
fatigue or loss of energy
diminished ability to think or concentrate
indecisiveness
Posttraumatic Stress Disorder
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
being easily fatigued
difficulty concentrating or going blank
muscle tension (see hypervigilance under PTSD)
sleep disturbance
Major Depressive Disorder
insomnia or hypersomnia
fatigue or loss of energy
diminished ability to think or concentrate
indecisiveness
Posttraumatic Stress Disorder
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
After determining the current level of anxiety, it is often helpful to further assess the client’s
history of anxiety symptoms at various ages such as childhood, teenage, 20-30, 30-40, 4060. There may be a genetic predisposition for it, but sometimes anxiety is in response to
what was happening in the family system.
After determining the current level of anxiety, it is often helpful to further assess the client’s
history of anxiety symptoms at various ages such as childhood, teenage, 20-30, 30-40, 4060. There may be a genetic predisposition for it, but sometimes anxiety is in response to
what was happening in the family system.
Example
Example
A young female client presented with a high level of anxiety. Her mother was
chronically ill. As a teenager, the client’s mother was diagnosed with a terminal
disease. The client became very anxious in trying to care for her younger siblings, keep the household running, and maintain her school work.
A young female client presented with a high level of anxiety. Her mother was
chronically ill. As a teenager, the client’s mother was diagnosed with a terminal
disease. The client became very anxious in trying to care for her younger siblings, keep the household running, and maintain her school work.
With clients who have trauma and/or abuse in their history we often see the following diagnoses: Anxiety Disorders such as Generalized Anxiety, Obsessive-Compulsive, Panic
Disorder, and Posttraumatic Stress Disorder. Mood Disorders often seen are Major Depressive, Dysthymia, Cyclothymia and Bipolar II. Eating Disorders often seen are Anorexia
Nervosa and Bulimia.
With clients who have trauma and
and/or
or abuse in their history we often see the following diagnoses: Anxiety Disorders such as Generalized Anxiety, Obsessive-Compulsive, Panic
Disorder, and Posttraumatic Stress Disorder. Mood Disorders often seen are Major Depressive, Dysthymia, Cyclothymia and Bipolar II. Eating Disorders often seen are Anorexia
Nervosa and Bulimia.
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Note: A careful diagnosis is important for purposes of treatment. The DSM-IV-TR (2000) in
Appendix A has Decision Trees for Differential Diagnosis that may be helpful in ascertaining
a diagnosis. Without medication, it may be difficult to proceed.
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Note: A careful diagnosis is important for purposes of treatment. The DSM-IV-TR (2000) in
Appendix A has Decision Trees for Differential Diagnosis that may be helpful in ascertaining
a diagnosis. Without medication, it may be difficult to proceed.
POSTTRAUMATIC STRESS HISTORY
POSTTRAUMATIC STRESS HISTORY
Many people present with anxiety symptoms, depression, or relationship issues that in fact
are disguised posttraumatic stress disorder (PTSD). When there is a history of abuse or obvious trauma, an assessment for PTSD may be indicated to rule out that possibility. If a client is experiencing PTSD, then adequate stabilization is in order to reduce such symptoms
as inadequate, unrestful sleep, irritability, hyperarousal, eating disturbances or disorders,
and inability to self-soothe.
Many people present with anxiety symptoms, depression, or relationship issues that in fact
are disguised posttraumatic stress disorder (PTSD). When there is a history of abuse or obvious trauma, an assessment for PTSD may be indicated to rule out that possibility. If a client is experiencing PTSD, then adequate stabilization is in order to reduce such symptoms
as inadequate, unrestful sleep, irritability, hyperarousal, eating disturbances or disorders,
and inability to self-soothe.
It is common to see PTSD symptoms in clients who do not meet all the diagnostic criteria
in the DSM-IV-TR (2000). A number of clients who have abuse in their background experience higher levels of intrusiveness, avoidance and numbing, or hyperarousal without diagnosable PTSD. Numbing is a way to avoid contact and can lead to depression. Another
way to avoid is through dissociation. Nightmares are a form of intrusiveness. Hyperarousal
leads to the anxiety cluster of disorders. Often addictive behaviors are used as an attempt
to self-soothe the hyperarousal. With PTSD, clients tend to swing between intrusiveness
and avoidance. Rarely do I see clients with abuse in their history without some aspect of
PTSD. Many of the clients I see have PTSD, chronic, delayed. If clients are experiencing
symptoms of PTSD, then safety work is imperative before any integrative memory work
around the abuse can be considered. Clients must be able to live their life on a daily basis
(i.e., go to work, care for themselves and/or family, and not decompensate). PTSD is frequently diagnosed in conjunction with another anxiety disorder, a mood disorder, or a dissociative disorder. Eating disorders and substance abuse may also be present.
It is common to see PTSD symptoms in clients who do not meet all the diagnostic criteria
in the DSM-IV-TR (2000). A number of clients who have abuse in their background experience higher levels of intrusiveness, avoidance and numbing, or hyperarousal without diagnosable PTSD. Numbing is a way to avoid contact and can lead to depression. Another
way to avoid is through dissociation. Nightmares are a form of intrusiveness. Hyperarousal
leads to the anxiety cluster of disorders. Often addictive behaviors are used as an attempt
to self-soothe the hyperarousal. With PTSD, clients tend to swing between intrusiveness
and avoidance. Rarely do I see clients with abuse in their history without some aspect of
PTSD. Many of the clients I see have PTSD, chronic, delayed. If clients are experiencing
symptoms of PTSD, then safety work is imperative before any integrative memory work
around the abuse can be considered. Clients must be able to live their life on a daily basis
(i.e., go to work, care for themselves and/or family, and not decompensate). PTSD is frequently diagnosed in conjunction with another anxiety disorder, a mood disorder, or a dissociative disorder. Eating disorders and substance abuse may also be present.
When using the DSM-IV-TR (2000) to assess for PTSD, it is important to remember that
clients must report having experienced an event that seriously threatens them or another
and that their response was intense fear, helplessness, or horror. This may be a difficult area
to explore with clients, as they may be reluctant or unable to share these experiences. It is
worth carefully reading this manual (see Chapter 7, especially) and the DSM-IV-TR (2000)
so that there is an awareness of the numerous symptoms clients may report that may lead
to a diagnosis of PTSD. The DSM-IV-TR (2000) can be utilized to form questions concerning the symptoms clients may be experiencing:
• Are you having nightmares?
• Does it ever feel as if the traumatic event is recurring in the present?
• Do you find yourself attempting to avoid certain thoughts, feelings, or conversations
associated with the trauma?
• Do you find yourself avoiding people, places, or activities that cause you to remember what happened to you?
• Do you find it difficult to go to sleep or stay asleep?
• Are you experiencing a sense of hypervigilance?
When using the DSM-IV-TR (2000) to assess for PTSD, it is important to remember that
clients must report having experienced an event that seriously threatens them or another
and that their response was intense fear, helplessness, or horror. This may be a difficult area
to explore with clients, as they may be reluctant or unable to share these experiences. It is
worth carefully reading this manual (see Chapter 7, especially) and the DSM-IV-TR (2000)
so that there is an awareness of the numerous symptoms clients may report that may lead
to a diagnosis of PTSD. The DSM-IV-TR (2000) can be utilized to form questions concerning the symptoms clients may be experiencing:
• Are you having nightmares?
• Does it ever feel as if the traumatic event is recurring in the present?
• Do you find yourself attempting to avoid certain thoughts, feelings, or conversations
associated with the trauma?
• Do you find yourself avoiding people, places, or activities that cause you to remember what happened to you?
• Do you find it difficult to go to sleep or stay asleep?
• Are you experiencing a sense of hypervigilance?
Several inventories that may be useful for assessing trauma and abuse are as follows:
Several inventories that may be useful for assessing trauma and abuse are as follows:
Trauma Symptoms Inventory (TSI). (Briere, 1995). The TSI evaluates posttraumatic
stress and responds to traumatic events, including the effects of rape, spousal abuse, physical assault, combat, major accidents, natural disasters, and child abuse. This is an excellent
Trauma Symptoms Inventory (TSI). (Briere, 1995). The TSI evaluates posttraumatic
stress and responds to traumatic events, including the effects of rape, spousal abuse, physical assault, combat, major accidents, natural disasters, and child abuse. This is an excellent
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inventory highly valued in the field that taps acute and chronic posttraumatic symptomology. The 10 scales of the TSI report levels of Anxious Arousal, Depression, Anger/Irritability, Intrusive Experiences, Defensive Avoidance, Dissociation, Sexual Concerns,
Dysfunctional Sexual Behavior, Impaired Self-Reference, and Tension Reduction Behavior. The TSI can be purchased at Psychological Assessment Resources, Inc., (800)3318378 or www.parinc.com
inventory highly valued in the field that taps acute and chronic posttraumatic symptomology. The 10 scales of the TSI report levels of Anxious Arousal, Depression, Anger/Irritability, Intrusive Experiences, Defensive Avoidance, Dissociation, Sexual Concerns,
Dysfunctional Sexual Behavior, Impaired Self-Reference, and Tension Reduction Behavior. The TSI can be purchased at Psychological Assessment Resources, Inc., (800)3318378 or www.parinc.com
Structured Clinical Interview for DSM-IV-TR (2000) Axis I Disorders (SCID-I), Clinical Version. (First, Spitzer, Gibbons, & Williams, 1997). The SCID-I allows clinicians to
improve their assessment and interviewing skills thus allowing them to make a more accurate diagnosis. As one of the most widely used diagnostic interview systems, it has the advantage of screening for PTSD and other diagnostic categories even though it does not
assess specifically for dissociative disorders. This instrument can be purchased at American Psychiatric Publishing, Inc., (800)368-5777 or www.appi.org
Structured Clinical Interview for DSM-IV-TR (2000) Axis I Disorders (SCID-I), Clinical Version. (First, Spitzer, Gibbons, & Williams, 1997). The SCID-I allows clinicians to
improve their assessment and interviewing skills thus allowing them to make a more accurate diagnosis. As one of the most widely used diagnostic interview systems, it has the advantage of screening for PTSD and other diagnostic categories even though it does not
assess specifically for dissociative disorders. This instrument can be purchased at American Psychiatric Publishing, Inc., (800)368-5777 or www.appi.org
Structured Clinical Interview for DSM-IV-TR (2000) Axis II Personality Disorders
(SCID-II). (First, Gibbon, Spitzer, Williams, & Benjamin, 1997). The advantage of this instrument when used in addition to SCID-I is that it allows the clinician to diagnose the
DSM-IV-TR (2000) Axis II personality disorders which are sometimes the result of trauma
or abusive experiences. This instrument can be purchased at American Psychiatric Publishing, Inc., (800)368-5777 or www.appi.org
Structured Clinical Interview for DSM-IV-TR (2000) Axis II Personality Disorders
(SCID-II). (First, Gibbon, Spitzer, Williams, & Benjamin, 1997). The advantage of this instrument when used in addition to SCID-I is that it allows the clinician to diagnose the
DSM-IV-TR (2000) Axis II personality disorders which are sometimes the result of trauma
or abusive experiences. This instrument can be purchased at American Psychiatric Publishing, Inc., (800)368-5777 or www.appi.org
Structured Clinical Interview Dissociative Disorder (SCID-D), Revised. (Steinberg,
1994). This instrument allows the clinician to assess the nature and severity of the five core
dissociative symptoms (amnesia, depersonalization, derealization, identity confusion, and
identity alteration) using DSM-IV-TR (2000) criteria. The SCID-D, Revised enables the clinician to provide diagnoses for the five DSM-IV-TR (2000) dissociative disorders: Dissociative Amnesia, Dissociative Fugue, Depersonalization Disorder, Dissociative Identity
Disorder, and Dissociative Disorder Not Otherwise Specified. There is also an Interviewer’s Guide for using this instrument. To be most effective, training in its use is recommended. Both the SCID-D, Revised and the Interviewer’s Guide can be purchased at American
Psychiatric Publishing, Inc., (800)368-5777 or www.appi.org
Structured Clinical Interview Dissociative Disorder (SCID-D), Revised. (Steinberg,
1994). This instrument allows the clinician to assess the nature and severity of the five core
dissociative symptoms (amnesia, depersonalization, derealization, identity confusion, and
identity alteration) using DSM-IV-TR (2000) criteria. The SCID-D, Revised enables the clinician to provide diagnoses for the five DSM-IV-TR (2000) dissociative disorders: Dissociative Amnesia, Dissociative Fugue, Depersonalization Disorder, Dissociative Identity
Disorder, and Dissociative Disorder Not Otherwise Specified. There is also an Interviewer’s Guide for using this instrument. To be most effective, training in its use is recommended. Both the SCID-D, Revised and the Interviewer’s Guide can be purchased at American
Psychiatric Publishing, Inc., (800)368-5777 or www.appi.org
REFERENCES
REFERENCES
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental
Disorders. Text Revision. (4th ed.). Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental
Disorders. Text Revision. (4th ed.)
ed.).Washington,
Washington,DC:
DC:American
AmericanPsychiatric
PsychiatricAssoAssociation.
Beck, A. T. (1988, 1993). Beck Hopelessness Inventory (BHS). San Antonio, TX: The
Psychological Corporation. (800)872-1726 or www.PsychCorp.com
Beck, A. T. (1988, 1993). Beck Hopelessness Inventory (BHS). San Antonio, TX: The
Psychological Corporation. (800)872-1726 or www.PsychCorp.com
Beck, A. T. (1990,1993). Beck Anxiety Inventory (BAI). San Antonio, TX: The Psychological Corporation. (800)872-1726 or www.PsychCorp.com
Beck, A. T. (1990,1993). Beck Anxiety Inventory (BAI). San Antonio, TX: The Psychological Corporation. (800)872-1726 or www.PsychCorp.com
Beck, A. T. (1991). Beck Scale for Suicide Ideation (BSS). San Antonio, TX: The Psychological Corporation. (800)872-1726 or www.PsychCorp.com
Beck, A. T. (1991). Beck Scale for Suicide Ideation (BSS). San Antonio, TX: The Psychological Corporation. (800)872-1726 or www.PsychCorp.com
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II (BDI-II).
San Antonio, TX: The Psychological Corporation. (800)872-1726 or www.PsychCorp.com
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II (BDI-II).
San Antonio, TX: The Psychological Corporation. (800)872-1726 or www.PsychCorp.com
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Bezchlibnyk-Butler, K. Z., & Jeffries, J. J. (Eds.). (2003). Clinical Handbook of Psychotropic Drugs. (13th Rev. Ed.). Seattle, WA: Hogrefe & Huber Publishers.
Bezchlibnyk-Butler, K. Z., & Jeffries, J. J. (Eds.). (2003). Clinical Handbook of Psychotropic Drugs. (13th Rev. Ed.). Seattle, WA: Hogrefe & Huber Publishers.
Briere, J. N. (1995). Trauma Symptoms Inventory (TSI). Lutz, FL: Psychological Assessment Resources. (800)331-8378 or www.parinc.com
Briere, J. N. (1995). Trauma Symptoms Inventory (TSI). Lutz, FL: Psychological Assessment Resources. (800)331-8378 or www.parinc.com
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B.W. (1997). Structured Clinical
Interview for DSM-IV Axis I Disorders (SCID-I), Clinical Version. Arlington, VA:
American Psychiatric Publishing, Inc. (800)368-5777.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B.W. (1997). Structured Clinical
Interview for DSM-IV Axis I Disorders (SCID-I), Clinical Version. Arlington, VA:
American Psychiatric Publishing, Inc. (800)368-5777.
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. (1997). Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II).
Arlington, VA: American Psychiatric Publishing, Inc. (800)368-5777.
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. (1997). Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II).
Arlington, VA: American Psychiatric Publishing, Inc. (800)368-5777.
Pope, K. S., & Brown, L. (1996). Recovered Memories of Abuse. Washington, DC: American Psychological Association.
Pope, K. S., & Brown, L. (1996). Recovered Memories of Abuse. Washington, DC: American Psychological Association.
Steinberg, M. (1994). Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R). Arlington, VA: American Psychiatric Publishing, Inc.
(800)368-5777 or www.appi.org
Steinberg, M. (1994). Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R). Arlington, VA: American Psychiatric Publishing, Inc.
(800)368-5777 or www.appi.org
Zur, O. (2002). Clinical Forms. www.drzur.com or call (707)935-0655. (Dr. Zur has provided an extensive set of forms that are useful for clinicians.)
Zur, O. (2002). Clinical Forms. www.drzur.com or call (707)935-0655. (Dr. Zur has provided an extensive set of forms that are useful for clinicians.)
RECOMMENDED RESOURCES
RECOMMENDED RESOURCES
This section includes: substance abuse, anxiety, depression, bereavement, minimal PTSD
and pharmacology.
This section includes: substance abuse, anxiety, depression, bereavement, minimal PTSD
and pharmacology.
Akner, L. F. with Whitney, C. (1993). How to Survive the Loss of a Parent: A Guide for
Adults. New York: William Morrow & Co.
Akner, L. F. with Whitney, C. (1993). How to Survive the Loss of a Parent: A Guide for
Adults. New York: William Morrow & Co.
Baer, L. (2001). The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad
Thoughts. New York: Plume.
Baer, L. (2001). The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad
Thoughts. New York: Plume.
Black, C. (1981). It Will Never Happen to Me: Children of Alcoholics as Youngsters, Adolescents and Adults. New York: Ballantine Books.
Black, C. (1981). It Will Never Happen to Me: Children of Alcoholics as Youngsters, Adolescents and Adults. New York: Ballantine Books.
Bourne, E. J. (1995). The Anxiety and Phobic Workbook (2nd ed.). Oakland, CA: New
Harbinger Publications, Inc.
Bourne, E. J. (1995). The Anxiety and Phobic Workbook (2nd ed.). Oakland, CA: New
Harbinger Publications, Inc.
Bozarth-Campbell, A. (1982). Life is Goodbye. Life is Hello: Grieving Well Through All
Kinds of Loss. Minneapolis: CampCare Publications.
Bozarth-Campbell, A. (1982). Life is Goodbye. Life is Hello: Grieving Well Through All
Kinds of Loss. Minneapolis: CampCare Publications.
Briere, J. N. (1996). Trauma Symptoms Checklist for Children (TSCC). Lutz, FL: Psychological Assessment Resources. (800)331-8378 or www.parinc.com
Briere, J. N. (1996). Trauma Symptoms Checklist for Children (TSCC). Lutz, FL: Psychological Assessment Resources. (800)331-8378 or www.parinc.com
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Briere, J. N. (1998). Psychological Assessment of Adult Posttraumatic States. Washington, DC: American Psychological Association.
Briere, J. N. (1998). Psychological Assessment of Adult Posttraumatic States. Washington, DC: American Psychological Association.
Britten, R. (2002). Fearless Living: Live without Excuses and Love without Regret. New
York: Penguin Putnam, Inc.
Britten, R. (2002). Fearless Living: Live without Excuses and Love without Regret. New
York: Penguin Putnam, Inc.
Carnes, P. (1989). Contrary to Love: Helping the Sexual Addict. Minneapolis: CompCare
Publishers.
Carnes, P. (1989). Contrary to Love: Helping the Sexual Addict. Minneapolis: CompCare
Publishers.
Carnes, P. (1992). Out of the Shadows: Understanding Sexual Addiction. Minneapolis:
CompCare Publishers.
Carnes, P. (1992). Out of the Shadows: Understanding Sexual Addiction. Minneapolis:
CompCare Publishers.
Copeland, M. E. with contributions by Mc Kay, M. (1998). The Depression Workbook: A
Guide for Living with Depression and Manic Depression. Oakland, CA: New Harbinger Publications, Inc.
Copeland, M. E. with contributions by Mc Kay, M. (1998). The Depression Workbook: A
Guide for Living with Depression and Manic Depression. Oakland, CA: New Harbinger Publications, Inc.
Deits, B. (1988). Life After Loss: A Personal Guide Dealing with Death, Divorce, Job
Change and Relocation. Tucson, AZ: Fisher Books.
Deits, B. (1988). Life After Loss: A Personal Guide Dealing with Death, Divorce, Job
Change and Relocation. Tucson, AZ: Fisher Books.
Dunnewold, A., & Sanford, D. G. (1994). Post Partum Survival Guide. Oakland, CA:
New Harbinger Publications.
Dunnewold, A., & Sanford, D. G. (1994). Post Partum Survival Guide. Oakland, CA:
New Harbinger Publications.
Everly, G. S., & Lating, J. M. (Eds.). (1995). Psychotraumatology: Key Papers and Core
Concepts in Post-Traumatic Stress. New York: Plenum Press.
Everly, G. S., & Lating, J. M. (Eds.). (1995). Psychotraumatology: Key Papers and Core
Concepts in Post-Traumatic Stress. New York: Plenum Press.
Foehner, C., & Cozart, C. (1988). The Widow’s Handbook: A Guide for Living. Golden,
CO: Fulcrum, Inc.
Foehner, C., & Cozart, C. (1988). The Widow’s Handbook: A Guide for Living. Golden,
CO: Fulcrum, Inc.
Herman, J. L. (1992). Trauma and Recovery. New York: Basic Books.
Herman, J. L. (1992). Trauma and Recovery. New York: Basic Books.
James, J. W., & Cherry, F. (1988). The Grief Recovery Handbook: A Step-by-Step Program for Moving Beyond Loss. New York: Harper & Row.
James, J. W., & Cherry, F. (1988). The Grief Recovery Handbook: A Step-by-Step Program for Moving Beyond Loss. New York: Harper & Row.
Janoff-Bulman, R. (1992). Shattered Assumptions: Toward a New Psychology of Trauma.
New York: Macmillan Publishing Co., Inc.
Janoff-Bulman, R. (1992). Shattered Assumptions: Toward a New Psychology of Trauma.
New York: Macmillan Publishing Co., Inc.
Kubler-Ross, E. (1997). On Death and Dying. New York: Macmillan Publishing Co., Inc.
Kubler-Ross, E. (1997). On Death and Dying. New York: Macmillan Publishing Co., Inc.
Levin, J. (1991). Treatment of Alcoholism and Other Addictions: A Self Psychology
Approach. Northvale, NJ: Jason Aronson Publishers.
Levin, J. (1991). Treatment of Alcoholism and Other Addictions: A Self Psychology
Approach. Northvale, NJ: Jason Aronson Publishers.
Linehan, M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Publications, Inc.
Linehan, M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Publications, Inc.
Meichenbaum, D. (1994). A Clinical Handbook Practical Therapist Manual: For Assessing and Treating Adults with Post-Traumatic Stress Disorder (PTSD). Waterloo,
Ontario, Canada: Institute Press.
Meichenbaum, D. (1994). A Clinical Handbook Practical Therapist Manual: For Assessing and Treating Adults with Post-Traumatic Stress Disorder (PTSD). Waterloo,
Ontario, Canada: Institute Press.
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Nye, M. B. (1978). But I Never Thought He’d Die: Practical Help for Widows. Philadelphia: The Westminster Press.
Nye, M. B. (1978). But I Never Thought He’d Die: Practical Help for Widows. Philadelphia: The Westminster Press.
Osborn, I. (1998). Tormenting Thoughts and Secret Rituals: The Hidden Epidemic of
Obsessive-Compulsive Disorder. New York: Random House, Inc.
Osborn, I. (1998). Tormenting Thoughts and Secret Rituals: The Hidden Epidemic of
Obsessive-Compulsive Disorder. New York: Random House, Inc.
Penzel, F. (2000). Obsessive-Compulsive Disorders: A Complete Guide to Getting Well
and Staying Well. New York: Oxford University Press.
Penzel, F. (2000). Obsessive-Compulsive Disorders: A Complete Guide to Getting Well
and Staying Well. New York: Oxford University Press.
Preston, J., O’Neal, J. H., & Talaga, M. C. (2002). Handbook of Clinical Psychopharmacology (3rd ed.). Oakland, CA: New Harbinger Publications, Inc.
Preston, J., O’Neal, J. H., & Talaga, M. C. (2002). Handbook of Clinical Psychopharmacology (3rd ed.). Oakland, CA: New Harbinger Publications, Inc.
Rando, T. A. (1988). How to Go on Living When Someone You Love Dies. New York:
Lexington Books.
Rando, T. A. (1988). How to Go on Living When Someone You Love Dies. New York:
Lexington Books.
Rando, T. A. (1993). Treatment of Complicated Mourning. Champaign, IL: Research
Press.
Rando, T. A. (1993). Treatment of Complicated Mourning. Champaign, IL: Research
Press.
Real, T. (1997). I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male
Depression. New York: Simon & Schuster.
Real, T. (1997). I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male
Depression. New York: Simon & Schuster.
Roberts, L. J., & McCrady, B. S. (2003). Alcohol Problems in Intimate Relationships:
Identification and Intervention. National Institute on Alcohol Abuse and Alcoholism (NIAAA), Healthy People Information line: (800)367-4725 or http://
www.healthy people.gov
Roberts, L. J., & McCrady, B. S. (2003). Alcohol Problems in Intimate Relationships:
Identification and Intervention. National Institute on Alcohol Abuse and Alcoholism (NIAAA), Healthy People Information line: (800)367-4725 or http://
www.healthy people.gov
Russell, D. (1983). Incidence and Prevalence of Intrafamilial and Extrafamilial Sexual
Abuse of Female Children. Child Abuse and Neglect, 7, 133-146.
Russell, D. (1983). Incidence and Prevalence of Intrafamilial and Extrafamilial Sexual
Abuse of Female Children. Child Abuse and Neglect, 7, 133-146.
Schwartz, J. M. with Beyette, B. (1996). Brain Lock: Free Yourself from Obsessive-Compulsive Behavior. New York: Harper Collins Publishers, Inc.
Schwartz, J. M. with Beyette, B. (1996). Brain Lock: Free Yourself from Obsessive-Compulsive Behavior. New York: Harper Collins Publishers, Inc.
Staudacher, C. (1991). Men and Grief: A Guide for Men Surviving the Death of a Loved
One, a Resource for Caregivers and Mental Health Professional. Oakland, CA:
New Harbinger Publications.
Staudacher, C. (1991). Men and Grief: A Guide for Men Surviving the Death of a Loved
One, a Resource for Caregivers and Mental Health Professional. Oakland, CA:
New Harbinger Publications.
Stein, M. B., & Walker, J. R. (2002). Triumph Over Shyness: Conquering Shyness and
Social Anxiety. New York: McGraw-Hill.
Stein, M. B., & Walker, J. R. (2002). Triumph Over Shyness: Conquering Shyness and
Social Anxiety. New York: McGraw-Hill.
Verrier, N. N. (1993). The Primal Wound: Understanding the Adopted Child. Baltimore,
MD: Gateway Press.
Verrier, N. N. (1993). The Primal Wound: Understanding the Adopted Child. Baltimore,
MD: Gateway Press.
Viorst, J. (1986). Necessary Losses: The Loves, Illusions, Dependencies and Impossible
Expectations That All of Us Have to Give Up in Order to Grow. New York:
Fawcett Gold Medal.
Viorst, J. (1986). Necessary Losses: The Loves, Illusions, Dependencies and Impossible
Expectations That All of Us Have to Give Up in Order to Grow. New York:
Fawcett Gold Medal.
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Wolfelt, A. D. (1992). Understanding Grief: Helping Yourself Heal. Bristol, PA: Accelerated Development.
Wolfelt, A. D. (1992). Understanding Grief: Helping Yourself Heal. Bristol, PA: Accelerated Development.
Worden, J. W. (Ed.). (1991). Grief Counseling & Grief Therapy: A Handbook for the
Mental Health Practitioner. New York: The Springer Publishing, Inc.
Worden, J. W. (Ed.). (1991). Grief Counseling & Grief Therapy: A Handbook for the
Mental Health Practitioner. New York: The Springer Publishing, Inc.
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Chapter 1 Appendix A
Chapter 1 Appendix A
Client Consent Form
Client Consent Form
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Adapted by permission from Clinical Forms by Ofer Zur, Ph.D. For a complete list of
his forms go to www.drzur.com or call (707)935-0655.
Adapted by permission from Clinical Forms by Ofer Zur, Ph.D. For a complete list of
his forms go to www.drzur.com or call (707)935-0655.
Client Consent Form
Client Consent Form
INFORMATION FOR CLIENTS AND CONSENT FOR TREATMENT
INFORMATION FOR CLIENTS AND CONSENT FOR TREATMENT
Please read the following guidelines for services provided by me. If you have any questions feel free to discuss them with me. This is a statement of your rights and responsibilities as a valued client of Name and Degree . Please take the time to read each point before
signing this form. I want to make sure you understand my policies and procedures so that
the therapy process will in no way be hindered.
Please read the following guidelines for services provided by me. If you have any questions feel free to discuss them with me. This is a statement of your rights and responsibilities as a valued client of Name and Degree . Please take the time to read each point before
signing this form. I want to make sure you understand my policies and procedures so that
the therapy process will in no way be hindered.
I operate my professional practice with the commitment to provide high quality psychotherapy. As such, I am appropriately trained and am licensed as a ________________. If
you have any questions concerning my particular training or areas of expertise, please feel
free to inquire at any time.
I operate my professional practice with the commitment to provide high quality psychotherapy. As such, I am appropriately trained and am licensed as a ________________. If
you have any questions concerning my particular training or areas of expertise, please feel
free to inquire at any time.
CONFIDENTIALITY
CONFIDENTIALITY
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission,
except where disclosure is required by law. In the case of persons under 18 years of age, I
will ask for a parent’s written permission to release information.
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission,
except where disclosure is required by law. In the case of persons under 18 years of age, I
will ask for a parent’s written permission to release information.
When Disclosure Is Required by Law
Disclosure is required by law when there is reasonable suspicion of child, dependent, or
elder abuse or neglect and when a client presents a danger to others, to property, or is
gravely disabled.
When Disclosure Is Required by Law
Disclosure is required by law when there is reasonable suspicion of child, dependent, or
elder abuse or neglect and when a client presents a danger to others, to property, or is
gravely disabled.
When Disclosure May Be Required
Disclosure may be required pursuant to a legal proceeding. If you place your mental status
at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your therapist. In couple and family therapy or
when different family members are seen individually, confidentiality and privilege do not
apply between the couple or among family members. I will use my clinical judgment
when revealing such information. I will not release records to any outside party unless I
have been authorized to do so by all adult family members who were part of the treatment.
When Disclosure May Be Required
Disclosure may be required pursuant to a legal proceeding. If you place your mental status
at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your therapist. In couple and family therapy or
when different family members are seen individually, confidentiality and privilege do not
apply between the couple or among family members. I will use my clinical judgment
when revealing such information. I will not release records to any outside party unless I
have been authorized to do so by all adult family members who were part of the treatment.
Health Insurance and Confidentiality of Records
Health Insurance and Confidentiality of Records
Disclosure of confidential information may be required by your health insurance carrier or
HMO/PPO/MCO/EAP in order to process the claims. If you instruct me to do so, I will
only communicate the minimum necessary information to the carrier. I have no control or
knowledge over what insurance companies do with the information I submit or who has
access to this information. You must be aware that submitting a mental health invoice for
Disclosure of confidential information may be required by your health insurance carrier or
HMO/PPO/MCO/EAP in order to process the claims. If you instruct me to do so, I will
only communicate the minimum necessary information to the carrier. I have no control or
knowledge over what insurance companies do with the information I submit or who has
access to this information. You must be aware that submitting a mental health invoice for
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reimbursement carries a certain amount of risk to confidentiality, privacy, or to future
capacity to obtain health or life insurance. The risk stems from the fact that mental health
information is entered into big insurance companies’ computers and soon will also be
reported to a congress approved, National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank data base is always in question as
computers are inherently vulnerable to unauthorized access. Medical data has been
reported to be sold, stolen, or accessed by enforcement agencies, which puts you in a vulnerable position.
reimbursement carries a certain amount of risk to confidentiality, privacy, or to future
capacity to obtain health or life insurance. The risk stems from the fact that mental health
information is entered into big insurance companies’ computers and soon will also be
reported to a congress approved, National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank data base is always in question as
computers are inherently vulnerable to unauthorized access. Medical data has been
reported to be sold, stolen, or accessed by enforcement agencies, which puts you in a vulnerable position.
Confidentiality of E-Mail Communication
Confidentiality of E-Mail Communication
It is important to be aware that e-mail communication can be relatively easily accessed by
unauthorized people and hence can compromise the privacy and confidentiality of such
communication. Please do not use e-mail for emergencies.
It is important to be aware that e-mail communication can be relatively easily accessed by
unauthorized people and hence can compromise the privacy and confidentiality of such
communication. Please do not use e-mail for emergencies.
Litigation Limitation
Litigation Limitation
Due to the nature of the therapeutic process and the fact that it often involves making a full
disclosure with regard to many matters which may be of a confidential nature, it is agreed
that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney, nor anyone else acting on
your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Due to the nature of the therapeutic process and the fact that it often involves making a full
disclosure with regard to many matters which may be of a confidential nature, it is agreed
that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney, nor anyone else acting on
your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Consultation
Consultation
I consult regularly with other professionals regarding my clients; however, when this
occurs, identifying information is never mentioned. Your identity remains completely
anonymous, and confidentiality is fully maintained.
I consult regularly with other professionals regarding my clients; however, when this
occurs, identifying information is never mentioned. Your identity remains completely
anonymous, and confidentiality is fully maintained.
Your Right to Review Records
Your Right to Review Records
Both law and the standards of my profession require that I keep appropriate treatment
records. As a client, you have the right to review or receive a summary of your records at
any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case, I will provide the
records to an appropriate and legitimate mental health professional of your choice.
Both law and the standards of my profession require that I keep appropriate treatment
records. As a client, you have the right to review or receive a summary of your records at
any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case, I will provide the
records to an appropriate and legitimate mental health professional of your choice.
Considering all the previous exclusions, if it is still appropriate, upon your request, I will
release information to any agency/person you specify unless I assess that releasing such
information might be harmful in any way.
Considering all the previous exclusions, if it is still appropriate, upon your request, I will
release information to any agency/person you specify unless I assess that releasing such
information might be harmful in any way.
THE PROCESS OF THERAPY/EVALUATION
THE PROCESS OF THERAPY/EVALUATION
Participation in therapy can result in a number of benefits to you, including improving
interpersonal relationships and resolution of the specific concerns that led you to seek
therapy. My goal is to attend to your individual needs. Working toward these benefits,
however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. I
will ask you for your feedback and views on your therapy, its progress, and other aspects
of the therapy and will expect you to respond openly and honestly. Sometimes more than
one approach can be helpful in dealing with a certain situation. During the initial evalua-
Participation in therapy can result in a number of benefits to you, including improving
interpersonal relationships and resolution of the specific concerns that led you to seek
therapy. My goal is to attend to your individual needs. Working toward these benefits,
however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. I
will ask you for your feedback and views on your therapy, its progress, and other aspects
of the therapy and will expect you to respond openly and honestly. Sometimes more than
one approach can be helpful in dealing with a certain situation. During the initial evalua-
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tion or therapy, remembering or talking about unpleasant events, feelings, or thoughts can
result in you experiencing considerable discomfort or strong feelings of anger, sadness,
worry, fear, or anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling
situations which can cause you to feel very upset, angry, depressed, challenged, or disappointed.
tion or therapy, remembering or talking about unpleasant events, feelings, or thoughts can
result in you experiencing considerable discomfort or strong feelings of anger, sadness,
worry, fear, or anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling
situations which can cause you to feel very upset, angry, depressed, challenged, or disappointed.
Attempting to resolve issues that brought you to therapy in the first place, such as personal
or interpersonal relationships, may result in changes that were not originally intended.
Psychotherapy may result in decisions about changing behaviors, employment, substance
use, schooling, housing, or relationships. Sometimes a decision that is positive for one
family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no
guarantee that psychotherapy will yield positive or intended results.
Attempting to resolve issues that brought you to therapy in the first place, such as personal
or interpersonal relationships, may result in changes that were not originally intended.
Psychotherapy may result in decisions about changing behaviors, employment, substance
use, schooling, housing, or relationships. Sometimes a decision that is positive for one
family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no
guarantee that psychotherapy will yield positive or intended results.
During the course of therapy, I may draw on various psychological approaches according,
in part, to the problem that is being treated and my assessment of what will best benefit
you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), or psychoeducational.
During the course of therapy, I may draw on various psychological approaches according,
in part, to the problem that is being treated and my assessment of what will best benefit
you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), or psychoeducational.
DISCUSSION OF TREATMENT PLAN
DISCUSSION OF TREATMENT PLAN
Within a reasonable period of time after the initiation of treatment, I will discuss with you
my working understanding of the problem, treatment plan, therapeutic objectives and my
view of the possible outcomes of treatment. If you have any unanswered questions about
any of the procedures used in the course of your therapy, their possible risks, my expertise
in employing them, or about the treatment plan, please ask and you will be answered fully.
You also have the right to ask about other treatments for your condition and their risks and
benefits. If you could benefit from any treatment that I do not provide, I have an ethical
obligation to assist you in obtaining those treatments.
Within a reasonable period of time after the initiation of treatment, I will discuss with you
my working understanding of the problem, treatment plan, therapeutic objectives and my
view of the possible outcomes of treatment. If you have any unanswered questions about
any of the procedures used in the course of your therapy, their possible risks, my expertise
in employing them, or about the treatment plan, please ask and you will be answered fully.
You also have the right to ask about other treatments for your condition and their risks and
benefits. If you could benefit from any treatment that I do not provide, I have an ethical
obligation to assist you in obtaining those treatments.
PHYSICAL AND MEDICAL CONSIDERATIONS
PHYSICAL AND MEDICAL CONSIDERATIONS
Many psychological and emotional issues are related to physical problems. I recommend
at the outset of therapy that you undergo a complete physical examination. You may wish
to discuss this further with me.
Many psychological and emotional issues are related to physical problems. I recommend
at the outset of therapy that you undergo a complete physical examination. You may wish
to discuss this further with me.
SUBSTANCE ABUSE
SUBSTANCE ABUSE
Ingesting drugs or alcohol can inhibit our processing of therapeutic information. Therefore, I expect that you will come to each session without being under the influence of
drugs or alcohol.
Ingesting drugs or alcohol can inhibit our processing of therapeutic information. Therefore, I expect that you will come to each session without being under the influence of
drugs or alcohol.
CLOSURE/TERMINATION
CLOSURE/TERMINATION
Our sessions together may end due to a decision on your part or mine. In psychotherapeutic treatment, the relationship is an important part of the process. Therefore, I find it most
effective when we can plan for at least one session to do closure.
Our sessions together may end due to a decision on your part or mine. In psychotherapeutic treatment, the relationship is an important part of the process. Therefore, I find it most
effective when we can plan for at least one session to do closure.
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As mentioned, after the first couple of meetings, I will assess if I can be of benefit to you.
I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a
number of referrals that you can contact. If at any point during psychotherapy I assess that
I am not effective in helping you reach the therapeutic goals, I am obligated to discuss it
with you and, if appropriate, to terminate treatment. In such a case, I would give you a
number of referrals that may be of help to you. If you request it and authorize it in writing,
I will talk to the psychotherapist of your choice in order to help with the transition. If at
any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and if I have your written consent, I
will provide this therapist with the essential information needed.
As mentioned, after the first couple of meetings, I will assess if I can be of benefit to you.
I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a
number of referrals that you can contact. If at any point during psychotherapy I assess that
I am not effective in helping you reach the therapeutic goals, I am obligated to discuss it
with you and, if appropriate, to terminate treatment. In such a case, I would give you a
number of referrals that may be of help to you. If you request it and authorize it in writing,
I will talk to the psychotherapist of your choice in order to help with the transition. If at
any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and if I have your written consent, I
will provide this therapist with the essential information needed.
Unfortunately, therapy is not always successful. Sometimes the therapeutic relationship is
not what was anticipated. Termination is available to you whenever you desire it. Hopefully, we will have a chance to discuss and work through this process when the time
comes. If you choose to do so, I will provide you with names of other qualified professionals whose services you might prefer.
Unfortunately, therapy is not always successful. Sometimes the therapeutic relationship is
not what was anticipated. Termination is available to you whenever you desire it. Hopefully, we will have a chance to discuss and work through this process when the time
comes. If you choose to do so, I will provide you with names of other qualified professionals whose services you might prefer.
DUAL RELATIONSHIPS
DUAL RELATIONSHIPS
Not all dual relationships are unethical or avoidable. Some non-sexual dual relationships
are unavoidable and some can be clinically beneficial. Therapy never involves a sexual or
any other type of dual relationship that could impair my objectivity, clinical judgment, and
therapeutic effectiveness or be exploitative in nature. I will assess carefully before entering into non-sexual and non-exploitative dual relationships with you, discuss with you the
potential benefits and difficulties that may be involved in such relationships, and will discontinue the dual relationship if I find it interferes with the effectiveness of the therapeutic
process.
Not all dual relationships are unethical or avoidable. Some non-sexual dual relationships
are unavoidable and some can be clinically beneficial. Therapy never involves a sexual or
any other type of dual relationship that could impair my objectivity, clinical judgment, and
therapeutic effectiveness or be exploitative in nature. I will assess carefully before entering into non-sexual and non-exploitative dual relationships with you, discuss with you the
potential benefits and difficulties that may be involved in such relationships, and will discontinue the dual relationship if I find it interferes with the effectiveness of the therapeutic
process.
TELEPHONE AND EMERGENCY PROCEDURES
TELEPHONE AND EMERGENCY PROCEDURES
I encourage you to schedule an office appointment to discuss important issues. Sometimes
you may find it necessary to consult with me by telephone between appointments, and I
am happy to respond to your calls. A telephone consultation lasting longer than 5-10 minutes is considered to be a session as previously described and will be billed on a pro-rated
basis. This is also true if you ask me to contact another professional on your behalf (e.g.,
physician, teacher).
I encourage you to schedule an office appointment to discuss important issues. Sometimes
you may find it necessary to consult with me by telephone between appointments, and I
am happy to respond to your calls. A telephone consultation lasting longer than 5-10 minutes is considered to be a session as previously described and will be billed on a pro-rated
basis. This is also true if you ask me to contact another professional on your behalf (e.g.,
physician, teacher).
If you need to contact me between therapy sessions, please leave me a message on the
answering machine at phone number , and your call will be returned as soon as possible. If
an emergency situation arises, please indicate it clearly in your message. Messages can be
left at any time of the night or day. I check my messages and respond to calls between __
AM and __ PM weekdays. In the event that you are unable to reach me or have a late night
emergency, you may call any of the following numbers:
If you need to contact me between therapy sessions, please leave me a message on the
answering machine at phone number , and your call will be returned as soon as possible. If
an emergency situation arises, please indicate it clearly in your message. Messages can be
left at any time of the night or day. I check my messages and respond to calls between __
AM and __ PM weekdays. In the event that you are unable to reach me or have a late night
emergency, you may call any of the following numbers:
Battered Person’s Hotline ________________
Child Abuse Hotline _________________
A Local Hospital 24-Hour Crisis Intervention ______________
Battered Person’s Hotline ________________
Child Abuse Hotline _________________
A Local Hospital 24-Hour Crisis Intervention ______________
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Drug, Alcohol, and Psychiatric Referral Hotline ________________
24-Hour Suicide Prevention Center Hotline ________________
A Local Trauma Center 24-hour Hotline _______________
Police Department (911)
Drug, Alcohol, and Psychiatric Referral Hotline ________________
24-Hour Suicide Prevention Center Hotline ________________
A Local Trauma Center 24-hour Hotline _______________
Police Department (911)
VACATIONS
VACATIONS
Frequently, when I am on vacation, I leave a colleague on call for me. Sometimes when I
am away I choose to pick up my own calls. In that case, I usually call and check my
answering machine 2-3 times a day.
Frequently, when I am on vacation, I leave a colleague on call for me. Sometimes when I
am away I choose to pick up my own calls. In that case, I usually call and check my
answering machine 2-3 times a day.
PAYMENTS AND INSURANCE REIMBURSEMENT
PAYMENTS AND INSURANCE REIMBURSEMENT
Clients are expected to pay the standard fee of $____ per 50 minute session at the end of
each session unless other arrangements are made. Cancellations made with less than 48
hours notice or “missed” appointments cannot be billed on your insurance and payment
for these sessions will be your responsibility. There is a ____ fee for returned checks that
is equivalent to the amount the bank charges me. Telephone conversations, site visits,
report writing and reading, consultation with other professionals, release of information,
reading records, longer sessions, travel time, etc. will be charged at the same rate, unless
indicated and agreed otherwise.
Clients are expected to pay the standard fee of $____ per 50 minute session at the end of
each session unless other arrangements are made. Cancellations made with less than 48
hours notice or “missed” appointments cannot be billed on your insurance and payment
for these sessions will be your responsibility. There is a ____ fee for returned checks that
is equivalent to the amount the bank charges me. Telephone conversations, site visits,
report writing and reading, consultation with other professionals, release of information,
reading records, longer sessions, travel time, etc. will be charged at the same rate, unless
indicated and agreed otherwise.
Please let me know if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not the insurance company.
Unless agreed upon differently, I will provide you with a copy of your receipt on a
monthly basis, which you can then submit to your insurance company for reimbursement
if you so choose. As was indicated in the section Health Insurance and Confidentiality of
Records, you must be aware that submitting a mental health invoice for reimbursement
carries a certain amount of risk. Not all conditions/problems that are the focus of psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage.
Please let me know if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not the insurance company.
Unless agreed upon differently, I will provide you with a copy of your receipt on a
monthly basis, which you can then submit to your insurance company for reimbursement
if you so choose. As was indicated in the section Health Insurance and Confidentiality of
Records, you must be aware that submitting a mental health invoice for reimbursement
carries a certain amount of risk. Not all conditions/problems that are the focus of psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage.
CANCELLATIONS
CANCELLATIONS
Because scheduling of an appointment involves the reservation of time specifically for
you, a minimum of 48 hours (2 days) notice is required for rescheduling or cancelling an
appointment. Clients are charged the full fee for a missed session, or for cancelling a session with less than 48 hours notice except in the event of an emergency. In the event you
are late for an appointment, I will meet with you for the time remaining of your session.
Because scheduling of an appointment involves the reservation of time specifically for
you, a minimum of 48 hours (2 days) notice is required for rescheduling or cancelling
canceling an
an
appointment. Clients are charged the full fee for a missed session, or for cancelling a session with less than 48 hours notice except in the event of an emergency. In the event you
are late for an appointment, I will meet with you for the time remaining of your session.
MEDIATION AND ARBITRATION
MEDIATION AND ARBITRATION
All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of
arbitration. The mediator shall be a mutually agreed upon neutral third party. The cost of
such mediation, if any, shall be split equally, unless otherwise agreed. In the event that
mediation is unsuccessful, any unresolved controversy related to this agreement should be
submitted to and settled by binding arbitration in City, County, State in accordance with the
All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of
arbitration. The mediator shall be a mutually agreed upon neutral third party. The cost of
such mediation, if any, shall be split equally, unless otherwise agreed. In the event that
mediation is unsuccessful, any unresolved controversy related to this agreement should be
submitted to and settled by binding arbitration in City, County, State in accordance with the
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rules of the American Arbitration Association which are in effect at the time the demand
for arbitration is filed. Notwithstanding the foregoing, in the event that your account is
overdue (unpaid) and there is no agreement on a payment plan, I can use legal means
(court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or
collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In
the case of arbitration, the arbitrator will determine that sum.
rules of the American Arbitration Association which are in effect at the time the demand
for arbitration is filed. Notwithstanding the foregoing, in the event that your account is
overdue (unpaid) and there is no agreement on a payment plan, I can use legal means
(court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or
collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In
the case of arbitration, the arbitrator will determine that sum.
CLIENT SATISFACTION
CLIENT SATISFACTION
I do not expect any concerns to arise between us. However, if you feel dissatisfied for any
reason, please discuss your concerns with me. If you are not satisfied with the way I
resolve these concerns, you may contact the appropriate state licensing board with
address and phone number.
I do not expect any concerns to arise between us. However, if you feel dissatisfied for any
reason, please discuss your concerns with me. If you are not satisfied with the way I
resolve these concerns, you may contact the appropriate state licensing board with
address and phone number.
CONSENT FOR TREATMENT
CONSENT FOR TREATMENT
I have read and received a copy of the above information and agree to abide by these
guidelines. I hereby consent to my treatment. If I am bringing a minor for treatment,
I have the legal authority to consent to the minor's treatment and hereby do so consent.
I have read and received a copy of the above information and agree to abide by these
guidelines. I hereby consent to my treatment. If I am bringing a minor for treatment,
I have the legal authority to consent to the minor's treatment and hereby do so consent.
______________________________________________________________________________
Client Name (print)
Date
Signature
______________________________________________________________________________
Client Name (print)
Date
Signature
______________________________________________________________________________
Client Name (print)
Date
Signature
______________________________________________________________________________
Client Name (print)
Date
Signature
______________________________________________________________________________
Therapist Signature
Date
______________________________________________________________________________
Therapist Signature
Date
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Chapter 1 Appendix B
Chapter 1 Appendix B
Client Preliminary Interview
Form
Client Preliminary Interview
Form
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CLIENT PRELIMINARY INTERVIEW FORM
CLIENT PRELIMINARY INTERVIEW FORM
Date _______________
Date _______________
Name _______________________________________________ Gender _____________
Home address ____________________________________________________________
Home phone _____________________ Work phone _____________________________
Birthdate ________________ Age _____ Education _____________________________
Marital status __________________________
Name of spouse _______________________ Date of marriage _____________________
Children
Name_________________ Age _____ Living at home (Yes/No) ____________
Name_________________ Age _____ Living at home (Yes/No) ____________
Name_________________ Age _____ Living at home (Yes/No) ____________
Prior marriages/dates ______________________________________________________
Client’s employer _________________________________________________________
Business address __________________________________________________________
Occupation ______________________________________________________________
Name and type of health insurance carried _____________________________________
Person through whom you can always be reached (relative or close friend):
Name ____________________________________ Phone ________________________
Address ________________________________________________________________
Client referred by _________________________________________________________
May I send a note of acknowledgement to the referring person? _____________________
Religious preference ______________________________________________________
Race/Culture _____________________________________________________________
Family doctor ______________________________ Phone ________________________
Date of last visit to medical doctor ___________________________________________
Date of last physical exam __________________________________________________
Current medical problems & medications ______________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Previous psychological treatment/marriage counseling:
1) Therapist __________________________ Treatment dates ______________________
Address ______________________________________ Phone ____________________
Problem & length of treatment ______________________________________________
2) Therapist __________________________ Treatment dates ______________________
Address ______________________________________ Phone _____________________
Problem & length of treatment ______________________________________________
Name _______________________________________________ Gender _____________
Home address ____________________________________________________________
Home phone _____________________ Work phone _____________________________
Birthdate ________________ Age _____ Education _____________________________
Marital status __________________________
Name of spouse _______________________ Date of marriage _____________________
Children
Name_________________ Age _____ Living at home (Yes/No) ____________
Name_________________ Age _____ Living at home (Yes/No) ____________
Name_________________ Age _____ Living at home (Yes/No) ____________
Prior marriages/dates ______________________________________________________
Client’s employer _________________________________________________________
Business address __________________________________________________________
Occupation ______________________________________________________________
Name and type of health insurance carried _____________________________________
Person through whom you can always be reached (relative or close friend):
Name ____________________________________ Phone ________________________
Address ________________________________________________________________
Client referred by _________________________________________________________
May I send a note of acknowledgement to the referring person? _____________________
Religious preference ______________________________________________________
Race/Culture _____________________________________________________________
Family doctor ______________________________ Phone ________________________
Date of last visit to medical doctor ___________________________________________
Date of last physical exam __________________________________________________
Current medical problems & medications ______________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Previous psychological treatment/marriage counseling:
1) Therapist __________________________ Treatment dates ______________________
Address ______________________________________ Phone ____________________
Problem & length of treatment ______________________________________________
2) Therapist __________________________ Treatment dates ______________________
Address ______________________________________ Phone _____________________
Problem
Problem&
&length
lengthof
oftreatment
treatment ______________________________________________
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Have you ever been hospitalized for any mental health reason? If yes, when, where, and
for what reason? __________________________________________________________
________________________________________________________________________
________________________________________________________________________
List problems in order of their importance that you would like to discuss:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Client’s family of origin (mother, father, sisters, brothers). Please include yourself and list
in order of age.
Name
Age Occupation
Relationship
Living at Home
Alive or
(Yes or No)
Deceased
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you ever been hospitalized for any mental health reason? If yes, when, where, and
for what reason? __________________________________________________________
________________________________________________________________________
________________________________________________________________________
List problems in order of their importance that you would like to discuss:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Client’s family of origin (mother, father, sisters, brothers). Please include yourself and list
in order of age.
Name
Age Occupation
Relationship
Living at Home
Alive or
(Yes or No)
Deceased
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List any other information that you feel is pertinent.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List any other information that you feel is pertinent.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Chapter 1 Appendix C
Chapter 1 Appendix C
Consent for Bilateral Release
of Confidential Information
Consent for Bilateral Release
of Confidential Information
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Consent for Bilateral Release of Confidential Information
Consent for Bilateral Release of Confidential Information
Client Name ___________________________________________Birthdate ____________________
Client Name ___________________________________________Birthdate ____________________
I, ________________________________________, authorize the two parties listed below to release to
each other confidential information about me, including but not limited to history, functioning, symptoms,
diagnoses, treatment, prognoses, etc., for the purpose of:
I, ________________________________________, authorize the two parties listed below to release to
each other confidential information about me, including but not limited to history, functioning, symptoms,
diagnoses, treatment, prognoses, etc., for the purpose of:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
These parties are:
These parties are:
Name ___________________________________ Name _________________________________
Name ___________________________________ Name _________________________________
Professional
Professional
Designation _____________________________ Designation ____________________________
Professional
Professional
Designation _____________________________ Designation ____________________________
Address _________________________________ Address _______________________________
Address _________________________________ Address _______________________________
________________________________________
______________________________________
________________________________________
______________________________________
Phone ___________________________________ Phone _________________________________
Phone ___________________________________ Phone _________________________________
Fax _____________________________________ Fax ___________________________________
Fax _____________________________________ Fax ___________________________________
This consent shall be valid from ______________ to ______________. I understand that I may revoke
this release, in writing, at any time, except to the extent that it has already been acted upon.
This consent shall be valid from ______________ to ______________. I understand that I may revoke
this release, in writing, at any time, except to the extent that it has already been acted upon.
A fax or photocopy of this release is to be considered as valid as the original.
A fax or photocopy of this release is to be considered as valid as the original.
__________________ __________________________
Date
Signature of Client
__________________________
Printed Name
__________________ __________________________
Date
Signature of Client
__________________________
Printed Name
Copy given to: ‰ Client
‰ Guardian
Copy given to: ‰ Client
‰ Guardian
‰ Other Party
‰ Copy kept by therapist
‰ Parent
‰ Representative
‰ Other Party
‰ Copy kept by therapist
‰ Parent
‰ Representative
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2
Exploring the Current Level of
Safety
Exploring the Current Level of
Safety
Chapter Outline
Chapter Outline
A. Assessing Safety and Stability of Physical Self-Care
A. Assessing Safety and Stability of Physical Self-Care
1. Sleeping
1. Sleeping
2. Eating
2. Eating
3. Physical Activity
3. Physical Activity
4. Relaxation and Play
4. Relaxation and Play
5. Managing Stress
5. Managing Stress
6. Health or Medical Issues
6. Health or Medical Issues
B. Looking for Self-Harming Behaviors
B. Looking for Self-Harming Behaviors
1. Assessment for Suicidality and Self-Inflicted Violence
1. Assessment for Suicidality and Self-Inflicted Violence
2. Suicidality
2. Suicidality
3. Self-Inflicted Violence
3. Self-Inflicted Violence
4. Eating Disorders
4. Eating Disorders
5. Risk-Taking
5. Risk-Taking
6. Exploitative or Dangerous Relationships
6. Exploitative or Dangerous Relationships
7. Other Addictions
7. Other Addictions
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C. Assessing Safety and Stability at an Environmental Level
C. Assessing Safety and Stability at an Environmental Level
1. Insecure Living Situation
1. Insecure Living Situation
2. Financial Problems
2. Financial Problems
3. Occupational Instability
3. Occupational Instability
4. Relationship Difficulties
4. Relationship Difficulties
D. Exploring the Interpersonal Aspects of Safety
D. Exploring the Interpersonal Aspects of Safety
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Exploring the Current Level of Safety
Exploring the Current Level of Safety
An aspect of safety that I like to explore is the client’s history of safety or lack of it. As early
as 1970, Abraham Maslow proposed a theory of how individuals are motivated to meet
their basic human needs (Everly & Lating, 1995). At the base of the hierarchy is the drive
to satisfy basic physiological needs (e.g., food, water). Beyond these physical needs, the
second drive is the need for safety. Maslow defined safety as “having security, freedom
from fear, the need for structure and order, stability, and protection” (pp. 39-40).
“Maslow’s hierarchy of needs was completed by the addition of the need to belong and be
loved, the need for self-esteem, and, finally, self-actualization. Maslow makes the point
that one cannot progress up the hierarchy until one has satisfied the need beneath it” (p. 40).
Most people entering treatment have found a way to meet their core physiological needs
such as food, water, shelter, etc. (If these core physiological needs have not been met, then
they are the first focus of treatment).
An aspect of safety that I like to explore is the client’s history of safety or lack of it. As early
as 1970, Abraham Maslow proposed a theory of how individuals are motivated to meet
their basic human needs (Everly & Lating, 1995). At the base of the hierarchy is the drive
to satisfy basic physiological needs (e.g., food, water). Beyond these physical needs, the
second drive is the need for safety. Maslow defined safety as “having security, freedom
from fear, the need for structure and order, stability, and protection” (pp. 39-40).
“Maslow’s hierarchy of needs was completed by the addition of the need to belong and be
loved, the need for self-esteem, and, finally, self-actualization. Maslow makes the point
that one cannot progress up the hierarchy until one has satisfied the need beneath it” (p. 40).
Most people entering treatment have found a way to meet their core physiological needs
such as food, water, shelter, etc. (If these core physiological needs have not been met, then
they are the first focus of treatment).
There is a continuum between the meeting of physiological needs and safety needs. I will
address the following aspects of safety in this chapter, some of which are related to physiological needs in their less extreme form. First, I assess the safety and stability of the client’s physical self-care. Second, I assess for any self-harming behaviors the client may be
engaging in. Third, I assess safety and stability at an environmental level. Finally, I assess
the interpersonal aspects of safety.
There is a continuum between the meeting of physiological needs and safety needs. I will
address the following aspects of safety in this chapter, some of which are related to physiological needs in their less extreme form. First, I assess the safety and stability of the client’s physical self-care. Second, I assess for any self-harming behaviors the client may be
engaging in. Third, I assess safety and stability at an environmental level. Finally, I assess
the interpersonal aspects of safety.
ASSESSING SAFETY AND STABILITY OF
PHYSICAL SELF-CARE
ASSESSING SAFETY
STABILITY
AND
AND
STABILITY
SAFETY OF
PHYSICAL SELF-CARE
It is important to assess the stability and safety of the client’s physical self-care. The therapist may already have enough information from the initial history-taking to evaluate a client who is currently functioning well. I recommend that all the areas be at least minimally
addressed with the client so nothing is missed that would be relevant to increasing the client’s safety level. It is especially important to do a careful assessment for clients who have
a history of trauma or abuse. For these clients the process of physical self-care is often moderately to severely disabled. Survivors of trauma or abuse tend to feel unsafe in their bodies.
Their emotions and thinking may feel out of control. They tend to feel unsafe in their reaction to others. The goal is to restore the sense that they control their bodies. When the need
is indicated, the therapist should assess the patterns of sleeping, eating, physical activity,
relaxation or play, managing stress, and health or medical issues. Questions for each of
these areas of self-care are provided.
It is important to assess the stability and safety of the client’s physical self-care. The therapist may already have enough information from the initial history-taking to evaluate a client who is currently functioning well. I recommend that all the areas be at least minimally
addressed with the client so nothing is missed that would be relevant to increasing the client’s safety level. It is especially important to do a careful assessment for clients who have
a history of trauma or abuse. For these clients the process of physical self-care is often moderately to severely disabled. Survivors of trauma or abuse tend to feel unsafe in their bodies.
Their emotions and thinking may feel out of control. They tend to feel unsafe in their reaction to others. The goal is to restore the sense that they control their bodies. When the need
is indicated, the therapist should assess the patterns of sleeping, eating, physical activity,
relaxation or play, managing stress, and health or medical issues. Questions for each of
these areas of self-care are provided.
Note: Some of these areas have been partially covered under History-Taking, Chapter 1.
Note: Some of these areas have been partially covered under History-Taking, Chapter 1.
SLEEPING
SLEEPING
It may be useful to ask the following questions regarding sleep patterns, since problems in
this area may serve as indicators of any number of difficulties (e.g., a sleep disturbance, depression, or anxiety):
• How are you sleeping?
• How many hours of sleep do you get a night?
• Do you awaken before the alarm goes off? (Many people in this country are suffering
from sleep deprivation.)
It may be useful to ask the following questions regarding sleep patterns, since problems in
this area may serve as indicators of any number of difficulties (e.g., a sleep disturbance, depression, or anxiety):
• How are you sleeping?
• How many hours of sleep do you get a night?
• Do you awaken before the alarm goes off? (Many people in this country are suffering
from sleep deprivation.)
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• Do you awaken feeling rested?
• Do you fall asleep right away?
• Do you wake up in the night? How many times? For how long?
• Do you have difficulty going back to sleep?
• How many mornings of the week do you awaken feeling rested?
• Do you awaken feeling rested?
• Do you fall asleep right away?
• Do you wake up in the night? How many times? For how long?
• Do you have difficulty going back to sleep?
• How many mornings of the week do you awaken feeling rested?
Note: Clients who are experiencing problems in the area of sleep should be assessed for
mood disorders (Major Depressive Disorder, Bipolar Disorder, etc.) and anxiety disorders
(Generalized Anxiety, PTSD, etc.). Sometimes difficulties with sleep are indicators of suicidality. A careful assessment will clarify this issue. (See Suicidality and Self-Inflicted Violence,
this chapter.)
Note: Clients who are experiencing problems in the area of sleep should be assessed for
mood disorders (Major Depressive Disorder, Bipolar Disorder, etc.) and anxiety disorders
(Generalized Anxiety, PTSD, etc.). Sometimes difficulties with sleep are indicators of suicidality. A careful assessment will clarify this issue. (See Suicidality and Self-Inflicted Violence,
this chapter.)
Note: If a client is reporting difficulty going to sleep, waking up, or not having 3-4 hours of
uninterrupted sleep, then a medical referral for evaluation and medication is needed to address this issue before any other interventions are useful.
Note: If a client is reporting difficulty going to sleep, waking up, or not having 3-4 hours of
uninterrupted sleep, then a medical referral for evaluation and medication is needed to address this issue before any other interventions are useful.
EATING
EATING
Asking the following questions provides valuable information regarding nutrition and diet,
as problems in these areas may be indicators of a number of difficulties including high
stress, depression, and eating disorders:
• How is your appetite?
• How often do you eat?
• What kinds of foods do you eat daily?
• How much caffeine or sugar do you consume daily?
• Have you lost weight recently? How much?
• Were you trying to lose weight?
• Have you gained weight recently? How much?
• Were you trying to gain weight?
• Do you see yourself as overweight or underweight?
• Are there times you eat excessively or it seems like you are not able to stop? How
often?
• What does that look like?
• Are there ever times that you take laxatives when it is not medically indicated or
force yourself to vomit when you are not ill?
Asking the following questions provides valuable information regarding nutrition and diet,
as problems in these areas may be indicators of a number of difficulties including high
stress, depression, and eating disorders:
• How is your appetite?
• How often do you eat?
• What kinds of foods do you eat daily?
• How much caffeine or sugar do you consume daily?
• Have you lost weight recently? How much?
• Were you trying to lose weight?
• Have you gained weight recently? How much?
• Were you trying to gain weight?
• Do you see yourself as overweight or underweight?
• Are there times you eat excessively or it seems like you are not able to stop? How
often?
• What does that look like?
• Are there ever times that you take laxatives when it is not medically indicated or
force yourself to vomit when you are not ill?
Note: See Eating Disorders, this chapter.
Note: See Eating Disorders, this chapter.
PHYSICAL ACTIVITY
PHYSICAL ACTIVITY
The following questions provide useful information regarding how physically active the
client is and whether this area can be utilized for self-soothing:
The following questions provide useful information regarding how physically active the
client is and whether this area can be utilized for self-soothing:
Note: I recommend using the words physical activity as some clients are put off by the idea
of exercise. There are many common physical activities that are not seen as exercise yet
help to keep a person physically active and healthy. I suggest these examples of physical
activity: gardening, walking the dog, care of young children, and house cleaning.
Note: I recommend using the words physical activity as some clients are put off by the idea
of exercise. There are many common physical activities that are not seen as exercise yet
help to keep a person physically active and healthy. I suggest these examples of physical
activity: gardening, walking the dog, care of young children, and house cleaning.
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• What kind of physical activity do you engage in regularly?
• How often do you engage in physical activity in a week? For how long at a time?
• What other types of big muscle activity are you doing?
• Do you enjoy engaging in physical activity? What kind?
Note: I usually suggest to clients who are depressed that they engage in some kind of daily
physical activity for at least 10-20 minutes or if it is aerobic in nature, 3-5 times a week.
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• What kind of physical activity do you engage in regularly?
• How often do you engage in physical activity in a week? For how long at a time?
• What other types of big muscle activity are you doing?
• Do you enjoy engaging in physical activity? What kind?
Note: I usually suggest to clients who are depressed that they engage in some kind of daily
physical activity for at least 10-20 minutes or if it is aerobic in nature, 3-5 times a week.
RELAXATION AND PLAY
RELAXATION AND PLAY
The following questions provide useful information regarding relaxation and play as ways
of increasing the client’s ability to self-soothe:
• What do you do for play or relaxation? How often?
• Who do you do it with?
• Do you enjoy taking time to play or relax?
• Are there other things you do for fun?
The following questions provide useful information regarding relaxation and play as ways
of increasing the client’s ability to self-soothe:
• What do you do for play or relaxation? How often?
• Who do you do it with?
• Do you enjoy taking time to play or relax?
• Are there other things you do for fun?
MANAGING STRESS
MANAGING STRESS
Asking the following questions about how clients manage their stress provides a way of assessing their stress level and helping them to learn better ways to self-soothe:
Asking the following questions about how clients manage their stress provides a way of assessing their stress level and helping them to learn better ways to self-soothe:
• When you are really uptight and tense, what do you do?
• When you are really uptight and tense, what do you do?
• How do you unwind?
• How do you unwind?
• Are you able to decrease your tension level?
• Are you able to decrease your tension level?
• How often do you use either over-the-counter or doctor prescribed medications to
relax?
• How often do you use either over-the-counter or doctor prescribed medications to
relax?
• What do you use? How often?
• What do you use? How often?
• How often do you use substances such as alcohol, marijuana, or other drugs to relax?
• How often do you use substances such as alcohol, marijuana, or other drugs to relax?
• What do you use? How much? How often? (See Substance Abuse, Chapter 1.)
• What do you use? How much? How often? (See Substance Abuse, Chapter 1.)
• When do you feel angry and irritable? How often do you experience these reactions?
• When do you feel angry and irritable? How often do you experience these reactions?
• Have you ever done any relaxation training? When? How often?
• Have you ever done any relaxation training? When? How often?
• Did the relaxation training help you to relax?
• Did the relaxation training help you to relax?
Note: Substance abuse must be addressed before any real treatment can begin.
Note: Substance abuse must be addressed before any real treatment can begin.
HEALTH OR MEDICAL ISSUES
HEALTH OR MEDICAL ISSUES
Asking the following questions regarding health or medical issues provides useful information since the symptoms clients present with in our office may be a direct result of unidentified or untreated medical issues:
• How long has it been since you have had a thorough physical examination?
• Were there any problems found?
Asking the following questions regarding health or medical issues provides useful information since the symptoms clients present with in our office may be a direct result of unidentified or untreated medical issues:
• How long has it been since you have had a thorough physical examination?
• Were there any problems found?
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• Are the problems being treated?
• Are you willing to get a physical examination?
Note: If there has not been a recent physical examination, I ask them to get one as soon as
possible. Some medical problems such as thyroid activity can influence the mood of a person.
• Are the problems being treated?
• Are you willing to get a physical examination?
Note: If there has not been a recent physical examination, I ask them to get one as soon as
possible. Some medical problems such as thyroid activity can influence the mood of a person.
• What health or medical problems do you have?
• How long have you had these problems?
• How do these problems affect your life?
• Do you see a doctor for any of these problems?
• Are these problems being successfully treated?
• Are you taking medications for any of these problems?
• Are there any other health or medical issues that you have not mentioned?
• How would you rate your health overall? Excellent? Good? Fair? Poor?
• What health or medical problems do you have?
• How long have you had these problems?
• How do these problems affect your life?
• Do you see a doctor for any of these problems?
• Are these problems being successfully treated?
• Are you taking medications for any of these problems?
• Are there any other health or medical issues that you have not mentioned?
• How would you rate your health overall? Excellent? Good? Fair? Poor?
LOOKING FOR SELF-HARMING BEHAVIORS
LOOKING FOR SELF-HARMING BEHAVIORS
When a client has a history of trauma or abuse, it is particularly important to assess for selfharming behaviors. Until these issues are addressed, substantive treatment cannot begin.
Areas covered in the following section are suicide, self-inflicted violence, eating disorders,
risk-taking, exploitative or dangerous relationships, and other addictions. For your convenience in assessing for suicidality, I have included some key questions from topics mentioned in Chapter 1 on substance abuse and depression. Topics covered in the previous
section of this chapter that may be helpful in assessing for suicidality are sleeping, eating,
physical activity, and health or medical issues. Destructive behaviors are often an attempt
to reenact the original abuse or trauma at a symbolic or literal level. In the absence of
healthy self-soothing strategies, clients may utilize these behaviors to regulate their intolerable feelings.
When a client has a history of trauma or abuse, it is particularly important to assess for selfharming behaviors. Until these issues are addressed, substantive treatment cannot begin.
Areas covered in the following section are suicide, self-inflicted violence, eating disorders,
risk-taking, exploitative or dangerous relationships, and other addictions. For your convenience in assessing for suicidality, I have included some key questions from topics mentioned in Chapter 1 on substance abuse and depression. Topics covered in the previous
section of this chapter that may be helpful in assessing for suicidality are sleeping, eating,
physical activity, and health or medical issues. Destructive behaviors are often an attempt
to reenact the original abuse or trauma at a symbolic or literal level. In the absence of
healthy self-soothing strategies, clients may utilize these behaviors to regulate their intolerable feelings.
Note: Some of these areas have been covered extensively under History-Taking, Chapter
1 or in Appendices A and B, this chapter. Refer to these sections as needed to assist you in
a thorough assessment.
Note: Some of these areas have been covered extensively under History-Taking, Chapter
1 or in Appendices A and B, this chapter. Refer to these sections as needed to assist you in
a thorough assessment.
ASSESSMENT FOR SUICIDALITY AND SELF-INFLICTED
VIOLENCE
ASSESSMENT FOR SUICIDALITY AND SELF-INFLICTED
VIOLENCE
Assessment for suicidality is important when there is evidence of depression or PTSD. In
addition, an assessment for self-inflicted violence (SIV) should be done. Clients who have
experienced abuse or trauma may have inflicted injury on themselves. These clients, in particular, need to be carefully assessed for this behavior. (See Appendices A and B, this chapter for brief assessment tools.) Basic questions to assess for SIV or suicidality are:
• Are you thinking of hurting yourself?
• How long have you felt like hurting yourself?
• Have you ever had thoughts of hurting yourself even if you are not having them now?
• How many times have you thought about hurting yourself?
• What is your earliest memory of these feelings?
Assessment for suicidality is important when there is evidence of depression or PTSD. In
addition, an assessment for self-inflicted violence (SIV) should be done. Clients who have
experienced abuse or trauma may have inflicted injury on themselves. These clients, in particular, need to be carefully assessed for this behavior. (See Appendices A and B, this chapter for brief assessment tools.) Basic questions to assess for SIV or suicidality are:
• Are you thinking of hurting yourself?
• How long have you felt like hurting yourself?
• Have you ever had thoughts of hurting yourself even if you are not having them now?
• How many times have you thought about hurting yourself?
• What is your earliest memory of these feelings?
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• How old were you the first time you had these feelings?
• What were the thoughts or feelings that you had at that time?
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• How old were you the first time you had these feelings?
• What were the thoughts or feelings that you had at that time?
SUICIDALITY
SUICIDALITY
When assessing for suicidality, I usually begin by asking the following question:
• Are there other ways you have ever tried to hurt yourself?
When assessing for suicidality, I usually begin by asking the following question:
• Are there other ways you have ever tried to hurt yourself?
If clients talk about killing themselves, then it is okay to use these words with them:
• Have you thought about killing yourself? How?
• What would that look like?
• When would you do it?
If clients talk about killing themselves, then it is okay to use these words with them:
• Have you thought about killing yourself? How?
• What would that look like?
• When would you do it?
Note: When clients are actively considering killing themselves, it is important to assess the lethality of the plan. Do they have the means at their disposal to easily carry out the plan? If there
is a weapon in the house, it may be necessary to have a family member remove the weapon.
A member of the family may need to take responsibility for medications until the threat of suicide passes.
Note: When clients are actively considering killing themselves, it is important to assess the lethality of the plan. Do they have the means at their disposal to easily carry out the plan? If there
is a weapon in the house, it may be necessary to have a family member remove the weapon.
A member of the family may need to take responsibility for medications until the threat of suicide passes.
• Have you ever tried to kill yourself before? When?
• Have you ever tried to kill yourself before? When?
• How many times have you tried to kill yourself?
• How many times have you tried to kill yourself?
• Under what circumstances did you try to kill yourself?
• Under what circumstances did you try to kill yourself?
• What happened when you tried to kill yourself?
• What happened when you tried to kill yourself?
• If you stopped, what stopped you?
• If you stopped, what stopped you?
• Were you hospitalized? For how long?
• Were you hospitalized? For how long?
• Did you get any therapy during or after any of these times?
• Did you get any therapy during or after any of these times?
• Was the therapy helpful?
• Was the therapy helpful?
Note: If assessment for substance abuse has not been done previously, please refer to Substance Abuse, Chapter 1. For your convenience in further assessing the risk of suicidality, I
have included a few questions from this section.
Ask the following questions regarding drugs or alcohol because substance abuse can be a
contributing factor in suicidality:
Note: If assessment for substance abuse has not been done previously, please refer to Substance Abuse, Chapter 1. For your convenience in further assessing the risk of suicidality, I
have included a few questions from this section.
Ask the following questions regarding drugs or alcohol because substance abuse can be a
contributing factor in suicidality:
• Are you using any drugs or alcohol right now?
• Are you using any drugs or alcohol right now?
• Which substances are you using? How much? How often?
• Which substances are you using? How much? How often?
• Are you using prescription drugs? How much? How often?
• Are you using prescription drugs? How much? How often?
• Does your doctor know that you are suicidal or have been in the past?
• Does your doctor know that you are suicidal or have been in the past?
• When you are suicidal, have you been drinking or using?
• When you are suicidal, have you been drinking or using?
Note: Alcohol increases depression which, in turn, may increase suicidality. If assessment for
depression has not been done previously, please refer to Depressive History, Chapter 1 to do
an assessment for suicidality. I have included some general questions for your convenience.
Note: Alcohol increases depression which, in turn, may increase suicidality. If assessment for
depression has not been done previously, please refer to Depressive History, Chapter 1 to do
an assessment for suicidality. I have included some general questions for your convenience.
Ask the following questions regarding depression because it is a major factor in suicidality:
Ask the following questions regarding depression because it is a major factor in suicidality:
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• Are you being treated for depression?
• Who are you seeing?
• Is the person a psychiatrist or a general practitioner?
• Has it been helpful or not?
• What are you taking?
• Have you ever seen a psychiatrist?
• Are you willing to see a psychiatrist?
• Are you being treated for depression?
• Who are you seeing?
• Is the person a psychiatrist or a general practitioner?
• Has it been helpful or not?
• What are you taking?
• Have you ever seen a psychiatrist?
• Are you willing to see a psychiatrist?
If clients are actively suicidal and are not being treated for depression, I usually say the following to them:
If clients are actively suicidal and are not being treated for depression, I usually say the following to them:
I would like you to see a psychiatrist and have you carefully evaluated. Are
you willing to call and make an appointment?
I would like you to see a psychiatrist and have you carefully evaluated. Are
you willing to call and make an appointment?
If the answer is affirmative, I say the following:
If the answer is affirmative, I say the following:
I will need a signed consent form from you so that I can talk to the psychiatrist. I like to take a team approach with the doctor that I send you to for an
evaluation.
I will need a signed consent form from you so that I can talk to the psychiatrist. I like to take a team approach with the doctor that I send you to for an
evaluation.
Note: I have a preference for clients to be seen by a psychiatrist who is likely to be more
familiar with the wealth of psychotropic medications that are available. However, more and
more clients are being seen by general practitioners for depression and anxiety. If a client
prefers not to see a psychiatrist, a team approach needs to be taken with the general practitioner just as you would with a psychiatrist. It is important to assess the doctor’s willingness
to be available when a client is actively suicidal. It is also helpful to assess the doctor’s feelings about a psychiatric referral if you deem it necessary to protect the client.
Note: I have a preference for clients to be seen by a psychiatrist who is likely to be more
familiar with the wealth of psychotropic medications that are available. However, more and
more clients are being seen by general practitioners for depression and anxiety. If a client
prefers not to see a psychiatrist, a team approach needs to be taken with the general practitioner just as you would with a psychiatrist. It is important to assess the doctor’s willingness
to be available when a client is actively suicidal. It is also helpful to assess the doctor’s feelings about a psychiatric referral if you deem it necessary to protect the client.
Ask the following questions regarding mood or anxiety disorders to rule out the possibility
of a family history of mental illness:
Ask the following questions regarding mood or anxiety disorders to rule out the possibility
of a family history of mental illness:
Note: It is helpful to assess if there is a long-term history of depressive or anxiety disorders.
Note: It is helpful to assess if there is a long-term history of depressive or anxiety disorders.
• Is there a family history of severe emotional problems such as depression, anxiety,
panic attacks, phobias?
• Has anyone in your family ever tried to hurt or kill themselves? Who?
• Did they succeed?
• What was the meaning of that for you?
• How did you feel in response to that happening?
• How do you feel about it today?
• Is there a family history of severe emotional problems such as depression, anxiety,
panic attacks, phobias?
• Has anyone in your family ever tried to hurt or kill themselves? Who?
• Did they succeed?
• What was the meaning of that for you?
• How did you feel in response to that happening?
• How do you feel about it today?
Note: When a family member attempts or succeeds in killing himself or herself, it opens a
Pandora's Box that has heretofore not been open for resolving painful issues in one's life.
Note: When a family member attempts or succeeds in killing himself or herself, it opens a
Pandora's Box that has heretofore not been open for resolving painful issues in one's life.
It may be helpful to ask the following work-related questions because this area can be a potential source of major stress:
• What is happening at work?
• Are you experiencing any conflicts at work?
• Are there any conflicts with your boss, supervisor, or peers?
It may be helpful to ask the following work-related questions because this area can be a potential source of major stress:
• What is happening at work?
• Are you experiencing any conflicts at work?
• Are there any conflicts with your boss, supervisor, or peers?
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• Have their been any changes in the kind or the amount of work you are doing?
• How do you feel about those changes?
• Have their been any changes in the kind or the amount of work you are doing?
• How do you feel about those changes?
It may be useful to ask the following relationship questions because this area can often be
a major source of stress as well as support:
• What is happening in your current relationships?
• Are you having any problems?
• What does your support system look like?
• Are you close to your family?
• Is your family aware of how you are feeling?
• Would your family be supportive if they knew you were suicidal?
• What support would you like from them?
It may be useful to ask the following relationship questions because this area can often be
a major source of stress as well as support:
• What is happening in your current relationships?
• Are you having any problems?
• What does your support system look like?
• Are you close to your family?
• Is your family aware of how you are feeling?
• Would your family be supportive if they knew you were suicidal?
• What support would you like from them?
Note: There are times that clients need additional support from a family member or friend
to help them stay physically safe. It is important to get a signed release from the client before
talking to a support person in the office or by phone. Whenever it is possible, the client
should be present. It is important that confidentiality be maintained except for purposes of
keeping clients safe from seriously harming themselves.
Note: There are times that clients need additional support from a family member or friend
to help them stay physically safe. It is important to get a signed release from the client before
talking to a support person in the office or by phone. Whenever it is possible, the client
should be present. It is important that confidentiality be maintained except for purposes of
keeping clients safe from seriously harming themselves.
• Are there other people in your support system that you can call on if needed? Who?
• What kind of support would be helpful?
• Could these people give you the support?
• Can you ask for that support?
• Are you aware of what happens just before you begin to feel suicidal?
• What was going on in your life just before you began to feel this way?
• What did you feel just before you began to feel suicidal?
• Are there other people in your support system that you can call on if needed? Who?
• What kind of support would be helpful?
• Could these people give you the support?
• Can you ask for that support?
• Are you aware of what happens just before you begin to feel suicidal?
• What was going on in your life just before you began to feel this way?
• What did you feel just before you began to feel suicidal?
Note: It is helpful to attempt to reconstruct the events, people involved, and the feelings clients have just before they became suicidal.
Note: It is helpful to attempt to reconstruct the events, people involved, and the feelings clients have just before they became suicidal.
• What decisions did you make at that time?
• What triggers or feelings seem to set up a pattern that you can identify?.
• Do you feel as though you can keep yourself safe without being hospitalized?
• What decisions did you make at that time?
• What triggers or feelings seem to set up a pattern that you can identify?.
• Do you feel as though you can keep yourself safe without being hospitalized?
Note: If clients appear to be at a high risk of suicide, a psychiatric evaluation team (PET)
can be called to evaluate them in your office, or the police can be called to take a client to a
PET in the local area. Clients with insurance usually must use their own providers of care.
The client's physician or insurance company can be called to set up a psychiatric referral.
Be sure to get release forms from the client to make these contacts and/or to talk to a physician. Clients can also be released to a family member.
Note: If clients appear to be at a high risk of suicide, a psychiatric evaluation team (PET)
can be called to evaluate them in your office, or the police can be called to take a client to a
PET in the local area. Clients with insurance usually must use their own providers of care.
The client's physician or insurance company can be called to set up a psychiatric referral.
Be sure to get release forms from the client to make these contacts and/or to talk to a physician. Clients can also be released to a family member.
When working with suicidal clients, I often ask them if they are willing to make a contract
that says the following:
When working with suicidal clients, I often ask them if they are willing to make a contract
that says the following:
No matter how scared, depressed, sad, or angry I get, I will not accidentally or on purpose kill myself or anyone else.
No matter how scared, depressed, sad, or angry I get, I will not accidentally or on purpose kill myself or anyone else.
Note: I eventually use the word hurt, but initially asking clients not to hurt themselves may
feel like too big of a commitment.
Note: I eventually use the word hurt, but initially asking clients not to hurt themselves may
feel like too big of a commitment.
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The contract is not between the client and the therapist. One metaphor I often use in my
work with clients is that of an internal child. The child is a metaphor for the more vulnerable feeling state originally described in Transactional Analysis and subsequently used in
a modified form by John Bradshaw and others. Some clients are not comfortable with this
metaphor. The contract is an attempt to stop the internal child from being injured. I try to
help clients get an image of them holding their internal child.
The contract is not between the client and the therapist. One metaphor I often use in my
work with clients is that of an internal child. The child is a metaphor for the more vulnerable feeling state originally described in Transactional Analysis and subsequently used in
a modified form by John Bradshaw and others. Some clients are not comfortable with this
metaphor. The contract is an attempt to stop the internal child from being injured. I try to
help clients get an image of them holding their internal child.
Sometimes, it is helpful for clients to draw a picture of the child or remember a picture of
themselves as a child. Then, I see if they can access the hidden feelings of fear, sadness and
anger. It is important to help clients take responsibility for their own health and not make
the therapist responsible for keeping them alive.
Sometimes, it is helpful for clients to draw a picture of the child or remember a picture of
themselves as a child. Then, I see if they can access the hidden feelings of fear, sadness and
anger. It is important to help clients take responsibility for their own health and not make
the therapist responsible for keeping them alive.
It may be helpful to have the clients write out the contract and read it aloud in the room to
see how it feels to them.
It may be helpful to have the clients write out the contract and read it aloud in the room to
see how it feels to them.
No matter how scared, depressed, sad, or angry I get, I will not accidentally or on purpose hurt myself or anyone else.
No matter how scared, depressed, sad, or angry I get, I will not accidentally or on purpose hurt myself or anyone else.
I ask clients to say it three or four times. Each time I ask the following kinds of questions:
• What is happening inside of you?
• What are you feeling?
• What are you thinking?
I ask clients to say it three or four times. Each time I ask the following kinds of questions:
• What is happening inside of you?
• What are you feeling?
• What are you thinking?
I ask clients to do this at home several times a day during the week. I say to them the following:
I ask clients to do this at home several times a day during the week. I say to them the following:
This week I want you to say this statement 5-10 times a day. You do not have
to believe it. I just want you to do it. Belief systems and behaviors change when
This week I want you to say this statement 5-10 times a day. You do not have
to believe it. I just want you to do it. Belief systems and behaviors change when
we begin to feed new information into our brains. We begin to act as if it were so.
We want the grown-up part of you to take care of the little kid part of you. Or, we
want that part of you that wants to live to take care of the part that does not. Are
we begin to feed new information into our brains. We begin to act as if it were so.
We want the grown-up part of you to take care of the little kid part of you. Or, we
want that part of you that wants to live to take care of the part that does not. Are
If the answer is affirmative, we then process in the next session what it was like for them
to do this exercise.
If the answer is affirmative, we then process in the next session what it was like for them
to do this exercise.
It is important to align with the clients’ desire to live that brought them into treatment and
to assess if they have the ability to self-soothe and modulate their feelings generally. It is
useful for therapists to ask themselves if they can help clients create enough safety by engaging in any number of the following:
• strengthening their ability to regulate their feelings
• seeing a doctor for a psychiatric evaluation and possible medication
• incorporating regular physical activity
• engaging in an assortment of self-soothing exercises
• changing their diet
• getting an adequate support system
• strengthening or utilizing an existing support system
• making a contract for their adult to protect their internal child
It is important to align with the clients’ desire to live that brought them into treatment and
to assess if they have the ability to self-soothe and modulate their feelings generally. It is
useful for therapists to ask themselves if they can help clients create enough safety by engaging in any number of the following:
• strengthening their ability to regulate their feelings
• seeing a doctor for a psychiatric evaluation and possible medication
• incorporating regular physical activity
• engaging in an assortment of self-soothing exercises
• changing their diet
• getting an adequate support system
• strengthening or utilizing an existing support system
• making a contract for their adult to protect their internal child
you willing to do this?
you willing to do this?
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• doing relationship work with a significant other or family members
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• doing relationship work with a significant other or family members
If the answer is negative, then hospitalization may be necessary. A suicidal client who is
not hospitalized usually needs to be seen two or more times a week, and phone check-ins
may also be warranted. Each time clients are seen, it is important to carefully assess the level of suicidality and affirm each self-care step that they have taken toward health.
If the answer is negative, then hospitalization may be necessary. A suicidal client who is
not hospitalized usually needs to be seen two or more times a week, and phone check-ins
may also be warranted. Each time clients are seen, it is important to carefully assess the level of suicidality and affirm each self-care step that they have taken toward health.
Note: If clients are determined to kill themselves, a therapist cannot ultimately keep that
from happening. It is the job of the therapist to assess for suicidality, treat as long as safety
can be maintained, seek voluntary or involuntary hospitalization, and/or refer for medications.
Note: If clients are determined to kill themselves, a therapist cannot ultimately keep that
from happening. It is the job of the therapist to assess for suicidality, treat as long as safety
can be maintained, seek voluntary or involuntary hospitalization, and/or refer for medications.
Suicidal Hot Line numbers should be included in the client consent form that was given to
clients in the initial session. Clients may need to be given these numbers again and reminded that they can call these numbers at any time of the day or night.
Suicidal Hot Line numbers should be included in the client consent form that was given to
clients in the initial session. Clients may need to be given these numbers again and reminded that they can call these numbers at any time of the day or night.
See the material in Chapter 5 for additional aids in assisting a suicidal client. Over a period
of time it is important to teach suicidal clients several ways to soothe themselves and then
have them choose which ones they are willing to use on a regular basis.
See the material in Chapter 5 for additional aids in assisting a suicidal client. Over a period
of time it is important to teach suicidal clients several ways to soothe themselves and then
have them choose which ones they are willing to use on a regular basis.
Safety is clearly an issue when working with suicidal clients. The safety of both the client
and therapist need to be carefully considered. In summary, there are several recommendations that are helpful when working with suicidal clients:
Safety is clearly an issue when working with suicidal clients. The safety of both the client
and therapist need to be carefully considered. In summary, there are several recommendations that are helpful when working with suicidal clients:
• The therapist needs to keep detailed case notes.
• The therapist needs to keep detailed case notes.
• The therapist should ask clients to make a contract to agree not to harm themselves.
• The therapist should ask clients to make a contract to agree not to harm themselves.
• Clients need to be willing to contact the therapist, the psychiatrist, or a suicide hot
line if they feel like they are going to hurt themselves.
• Clients need to be willing to contact the therapist, the psychiatrist, or a suicide hot
line if they feel like they are going to hurt themselves.
• The therapist needs to set up telephone contact in between sessions as seems needed.
• The therapist needs to set up telephone contact in between sessions as seems needed.
• The therapist needs to set up additional sessions as needed to increase support.
• The therapist needs to set up additional sessions as needed to increase support.
• The therapist needs to get supervision or consultation regarding the client.
• The therapist needs to get supervision or consultation regarding the client.
• It is helpful for the therapist to get permission to talk to a family member or close
friend to increase support for the client. When possible, I recommend this be done with
the client present.
• It is helpful for the therapist to get permission to talk to a family member or close
friend to increase support for the client. When possible, I recommend this be done with
the client present.
• The therapist needs to ask clients to voluntarily hospitalize themselves if they cannot
maintain themselves.
• The therapist needs to ask clients to voluntarily hospitalize themselves if they cannot
maintain themselves.
• If needed, the therapist needs to initiate involuntary hospitalization of the client.
• If needed, the therapist needs to initiate involuntary hospitalization of the client.
• In the event that a client does not need to be involuntarily hospitalized, it is important
to carefully document that this option was explored and why it was not chosen.
• In the event that a client does not need to be involuntarily hospitalized, it is important
to carefully document that this option was explored and why it was not chosen.
Note: If the therapist is hard to reach by phone between sessions, one way that may be useful is to stay in touch by e-mail. Of course, this depends on the level of trust you have with
the client and the diligence in checking one’s e-mail. It is important to check state laws that
may regulate this type of contact in your state. It is necessary to remind the client that all email messages are not secure.
Note: If the therapist is hard to reach by phone between sessions, one way that may be useful is to stay in touch by e-mail. Of course, this depends on the level of trust you have with
the client and the diligence in checking one’s e-mail. It is important to check state laws that
may regulate this type of contact in your state. It is necessary to remind the client that all email messages are not secure.
Note: It is important to carefully monitor clients who have been severely depressed and/or
suicidal as the depression begins to lift. Clients now have the energy to commit suicide that
they may not have had previously when they were more depressed.
Note: It is important to carefully monitor clients who have been severely depressed and/or
suicidal as the depression begins to lift. Clients now have the energy to commit suicide that
they may not have had previously when they were more depressed.
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SELF-INFLICTED VIOLENCE
SELF-INFLICTED VIOLENCE
Clients who have a history of trauma or abuse may engage in self-inflicted violence (SIV).
If the client has a history of SIV, then a careful assessment should be made to determine
whether a mood disorder (Major Depressive, Bipolar, etc.) or anxiety disorder (PTSD, Obsessive-Compulsive, etc.) is present. Clients who engage in SIV should be carefully assessed for eating disorders, substance abuse, and suicidal behavior. A medical referral for
evaluation and medication may be needed.
Clients who have a history of trauma or abuse may engage in self-inflicted violence (SIV).
If the client has a history of SIV, then a careful assessment should be made to determine
whether a mood disorder (Major Depressive, Bipolar, etc.) or anxiety disorder (PTSD, Obsessive-Compulsive, etc.) is present. Clients who engage in SIV should be carefully assessed for eating disorders, substance abuse, and suicidal behavior. A medical referral for
evaluation and medication may be needed.
SIV may be seen as suicidal, but usually it is a symptom of other psychological problems.
Clients who have been physically, sexually, or emotionally abused need to be assessed for
SIV. Clients who dissociate use it to go away or come back. SIV is often present with Borderline Personality Disorder. It may coexist with anxiety disorders when clients have difficulty self-soothing.
SIV may be seen as suicidal, but usually it is a symptom of other psychological problems.
Clients who have been physically, sexually, or emotionally abused need to be assessed for
SIV. Clients who dissociate use it to go away or come back. SIV is often present with Borderline Personality Disorder. It may coexist with anxiety disorders when clients have difficulty self-soothing.
Most clients are uncomfortable talking about these behaviors. I think it is useful to ask
questions that will encourage clients to reveal any SIV. If the answer is affirmative, then
this line of questioning can be revisited after trust has begun to develop. Questions that
might be asked are:
• Do you ever engage in any self-injurious behavior such as cutting yourself, burning
yourself, etc.?
• What other ways have you inflicted injury on yourself?
• How often do you engage in this behavior?
• When did you first begin to inflict injury on yourself?
• How does it feel to have me ask you about this?
Most clients are uncomfortable talking about these behaviors. I think it is useful to ask
questions that will encourage clients to reveal any SIV. If the answer is affirmative, then
this line of questioning can be revisited after trust has begun to develop. Questions that
might be asked are:
• Do you ever engage in any self-injurious behavior such as cutting yourself, burning
yourself, etc.?
• What other ways have you inflicted injury on yourself?
• How often do you engage in this behavior?
• When did you first begin to inflict injury on yourself?
• How does it feel to have me ask you about this?
I follow up with a more careful assessment at another time. (See Self-Inflicted Violence in
Appendices A and B, this chapter.)
I follow up with a more careful assessment at another time. (See Self-Inflicted Violence in
Appendices A and B, this chapter.)
EATING DISORDERS
EATING DISORDERS
One of the most life threatening issues with which therapists are presented is eating disorders. Due to the complexity of this disorder, it is very important that therapists do not treat
clients with these disorders unless they have sufficient training. A careful assessment needs
to be made due to the high frequency of co-occurring mood and anxiety disorders. Clients
with eating disorders should be carefully monitored by a nutritionist to maintain a healthy
body weight. The client should also be assessed for suicidality, SIV, and substance abuse.
A psychiatric referral can help determine whether or not medications would be useful in
helping to control the symptomology that is usually present. Therapists who choose to work
in this area should gain extensive training through workshops and reading and get ongoing
supervision. For additional information see Recommended Resources for this chapter. Ali
Borden, M.A., M.F.T., an expert in working with those suffering from eating disorders, recommends the following questions as a way of assessing whether or not new clients have an
eating disorder:
One of the most life threatening issues with which therapists are presented is eating disorders. Due to the complexity of this disorder, it is very important that therapists do not treat
clients with these disorders unless they have sufficient training. A careful assessment needs
to be made due to the high frequency of co-occurring mood and anxiety disorders. Clients
with eating disorders should be carefully monitored by a nutritionist to maintain a healthy
body weight. The client should also be assessed for suicidality, SIV, and substance abuse.
A psychiatric referral can help determine whether or not medications would be useful in
helping to control the symptomology that is usually present. Therapists who choose to work
in this area should gain extensive training through workshops and reading and get ongoing
supervision. For additional information see Recommended Resources for this chapter. Ali
Borden, M.A., M.F.T., an expert in working with those suffering from eating disorders, recommends the following questions as a way of assessing whether or not new clients have an
eating disorder:
• Is anyone in your life concerned that you do not eat enough?
• Do you still have your period?
• Have you ever intentionally thrown up your food?
• Have you ever intentionally taken laxatives for weight loss?
• Is anyone in your life concerned that you do not eat enough?
• Do you still have your period?
• Have you ever intentionally thrown up your food?
• Have you ever intentionally taken laxatives for weight loss?
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• Do you count calories? If so, how many calories do you allow yourself a day? (less
than 1000 calories should be of concern)
• Do you exercise even if you are injured?
• Do you ever have trouble concentrating because you have not eaten enough?
• Are you preoccupied by food, weight, recipes, calories, dieting, other people’s bodies?
• Do you ever feel like you should be punished?
• Have you ever eaten until you were physically ill? How often has this happened?
• Do you think eating shows you are weak?
• How does your family treat physical appearance?
• If you cannot do something perfectly, do you decide you should not do it at all?
• Do you avoid social situations because you do not feel good enough about yourself?
• Do you regularly skip meals?
• Do you believe you have to be thin to be loved?
• Did you experience your family as overly interested in your body and how it functioned?
• Did you experience physical or sexual abuse?
• Do you count calories? If so, how many calories do you allow yourself a day? (less
than 1000 calories should be of concern)
• Do you exercise even if you are injured?
• Do you ever have trouble concentrating because you have not eaten enough?
• Are you preoccupied by food, weight, recipes, calories, dieting, other people’s bodies?
• Do you ever feel like you should be punished?
• Have you ever eaten until you were physically ill? How often has this happened?
• Do you think eating shows you are weak?
• How does your family treat physical appearance?
• If you cannot do something perfectly, do you decide you should not do it at all?
• Do you avoid social situations because you do not feel good enough about yourself?
• Do you regularly skip meals?
• Do you believe you have to be thin to be loved?
• Did you experience your family as overly interested in your body and how it functioned?
• Did you experience physical or sexual abuse?
RISK-TAKING
RISK-TAKING
Risk-taking may be seen in clients with a history of trauma or abuse. Traumatized clients
may find themselves reenacting some aspect of traumatic scenes from their past in disguised form, without realizing what they are doing. It is important for the therapist to help
the client to become aware of the link between dangerous risk-taking behavior and a childhood history of abuse when that is present. A careful assessment should be made to determine whether a mood disorder (Major Depressive, Bipolar, etc.) or an anxiety disorder
(PTSD, etc.) is present. A medical referral for evaluation and medication may be warranted.
Clients who engage in risk-taking need to be taught how to self-soothe as a way of regaining control of their bodies and feelings. (See Chapter 5). Risk-taking can take various
forms.
• acting out a wish to die by having unprotected sex
• frequenting bars, getting drunk, and ending up being raped or physically assaulted
• walking on the streets late at night with earphones
• engaging in road rage on the streets and freeways acting out unresolved rage around
being physically abused
• going to the gym late at night as an attempt to regulate an internal emotional state
Risk-taking may be seen in clients with a history of trauma or abuse. Traumatized clients
may find themselves reenacting some aspect of traumatic scenes from their past in disguised form, without realizing what they are doing. It is important for the therapist to help
the client to become aware of the link between dangerous risk-taking behavior and a childhood history of abuse when that is present. A careful assessment should be made to determine whether a mood disorder (Major Depressive, Bipolar, etc.) or an anxiety disorder
(PTSD, etc.) is present. A medical referral for evaluation and medication may be warranted.
Clients who engage in risk-taking need to be taught how to self-soothe as a way of regaining control of their bodies and feelings. (See Chapter 5). Risk-taking can take various
forms.
• acting out a wish to die by having unprotected sex
• frequenting bars, getting drunk, and ending up being raped or physically assaulted
• walking on the streets late at night with earphones
• engaging in road rage on the streets and freeways acting out unresolved rage around
being physically abused
• going to the gym late at night as an attempt to regulate an internal emotional state
It may be useful to ask the following questions to determine whether or not risk-taking is
an issue:
• Do you engage in any behaviors that put you at risk? What?
• How do they put you at risk?
• What do you get out of putting yourself at risk?
• Do others feel you are engaging in risk-taking behaviors?
It may be useful to ask the following questions to determine whether or not risk-taking is
an issue:
• Do you engage in any behaviors that put you at risk? What?
• How do they put you at risk?
• What do you get out of putting yourself at risk?
• Do others feel you are engaging in risk-taking behaviors?
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• How does it feel to know that others may be concerned for you in this area?
• Has their concern changed your behavior in any way?
• Is this an area that you see a need to make any change?
• What would you like to change, if anything?
• How does it feel to know that others may be concerned for you in this area?
• Has their concern changed your behavior in any way?
• Is this an area that you see a need to make any change?
• What would you like to change, if anything?
EXPLOITATIVE OR DANGEROUS RELATIONSHIPS
EXPLOITATIVE OR DANGEROUS RELATIONSHIPS
Clients who have a history of trauma or abuse may find themselves in exploitative or dangerous relationships. These clients are reenacting some aspect of their history in disguised
form without realizing what they are doing. It is important for the therapist to help the client
to become aware of the link between exploitative or dangerous relationships and a childhood history of abuse. This is often a very long and difficult process. Even when clients
become aware that the person with whom they are in relationship is dangerous or exploiting
them, they still may not be willing to end the relationship. Clients may seem to split into
the part of them that knows they deserve better and the part that is reenacting the abuse they
believe must have been deserved.
Clients who have a history of trauma or abuse may find themselves in exploitative or dangerous relationships. These clients are reenacting some aspect of their history in disguised
form without realizing what they are doing. It is important for the therapist to help the client
to become aware of the link between exploitative or dangerous relationships and a childhood history of abuse. This is often a very long and difficult process. Even when clients
become aware that the person with whom they are in relationship is dangerous or exploiting
them, they still may not be willing to end the relationship. Clients may seem to split into
the part of them that knows they deserve better and the part that is reenacting the abuse they
believe must have been deserved.
Examples
Examples
A female client who was sexually abused as a child has been raped several
times.
A female client who was beaten and sexually abused as a child finds men
who are emotionally controlling and physically abusive.
A male client who was emotionally abused by his father finds himself in relationships where he takes care of others at his own expense.
A female client who was sexually abused as a child has been raped several
times.
A female client who was beaten and sexually abused as a child finds men
who are emotionally controlling and physically abusive.
A male client who was emotionally abused by his father finds himself in relationships where he takes care of others at his own expense.
OTHER ADDICTIONS
OTHER ADDICTIONS
Shame is at the root of many addictions. Clients who have a history of trauma or abuse in
their background frequently have multiple addictions in their life as an attempt to deal with
the shame that they keep trying to avoid. These clients often come from shame-based families where the members of the family suffered from various addictions or compulsions.
The therapist needs to carefully assess for substance abuse, mood disorders (especially Major Depressive) and anxiety disorders (PTSD). (See Substance Abuse, Depressive History,
and Anxiety History, Chapter 1.) A medical referral for evaluation and medication is recommended. Any number of addictions may be seen including sexual addiction, gambling,
prescription drugs, compulsive shopping, shoplifting, street drugs as well as nicotine and
caffeine. Before assessing what other addictions may be present, the following questions
might be asked as a way of introducing this topic to clients:
• When you are feeling particularly bad about yourself, what kinds of behaviors do you
engage in as an attempt to self-soothe?
• Do you feel comfortable engaging in these behaviors?
• What kinds of behaviors do you engage in that make you uncomfortable?
Shame is at the root of many addictions. Clients who have a history of trauma or abuse in
their background frequently have multiple addictions in their life as an attempt to deal with
the shame that they keep trying to avoid. These clients often come from shame-based families where the members of the family suffered from various addictions or compulsions.
The therapist needs to carefully assess for substance abuse, mood disorders (especially Major Depressive) and anxiety disorders (PTSD). (See Substance Abuse, Depressive History,
and Anxiety History, Chapter 1.) A medical referral for evaluation and medication is recommended. Any number of addictions may be seen including sexual addiction, gambling,
prescription drugs, compulsive shopping, shoplifting, street drugs as well as nicotine and
caffeine. Before assessing what other addictions may be present, the following questions
might be asked as a way of introducing this topic to clients:
• When you are feeling particularly bad about yourself, what kinds of behaviors do you
engage in as an attempt to self-soothe?
• Do you feel comfortable engaging in these behaviors?
• What kinds of behaviors do you engage in that make you uncomfortable?
It is important to ask about each addiction separately. When asking about addictions, the
following kinds of questions may be useful:
• What kinds of addictive behaviors do you engage in?
• Is there an addictive behavior you do more than the others? What?
• How often do you engage in this behavior? (hourly, once a day, week, month, year)
• How long do you engage in this behavior? (hours, days, weeks)
It is important to ask about each addiction separately. When asking about addictions, the
following kinds of questions may be useful:
• What kinds of addictive behaviors do you engage in?
• Is there an addictive behavior you do more than the others? What?
• How often do you engage in this behavior? (hourly, once a day, week, month, year)
• How long do you engage in this behavior? (hours, days, weeks)
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• Do you engage in this addictive behavior alone or with someone else?
• What various forms does this addictive behavior take?
• How long have you been engaging in this behavior?
• Do you remember when you first engaged in this behavior?
• What was happening in your life at that time?
• Were there periods of your life when you did not do this? When?
• What was different in your life that you did not engage in this behavior?
• Is there a history of this addictive behavior in your family of origin?
• Is your family aware of this behavior?
• Does your family see it as a problem?
• Is your significant other aware of this behavior?
• Does your significant other have a problem with this behavior?
• How has this behavior affected your relationships?
• Is this behavior something that you want to change?
• What would you want that change to look like?
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• Do you engage in this addictive behavior alone or with someone else?
• What various forms does this addictive behavior take?
• How long have you been engaging in this behavior?
• Do you remember when you first engaged in this behavior?
• What was happening in your life at that time?
• Were there periods of your life when you did not do this? When?
• What was different in your life that you did not engage in this behavior?
• Is there a history of this addictive behavior in your family of origin?
• Is your family aware of this behavior?
• Does your family see it as a problem?
• Is your significant other aware of this behavior?
• Does your significant other have a problem with this behavior?
• How has this behavior affected your relationships?
• Is this behavior something that you want to change?
• What would you want that change to look like?
I recommend that therapists become familiar with Nathanson’s (1992) work on the shame
cycle so that it can be used in the treatment of addictions. (See Recognizing and Responding
to Feelings of Shame and Guilt in Appendix A, Chapter 4.) It can be taught to clients so that
they can identify their own shame cycle and begin to change it. Most importantly, the therapist will want to determine whether or not the client wants to work on changing the addictive behavior. Substantive treatment cannot begin without successfully resolving the most
severe addictive behaviors such as drug or alcohol abuse.
I recommend that therapists become familiar with Nathanson’s (1992) work on the shame
cycle so that it can be used in the treatment of addictions. (See Recognizing and Responding
to Feelings of Shame and Guilt in Appendix A, Chapter 4.) It can be taught to clients so that
they can identify their own shame cycle and begin to change it. Most importantly, the therapist will want to determine whether or not the client wants to work on changing the addictive behavior. Substantive treatment cannot begin without successfully resolving the most
severe addictive behaviors such as drug or alcohol abuse.
ASSESSING SAFETY AND STABILITY AT AN
ENVIRONMENTAL LEVEL
ASSESSING SAFETY AND STABILITY AT AN
ENVIRONMENTAL LEVEL
It is important to assess the client’s safety and stability at an environmental level. The therapist may already have enough information from the initial history-taking to evaluate a client who is currently functioning well. I recommend that all the following areas be at least
minimally addressed with clients so nothing is missed that would be relevant to increasing
their safety level. Potential areas of difficulty to be explored are safety and instability of
living situation, relationship difficulties, financial problems, occupational instability, and
absence of a support system.
It is important to assess the client’s safety and stability at an environmental level. The therapist may already have enough information from the initial history-taking to evaluate a client who is currently functioning well. I recommend that all the following areas be at least
minimally addressed with clients so nothing is missed that would be relevant to increasing
their safety level. Potential areas of difficulty to be explored are safety and instability of
living situation, relationship difficulties, financial problems, occupational instability, and
absence of a support system.
INSECURE LIVING SITUATION
INSECURE LIVING SITUATION
Maslow, in the second level of his hierarchy of human needs, defined safety as “having security, freedom from fear, the need for structure and order, stability, and protection” (Everly & Lating, 1995, pp. 39-40). I further refine this definition to note the necessity of a
stable, safe living situation. This means not having to worry about shelter, food, and clothing. I assess the following: Is there emotional safety if clients live alone or with others? Are
they worried about being evicted due to the inability to pay the rent, mortgage, etc.? If clients have been traumatized by spousal battering, then their home may not be a safe place.
Maslow, in the second level of his hierarchy of human needs, defined safety as “having security, freedom from fear, the need for structure and order, stability, and protection” (Everly & Lating, 1995, pp. 39-40). I further refine this definition to note the necessity of a
stable, safe living situation. This means not having to worry about shelter, food, and clothing. I assess the following: Is there emotional safety if clients live alone or with others? Are
they worried about being evicted due to the inability to pay the rent, mortgage, etc.? If clients have been traumatized by spousal battering, then their home may not be a safe place.
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Choosing to go to a shelter may ensure safety in this situation. It is not unusual for an abuse
survivor still living at home to have the perpetrator living there as well. Some clients may
still be at risk of being abused. Even when the abuse happened a long time ago, clients may
not feel emotionally safe around their perpetrator. The abuse may have been kept a secret
between the perpetrator and the victim. The family may know about the abuse and blame
the one who was abused. In the case of acute trauma in the present (e.g., rape, physical assault, natural disasters, kidnapping, hostage situations, etc.), the person may not feel safe
anywhere.
Choosing to go to a shelter may ensure safety in this situation. It is not unusual for an abuse
survivor still living at home to have the perpetrator living there as well. Some clients may
still be at risk of being abused. Even when the abuse happened a long time ago, clients may
not feel emotionally safe around their perpetrator. The abuse may have been kept a secret
between the perpetrator and the victim. The family may know about the abuse and blame
the one who was abused. In the case of acute trauma in the present (e.g., rape, physical assault, natural disasters, kidnapping, hostage situations, etc.), the person may not feel safe
anywhere.
Depending on your clientele and their history, it may be useful to ask the following questions to determine the level of safety clients have in their living situation:
Depending on your clientele and their history, it may be useful to ask the following questions to determine the level of safety clients have in their living situation:
Basic Needs
Basic Needs
• Do you have any concerns about having adequate shelter, food, clothing, or sleep?
• Are you worried about being evicted due to the inability to pay your rent or mortgage?
• Do you have any concerns about having adequate shelter, food, clothing, or sleep?
• Are you worried about being evicted due to the inability to pay your rent or mortgage?
Safety Needs
Safety Needs
• Is anyone physically hurting you in your home? Who?
• Is anyone physically hurting you in your home? Who?
• Is there any emotional or verbal battering going on?
• Is there any emotional or verbal battering going on?
• Who is doing this to you?
• Who is doing this to you?
• Does the person who abused you live in your home?
• Does the person who abused you live in your home?
• What is your relationship like with this person?
• What is your relationship like with this person?
• How does it feel to you to be around this person?
• How does it feel to you to be around this person?
• Do you feel emotionally and physically safe in your home?
• Do you feel emotionally and physically safe in your home?
FINANCIAL PROBLEMS
FINANCIAL PROBLEMS
When dealing with clients, it is important to assess whether or not the person has enough
money to pay the fee that is being asked for therapy. My experience with this issue has been
over a broad spectrum of clients with a wide range of income. Clients feel safer when they
get a therapist who is committed to working with them at a fee that is affordable for them.
Clients may not understand that therapy could go on for a number of sessions. I usually set
the fee with the client over the phone, but this may not be possible in every clinical setting.
Clients who are very adaptive, want to please, are embarrassed, or feeling shame may not
tell you that they cannot afford the fee. If prospective clients cannot pay my fee, then I tell
them I can provide them with a referral. I tell them that therapy is available at almost any
fee. I do not want them to pay a fee that causes a hardship for them. If they tell me what
they can afford to pay per month, then I help them to find therapy in their price range. Then,
I offer them a couple of referrals.
When dealing with clients, it is important to assess whether or not the person has enough
money to pay the fee that is being asked for therapy. My experience with this issue has been
over a broad spectrum of clients with a wide range of income. Clients feel safer when they
get a therapist who is committed to working with them at a fee that is affordable for them.
Clients may not understand that therapy could go on for a number of sessions. I usually set
the fee with the client over the phone, but this may not be possible in every clinical setting.
Clients who are very adaptive, want to please, are embarrassed, or feeling shame may not
tell you that they cannot afford the fee. If prospective clients cannot pay my fee, then I tell
them I can provide them with a referral. I tell them that therapy is available at almost any
fee. I do not want them to pay a fee that causes a hardship for them. If they tell me what
they can afford to pay per month, then I help them to find therapy in their price range. Then,
I offer them a couple of referrals.
Depending on the clientele, it may be useful to ask the following questions regarding financial stability:
Depending on the clientele, it may be useful to ask the following questions regarding financial stability:
• Can you pay my fee without undue hardship?
• Are you living within your income?
• Do you have a great deal of debt?
• Is that debt something you want to work toward changing?
• Can you pay my fee without undue hardship?
• Are you living within your income?
• Do you have a great deal of debt?
• Is that debt something you want to work toward changing?
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OCCUPATIONAL INSTABILITY
OCCUPATIONAL INSTABILITY
Occupational instability seems to be happening regularly to both higher and lower income
clients with downsizing of companies, mergers, moving of companies to different geographical locations, the economy, age barriers, etc. Some other reasons for occupational instability are lack of education, training, language barriers, lack of citizenship, chronic
illness, medical issues, care of family members, mental illness, retirement, etc. Occupational instability puts a great deal of stress on individuals and the family system. These clients
may not be able to deal with substantive treatment issues until they are stable economically.
Therapy will often be at a basic, rudimentary level until they are feeling secure.
Occupational instability seems to be happening regularly to both higher and lower income
clients with downsizing of companies, mergers, moving of companies to different geographical locations, the economy, age barriers, etc. Some other reasons for occupational instability are lack of education, training, language barriers, lack of citizenship, chronic
illness, medical issues, care of family members, mental illness, retirement, etc. Occupational instability puts a great deal of stress on individuals and the family system. These clients
may not be able to deal with substantive treatment issues until they are stable economically.
Therapy will often be at a basic, rudimentary level until they are feeling secure.
It may be useful to ask the following questions regarding occupational instability:
• Do you feel that you have job security right now?
• Do you feel like there is anything that you can do to change your level of instability
in your job?
It may be useful to ask the following questions regarding occupational instability:
• Do you feel that you have job security right now?
• Do you feel like there is anything that you can do to change your level of instability
in your job?
• What change do you feel that you can make?
• How is your instability in the job market affecting you?
• How is it affecting your family?
• What change do you feel that you can make?
• How is your instability in the job market affecting you?
• How is it affecting your family?
RELATIONSHIP DIFFICULTIES
RELATIONSHIP DIFFICULTIES
Many clients have relationship issues. Relationship problems may affect the stability and
safety of the client. These difficulties may be with a significant other, parents, family, abuser, friends, supervisors, or co-workers.
Many clients have relationship issues. Relationship problems may affect the stability and
safety of the client. These difficulties may be with a significant other, parents, family, abuser, friends, supervisors, or co-workers.
When applicable, it is important to assess clients’ relationships with their significant other.
This information may have been covered in the history-taking section. However, clients
may not be safe enough to share this information initially. When battering is suspected in
the relationship, it is necessary to see each partner separately so that a careful assessment
can be done to rule out violence. It may be necessary to assist the battered spouse in getting
into a shelter, providing they are willing to do so. (See Recommended Resources, this chapter.)
When applicable, it is important to assess clients’ relationships with their significant other.
This information may have been covered in the history-taking section. However, clients
may not be safe enough to share this information initially. When battering is suspected in
the relationship, it is necessary to see each partner separately so that a careful assessment
can be done to rule out violence. It may be necessary to assist the battered spouse in getting
into a shelter, providing they are willing to do so. (See Recommended Resources, this chapter.)
Note: The Conflict Tactics Scale (CTS 2), (Straus, Hamby, Boney-McCoy, Sugarman, Finklehor, Moore, & Runyan, 2003) may be useful for assessing violence within families. The
CTS 2 measures violence within families and intimate relationships. It asks individuals to indicate whether they engaged in specific violent or abusive behaviors during a dispute in the
past year. Scoring of this instrument provides information about the client and their partner
for the following dimensions: Negotiation, Physical Assault, Injury, Psychological Aggression, and Sexual Coercion. It is an especially valuable instrument as it can be completed in
10 minutes. The CTS 2 can be purchased at Western Psychological Services. (800)6488857 or www.wpspublish.com.
Note: The Conflict Tactics Scale (CTS 2), (Straus, Hamby, Boney-McCoy, Sugarman, Finklehor, Moore, & Runyan, 2003) may be useful for assessing violence within families. The
CTS 2 measures violence within families and intimate relationships. It asks individuals to indicate whether they engaged in specific violent or abusive behaviors during a dispute in the
past year. Scoring of this instrument provides information about the client and their partner
for the following dimensions: Negotiation, Physical Assault, Injury, Psychological Aggression, and Sexual Coercion. It is an especially valuable instrument as it can be completed in
10 minutes. The CTS 2 can be purchased at Western Psychological Services. (800)6488857 or www.wpspublish.com.
If a client is being sexually or emotionally harassed or stalked by someone in their life such
as a supervisor, a co-worker, a spouse, a fan, or a former love relationship, then their level
of safety and stability may be greatly compromised. The work will be at a rudimentary level
until a greater level of safety is present, and the client is feeling more secure.
If a client is being sexually or emotionally harassed or stalked by someone in their life such
as a supervisor, a co-worker, a spouse, a fan, or a former love relationship, then their level
of safety and stability may be greatly compromised. The work will be at a rudimentary level
until a greater level of safety is present, and the client is feeling more secure.
For some clients there is no safety and stability within their family of origin or with their
partner’s family. This may happen for many reasons including marrying out of the faith,
culture, race, economic status, role of women, siding with the relative against the in-law,
For some clients there is no safety and stability within their family of origin or with their
partner’s family. This may happen for many reasons including marrying out of the faith,
culture, race, economic status, role of women, siding with the relative against the in-law,
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presence of abuse that is not acknowledged, any unresolved conflict, favoritism, power
struggles, or communication issues. The client may feel isolated, alone, and totally abandoned in the midst of family.
presence of abuse that is not acknowledged, any unresolved conflict, favoritism, power
struggles, or communication issues. The client may feel isolated, alone, and totally abandoned in the midst of family.
There may be conflicts with friends that are very painful and will affect the safety and stability of the client. Clients may need to deal with these conflicts before they can look at other therapeutic issues.
There may be conflicts with friends that are very painful and will affect the safety and stability of the client. Clients may need to deal with these conflicts before they can look at other therapeutic issues.
Safety and stability may be compromised when there is a lack of a healthy support system.
If clients have no one with whom they trust to share their feelings, then the work may be
very slow and basic as they begin to learn to trust themselves and others. Initially, it is helpful to ask the following questions to assess a client’s support system:
• Do you have a reasonably supportive partner?
• Do you have a family member that is emotionally supportive?
• Do you have any friends that can be supportive?
Safety and stability may be compromised when there is a lack of a healthy support system.
If clients have no one with whom they trust to share their feelings, then the work may be
very slow and basic as they begin to learn to trust themselves and others. Initially, it is helpful to ask the following questions to assess a client’s support system:
• Do you have a reasonably supportive partner?
• Do you have a family member that is emotionally supportive?
• Do you have any friends that can be supportive?
Additional questions that may be useful to ask regarding the stability of their relationships
are:
• Are you having any difficulties in your relationship with your significant other?
• What kinds of problems are you having?
• Do you feel safe with your significant other?
• Are you being physically hurt or injured? In what way?
• Have you ever sought medical treatment for an injury?
• How do you resolve conflict with your significant other?
• Who has the power in the relationship?
• Is anyone in your life harassing or stalking you?
• What is your relationship like in your family of origin?
• Do you feel safe with your family of origin?
• What is your relationship like with your significant other’s family?
• Do you feel safe with your significant other’s family?
• Do you have anyone with whom you feel safe?
Additional questions that may be useful to ask regarding the stability of their relationships
are:
• Are you having any difficulties in your relationship with your significant other?
• What kinds of problems are you having?
• Do you feel safe with your significant other?
• Are you being physically hurt or injured? In what way?
• Have you ever sought medical treatment for an injury?
• How do you resolve conflict with your significant other?
• Who has the power in the relationship?
• Is anyone in your life harassing or stalking you?
• What is your relationship like in your family of origin?
• Do you feel safe with your family of origin?
• What is your relationship like with your significant other’s family?
• Do you feel safe with your significant other’s family?
• Do you have anyone with whom you feel safe?
EXPLORING THE INTERPERSONAL ASPECTS OF
SAFETY
EXPLORING THE INTERPERSONAL ASPECTS OF
SAFETY
Many clients have a number of reasons why they have a lack of safety in their lives. A frequent reason for a lack of safety is a history of trauma or abuse. Substance abuse in the family system is often a contributing factor. Lack of healthy attachment to the primary
caregiver is another factor. Briere talks about children who come from good homes versus
bad homes. Children who come from bad homes have a lot more difficulty feeling safe. It
is the task of the therapist to explore the client’s history of safety. Careful history-taking
allows the therapist to understand some of the reasons for the lack of safety in the client’s
life. It is helpful for both clients and therapists to begin to reconstruct when, where, how,
and with whom the client experienced feeling safe(er) or unsafe. Looking at different periods of their life helps clients comprehend their level of safety. Exploring their interpersonal
Many clients have a number of reasons why they have a lack of safety in their lives. A frequent reason for a lack of safety is a history of trauma or abuse. Substance abuse in the family system is often a contributing factor. Lack of healthy attachment to the primary
caregiver is another factor. Briere talks about children who come from good homes versus
bad homes. Children who come from bad homes have a lot more difficulty feeling safe. It
is the task of the therapist to explore the client’s history of safety. Careful history-taking
allows the therapist to understand some of the reasons for the lack of safety in the client’s
life. It is helpful for both clients and therapists to begin to reconstruct when, where, how,
and with whom the client experienced feeling safe(er) or unsafe. Looking at different periods of their life helps clients comprehend their level of safety. Exploring their interpersonal
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safety conveys to clients that being safe is a healthy thing. It also helps to clarify that creating safety is a goal that needs to permeate all the therapeutic work as well as their outside
relationships.
safety conveys to clients that being safe is a healthy thing. It also helps to clarify that creating safety is a goal that needs to permeate all the therapeutic work as well as their outside
relationships.
When trauma recurs, there is a need to reestablish safety. Any further personal growth is
put on hold until this task is accomplished. The posttraumatic world appears threatening
and insecure. Once the need for safety has been compromised, a person may remain focused at this basic level of existence, perhaps for a lifetime.
When trauma recurs, there is a need to reestablish safety. Any further personal growth is
put on hold until this task is accomplished. The posttraumatic world appears threatening
and insecure. Once the need for safety has been compromised, a person may remain focused at this basic level of existence, perhaps for a lifetime.
An exercise titled Interpersonal History of Safety Questionnaire is included in Appendix
C, this chapter. It could be used in different ways. The client could be asked to do the exercise at home and then explore the answers to the questions in depth with the therapist. I
prefer to do this exploration in the room, as I am always looking for the affect that accompanies the content. I usually address it over several sessions or parts of sessions.
An exercise titled Interpersonal History of Safety Questionnaire is included in Appendix
C, this chapter. It could be used in different ways. The client could be asked to do the exercise at home and then explore the answers to the questions in depth with the therapist. I
prefer to do this exploration in the room, as I am always looking for the affect that accompanies the content. I usually address it over several sessions or parts of sessions.
To provide some insight into the use of this exercise, after each question I have provided
responses from multiple workshop participants or clients along with comments:
To provide some insight into the use of this exercise, after each question I have provided
responses from multiple workshop participants or clients along with comments:
1. Do you deserve to feel safe? Why? Why not?
1. Do you deserve to feel safe? Why? Why not?
Many clients will answer “No.”
Many clients will answer “No.”
Clients may have decided that they do not deserve to feel safe. Often clients who have been
abused as children have never felt safe. As children they may never have even thought
about being safe or unsafe; it was just a given of their life.
Clients may have decided that they do not deserve to feel safe. Often clients who have been
abused as children have never felt safe. As children they may never have even thought
about being safe or unsafe; it was just a given of their life.
I believe that it is a God-given birthright that every child feel loved, cared for, and safe.
Many people have lost touch with their own spirituality or a sense of a higher power because their model of God has been an abusive or neglectful parent.
I believe that it is a God-given birthright that every child feel loved, cared for, and safe.
Many people have lost touch with their own spirituality or a sense of a higher power because their model of God has been an abusive or neglectful parent.
2. When have you felt safe(r)?
2. When have you felt safe(r)?
“Being around my mom made me feel safe when I was little.”
“Being around my mom made me feel safe when I was little.”
The child wants the attachment figure close.
The child wants the attachment figure close.
“Being outside with my animals.”
“Being outside with my animals.”
Children give and receive love from a pet that they could not get from their caregiver. Loving a pet is often a way that clients use to self-soothe. See Self-Soothing Activities in Chapter 5.
Children give and receive love from a pet that they could not get from their caregiver. Loving a pet is often a way that clients use to self-soothe. See Self-Soothing Activities in Chapter 5.
“Having my husband hold me in his arms makes me feel safe.”
“Having my husband hold me in his arms makes me feel safe.”
“When I was 3 years old, my Dad held me on his lap and read me a story. I can
still remember that time.”
“When I was 3 years old, my Dad held me on his lap and read me a story. I can
still remember that time.”
“I felt safe when my sister let me play with her makeup while she was doing her
homework.”
“I felt safe when my sister let me play with her makeup while she was doing her
homework.”
Often there is someone with whom the client felt safe. Sometimes that person was only in
the client’s life a short time.
Often there is someone with whom the client felt safe. Sometimes that person was only in
the client’s life a short time.
Physical touch is especially important for those clients who are kinesthetic. Many clients
who have sexual abuse in their background have unmet physical touch needs.
Physical touch is especially important for those clients who are kinesthetic. Many clients
who have sexual abuse in their background have unmet physical touch needs.
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3. What made this experience safe(r)?
3. What made this experience safe(r)?
“I felt safe because my father was holding me.”
“I felt safe because my father was holding me.”
“When I was with my sister, nothing bad ever happened to me.”
“When I was with my sister, nothing bad ever happened to me.”
Often safety has to do with someone being fully present to the child, doing something with
them or giving them special attention. For that period of time there was an oasis of safety.
In a workshop I attended several years ago, Claudia Black talked about the cookie people.
The cookie people were those people in the child’s neighborhood or extended family who
gave attention, caring, and/or cookies to the child growing up.
Often safety has to do with someone being fully present to the child, doing something with
them or giving them special attention. For that period of time there was an oasis of safety.
In a workshop I attended several years ago, Claudia Black talked about the cookie people.
The cookie people were those people in the child’s neighborhood or extended family who
gave attention, caring, and/or
and/ orcookies
cookiesto
tothe
thechild
childgrowing
growingup.
up.
4. Describe the experience(s) that keeps you from feeling safe(r)?
4. Describe the experience(s) that keeps you from feeling safe(r)?
“I feel unsafe when I am all alone in my house.”
“I feel unsafe when I am all alone in my house.”
“I am unsafe when I need to be touched, and there is no one to touch me.”
“I am unsafe when I need to be touched, and there is no one to touch me.”
“I feel unsafe when it is night, and the windows cannot be fully covered.”
“I feel unsafe when it is night, and the windows cannot be fully covered.”
“I feel unsafe at night when I go to bed and no one is there.”
“I feel unsafe at night when I go to bed and no one is there.”
It is often helpful for clients to carefully explore and acknowledge what makes them unsafe.
Then, they can take steps to take extra care without shaming themselves.
It is often helpful for clients to carefully explore and acknowledge what makes them unsafe.
Then, they can take steps to take extra care without shaming themselves.
5. What would you need to feel safe(r)?
5. What would you need to feel safe(r)?
“I would need to have my husband there to go through it with me when
something bad like an earthquake happens.”
“I would need to have my husband there to go through it with me when
something bad like an earthquake happens.”
There are many clients who have no one in their life with whom they feel safe. The above
questions and responses feed into exploring this question. It is empowering for the client to
begin to create or increase their safety level in the present.
There are many clients who have no one in their life with whom they feel safe. The above
questions and responses feed into exploring this question. It is empowering for the client to
begin to create or increase their safety level in the present.
6. During which periods of your life have you felt safest? What made these periods
safe?
6. During which periods of your life have you felt safest? What made these periods
safe?
“I felt safest up until I was 5 years old which is when the abuse started.”
“I felt safest up until I was 5 years old which is when the abuse started.”
“I felt safer when my brother got married and left home.”
“I felt safer when my brother got married and left home.”
“My safety level increased when I got married and I had someone in my house.”
“My safety level increased when I got married and I had someone in my house.”
Often there are windows of safety for the client, though they may be very brief.
Often there are windows of safety for the client, though they may be very brief.
7. What are the times of day you feel safest? Why?
7. What are the times of day you feel safest? Why?
“I felt safest in the morning as my father was not drunk then.”
“I felt safest in the morning as my father was not drunk then.”
“My safest time is in the nighttime as it makes me feel connected to God.”
“My safest time is in the nighttime as it makes me feel connected to God.”
“My safest time was when my brother was away from the house.”
“My safest time was when my brother was away from the house.”
“My safest time was in the daytime as the abuse always happened at night.”
“My safest time was in the daytime as the abuse always happened at night.”
“I felt safe when I was at school and away from my family.”
“I felt safe when I was at school and away from my family.”
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The times of day that the client felt safe as a child may carry over into their adult life with
or without awareness.
The times of day that the client felt safe as a child may carry over into their adult life with
or without awareness.
8. What are the times of day you feel least safe? What makes these times unsafe?
8. What are the times of day you feel least safe? What makes these times unsafe?
For some clients who have abuse in their history mealtimes, nighttimes, or daytimes may
have been especially awful.
For some clients who have abuse in their history mealtimes, nighttimes, or daytimes may
have been especially awful.
Some children were abused when their parents went away and the person responsible for
them abused them.
Some children were abused when their parents went away and the person responsible for
them abused them.
It is often helpful for clients to explore the times of day they feel most vulnerable and most
safe.
It is often helpful for clients to explore the times of day they feel most vulnerable and most
safe.
9. List the places you feel safe(r). What makes them safe(r)?
9. List the places you feel safe(r). What makes them safe(r)?
“The mountains are safe for me. As a child, my house was not safe, so I went
to the mountains that were nearby whenever I could.”
“The mountains are safe for me. As a child, my house was not safe, so I went
to the mountains that were nearby whenever I could.”
“I spent a lot of time outside on a great big boulder watching the sky and the
clouds floating by. I did a lot of spacing out to deal with what was going on in
my life.”
“I spent a lot of time outside on a great big boulder watching the sky and the
clouds floating by. I did a lot of spacing out to deal with what was going on in
my life.”
Clients will often find places where they feel some sense of safety. If a child has no place
to go, then they often dissociate, create fantasies, daydream or, tune out to deal with what
they cannot change.
Clients will often find places where they feel some sense of safety. If a child has no place
to go, then they often dissociate, create fantasies, daydream or, tune out to deal with what
they cannot change.
10. Which person or persons do you feel safest with? What has made them safe?
10. Which person or persons do you feel safest with? What has made them safe?
“I feel safest when I am with my husband and/or my children.”
“I feel safest when I am with my husband and/or my children.”
“My wife makes me feel safe because of her love for me. I can count on her.”
“My wife makes me feel safe because of her love for me. I can count on her.”
“I feel safe around my children because they need me and I can be there for
them.”
“I feel safe around my children because they need me and I can be there for
them.”
“I feel safest when people hear me and acknowledge my feelings.”
“I feel safest when people hear me and acknowledge my feelings.”
11. Which person or persons do you feel least safe with? What makes them unsafe?
11. Which person or persons do you feel least safe with? What makes them unsafe?
“Angry people make me feel unsafe. My body goes into a fight or flight place,
and I am not sure how to handle them.”
“Angry people make me feel unsafe. My body goes into a fight or flight place,
and I am not sure how to handle them.”
Clients who have experienced a lot of anger or abuse as children may react to people in the
present the same way they did in the past.
Clients who have experienced a lot of anger or abuse as children may react to people in the
present the same way they did in the past.
“I am afraid of men who stare at me.”
“I am afraid of men who stare at me.”
“People who do not listen to what I have said.”
“People who do not listen to what I have said.”
Children who are not listened to often believe that their thoughts and feelings are not important. They may believe that they have no worth as a person.
Children who are not listened to often believe that their thoughts and feelings are not important. They may believe that they have no worth as a person.
12. Who would you most like to feel safe with?
12. Who would you most like to feel safe with?
It may be someone in their family of origin (parent, sibling), extended family (relatives),
It may be someone in their family of origin (parent, sibling), extended family (relatives),
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step-family, a friend, or co-worker that a client most wants to feel safe with.
step-family, a friend, or co-worker that a client most wants to feel safe with.
It may be a sibling who parented them as a child.
It may be a sibling who parented them as a child.
It might be a significant other that the client most wants to feel safe with.
It might be a significant other that the client most wants to feel safe with.
13. What would you need to feel safe with this person?
13. What would you need to feel safe with this person?
“I would need to have this person hear me.”
“I would need to have this person hear me.”
“I would need to be able to talk about what was done to me.”
“I would need to be able to talk about what was done to me.”
“I would need to know that I am not going to have my words twisted around
and somehow be blamed for what happened to me.”
“I would need to know that I am not going to have my words twisted around
and somehow be blamed for what happened to me.”
“I would need to be able to hold onto myself and not become a little kid again.”
“I would need to be able to hold onto myself and not become a little kid again.”
“I would need to know the person is sorry for what they did or did not do.”
“I would need to know the person is sorry for what they did or did not do.”
“I would want to be able to express my feelings and have them heard.”
“I would want to be able to express my feelings and have them heard.”
Further questions that may be helpful to ask the client are:
Further questions that may be helpful to ask the client are:
14. What did you learn about yourself from doing this exercise?
14. What did you learn about yourself from doing this exercise?
15. Did it increase or decrease your safety level by doing this exercise?
15. Did it increase or decrease your safety level by doing this exercise?
16. How did it feel to do this exercise? (mad, sad, glad, or scared)
16. How did it feel to do this exercise? (mad, sad, glad, or scared)
17. Can you tell me about the feelings?
17. Can you tell me about the feelings?
18. Did doing the exercise evoke any shame about not being safe?
18. Did doing the exercise evoke any shame about not being safe?
19. How did it feel to have me inquire about your safety level?
19. How did it feel to have me inquire about your safety level?
Some suggestions for using this exercise with clients are:
• Explore together over one or several sessions the answers to questions on the handout.
• Take periods of the client’s life e.g., (0-5 years, 5-10, 10-15, 15-20, 20-30) and ask
questions from the exercise for each of those periods.
• Take houses that clients have lived in and explore their safety level during those periods in their life.
Some suggestions for using this exercise with clients are:
• Explore together over one or several sessions the answers to questions on the handout.
• Take periods of the client’s life e.g., (0-5 years, 5-10, 10-15, 15-20, 20-30) and ask
questions from the exercise for each of those periods.
• Take houses that clients have lived in and explore their safety level during those periods in their life.
Note: I am especially interested in whether they have ever felt safe or safer, and how safe
they are in their life at present. As a rule clients are not going to tell you that they feel unsafe
unless you begin to explore that issue with them.
Note: I am especially interested in whether they have ever felt safe or safer, and how safe
they are in their life at present. As a rule clients are not going to tell you that they feel unsafe
unless you begin to explore that issue with them.
REFERENCES
REFERENCES
Alderman, T. (1997). The Scarred Soul: Understanding and Ending Self-Inflicted Violence. Oakland, CA: New Harbinger Publishers, Inc.
Alderman, T. (1997). The Scarred Soul: Understanding and Ending Self-Inflicted Violence. Oakland, CA: New Harbinger Publishers, Inc.
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Everly, G. S., Jr., & Lating, J. M. (Eds.). (1995). Psychotraumatology: Key Papers and
Core Concepts in Post-Traumatic Stress. New York: Plenum Press.
Everly, G. S., Jr., & Lating, J. M. (Eds.). (1995). Psychotraumatology: Key Papers and
Core Concepts in Post-Traumatic Stress. New York: Plenum Press.
Maslow, A. H. (1970). Motivation and Personality. New York: Harper & Row.
Maslow, A. H. (1970). Motivation and Personality. New York: Harper & Row.
Nathanson, D. L. (1992). Shame and Pride: Affect, Sex, and the Birth of the Self. New
York: W.W. Norton & Co.
Nathanson, D. L. (1992). Shame and Pride: Affect, Sex, and the Birth of the Self. New
York: W.W. Norton & Co.
Straus, M. A., Hamby, S. L., Boney-McCoy, S., Sugarman, D. B., Finklehor, D., Moore,
D. W., & Runyan, D. K. (2003). Conflict Tactics Scales (CTS 2). Los Angeles:
Western Psychological Services. (310)478-2061.
Straus, M. A., Hamby, S. L., Boney-McCoy, S., Sugarman, D. B., Finklehor, D., Moore,
D. W., & Runyan, D. K. (2003). Conflict Tactics Scales (CTS 2). Los Angeles:
Western Psychological Services. (310)478-2061.
RECOMMENDED RESOURCES
RECOMMENDED RESOURCES
This section includes: suicide, self-inflicted violence, eating disorders, and domestic violence
This section includes: suicide, self-inflicted violence, eating disorders, and domestic violence
Barnett, O., & La Violette, A. (2000). It Could Happen to Anyone: Why Battered Women
Stay. Thousand Oaks, CA: Sage.
Barnett, O., & La Violette, A. (2000). It Could Happen to Anyone: Why Battered Women
Stay. Thousand Oaks, CA: Sage.
Bongar, B. (1991). The Suicidal Patient. Washington, DC: American Psychological Association.
Bongar, B. (1991). The Suicidal Patient. Washington, DC: American Psychological Association.
Brown, S. L. (1991). Counseling Victims of Violence. Alexandria, VA: American Association for Counseling and Development.
Brown, S. L. (1991). Counseling Victims of Violence. Alexandria, VA: American Association for Counseling and Development.
Engel, B. (1990). The Emotionally Abused Woman: Overcoming Destructive Patterns of
Reclaiming Yourself. New York: Random House, Inc.
Engel, B. (1990). The Emotionally Abused Woman: Overcoming Destructive Patterns of
Reclaiming Yourself. New York: Random House, Inc.
Evans, P. (1996). The Verbally Abusive Relationship. Halbrook, MA: Adams Media
Group.
Evans, P. (1996). The Verbally Abusive Relationship. Halbrook, MA: Adams Media
Group.
Hornyak, L. M., & Baker, E. K. (Eds.). (1989). Experiential Therapies for Eating Disorders. New York: Guilford Publications, Inc.
Hornyak, L. M., & Baker, E. K. (Eds.). (1989). Experiential Therapies for Eating Disorders. New York: Guilford Publications, Inc.
Jacobson, N., & Gottman, J. (1998). When Men Batter Women: New Insights into Ending
Abusive Relationships. New York: Simon & Schuster.
Jacobson, N., & Gottman, J. (1998). When Men Batter Women: New Insights into Ending
Abusive Relationships. New York: Simon & Schuster.
Jaffe, P. G., Wolfe, D. A., & Wilson, S. K. (1990). Children of Battered Women. Newbury
Park, CA: Sage Publications.
Jaffe, P. G., Wolfe, D. A., & Wilson, S. K. (1990). Children of Battered Women. Newbury
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Knapp, C. (2002). Appetites: Why Women Want. New York: Counterpoint.
Knapp, C. (2002). Appetites: Why Women Want. New York: Counterpoint.
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Levin, J. (1991). Treatment of Alcoholism and Other Addictions: A Self Psychology
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Levin, J. (1991). Treatment of Alcoholism and Other Addictions: A Self Psychology
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Maisel, R., Epston, D., & Borden, A. (2004). Biting the Hand That Feeds You: Inspiring
Resistance to Anorexia. New York: W.W. Norton & Co.
Maisel, R., Epston, D., & Borden, A. (2004). Biting the Hand That Feeds You: Inspiring
Resistance to Anorexia. New York: W.W. Norton & Co.
Miller, D. (1994). Women Who Hurt Themselves. New York: Harper Collins Publishers,
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Miller, D. (1994). Women Who Hurt Themselves. New York: Harper Collins Publishers,
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Paymar, M. (1993). Violent No More: Helping Men End Domestic Abuse. Alameda, CA:
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Porterfield, K. (1989). Violent Voices: 12 Steps to Freedom from Emotional and Verbal
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Abuse. Deerfield Beach, FL: Health Communications, Inc.
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Chapter 2 Appendix A
Chapter 2 Appendix A
Self-Inflicted Violence
Self-Inflicted Violence
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Self-Inflicted Violence
Self-Inflicted Violence
Tracy Alderman (1997) in The Scarred Soul provides an excellent overview of the nature
of self-inflicted violence (SIV). Although I hope you will read the book in its entirety, I
have permission to give you a summary of some of her concepts regarding SIV.
Tracy Alderman (1997) in The Scarred Soul provides an excellent overview of the nature
of self-inflicted violence (SIV). Although I hope you will read the book in its entirety, I
have permission to give you a summary of some of her concepts regarding SIV.
Acts of SIV, though intentional and purposeful ways of harming oneself, are not consciously suicidal. However, if the SIV threatens a client’s life, then it should be treated as a suicide
attempt and steps taken accordingly to help keep the client safe. (See Suicidality, Chapter
2.) The numbers of men and women who intentionally injure themselves are about equal.
Typically, SIV begins during adolescence, becomes more frequent in the early 20s, and decreases or disappears in the 30s. Many of the people who injure themselves are abusing
substances as well. Eating disorders may also be present as a way to cope with the difficult
emotions. Self-injurious behavior often indicates that clients have difficulties in regulating
their emotions in more effective ways (Alderman, 1997).
Acts of SIV, though intentional and purposeful ways of harming oneself, are not consciously suicidal. However, if the SIV threatens a client’s life, then it should be treated as a suicide
attempt and steps taken accordingly to help keep the client safe. (See Suicidality, Chapter
2.) The numbers of men and women who intentionally injure themselves are about equal.
Typically, SIV begins during adolescence, becomes more frequent in the early 20s, and decreases or disappears in the 30s. Many of the people who injure themselves are abusing
substances as well. Eating disorders may also be present as a way to cope with the difficult
emotions. Self-injurious behavior often indicates that clients have difficulties in regulating
their emotions in more effective ways (Alderman, 1997).
Not all clients who engage in SIV have experienced trauma, but many have been physically, sexually, or emotionally abused. In that many therapists lack experience handling SIV,
the client’s previous psychological treatment may not have been effective. Therapists often
get scared about keeping clients safe when they encounter SIV. Experience and training often decrease this anxiety. As clients become safe with the therapist, they may want to work
on changing the behavior. The Self-Inflicted Violence Questionnaire in Appendix B, Chapter 2 can be helpful in figuring out the role and meaning of the SIV. I highly recommend
further training and education in this area. (See Recommended Resources, Chapter 2.)
Not all clients who engage in SIV have experienced trauma, but many have been physically, sexually, or emotionally abused. In that many therapists lack experience handling SIV,
the client’s previous psychological treatment may not have been effective. Therapists often
get scared about keeping clients safe when they encounter SIV. Experience and training often decrease this anxiety. As clients become safe with the therapist, they may want to work
on changing the behavior. The Self-Inflicted Violence Questionnaire in Appendix B, Chapter 2 can be helpful in figuring out the role and meaning of the SIV. I highly recommend
further training and education in this area. (See Recommended Resources, Chapter 2.)
ACTS OF SELF-INFLICTED VIOLENCE
ACTS OF SELF-INFLICTED VIOLENCE
• cutting oneself
• excessive scratching
• piercing oneself
• reopening wounds
• breaking own bones intentionally
• excessive fingernail biting
• excessive pulling out of hair
• hitting or bruising oneself
• burning oneself
• cutting oneself
• excessive scratching
• piercing oneself
• reopening wounds
• breaking own bones intentionally
• excessive fingernail biting
• excessive pulling out of hair
• hitting or bruising oneself
• burning oneself
Alderman, (1997)
Alderman, (1997)
REASONS FOR SELF-INFLICTED VIOLENCE
REASONS FOR SELF-INFLICTED VIOLENCE
1. Decreases Feelings that are Overwhelming
1. Decreases Feelings that are Overwhelming
SIV offers relief from feelings that are emotionally overwhelming and that can seem uncontrollable, frightening, and dangerous. Clients may find it difficult to express emotions;
thus SIV offers a way to get relief from intense and uncomfortable feelings (Alderman,
1997).
SIV offers relief from feelings that are emotionally overwhelming and that can seem uncontrollable, frightening, and dangerous. Clients may find it difficult to express emotions;
thus SIV offers a way to get relief from intense and uncomfortable feelings (Alderman,
1997).
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2. Creates a Way of Minimizing Pain
2. Creates a Way of Minimizing Pain
SIV causes physical trauma to the body. The body responds by trying to minimize the pain
and heal itself. The brain releases chemicals called endorphins which work like morphine
so that the pain from SIV is not felt (Alderman, 1997). Due to the addictive nature of endorphins, clients who engage in SIV are more likely to engage in some form of substance
abuse that has a similar effect to SIV. Substances used may be drugs that are over-thecounter, prescription, or illegal, as well as alcohol, caffeine, and nicotine (Alderman, 1997).
SIV causes physical trauma to the body. The body responds by trying to minimize the pain
and heal itself. The brain releases chemicals called endorphins which work like morphine
so that the pain from SIV is not felt (Alderman, 1997). Due to the addictive nature of endorphins, clients who engage in SIV are more likely to engage in some form of substance
abuse that has a similar effect to SIV. Substances used may be drugs that are over-thecounter, prescription, or illegal, as well as alcohol, caffeine, and nicotine (Alderman, 1997).
3. Provides a Way of Nurturing the Physical Self
3. Provides a Way of Nurturing the Physical Self
SIV provides a way of nurturing one’s self physically. This physical nurture becomes important when one cannot do so emotionally. It is an attempt to heal the emotional internal
wounds by making them external and then nurturing these physical wounds. Clients who
have engaged in SIV usually feel uncared for and all alone in the world. SIV creates a situation in which self-nurturing must occur in response to the physical injury (Alderman,
1997).
SIV provides a way of nurturing one’s self physically. This physical nurture becomes important when one cannot do so emotionally. It is an attempt to heal the emotional internal
wounds by making them external and then nurturing these physical wounds. Clients who
have engaged in SIV usually feel uncared for and all alone in the world. SIV creates a situation in which self-nurturing must occur in response to the physical injury (Alderman,
1997).
4. Promotes the Dissociative Cycle
4. Promotes the Dissociative Cycle
SIV can be used to start, stop, or even prevent dissociation. Dissociation is a term for the
psychological state in which the individual experiences an alteration of consciousness,
memory, and sometimes identity. Some people report being detached from their bodies,
some may feel a floating sensation, and some actually feel as if they are separate from their
bodies and are watching themselves. Alderman (1997) states that “SIV, which draws attention back to your physical being, is quite effective in increasing self-awareness, and helps
to reduce or end a dissociative state” (p. 37). Alderman further states, “High levels of dissociation can increase the physical risk associated with self-inflicted violence” (p. 38).
SIV can be used to start, stop, or even prevent dissociation. Dissociation is a term for the
psychological state in which the individual experiences an alteration of consciousness,
memory, and sometimes identity. Some people report being detached from their bodies,
some may feel a floating sensation, and some actually feel as if they are separate from their
bodies and are watching themselves. Alderman (1997) states that “SIV, which draws attention back to your physical being, is quite effective in increasing self-awareness, and helps
to reduce or end a dissociative state” (p. 37). Alderman further states, “High levels of dissociation can increase the physical risk associated with self-inflicted violence” (p. 38).
5. Acts as a Coping Mechanism
5. Acts as a Coping Mechanism
SIV acts as a coping mechanism even though it causes physical injury. SIV provides relief
of uncomfortable physical and psychological sensations. Unfortunately, it also creates
physical trauma, shame, and guilt for the person (Alderman, 1997).
SIV acts as a coping mechanism even though it causes physical injury. SIV provides relief
of uncomfortable physical and psychological sensations. Unfortunately, it also creates
physical trauma, shame, and guilt for the person (Alderman, 1997).
6. Increases a Sense of Connection
6. Increases a Sense of Connection
The painful feelings of isolation, abandonment, loneliness, and frustration often precede
self-injury. Clients often feel as though they have no ability to manage these feelings. SIV
is an attempt to gain control over the emotional states. SIV is a way for clients to keep from
dissociating and stay connected to themselves even when they feel cut off from others (Alderman, 1997).
The painful feelings of isolation, abandonment, loneliness, and frustration often precede
self-injury. Clients often feel as though they have no ability to manage these feelings. SIV
is an attempt to gain control over the emotional states. SIV is a way for clients to keep from
dissociating and stay connected to themselves even when they feel cut off from others (Alderman, 1997).
7. Helps Express Emotional Pain
7. Helps Express Emotional Pain
Emotional pain can be difficult to express. The use of SIV allows clients to see actual evidence of their internal pain. A lack of trust usually occurs because others have not provided
adequate mirroring of their emotional states. Clients doubt their own experience as a result
of this lack of support. SIV allows clients to acknowledge and in a way mirror their own
emotions (Alderman, 1997). Learning to trust their own feelings and experiences allows
clients to reduce their SIV behavior.
Emotional pain can be difficult to express. The use of SIV allows clients to see actual evidence of their internal pain. A lack of trust usually occurs because others have not provided
adequate mirroring of their emotional states. Clients doubt their own experience as a result
of this lack of support. SIV allows clients to acknowledge and in a way mirror their own
emotions (Alderman, 1997). Learning to trust their own feelings and experiences allows
clients to reduce their SIV behavior.
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8. Attempts to Communicate Feelings, Thoughts, or Experiences
8. Attempts to Communicate Feelings, Thoughts, or Experiences
SIV is a way of communicating the need for help that cannot be asked for directly. SIV can
be clients attempting to share their feelings, thoughts, or experiences with others as well as
themselves. Basically, SIV is a cry for help. Unfortunately, the message sent with the use
of SIV may not be the message that is interpreted. Clients may be wanting to say that they
hurt or need help.The observer may experience them as crazy or suicidal. The possible misinterpretation of the SIV makes it an ineffective method of communication because others
may see it only as a way to manipulate or control (Alderman, 1997).
SIV is a way of communicating the need for help that cannot be asked for directly. SIV can
be clients attempting to share their feelings, thoughts, or experiences with others as well as
themselves. Basically, SIV is a cry for help. Unfortunately, the message sent with the use
of SIV may not be the message that is interpreted. Clients may be wanting to say that they
hurt or need help.The observer may experience them as crazy or suicidal. The possible misinterpretation of the SIV makes it an ineffective method of communication because others
may see it only as a way to manipulate or control (Alderman, 1997).
9. Criticism is a Shaming Process
9. Criticism is a Shaming Process
Clients who have been physically, sexually, or emotionally abused as children often believe
they deserved the abuse because of what they were thinking, feeling, or doing. They were
shamed by what was done to them and often engage in internally shaming themselves. No
matter where the criticism comes from, internally or externally, it leads to a painful cycle
of shame and blame that can result in SIV (Alderman, 1997).
Clients who have been physically, sexually, or emotionally abused as children often believe
they deserved the abuse because of what they were thinking, feeling, or doing. They were
shamed by what was done to them and often engage in internally shaming themselves. No
matter where the criticism comes from, internally or externally, it leads to a painful cycle
of shame and blame that can result in SIV (Alderman, 1997).
10. Reenacts the Childhood Abuse as an Attempt to Gain Control
10. Reenacts the Childhood Abuse as an Attempt to Gain Control
Reenacting the abuse in the present may be an attempt to gain control over a situation the
client did not control originally. When children are being abused, they are basically powerless to change the outcome. In the present, the adult is in total control and can decide
where, when, and how long to inflict injury. The method of injury may differ, but it serves
to help relieve tension and maintain a feeling of being in control. SIV may be acted out by
those with PTSD when they are having a flashback. They replicate the original trauma and
inflict the same or different injuries on themselves (Alderman, 1997).
Reenacting the abuse in the present may be an attempt to gain control over a situation the
client did not control originally. When children are being abused, they are basically powerless to change the outcome. In the present, the adult is in total control and can decide
where, when, and how long to inflict injury. The method of injury may differ, but it serves
to help relieve tension and maintain a feeling of being in control. SIV may be acted out by
those with PTSD when they are having a flashback. They replicate the original trauma and
inflict the same or different injuries on themselves (Alderman, 1997).
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Chapter 2 Appendix B
Chapter 2 Appendix B
Self-Inflicted Violence
Questionnaire
Self-Inflicted Violence
Questionnaire
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Self-Inflicted Violence Questionnaire
Self-Inflicted Violence Questionnaire
The following questions might be asked to initially assess and treat self-inflicted violence:
The following questions might be asked to initially assess and treat self-inflicted violence:
1. What type of self-inflicted violence do you engage in?
1. What type of self-inflicted violence do you engage in?
2. What instruments do you use?
2. What instruments do you use?
3. What type of self-inflicted violence do you do the most?
3. What type of self-inflicted violence do you do the most?
4. Have you tried to stop the self-inflicted violence? How?
4. Have you tried to stop the self-inflicted violence? How?
5. Does anyone else know about the self-inflicted violence?
5. Does anyone else know about the self-inflicted violence?
6. What do you say to yourself about the self-inflicted violence?
6. What do you say to yourself about the self-inflicted violence?
7. When did the self-inflicted violence begin?
7. When did the self-inflicted violence begin?
8. How often do you engage in self-inflicted violence: daily, weekly, monthly? For
how long?
8. How often do you engage in self-inflicted violence: daily, weekly, monthly? For
how long?
9. Is this something you want to change? Why?
9. Is this something you want to change? Why?
10. What do you imagine my reaction to be about the self-inflicted violence?
10. What do you imagine my reaction to be about the self-inflicted violence?
11. How did it feel to have me ask you these questions? Are there any scared, sad,
angry, or glad feelings? Tell me about them.
11. How did it feel to have me ask you these questions? Are there any scared, sad,
angry, or glad feelings? Tell me about them.
Note: See References and Recommended Resources for Chapter 2 to obtain further tools in assessment and treatment for SIV.
Note: See References and Recommended Resources for Chapter 2 to obtain further tools in assessment and treatment for SIV.
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Chapter 2 Appendix C
Chapter 2 Appendix C
Interpersonal History of Safety
Questionnaire
Interpersonal History of Safety
Questionnaire
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Interpersonal History of Safety Questionnaire
Interpersonal History of Safety Questionnaire
1. Do you deserve to feel safe? Why? Why not?
1. Do you deserve to feel safe? Why? Why not?
2. When have you felt safe(r)?
2. When have you felt safe(r)?
3. What made this experience safe(r)?
3. What made this experience safe(r)?
4. Describe the experience(s) that keeps you from feeling safe(r)?
4. Describe the experience(s) that keeps you from feeling safe(r)?
5. What would you need to feel safe(r)?
5. What would you need to feel safe(r)?
6. During which periods of your life have you felt safest?
6. During which periods of your life have you felt safest?
7. What made these periods safe for you?
7. What made these periods safe for you?
8. What are the times of day you feel safest? Why?
8. What are the times of day you feel safest? Why?
9. What are the times of day you feel least safe? What makes these times unsafe?
9. What are the times of day you feel least safe? What makes these times unsafe?
10. List the places you feel safe(r). What makes them safe(r)?
10. List the places you feel safe(r). What makes them safe(r)?
11. List the places you feel least safe. What makes them unsafe?
11. List the places you feel least safe. What makes them unsafe?
12. Which person or persons do you feel safest with? What has made them safe?
12. Which person or persons do you feel safest with? What has made them safe?
13. Which person or persons do you feel least safe with? What makes them unsafe?
13. Which person or persons do you feel least safe with? What makes them unsafe?
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14. Who would you most like to feel safe with?
14. Who would you most like to feel safe with?
15. What would you need to feel safe with this person?
15. What would you need to feel safe with this person?
.
.
16. What did you learn about yourself from doing this exercise?
16. What did you learn about yourself from doing this exercise?
17. Did it increase or decrease your safety level by doing this exercise?
17. Did it increase or decrease your safety level by doing this exercise?
18. How did it feel to do this exercise? (mad, sad, glad, or scared) Tell me about the feelings.
18. How did it feel to do this exercise? (mad, sad, glad, or scared) Tell me about the feelings.
19. Did doing the exercise evoke any shame about not being safe?
19. Did doing the exercise evoke any shame about not being safe?
20. How did it feel to have me inquire about your safety level?
20. How did it feel to have me inquire about your safety level?
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3
Initial Treatment Issues Around
Safety
Initial Treatment Issues Around
Safety
Chapter Outline
Chapter Outline
A. Healing and the Therapeutic Process
A. Healing and the Therapeutic Process
1. Responding to Misses
1. Responding to Misses
2. Boundaries
2. Boundaries
3. Establishing a Clear Contract
3. Establishing a Clear Contract
4. Phone Containment in Times of Crisis
3. Phone Containment in Times of Crisis
4.
5. In Between Sessions
4. In Between Sessions
5.
B. Safety Issues Between the Client and Therapist
B. Safety Issues Between the Client and Therapist
3
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Initial Treatment Issues Around Safety
Initial Treatment Issues Around Safety
In Chapter 2, I addressed safety and stability of physical self-care, self-harming behaviors,
safety, and stability at both an environmental level and interpersonally. I want to further address Maslow’s second drive, the need for safety. Maslow described safety as “having security, freedom from fear, the need for structure and order, stability and protection” (Everly
& Lating, 1995, pp. 39-40). First, I want to share my views on healing and the therapeutic
process, and second, I want to look at the safety issues between the client and the therapist.
In Chapter 2, I addressed safety and stability of physical self-care, self-harming behaviors,
safety, and stability at both an environmental level and interpersonally. I want to further address Maslow’s second drive, the need for safety. Maslow described safety as “having security, freedom from fear, the need for structure and order, stability and protection” (Everly
& Lating, 1995, pp. 39-40). First, I want to share my views on healing and the therapeutic
process, and second, I want to look at the safety issues between the client and the therapist.
HEALING AND THE THERAPEUTIC PROCESS
HEALING AND THE THERAPEUTIC PROCESS
I believe that the most important aspect of healing for the client is the therapeutic relationship itself. Keeping that relationship safe is primary. The attachment that is formed between
the therapist and the client enables the client to begin to experience safety, in many instances for the first time. Often clients have not experienced a healthy attachment as children to
their primary caregiver. Some clients come into therapy never having had a chance to experience childhood and they need to explore their dependency needs. Their life circumstances pushed them to be prematurely, and inappropriately grown up which is sometimes
called the parentified child. Healing can begin to take place for those clients who never got
healthily attached as they learn to depend on and trust the therapist.
I believe that the most important aspect of healing for the client is the therapeutic relationship itself. Keeping that relationship safe is primary. The attachment that is formed between
the therapist and the client enables the client to begin to experience safety, in many instances for the first time. Often clients have not experienced a healthy attachment as children to
their primary caregiver. Some clients come into therapy never having had a chance to experience childhood and they need to explore their dependency needs. Their life circumstances pushed them to be prematurely, and inappropriately grown up which is sometimes
called the parentified child. Healing can begin to take place for those clients who never got
healthily attached as they learn to depend on and trust the therapist.
Other clients were discouraged from growing up and experiencing the joys of independence. These clients need encouragement and support to develop, try out, and trust their
abilities. For those clients who were overprotected and/or anxiously attached to their caregiver, the task is to begin to trust their own power to make changes in their lives. Ultimately, for therapy to be successful, both attachment and empowerment need to occur healthfully over the course of the therapeutic relationship. For those clients who have grown up
in a shame-based family system of trauma, abuse, or neglect, the shame can only be addressed in a safe, therapeutic relationship. It is the task of the therapist to be a healthy role
model or a good enough parent. Also, it is the therapist’s task to provide enough containment in an accepting, non-shaming climate so that clients can begin to experience enough
safety to complete unfinished developmental tasks.
Other clients were discouraged from growing up and experiencing the joys of independence. These clients need encouragement and support to develop, try out, and trust their
abilities. For those clients who were overprotected and/or anxiously attached to their caregiver, the task is to begin to trust their own power to make changes in their lives. Ultimately, for therapy to be successful, both attachment and empowerment need to occur healthfully over the course of the therapeutic relationship. For those clients who have grown up
in a shame-based family system of trauma, abuse, or neglect, the shame can only be addressed in a safe, therapeutic relationship. It is the task of the therapist to be a healthy role
model or a good enough parent. Also, it is the therapist’s task to provide enough containment in an accepting, non-shaming climate so that clients can begin to experience enough
safety to complete unfinished developmental tasks.
Note: Lack of healthy attachment between the child and the primary caregiver as well as
trauma, abuse, and neglect are major factors that prevent healthy development from occurring as it should.
Note: Lack of healthy attachment between the child and the primary caregiver as well as
trauma, abuse, and neglect are major factors that prevent healthy development from occurring as it should.
Because keeping the therapeutic relationship safe is primary, there are several issues that
need to be addressed so that safety can more easily occur. Addressing these issues helps
keep the client safe session to session.
Because keeping the therapeutic relationship safe is primary, there are several issues that
need to be addressed so that safety can more easily occur. Addressing these issues helps
keep the client safe session to session.
RESPONDING TO MISSES
RESPONDING TO MISSES
Misses occur within the therapeutic relationship and cause a rupture in the therapeutic attachment. It is usually the client’s need for emotional understanding that has been missed.
Clients may not be aware a miss has occurred or may not feel safe to report it. (See Safety
Issues Between the Client and Therapist, this chapter.) Therefore, therapists need to be
aware of discrete subtle changes in voice tone and nonverbal bodily changes.
Misses occur within the therapeutic relationship and cause a rupture in the therapeutic attachment. It is usually the client’s need for emotional understanding that has been missed.
Clients may not be aware a miss has occurred or may not feel safe to report it. (See Safety
Issues Between Client
the Client
andand
Therapist,
Therapist,
thisthis
chapter.)
chapter.)
Therefore,
Therefore,
therapists
therapists
needneed
to betoaware
be
of discrete
aware
of discrete
subtle subtle
changes
changes
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intone
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nonverbal
and nonverbal
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changes.
85
Example
The therapist was attuned to a client who had been physically and emotionally
abused. The client was doing integrative memory work - in this case actively
grieving the loss of someone to hear the pain of the child. There was a voice
change (a high falsetto voice) like a boy before his voice changes. He began to
verbalize his loneliness and grief. At the close of the session the therapist was
processing with the client what he had experienced. The therapist mentioned
that she had noted the change and wondered if it was the voice of the young
child. His response was to burst into tears. He had been seen and heard which
provided a corrective emotional experience for him. If the therapist had not
heard the voice change and commented on it, a miss would have occurred. The
client might never have consciously noted the miss or felt safe to share his feelings, but it still would have happened. The therapist kept a miss from occurring
by being present to his pain both verbally and nonverbally.
85
Example
The therapist was attuned to a client who had been physically and emotionally
abused. The client was doing integrative memory work - in this case actively
grieving the loss of someone to hear the pain of the child. There was a voice
change (a high falsetto voice) like a boy before his voice changes. He began to
verbalize his loneliness and grief. At the close of the session the therapist was
processing with the client what he had experienced. The therapist mentioned
that she had noted the change and wondered if it was the voice of the young
child. His response was to burst into tears. He had been seen and heard which
provided a corrective emotional experience for him. If the therapist had not
heard the voice change and commented on it, a miss would have occurred. The
client might never have consciously noted the miss or felt safe to share his feelings, but it still would have happened. The therapist kept a miss from occurring
by being present to his pain both verbally and nonverbally.
Misses can be described in a number of ways. I define a miss as anytime the therapist has
not heard the client whether or not the client is aware of not being heard. There is a miss
when the therapist has misinterpreted something the client has said. A miss happens when
the therapist has not given the client time to respond. Misses can occur when the therapist
asks clients to do something that they are uncomfortable doing. Misses also occur when a
feeling, need, or experience from the client’s past gets recreated in the present between the
client and the therapist, and the therapist fails to respond as desired by the client. The client
may experience a miss, and the therapist may not be aware one has occurred.
Misses can be described in a number of ways. I define a miss as anytime the therapist has
not heard the client whether or not the client is aware of not being heard. There is a miss
when the therapist has misinterpreted something the client has said. A miss happens when
the therapist has not given the client time to respond. Misses can occur when the therapist
asks clients to do something that they are uncomfortable doing. Misses also occur when a
feeling, need, or experience from the client’s past gets recreated in the present between the
client and the therapist, and the therapist fails to respond as desired by the client. The client
may experience a miss, and the therapist may not be aware one has occurred.
Example
Example
As a young child, a client had experienced her mother’s abandonment on a number of occasions. This sense of abandonment was replicated and experienced as
a miss when the therapist went on vacation, leaving her at a time when she felt
very vulnerable.
As a young child, a client had experienced her mother’s abandonment on a number of occasions. This sense of abandonment was replicated and experienced as
a miss when the therapist went on vacation, leaving her at a time when she felt
very vulnerable.
The client may have no ability to touch the original pain until the therapist is able to hear
the feelings (pain, anger, sadness, fear) regarding the unavailability of the therapist. Only
then can the therapist attempt to create a bridge back to the original event and touch the
grief that is there. This requires a very grounded, caring, nondefensive therapist who can
be fully present to the client and contain the anger and rage that may be projected inappropriately onto the therapist.
The client may have no ability to touch the original pain until the therapist is able to hear
the feelings (pain, anger, sadness, fear) regarding the unavailability of the therapist. Only
then can the therapist attempt to create a bridge back to the original event and touch the
grief that is there. This requires a very grounded, caring, nondefensive therapist who can
be fully present to the client and contain the anger and rage that may be projected inappropriately onto the therapist.
Example
The client had been physically, sexually, and emotionally abused as a child. The
therapist talked too much to explain something, and the client began to get irritated. The therapist listened, reflected nondefensively, and contained the client’s feelings about being missed by the therapist. As they processed what had
happened, the client was able to say that she felt controlled by the therapist
when the therapist talked a lot. When the therapist attempted to create a bridge
back to the past, the client remembered her father controlling her and the fear
that she would not be heard. Since the therapist and client had worked through
a number of misses over the course of treatment, this one was understood and
resolved satisfactorily. New insights were available to both client and therapist.
Example
The client had been physically, sexually, and emotionally abused as a child. The
therapist talked too much to explain something, and the client began to get irritated. The therapist listened, reflected nondefensively, and contained the client’s feelings about being missed by the therapist. As they processed what had
happened, the client was able to say that she felt controlled by the therapist
when the therapist talked a lot. When the therapist attempted to create a bridge
back to the past, the client remembered her father controlling her and the fear
that she would not be heard. Since the therapist and client had worked through
a number of misses over the course of treatment, this one was understood and
resolved satisfactorily. New insights were available to both client and therapist.
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Sometimes therapists will have anger directed at them with no prior awareness that there
has been a miss. While listening nondefensively, it is important to attempt to enter the client’s world and understand what the meaning of that event is to the client. If the therapist
has to choose between listening and reflecting nondefensively or understanding the meaning of the event, then the former must be chosen. The therapist and/or client can only create
a bridge back to the past when the client feels safe in the present. Sometimes it takes a long
time before the meaning of the event is fully understood. Often an experience from the client’s past has been recreated in the present. Clients frequently make the connection for
themselves. It is also important for the therapist to analyze the client’s expectations of how
the experience of this rupture may be received by the therapist. If a rupture occurs, then they
may expect another one to happen. Because therapists are not perfect, there may well be
another rupture as you continue to work together. I tell them that I cannot promise to never
miss them again. What I can promise is that I will do everything I possibly can to repair the
miss. I also tell them that I will not get angry with them for being hurt or angry with me for
missing them. Getting angry with me is healthy on their part. The gift is that it gives us a
window into the pain they experienced as a child and allows healing to occur. The non-gift
is that it is a re-injury and is often experienced as very painful.
Sometimes therapists will have anger directed at them with no prior awareness that there
has been a miss. While listening nondefensively, it is important to attempt to enter the client’s world and understand what the meaning of that event is to the client. If the therapist
has to choose between listening and reflecting nondefensively or understanding the meaning of the event, then the former must be chosen. The therapist and/or client can only create
a bridge back to the past when the client feels safe in the present. Sometimes it takes a long
time before the meaning of the event is fully understood. Often an experience from the client’s past has been recreated in the present. Clients frequently make the connection for
themselves. It is also important for the therapist to analyze the client’s expectations of how
the experience of this rupture may be received by the therapist. If a rupture occurs, then they
may expect another one to happen. Because therapists are not perfect, there may well be
another rupture as you continue to work together. I tell them that I cannot promise to never
miss them again. What I can promise is that I will do everything I possibly can to repair the
miss. I also tell them that I will not get angry with them for being hurt or angry with me for
missing them. Getting angry with me is healthy on their part. The gift is that it gives us a
window into the pain they experienced as a child and allows healing to occur. The non-gift
is that it is a re-injury and is often experienced as very painful.
Clients get very tuned in to how sensitive the therapist is to them. When I become aware
that I have injured a client, I do a lot of reflecting. I may say things like:
• Tell me about what you are feeling.
• What was that like for you?
• What happened when I said that?
Clients get very tuned in to how sensitive the therapist is to them. When I become aware
that I have injured a client, I do a lot of reflecting. I may say things like:
• Tell me about what you are feeling.
• What was that like for you?
• What happened when I said that?
I do not try to defend myself. I just listen, reflect, and explore the meaning of the injury for
them. At some point I ask:
• What did you need that you didn't get?
I do not try to defend myself. I just listen, reflect, and explore the meaning of the injury for
them. At some point I ask:
• What did you need that you didn't get?
It is helpful to remember that the client sitting in front of you may look like an angry adult
but is often feeling like a young child who has been misunderstood. If I get defensive, we
will polarize, and I may lose the client. Additionally, the client will have been re-injured. It
is my responsibility to understand what the injury was about. If I can create enough safety
for clients, then they may be able to teach me what they need. The client may not be safe
enough to stay in the therapeutic relationship when a miss has occurred and may terminate
therapy. However, if enough safety has been created in the relationship, it can often be
worked through. The ability to trust and make oneself vulnerable usually increases as the
relationship continues. With trust and vulnerability comes a greater longing on the client’s
part for the empathic responses to be the right ones.
It is helpful to remember that the client sitting in front of you may look like an angry adult
but is often feeling like a young child who has been misunderstood. If I get defensive, we
will polarize, and I may lose the client. Additionally, the client will have been re-injured. It
is my responsibility to understand what the injury was about. If I can create enough safety
for clients, then they may be able to teach me what they need. The client may not be safe
enough to stay in the therapeutic relationship when a miss has occurred and may terminate
therapy. However, if enough safety has been created in the relationship, it can often be
worked through. The ability to trust and make oneself vulnerable usually increases as the
relationship continues. With trust and vulnerability comes a greater longing on the client’s
part for the empathic responses to be the right ones.
Note: Sometimes a miss will continue to resurface for a long time afterward until there is
finally resolution. Each time it needs to be dealt with nondefensively by the therapist and
processed as sensitively as possible.
Note: Sometimes a miss will continue to resurface for a long time afterward until there is
finally resolution. Each time it needs to be dealt with nondefensively by the therapist and
processed as sensitively as possible.
BOUNDARIES
BOUNDARIES
Safety work is boundary work. Boundaries set the climate for the therapeutic relationship.
Boundaries keep both the client and the therapist safe. The policy statement spelled out in
the Client Consent Form (see Appendix A, Chapter 1) states what the therapist can and cannot offer. It needs to be read by the client and then reviewed with the therapist so that all
questions and/or concerns are addressed. It is important that both client and therapist sign
and date it with each retaining a copy. This protects both parties. Therapists create safety
by having clear boundaries. When working with abuse or trauma issues, there are clients
Safety work is boundary work. Boundaries set the climate for the therapeutic relationship.
Boundaries keep both the client and the therapist safe. The policy statement spelled out in
the Client Consent Form (see Appendix A, Chapter 1) states what the therapist can and cannot offer. It needs to be read by the client and then reviewed with the therapist so that all
questions and/or concerns are addressed. It is important that both client and therapist sign
and date it with each retaining a copy. This protects both parties. Therapists create safety
by having clear boundaries. When working with abuse or trauma issues, there are clients
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with borderline characteristics or symptoms due to the level of woundedness they have
experienced. Unresolved rage is often part of that woundedness. When therapists set clear
boundaries from the very beginning of treatment, they lessen the chance of getting rage directed at them. For instance, it is not a good idea to let clients with borderline characteristics
come without paying each session. Boundaries have often been blurred for those with abuse
or trauma in their background. Therapists need to model their ability to contain the client
and help the client in turn to contain.
with borderline characteristics or symptoms due to the level of woundedness they have
experienced. Unresolved rage is often part of that woundedness. When therapists set clear
boundaries from the very beginning of treatment, they lessen the chance of getting rage directed at them. For instance, it is not a good idea to let clients with borderline characteristics
come without paying each session. Boundaries have often been blurred for those with abuse
or trauma in their background. Therapists need to model their ability to contain the client
and help the client in turn to contain.
In childhood some clients may have experienced parental or caregiver boundaries that were
either rigid or chaotic and/or constantly changing depending on the kind of parenting they
received. This is particularly true of children who have been abused. In families where
abuse occurs, boundaries frequently meet the needs of the parent or perpetrator. Therapists
need to understand whether the boundaries they set are there to meet their own needs or the
needs of their clients. There is nothing wrong with setting boundaries that provide protection and security for the therapist. However, it is important that therapists acknowledge to
themselves as well as to their clients that these boundaries exist for that purpose. Some therapists tell their clients at the beginning of therapy that it is not okay for them to call between
sessions. It may be an attempt to protect their personal life by limiting their availability to
their clients. Without clarification, clients may think there is something wrong with them if
they experience a crisis and need support from their therapist in between sessions. Clients
should not be shamed for what they need to heal.
In childhood some clients may have experienced parental or caregiver boundaries that were
either rigid or chaotic and/or constantly changing depending on the kind of parenting they
received. This is particularly true of children who have been abused. In families where
abuse occurs, boundaries frequently meet the needs of the parent or perpetrator. Therapists
need to understand whether the boundaries they set are there to meet their own needs or the
needs of their clients. There is nothing wrong with setting boundaries that provide protection and security for the therapist. However, it is important that therapists acknowledge to
themselves as well as to their clients that these boundaries exist for that purpose. Some therapists tell their clients at the beginning of therapy that it is not okay for them to call between
sessions. It may be an attempt to protect their personal life by limiting their availability to
their clients. Without clarification, clients may think there is something wrong with them if
they experience a crisis and need support from their therapist in between sessions. Clients
should not be shamed for what they need to heal.
Therapists need to honor how they choose to make themselves available to their clients.
They also need to acknowledge to their clients that the boundaries they have set may not be
in the clients’ best interest and/or may prevent clients from getting their needs met at any
one time. It is helpful to explore together other possible resources on those occasions that
they need additional support. Many clients who have abuse issues draw on a number of resources for support such as 12-step groups, family support, church groups, etc. In addition,
it is helpful to teach clients a variety of ways to soothe and comfort themselves. (See Chapter 5.) Some clients may have a severe need for support, safety, and containment. When
you cannot safely meet that need and care for yourself, it is important that you refer them
to someone who can give them the help that is needed.
Therapists need to honor how they choose to make themselves available to their clients.
They also need to acknowledge to their clients that the boundaries they have set may not be
in the clients’ best interest and/or may prevent clients from getting their needs met at any
one time. It is helpful to explore together other possible resources on those occasions that
they need additional support. Many clients who have abuse issues draw on a number of resources for support such as 12-step groups, family support, church groups, etc. In addition,
it is helpful to teach clients a variety of ways to soothe and comfort themselves. (See Chapter 5.) Some clients may have a severe need for support, safety, and containment. When
you cannot safely meet that need and care for yourself, it is important that you refer them
to someone who can give them the help that is needed.
Example
Example
An actively suicidal client wanted to begin therapy. It became obvious to the
therapist that the client needed more support than she was willing to provide.
The therapist’s husband had recently had surgery and was still convalescing.
The therapist was feeling a high level of fatigue. Taking on this client was not
in the therapist’s best interest. The therapist told the client, “I want you to
have the care you need in order to heal. I think that you probably will need
twice a week sessions and/or possible phone contact to keep from being hospitalized. At this time I am only seeing clients once a week and am having to
limit my availability due to my husband’s recent surgery. I am not able to take
on clients who need multiple sessions in a week. However, I can provide you
with some referrals because I want you to get the help you need.”
Example
Over the course of a year a therapist took 4-6 weeks of vacation. Occasionally,
she was gone for 3 weeks at a time. Since she worked primarily with clients who
have abuse in their history, she was careful to take clients who were able to care
for themselves on an ongoing basis. She understood that abandonment was
likely to be an issue for this clientele. When vacations came up, she tried to explore the feelings before, during, and upon her return. She helped clients to develop a number of self-soothing techniques that they could use on an ongoing
An actively suicidal client wanted to begin therapy. It became obvious to the
therapist that the client needed more support than she was willing to provide.
The therapist’s husband had recently had surgery and was still convalescing.
The therapist was feeling a high level of fatigue. Taking on this client was not
in the therapist’s best interest. The therapist told the client, “I want you to
have the care you need in order to heal. I think that you probably will need
twice a week sessions and/or possible phone contact to keep from being hospitalized. At this time I am only seeing clients once a week and am having to
limit my availability due to my husband’s recent surgery. I am not able to take
on clients who need multiple sessions in a week. However, I can provide you
with some referrals because I want you to get the help you need.”
Example
Over the course of a year a therapist took 4-6 weeks of vacation. Occasionally,
she was gone for 3 weeks at a time. Since she worked primarily with clients who
have abuse in their history, she was careful to take clients who were able to care
for themselves on an ongoing basis. She understood that abandonment was
likely to be an issue for this clientele. When vacations came up, she tried to explore the feelings before, during, and upon her return. She helped clients to develop a number of self-soothing techniques that they could use on an ongoing
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Example Continued
Example Continued
basis and especially when she was not available (see self-soothing techniques,
Chapter 5). For instance, she made tapes for some clients to listen to that felt
comforting and soothing to them. When she knew that she would be away for
more than a week, she wrote notes to her clients ahead of time. She wrote
things that the clients asked for or that she thought would be supportive. She
either mailed a note to them or had her staff mail one while she was gone. This
process seemed to help many of her clients stay connected or attached to her
in a positive way.
basis and especially when she was not available (see self-soothing techniques,
Chapter 5). For instance, she made tapes for some clients to listen to that felt
comforting and soothing to them. When she knew that she would be away for
more than a week, she wrote notes to her clients ahead of time. She wrote
things that the clients asked for or that she thought would be supportive. She
either mailed a note to them or had her staff mail one while she was gone. This
process seemed to help many of her clients stay connected or attached to her
in a positive way.
Self-disclosure is a boundary issue that needs to be considered carefully. The amount of
self-disclosure that you use in treatment partially depends on your theoretical orientation.
Some guidelines that are useful to remember in self-disclosing are:
• What am I trying to convey to the client with this self-disclosure?
• How is this in service of the client’s healing?
• Will I feel better or will the client feel better?
• How will the client see me as a result of this disclosure?
• Am I using the self-disclosure as a form of shame reduction or twinship as used in
self psychology (Elson, 1987)?
Self-disclosure is a boundary issue that needs to be considered carefully. The amount of
self-disclosure that you use in treatment partially depends on your theoretical orientation.
Some guidelines that are useful to remember in self-disclosing are:
• What am I trying to convey to the client with this self-disclosure?
• How is this in service of the client’s healing?
• Will I feel better or will the client feel better?
• How will the client see me as a result of this disclosure?
• Am I using the self-disclosure as a form of shame reduction or twinship as used in
self psychology (Elson, 1987)?
Note: Shame reduction or normalizing an experience is a form of twinship. The therapist
self-discloses something that is similar to what the client is experiencing.
Note: Shame reduction or normalizing an experience is a form of twinship. The therapist
self-discloses something that is similar to what the client is experiencing.
Self-disclosure needs to be carefully timed as it can be as injurious to a relationship as it is
helpful. At numerous points in the treatment process, clients may need to idealize the therapist in order to establish trust. Self-disclosure during these periods may increase fear or
distrust that therapy is a safe place where they can be emotionally held. Rather than reducing the shame of their experience, it will increase it. This is sometimes experienced with
clients who have narcissistic traits or needs.
Self-disclosure needs to be carefully timed as it can be as injurious to a relationship as it is
helpful. At numerous points in the treatment process, clients may need to idealize the therapist in order to establish trust. Self-disclosure during these periods may increase fear or
distrust that therapy is a safe place where they can be emotionally held. Rather than reducing the shame of their experience, it will increase it. This is sometimes experienced with
clients who have narcissistic traits or needs.
When clients request that an established boundary be changed, it should be carefully evaluated with them. It is important for the therapist and the client to determine together whether the change will increase or decrease the safety level of the client. It is also necessary to
determine whether the therapeutic attachment will be more or less effective as a result of
the boundary change. Therapists need to evaluate the impact a requested boundary change
will have on themselves as well. Does it increase or decrease their own safety level? Therapists violate their boundaries by doing what they do not want to do and what is not good
for them. When therapists have violated their own boundaries, they are often overprotecting or violating their clients thereby creating an unhealthy dependency. The question that
always needs to be addressed is whether or not the requested change will make the therapeutic attachment more effective for both the therapist and the client.
When clients request that an established boundary be changed, it should be carefully evaluated with them. It is important for the therapist and the client to determine together whether the change will increase or decrease the safety level of the client. It is also necessary to
determine whether the therapeutic attachment will be more or less effective as a result of
the boundary change. Therapists need to evaluate the impact a requested boundary change
will have on themselves as well. Does it increase or decrease their own safety level? Therapists violate their boundaries by doing what they do not want to do and what is not good
for them. When therapists have violated their own boundaries, they are often overprotecting or violating their clients thereby creating an unhealthy dependency. The question that
always needs to be addressed is whether or not the requested change will make the therapeutic attachment more effective for both the therapist and the client.
It is the task of the therapist to create a therapeutic attachment in which clients can begin to
experience a sense of safety. When clients begin to get attached, they begin to heal. An integral part of building safety is providing healthy boundaries that offer containment to both
clients and therapists. Further, therapists need to explore the meaning of those limits or
boundaries with the client to avoid the possibility of misunderstanding in the future. It is
important to be aware of the power differential that exists between clients and therapists
and not misuse that power. It is helpful to remember that clients are not there to meet the
therapists’ needs.
It is the task of the therapist to create a therapeutic attachment in which clients can begin to
experience a sense of safety. When clients begin to get attached, they begin to heal. An integral part of building safety is providing healthy boundaries that offer containment to both
clients and therapists. Further, therapists need to explore the meaning of those limits or
boundaries with the client to avoid the possibility of misunderstanding in the future. It is
important to be aware of the power differential that exists between clients and therapists
and not misuse that power. It is helpful to remember that clients are not there to meet the
therapists’ needs.
Specific guidelines particularly useful for therapists around setting boundaries are:
Specific guidelines particularly useful for therapists around setting boundaries are:
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• Regular appointments should be scheduled and only interrupted for occasional vacations or conferences.
• A reasonable explanation should be given when appointments need to be rescheduled, because some clients have abandonment issues
• Maintain a regular starting and stopping time for each session except in the event of
an emergency.
• Regular appointments should be scheduled and only interrupted for occasional vacations or conferences.
• A reasonable explanation should be given when appointments need to be rescheduled, because some clients have abandonment issues
• Maintain a regular starting and stopping time for each session except in the event of
an emergency.
Note: When therapists do not stop and start sessions promptly, they violate their own
boundaries and those of their clients as well. It is a misuse of their power.
1
1
• 1 to1 --2- hour sessions are usually enough for most clients. I do1 --2- hours for my initial
1
session of history-taking. Frequently, I do1 --2- hour sessions when I work with couples.
• Once or twice a week sessions are sufficient unless the client is in crisis.
• Clients need to pay each session unless other arrangements are made.
• Phone calls should be returned in a reasonable length of time. Usually, a reasonable
length of time means the same day.
• When clients call in times of crisis, the goal is to contain them and give them support
to resume their own self-soothing process.
• Generally speaking, do not give clients your home phone number.
• Let clients know your hours of availability. I make myself available to clients from
9:00 am to 9:00 pm Monday through Friday. They can call earlier or later than these
times and leave a message.
Note: If they cannot reach me, I give them other phone numbers in the Client Consent Form
that they can call in the event of an emergency.
• Have a colleague cover for you when you plan to be away.
Note: When I am away over the weekend or for a day or two, I usually pick up my own calls.
(See Client Consent Form in Appendix A, Chapter 1.)
• Clients need to know whether or not it is okay to call in the event of an emergency.
I tell them that it is okay to call if they are in crisis and that I will return the call as soon
as I am able. Therapists who use an exchange generally have a similar policy.
Note: If clients are making frequent phone calls, I schedule them to be seen more often.
• No psychotherapy session takes place if clients arrive under the influence of drugs
or alcohol.
• I tell all my clients that I will never be sexual with them.
Note: A number of states require a pamphlet published by that state that spells out what recourse clients have under the law when their boundaries have been violated sexually in a
previous therapeutic relationship. The therapist should have immediate access to this pamphlet at all times in the event it might be needed.
• I tell clients that I will never touch them without their permission. Some clients will
never be comfortable with touch, and this is to be respected. Even when hugs are given, I normally ask the question, “Do you want a hug?” If the response is negative, I
am always respectful. (See Chapter 9.)
• Clients need to understand how and when confidentiality can be kept and when the
therapist has a duty to warn others or protect the client from self harm. (See Client
Consent Form in Appendix A, Chapter 1.)
Note: When therapists do not stop and start sessions promptly, they violate their own
boundaries and those of their clients as well. It is a misuse of their power.
1
1
• 1 to1 --2- hour sessions are usually enough for most clients. I do1 --2- hours for my initial
1
session of history-taking. Frequently, I do1 --2- hour sessions when I work with couples.
• Once or twice a week sessions are sufficient unless the client is in crisis.
• Clients need to pay each session unless other arrangements are made.
• Phone calls should be returned in a reasonable length of time. Usually, a reasonable
length of time means the same day.
• When clients call in times of crisis, the goal is to contain them and give them support
to resume their own self-soothing process.
• Generally speaking, do not give clients your home phone number.
• Let clients know your hours of availability. I make myself available to clients from
9:00 am to 9:00 pm Monday through Friday. They can call earlier or later than these
times and leave a message.
Note: If they cannot reach me, I give them other phone numbers in the Client Consent Form
that they can call in the event of an emergency.
• Have a colleague cover for you when you plan to be away.
Note: When I am away over the weekend or for a day or two, I usually pick up my own calls.
(See Client Consent Form in Appendix A, Chapter 1.)
• Clients need to know whether or not it is okay to call in the event of an emergency.
I tell them that it is okay to call if they are in crisis and that I will return the call as soon
as I am able. Therapists who use an exchange generally have a similar policy.
Note: If clients are making frequent phone calls, I schedule them to be seen more often.
• No psychotherapy session takes place if clients arrive under the influence of drugs
or alcohol.
• I tell all my clients that I will never be sexual with them.
Note: A number of states require a pamphlet published by that state that spells out what recourse clients have under the law when their boundaries have been violated sexually in a
previous therapeutic relationship. The therapist should have immediate access to this pamphlet at all times in the event it might be needed.
• I tell clients that I will never touch them without their permission. Some clients will
never be comfortable with touch, and this is to be respected. Even when hugs are given, I normally ask the question, “Do you want a hug?” If the response is negative, I
am always respectful. (See Chapter 9.)
• Clients need to understand how and when confidentiality can be kept and when the
therapist has a duty to warn others or protect the client from self harm. (See Client
Consent Form in Appendix A, Chapter 1.)
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• To avoid dual relationships, there should be no contact outside of therapy as a rule.
However, in rural areas or small communities, use careful discretion to avoid a blurring of boundaries as much as possible.
• To avoid dual relationships, there should be no contact outside of therapy as a rule.
However, in rural areas or small communities, use careful discretion to avoid a blurring of boundaries as much as possible.
Note: There are times when therapists may make exceptions to only seeing clients in their
office. Some therapists attend an occasional graduation or wedding. I do not go to the
homes of my clients for any celebrations. I do attend a wedding, if I am invited, but I decline
to attend the reception where I might have to explain my relationship. I attend graduations
when I am invited. I have seen clients in their home or the hospital when they were dying or
became chronically ill and could no longer come to the office providing that it seemed to be
therapeutic for them. I have done sessions with clients who were psychiatrically hospitalized
when that was allowed. Otherwise, I usually try to stay in touch by phone as seems appropriate.
Note: There are times when therapists may make exceptions to only seeing clients in their
office. Some therapists attend an occasional graduation or wedding. I do not go to the
homes of my clients for any celebrations. I do attend a wedding, if I am invited, but I decline
to attend the reception where I might have to explain my relationship. I attend graduations
when I am invited. I have seen clients in their home or the hospital when they were dying or
became chronically ill and could no longer come to the office providing that it seemed to be
therapeutic for them. I have done sessions with clients who were psychiatrically hospitalized
when that was allowed. Otherwise, I usually try to stay in touch by phone as seems appropriate.
Potential boundary conflicts include:
• paying the requested fee
• carrying an account balance
• time of appointment
• going over allotted time of session
• phone contact (how much, how often, fee involved)
• dual relationship (becoming friends, forming a love and/or sexual relationship, going
to lunch, business transactions)
• cancellations
• vacations
Potential boundary conflicts include:
• paying the requested fee
• carrying an account balance
• time of appointment
• going over allotted time of session
• phone contact (how much, how often, fee involved)
• dual
dualrelationship
relationship(becoming
(becomingfriends,
friends,forming
formingaalove
loveand/or
and/orsexual
sexualrelationship,
relationship,going
going
to lunch, business transactions)
• cancellations
• vacations
Therapists may want to ask themselves some preliminary questions regarding boundaries
before beginning to see clients. There are several different areas that often present concerns
when not carefully considered ahead of time. These questions need to be periodically reevaluated as circumstances change in the therapist’s life.
Therapists may want to ask themselves some preliminary questions regarding boundaries
before beginning to see clients. There are several different areas that often present concerns
when not carefully considered ahead of time. These questions need to be periodically reevaluated as circumstances change in the therapist’s life.
Emergencies or crises:
• How available am I willing to be to clients in times of crisis?
• Am I willing to see clients for additional sessions in times of crisis?
• Am I willing to be available to clients on weekends?
• Am I willing to do phone time in lieu of an office session?
• Am I willing to be available by phone to help clients contain until the next session?
• How often am I willing to make myself available by phone?
• How much phone time am I willing to make available to help a client contain in times
of crisis?
• How will I charge for time spent on the phone?
• Am I willing to give 10-15 minutes occasionally without charging?
Emergencies or crises:
• How available am I willing to be to clients in times of crisis?
• Am I willing to see clients for additional sessions in times of crisis?
• Am I willing to be available to clients on weekends?
• Am I willing to do phone time in lieu of an office session?
• Am I willing to be available by phone to help clients contain until the next session?
• How often am I willing to make myself available by phone?
• How much phone time am I willing to make available to help a client contain in times
of crisis?
• How will I charge for time spent on the phone?
• Am I willing to give 10-15 minutes occasionally without charging?
Clients are late for a session:
• Will I see clients only for the fraction of the hour remaining?
• Will I go into the next hour to give them their full session?
Clients are late for a session:
• Will I see clients only for the fraction of the hour remaining?
• Will I go into the next hour to give them their full session?
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• Will I refuse to see them?
• Will I charge clients for the full session whether they are present or not?
• Will I take any action if clients are very late on a continuous basis?
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• Will I refuse to see them?
• Will I charge clients for the full session whether they are present or not?
• Will I take any action if clients are very late on a continuous basis?
Late cancellations:
• What is my policy on cancellations?
• Is it acceptable to me to have clients cancel the same day?
• Can clients cancel due to an emergency such as illness, unexpected work, accidents?
• Will I charge for a late cancellation?
• Will I give clients one late cancellation without charging?
• Are there times I will not charge for a late cancellation?
Late cancellations:
• What is my policy on cancellations?
• Is it acceptable to me to have clients cancel the same day?
• Can clients cancel due to an emergency such as illness, unexpected work, accidents?
• Will I charge for a late cancellation?
• Will I give clients one late cancellation without charging?
• Are there times I will not charge for a late cancellation?
Fees:
• Will I always charge my full fee?
• Under what circumstances will I charge full fee?
• How will I set my fee?
• Will I consult with my colleagues about fee setting or decide on my own?
• What will I do if clients can no longer pay my fee due to a change in their finances?
• Am I willing to continue to see them at a reduced fee?
• How long am I willing to see them at a reduced fee?
• Am I willing to carry my clients on account?
• What will I do if clients run up a bill?
Fees:
• Will I always charge my full fee?
• Under what circumstances will I charge full fee?
• How will I set my fee?
• Will I consult with my colleagues about fee setting or decide on my own?
• What will I do if clients can no longer pay my fee due to a change in their finances?
• Am I willing to continue to see them at a reduced fee?
• How long am I willing to see them at a reduced fee?
• Am I willing to carry my clients on account?
• What will I do if clients run up a bill?
ESTABLISHING A CLEAR CONTRACT
ESTABLISHING A CLEAR CONTRACT
Establishing a clear contract for mutually agreed upon goals is essential to keep both the
client and therapist safe. In the initial sessions or assessment stage, clients will often state
what they want to work on. These goals need to be evaluated together to determine whether
or not the client can safely begin the work around this issue. Often, a client will have no
idea where to begin, and it is the role of the therapist to clearly state what they see the work
to be. Then, the therapist and client need to explore how this feels to them and from this
process get a clear contract of how they will proceed. This process helps the client to build
trust that the therapist understands what is needed to heal. It helps clients to feel a part of
the process and to demystify the belief that someone is going to do something to or for
them. It helps the client to have a sense of control or choice in the process. When the therapist and the client have a clear contract, both will experience a higher level of safety.
Establishing a clear contract for mutually agreed upon goals is essential to keep both the
client and therapist safe. In the initial sessions or assessment stage, clients will often state
what they want to work on. These goals need to be evaluated together to determine whether
or not the client can safely begin the work around this issue. Often, a client will have no
idea where to begin, and it is the role of the therapist to clearly state what they see the work
to be. Then, the therapist and client need to explore how this feels to them and from this
process get a clear contract of how they will proceed. This process helps the client to build
trust that the therapist understands what is needed to heal. It helps clients to feel a part of
the process and to demystify the belief that someone is going to do something to or for
them. It helps the client to have a sense of control or choice in the process. When the therapist and the client have a clear contract, both will experience a higher level of safety.
Example
The client initially presented with depression and an eating disorder for which
she wanted help. The therapist felt the only way that she could ethically treat
the client was to refer her to a psychiatrist and a nutritionist. During the time
that she was becoming stabilized on medication and increasing her weight, the
contracts for change agreed upon were relaxation training to help her sleep better, couple therapy to increase her safety and support system, and exploration
of family of origin work.
Example
The client initially presented with depression and an eating disorder for which
she wanted help. The therapist felt the only way that she could ethically treat
the client was to refer her to a psychiatrist and a nutritionist. During the time
that she was becoming stabilized on medication and increasing her weight, the
contracts for change agreed upon were relaxation training to help her sleep better, couple therapy to increase her safety and support system, and exploration
of family of origin work.
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Example
A client broached a therapist and wanted to do hypnotherapy to access the
memories of childhood sexual abuse. She wanted to do only a few sessions. No
safety work would have been done to set the stage for integrative memory
work. In this case, getting a clear statement on the client’s part allowed the
therapist to understand that she could not comply without jeopardizing her own
integrity as well as that of the client. The client chose to not come back for treatment because the therapist and client could not come to an agreement on a contract.
Example
A client began to work with a new therapist. The client had done some work
with the previous therapist on sexual abuse. The client wanted to do integrative
memory work as the abuse was surfacing from time to time. The therapist
agreed but wanted to teach the client how to self-soothe and have her start
practicing those behaviors. Also, the therapist felt that they both needed to understand the dynamics of her family of origin. She suggested this to the client
who liked the idea, and together they formulated a clear contract weaving in the
abuse as it surfaced. The client was able to maintain a level of safety on a dayto-day basis.
Example
A client broached a therapist and wanted to do hypnotherapy to access the
memories of childhood sexual abuse. She wanted to do only a few sessions. No
safety work would have been done to set the stage for integrative memory
work. In this case, getting a clear statement on the client’s part allowed the
therapist to understand that she could not comply without jeopardizing her own
integrity as well as that of the client. The client chose to not come back for treatment because the therapist and client could not come to an agreement on a contract.
Example
A client began to work with a new therapist. The client had done some work
with the previous therapist on sexual abuse. The client wanted to do integrative
memory work as the abuse was surfacing from time to time. The therapist
agreed but wanted to teach the client how to self-soothe and have her start
practicing those behaviors. Also, the therapist felt that they both needed to understand the dynamics of her family of origin. She suggested this to the client
who liked the idea, and together they formulated a clear contract weaving in the
abuse as it surfaced. The client was able to maintain a level of safety on a dayto-day basis.
Note: When therapy must be done in a time-limited fashion, the nature of the contract is
changed. (See Brief Therapy in Appendix A, this chapter.)
Note: When therapy must be done in a time-limited fashion, the nature of the contract is
changed. (See Brief Therapy in Appendix A, this chapter.)
Note: A treatment plan may be required by a third party payer. Therapists may find that doing a treatment plan provides a clearer direction for their interventions. (See Treatment Planning Made Easy in Appendix B, this chapter.)
Note: A treatment plan may be required by a third party payer. Therapists may find that doing a treatment plan provides a clearer direction for their interventions. (See Treatment Planning Made Easy in Appendix B, this chapter.)
Contracts need to be evaluated frequently – every few weeks or months. I often use the
1-year anniversary to explore with clients where they were when they came in versus where
they are now. This process helps them to affirm their own growth. I then help clients to formulate where they want to go which in turn clarifies the contract for our future work.
Contracts need to be evaluated frequently – every few weeks or months. I often use the
1-year anniversary to explore with clients where they were when they came in versus where
they are now. This process helps them to affirm their own growth. I then help clients to formulate where they want to go which in turn clarifies the contract for our future work.
When therapists begin to feel lost, anxious, or unclear about the direction of the work, it is
a good indicator that they no longer have a clear contract with the client. The therapist has
lost the way. Good supervision can often remedy the situation by asking the therapist,
“What is your contract with this client?” This enables the therapist to evaluate what direction has been taken with this client. It also helps a therapist to go back to the client and get
a clear contract.
When therapists begin to feel lost, anxious, or unclear about the direction of the work, it is
a good indicator that they no longer have a clear contract with the client. The therapist has
lost the way. Good supervision can often remedy the situation by asking the therapist,
“What is your contract with this client?” This enables the therapist to evaluate what direction has been taken with this client. It also helps a therapist to go back to the client and get
a clear contract.
Example
Example
“I would like for us to take some time to talk about where you were when you
came in and where you are now. Is that okay with you?” If the client agrees, I
ask, “Would you like to do that today or next time?” We then walk through the
process together.
“I would like for us to take some time to talk about where you were when you
came in and where you are now. Is that okay with you?” If the client agrees, I
ask, “Would you like to do that today or next time?” We then walk through the
process together.
It is a wonderful way for clients to step back and affirm their own growth process. Many times they are not aware of how much growth has been made. I
write these changes down and offer them a copy to take with them if they wish.
Often clients will share ways that they have grown that the therapist has no
awareness of. This growth offers additional insights and is often very helpful for
both client and therapist to affirm. We then look at what the focus of the work
will be and discuss options.
It is a wonderful way for clients to step back and affirm their own growth process. Many times they are not aware of how much growth has been made. I
write these changes down and offer them a copy to take with them if they wish.
Often clients will share ways that they have grown that the therapist has no
awareness of. This growth offers additional insights and is often very helpful for
both client and therapist to affirm. We then look at what the focus of the work
will be and discuss options.
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Example
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Example
A therapist who is feeling a bit confused and unclear about the direction of the
therapeutic work might say to a client, “We have been talking about your father
and your anger toward him. Then we got into talking about what your babysitter had done to you and your feelings about that. Then, we opened the door
regarding your feelings about your mother. Where would you like to go? What
would you like the focus of the work to be in these next months?”
A therapist who is feeling a bit confused and unclear about the direction of the
therapeutic work might say to a client, “We have been talking about your father
and your anger toward him. Then we got into talking about what your babysitter had done to you and your feelings about that. Then, we opened the door
regarding your feelings about your mother. Where would you like to go? What
would you like the focus of the work to be in these next months?”
After exploring with clients what they want and keeping in mind their current
safety level, a decision gets made, and a clear contract is reestablished. The client gets to make a choice which creates a sense of safety. Usually, the anxiety
of the therapist is alleviated as there is a sense of safety once again.
After exploring with clients what they want and keeping in mind their current
safety level, a decision gets made, and a clear contract is reestablished. The client gets to make a choice which creates a sense of safety. Usually, the anxiety
of the therapist is alleviated as there is a sense of safety once again.
PHONE CONTAINMENT IN TIMES OF CRISIS
PHONE CONTAINMENT IN TIMES OF CRISIS
Clients in crises may need to touch base with you a few minutes a day in order to get enough
support to maintain themselves healthfully. It may make more sense to do this for a short
period of time than to be hospitalized. When clients call in crisis, it is the role of the therapist to help clients stabilize and not open up new material. Depending on the crisis, I may
suggest that they make an appointment instead of doing phone time, as that may be most
therapeutic for them. I do not want to create a dependency situation by encouraging lots of
phone time; however, I do want them to feel safe enough to call if they are distraught and
are not able to self-soothe. For clients who have never had anyone that they could depend
on, knowing they can call and get support is a new experience. Clients can access the
healthy attachment that they did not get to experience as a child, which helps them to heal.
The role of the therapist is to be supportive and to empower clients to care for themselves
in a healthy manner.
Clients in crises may need to touch base with you a few minutes a day in order to get enough
support to maintain themselves healthfully. It may make more sense to do this for a short
period of time than to be hospitalized. When clients call in crisis, it is the role of the therapist to help clients stabilize and not open up new material. Depending on the crisis, I may
suggest that they make an appointment instead of doing phone time, as that may be most
therapeutic for them. I do not want to create a dependency situation by encouraging lots of
phone time; however, I do want them to feel safe enough to call if they are distraught and
are not able to self-soothe. For clients who have never had anyone that they could depend
on, knowing they can call and get support is a new experience. Clients can access the
healthy attachment that they did not get to experience as a child, which helps them to heal.
The role of the therapist is to be supportive and to empower clients to care for themselves
in a healthy manner.
If clients are too distraught to talk, I may ask them to stop and take some breaths in through
their nose and out through their mouth breathing into the diaphragm area. I have them do
this until they are calm enough to tell me what has happened. Once they are calm enough,
I want to hear briefly what they are experiencing so I have enough clarity to respond. I ask
what they have been doing to take care of themselves and affirm what they have already
done. (See Chapter 5.)
If clients are too distraught to talk, I may ask them to stop and take some breaths in through
their nose and out through their mouth breathing into the diaphragm area. I have them do
this until they are calm enough to tell me what has happened. Once they are calm enough,
I want to hear briefly what they are experiencing so I have enough clarity to respond. I ask
what they have been doing to take care of themselves and affirm what they have already
done. (See Chapter 5.)
Note: As a part of creating safety with clients, I teach them a number of self-soothing methods that they can use on a regular basis to self maintain. Often when crises occur, these
self-soothing methods have not been regularly used, and the client begins to decompensate.
Note: As a part of creating safety with clients, I teach them a number of self-soothing methods that they can use on a regular basis to self maintain. Often when crises occur, these
self-soothing methods have not been regularly used, and the client begins to decompensate.
I check what they have been doing around exercise, relaxation, journaling, play, etc. I usually get directive at this point:
• I want you to go to the gym, walk, or jog today so you can get the neurotransmitters
kicked in and the adrenalin flowing. Are you willing to do that?
• Is there anything else that you are willing to do that would help you to feel better?
I check what they have been doing around exercise, relaxation, journaling, play, etc. I usually get directive at this point:
• I want you to go to the gym, walk, or jog today so you can get the neurotransmitters
kicked in and the adrenalin flowing. Are you willing to do that?
• Is there anything else that you are willing to do that would help you to feel better?
better ?
If clients cannot seem to come up with anything, I may make suggestions. If major depression is an issue, then I assess for suicidality. (See Suicidality, Chapter 2.) I often ask if there
is something they would like to hear from me before I end the phone time. After they tell
me what they would like to hear, I then say to them what they have asked for. I have found
doing this with clients often empowers them to take better care of themselves.
If clients cannot seem to come up with anything, I may make suggestions. If major depression is an issue, then I assess for suicidality. (See Suicidality, Chapter 2.) I often ask if there
is something they would like to hear from me before I end the phone time. After they tell
me what they would like to hear, I then say to them what they have asked for. I have found
doing this with clients often empowers them to take better care of themselves.
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Sample Requests and Responses
Sample Requests and Responses
Client Request:
“I need to hear you tell me that you trust I can take care of myself.”
Therapist Response:
“I trust that you will take care of yourself.”
Client Request:
“I need to hear you tell me that you trust I can take care of myself.”
Therapist Response:
“I trust that you will take care of yourself.”
Client Request:
“I need to hear that it’s okay for me to set boundaries for myself.”
Therapist Response:
“It is okay for you to set boundaries for yourself.”
Client Request:
“I need to hear that it’s okay for me to set boundaries for myself.”
Therapist Response:
“It is okay for you to set boundaries for yourself.”
Client Request:
“I need to hear that I deserve to do good things for myself.”
Therapist Response:
“You deserve to do good things for yourself.”
Client Request:
“I need to hear that I deserve to do good things for myself.”
Therapist Response:
“You deserve to do good things for yourself.”
Example
A female client called the therapist in tears. She had just had an argument with
her mother. The client needed reassurance and support. After the therapist ascertained that the client was okay, she asked the client what she needed to take
care of herself around her mother. The client stated that she just needed to
know that she hadn’t done anything bad or wrong. Then the therapist asked the
client if there was anything else that she needed to hear from her before she
ended the phone conversation. The client stated that she needed to hear that it
was okay to stand up for herself. The therapist then said to her, “It is okay for
you to take care of yourself, even if the other person gets hurt or angry.” The
therapist asked her how she was feeling at that point. The client stated that she
was feeling much better. When the therapist asked her what had been helpful
for her, the client told her that it was very helpful for her to have the therapist
tell her that it was okay to take care of herself even if the other person got hurt
or angry. The therapist told the client that she would see her at her regular time
next week and then hung up.
Example
A female client called the therapist in tears. She had just had an argument with
her mother. The client needed reassurance and support. After the therapist ascertained that the client was okay, she asked the client what she needed to take
care of herself around her mother. The client stated that she just needed to
know that she hadn’t done anything bad or wrong. Then the therapist asked the
client if there was anything else that she needed to hear from her before she
ended the phone conversation. The client stated that she needed to hear that it
was okay to stand up for herself. The therapist then said to her, “It is okay for
you to take care of yourself, even if the other person gets hurt or angry.” The
therapist asked her how she was feeling at that point. The client stated that she
was feeling much better. When the therapist asked her what had been helpful
for her, the client told her that it was very helpful for her to have the therapist
tell her that it was okay to take care of herself even if the other person got hurt
or angry. The therapist told the client that she would see her at her regular time
next week and then hung up.
I find it helpful with clients in crisis to assess how effective the phone time has been for
them. It allows me to evaluate how useful it is for containment purposes in times of crisis.
To be effective, it should increase their safety level. Before bringing the phone conversation to a close, I often ask the following questions:
• How are you feeling?
• Was there anything that did or did not feel good that we did?
• What was and was not helpful?
I find it helpful with clients in crisis to assess how effective the phone time has been for
them. It allows me to evaluate how useful it is for containment purposes in times of crisis.
To be effective, it should increase their safety level. Before bringing the phone conversation to a close, I often ask the following questions:
• How are you feeling?
• Was there anything that did or did not feel good that we did?
• What was and was not helpful?
Depending on our contract, I may remind a client of my fee policy. I do this when the client
calls on a frequent basis. I also remind the client of this when I think the time spent to stabilize the client is probably going to exceed 10-15 minutes. I usually make the following
statements:
• The first 10-15 minutes there will be no charge.
• If we talk for more than the 15 minutes, I will prorate the entire amount at your regular fee.
Depending on our contract, I may remind a client of my fee policy. I do this when the client
calls on a frequent basis. I also remind the client of this when I think the time spent to stabilize the client is probably going to exceed 10-15 minutes. I usually make the following
statements:
• The first 10-15 minutes there will be no charge.
• If we talk for more than the 15 minutes, I will prorate the entire amount at your regular fee.
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These statements keep therapists from violating their own boundaries and set a limit that
clients can come to expect. After 15 minutes, you may choose as I do to prorate the phone
time at the client’s normal fee for whatever fraction of the hour that is used. Safety is therefore created for both the client and the therapist. Clients who frequently need phone time
to help them maintain between sessions can feel comfortable knowing what to expect on a
monetary basis. For clients who call infrequently, I do not charge for the 10-15 minutes
phone time.
These statements keep therapists from violating their own boundaries and set a limit that
clients can come to expect. After 15 minutes, you may choose as I do to prorate the phone
time at the client’s normal fee for whatever fraction of the hour that is used. Safety is therefore created for both the client and the therapist. Clients who frequently need phone time
to help them maintain between sessions can feel comfortable knowing what to expect on a
monetary basis. For clients who call infrequently, I do not charge for the 10-15 minutes
phone time.
Occasionally, I plan phone time in lieu of a regular office visit:
Occasionally, I plan phone time in lieu of a regular office visit:
• A client cannot come due to illness, lack of baby-sitter, etc. and needs support.
• A client cannot come due to illness, lack of baby-sitter, etc. and needs support.
• A client is on vacation and needs support for an issue that comes up.
• A client is on vacation and needs support for an issue that comes up.
• A client is away doing healing work with a family member and asks for emotional
support.
• A client is away doing healing work with a family member and asks for emotional
support.
• A client moves away and wants to continue therapy until a new therapist is found.
• A client moves away and wants to continue therapy until a new therapist is found.
• A client may move away, not go back into therapy, and have an issue come up that
needs to be worked on.
• A client may move away, not go back into therapy, and have an issue come up that
needs to be worked on.
• A client may be away from home for an extended period of time for work and/or family problems and wants support.
• A client may be away from home for an extended period of time for work and/or family problems and wants support.
• A client may be away at college and asks for phone time to deal with an issue.
• A client may be away at college and asks
ask for
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phonetime
timetotodeal
dealwith
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anissue.
issue.
Obviously, during phone contact it is important to attend much more carefully to voice inflection since the nonverbal clues are not available. It is helpful to regularly check in with
what clients are feeling so as to determine their safety level during the phone session. Being
willing to give phone time as needed can help clients get the support that will often enhance
their safety level.
Obviously, during phone contact it is important to attend much more carefully to voice inflection since the nonverbal clues are not available. It is helpful to regularly check in with
what clients are feeling so as to determine their safety level during the phone session. Being
willing to give phone time as needed can help clients get the support that will often enhance
their safety level.
There are times when phone time is contraindicated. It should not be used for integrative
memory work, due to the inability to provide adequate containment for the client. Inadequate containment negatively affects the safety level of both client and therapist. It is important that the therapist not create an unhealthy dependency. Therapists need to be aware
of their own countertransference issues so that they are not meeting their own needs
through creating a dependency. If it appears that the client is enmeshed with the therapist,
it is not likely that there will be safety for either the client or the therapist. Phone time
should be used to increase safety, not decrease it.
There are times when phone time is contraindicated. It should not be used for integrative
memory work, due to the inability to provide adequate containment for the client. Inadequate containment negatively affects the safety level of both client and therapist. It is important that the therapist not create an unhealthy dependency. Therapists need to be aware
of their own countertransference issues so that they are not meeting their own needs
through creating a dependency. If it appears that the client is enmeshed with the therapist,
it is not likely that there will be safety for either the client or the therapist. Phone time
should be used to increase safety, not decrease it.
IN BETWEEN SESSIONS
IN BETWEEN SESSIONS
At the onset of a session, it is helpful for the therapist to inquire whether or not clients have
any thoughts or feelings about their last session. Checking in helps to increase their safety
level. The last session may have affected them positively or negatively. They may not feel
free to share this information unless they see that the therapist is interested. It is especially
important when something has not felt good to them. Also, it is important to ask how the
week has gone. This question is of particular importance if the client is working on integrating memories. If the client is not doing well with self-care, sleeping, eating, relationship, and/or work and is more depressed or anxious, etc., then the integrating of memories
needs to be stopped. Clients need to be able to safely maintain themselves, go about their
daily lives, and integrate memories. Additional safety work around self-soothing and selfcare needs to be implemented.
At the onset of a session, it is helpful for the therapist to inquire whether or not clients have
any thoughts or feelings about their last session. Checking in helps to increase their safety
level. The last session may have affected them positively or negatively. They may not feel
free to share this information unless they see that the therapist is interested. It is especially
important when something has not felt good to them. Also, it is important to ask how the
week has gone. This question is of particular importance if the client is working on integrating memories. If the client is not doing well with self-care, sleeping, eating, relationship, and/or work and is more depressed or anxious, etc., then the integrating of memories
needs to be stopped. Clients need to be able to safely maintain themselves, go about their
daily lives, and integrate memories. Additional safety work around self-soothing and selfcare needs to be implemented.
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Clients process their feelings and thoughts at their own pace. They may need to ask for clarity regarding something that was said. They may have misunderstood what was being said.
They may have positive or negative feelings about what was discussed. They may have further insights into their own process. When a therapist is open to exploring this avenue, a
deeper level of safety can occur.
Clients process their feelings and thoughts at their own pace. They may need to ask for clarity regarding something that was said. They may have misunderstood what was being said.
They may have positive or negative feelings about what was discussed. They may have further insights into their own process. When a therapist is open to exploring this avenue, a
deeper level of safety can occur.
SAFETY ISSUES BETWEEN THE CLIENT AND
THERAPIST
SAFETY ISSUES BETWEEN THE CLIENT AND
THERAPIST
It is important to remember that it may take a very long time for clients to feel safe, especially if they have felt deeply unsafe due to various circumstances in their life. One reason
for checking in with what they feel in the session is to try to increase their safety level in
the room between you and them. Indicators that checking in with the client may be needed
are:
• the client changes the subject
• the client gets quiet
• the client starts to cry
• the client starts to get really sleepy
• the energy in the session seems to go flat
• the client reports losing touch with feelings
• the client reports a loss of bodily feeling
• the client reports or seems to be feeling really anxious
• the client has a sudden surge of feelings
• the client’s body becomes agitated
• the client starts shaking
• the client sighs
• the client becomes flushed, pale
• the client’s affect state shifts markedly
It is important to remember that it may take a very long time for clients to feel safe, especially if they have felt deeply unsafe due to various circumstances in their life. One reason
for checking in with what they feel in the session is to try to increase their safety level in
the room between you and them. Indicators that checking in with the client may be needed
are:
• the client changes the subject
• the client gets quiet
• the client starts to cry
• the client starts to get really sleepy
• the energy in the session seems to go flat
• the client reports losing touch with feelings
• the client reports a loss of bodily feeling
• the client reports or seems to be feeling really anxious
• the client has a sudden surge of feelings
• the client’s body becomes agitated
• the client starts shaking
• the client sighs
• the client becomes flushed, pale
• the client’s affect state shifts markedly
Check-in questions include:
• What just happened?
• Where did you go?
• How old are you right now?
• What are you feeling right now? (mad, sad, glad, scared)
• What is happening in your body?
• What are you feeling in response to what I said?
Check-in questions include:
• What just happened?
• Where did you go?
• How old are you right now?
• What are you feeling right now? (mad, sad, glad, scared)
• What is happening in your body?
• What are you feeling in response to what I said?
At the close of a session, the following questions can be helpful as a way of gaining insights
into what was useful for the client and in turn can increase the safety level between them
and you:
• How did you feel about our session today?
At the close of a session, the following questions can be helpful as a way of gaining insights
into what was useful for the client and in turn can increase the safety level between them
and you:
• How did you feel about our session today?
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• What felt good? What did not feel good?
• What was helpful? What was not helpful?
• Did you gain any new insights?
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• What felt good? What did not feel good?
• What was helpful? What was not helpful?
• Did you gain any new insights?
It is the task of the therapist to look at what makes the therapeutic experience safe or safer.
It may be helpful at regular intervals to check in with the level of safety between you and
the client. Questions to explore the client’s safety level in the room might be as follows:
• Do you feel safe when we work together?
• What makes you feel safe?
• What would make you feel safe or safer here?
• Is there anything that would make it safer?
• If you were less than safe, what would be happening?
• What would be happening if you were safer?
• Has your level of safety increased or decreased these past months?
• To what do you attribute that increase or decrease?
• How did it feel to have me ask about your safety level?
It is the task of the therapist to look at what makes the therapeutic experience safe or safer.
It may be helpful at regular intervals to check in with the level of safety between you and
the client. Questions to explore the client’s safety level in the room might be as follows:
• Do you feel safe when we work together?
• What makes you feel safe?
• What would make you feel safe or safer here?
• Is there anything that would make it safer?
• If you were less than safe, what would be happening?
• What would be happening if you were safer?
• Has your level of safety increased or decreased these past months?
• To what do you attribute that increase or decrease?
• How did it feel to have me ask about your safety level?
Clients may not know how to increase their safety level. By asking these questions, you
convey that safety is an important issue and that their feelings are important.
Clients may not know how to increase their safety level. By asking these questions, you
convey that safety is an important issue and that their feelings are important.
REFERENCES
REFERENCES
Elson, M. (Ed.). (1987). The Kohut Seminars on Self Psychology and Psychotherapy with
Adolescents and Young Adults. New York: W.W. Norton & Co.
Elson, M. (Ed.). (1987). The Kohut Seminars on Self Psychology and Psychotherapy with
Adolescents and Young Adults. New York: W.W. Norton & Co.
Everly, G. S., Jr., & Lating, J. M. (Eds.). (1995). Psychotraumatology: Key Papers and
Core Concepts in Post-Traumatic Stress. New York: Plenum Press.
Everly, G. S., Jr., & Lating, J. M. (Eds.). (1995). Psychotraumatology: Key Papers and
Core Concepts in Post-Traumatic Stress. New York: Plenum Press.
RECOMMENDED RESOURCES
RECOMMENDED RESOURCES
This section includes: boundaries, “misses” and brief therapy
This section includes: boundaries, “misses” and brief therapy
Basch, M. F. (1985). Interpretation: Toward a Developmental Mode. In A. Goldberg
(Ed.), Progress in Self-Psychology (Vol.1, pp. 33-41). New York: Guilford Publications, Inc.
Basch, M. F. (1985). Interpretation: Toward a Developmental Mode. In A. Goldberg
(Ed.), Progress in Self-Psychology (Vol.1, pp. 33-41). New York: Guilford Publications, Inc.
Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford Publications, Inc.
Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford Publications, Inc.
Black, J., & Enns, G. (1997). Better Boundaries: Owning and Treasuring Your Life. Oakland, CA: New Harbinger Publications.
Black, J., & Enns, G. (1997). Better Boundaries: Owning and Treasuring Your Life. Oakland, CA: New Harbinger Publications.
Kottler, J. A. (2001). Making Changes Last. Philadelphia: Taylor & Francis.
Kottler, J. A. (2001). Making Changes Last. Philadelphia: Taylor & Francis.
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Lee, R. G., & Wheeler, G. (Eds.). (1997). The Voice of Shame: Silence and Connection in
Psychotherapy. San Francisco: Jossey-Bass.
Lee, R. G., & Wheeler, G. (Eds.). (1997). The Voice of Shame: Silence and Connection in
Psychotherapy. San Francisco: Jossey-Bass.
Maslow, A. H. (1970). Motivation and Personality. New York: Harper & Row.
Maslow, A. H. (1970). Motivation and Personality. New York: Harper & Row.
Messer, S. B., & Warren, C. S. (1995). Models of Brief Psychodynamic Therapy. New
York: Guilford Publications, Inc.
Messer, S. B., & Warren, C. S. (1995). Models of Brief Psychodynamic Therapy. New
York: Guilford Publications, Inc.
Preston, J. (1998). Integrative Brief Therapy: Cognitive, Psychodynamic, Humanistic and
Neurobehavioral Approaches. San Luis Obispo, CA: Impact Publishers.
Preston, J. (1998). Integrative Brief Therapy: Cognitive, Psychodynamic, Humanistic and
Neurobehavioral Approaches. San Luis Obispo, CA: Impact Publishers.
Stern, D. N. (1995). Interpersonal World of the Infant. New York: Basic Books.
Stern, D. N. (1995). Interpersonal World of the Infant. New York: Basic Books.
Stern, D. N. (2004). The Present Moment in Psychotherapy and Everyday Life. New York:
W.W. Norton & Co.
Stern, D. N. (2004). The Present Moment in Psychotherapy and Everyday Life. New York:
W.W. Norton & Co.
Storolow, R. D. (1994). The Intersubjective Context of Intrapsychic Experience. In R. D.
Stolorow & B. Brandcaft (Eds.), The Intersubjective Perspective, (pp. 3-14),
Northvale, NJ: Jason Aronson.
Storolow, R. D. (1994). The Intersubjective Context of Intrapsychic Experience. In R. D.
Stolorow & B. Brandcaft (Eds.), The Intersubjective Perspective, (pp. 3-14),
Northvale, NJ: Jason Aronson.
Teyber, E. (2000). Interpersonal Process in Psychotherapy: A Relational Approach (4th
ed.). Stamford, CT: Thomson Learning.
Teyber, E. (2000). Interpersonal Process in Psychotherapy: A Relational Approach (4th
ed.). Stamford, CT: Thomson Learning.
Whitfield, C. L. (1990). A Gift to Myself. Deerfield Beach, FL: Health Communications,
Inc.
Whitfield, C. L. (1990). A Gift to Myself. Deerfield Beach, FL: Health Communications,
Inc.
Whitfield, C. L. (1993). Boundaries and Relationships: Knowing, Protecting and Enjoying the Self. Deerfield Beach, FL: Health Communications, Inc.
Whitfield, C. L. (1993). Boundaries and Relationships: Knowing, Protecting and Enjoying the Self. Deerfield Beach, FL: Health Communications, Inc.
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Chapter 3 Appendix A
Chapter 3 Appendix A
Brief Therapy
Brief Therapy
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Brief Therapy
Brief Therapy
Many clients choose or can only afford to be in therapy for a few months. When these clients have serious early traumas or severe emotional disorders, brief therapy allows for the
learning of some new skills and perhaps alleviates some of the current symptoms. Long
term therapy, i.e., more than 16 sessions, is usually needed to heal severe forms of trauma,
attachment disorders, etc. One thing that happens for many people is that they cycle in and
out of therapy over a period of years in order to maintain a basic level of functioning. Many
of the issues of brief therapy are part of the initial stage of a longer therapeutic process.
Many clients choose or can only afford to be in therapy for a few months. When these clients have serious early traumas or severe emotional disorders, brief therapy allows for the
learning of some new skills and perhaps alleviates some of the current symptoms. Long
term therapy, i.e., more than 16 sessions, is usually needed to heal severe forms of trauma,
attachment disorders, etc. One thing that happens for many people is that they cycle in and
out of therapy over a period of years in order to maintain a basic level of functioning. Many
of the issues of brief therapy are part of the initial stage of a longer therapeutic process.
The goals for brief therapy are different, but the need for the development of safety is very
similar. The kinds of things that might look different are as follows:
• Therapy is more goal oriented and often directed toward stabilizing the client.
• The contract for change is very specific and behavioral in nature.
• Homework is utilized extensively.
• The therapist clarifies for the client what can and cannot be accomplished in the stated time frame.
• Due to the limited time frame, the therapist does not attempt to probe deeply into the
source of the problems or issues presented.
• The therapist responds specifically to the client’s reported issues or problems and
provides reassurance that change is possible.
• The therapist focuses and builds upon the strengths that clients have previously used
to cope with difficulties in their life.
The goals for brief therapy are different, but the need for the development of safety is very
similar. The kinds of things that might look different are as follows:
• Therapy is more goal oriented and often directed toward stabilizing the client.
• The contract for change is very specific and behavioral in nature.
• Homework is utilized extensively.
• The therapist clarifies for the client what can and cannot be accomplished in the stated time frame.
• Due to the limited time frame, the therapist does not attempt to probe deeply into the
source of the problems or issues presented.
• The therapist responds specifically to the client’s reported issues or problems and
provides reassurance that change is possible.
• The therapist focuses and builds upon the strengths that clients have previously used
to cope with difficulties in their life.
In terms of this particular manual, those doing brief therapy may not be able to address the
issues in Chapters 6-9. However, it is still useful for therapists doing brief therapy to be
aware of the issues explored in these chapters.
In terms of this particular manual, those doing brief therapy may not be able to address the
issues in Chapters 6-9. However, it is still useful for therapists doing brief therapy to be
aware of the issues explored in these chapters.
Example of Brief Therapy
A male client seeks therapy for depression. He has been given 8 sessions by his
managed health care.
Example of Brief Therapy
A male client seeks therapy for depression. He has been given 8 sessions by his
managed health care.
Rather than exploring the historical roots that likely contribute to his current experience,
the following steps might be taken:
Rather than exploring the historical roots that likely contribute to his current experience,
the following steps might be taken:
1. Make a referral to a physician to consider possible medication.
1. Make a referral to a physician to consider possible medication.
2. State the contract in terms of good self-care as exemplified by eating appropriately, getting some physical activity, and attending work regularly.
2. State the contract in terms of good self-care as exemplified by eating appropriately, getting some physical activity, and attending work regularly.
3. Assign homework to support these changes consisting of having the client keep a daily
record of his sleeping, eating, and exercise patterns.
3. Assign homework to support these changes consisting of having the client keep a daily
record of his sleeping, eating, and exercise patterns.
4. Schedule subsequent sessions toward helping the client develop specific behavioral
changes to address the problem assessed from his journal.
4. Schedule subsequent sessions toward helping the client develop specific behavioral
changes to address the problem assessed from his journal.
Note: Brief therapy assumes that clients feel safe enough to implement changes quickly and
effectively. Assessment for this level of safety is an important part of the first session. Interventions are based on the level of safety clients can maintain with this limited support.
Note: Brief therapy assumes that clients feel safe enough to implement changes quickly and
effectively. Assessment for this level of safety is an important part of the first session. Interventions are based on the level of safety clients can maintain with this limited support.
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Chapter 3 Appendix B
Chapter 3 Appendix B
Treatment Planning Made
Easy
Treatment Planning Made
Easy
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Treatment Planning Made Easy
Treatment Planning Made Easy
Although sometimes described explicitly for the benefit of third-party-payers and sometimes
only implicitly present, treatment planning is always a part of every clinical interaction. We
need to know where we are going and how we will know when we get there. One way to think
of the treatment plan is to imagine yourself as a travel agent. Clients need to determine the ultimate destination of the trip they wish to take. It is up to us to explore with them the most effective way to get there given their abilities and preferences. They may be afraid of certain
forms of transportation and some desired destinations may be too expensive or difficult to attain. In fact as the travel agent you need to explore with them how far they can afford to go.
They may want to travel around the world but only have the time and funds to make a much
shorter trip. So destination, manner of transport, and personal abilities and preferences all play
into the travel plan.
Although sometimes described explicitly for the benefit of third-party-payers and sometimes
only implicitly present, treatment planning is always a part of every clinical interaction. We
need to know where we are going and how we will know when we get there. One way to think
of the treatment plan is to imagine yourself as a travel agent. Clients need to determine the ultimate destination of the trip they wish to take. It is up to us to explore with them the most effective way to get there given their abilities and preferences. They may be afraid of certain
forms of transportation and some desired destinations may be too expensive or difficult to attain. In fact as the travel agent you need to explore with them how far they can afford to go.
They may want to travel around the world but only have the time and funds to make a much
shorter trip. So destination, manner of transport, and personal abilities and preferences all play
into the travel plan.
When this metaphor is translated into the therapeutic situation, it looks more or less like the
following.
When this metaphor is translated into the therapeutic situation, it looks more or less like the
following.
PHASE I: INITIAL SESSIONS
PHASE I: INITIAL SESSIONS
Goal: to determine what clients want to change (destination) and their ability to take the trip and
to make any necessary diagnosis
Goal: to determine what clients want to change (destination) and their ability to take the trip and
to make any necessary diagnosis
A. Basic aspects of case management
A. Basic aspects of case management
B. Forming a relationship
B. Forming a relationship
C. Determining ability and commitment to change
C. Determining ability and commitment to change
PHASE II: MIDDLE SESSIONS
PHASE II: MIDDLE SESSIONS
Goal: to provide effective interventions (travel arrangements) to enable clients to make desired
changes to reach their goals.
Goal: to provide effective interventions (travel arrangements) to enable clients to make desired
changes to reach their goals.
A. Emotional - Dealing with the emotions that are attached to the current problem and those
that might be involved in promoting change or hindering it.
A. Emotional - Dealing with the emotions that are attached to the current problem and those
that might be involved in promoting change or hindering it.
B. Cognitive - Coming to an understanding about the nature of the problem, thinking patterns
that support change or hinder it.
B. Cognitive - Coming to an understanding about the nature of the problem, thinking patterns
that support change or hinder it.
C. Behavioral - Developing actual behavioral goals that indicate the desired changes are taking
place and exploring which behaviors may sabotage change.
C. Behavioral - Developing actual behavioral goals that indicate the desired changes are taking
place and exploring which behaviors may sabotage change.
D. Systemic - All change unbalances the larger system of the client, and it is important to develop interventions that address these situations and help the client to respond to the pressure to stay the same that may come from their environment.
D. Systemic - All change unbalances the larger system of the client, and it is important to develop interventions that address these situations and help the client to respond to the pressure to stay the same that may come from their environment.
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PHASE III: ENDING SESSIONS
Goal: to explore possible relapse potentials and develop supports for maintaining changes
over time.
PHASE III: ENDING SESSIONS
Goal: to explore possible relapse potentials and develop supports for maintaining changes
over time.
A. Articulate changes that have been made and celebrate those.
A. Articulate changes that have been made and celebrate those.
B. Consider situations that might promote relapse to previous problem situations and possible
supportive individuals, groups, or other activities to avoid regression.
B. Consider situations that might promote relapse to previous problem situations and possible
supportive individuals, groups, or other activities to avoid regression.
C. Process attachment and separation issues as they influence the client.
C. Process attachment and separation issues as they influence the client.
Phases will often blend and overlap during the therapy process. The topics to be dealt with in
a phase will also have a tendency to be addressed in a circular fashion more than sequentially
with the therapist choosing the most applicable and appropriate level on which to intervene.
The choice of intervention on each occasion depends on the therapist's abilities, experience,
and sense of what is clinically most appropriate.
Phases will often blend and overlap during the therapy process. The topics to be dealt with in
a phase will also have a tendency to be addressed in a circular fashion more than sequentially
with the therapist choosing the most applicable and appropriate level on which to intervene.
The choice of intervention on each occasion depends on the therapist's abilities, experience,
and sense of what is clinically most appropriate.
SAMPLE TREATMENT PLAN
SAMPLE TREATMENT PLAN
Client presents with depression
Client presents with depression
PHASE I INITIAL SESSIONS
PHASE I INITIAL SESSIONS
A. Basic aspects of case management
A. Basic aspects of case management
1. Complete Client Consent Form
1. Complete Client Consent Form
2. Discuss limits of confidentiality, especially focusing on suicidality and possibilities
of hospitalization
2. Discuss limits of confidentiality, especially focusing on suicidality and possibilities
of hospitalization
3. Review financial arrangement
3. Review financial arrangement
B. Forming a relationship
B. Forming a relationship
1. Discuss issues leading to depression
1. Discuss issues leading to depression
2. Reasons for coming now
2. Reasons for coming now
3. Look at support system
3. Look at support system
4. Provide empathy
4. Provide empathy
5. Set a goal for expected changes such as alleviating depression as signified by regular eating, sleeping, and work habits
5. Set a goal for expected changes such as alleviating depression as signified by regular eating, sleeping, and work habits
C. Determining ability and commitment to change
C. Determining ability and commitment to change
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1. Presence of adequate support
1. Presence of adequate support
2. Level of cognitive functioning
2. Level of cognitive functioning
3. Referral for medical evaluation including psychotropic medication
3. Referral for medical evaluation including psychotropic medication
PHASE II: MIDDLE SESSIONS
PHASE II: MIDDLE SESSIONS
A. Emotional -
A. Emotional -
1. Express sadness concerning losses that client recently experienced
B. Cognitive 1. Normalize response to losses and provide client with statements that reframe inaccurate current conclusions
C. Behavioral -
1. Express sadness concerning losses that client recently experienced
B. Cognitive 1. Normalize response to losses and provide client with statements that reframe inaccurate current conclusions
C. Behavioral -
1. Getting up and going to bed at regular times
1. Getting up and going to bed at regular times
2. Monitor eating patterns and report changes
2. Monitor eating patterns and report changes
3. Encourage return to work even though feelings of depression are present
3. Encourage return to work even though feelings of depression are present
4. Keep record of medication compliance
4. Keep record of medication compliance
D. Systemic -
D. Systemic -
1. Develop support system by asking friends to go to dinner or calling friends
1. Develop support system by asking friends to go to dinner or calling friends
2. Keep journal of these experiences
2. Keep journal of these experiences
PHASE III: ENDING SESSIONS
PHASE III: ENDING SESSIONS
A. Articulate changes that have been made and celebrate those.
A. Articulate changes that have been made and celebrate those.
1. Support clients regular eating, sleeping, and work patterns
1. Support clients regular eating, sleeping, and work patterns
2. Describe new client behaviors
2. Describe new client behaviors
B. Consider relapse situations and possible supportive individuals or groups
B. Consider relapse situations and possible supportive individuals or groups
1. Work with client to put regular support in place and discuss possible responses
to sense of rejection and refusal by others
1. Work with client to put regular support in place and discuss possible responses
to sense of rejection and refusal by others
2. Refer to appropriate support group, e.g., church
2. Refer to appropriate support group, e.g., church
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3. Review medication compliance
3. Review medication compliance
4. Describe possible relapse situations and brainstorm new responses
4. Describe possible relapse situations and brainstorm new responses
C. Process attachment and separation issues as they influence the client
1. Discuss sense of loss at end of sessions and grieve if necessary.
C. Process attachment and separation issues as they influence the client
1. Discuss sense of loss at end of sessions and grieve if necessary.
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4
4
Learning to Identify Basic Feelings
and Needs Around Those Feelings
Learning to Identify Basic Feelings
and Needs Around Those Feelings
Chapter Outline
Chapter Outline
A. Expanding Clients’ Affect
A. Expanding Clients’ Affect
B. Identifying Recurrent Feelings
B. Identifying Recurrent Feelings
C. Dealing with Uncomfortable Feelings and Defense Mechanisms
C. Dealing with Uncomfortable Feelings and Defense Mechanisms
D. Use of Anger to Cover Up Sad or Scared Feelings
D. Use of Anger to Cover Up Sad or Scared Feelings
E. Lack of Expressed Affect
E. Lack of Expressed Affect
F. Real vs. Shame-Based Feelings
F. Real vs. Shame-Based Feelings
G. When Clients Ask What the Therapist Thinks or Feels
G. When Clients Ask What the Therapist Thinks or Feels
H. Frequent Checking with Clients in Session
H. Frequent Checking with Clients in Session
I. How Therapists May Block Themselves from Dealing with Clients’ Feelings
I. How Therapists May Block Themselves from Dealing with Clients’ Feelings
1. Need for Therapists to Identify Own Feelings
1. Need for Therapists to Identify Own Feelings
2. A Need to Be Liked
2. A Need to Be Liked
3. A Need to Take Care of Others
3. A Need to Take Care of Others
4. Feeling Responsible for Causing or Taking Away the Pain
4. Feeling Responsible for Causing or Taking Away the Pain
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5. Rules Learned About Feelings in the Family System or Culture
5. Rules Learned About Feelings in the Family System or Culture
6. Problems That Exist in the Therapist’s Life
6. Problems That Exist in the Therapist’s Life
J. Exercises for Identifying Feelings
J. Exercises for Identifying Feelings
l. Teaching the Basic Feelings
l. Teaching the Basic Feelings
2. Asking Directly vs. Indirectly Around Feelings and Needs
2. Asking Directly vs. Indirectly Around Feelings and Needs
3. Checking In with the Body to Access Feelings
3. Checking In with the Body to Access Feelings
4. Drawing as a Tool to Access Feelings
4. Drawing as a Tool to Access Feelings
5. History of Basic Feelings
5. History of Basic Feelings
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Learning to Identify Basic Feelings and Needs
Around Those Feelings
Learning to Identify Basic Feelings and Needs
Around Those Feelings
Clients come to therapy with conflicting desires. They need to have their emotions understood and yet may want to avoid any uncomfortable feelings. Clients may have a fear of
feeling shame over their inability to handle these feelings. They may also fear judgment or
criticism by the therapist for their unacceptable feelings or a fear of a loss of control. These
concerns may make it difficult for clients to have hope of receiving the help they need. Responding to the client’s feelings will often produce the most information and create safety
by intensifying the therapeutic relationship.
Clients come to therapy with conflicting desires. They need to have their emotions understood and yet may want to avoid any uncomfortable feelings. Clients may have a fear of
feeling shame over their inability to handle these feelings. They may also fear judgment or
criticism by the therapist for their unacceptable feelings or a fear of a loss of control. These
concerns may make it difficult for clients to have hope of receiving the help they need. Responding to the client’s feelings will often produce the most information and create safety
by intensifying the therapeutic relationship.
EXPANDING CLIENTS’ AFFECT
EXPANDING CLIENTS’ AFFECT
In the initial session after I have given strokes for seeking help, I always ask clients how it
feels to be here? (See Initial Session, Chapter 1.) I am especially looking for angry or scared
feelings. I ask them to verbalize their feelings. I acknowledge that their feelings are valued
and that I am interested in their feelings. In doing this, I begin to create safety between clients and myself. Often, feelings will come up when these questions are asked. In this way
I have modeled for clients that our work will be feeling-oriented and that their feelings are
important to me. At the close of the initial session, I always ask several questions:
• What felt good?
• What did not feel good?
• What was helpful?
• What was not helpful?
• Was there anything that felt scary?
In the initial session after I have given strokes for seeking help, I always ask clients how it
feels to be here? (See Initial Session, Chapter 1.) I am especially looking for angry or scared
feelings. I ask them to verbalize their feelings. I acknowledge that their feelings are valued
and that I am interested in their feelings. In doing this, I begin to create safety between clients and myself. Often, feelings will come up when these questions are asked. In this way
I have modeled for clients that our work will be feeling-oriented and that their feelings are
important to me. At the close of the initial session, I always ask several questions:
• What felt good?
• What did not feel good?
• What was helpful?
• What was not helpful?
• Was there anything that felt scary?
It is the role of the therapist to help expand clients’ affect. Expanding the clients’ affect can
best be done by inviting clients to further explore their feelings:
• What are you feeling right now?
• Tell me more about that feeling.
It is the role of the therapist to help expand clients’ affect. Expanding the clients’ affect can
best be done by inviting clients to further explore their feelings:
• What are you feeling right now?
• Tell me more about that feeling.
This invitation both helps to elicit and expand clients’ feelings and creates a greater level
of safety in the therapeutic relationship. Usually asking why is not helpful. Most clients do
not know why they feel, think, or do a particular thing. Clients tend to feel inadequate or
bad (angry, sad, scared) when they cannot tell the therapist why. It is more useful to say:
• Tell me about what you are feeling.
• Help me to understand your........(angry, sad, or scared) feelings.
This invitation both helps to elicit and expand clients’ feelings and creates a greater level
of safety in the therapeutic relationship. Usually asking why is not helpful. Most clients do
not know why they feel, think, or do a particular thing. Clients tend to feel inadequate or
bad (angry, sad, scared) when they cannot tell the therapist why. It is more useful to say:
• Tell me about what you are feeling.
• Help me to understand your........(angry, sad, or scared) feelings.
Therapists need to convey to clients that they are interested and comfortable sharing their
clients’ feelings with them. This is one of the most important responses a therapist can give
to clients. Most clients have not been able to share their feelings and stay connected in a
relationship. Clients begin to risk expressing their feelings and trying new behaviors when
they feel safe. Clients also begin to experience a greater level of trust in the therapeutic relationship because they feel safe. It is important for the therapist to invite clients to explore
and/or clarify the meaning of a particular feeling. Clients often need help in clarifying their
own feelings. Clients’ statements may mean something quite different than what the
Therapists need to convey to clients that they are interested and comfortable sharing their
clients’ feelings with them. This is one of the most important responses a therapist can give
to clients. Most clients have not been able to share their feelings and stay connected in a
relationship. Clients begin to risk expressing their feelings and trying new behaviors when
they feel safe. Clients also begin to experience a greater level of trust in the therapeutic relationship because they feel safe. It is important for the therapist to invite clients to explore
and/or clarify the meaning of a particular feeling. Clients often need help in clarifying their
own feelings. Clients’ statements may mean something quite different than what the
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therapist perceived it to mean. The following questions can be used to learn more about
what clients are experiencing:
• Can you help me to understand what it is like for you when you have this feeling?
• Are there any images that symbolize this feeling for you?
• Where in your body do you experience this feeling?
• Do you remember the first time you felt this feeling?
• How old were you when you felt this feeling?
• Where were you when you felt this feeling?
• Was there anyone with you when you felt this feeling?
• How did the person respond to you when you felt this feeling?
therapist perceived it to mean. The following questions can be used to learn more about
what clients are experiencing:
• Can you help me to understand what it is like for you when you have this feeling?
• Are there any images that symbolize this feeling for you?
• Where in your body do you experience this feeling?
• Do you remember the first time you felt this feeling?
• How old were you when you felt this feeling?
• Where were you when you felt this feeling?
• Was there anyone with you when you felt this feeling?
• How did the person respond to you when you felt this feeling?
Some clients will do well with this kind of exploration, and others will not. Therapists need
to find what works best with each client.
Some clients will do well with this kind of exploration, and others will not. Therapists need
to find what works best with each client.
IDENTIFYING RECURRING FEELINGS
IDENTIFYING RECURRING FEELINGS
During the course of therapy, the therapist gradually becomes able to identify the recurring
feelings that predominate in both the present conflict and throughout the client’s life. These
recurring feelings often help define the theme of the therapeutic work. Clients often have
one or two core feelings they keep reexperiencing that seem to be connected to their sense
of self. When therapists can identify these feelings, it often evokes a tremendous feeling of
being seen for the client. These feelings have often been with clients since they were young
children. Sample statements that the therapist might use are:
• You seem to be fearful that people will find you out.
• You feel angry that you could never be good enough.
• It has been too scary to risk letting people see your pain for fear of being rejected.
During the course of therapy, the therapist gradually becomes able to identify the recurring
feelings that predominate in both the present conflict and throughout the client’s life. These
recurring feelings often help define the theme of the therapeutic work. Clients often have
one or two core feelings they keep reexperiencing that seem to be connected to their sense
of self. When therapists can identify these feelings, it often evokes a tremendous feeling of
being seen for the client. These feelings have often been with clients since they were young
children. Sample statements that the therapist might use are:
• You seem to be fearful that people will find you out.
• You feel angry that you could never be good enough.
• It has been too scary to risk letting people see your pain for fear of being rejected.
DEALING WITH UNCOMFORTABLE FEELINGS
AND DEFENSE MECHANISMS
DEALING WITH UNCOMFORTABLE FEELINGS
AND DEFENSE MECHANISMS
Clients may guard against difficult feelings as an attempt to protect themselves. Clients often expect the therapist to respond to them as others have from their past, thus evoking feelings of shame, guilt, fear, or sadness. The therapist and client need to explore what makes
it unsafe for the client to feel an uncomfortable feeling. Clients who are not safe enough to
share a feeling should not be pushed to do so. It makes more sense to explore with them
what is threatening for them if they do share it. I might say to them the following:
Clients may guard against difficult feelings as an attempt to protect themselves. Clients often expect the therapist to respond to them as others have from their past, thus evoking feelings of shame, guilt, fear, or sadness. The therapist and client need to explore what makes
it unsafe for the client to feel an uncomfortable feeling. Clients who are not safe enough to
share a feeling should not be pushed to do so. It makes more sense to explore with them
what is threatening for them if they do share it. I might say to them the following:
I would like to suggest that we set aside the feeling (name it: sad, angry,
scared) and do some exploration about what happened when you experienced this feeling in the past.
Some helpful questions the therapist might ask are:
• What do you think might happen if we did talk about this feeling?
• If you did let yourself feel vulnerable in here, then what might happen?
• What would happen if you felt this feeling here?
I would like to suggest that we set aside the feeling (name it: sad, angry,
scared) and do some exploration about what happened when you experienced this feeling in the past.
Some helpful questions the therapist might ask are:
• What do you think might happen if we did talk about this feeling?
• If you did let yourself feel vulnerable in here, then what might happen?
• What would happen if you felt this feeling here?
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• What has happened in the past when you have allowed yourself to feel this feeling?
• What makes it unsafe for you to feel this feeling here?
• Help me understand how you have been hurt in the past.
• What kind of response have you gotten from others now or in the past when you have
felt this feeling? What do you think they were feeling toward you? What was the expression on their face?
• If you allowed yourself to feel this feeling, what would it say about you?
• What are you afraid would change if you let yourself feel this feeling?
• How do you think I would respond to you if you felt this feeling?
• How did it feel to have us do this exploration without asking you to experience this
feeling?
• What did you learn from our doing this exploration?
• Did you gain any new insights?
• What has happened in the past when you have allowed yourself to feel this feeling?
• What makes it unsafe for you to feel this feeling here?
• Help me understand how you have been hurt in the past.
• What kind of response have you gotten from others now or in the past when you have
felt this feeling? What do you think they were feeling toward you? What was the expression on their face?
• If you allowed yourself to feel this feeling, what would it say about you?
• What are you afraid would change if you let yourself feel this feeling?
• How do you think I would respond to you if you felt this feeling?
• How did it feel to have us do this exploration without asking you to experience this
feeling?
• What did you learn from our doing this exploration?
• Did you gain any new insights?
Exploration of denied feelings helps both therapists and clients to understand how the clients’defenses developed as a coping mechanism. The therapist conveys to the client that
understanding the need to guard against certain feelings is an important part of the therapeutic process. Clients come to understand that what they feel in the present makes sense
in light of their past experiences. As clients feel safe enough in the therapeutic relationship,
these feelings are gradually expressed. When the avoided feelings are shared, it is often
helpful for the therapist to process what that experience was like for clients, what feelings
were evoked, what expectations they had, etc. Based on their past relationships, many clients expect therapists to discount, ridicule, ignore, criticize, shame, and/or be hurt or burdened by their feelings. Beginning therapists may have difficulty understanding that their
clients expect them to respond as others have. These fears may be there even when the therapist has never responded to them ineffectively.
Exploration of denied feelings helps both therapists and clients to understand how the clients’defenses developed as a coping mechanism. The therapist conveys to the client that
understanding the need to guard against certain feelings is an important part of the therapeutic process. Clients come to understand that what they feel in the present makes sense
in light of their past experiences. As clients feel safe enough in the therapeutic relationship,
these feelings are gradually expressed. When the avoided feelings are shared, it is often
helpful for the therapist to process what that experience was like for clients, what feelings
were evoked, what expectations they had, etc. Based on their past relationships, many clients expect therapists to discount, ridicule, ignore, criticize, shame, and/or be hurt or burdened by their feelings. Beginning therapists may have difficulty understanding that their
clients expect them to respond as others have. These fears may be there even when the therapist has never responded to them ineffectively.
Clients may defend against their own feelings because of a need to protect their original
caregivers. Clients continue to abide by old family rules and often deny how these rules influence their current lives. By doing this, clients maintain some sense of attachment to both
their actual caregivers and those they have internalized. Therapists need to create enough
safety to allow clients to express painful feelings and then validate their experience. As
family rules get broken and emotional ties to caregivers get called into question, clients
need a great deal of safety and containment to feel and express their feelings.
Clients may defend against their own feelings because of a need to protect their original
caregivers. Clients continue to abide by old family rules and often deny how these rules influence their current lives. By doing this, clients maintain some sense of attachment to both
their actual caregivers and those they have internalized. Therapists need to create enough
safety to allow clients to express painful feelings and then validate their experience. As
family rules get broken and emotional ties to caregivers get called into question, clients
need a great deal of safety and containment to feel and express their feelings.
USE OF ANGER TO COVER UP SAD OR SCARED
FEELINGS
USE OF ANGER TO COVER UP SAD OR SCARED
FEELINGS
Clients often use anger to cover up sad or scared feelings. The therapist will want to explore
what feelings might be under the anger. It is often helpful to ask, “What were you feeling
just before you got angry?” The therapist will want to look particularly for unexpressed sad
or scared feelings. If sad or scared feelings are identified, then the client needs to be invited
to express them. Generally, in our society men have not been given permission to feel and
express sad and scared feelings. Men are often more comfortable expressing anger. In our
society, women have not been given permission to be angry. Women are often more comfortable expressing sad or scared feelings. Generalizations can get us into trouble; however,
I see this pattern in my office. Exceptions include the following:
Clients often use anger to cover up sad or scared feelings. The therapist will want to explore
what feelings might be under the anger. It is often helpful to ask, “What were you feeling
just before you got angry?” The therapist will want to look particularly for unexpressed sad
or scared feelings. If sad or scared feelings are identified, then the client needs to be invited
to express them. Generally, in our society men have not been given permission to feel and
express sad and scared feelings. Men are often more comfortable expressing anger. In our
society, women have not been given permission to be angry. Women are often more comfortable expressing sad or scared feelings. Generalizations can get us into trouble; however,
I see this pattern in my office. Exceptions include the following:
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• a woman who has frequent rage attacks which normally occur as a result of deep
emotional injuries
• a man who feels and expresses intensely sad feelings but seems to become immobilized in those feelings
• a woman who has frequent rage attacks which normally occur as a result of deep
emotional injuries
• a man who feels and expresses intensely sad feelings but seems to become immobilized in those feelings
Both of these clients should be carefully assessed for mood disorders and have a thorough
family history taken. Both men and women are capable of feeling and expressing all the
basic feelings given enough internal safety. Clients who have experienced trauma, physical, sexual, or emotional abuse or neglect in their lives often have difficulty feeling or expressing feelings.
Both of these clients should be carefully assessed for mood disorders and have a thorough
family history taken. Both men and women are capable of feeling and expressing all the
basic feelings given enough internal safety. Clients who have experienced trauma, physical, sexual, or emotional abuse or neglect in their lives often have difficulty feeling or expressing feelings.
LACK OF EXPRESSED AFFECT
LACK OF EXPRESSED AFFECT
Some clients have difficulty with feelings without having experienced major dysfunction
in their family of origin. Feelings may not have been valued in their family of origin due to
cultural or family rules. I have seen several clients who do not seem to have any awareness
of what they feel or the ability to identify their feelings. In their homes, the family members
may have shown love and respect for each other, but their family did not share feelings. I
have found reflecting or mirroring of feelings becomes very important to access the hidden
feelings. Clients may be totally unaware of what they feel until the reflecting process has
gone on for some time. It can be helpful for the therapist to reflect the client’s sad, scared,
or angry feelings and then check it out with the client to see if their assumptions were correct. This same process can be used with clients who have experienced trauma or abuse and
are not in touch with their feelings.
Some clients have difficulty with feelings without having experienced major dysfunction
in their family of origin. Feelings may not have been valued in their family of origin due to
cultural or family rules. I have seen several clients who do not seem to have any awareness
of what they feel or the ability to identify their feelings. In their homes, the family members
may have shown love and respect for each other, but their family did not share feelings. I
have found reflecting or mirroring of feelings becomes very important to access the hidden
feelings. Clients may be totally unaware of what they feel until the reflecting process has
gone on for some time. It can be helpful for the therapist to reflect the client’s sad, scared,
or angry feelings and then check it out with the client to see if their assumptions were correct. This same process can be used with clients who have experienced trauma or abuse and
are not in touch with their feelings.
Remember that cultures vary in how feelings are expressed. Some cultures discourage verbal or facial expressions of feelings. Some cultures encourage the expression of feelings no
matter how small. The cultural background of clients needs to be factored into the therapist’s assessment of any problems clients might be having that are related to their expression of affect.
Remember that cultures vary in how feelings are expressed. Some cultures discourage verbal or facial expressions of feelings. Some cultures encourage the expression of feelings no
matter how small. The cultural background of clients needs to be factored into the therapist’s assessment of any problems clients might be having that are related to their expression of affect.
REAL VS. SHAME-BASED FEELINGS
REAL VS. SHAME-BASED FEELINGS
In most family systems it is not okay to feel a particular feeling or feelings. Therefore, clients may present with the feeling that was acceptable for them to feel in their family. Sometimes clients will feel that it was not okay to feel scared, but it was okay to feel sad. They
may have learned that it was not okay to feel sad or scared, but it was okay to feel angry.
As a response to being traumatized, clients may have learned to dissociate, go numb, and
cut off their feelings. The concept of dissociation is explored in Chapter 7. However, there
are several ways clients may handle feelings that are not necessarily dissociative:
• They may not be cued into feelings or be able to identify them.
• They may cover up feelings with another feeling.
• They may substitute an acceptable feeling for an unacceptable feeling.
In most family systems it is not okay to feel a particular feeling or feelings. Therefore, clients may present with the feeling that was acceptable for them to feel in their family. Sometimes clients will feel that it was not okay to feel scared, but it was okay to feel sad. They
may have learned that it was not okay to feel sad or scared, but it was okay to feel angry.
As a response to being traumatized, clients may have learned to dissociate, go numb, and
cut off their feelings. The concept of dissociation is explored in Chapter 7. However, there
are several ways clients may handle feelings that are not necessarily dissociative:
• They may not be cued into feelings or be able to identify them.
• They may cover up feelings with another feeling.
• They may substitute an acceptable feeling for an unacceptable feeling.
When feelings are covered by another feeling, it may be because they are shame-based feelings. (See Appendix A, this chapter.) Clients may experience a sense of shame due to the
vulnerability they experience in sharing their feelings with the therapist.
When feelings are covered by another feeling, it may be because they are shame-based feelings. (See Appendix A, this chapter.) Clients may experience a sense of shame due to the
vulnerability they experience in sharing their feelings with the therapist.
When people experience shame, they do not see themselves as deserving of love or understanding from another. They may feel a need for connection but are frequently immobilized
by that need. When people are shamed, they tend to withdraw and isolate rather than reach
When people experience shame, they do not see themselves as deserving of love or understanding from another. They may feel a need for connection but are frequently immobilized
by that need. When people are shamed, they tend to withdraw and isolate rather than reach
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out for connection. That which they need the most they do not allow themselves to have.
out for connection. That which they need the most they do not allow themselves to have.
It is particularly useful to teach clients the difference between real and shame-based feelings. Real feelings come from the core of the person and can usually be described as the
four basic feelings (mad, sad, glad, and scared) or a combination of two or more. Shamebased feelings may surface in any number of ways. (See Appendix A, this chapter.)
It is particularly useful to teach clients the difference between real and shame-based feelings. Real feelings come from the core of the person and can usually be described as the
four basic feelings (mad, sad, glad, and scared) or a combination of two or more. Shamebased feelings may surface in any number of ways. (See Appendix A, this chapter.)
It is important to help clients access and begin to trust their intuitive, emotional, and spiritual wisdom that can be utilized for their healing. As clients become aware of shame-based
feelings, the goal is:
• encouraging clients to listen to and trust their basic feelings (mad, sad, glad, and
scared)
• encouraging clients to integrate those feelings that have been too unacceptable, painful, or shameful to feel before
• encouraging clients to become aware of which feelings are shame-based and consciously reject them as untruths about themselves
It is important to help clients access and begin to trust their intuitive, emotional, and spiritual wisdom that can be utilized for their healing. As clients become aware of shame-based
feelings, the goal is:
• encouraging clients to listen to and trust their basic feelings (mad, sad, glad, and
scared)
• encouraging clients to integrate those feelings that have been too unacceptable, painful, or shameful to feel before
• encouraging clients to become aware of which feelings are shame-based and consciously reject them as untruths about themselves
In order to differentiate shame-based from real feelings, it is often helpful to teach clients
to check in with others to test the accuracy of their perceptions. Clients who make incorrect
assumptions based on their own internal world or their family of origin can benefit from
this process. Many times reflecting, checking for accuracy, or asking for clarity can prevent
misperceptions, anxiety, and feelings of shame. This process is often helpful for highly anxious clients. Clients who project their thoughts and feelings on other people can often clarify their projections by getting information as to what was intended by the other. It can be
done as simply as reflecting what was just said. Some sample reflections are as follows:
In order to differentiate shame-based from real feelings, it is often helpful to teach clients
to check in with others to test the accuracy of their perceptions. Clients who make incorrect
assumptions based on their own internal world or their family of origin can benefit from
this process. Many times reflecting, checking for accuracy, or asking for clarity can prevent
misperceptions, anxiety, and feelings of shame. This process is often helpful for highly anxious clients. Clients who project their thoughts and feelings on other people can often clarify their projections by getting information as to what was intended by the other. It can be
done as simply as reflecting what was just said. Some sample reflections are as follows:
Sample Reflections
Sample Reflections
“Are you saying that you want me to take you to the concert at the amphitheater next month?”
“Are you saying that you want me to take you to the concert at the amphitheater next month?”
“I’m not sure I understood what you were saying. Can you run that by me
again?”
“I’m not sure I understood what you were saying. Can you run that by me
again?”
“Let me see if I’m understanding correctly. You really want to do this report
for me but you can’t possibly get to it until Monday.”
“Let me see if I’m understanding correctly. You really want to do this report
for me but you can’t possibly get to it until Monday.”
A Sample Dialogue
Wife: “I’m feeling as though you’re angry at me.”
Husband: “I’m not angry at you. I just had a run-in with a coworker.”
Wife: “Would you tell me about it? I’d like to hear.”
A Sample Dialogue
Wife: “I’m feeling as though you’re angry at me.”
Husband: “I’m not angry at you. I just had a run-in with a coworker.”
Wife: “Would you tell me about it? I’d like to hear.”
John Gottman (1994), reporting on his clinical research with couples in Why Marriages
Succeed or Fail: What You Can Learn from the Breakthrough Research to Make Your Marriage Last, does an excellent job of illustrating how destructive criticism, contempt, defensiveness, and stonewalling are in relationships. These four patterns of shaming are used
extensively in highly stressed marital relationships. When relating to people who use any
of these interactions, we will tend to feel shamed and respond with hurt or anger.
John Gottman (1994), reporting on his clinical research with couples in Why Marriages
Succeed or Fail: What You Can Learn from the Breakthrough Research to Make Your Marriage Last, does an excellent job of illustrating how destructive criticism, contempt, defensiveness, and stonewalling are in relationships. These four patterns of shaming are used
extensively in highly stressed marital relationships. When relating to people who use any
of these interactions, we will tend to feel shamed and respond with hurt or anger.
Gottman (1994) differentiates between criticism and a complaint by explaining that a
Gottman (1994) differentiates between criticism and a complaint by explaining that a
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complaint is usually a negative “I” statement about a specific behavior you wish were different. A criticism is generally a “you” statement and is usually an attack on the other’s
character that tends to be personal in nature and is usually a generalization.
complaint is usually a negative “I” statement about a specific behavior you wish were different. A criticism is generally a “you” statement and is usually an attack on the other’s
character that tends to be personal in nature and is usually a generalization.
Complaint vs. Criticism
Complaint vs. Criticism
Complaint: “I asked you to take out the trash this morning so I could get
to school early.”
Criticism: “I knew I couldn’t count on you to do what you said.”
Complaint: “I asked you to take out the trash this morning so I could get
to school early.”
Criticism: “I knew I couldn’t count on you to do what you said.”
Sample Critical Statements
Sample Critical Statements
“You should know better than to leave your clothes on the floor.”
“You never do anything right.”
“You always forget to hang up your coat.”
“You never do what I ask you to. I can’t count on you to do anything. I just
can’t trust you.”
“You should know better than to leave your clothes on the floor.”
“You never do anything right.”
“You always forget to hang up your coat.”
“You never do what I ask you to. I can’t count on you to do anything. I just
can’t trust you.”
Gottman (1994) states that contempt “is the intention to insult and psychologically abuse
your partner” (p. 79). Contempt can come in the form of “sarcasm, hostile humor, sneering,
insults, name calling, mockery, body language” (p. 79).
Gottman (1994) states that contempt “is the intention to insult and psychologically abuse
your partner” (p. 79). Contempt can come in the form of “sarcasm, hostile humor, sneering,
insults, name calling, mockery, body language” (p. 79).
Sample Contemptuous Statements
Sample Contemptuous Statements
“You really sounded stupid tonight when you told that story.”
“What does she know, she’s never even gone to college.”
“You’re so fat. You really need to lose weight.”
“I didn’t know I was married to a beauty queen.”
Sample Contemptuous Behaviors
A husband rolls his eyes at his wife when she starts to talk about what is
bothering her.
A wife looks at her husband with a sneer on her face when he tries to tell
her how he feels.
Gottman (1994) discusses defensiveness as a way of blaming the other and basically says,
“You have a problem. I don’t have one.” Ways he notes that people can be defensive are
by denying responsibility, making excuses, whining, using negative body language, and repeating themselves.
“You really sounded stupid tonight when you told that story.”
“What does she know, she’s never even gone to college.”
“You’re so fat. You really need to lose weight.”
“I didn’t know I was married to a beauty queen.”
Sample Contemptuous Behaviors
A husband
“A
husbandrolls
rollshis
hiseyes
eyesatathis
hiswife
wifewhen
whenshe
shestarts
startstototalk
talkabout
aboutwhat
whatisis
bothering her.
her.”
“Awife
A
wifelooks
looksatather
herhusband
husbandwith
withaasneer
sneeron
onher
herface
facewhen
whenhe
hetries
triestototell
tell
her how he feels.”
feels.
Gottman (1994) discusses defensiveness as a way of blaming the other and basically says,
“You have a problem. I don’t have one.” Ways he notes that people can be defensive are
by denying responsibility, making excuses, whining, using negative body language, and repeating themselves.
Sample Defensive Statements
Sample Defensive Statements
Denying Responsibility
Wife: “You made me feel really bad when you yelled at me.”
Husband: “I wasn’t yelling at you.”
Making Excuses
Wife: “I don’t understand why you’re always late coming home from work
when we live so close.”
Husband: “I always have work to finish. You just don’t get it, do you?”
Denying Responsibility
Wife: “You made me feel really bad when you yelled at me.”
Husband: “I wasn’t yelling at you.”
Making Excuses
Wife: “I don’t understand why you’re always late coming home from work
when we live so close.”
Husband: “I always have work to finish. You just don’t get it, do you?”
Gottman (1994) defines stonewalling as a way of tuning out, removing oneself from the
Gottman (1994) defines stonewalling as a way of tuning out, removing oneself from the
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conversation, and/or acting as though one does not care about what is being said. It is particularly upsetting for a woman to be stonewalled by a man.
conversation, and/or acting as though one does not care about what is being said. It is particularly upsetting for a woman to be stonewalled by a man.
Sample Stonewalling Statements
Sample Stonewalling Statements
Wife: “I feel really depressed and sad that I can’t ski with you because of
hurting my foot.”
Husband: He stays silent and doesn’t look at her.
Wife: “Don’t you even feel sad for me that I have to sit here while you have
all the fun?”
Husband: “You’re the one who wanted to come for the weekend. (Blames)
What do you want me to do?” (He stomps out the door.)
Wife: “I feel really depressed and sad that I can’t ski with you because of
hurting my foot.”
Husband: He stays silent and doesn’t look at her.
Wife: “Don’t you even feel sad for me that I have to sit here while you have
all the fun?”
Husband: “You’re the one who wanted to come for the weekend. (Blames)
What do you want me to do?” (He stomps out the door.)
Although Gottman’s research has been with couples, everyone experiences these feelings
when they are relating to those who use criticism, contempt, defensiveness, or stonewalling. These patterns can be found in other relationships such as parent/child, employer/employee, friend/friend, teacher/student, and therapist/client. They lead to people feeling
shamed and feeling controlled by others.
Although Gottman’s research has been with couples, everyone experiences these feelings
when they are relating to those who use criticism, contempt, defensiveness, or stonewalling. These patterns can be found in other relationships such as parent/child, employer/employee, friend/friend, teacher/student, and therapist/client. They lead to people feeling
shamed and feeling controlled by others.
WHEN CLIENTS ASK WHAT THE THERAPIST
THINKS OR FEELS
WHEN CLIENTS ASK WHAT THE THERAPIST
THINKS OR FEELS
Occasionally, clients ask what I think or feel about something we have been talking about.
I am willing to respond to them, but I often find it helpful to ascertain why they are asking.
I usually ask one of the following questions:
• I am wondering why you asked that?
• I am curious why you ask?
• Tell me where you are coming from around this?
• I am curious how it might be helpful for you to know my thoughts or feelings?
Occasionally, clients ask what I think or feel about something we have been talking about.
I am willing to respond to them, but I often find it helpful to ascertain why they are asking.
I usually ask one of the following questions:
• I am wondering why you asked that?
• I am curious why you ask?
• Tell me where you are coming from around this?
• I am curious how it might be helpful for you to know my thoughts or feelings?
Asking one or more of these questions allows me to get clarity regarding what clients really
want. As it seems appropriate, I may respond with my own thoughts and feelings but often
address the client’s feelings instead. On occasion, therapists experience anxiety in response
to their clients’ questions. Getting clarity will normally increase the therapist’s safety level.
Clients generally experience a greater level of safety when they are invited to express their
thoughts or feelings.
Asking one or more of these questions allows me to get clarity regarding what clients really
want. As it seems appropriate, I may respond with my own thoughts and feelings but often
address the client’s feelings instead. On occasion, therapists experience anxiety in response
to their clients’ questions. Getting clarity will normally increase the therapist’s safety level.
Clients generally experience a greater level of safety when they are invited to express their
thoughts or feelings.
FREQUENT CHECKING WITH CLIENTS IN
SESSION
FREQUENT CHECKING WITH CLIENTS IN
SESSION
As it is appropriate I may check in with clients in our sessions together. Questions that
might be asked are:
• What are you feeling?
• What just happened?
• What are you feeling right now?
• How did it feel when I said that?
As it is appropriate I may check in with clients in our sessions together. Questions that
might be asked are:
• What are you feeling?
• What just happened?
• What are you feeling right now?
• How did it feel when I said that?
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• What did that mean to you?
• What did you hear me say?
• What did that mean to you?
• What did you hear me say?
The message the therapist intended to convey can be very different than the message the
client received. It is always important to look for those nonverbal cues that will indicate a
need to check in with what clients are feeling and/or processing. (See Safety Issues Between
the Client and Therapist, Chapter 3).
The message the therapist intended to convey can be very different than the message the
client received. It is always important to look for those nonverbal cues that will indicate a
need to check in with what clients are feeling and/or processing. (See Safety Issues Between
the Client and Therapist, Chapter 3).
I tell clients that when I reflect a feeling or make an interpretation, I may get it wrong. If I
am incorrect or even partially off the mark, I want them to tell me. I want to hear them as
accurately as possible. For clients who have not had people in their lives who seemed to
care if they heard correctly, their tendency may be to say nothing. Therefore, I check to see
if I understood them:
• Is this what you were saying?
• Did I get it right?
I tell clients that when I reflect a feeling or make an interpretation, I may get it wrong. If I
am incorrect or even partially off the mark, I want them to tell me. I want to hear them as
accurately as possible. For clients who have not had people in their lives who seemed to
care if they heard correctly, their tendency may be to say nothing. Therefore, I check to see
if I understood them:
• Is this what you were saying?
• Did I get it right?
It is important for the therapist to be assessing the congruence between expressed feelings
and inflection, volume, facial expression, body posture, etc.
It is important for the therapist to be assessing the congruence between expressed feelings
and inflection, volume, facial expression, body posture, etc.
Example
Example
A therapist said to his client, “I’m aware that you're expressing a lot of anger and yet you're smiling. Are you aware that you are smiling? I’m curious.
What is that about?”
A therapist said to his client, “I’m aware that you're expressing a lot of anger and yet you're smiling. Are you aware that you are smiling? I’m curious.
What is that about?”
Then he explored the meaning with his client. He was careful not to make
an interpretation.
Then he explored the meaning with his client. He was careful not to make
an interpretation.
Example
Example
The therapist became aware that a client was angry with her significant other who was sitting beside her. Rather than express that anger, the client
started to get sleepy and began to yawn. The therapist said to her, “I am
sensing that you started feeling angry a few moments ago. Is that correct?
I am noticing that as you got angry, you seemed to get very sleepy and started yawning. Are you aware that you did that? What do you think that is
about?”
The therapist became aware that a client was angry with her significant other who was sitting beside her. Rather than express that anger, the client
started to get sleepy and began to yawn. The therapist said to her, “I am
sensing that you started feeling angry a few moments ago. Is that correct?
I am noticing that as you got angry, you seemed to get very sleepy and started yawning. Are you aware that you did that? What do you think that is
about?”
HOW THERAPISTS MAY BLOCK THEMSELVES
FROM DEALING WITH CLIENTS’ FEELINGS
HOW THERAPISTS MAY BLOCK THEMSELVES
FROM DEALING WITH CLIENTS’ FEELINGS
There are a number of reasons that therapists might keep themselves from responding to a
client’s feelings. Getting ongoing supervision, personal therapy, and the support of colleagues are all methods that provide therapists support when they are blocked. Several ways
therapists may block themselves are discussed in the following sections.
There are a number of reasons that therapists might keep themselves from responding to a
client’s feelings. Getting ongoing supervision, personal therapy, and the support of colleagues are all methods that provide therapists support when they are blocked. Several ways
therapists may block themselves are discussed in the following sections.
NEED FOR THERAPISTS TO IDENTIFY OWN FEELINGS
NEED FOR THERAPISTS TO IDENTIFY OWN FEELINGS
It is important for therapists to be able to identify their own feelings and use that knowledge
in session with their clients. When therapists are not able to identify and access their own
feelings, they cannot use this knowledge to increase the safety level both in their clients and
in the therapeutic relationship.
It is important for therapists to be able to identify their own feelings and use that knowledge
in session with their clients. When therapists are not able to identify and access their own
feelings, they cannot use this knowledge to increase the safety level both in their clients and
in the therapeutic relationship.
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Example
Example
The client was talking about something that was very sad without showing
any affect. The therapist became aware of feeling a deep level of sadness.
The therapist said to the client, “I am aware that I am feeling a deep level
of sadness as you share with me. Tears are welling up in me. I am wondering
what you are feeling?”
The client was talking about something that was very sad without showing
any affect. The therapist became aware of feeling a deep level of sadness.
The therapist said to the client, “I am aware that I am feeling a deep level
of sadness as you share with me. Tears are welling up in me. I am wondering
what you are feeling?”
This may be the first time clients have experienced someone seeking out their feelings or
expressing honest emotion in response to what they have shared. To experience a therapist
feeling pain in response to what has been shared is often healing. A greater level of safety
gradually begins to develop internally and in the therapeutic process. It conveys to clients
the following kinds of things:
This may be the first time clients have experienced someone seeking out their feelings or
expressing honest emotion in response to what they have shared. To experience a therapist
feeling pain in response to what has been shared is often healing. A greater level of safety
gradually begins to develop internally and in the therapeutic process. It conveys to clients
the following kinds of things:
• It is okay to feel.
• It is okay to feel.
• Another person can feel in response to them.
• Another person can feel in response to them.
• Their feelings are okay and will not be punished.
• Their feelings are okay and will not be punished.
• It is okay to express their feelings.
• It is okay to express their feelings.
• They can learn to feel and express feelings.
• They can learn to feel and express feelings.
If the client cannot experience the affect, it gives the therapist a window into how feelings
were experienced and handled in the family system. (See History of Basic Feelings Questionnaire in Appendix B, this chapter.) How feelings were dealt with in the family system
can be explored in this session or in a subsequent session.
If the client cannot experience the affect, it gives the therapist a window into how feelings
were experienced and handled in the family system. (See History of Basic Feelings Questionnaire in Appendix B, this chapter.) How feelings were dealt with in the family system
can be explored in this session or in a subsequent session.
A NEED TO BE LIKED
A NEED TO BE LIKED
Therapists often have a need to be liked. Therapists need to explore and understand what
their motivations are for wanting to do this work. Sometimes therapists are not getting
enough love in the rest of their lives and can become dependent on strokes from their clients. Sometimes therapists do not keep their lives in balance and depend on clients to help
them feel good.
Therapists often have a need to be liked. Therapists need to explore and understand what
their motivations are for wanting to do this work. Sometimes therapists are not getting
enough love in the rest of their lives and can become dependent on strokes from their clients. Sometimes therapists do not keep their lives in balance and depend on clients to help
them feel good.
Example
Example
A therapist had a newly married daughter who was trying to bond with her
husband and establish a healthy relationship with him. The therapist felt a
separation loss. She missed the connection with her daughter that she had
before. Her husband was quite busy so there were unmet love needs in the
therapist’s life. She found herself disclosing too much about her personal
life to her clients. She also realized that when clients wanted to terminate,
she was reluctant to let them go.
A therapist had a newly married daughter who was trying to bond with her
husband and establish a healthy relationship with him. The therapist felt a
separation loss. She missed the connection with her daughter that she had
before. Her husband was quite busy so there were unmet love needs in the
therapist’s life. She found herself disclosing too much about her personal
life to her clients. She also realized that when clients wanted to terminate,
she was reluctant to let them go.
All therapists have countertransference issues that need to be explored in their own therapy.
Therapists are more likely to experience frustration when their attempts to access feelings
are met with anger or defensiveness on the part of the client. However, therapists must find
ways to work with the client’s defenses so that a healthy, safe therapeutic relationship can
be established.
All therapists have countertransference issues that need to be explored in their own therapy.
Therapists are more likely to experience frustration when their attempts to access feelings
are met with anger or defensiveness on the part of the client. However, therapists must find
ways to work with the client’s defenses so that a healthy, safe therapeutic relationship can
be established.
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A NEED TO TAKE CARE OF OTHERS
A NEED TO TAKE CARE OF OTHERS
Therapists often have a desire to take care of others. They may be attracted to this field by
an unrecognized need to rescue their caregivers from substance abuse, depression, an abusive relationship, or for other painful reasons. Sometimes therapists have grown up in
homes where they have been asked to prematurely take care of other family members, either siblings or parents. They have learned to focus on the needs and feelings of others and
ignore their own. In doing this they often lose touch with their own needs and feelings. In
doing therapy therapists’ own needs and countertransference issues place them in the familiar role of attempting to fix someone, which is impossible. As in childhood the therapist
will once again be faced with feeling inadequate or disappointed.
Therapists often have a desire to take care of others. They may be attracted to this field by
an unrecognized need to rescue their caregivers from substance abuse, depression, an abusive relationship, or for other painful reasons. Sometimes therapists have grown up in
homes where they have been asked to prematurely take care of other family members, either siblings or parents. They have learned to focus on the needs and feelings of others and
ignore their own. In doing this they often lose touch with their own needs and feelings. In
doing therapy therapists’ own needs and countertransference issues place them in the familiar role of attempting to fix someone, which is impossible. As in childhood the therapist
will once again be faced with feeling inadequate or disappointed.
One way of conceptualizing dysfunctional interactions is the Drama Triangle as defined in
Transactional Analysis (Stewart & Joines, 1987). There are three basic positions of Victim,
Rescuer, and Persecutor with each having its own thoughts, feelings, and behaviors. (Capital letters are used to clarify when a person is in the role of Rescuer, Persecutor, or Victim.)
The Rescuer tends to feel one up but guilty if they are not helping others. The Persecutor
often feels angry that others do not take responsibility for themselves and get it together.
The Victim feels helpless and hopeless, in a one down position, inviting rescuing or persecuting but unable to see that there is any hope for feeling better.
One way of conceptualizing dysfunctional interactions is the Drama Triangle as defined in
Transactional Analysis (Stewart & Joines, 1987). There are three basic positions of Victim,
Rescuer, and Persecutor with each having its own thoughts, feelings, and behaviors. (Capital letters are used to clarify when a person is in the role of Rescuer, Persecutor, or Victim.)
The Rescuer tends to feel one up but guilty if they are not helping others. The Persecutor
often feels angry that others do not take responsibility for themselves and get it together.
The Victim feels helpless and hopeless, in a one down position, inviting rescuing or persecuting but unable to see that there is any hope for feeling better.
When people are functioning as a Rescuer or Persecutor, the release of certain neurotransmitters gives an adrenalin rush. Conversely, there is a different set of neurotransmitters that
are released when a person is in a Victim position. When therapists are in the Victim role,
it may feel like their hands are tied behind their back, that they are helpless and overwhelmed, and that they cannot think or organize appropriate interventions for the client or
for effective self-care.
When people are functioning as a Rescuer or Persecutor, the release of certain neurotransmitters gives an adrenalin rush. Conversely, there is a different set of neurotransmitters that
are released when a person is in a Victim position. When therapists are in the Victim role,
it may feel like their hands are tied behind their back, that they are helpless and overwhelmed, and that they cannot think or organize appropriate interventions for the client or
for effective self-care.
When therapists Rescue their clients, they move from being a healthy provider to a Rescuer.
Rescuing is a perversion of providing. Rescuing discounts the others’ ability to think and
take care of themselves. When therapists are in the role of Rescuer, it protects them from
feeling like a Victim when clients do not take responsibility for taking care of themselves.
If therapists can do something to fix their clients, they do not feel so helpless themselves.
When therapists Rescue their clients, they move from being a healthy provider to a Rescuer.
Rescuing is a perversion of providing. Rescuing discounts the others’ ability to think and
take care of themselves. When therapists are in the role of Rescuer, it protects them from
feeling like a Victim when clients do not take responsibility for taking care of themselves.
If therapists can do something to fix their clients, they do not feel so helpless themselves.
Being helpless may bring up old terrifying feelings in the therapist. In fact clients may
choose to stay stuck even when alternatives are suggested or explored with them. This situation may make therapists feel frustrated or angry and make them want to persecute the
client. In order to avoid being persecuted, the therapist may avoid bringing up feelings that
would cause a client to be angry, disappointed, or frustrated with the therapist. When therapists are in the Victim role, the release of certain neurotransmitters can lead to a chemically depressive or anxious place. Conversely, when therapists are in a Rescuer or Persecutor
position, the neurotransmitters create an adrenal rush that will energize them, but they will
feel anxious as well. (Anxiety is one of the drivers of the Rescuer, Victim, Persecutor process.) The gift of getting caught in the Drama Triangle is that it gives a window into old and
often painful places for therapists. The nongift is that therapists may feel like they are reexperiencing feelings from childhood.
Being helpless may bring up old terrifying feelings in the therapist. In fact clients may
choose to stay stuck even when alternatives are suggested or explored with them. This situation may make therapists feel frustrated or angry and make them want to persecute the
client. In order to avoid being persecuted, the therapist may avoid bringing up feelings that
would cause a client to be angry, disappointed, or frustrated with the therapist. When therapists are in the Victim role, the release of certain neurotransmitters can lead to a chemically depressive or anxious place. Conversely, when therapists are in a Rescuer or Persecutor
position, the neurotransmitters create an adrenal rush that will energize them, but they will
feel anxious as well. (Anxiety is one of the drivers of the Rescuer, Victim, Persecutor process.) The gift of getting caught in the Drama Triangle is that it gives a window into old and
often painful places for therapists. The nongift is that therapists may feel like they are reexperiencing feelings from childhood.
Example
Example
A therapist worked with a client who, over time, was diagnosed with Dissociative Identity Disorder. The therapist did not empower the client to
care for herself thus creating too much dependency on the client’s part.
The therapist frequently made herself available to the client for crisis sessions during the week and weekends thus violating her own boundaries.
A therapist worked with a client who, over time, was diagnosed with Dissociative Identity Disorder. The therapist did not empower the client to
care for herself thus creating too much dependency on the client’s part.
The therapist frequently made herself available to the client for crisis sessions during the week and weekends thus violating her own boundaries.
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Example Continued
Example Continued
Because of the therapist’s own unresolved issues around being a Rescuer
in her family system, she tried to Rescue the client. She had tried as a child
to save her family and got caught up in trying to save her client. A miss on
the therapist’s part replicated the abandonment in the client’s childhood.
The client felt shaken and scared by the therapist’s unavailability. Due to
her own enmeshment, the therapist could not keep from becoming defensive and was unable to work through the pain with the client. The therapist
became the Victim, and the client became the Persecutor and angrily terminated therapy.
Because of the therapist’s own unresolved issues around being a Rescuer
in her family system, she tried to Rescue the client. She had tried as a child
to save her family and got caught up in trying to save her client. A miss on
the therapist’s part replicated the abandonment in the client’s childhood.
The client felt shaken and scared by the therapist’s unavailability. Due to
her own enmeshment, the therapist could not keep from becoming defensive and was unable to work through the pain with the client. The therapist
became the Victim, and the client became the Persecutor and angrily terminated therapy.
Example
Example
A therapist had been licensed for about 2 years. In his first years as a therapist, he got anxious at his inability to get clients unstuck or assist them in
making healthy decisions (Victim). He usually moved into the Rescuer position and tried in some way to fix them, which did not usually work. In his
anxious state, his body became hyperaroused which made him less able to
be present to their stuckness. He felt as though there was something
wrong with him or his abilities as a therapist to help his clients. He usually
got a bad headache. Over time with lots of good supervision and personal
therapy, he learned that whenever he moved into Rescuer, he ended up
trying to save his clients just like he had tried to save his family. He learned
to calm his own anxiety which helped him stay out of Victim. Then, he
could be empathically present to clients and allow them to be in the Victim
position, if necessary, and stay centered himself.
A therapist had been licensed for about 2 years. In his first years as a therapist, he got anxious at his inability to get clients unstuck or assist them in
making healthy decisions (Victim). He usually moved into the Rescuer position and tried in some way to fix them, which did not usually work. In his
anxious state, his body became hyperaroused which made him less able to
be present to their stuckness. He felt as though there was something
wrong with him or his abilities as a therapist to help his clients. He usually
got a bad headache. Over time with lots of good supervision and personal
therapy, he learned that whenever he moved into Rescuer, he ended up
trying to save his clients just like he had tried to save his family. He learned
to calm his own anxiety which helped him stay out of Victim. Then, he
could be empathically present to clients and allow them to be in the Victim
position, if necessary, and stay centered himself.
Note: For further information on the Drama Triangle for yourself or in order to teach the concept to your clients, see How Clients Get Tangled in Relationships, Chapter 6.
Note: For further information on the Drama Triangle for yourself or in order to teach the concept to your clients, see How Clients Get Tangled in Relationships, Chapter 6.
FEELING RESPONSIBLE FOR CAUSING OR TAKING AWAY THE
PAIN
FEELING RESPONSIBLE FOR CAUSING OR TAKING AWAY THE
PAIN
Therapists may take too much responsibility for causing clients pain and feeling like they
must resolve it. Doing this assumes that therapists are in a one up position, and clients are
in a one down position. Naomi Remen recently stated in a workshop that whenever we try
to help, it implies that the other person is helpless; whenever we try to fix, it implies the
other person is broken. Therapists usually feel inadequate when they take on too much responsibility for their clients’ feelings and believe that it is their responsibility to resolve clients’ problems.
Therapists may take too much responsibility for causing clients pain and feeling like they
must resolve it. Doing this assumes that therapists are in a one up position, and clients are
in a one down position. Naomi Remen recently stated in a workshop that whenever we try
to help, it implies that the other person is helpless; whenever we try to fix, it implies the
other person is broken. Therapists usually feel inadequate when they take on too much responsibility for their clients’ feelings and believe that it is their responsibility to resolve clients’ problems.
Sometimes it may feel that recognizing and labeling a feeling creates or causes the feeling.
It is helpful for therapists to remember that clients come to therapy in pain. Whatever pain
brought the client to therapy may be triggered by verbal or nonverbal responses offered by
the therapist. Clients become empowered when the therapist can be empathic and validate
their feelings.
Sometimes it may feel that recognizing and labeling a feeling creates or causes the feeling.
It is helpful for therapists to remember that clients come to therapy in pain. Whatever pain
brought the client to therapy may be triggered by verbal or nonverbal responses offered by
the therapist. Clients become empowered when the therapist can be empathic and validate
their feelings.
When therapists take too much responsibility for clients’ feelings and/or get caught in their
own conflicting feelings, they may do the following things to avoid the painful feelings clients express:
When therapists take too much responsibility for clients’ feelings and/or get caught in their
own conflicting feelings, they may do the following things to avoid the painful feelings clients express:
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• become silent and shut down emotionally
• distance themselves from the client
• interpret the meaning of a feeling
• try to dissuade clients from feeling their feelings
• rescue the client and thus move into a one up position
• criticize or judge the client’s feelings
• tell the client what to do
• tell the client that everything will be okay
• change the subject when the therapist gets anxious
• self-disclose inappropriately
• over-identify with the client
• fail to set aside their own feelings or interests
Note: All of the ways mentioned above tend to move clients away from their feelings.
There can be no safety for clients when therapists respond in ways that distance themselves from or control clients. It is the role of the therapist to provide a safe, caring environment where clients are encouraged to express their feelings and where those feelings are
affirmed.
• become silent and shut down emotionally
• distance themselves from the client
• interpret the meaning of a feeling
• try to dissuade clients from feeling their feelings
• rescue the client and thus move into a one up position
• criticize or judge the client’s feelings
• tell the client what to do
• tell the client that everything will be okay
• change the subject when the therapist gets anxious
• self-disclose inappropriately
• over-identify with the client
• fail to set aside their own feelings or interests
Note: All of the ways mentioned above tend to move clients away from their feelings.
There can be no safety for clients when therapists respond in ways that distance themselves from or control clients. It is the role of the therapist to provide a safe, caring environment where clients are encouraged to express their feelings and where those feelings are
affirmed.
Example
Example
A therapist who worked with cancer patients noticed that there was often
an unexpressed fear of dying. Usually, the clients would not voice it in the
room unless she was willing to acknowledge their fear of dying. At a time
that seemed appropriate in their work together, she would ask them if they
had thought about the possibility that they might die. This question opened
up pain for both of them as she grew to care deeply for the cancer patients
that she worked with in her clientele.
A therapist who worked with cancer patients noticed that there was often
an unexpressed fear of dying. Usually, the clients would not voice it in the
room unless she was willing to acknowledge their fear of dying. At a time
that seemed appropriate in their work together, she would ask them if they
had thought about the possibility that they might die. This question opened
up pain for both of them as she grew to care deeply for the cancer patients
that she worked with in her clientele.
In addressing the clients’ various emotions about the possibility that they
might die, the therapist created greater safety in the therapeutic relationship. The therapist conveyed that she could accept their feelings about dying as well as living. It allowed the clients to open the door to considering
the possibility of dying and begin to explore what that might mean for them
and their significant others. It also allowed them to reinvest in life in whatever ways seemed appropriate for them.
In addressing the clients’ various emotions about the possibility that they
might die, the therapist created greater safety in the therapeutic relationship. The therapist conveyed that she could accept their feelings about dying as well as living. It allowed the clients to open the door to considering
the possibility of dying and begin to explore what that might mean for them
and their significant others. It also allowed them to reinvest in life in whatever ways seemed appropriate for them.
There are several ways therapists can healthfully respond to their clients’ emotions:
• Therapists can help clients recognize and label what they feel and express it as much
as they possibly can.
• Therapists can respond empathically so that clients can experience their feelings in
the presence of someone who cares rather than doing it alone.
• Therapists can help clients understand what they feel and make sense of why they
are experiencing these feelings at this time.
There are several ways therapists can healthfully respond to their clients’ emotions:
• Therapists can help clients recognize and label what they feel and express it as much
as they possibly can.
• Therapists can respond empathically so that clients can experience their feelings in
the presence of someone who cares rather than doing it alone.
• Therapists can help clients understand what they feel and make sense of why they
are experiencing these feelings at this time.
Therapists are much more likely to respond effectively to their clients’ emotions when they
do not take responsibility for causing or changing their clients’ feelings.
Therapists are much more likely to respond effectively to their clients’ emotions when they
do not take responsibility for causing or changing their clients’ feelings.
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RULES LEARNED ABOUT FEELINGS IN THE FAMILY SYSTEM
OR CULTURE
RULES LEARNED ABOUT FEELINGS IN THE FAMILY SYSTEM
OR CULTURE
Therapists may be unable to respond to particular feelings expressed because of rules
learned about feelings in their own family system or culture. It is very important for therapists to carefully explore how feelings were dealt with in their family system. (See History
of Basic Feelings Questionnaire in Appendix B, this chapter.)
Therapists may be unable to respond to particular feelings expressed because of rules
learned about feelings in their own family system or culture. It is very important for therapists to carefully explore how feelings were dealt with in their family system. (See History
of Basic Feelings Questionnaire in Appendix B, this chapter.)
Example
Example
A male therapist came out of a family system where the family did not deal
with anger. As a child, if he showed anger to the mother, she would respond with sad or hurt feelings. If the father saw this occurring, he would
tell the child to stop acting angry. If anger was expressed between the parents, the child would try to resolve the conflict between them. The child’s
job was to keep a sense of calmness in the family. A client expressed anger
to the therapist and blamed him for making her feel bad. Because of his
history, the therapist felt uncomfortable with the client’s anger and attempted to reassure her that she would feel better if she kept working on
the difficult feelings. The therapist felt very anxious about being criticized.
A male therapist came out of a family system where the family did not deal
with anger. As a child, if he showed anger to the mother, she would respond with sad or hurt feelings. If the father saw this occurring, he would
tell the child to stop acting angry. If anger was expressed between the parents, the child would try to resolve the conflict between them. The child’s
job was to keep a sense of calmness in the family. A client expressed anger
to the therapist and blamed him for making her feel bad. Because of his
history, the therapist felt uncomfortable with the client’s anger and attempted to reassure her that she would feel better if she kept working on
the difficult feelings. The therapist felt very anxious about being criticized.
The therapist needed to allow the client to feel angry and disappointed and
then process the anger with her. Also, it was important for the therapist to
understand how his response to his client was a direct result of the role he
had played in his family system.
The therapist needed to allow the client to feel angry and disappointed and
then process the anger with her. Also, it was important for the therapist to
understand how his response to his client was a direct result of the role he
had played in his family system.
When therapists are unable to respond to a particular feeling that a client is experiencing,
therapy as a healing process will often stop. Personal therapy provides a safe place for therapists to understand and make new decisions about how feelings were dealt with in their
family system.
When therapists are unable to respond to a particular feeling that a client is experiencing,
therapy as a healing process will often stop. Personal therapy provides a safe place for therapists to understand and make new decisions about how feelings were dealt with in their
family system.
PROBLEMS THAT EXIST IN THE THERAPIST’S LIFE
PROBLEMS THAT EXIST IN THE THERAPIST’S LIFE
Therapists might block clients’ feelings because of problems that are going on in the therapist’s life such as marital conflict, life-threatening illness, parenting problems, loss of a
spouse, or other reasons. It may be more difficult for a therapist to allow clients to experience a full range of their emotions.
Therapists might block clients’ feelings because of problems that are going on in the therapist’s life such as marital conflict, life-threatening illness, parenting problems, loss of a
spouse, or other reasons. It may be more difficult for a therapist to allow clients to experience a full range of their emotions.
Example
Example
A therapist’s husband was diagnosed with cancer. Her future relationship
with him no longer felt totally secure. She found that couple work evoked
anger in her when the couples were not willing to work hard at making the
changes to have a healthy relationship. She stopped taking couples and
got careful supervision on the ones she was still seeing to be sure that she
was keeping her own concerns out of the process. She also explored her
anger, fear, and sadness in her personal therapy.
A therapist’s husband was diagnosed with cancer. Her future relationship
with him no longer felt totally secure. She found that couple work evoked
anger in her when the couples were not willing to work hard at making the
changes to have a healthy relationship. She stopped taking couples and
got careful supervision on the ones she was still seeing to be sure that she
was keeping her own concerns out of the process. She also explored her
anger, fear, and sadness in her personal therapy.
When therapists fail to identify clients’ emotions, move away from them, or become too
invested in clients’ choices, their own countertransference issues are being brought out.
When therapists fail to identify clients’ emotions, move away from them, or become too
invested in clients’ choices, their own countertransference issues are being brought out.
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EXERCISES FOR IDENTIFYING FEELINGS
EXERCISES FOR IDENTIFYING FEELINGS
TEACHING THE BASIC FEELINGS
TEACHING THE BASIC FEELINGS
Learning to identify basic feelings is very helpful for building safety in the therapeutic relationship. Clients gradually learn to check in with what they feel. They are able to use this
knowledge of their feelings in relationships with significant others, friends, and in work settings. They begin to trust their feelings, which allows them to set healthy boundaries for
themselves. An important part of the work with clients who have been abused is to identify
and trust their feelings. Once clients understand what they feel, they can begin to figure out
what their needs are in relation to their feelings. They may choose to ask themselves the
following kinds of questions regarding their needs:
• Can I get this particular need met from someone in my life?
• If not, how can I meet that need myself?
• If I ask someone in my life to meet that need, am I able to handle that person’s unwillingness to give it to me?
Learning to identify basic feelings is very helpful for building safety in the therapeutic relationship. Clients gradually learn to check in with what they feel. They are able to use this
knowledge of their feelings in relationships with significant others, friends, and in work settings. They begin to trust their feelings, which allows them to set healthy boundaries for
themselves. An important part of the work with clients who have been abused is to identify
and trust their feelings. Once clients understand what they feel, they can begin to figure out
what their needs are in relation to their feelings. They may choose to ask themselves the
following kinds of questions regarding their needs:
• Can I get this particular need met from someone in my life?
• If not, how can I meet that need myself?
• If I ask someone in my life to meet that need, am I able to handle that person’s unwillingness to give it to me?
I teach four basic feelings to all my clients. I usually begin to do this in the second session
unless further assessment (for depression, anxiety, PTSD, etc.) of the client is necessary. I
write the four basic feelings mad, sad, glad, and scared on a white board. I tell them these
are what I call the gut feelings. There are lots of other words for feelings that can be useful
like frustrated, confused, resentful, irritated, etc. When clients use these words, I invite
them to see which gut feeling they might be experiencing. Sometimes I just stay with the
words they have chosen. For example, when clients are experiencing irritation or resentment, they may really be feeling angry. When clients are experiencing confusion, they may
be feeling scared.
I teach four basic feelings to all my clients. I usually begin to do this in the second session
unless further assessment (for depression, anxiety, PTSD, etc.) of the client is necessary. I
write the four basic feelings mad, sad, glad, and scared on a white board. I tell them these
are what I call the gut feelings. There are lots of other words for feelings that can be useful
like frustrated, confused, resentful, irritated, etc. When clients use these words, I invite
them to see which gut feeling they might be experiencing. Sometimes I just stay with the
words they have chosen. For example, when clients are experiencing irritation or resentment, they may really be feeling angry. When clients are experiencing confusion, they may
be feeling scared.
In the initial phase of therapy I use a three-step sequential process over several sessions to
teach clients about their feelings. With high functioning clients, I may teach all three steps
initially. With lower functioning clients, I may teach only one step at a time. Clients who
are not aware of what they feel may need to work on only one step at a time.
In the initial phase of therapy I use a three-step sequential process over several sessions to
teach clients about their feelings. With high functioning clients, I may teach all three steps
initially. With lower functioning clients, I may teach only one step at a time. Clients who
are not aware of what they feel may need to work on only one step at a time.
Step 1
Usually in the early stages of therapy or soon thereafter, I teach the four basic feelings:
mad, sad, glad and scared.
• Several times a day I would like you to stop and check in with yourself.
• I want you to see if you can identify what you are feeling.
Step 1
Usually in the early stages of therapy or soon thereafter, I teach the four basic feelings:
mad, sad, glad and scared.
• Several times a day I would like you to stop and check in with yourself.
• I want you to see if you can identify what you are feeling.
Note: My goal is to have them become comfortable with identifying their feelings and
allowing themselves to feel them without any judgment or shaming of themselves.
Step 2
When clients are able to identify what they feel relatively easily, then I proceed with
the next step. I say these kinds of things to the client:
• When you have identified what you are feeling, I want you to stop and ask yourself
what you need in response to what you feel?
• Sometimes, the only need you may have is to feel the feelings and nothing else may
be required.
Note: My goal is to have them become comfortable with identifying their feelings and
allowing themselves to feel them without any judgment or shaming of themselves.
Step 2
When clients are able to identify what they feel relatively easily, then I proceed with
the next step. I say these kinds of things to the client:
• When you have identified what you are feeling, I want you to stop and ask yourself
what you need in response to what you feel?
• Sometimes, the only need you may have is to feel the feelings and nothing else may
be required.
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Note: Identifying what may be needed, if anything, may help the client create more safety
internally and in relationship.
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Note: Identifying what may be needed, if anything, may help the client create more safety
internally and in relationship.
Step 3
Sometimes, I move right into step three. However, it may be necessary for clients to
spend several sessions or more gaining confidence in their ability to identify their
needs. Once clients have gained some skill in identifying their feelings and needs, I
introduce the third step by saying something like the following:
Step 3
Sometimes, I move right into step three. However, it may be necessary for clients to
spend several sessions or more gaining confidence in their ability to identify their
needs. Once clients have gained some skill in identifying their feelings and needs, I
introduce the third step by saying something like the following:
• Can you get your need met by someone in your life?
• Can you get your need met by someone in your life?
• Do you need to give it to yourself?
• Do you need to give it to yourself?
If they ask for something from someone in their life, they have to be able to deal with
the possibility of rejection. I say to them the following kinds of things:
If they ask for something from someone in their life, they have to be able to deal with
the possibility of rejection. I say to them the following kinds of things:
• When you ask, you are taking a chance that you may be told “no.”
• When you ask, you are taking a chance that you may be told “no.”
• Being told “no” may feel like a rejection to you.
• Being told “no” may feel like a rejection to you.
• You may have to wait for what you want until the person is willing or able to give it
to you.
• You may have to wait for what you want until the person is willing or able to give it
to you.
• If the person is not willing or able to give what is being asked, can it be given at a
later time?
• If the person is not willing or able to give what is being asked, can it be given at a
later time?
• Can you accept a delay in getting your need met?
• Can you accept a delay in getting your need met?
• Can you negotiate a time in the future when the need can be met?
• Can you negotiate a time in the future when the need can be met?
ASKING DIRECTLY VS. INDIRECTLY AROUND FEELINGS AND
NEEDS
ASKING DIRECTLY VS. INDIRECTLY AROUND FEELINGS AND
NEEDS
Many clients need to learn how to ask directly for what they need. I teach this process to all
my clients just to be sure they understand the difference between asking directly and indirectly. Asking directly raises the level of risk, but it can provide clarity for both clients and
the person from whom they are making a request. Clients will gradually get clear whether
or not they can get their needs met with this person. Can they give themselves what they
need? Many clients with abuse in their background have a lot of difficulty soothing themselves around their feelings. (See Chapter 5.) I want to teach them to become both aware of
and comfortable with their feelings, their needs, and getting those needs met.
Many clients need to learn how to ask directly for what they need. I teach this process to all
my clients just to be sure they understand the difference between asking directly and indirectly. Asking directly raises the level of risk, but it can provide clarity for both clients and
the person from whom they are making a request. Clients will gradually get clear whether
or not they can get their needs met with this person. Can they give themselves what they
need? Many clients with abuse in their background have a lot of difficulty soothing themselves around their feelings. (See Chapter 5.) I want to teach them to become both aware of
and comfortable with their feelings, their needs, and getting those needs met.
Asking Directly
Asking Directly
Wife: “I would like you to take me to the movies tonight. I would like to
see Sixth Sense at 7:00 p.m. Would you take me?”
Husband: “I am too tired to take you tonight, but I would be willing to take
you on Friday. Would that be okay?”
Wife: “I can see that you are tired. Friday would be fine.”
Wife: “I would like you to take me to the movies tonight. I would like to
see Sixth Sense at 7:00 p.m. Would you take me?”
Husband: “I am too tired to take you tonight, but I would be willing to take
you on Friday. Would that be okay?”
Wife: “I can see that you are tired. Friday would be fine.”
The wife has asked directly and was told “no.” However, her husband was
willing to take her another time. The wife was able to accept that gratification would be delayed and still feel okay about herself and her husband.
The wife has asked directly and was told “no.” However, her husband was
willing to take her another time. The wife was able to accept that gratification would be delayed and still feel okay about herself and her husband.
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Asking Indirectly
Asking Indirectly
Wife: “What are you planning to do tonight?”
Husband: “I’m planning to read the paper.”
Wife: “Do you want to go to a movie?”
Husband: “Not particularly.”
Wife: “You never want to go anywhere I want to go.”
Wife: “What are you planning to do tonight?”
Husband: “I’m planning to read the paper.”
Wife: “Do you want to go to a movie?”
Husband: “Not particularly.”
Wife: “You never want to go anywhere I want to go.”
The wife walked away hurt and angry. However, she did not ask directly
for what she needed. She had not risked a great deal. Her husband did not
initially realize that she was telling him that she really wanted him to take
her to the movies. She felt rejected, and he felt angry.
The wife walked away hurt and angry. However, she did not ask directly
for what she needed. She had not risked a great deal. Her husband did not
initially realize that she was telling him that she really wanted him to take
her to the movies. She felt rejected, and he felt angry.
CHECKING IN WITH THE BODY TO ACCESS FEELINGS
CHECKING IN WITH THE BODY TO ACCESS FEELINGS
Often clients who have abuse and trauma in their background have learned to numb themselves or dissociate from their bodies. Abuse and trauma are frequently experienced as
physically intrusive (incest, rape, car accidents, assaults, surgeries, etc.), and there may be
a loss of bodily integrity. Conversely, increasing bodily integrity often helps to begin the
healing process. When trauma and abuse have occurred, healing usually needs to take place
at three different levels:
1. Clients need to be able to talk at an intellectual level about what happened to them.
Often they will not be able to access any affect or bodily feelings.
2. Clients need to be able to feel their feelings and express them at an emotional level.
3. Clients need to be able to feel any feelings or sensations that are stored at a bodily
level.
Often clients who have abuse and trauma in their background have learned to numb themselves or dissociate from their bodies. Abuse and trauma are frequently experienced as
physically intrusive (incest, rape, car accidents, assaults, surgeries, etc.), and there may be
a loss of bodily integrity. Conversely, increasing bodily integrity often helps to begin the
healing process. When trauma and abuse have occurred, healing usually needs to take place
at three different levels:
1. Clients need to be able to talk at an intellectual level about what happened to them.
Often they will not be able to access any affect or bodily feelings.
2. Clients need to be able to feel their feelings and express them at an emotional level.
3. Clients need to be able to feel any feelings or sensations that are stored at a bodily
level.
When trauma or abuse have been experienced at a bodily level, those feelings or sensations
that get reawakened in the healing process need to be felt and processed. For clients who
are out of touch with their feelings, it can sometimes be helpful to ask them the following
questions:
• What is happening in your body?
• What is happening in your body right now?
• Where do you feel it?
• How big is it?
• What shape is it?
• Is there a color to it?
• Does it have a voice?
• Are there sounds that it makes?
• If you gave it a voice, what would it say?
• How did it feel to have me ask these questions?
When trauma or abuse have been experienced at a bodily level, those feelings or sensations
that get reawakened in the healing process need to be felt and processed. For clients who
are out of touch with their feelings, it can sometimes be helpful to ask them the following
questions:
• What is happening in your body?
• What is happening in your body right now?
• Where do you feel it?
• How big is it?
• What shape is it?
• Is there a color to it?
• Does it have a voice?
• Are there sounds that it makes?
• If you gave it a voice, what would it say?
• How did it feel to have me ask these questions?
DRAWING AS A TOOL TO ACCESS FEELINGS
DRAWING AS A TOOL TO ACCESS FEELINGS
Drawing can be another tool for clients who have difficulty feeling or expressing their
Drawing can be another tool for clients who have difficulty feeling or expressing their
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feelings. I keep a decorated can with crayons, pencils, oil pastels, and felt-tips in it. I always
have a sketch pad available. I offer these art supplies to clients by saying something like the
following:
• I am wondering if you would feel comfortable trying to access your feelings by drawing them?
feelings. I keep a decorated can with crayons, pencils, oil pastels, and felt-tips in it. I always
have a sketch pad available. I offer these art supplies to clients by saying something like the
following:
• I am wondering if you would feel comfortable trying to access your feelings by drawing them?
If the answer is affirmative, then I say the following as a way of giving permission to draw
in their own way:
If the answer is affirmative, then I say the following as a way of giving permission to draw
in their own way:
I am not looking for great art. I am looking for an expression of your feelings. You can use stick figures if you wish. You can draw symbolically or literally what you want to express. It’s okay to break the crayons or pastels as
you wish. (If clients are expressing a lot of anger, then crayons may break.)
I am not looking for great art. I am looking for an expression of your feelings. You can use stick figures if you wish. You can draw symbolically or literally what you want to express. It’s okay to break the crayons or pastels as
you wish. (If clients are expressing a lot of anger, then crayons may break.)
Some clients use this medium a great deal while others never seem to feel comfortable expressing their feelings in this manner. I might say the following kinds of things to the client:
• I would like you to draw what you are feeling. Would you be willing to do that?
• I would like you to draw what you are feeling in your body? Would you be willing
to do that?
• Be aware as you draw what you are feeling inside.
• Try using your nondominant hand to draw what you are feeling.
Some clients use this medium a great deal while others never seem to feel comfortable expressing their feelings in this manner. I might say the following kinds of things to the client:
• I would like you to draw what you are feeling. Would you be willing to do that?
• I would like you to draw what you are feeling in your body? Would you be willing
to do that?
• Be aware as you draw what you are feeling inside.
• Try using your nondominant hand to draw what you are feeling.
When they have finished their drawing, I may ask or say any of the following as a way of
accessing feelings:
• What were you feeling in your body as you made this drawing?
• Tell me about your drawing.
• What does this... represent?
• What is the meaning of this?
• Tell me about this....
• What does this color represent for you?
• What feelings are coming up for you?
• Are there any sounds coming from this drawing?
• If you gave this drawing a name, what would it be?
• I would like you to write that name on your drawing?
• Tell me about the name you chose.
• I would like you to date it. Sometimes it is helpful to be able to look back where you
were at this point in time. Dating it will allow you to do that.
• How does it feel to share this drawing with me?
When they have finished their drawing, I may ask or say any of the following as a way of
accessing feelings:
• What were you feeling in your body as you made this drawing?
• Tell me about your drawing.
• What does this... represent?
• What is the meaning of this?
• Tell me about this....
• What does this color represent for you?
• What feelings are coming up for you?
• Are there any sounds coming from this drawing?
• If you gave this drawing a name, what would it be?
• I would like you to write that name on your drawing?
• Tell me about the name you chose.
• I would like you to date it. Sometimes it is helpful to be able to look back where you
were at this point in time. Dating it will allow you to do that.
• How does it feel to share this drawing with me?
• Are there any new insights from having done this exercise?
• Are there any good feelings? Bad feelings?
• Would you like to take this drawing with you, or would you like me to keep it in your
file? (If clients choose to take their drawings, I suggest that they keep it in a folder or
notebook designated for their healing work.)
• Are there any new insights from having done this exercise?
• Are there any good feelings? Bad feelings?
• Would you like to take this drawing with you, or would you like me to keep it in your
file? (If clients choose to take their drawings, I suggest that they keep it in a folder or
notebook designated for their healing work.)
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HISTORY OF BASIC FEELINGS
HISTORY OF BASIC FEELINGS
Note: I recommend that therapists do this exercise around feelings before using it with their
clients. It is helpful for therapists to think about how feelings were handled in their own family
system before exploring this issue with their clients.
Note: I recommend that therapists do this exercise around feelings before using it with their
clients. It is helpful for therapists to think about how feelings were handled in their own family
system before exploring this issue with their clients.
The History of Basic Feelings Questionnaire (Appendix B, this Chapter) can be done with
individuals or couples. Therapists can verbally ask these questions of their clients and then
process their answers with them. Much can be learned from experiencing their affect as
they respond to these questions. This exercise could be sent home with clients and then discussed in the next session. It could be given to clients to complete in session and then discussed. It allows therapists to do a piece of family of origin work with their clients. Both
the therapist and client begin to understand that there is a parallel between how feelings
were dealt with in the family and how the client is dealing with feelings now. Gaining this
understanding usually increases the safety level of clients. The therapist has conveyed to
the client not only that feelings are important, but also that understanding how those feelings originated is important.
The History of Basic Feelings Questionnaire (Appendix B, this Chapter) can be done with
individuals or couples. Therapists can verbally ask these questions of their clients and then
process their answers with them. Much can be learned from experiencing their affect as
they respond to these questions. This exercise could be sent home with clients and then discussed in the next session. It could be given to clients to complete in session and then discussed. It allows therapists to do a piece of family of origin work with their clients. Both
the therapist and client begin to understand that there is a parallel between how feelings
were dealt with in the family and how the client is dealing with feelings now. Gaining this
understanding usually increases the safety level of clients. The therapist has conveyed to
the client not only that feelings are important, but also that understanding how those feelings originated is important.
Usually, the feeling that was easiest for the family to deal with is easiest for the client to
deal with. As a rule, the feeling that was most difficult for the family to deal with is most
difficult for the client as well. It is helpful to remember that clients may struggle with more
than one uncomfortable feeling. Occasionally, clients’ beliefs will have some variance
from the family script. That variance should be carefully explored to be sure it really fits.
When working with couples, it is helpful to walk through this process individually with the
other present. This allows the therapist to explore how each partner plays off the other with
the easiest and most difficult feelings. It is a very valuable exercise for clients to see how
they are playing out their family of origin scripts or patterns.
Usually, the feeling that was easiest for the family to deal with is easiest for the client to
deal with. As a rule, the feeling that was most difficult for the family to deal with is most
difficult for the client as well. It is helpful to remember that clients may struggle with more
than one uncomfortable feeling. Occasionally, clients’ beliefs will have some variance
from the family script. That variance should be carefully explored to be sure it really fits.
When working with couples, it is helpful to walk through this process individually with the
other present. This allows the therapist to explore how each partner plays off the other with
the easiest and most difficult feelings. It is a very valuable exercise for clients to see how
they are playing out their family of origin scripts or patterns.
REFERENCES
REFERENCES
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from the Breakthrough Research to Make Your Marriage Last. New York: Simon
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Jordan, J. V., & Dooley, C. (2001). Relational Practice in Action: A Group Manual.
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Jordan, J. V., & Dooley, C. (2001). Relational Practice in Action: A Group Manual.
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RECOMMENDED RESOURCES
RECOMMENDED RESOURCES
This section includes: feelings, shame, and Transactional Analysis
This section includes: feelings, shame, and Transactional Analysis
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Black, C. (1995). Repeat After Me (2nd ed.). Bainbridge Island, WA: MAC Publishing.
Black, C. (1995). Repeat After Me (2nd ed.). Bainbridge Island, WA: MAC Publishing.
Bradshaw, J., (1988). Healing the Shame That Binds You. Deerfield Beach, FL: Health
Communications, Inc.
Bradshaw, J., (1988). Healing the Shame That Binds You. Deerfield Beach, FL: Health
Communications, Inc.
Fosha, D. (2000). The Transforming Power of Affect: A Model for Accelerated Change.
New York: Basic Books.
Fosha, D. (2000). The Transforming Power of Affect: A Model for Accelerated Change.
New York: Basic Books.
Gottman, J., with Silver, N. (1999). The Seven Principles for Making Marriage Work.
New York: Three Rivers Press.
Gottman, J., with Silver, N. (1999). The Seven Principles for Making Marriage Work.
New York: Three Rivers Press.
James, M., & Jongeward, D. (1996). Born to Win. Cambridge, MA: Perseus Books.
James, M., & Jongeward, D. (1996). Born to Win. Cambridge, MA: Perseus Books.
Jordan, J. (1991). Empathy, Mutuality and Therapeutic Change. In J. Jordan, A. Kaplan, J.
B. Miller, I. P. Stiver, & J. L. Surrey, (Eds.), Women’s Growth in Connection. New
York: Guilford Publications, Inc.
Jordan, J. (1991). Empathy, Mutuality and Therapeutic Change. In J. Jordan, A. Kaplan, J.
B. Miller, I. P. Stiver, & J. L. Surrey, (Eds.), Women’s Growth in Connection. New
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Karen, R. (1994). Becoming Attached: Unfolding the Mystery of the Infant-Mother Bond
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Karen, R. (1994). Becoming Attached: Unfolding the Mystery of the Infant-Mother Bond
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York: Basic Books.
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Chapter 4 Appendix A
Chapter 4 Appendix A
Recognizing and Responding
to Feelings of Shame and Guilt
Recognizing and Responding
to Feelings of Shame and Guilt
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Recognizing and Responding
to Feelings of Shame and Guilt
Recognizing and Responding
to Feelings of Shame and Guilt
Definitions of Shame and Guilt:
Shame - Feeling bad about who one is
Guilt - Feeling bad about what one has done
Definitions of Shame and Guilt:
Shame - Feeling bad about who one is
Guilt - Feeling bad about what one has done
Shame-related reactions very likely account for many failures in treatment, including pervasive resistance and premature termination of therapy. Resistance can be defined as the
unwillingness to make changes or accept feedback. Clients may experience a fearful feeling
of shame about who they are and how unacceptable they are when the therapist suggests
changes they might make in their life. This information can heighten the fear-shame process, as it may appear that the therapist is pointing out inadequacies and imperfections.
These shame-related reactions frequently are the result of therapists’ lack of awareness of
how they impact their clients. So when this shame-related reaction happens in treatment,
clients may find reasons not to come back. Being very sensitive to clients’ levels of safety
can help to address these reactions before they become intolerable.
Shame-related reactions very likely account for many failures in treatment, including pervasive resistance and premature termination of therapy. Resistance can be defined as the
unwillingness to make changes or accept feedback. Clients may experience a fearful feeling
of shame about who they are and how unacceptable they are when the therapist suggests
changes they might make in their life. This information can heighten the fear-shame process, as it may appear that the therapist is pointing out inadequacies and imperfections.
These shame-related reactions frequently are the result of therapists’ lack of awareness of
how they impact their clients. So when this shame-related reaction happens in treatment,
clients may find reasons not to come back. Being very sensitive to clients’ levels of safety
can help to address these reactions before they become intolerable.
Feelings of shame or guilt influence our self-esteem and how we function. A shame-prone
person tends to be very self-focused, and this impedes sensitivity to what is really happening with others. A guilt-prone person who focuses on specific behaviors that may need to
be changed tends to be more other-oriented and makes more empathic connections. The
painful global self-focus that feelings of shame can create may lead to a range of difficulties
including problems in interpersonal behavior and functioning. Shamed people are not only
prone to anger, but are also inclined to express their anger in nonconstructive ways. Guilt
can motivate people to accept responsibility and may inhibit interpersonal anger and hostility. Shame-proneness can also lead to a depressive way of looking at the world.
Feelings of shame or guilt influence our self-esteem and how we function. A shame-prone
person tends to be very self-focused, and this impedes sensitivity to what is really happening with others. A guilt-prone person who focuses on specific behaviors that may need to
be changed tends to be more other-oriented and makes more empathic connections. The
painful global self-focus that feelings of shame can create may lead to a range of difficulties
including problems in interpersonal behavior and functioning. Shamed people are not only
prone to anger, but are also inclined to express their anger in nonconstructive ways. Guilt
can motivate people to accept responsibility and may inhibit interpersonal anger and hostility. Shame-proneness can also lead to a depressive way of looking at the world.
Jordan and Dooley (2001) from The Stone Center at Wellesley College propose a relational
model that focuses on connection and disconnection in relationships. In Relational Practice
in Action, these authors state that when people experience shame they do not see themselves as deserving of love or understanding from another. They feel a need for connection
but will frequently be immobilized by that need. When people are shamed, they tend to
withdraw and isolate rather than reach out for connection. Ironically enough, when people
share or connect with another in a safe relationship, they can begin to let shame go. An important part of the therapeutic process is helping clients to touch their shame and empower
them to make new decisions about themselves.
Jordan and Dooley (2001) from The Stone Center at Wellesley College propose a relational
model that focuses on connection and disconnection in relationships. In Relational Practice
in Action, these authors state that when people experience shame they do not see themselves as deserving of love or understanding from another. They feel a need for connection
but will frequently be immobilized by that need. When people are shamed, they tend to
withdraw and isolate rather than reach out for connection. Ironically enough, when people
share or connect with another in a safe relationship, they can begin to let shame go. An important part of the therapeutic process is helping clients to touch their shame and empower
them to make new decisions about themselves.
Shame is used to socialize children. Children are shamed for being too clingy, for throwing
a tantrum, or for doing something that embarrasses their caretakers. Children may believe
if they do not conform to a set of rules, then they are not deserving of connection. Jordan
and Dooley (2001) also state that shame can be used to silence others. Those who are in
power may use it to silence the voice of those who are not in power by shaming them in
some way. In an attempt to silence the pain of having no voice, the shame may lead to various addictions which lead to further disconnection.
Shame is used to socialize children. Children are shamed for being too clingy, for throwing
a tantrum, or for doing something that embarrasses their caretakers. Children may believe
if they do not conform to a set of rules, then they are not deserving of connection. Jordan
and Dooley (2001) also state that shame can be used to silence others. Those who are in
power may use it to silence the voice of those who are not in power by shaming them in
some way. In an attempt to silence the pain of having no voice, the shame may lead to various addictions which lead to further disconnection.
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RECOGNIZING SHAME IN THERAPY
RECOGNIZING SHAME IN THERAPY
Coming into therapy can be in and of itself a shaming experience. There may be an undercurrent of shame in every session as clients share the most intimate details about themselves. Therapists empower their clients to be themselves by helping them to identify their
own shame and understand how they defend against it to protect themselves. Shame issues
can generate depression, anxiety, phobias, panic, or obsessive-compulsive behaviors. Some
recent research also links internalized shame with the effects of sexual abuse and the presence of eating disorders.
Coming into therapy can be in and of itself a shaming experience. There may be an undercurrent of shame in every session as clients share the most intimate details about themselves. Therapists empower their clients to be themselves by helping them to identify their
own shame and understand how they defend against it to protect themselves. Shame issues
can generate depression, anxiety, phobias, panic, or obsessive-compulsive behaviors. Some
recent research also links internalized shame with the effects of sexual abuse and the presence of eating disorders.
Indicators that clients are experiencing shame reactions vary as much as clients do. However, there are physiological clues tied to the experience of shame. These physiological
clues are:
• flushing of the face
• head hung
Indicators that clients are experiencing shame reactions vary as much as clients do. However, there are physiological clues tied to the experience of shame. These physiological
clues are:
• flushing of the face
• head hung
• momentary cognitive confusion
• downcast or averted eyes
• changes in skin tone of neck, chest, etc.
• lowered voice or becoming silent
• frozen facial expression
• momentary cognitive confusion
• downcast or averted eyes
• changes in skin tone of neck, chest, etc.
• lowered voice or becoming silent
• frozen facial expression
Clients may experience shame in response to a number of situations:
• when they feel a sense of rejection whether or not they are actually being rejected
• when they say something they decide is stupid or ridiculous
• when they want to be intimately connected to another person and that person is not
interested in intimacy
• when they want someone they respect, or who has authority, to recognize or approve
of them and instead get ignored, criticized, or devalued in some way
Clients may experience shame in response to a number of situations:
• when they feel a sense of rejection whether or not they are actually being rejected
• when they say something they decide is stupid or ridiculous
• when they want to be intimately connected to another person and that person is not
interested in intimacy
• when they want someone they respect, or who has authority, to recognize or approve
of them and instead get ignored, criticized, or devalued in some way
Donald L. Nathanson (1992), a well-known researcher concerning the issues of shame, proposes in his book Shame and Pride that beyond the physiological responses most people
will behave in one of four ways:
Donald L. Nathanson (1992), a well-known researcher concerning the issues of shame, proposes in his book Shame and Pride that beyond the physiological responses most people
will behave in one of four ways:
1. They may attack themselves (either physically or psychologically).
1. They may attack themselves (either physically or psychologically).
2. They may attack others (either physically or psychologically).
2. They may attack others (either physically or psychologically).
3. They may withdraw from contact (either with themselves or from others).
3. They may withdraw from contact (either with themselves or from others).
4. They may avoid the feelings of shame (particularly using distracting behaviors such as
excessive working, eating, drug abuse, etc. that are often seen as addictive).
4. They may avoid the feelings of shame (particularly using distracting behaviors such as
excessive working, eating, drug abuse, etc. that are often seen as addictive).
Although it is not usually the intention of therapists to shame their clients, shaming still occurs. If it appears that clients are feeling shamed, it is important to address this response as
soon as possible. Essentially, therapy has stopped due to clients’ feelings of shame. Empathic responses such as the following may be helpful:
• I’m wondering if you may feel like I was criticizing you.
• Can you tell me what just happened?
Although it is not usually the intention of therapists to shame their clients, shaming still occurs. If it appears that clients are feeling shamed, it is important to address this response as
soon as possible. Essentially, therapy has stopped due to clients’ feelings of shame. Empathic responses such as the following may be helpful:
• I’m wondering if you may feel like I was criticizing you.
• Can you tell me what just happened?
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• It looks like you are feeling badly.
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• It looks like you are feeling badly.
Frequently, clients do not recognize the feeling of shame until it has been labeled for them,
and their awareness of its presence has been heightened through these types of interventions. Differentiating shame from guilt may also be helpful, as many clients confuse the
two, and culturally, the words are often used interchangeably.
Frequently, clients do not recognize the feeling of shame until it has been labeled for them,
and their awareness of its presence has been heightened through these types of interventions. Differentiating shame from guilt may also be helpful, as many clients confuse the
two, and culturally, the words are often used interchangeably.
Kaufman (1980) states in Shame: The Power of Caring that “we are only vulnerable to the
experience of shame when we care about something” (p. 5). Caring about something makes
people vulnerable to experiencing shame. The experience of shame always manifests itself
in the context of relationship. Even when people experience shame at those moments of
aloneness, it is still experienced relative to another’s needs, thoughts, feelings, judgments,
values, rules, etc. or their own feelings of ineffectiveness as related to their self-expectations.
Kaufman (1980) states in Shame: The Power of Caring that “we are only vulnerable to the
experience of shame when we care about something” (p. 5). Caring about something makes
people vulnerable to experiencing shame. The experience of shame always manifests itself
in the context of relationship. Even when people experience shame at those moments of
aloneness, it is still experienced relative to another’s needs, thoughts, feelings, judgments,
values, rules, etc. or their own feelings of ineffectiveness as related to their self-expectations.
“People are ashamed of being ashamed,” notes Thomas Scheff as cited by Karen (1992) in
his article, Shame, in The Atlantic Monthly. “So we don’t talk about it (shame), we don’t
express it, we don’t acknowledge it. We say we’re uncomfortable, or ‘It was an awkward
moment’- these are code words for shame” (p. 49). Thus, each person is left with a sense
that no one else has ever had this particular shameful experience.
“People are ashamed of being ashamed,” notes Thomas Scheff as cited by Karen (1992) in
his article, Shame, in The Atlantic Monthly. “So we don’t talk about it (shame), we don’t
express it, we don’t acknowledge it. We say we’re uncomfortable, or ‘It was an awkward
moment’- these are code words for shame” (p. 49). Thus, each person is left with a sense
that no one else has ever had this particular shameful experience.
Shame almost always seems to be decreased by air-time or having the chance to share what
has happened and how one is feeling. In that shame tends to make people feel like they are
no longer a part of the human race, giving it a name and talking about the experience is one
of the effective ways of recovering a sense of self. Remembering that shame is about who
one is and not what one has done is important at this point. Clients may even experience
both shame and guilt about the same event.
Shame almost always seems to be decreased by air-time or having the chance to share what
has happened and how one is feeling. In that shame tends to make people feel like they are
no longer a part of the human race, giving it a name and talking about the experience is one
of the effective ways of recovering a sense of self. Remembering that shame is about who
one is and not what one has done is important at this point. Clients may even experience
both shame and guilt about the same event.
Example
Example
A male client failed to tell the salesperson that he was not charged for a
particular item of significant value. The client may feel guilt about not reporting the oversight and also shame that he is the kind of person who
did not say anything.
A male client failed to tell the salesperson that he was not charged for a
particular item of significant value. The client may feel guilt about not reporting the oversight and also shame that he is the kind of person who
did not say anything.
Discussing shame and guilt needs to be part of the conversation with the client. Just proposing that the client return the item or report the oversight will not address the feelings of
shame nor will the sharing of the shameful feelings necessarily remove the feelings of guilt
about the behavior.
Discussing shame and guilt needs to be part of the conversation with the client. Just proposing that the client return the item or report the oversight will not address the feelings of
shame nor will the sharing of the shameful feelings necessarily remove the feelings of guilt
about the behavior.
The following shame-filled beliefs are frequently found in clients:
• I am humiliated.
• I am unattractive.
• I am dumb.
• I am incompetent.
• I am helpless.
• I am impotent.
• I am unmanly.
• I am unfeminine.
• I am phony.
• I am ignorant.
• I am boring.
• I am insignificant.
• I am immature.
• I am unlovable.
• I am weak.
• I am needy.
The following shame-filled beliefs are frequently found in clients:
• I am humiliated.
• I am unattractive.
• I am dumb.
• I am incompetent.
• I am helpless.
• I am impotent.
• I am unmanly.
• I am unfeminine.
• I am phony.
• I am ignorant.
• I am boring.
• I am insignificant.
• I am immature.
• I am unlovable.
• I am weak.
• I am needy.
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THE THERAPIST AND SHAME
THE THERAPIST AND SHAME
Shame-based clients need to be able to fully reexperience (touch, feel, and ultimately make
new decisions about) their shame. If therapists stay emotionally distant and do not allow
themselves to be known and vulnerable, then they replay the original trauma. Clients’ feelings of shame may also trigger shame in the therapist. When therapists are open to examining how they have contributed to the shame state experienced by the client, healing
begins to take place for both the client and the therapist. The original shame state has been
recreated, but this time there is someone who can be present to what clients feel and need
to help them to get unstuck. When this happens, clients are more likely to be empowered
to break their silence the next time they feel shame in the therapeutic relationship. Therapists cannot be supportive of the shame-based feelings or needs of their clients if they cannot experience their own shame-based feelings or needs for themselves. It is unlikely that
clients will feel safe enough to touch shame-based feelings or needs if their therapist is unwilling to do so. Therapists need to be able to touch and feel their own shame in response
to their clients and use that knowledge to be present to the client’s healing. Being known,
being vulnerable, acknowledging one’s own shame cycle does not mean sharing all of these
dynamics with the client.
Shame-based clients need to be able to fully reexperience (touch, feel, and ultimately make
new decisions about) their shame. If therapists stay emotionally distant and do not allow
themselves to be known and vulnerable, then they replay the original trauma. Clients’ feelings of shame may also trigger shame in the therapist. When therapists are open to examining how they have contributed to the shame state experienced by the client, healing
begins to take place for both the client and the therapist. The original shame state has been
recreated, but this time there is someone who can be present to what clients feel and need
to help them to get unstuck. When this happens, clients are more likely to be empowered
to break their silence the next time they feel shame in the therapeutic relationship. Therapists cannot be supportive of the shame-based feelings or needs of their clients if they cannot experience their own shame-based feelings or needs for themselves. It is unlikely that
clients will feel safe enough to touch shame-based feelings or needs if their therapist is unwilling to do so. Therapists need to be able to touch and feel their own shame in response
to their clients and use that knowledge to be present to the client’s healing. Being known,
being vulnerable, acknowledging one’s own shame cycle does not mean sharing all of these
dynamics with the client.
Therapists may feel threatened at both a personal and professional level when verbally attacked by a client and may feel shame as a result. Since feeling shame is not a comfortable
experience, therapists may do any number of things to avoid feeling shame. It is not uncommon for therapists to transfer the shame to the client by using any of the following defense
mechanisms:
Therapists may feel threatened at both a personal and professional level when verbally attacked by a client and may feel shame as a result. Since feeling shame is not a comfortable
experience, therapists may do any number of things to avoid feeling shame. It is not uncommon for therapists to transfer the shame to the client by using any of the following defense
mechanisms:
• by blaming
• being judgmental
• by blaming
• being judgmental
• by denying
• being contemptuous
• by denying
• being contemptuous
• by intellectualizing
• making interpretations
• by intellectualizing
• making interpretations
• by confronting
• falling silent
• by confronting
• falling silent
• making evaluations
• being critical
• making evaluations
• being critical
• offering explanations
• withdrawing emotionally or verbally
• offering explanations
• withdrawing emotionally or verbally
Sometimes, when a person feels shamed by someone, there is a tendency to shame them
back (attack the other). Therapists need to be able to identify when they feel shamed by clients so that they do not shame clients in response. When this happens, therapists have
missed their clients in some way. It is important that the therapist carefully explore in a nondefensive manner, the meaning of the miss with the client. (See Responding to Misses,
Chapter 3.)
Sometimes, when a person feels shamed by someone, there is a tendency to shame them
back (attack the other). Therapists need to be able to identify when they feel shamed by clients so that they do not shame clients in response. When this happens, therapists have
missed their clients in some way. It is important that the therapist carefully explore in a nondefensive manner, the meaning of the miss with the client. (See Responding to Misses,
Chapter 3.)
Example
Example
Client: A male client came into the therapy session and said to the therapist, “I’ve been coming to therapy for six weeks and nothing has changed
in my life.”
Therapist: “You’re feeling really disappointed that nothing has changed in
your life.” (The therapist felt shame in response but contained her own
feelings to be with the client. She did not become defensive.)
Client: “Yes, I am disappointed. I had hoped you’d have something to offer
me.”
Client: A male client came into the therapy session and said to the therapist, “I’ve been coming to therapy for six weeks and nothing has changed
in my life.”
Therapist: “You’re feeling really disappointed that nothing has changed in
your life.” (The therapist felt shame in response but contained her own
feelings to be with the client. She did not become defensive.)
Client: “Yes, I am disappointed. I had hoped you’d have something to offer
me.”
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Example Continued
Example Continued
Therapist: “I can hear your disappointment. What do you think needs to
happen today that would make you feel that you are making progress?”
(The therapist was further shamed but realized that a miss had occurred.)
Client: “I don’t know.”
Therapist: “I was wondering how it felt to tell me that you did not think
anything had changed?”
Client: “Good, I guess. I just needed to tell you.”
Therapist: “I’m glad that you could tell me how you felt. Let’s talk about
what it is you want to change and what you want those changes to look
like. Then we can figure out how to help you make those changes a step
at a time.”
Client: “Okay.”
Therapist: “I can hear your disappointment. What do you think needs to
happen today that would make you feel that you are making progress?”
(The therapist was further shamed but realized that a miss had occurred.)
Client: “I don’t know.”
Therapist: “I was wondering how it felt to tell me that you did not think
anything had changed?”
Client: “Good, I guess. I just needed to tell you.”
Therapist: “I’m glad that you could tell me how you felt. Let’s talk about
what it is you want to change and what you want those changes to look
like. Then we can figure out how to help you make those changes a step
at a time.”
Client: “Okay.”
Therapists who cannot allow themselves to be aware of their own shame may tend to be
rigid and inflexible. They may feel as though they are the experts and have the answers.
Therapists who can accept that they will experience shame in the therapeutic relationship
as their clients see their imperfectness, are capable of examining how they might have contributed to their clients’ feeling of shame.
Therapists who cannot allow themselves to be aware of their own shame may tend to be
rigid and inflexible. They may feel as though they are the experts and have the answers.
Therapists who can accept that they will experience shame in the therapeutic relationship
as their clients see their imperfectness, are capable of examining how they might have contributed to their clients’ feeling of shame.
When therapists are not comfortable with their own shame, they are less likely to get adequate supervision and may be uncomfortable doing their own therapeutic work. It is important for therapists to understand the kinds of situations that trigger shame in them. This
knowledge can then be used to help them see how these situations play out in session with
their clients. It is helpful for therapists to explore how they have tried to protect themselves
from being shamed either in their own personal therapy or in consultation with supervisors
or colleagues.
When therapists are not comfortable with their own shame, they are less likely to get adequate supervision and may be uncomfortable doing their own therapeutic work. It is important for therapists to understand the kinds of situations that trigger shame in them. This
knowledge can then be used to help them see how these situations play out in session with
their clients. It is helpful for therapists to explore how they have tried to protect themselves
from being shamed either in their own personal therapy or in consultation with supervisors
or colleagues.
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Chapter 4 Appendix B
Chapter 4 Appendix B
History of Basic Feelings
Questionnaire
History of Basic Feelings
Questionnaire
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History of Basic Feelings Questionnaire
History of Basic Feelings Questionnaire
1. What feeling was easiest to deal with in the family? Mad? Sad? Glad? Scared?
1. What feeling was easiest to deal with in the family? Mad? Sad? Glad? Scared?
2. How did your mother deal with the easiest feeling? (What did that look like?)
2. How did your mother deal with the easiest feeling? (What did that look like?)
3. How did your father deal with the easiest feeling? (What did that look like?)
3. How did your father deal with the easiest feeling? (What did that look like?)
4. How did your family deal with the easiest feeling? (What did that look like?)
4. How did your family deal with the easiest feeling? (What did that look like?)
5. What was the most difficult feeling to deal with in the family? Was there another feeling
that was difficult? (Sometimes we major in one and minor in another.)
5. What was the most difficult feeling to deal with in the family? Was there another feeling
that was difficult? (Sometimes we major in one and minor in another.)
6. How did your mother deal with the most difficult feeling? (What did that look like?)
6. How did your mother deal with the most difficult feeling? (What did that look like?)
7. How did your father deal with the most difficult feeling? (What did that look like?)
7. How did your father deal with the most difficult feeling? (What did that look like?)
8. How were the most difficult feelings dealt with in the family system? (ignored, punished,
soothed, comforted)
8. How were the most difficult feelings dealt with in the family system? (ignored, punished,
soothed, comforted)
9. What feeling is easiest for you to express?
9. What feeling is easiest for you to express?
10. What feeling is most difficult for you to express?
10. What feeling is most difficult for you to express?
11. What feeling, if any, do you use to cover up the most difficult feeling?
11. What feeling, if any, do you use to cover up the most difficult feeling?
12. What feeling is hardest for you to express to your significant other?
12. What feeling is hardest for you to express to your significant other?
13.What did you learn about yourself from doing this exercise?
13.What did you learn about yourself from doing this exercise?
14. How did it feel to do this exercise?
14. How did it feel to do this exercise?
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5
5
Teaching Self-Soothing
Techniques to Create Safety within
the Client
Teaching Self-Soothing
Techniques to Create Safety within
the Client
Chapter Outline
Chapter Outline
A. Creating Safety Through the Use of Relaxation
A. Creating Safety Through the Use of Relaxation
1. Types of Relaxation
1. Types of Relaxation
2. When Is It Useful?
2. When Is It Useful?
3. When Relaxation Training Exercises Would Be Contraindicated
3. When Relaxation Training Exercises Would Be Contraindicated
4. Helpful Hints for the Therapist
4. Helpful Hints for the Therapist
B. First Teaching Session Details
1. How the Nervous System Functions
B. First Teaching Session Details
1. How the Nervous System Functions
a. Characteristics of Excessive Sympathetic Nervous System Activity
a. Characteristics of Excessive Sympathetic Nervous System Activity
b. Characteristics of Tying into the Parasympathetic Nervous System
b. Characteristics of Tying into the Parasympathetic Nervous System
2. What Will You Get Out of It?
C. Second Teaching Session Details
2. What Will You Get Out of It?
C. Second Teaching Session Details
1. Tensing and Relaxing Exercises
1. Tensing and Relaxing Exercises
2. Breathing Exercise
2. Breathing Exercise
3. Deep Muscle Relaxation Exercise
3. Deep Muscle Relaxation Exercise
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a. What Was It Like for You?
a. What Was It Like for You?
b. Normalizing Feelings
b. Normalizing Feelings
c. Eustress vs. Distress
c. Eustress vs. Distress
d. Homework Assignment
d. Homework Assignment
D. Third Teaching Session Details
D. Third Teaching Session Details
1. Checking on Practice at Home
1. Checking on Practice at Home
2. Deep Muscle Relaxation Exercise
2. Deep Muscle Relaxation Exercise
a. What Was It Like for You?
a. What Was It Like for You?
b. Normalizing Feelings
b. Normalizing Feelings
c. Homework Assignment
c. Homework Assignment
E. Fourth Teaching Session Details
E. Fourth Teaching Session Details
1. Checking on Practice at Home
1. Checking on Practice at Home
2. Creating a Safe Place Relaxation Exercise
2. Creating a Safe Place Relaxation Exercise
a. Evaluating the Exercise Experience
a. Evaluating the Exercise Experience
b. Examples of Safe Places
b. Examples of Safe Places
c. Homework Assignment
c. Homework Assignment
F. Additional Ways of Creating Safety
F. Additional Ways of Creating Safety
1. Alternative Ways of Developing Safe Places
1. Alternative Ways of Developing Safe Places
a. Creating an Actual Safe Place
a. Creating an Actual Safe Place
b. Drawing a Safe Place
b. Drawing a Safe Place
c. Imaging a Safe Place
c. Imaging a Safe Place
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2. Self-Soothing Activities
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2. Self-Soothing Activities
a. Creating a List of Self-Soothing Activities
a. Creating a List of Self-Soothing Activities
b. Creating a Customized Tape
b. Creating a Customized Tape
c. Use of Transition Objects as a Way of Creating Safety
c. Use of Transition Objects as a Way of Creating Safety
d. Use of Imagery to Create Safety
d. Use of Imagery to Create Safety
3. Affirmations
3. Affirmations
a. Definition of Affirmations
a. Definition of Affirmations
b. Working with Affirmations
b. Working with Affirmations
c. Suggestions for Using Affirmations
c. Suggestions for Using Affirmations
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Teaching Self-Soothing Techniques to Create
Safety within the Client
Teaching Self-Soothing Techniques to Create
Safety within the Client
Taking the time to teach clients how to self-soothe creates safety within clients and helps
them to take better care of themselves in their daily life. It conveys to clients that this is
important. Many clients do not have adequate skills for comforting and soothing themselves. Clients with a history of abuse or trauma may have never experienced safety in their
lives. Teaching these clients to self-soothe is mandatory for healing. For abuse and trauma
survivors, self-soothing helps clients to reconnect with their bodies and begin to heal at a
bodily level.
Taking the time to teach clients how to self-soothe creates safety within clients and helps
them to take better care of themselves in their daily life. It conveys to clients that this is
important. Many clients do not have adequate skills for comforting and soothing themselves. Clients with a history of abuse or trauma may have never experienced safety in their
lives. Teaching these clients to self-soothe is mandatory for healing. For abuse and trauma
survivors, self-soothing helps clients to reconnect with their bodies and begin to heal at a
bodily level.
It is especially important that therapists read and understand this chapter in its entirety before initiating the relaxation training process with clients.
It is especially important that therapists read and understand this chapter in its entirety before initiating the relaxation training process with clients.
Although I have specified the number of sessions and even the time it may take to teach
segments of this process, it is my hope that you will allow yourself to use all or parts of the
information in ways that fit your style.
Although I have specified the number of sessions and even the time it may take to teach
segments of this process, it is my hope that you will allow yourself to use all or parts of the
information in ways that fit your style.
CREATING SAFETY THROUGH THE USE OF
RELAXATION
CREATING SAFETY THROUGH THE USE OF
RELAXATION
TYPES OF RELAXATION
TYPES OF RELAXATION
It is very important that clients know how to fully relax. It helps them to care more effectively for their bodies. The method that a client uses to relax is not particularly important.
The important thing is to find a method that can be effectively used. There are many ways
to relax:
Progressive Relaxation - This process involves systematic tightening and relaxing of
the various muscle groups of the body. Clients focus on the difference between tensing
and relaxing so that they can begin to feel the difference in their bodies.
Autogenic Relaxation - Although infrequently suggested, this method utilizes mental
instruction to promote relaxation. Clients suggest to various parts of their system that
they are becoming more and more relaxed or quiet. “My mind is at peace.” “The muscles in my back are becoming fully relaxed.”
Biofeedback (BFB) - This is a valuable technique as it provides immediate biological
information via electrodes and electronic equipment as to the state of relaxation in the
body. Clients can learn to raise and lower skin temperature, raise and lower muscle
tension (EMG), and do Galvanic Skin Response (GSR) work which measures overall
arousal. This method takes special equipment and training to utilize.
Meditation - There are numerous ways to meditate using mantras, prayer, beads,
chanting, music, and/or Transcendental Meditation. Meditation exercises are normally introduced with a focus on the art of breathing. Repeating a word or a phrase may
be used to achieve relaxation. Many of these techniques are ancient in origin.
Imagery - This method can assist clients in engaging their senses (taste, touch, smell,
hearing, and sight) to create a state of relaxation.
It is very important that clients know how to fully relax. It helps them to care more effectively for their bodies. The method that a client uses to relax is not particularly important.
The important thing is to find a method that can be effectively used. There are many ways
to relax:
Progressive Relaxation - This process involves systematic tightening and relaxing of
the various muscle groups of the body. Clients focus on the difference between tensing
and relaxing so that they can begin to feel the difference in their bodies.
Autogenic Relaxation - Although infrequently suggested, this method utilizes mental
instruction to promote relaxation. Clients suggest to various parts of their system that
they are becoming more and more relaxed or quiet. “My mind is at peace.” “The muscles in my back are becoming fully relaxed.”
Biofeedback (BFB) - This is a valuable technique as it provides immediate biological
information via electrodes and electronic equipment as to the state of relaxation in the
body. Clients can learn to raise and lower skin temperature, raise and lower muscle
tension (EMG), and do Galvanic Skin Response (GSR) work which measures overall
arousal. This method takes special equipment and training to utilize.
Meditation - There are numerous ways to meditate using mantras, prayer, beads,
chanting, music, and/or Transcendental Meditation. Meditation exercises are normally introduced with a focus on the art of breathing. Repeating a word or a phrase may
be used to achieve relaxation. Many of these techniques are ancient in origin.
Imagery - This method can assist clients in engaging their senses (taste, touch, smell,
hearing, and sight) to create a state of relaxation.
Many people are confused about relaxation because they believe that relaxation means to
Many people are confused about relaxation because they believe that relaxation means to
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go to sleep. People can go to sleep and remain relatively tense. It is also possible to be very
relaxed and yet alert and aware. The goal of relaxation is to reduce or eliminate muscle tension. Anxious persons who are defensive and constantly feeling the need to protect themselves create a situation where the body becomes hyperaroused, and adapts by maintaining
a chronic state of muscle tension. If this condition persists, then a wide variety of physical
disorders can be produced or exacerbated (e.g., tension headaches, insomnia, muscle tension, constipation, diarrhea, colitis, muscle cramps, etc.)
go to sleep. People can go to sleep and remain relatively tense. It is also possible to be very
relaxed and yet alert and aware. The goal of relaxation is to reduce or eliminate muscle tension. Anxious persons who are defensive and constantly feeling the need to protect themselves create a situation where the body becomes hyperaroused, and adapts by maintaining
a chronic state of muscle tension. If this condition persists, then a wide variety of physical
disorders can be produced or exacerbated (e.g., tension headaches, insomnia, muscle tension, constipation, diarrhea, colitis, muscle cramps, etc.)
WHEN IS IT USEFUL?
WHEN IS IT USEFUL?
There are numerous everyday situations where relaxation techniques can be used by clients:
1. Clients who are highly stressed or anxious can use relaxation techniques to help
lower their stress level and drop adrenal arousal.
2. Clients who have been abused can use relaxation techniques to help develop trust
in themselves or their body. Using the relaxation techniques can help clients create
safety within and help them to self-soothe.
3. When clients have panic attacks or phobias, basic relaxation training is standard
treatment. With phobias it precedes desensitization work. Diaphragmatic breathing is
important to prevent hyperventilating.
4. Clients who are facing surgery can use relaxation techniques to help calm their fear
and enhance the success of the surgery and healing. Relaxation techniques can be used
as part of imagery for the surgical procedure or to enhance recovery.
5. When clients are in physical pain, relaxation techniques may help to take away or
lessen the pain.
6. Clients who are chronically ill may find it helpful to use relaxation techniques.
Chronically ill clients need all the help they can get to cope with what is happening in
their body.
7. When clients are obsessive-compulsive, relaxation techniques can help to calm the
fear that leads to this expression of anxiety. It often helps to ground or center clients
and lower their anxiety. Relaxation techniques can assist clients in accessing the feelings that may trigger the obsessive-compulsive behavior.
8. Clients who are practicing biofeedback (BFB) on a regular basis are often taught a
progressive relaxation exercise.
9. Children and teenagers are very receptive to relaxation techniques. They do not
have a belief system that says “It won’t work.” (I used relaxation techniques with my
daughter from age 11 through her teens when she had headaches. I coupled it with gently rubbing her forehead. The headaches usually went away.)
10. In times of fear, deadlines, or highly stressed situations, clients can use relaxation
techniques to soothe themselves. It can serve as a way for them to get control over
their own physiology and emotions.
There are numerous everyday situations where relaxation techniques can be used by clients:
1. Clients who are highly stressed or anxious can use relaxation techniques to help
lower their stress level and drop adrenal arousal.
2. Clients who have been abused can use relaxation techniques to help develop trust
in themselves or their body. Using the relaxation techniques can help clients create
safety within and help them to self-soothe.
3. When clients have panic attacks or phobias, basic relaxation training is standard
treatment. With phobias it precedes desensitization work. Diaphragmatic breathing is
important to prevent hyperventilating.
4. Clients who are facing surgery can use relaxation techniques to help calm their fear
and enhance the success of the surgery and healing. Relaxation techniques can be used
as part of imagery for the surgical procedure or to enhance recovery.
5. When clients are in physical pain, relaxation techniques may help to take away or
lessen the pain.
6. Clients who are chronically ill may find it helpful to use relaxation techniques.
Chronically ill clients need all the help they can get to cope with what is happening in
their body.
7. When clients are obsessive-compulsive, relaxation techniques can help to calm the
fear that leads to this expression of anxiety. It often helps to ground or center clients
and lower their anxiety. Relaxation techniques can assist clients in accessing the feelings that may trigger the obsessive-compulsive behavior.
8. Clients who are practicing biofeedback (BFB) on a regular basis are often taught a
progressive relaxation exercise.
9. Children and teenagers are very receptive to relaxation techniques. They do not
have a belief system that says “It won’t work.” (I used relaxation techniques with my
daughter from age 11 through her teens when she had headaches. I coupled it with gently rubbing her forehead. The headaches usually went away.)
10. In times of fear, deadlines, or highly stressed situations, clients can use relaxation
techniques to soothe themselves. It can serve as a way for them to get control over
their own physiology and emotions.
Relaxation techniques can also be utilized at various times during a therapy session:
1. A focus on breathing, in and of itself or as part of the relaxation process, can be utilized at the beginning, during, or end of a therapy session to calm, soothe, or ground
anxious or fearful clients. When a client becomes ungrounded, effective therapy ceases. Using this process in session continues to remind clients that diaphragmatic breathing is a skill that they can use at any time they need to relax themselves.
2. Relaxation techniques can be used as an introduction to hypnotherapy or imagery
Relaxation techniques can also be utilized at various times during a therapy session:
1. A focus on breathing, in and of itself or as part of the relaxation process, can be utilized at the beginning, during, or end of a therapy session to calm, soothe, or ground
anxious or fearful clients. When a client becomes ungrounded, effective therapy ceases. Using this process in session continues to remind clients that diaphragmatic breathing is a skill that they can use at any time they need to relax themselves.
2. Relaxation techniques can be used as an introduction to hypnotherapy or imagery
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work. When clients are relaxed, they are more easily able to explore their inner world.
3. Relaxation can be utilized to create a safe place within for deeply injured clients
where they can soothe themselves, as needed, when doing integrative memory work.
It helps to give clients more control over their fear or anxiety when touching painful
memories.
WHEN RELAXATION TRAINING EXERCISES WOULD BE
CONTRAINDICATED
1. Relaxation training should not be used with clients who are experiencing psychotic
episodes. These clients are already unsure of how to tell the difference between what
is happening inside of them vs. what is happening outside of them.
2. Relaxation training is not recommended with clients who are unable to think clearly
and stay present to what is happening to them.
3. Be cautious in using relaxation training with clients who have a recent history of
recovering memories.
4. Be very cautious when using relaxation training with highly dissociative clients.
They need to stay integrated and fully present.
HELPFUL HINTS FOR THE THERAPIST
1. It is not necessary to use a low, soothing voice when leading clients through a relaxation. I use a normal voice. I want to convey to my clients that it is not my voice
that makes them relax. They are giving themselves permission to relax.
2. Relaxation is not something that a therapist or a client can make happen. You have
to allow it to occur. It is like a paradox in that you have to let go of control in order to
get control over your physiology. I use the metaphor of a clenched fist to symbolize
control and an open fist to symbolize letting go. I clench my fist as a way of showing
that when I tense my muscles, I cannot make relaxation happen at a bodily level. Conversely, I use an open, relaxed hand as a way to symbolize allowing relaxation to take
place.
3. When you are ready to teach the relaxation exercise for the first time, you may sense
fear, skepticism, disbelief, anxiety, etc.; therefore, it is helpful to see what clients may
be feeling and be prepared to give them lots of permission to risk participating in this
experience.
4. Clients may believe that you did the relaxation to them. I usually say to them, “No,
you did it to yourself. I walked you through the exercise, but you allowed it to happen.”
5. Clients usually do not like to give talking time away, so I often schedule an extra
session just for relaxation training.
6. I have a bias for actually tensing and relaxing the muscle groups for those clients
who are out of touch with their bodies. It seems to help them reconnect with their bodies so they can begin to feel the difference between the tense and relaxed state. Even
if clients do not continue to use the tensing and relaxing process, they may get to experience the difference in their bodies.
7. It is important to tell clients what you are going to do with them before you do it
and get their permission to proceed. Some clients may feel too unsafe to do what you
ask, and you may violate their trust if they feel they must comply.
work. When clients are relaxed, they are more easily able to explore their inner world.
3. Relaxation can be utilized to create a safe place within for deeply injured clients
where they can soothe themselves, as needed, when doing integrative memory work.
It helps to give clients more control over their fear or anxiety when touching painful
memories.
WHEN RELAXATION TRAINING EXERCISES WOULD BE
CONTRAINDICATED
1. Relaxation training should not be used with clients who are experiencing psychotic
episodes. These clients are already unsure of how to tell the difference between what
is happening inside of them vs. what is happening outside of them.
2. Relaxation training is not recommended with clients who are unable to think clearly
and stay present to what is happening to them.
3. Be cautious in using relaxation training with clients who have a recent history of
recovering memories.
4. Be very cautious when using relaxation training with highly dissociative clients.
They need to stay integrated and fully present.
HELPFUL HINTS FOR THE THERAPIST
1. It is not necessary to use a low, soothing voice when leading clients through a relaxation. I use a normal voice. I want to convey to my clients that it is not my voice
that makes them relax. They are giving themselves permission to relax.
2. Relaxation is not something that a therapist or a client can make happen. You have
to allow it to occur. It is like a paradox in that you have to let go of control in order to
get control over your physiology. I use the metaphor of a clenched fist to symbolize
control and an open fist to symbolize letting go. I clench my fist as a way of showing
that when I tense my muscles, I cannot make relaxation happen at a bodily level. Conversely, I use an open, relaxed hand as a way to symbolize allowing relaxation to take
place.
3. When you are ready to teach the relaxation exercise for the first time, you may sense
fear, skepticism, disbelief, anxiety, etc.; therefore, it is helpful to see what clients may
be feeling and be prepared to give them lots of permission to risk participating in this
experience.
4. Clients may believe that you did the relaxation to them. I usually say to them, “No,
you did it to yourself. I walked you through the exercise, but you allowed it to happen.”
5. Clients usually do not like to give talking time away, so I often schedule an extra
session just for relaxation training.
6. I have a bias for actually tensing and relaxing the muscle groups for those clients
who are out of touch with their bodies. It seems to help them reconnect with their bodies so they can begin to feel the difference between the tense and relaxed state. Even
if clients do not continue to use the tensing and relaxing process, they may get to experience the difference in their bodies.
7. It is important to tell clients what you are going to do with them before you do it
and get their permission to proceed. Some clients may feel too unsafe to do what you
ask, and you may violate their trust if they feel they must comply.
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8. It is important to give them permission to open their eyes at any time to check out
their surroundings.
9. It is helpful to give clients permission to move their bodies in whatever way they
need so that they feel comfortable.
10. I tell clients that it is okay to tell me at any time that they want to stop.
11. I tell them that the goal of relaxation is not to go to sleep.
12. I watch to see if they are breathing from the chest or from the diaphragm. If I see
that they are breathing somewhat consistently from the diaphragm, then I no longer
offer suggestions to breathe as I lead them through a relaxation exercise.
8. It is important to give them permission to open their eyes at any time to check out
their surroundings.
9. It is helpful to give clients permission to move their bodies in whatever way they
need so that they feel comfortable.
10. I tell clients that it is okay to tell me at any time that they want to stop.
11. I tell them that the goal of relaxation is not to go to sleep.
12. I watch to see if they are breathing from the chest or from the diaphragm. If I see
that they are breathing somewhat consistently from the diaphragm, then I no longer
offer suggestions to breathe as I lead them through a relaxation exercise.
FIRST TEACHING SESSION DETAILS (Time needed: 30-35
FIRST TEACHING SESSION DETAILS (Time needed: 30-35
minutes)
minutes)
Usually at some point in the first few sessions, I offer to teach all my clients the relaxation
process coupled with the basic diaphragmatic breathing and help them to create a safe place
inside themselves. I think of doing this as teaching Relaxation Therapy 101. I see this as a
basic skill that is offered as part of therapy. I rarely have clients who are unwilling to allow
me to teach them this process, but every client does not choose to use it.
Usually at some point in the first few sessions, I offer to teach all my clients the relaxation
process coupled with the basic diaphragmatic breathing and help them to create a safe place
inside themselves. I think of doing this as teaching Relaxation Therapy 101. I see this as a
basic skill that is offered as part of therapy. I rarely have clients who are unwilling to allow
me to teach them this process, but every client does not choose to use it.
I introduce the topic of relaxation training by saying the following kinds of things:
In these next weeks, I would like to teach you how to relax your body and
learn how to feel the difference between being tense and being relaxed. I
will teach you how to do diaphragmatic breathing and then walk you
through a progressive relaxation process allowing you to relax each muscle
group. At another time I will teach you how to create a place of safety inside
yourself that you can go to when you need to soothe yourself. Are you willing to let me teach you this process?
I introduce the topic of relaxation training by saying the following kinds of things:
In these next weeks, I would like to teach you how to relax your body and
learn how to feel the difference between being tense and being relaxed. I
will teach you how to do diaphragmatic breathing and then walk you
through a progressive relaxation process allowing you to relax each muscle
group. At another time I will teach you how to create a place of safety inside
yourself that you can go to when you need to soothe yourself. Are you willing to let me teach you this process?
Usually, the answer is affirmative. If clients refuse, then I briefly explore what their reasons
are. It may be that they have another agenda for the current session or may not be ready to
learn the relaxation process. I want to affirm that they have a right to make that choice. If
it seems appropriate, at a future time, then I may again offer to teach it to them.
Usually, the answer is affirmative. If clients refuse, then I briefly explore what their reasons
are. It may be that they have another agenda for the current session or may not be ready to
learn the relaxation process. I want to affirm that they have a right to make that choice. If
it seems appropriate, at a future time, then I may again offer to teach it to them.
Once we have reached an agreement about them learning this process, we set up the next
session or an alternate time for them to learn the material. Then, I say to them the following:
I will be giving you a bit of information about how the nervous system functions. I will talk briefly about the characteristics of excessive sympathetic
nervous system activity and what happens when you tie into the parasympathetic nervous system. We will talk about what you will get out it. It will take
about 30-35 minutes for me to teach you this material. Do you have any
questions about this process? In this coming week, I would like you to take
a few moments to become aware of your breathing. Just check in two or
three times and note your breathing process.
Once we have reached an agreement about them learning this process, we set up the next
session or an alternate time for them to learn the material. Then, I say to them the following:
IIwill
willbe
begiving
givingyou
youaabit
bitof
ofinformation
informationabout
abouthow
howthe
thenervous
nervoussystem
systemfuncfunctions. I will talk briefly about the characteristics of excessive sympathetic
nervous system activity and what happens when you tie into the parasympathetic nervous system. We will talk about what you will get out it. It will take
about 30-35 minutes for me to teach you this material. Do you have any
questions about this process? In this coming week, I would like you to take
a few moments to become aware of your breathing. Just check in two or
three times and note your breathing process.
When clients are amenable to being taught the material in the current session I proceed by saying the following:
I want to thank you for your willingness to let me teach you the relaxation
process. First of all, I am going to teach you a little bit about how the nervous system functions. I do not expect you to remember everything that I say,
When clients are amenable to being taught the material in the current session I proceed by saying the following:
I want to thank you for your willingness to let me teach you the relaxation
process. First of all, I am going to teach you a little bit about how the nervous system functions. I do not expect you to remember everything that I say,
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but I believe it will give you an understanding of what happens in your nervous system and how that translates all over your body when you are tense
vs. when you are relaxed. Do you have any questions at this point? Feel free
to stop me at any time if you have any questions or are wanting to understand something better.
but I believe it will give you an understanding of what happens in your nervous system and how that translates all over your body when you are tense
vs. when you are relaxed. Do you have any questions at this point? Feel free
to stop me at any time if you have any questions or are wanting to understand something better.
After I have responded to any questions they may have, I proceed to teach them the basics
of how the nervous system functions. I use a combination of a white board and a flip chart.
After I have responded to any questions they may have, I proceed to teach them the basics
of how the nervous system functions. I use a combination of a white board and a flip chart.
The following sections include the basic information that I think is important for clients to
have about their bodies. I generally teach them most of this information. I tend to paraphrase it and gear it according to clients’ ability to understand it. I go slowly enough that
they can grasp the concepts. I use the board to draw pictures and to illustrate key points or
words. When I first started to teach it, I put the information on 4 x 6 note cards and flipped
through them while talking and/or writing on the board. It enabled me to teach the information comfortably without distracting the client. I still use the note cards but refer to them
less.
The following sections include the basic information that I think is important for clients to
have about their bodies. I generally teach them most of this information. I tend to paraphrase it and gear it according to clients’ ability to understand it. I go slowly enough that
they can grasp the concepts. I use the board to draw pictures and to illustrate key points or
words. When I first started to teach it, I put the information on 4 x 6 note cards and flipped
through them while talking and/or writing on the board. It enabled me to teach the information comfortably without distracting the client. I still use the note cards but refer to them
less.
HOW THE NERVOUS SYSTEM FUNCTIONS (Time needed: 15-20 min-
HOW THE NERVOUS SYSTEM FUNCTIONS (Time needed: 15-20 min-
utes)
utes)
Note: If the following material is relatively new for you, then it may be helpful to read it
through 2-3 times until you grasp the main points. It gets easier with practice!
Note: If the following material is relatively new for you, then it may be helpful to read it
through 2-3 times until you grasp the main points. It gets easier with practice!
There are two primary systems in the body. One is the central nervous system (CNS), and
the other is the peripheral nervous system. For our purposes, we will be talking only about
the CNS. Within the CNS there are two nervous systems. One is the voluntary nervous system (VNS) which is the newly evolved outer brain called the cortex. All voluntary movement comes from the cortical area by conscious choice. If we want to raise or lower our
arm, our brain sends the signal to those muscles and we are able to raise or lower our arm.
Muscles that control movement are striated muscles. The striated muscles are controlled by
neurons in the motor cortex so are under voluntary control. These muscles look like string
cheese. These are the muscles that cause movement around joints. Striated muscles have a
sense to let us know when something is wrong. We experience pain, strain, sprain.
There are two primary systems in the body. One is the central nervous system (CNS), and
the other is the peripheral nervous system. For our purposes, we will be talking only about
the CNS. Within the CNS there are two nervous systems. One is the voluntary nervous system (VNS) which is the newly evolved outer brain called the cortex. All voluntary movement comes from the cortical area by conscious choice. If we want to raise or lower our
arm, our brain sends the signal to those muscles and we are able to raise or lower our arm.
Muscles that control movement are striated muscles. The striated muscles are controlled by
neurons in the motor cortex so are under voluntary control. These muscles look like string
cheese. These are the muscles that cause movement around joints. Striated muscles have a
sense to let us know when something is wrong. We experience pain, strain, sprain.
The other nervous system in the CNS is the autonomic nervous system (ANS), sometimes
called the involuntary nervous system. It is the subcortex, or older brain. We have the subcortical area of the brain in common with other animals. The subcortex has to do with the
survival function. The subcortical area is concerned with vital body functions that comprise
the basic control center for the ANS which is principally responsible for physiological activation during a stress response. The muscles these movements control are called smooth
muscles. These smooth muscles are generally found in the blood vessels of internal organs
such as the muscles of the heart, intestines, stomach, sex arousal, and breathing. These
smooth muscles internally affect the body. They give limited feedback to tell us what is going on in our body. Adjustments that are made occur below our level of conscious awareness. However, feedback is provided, and conscious control takes place through the
biofeedback (BFB) process and related relaxation techniques.
The other nervous system in the CNS is the autonomic nervous system (ANS), sometimes
called the involuntary nervous system. It is the subcortex, or older brain. We have the subcortical area of the brain in common with other animals. The subcortex has to do with the
survival function. The subcortical area is concerned with vital body functions that comprise
the basic control center for the ANS which is principally responsible for physiological activation during a stress response. The muscles these movements control are called smooth
muscles. These smooth muscles are generally found in the blood vessels of internal organs
such as the muscles of the heart, intestines, stomach, sex arousal, and breathing. These
smooth muscles internally affect the body. They give limited feedback to tell us what is going on in our body. Adjustments that are made occur below our level of conscious awareness. However, feedback is provided, and conscious control takes place through the
biofeedback (BFB) process and related relaxation techniques.
At yet another level of the ANS we find two distinct but interdependent nervous systems
that are responsible for neurophysiological and biological changes in the body. These two
nervous systems are the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system tenses and vasoconstricts the involuntary muscles
such as the tiny muscles in the walls of the blood vessels. (Using my white board I draw
At yet another level of the ANS we find two distinct but interdependent nervous systems
that are responsible for neurophysiological and biological changes in the body. These two
nervous systems are the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system tenses and vasoconstricts the involuntary muscles
such as the tiny muscles in the walls of the blood vessels. (Using my white board I draw
151
two parallel horizontal lines to represent the exterior of a blood vessel - [Figure 1]).
Blood
Vessel
Wall
Muscle
Vasoconstricting
Wall of Vessel
151
two parallel horizontal lines to represent the exterior of a blood vessel - [Figure 1]).
Blood
Vessel
Wall
Wall
Muscle
Vasoconstricting
Wall of Vessel
Figure 1
Figure 1
Then I draw two more lines that are close together inside of those to show how the muscle
vasoconstricts the inside of the blood vessel.) When this vasoconstriction takes place, the
blood supply is cut off and shunted to the big muscles in preparation to fight or flee. It prepares the body for action in times of stress. It activates the endocrine system via the hypothalamus which acts on the pituitary which is the master gland of the endocrine system.
Then I draw two more lines that are close together inside of those to show how the muscle
vasoconstricts the inside of the blood vessel.) When this vasoconstriction takes place, the
blood supply is cut off and shunted to the big muscles in preparation to fight or flee. It prepares the body for action in times of stress. It activates the endocrine system via the hypothalamus which acts on the pituitary which is the master gland of the endocrine system.
The parasympathetic nervous system generally initiates a vasodilation of the body’s
smooth muscles inducing a state of relaxation and conservation of energy. (Again, I draw
two parallel lines to represent the outside of a blood vessel, and then I draw two more lines
inside those lines that are quite far apart - [Figure 2].) These lines show how the vasodilation of the muscles inside the blood vessel open it wide allowing the blood to flow freely
throughout the body. There is one vital distinction between the two systems that is central
to understanding the stress response. The parasympathetic nerve activity is relatively specific in its influence and selective in its activation of the organ it controls. The sympathetic
nervous system may act selectively, but usually acts through a general excitation effect
upon neural and glandular functions, termed a mass discharge. By means of this mass discharge response, large portions of the sympathetic nervous system are stimulated simultaneously. This phenomenon is commonly known as the fight or flight response and is the
body’s most comprehensive reaction to stress.
The parasympathetic nervous system generally initiates a vasodilation of the body’s
smooth muscles inducing a state of relaxation and conservation of energy. (Again, I draw
two parallel lines to represent the outside of a blood vessel, and then I draw two more lines
inside those lines that are quite far apart - [Figure 2].) These lines show how the vasodilation of the muscles inside the blood vessel open it wide allowing the blood to flow freely
throughout the body. There is one vital distinction between the two systems that is central
to understanding the stress response. The parasympathetic nerve activity is relatively specific in its influence and selective in its activation of the organ it controls. The sympathetic
nervous system may act selectively, but usually acts through a general excitation effect
upon neural and glandular functions, termed a mass discharge. By means of this mass discharge response, large portions of the sympathetic nervous system are stimulated simultaneously. This phenomenon is commonly known as the fight or flight response and is the
body’s most comprehensive reaction to stress.
Blood
Vessel
Muscle
Vasodilating
Wall of Vessel
Figure 2
The ANS has the ability to monitor the amount of blood supply that goes to the surface of
the body by tightening or releasing tiny blood vessels or capillaries that go to the surface.
Those capillaries have muscles in their lining that can be restricted or opened. It is not
something we have conscious control of without practice. BFB or various relaxation techniques allow us to have that control. Controlling the blood supply has two purposes:
Blood
Vessel
Muscle
Vasodilating
Wall of Vessel
Figure 2
The ANS has the ability to monitor the amount of blood supply that goes to the surface of
the body by tightening or releasing tiny blood vessels or capillaries that go to the surface.
Those capillaries have muscles in their lining that can be restricted or opened. It is not
something we have conscious control of without practice. BFB or various relaxation techniques allow us to have that control. Controlling the blood supply has two purposes:
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1. Heat Management- If we are too hot, our body releases heat by opening blood vessels and letting heat out, which is what happens when we sweat. If we are cold, our
body constricts blood vessels to conserve heat and maintain our body temperature.
2. Dealing with Danger- If we are faced with danger where we have to fight or flee,
we need big muscle activity, which means the blood supply needs to be redistributed
to big muscles to get ready for action. The body is equipped to do this by shunting
blood from tiny blood vessels on the periphery to activate the big muscles. This process works well in an emergency but not when we deal with stress on a prolonged basis. In the days of the cave man, if we encountered a tiger, the ANS via the sympathetic
nervous system was activated, and the blood was shunted to the big muscles ready to
fight or flee. This was an appropriate response. Hans Selye (1956) identified the fight
or flight response and helped us to understand that even when the threat is between our
ears, our brains react as if it were a life and death issue, i.e., our brain cannot distinguish the difference between a life and death threat and a psychological threat. If we
are almost hit on the freeway, a fight or flight response would be appropriate. If we
are threatened by something our significant other or boss says to us, then moving into
a flight or flight response is probably inappropriate.
1. Heat Management- If we are too hot, our body releases heat by opening blood vessels and letting heat out, which is what happens when we sweat. If we are cold, our
body constricts blood vessels to conserve heat and maintain our body temperature.
2. Dealing with Danger- If we are faced with danger where we have to fight or flee,
we need big muscle activity, which means the blood supply needs to be redistributed
to big muscles to get ready for action. The body is equipped to do this by shunting
blood from tiny blood vessels on the periphery to activate the big muscles. This process works well in an emergency but not when we deal with stress on a prolonged basis. In the days of the cave man, if we encountered a tiger, the ANS via the sympathetic
nervous system was activated, and the blood was shunted to the big muscles ready to
fight or flee. This was an appropriate response. Hans Selye (1956) identified the fight
or flight response and helped us to understand that even when the threat is between our
ears, our brains react as if it were a life and death issue, i.e., our brain cannot distinguish the difference between a life and death threat and a psychological threat. If we
are almost hit on the freeway, a fight or flight response would be appropriate. If we
are threatened by something our significant other or boss says to us, then moving into
a flight or flight response is probably inappropriate.
Characteristics of Excessive Sympathetic Nervous System Activity (Time need-
Characteristics of Excessive Sympathetic Nervous System Activity (Time need-
I use previously prepared pages of a flip chart to give additional examples concerning the
functioning of the nervous system. Initially, I begin with the page titled Characteristics of
Excessive Sympathetic Nervous System Activity. I show clients during the mini-lecture how
the nervous system functions. I tell them that as the blood shifts away from the periphery
of the body toward the head or trunk, it causes excessive sympathetic nervous system activity. I go over each one with them to determine which characteristics they are aware of
having experienced.
I use previously prepared pages of a flip chart to give additional examples concerning the
functioning of the nervous system. Initially, I begin with the page titled Characteristics of
Excessive Sympathetic Nervous System Activity. I show clients during the mini-lecture how
the nervous system functions. I tell them that as the blood shifts away from the periphery
of the body toward the head or trunk, it causes excessive sympathetic nervous system activity. I go over each one with them to determine which characteristics they are aware of
having experienced.
Characteristics of Excessive Sympathetic
Nervous System Activity
• cold hands and feet
Characteristics of Excessive Sympathetic
Nervous System Activity
• cold hands and feet
• accelerated pulse rate (heart works faster)
• accelerated pulse rate (heart works faster)
• increased respiration rate (breathe more often)
• increased respiration rate (breathe more often)
• shallow respiration (don’t breathe as deeply)
• shallow respiration (don’t breathe as deeply)
• cool, perspiring hands
• cool, perspiring hands
• dilated pupils
• dilated pupils
• tight throat, dry throat
• tight throat, dry throat
• tense neck, upper back, shoulders raised
• tense neck, upper back, shoulders raised
• locked diaphragm (tight, tense)
• locked diaphragm (tight, tense)
• rigid pelvis
• rigid pelvis
• genital numbing
• genital numbing
• anus tightening
• anus tightening
ed: 3-5 minutes)
• leg muscle contractions
Flip Chart Page 1
ed: 3-5 minutes)
• leg muscle contractions
Flip Chart Page 1
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Characteristics of Tying into the Parasympathetic Nervous System (Time need-
Characteristics of Tying into the Parasympathetic Nervous System (Time need-
The next page of the flip chart is titled Characteristics of Tying into the Parasympathetic
Nervous System. I tell them that as they focus on their breathing and begin to move into a
relaxed state they activate the parasympathetic nervous system. Then, I show them this
page from my flip chart, and we go over each of the characteristics.
The next page of the flip chart is titled Characteristics of Tying into the Parasympathetic
Nervous System. I tell them that as they focus on their breathing and begin to move into a
relaxed state they activate the parasympathetic nervous system. Then, I show them this
page from my flip chart, and we go over each of the characteristics.
ed: 2-3 minutes)
Characteristics of Tying into the Parasympathetic Nervous System
ed: 2-3 minutes)
Characteristics of Tying into the Parasympathetic Nervous System
• feeling of heaviness
• warmth
• slower, deeper respiration (breathing)
• slower pulse rate (heart rate)
• feeling of heaviness
• warmth
• slower, deeper respiration (breathing)
• slower pulse rate (heart rate)
Flip Chart Page 2
Flip Chart Page 2
WHAT WILL YOU GET OUT OF IT? (Time needed: 3-5 minutes)
WHAT WILL YOU GET OUT OF IT? (Time needed: 3-5 minutes)
Subsequently, I move to the last page of the flip chart, What Will You Get Out of It? This
is useful for further emphasizing the value of the relaxation process.
Subsequently, I move to the last page of the flip chart, What Will You Get Out of It? This
is useful for further emphasizing the value of the relaxation process.
What Will You Get Out of It?
What Will You Get Out of It?
• increased well-being
• better able to cope
• higher energy level
• positive outlook on life
• sense of control
• lessening or elimination of pain
• better relationships
• more comfort in handling changes
• no longer feeling driven
• less helplessness and depression
• decreased tension level
• attitude changes
• altering of current beliefs to those more compatible to health
• a tool for communicating with the unconscious where many beliefs are buried
• more effective functioning of body organs
• skills for problem solving, goal setting, overcoming resentments, receptivity to your highest potential
Flip Chart Page 3
• increased well-being
• better able to cope
• higher energy level
• positive outlook on life
• sense of control
• lessening or elimination of pain
• better relationships
• more comfort in handling changes
• no longer feeling driven
• less helplessness and depression
• decreased tension level
• attitude changes
• altering of current beliefs to those more compatible to health
• a tool for communicating with the unconscious where many beliefs are buried
• more effective functioning of body organs
• skills for problem solving, goal setting, overcoming resentments, receptivity to your highest potential
Flip Chart Page 3
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After we have finished looking at this material, I answer any questions clients might have.
Then, I usually say the following:
There will not be any time for us to talk about other things in our next session. It will take the whole session for me to teach you the tensing and relaxing, walk you through the diaphragmatic breathing, do the relaxation
exercise, and then talk about what that was like for you. Finally, we will talk
a little bit about eustress, which is the good kind of stress. Do you have any
questions about this process? In this coming week, I would like you to take
a few moments to become aware of your breathing. Just check in two or
three times and note your breathing process.
After we have finished looking at this material, I answer any questions clients might have.
Then, I usually say the following:
There will not be any time for us to talk about other things in our next session. It will take the whole session for me to teach you the tensing and relaxing, walk you through the diaphragmatic breathing, do the relaxation
exercise, and then talk about what that was like for you. Finally, we will talk
a little bit about eustress, which is the good kind of stress. Do you have any
questions about this process? In this coming week, I would like you to take
a few moments to become aware of your breathing. Just check in two or
three times and note your breathing process.
If I have their permission, we set up an extra session or take their next scheduled appointment. When money is an issue, I do not schedule an extra appointment.
If I have their permission, we set up an extra session or take their next scheduled appointment. When money is an issue, I do not schedule an extra appointment.
I then direct their attention back to the issues that brought them to therapy.
I then direct their attention back to the issues that brought them to therapy.
SECOND TEACHING SESSION DETAILS (Time needed:
SECOND TEACHING SESSION DETAILS (Time needed:
45-50 minutes, or entire session)
45-50 minutes, or entire session)
Note: All forms can be reproduced for use with clients.
Note: All forms can be reproduced for use with clients.
I say the following to clients so they will know what to expect in this session.
In this session I will ask you to rate your tension level before and after you
do the relaxation exercise. We will practice tensing and relaxing each muscle group. Then, we will practice the diaphragmatic breathing. After this we
will do a progressive relaxation exercise and then talk about what that was
like for you. Finally, we will talk about eustress. Do you have any questions
at this point?
I say the following to clients so they will know what to expect in this session.
In this session I will ask you to rate your tension level before and after you
do the relaxation exercise. We will practice tensing and relaxing each muscle group. Then, we will practice the diaphragmatic breathing. After this we
will do a progressive relaxation exercise and then talk about what that was
like for you. Finally, we will talk about eustress. Do you have any questions
at this point?
I address any questions they might have. I give clients the General Tension Record, a form
to measure how tense and/or relaxed they currently are in order to increase their self awareness. (See Appendix A, this chapter.) It is an arbitrary measurement. I have them note the
categories (1-10) and choose which level indicates how they are presently feeling. At the
end of the session, using the same categories, I ask them to share which level fits them best.
Using this form, clients are given a homework assignment to rate themselves on a daily basis for the next couple of weeks.
I address any questions they might have. I give clients the General Tension Record, a form
to measure how tense and/or relaxed they currently are in order to increase their self awareness. (See Appendix A, this chapter.) It is an arbitrary measurement. I have them note the
categories (1-10) and choose which level indicates how they are presently feeling. At the
end of the session, using the same categories, I ask them to share which level fits them best.
Using this form, clients are given a homework assignment to rate themselves on a daily basis for the next couple of weeks.
TENSING AND RELAXING EXERCISES (Time needed: 6-7 minutes)
TENSING AND RELAXING EXERCISES (Time needed: 6-7 minutes)
The next thing that I do is hand them a paper called Tensing and Relaxing Muscle Group
Exercises that they can take home with them. (See Appendix B, this chapter.) I go through
each muscle group in turn asking them to tense and relax it. Most clients have no difficulty
doing the exercises. Elderly clients who have not been exposed to relaxation exercises may
experience some difficulty. I tell my clients the following:
If you have any neck or back problems, it is important to use caution. The
neck and back exercises should only be done in a way that is comfortable
for you. You should not do any exercise that feels uncomfortable to you. I
am going to walk you through a practice session of tensing and relaxing
your various muscle groups. I will do the tensing and relaxing at the same
time so you can see it being done in front of you. At this point, all we are
doing is practicing the “how to” of the exercises, so keeping your eyes open
except when tensing and relaxing the eye muscles will be helpful. To begin
The next thing that I do is hand them a paper called Tensing and Relaxing Muscle Group
Exercises that they can take home with them. (See Appendix B, this chapter.) I go through
each muscle group in turn asking them to tense and relax it. Most clients have no difficulty
doing the exercises. Elderly clients who have not been exposed to relaxation exercises may
experience some difficulty. I tell my clients the following:
If you have any neck or back problems, it is important to use caution. The
neck and back exercises should only be done in a way that is comfortable
for you. You should not do any exercise that feels uncomfortable to you. I
am going to walk you through a practice session of tensing and relaxing
your various muscle groups. I will do the tensing and relaxing at the same
time so you can see it being done in front of you. At this point, all we are
doing is practicing the “how to” of the exercises, so keeping your eyes open
except when tensing and relaxing the eye muscles will be helpful. To begin
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the process, I want you to tense and relax your forehead by wrinkling it up
or by frowning......
the process, I want you to tense and relax your forehead by wrinkling it up
or by frowning......
After walking clients through the exercises on the sheet called Tensing and Relaxing Muscle Group Exercises, I teach them the breathing exercise.
After walking clients through the exercises on the sheet called Tensing and Relaxing Muscle Group Exercises, I teach them the breathing exercise.
BREATHING EXERCISE (Time needed: 3-5 minutes)
BREATHING EXERCISE (Time needed: 3-5 minutes)
There are many different exercises to teach people to use their breathing process. I teach
diaphragmatic breathing. I walk clients through the breathing exercise by saying the following:
I want you to put your hand on your diaphragm just above your stomach.
With your hand still in place, I want you to breathe in through your nose and
out through your mouth into the diaphragm area. You may want to exaggerate your exhale with a little whoosh or you may prefer to just breathe normally. When you breathe in, your diaphragm goes out; when you breathe
out your diaphragm goes in. I want you to quietly breathe and see if you can
feel your diaphragm “going out” as you breathe in and your diaphragm
“going in” as you breathe out.
There are many different exercises to teach people to use their breathing process. I teach
diaphragmatic breathing. I walk clients through the breathing exercise by saying the following:
I want you to put your hand on your diaphragm just above your stomach.
With your hand still in place, I want you to breathe in through your nose and
out through your mouth into the diaphragm area. You may want to exaggerate your exhale with a little whoosh or you may prefer to just breathe normally. When you breathe in, your diaphragm goes out; when you breathe
out your diaphragm goes in. I want you to quietly breathe and see if you can
feel your diaphragm “going out” as you breathe in and your diaphragm
“going in” as you breathe out.
I have them practice the breathing process two or three times and then move on.
As you breathe in through your nose and out through your mouth, be aware
of breathing into the diaphragm area. Let your shoulders drop and be aware
if they are moving up and down as you breathe. If you are breathing from
your upper chest, your shoulders will be going up and down. I want you to
mentally say the word “relax” to yourself as you breathe in through your
nose and out through your mouth breathing into your diaphragm area.
I have them practice the breathing process two or three times and then move on.
As you breathe in through your nose and out through your mouth, be aware
of breathing into the diaphragm area. Let your shoulders drop and be aware
if they are moving up and down as you breathe. If you are breathing from
your upper chest, your shoulders will be going up and down. I want you to
mentally say the word “relax” to yourself as you take
breathe
each
inbreath
through
in your
through
nose andyour
out through
nose andyour
out mouth
throughbreathing
your mouth
intointo
your
your
diaphragm
diaphragm
area.
area.
Then I watch their body and say the word relax as they exhale. I do this 3-4 times until I
think they grasp the idea of diaphragmatic breathing.
As we do the relaxation exercise, I want you to breathe in through your nose
and out through your mouth breathing into the diaphragm area. I will remind you several times to help you to remember to breathe in this way.
Breathing is the most important part of relaxation. Focusing on your
breathing begins to move you into the parasympathetic nervous system and
into a state of relaxation. Are there any questions at this point?
Then I watch their body and say the word relax as they exhale. I do this 3-4 times until I
think they grasp the idea of diaphragmatic breathing.
As we do the relaxation exercise, I want you to breathe in through your nose
and out through your mouth breathing into the diaphragm area. I will remind you several times to help you to remember to breathe in this way.
Breathing is the most important part of relaxation. Focusing on your
breathing begins to move you into the parasympathetic nervous system and
into a state of relaxation. Are there any questions at this point?
DEEP MUSCLE RELAXATION EXERCISE (Time needed: about 20 min-
DEEP MUSCLE RELAXATION EXERCISE (Time needed: about 20 min-
utes)
utes)
Note: The Deep Muscle Relaxation Script in its entirety is provided in Appendix C, this chapter and can be used to lead clients through the exercise. I usually do not give this script to
clients.This script takes approximately 28 minutes if it is put on tape
Note: The Deep Muscle Relaxation Script in its entirety is provided in Appendix C, this chapter and can be used to lead clients through the exercise. I usually do not give this script to
clients.This script takes approximately 28 minutes if it is put on tape
It is important to create a climate of safety especially for those clients who may have a history of abuse or trauma. I tell clients what I am going to do and the order in which I am
going to do it so there are no surprises. I say the following to them:
Now I would like to lead you in a deep muscle progressive relaxation exercise. I want you to get comfortable in your chair. You may want to put both
of your feet on the floor and let your hands rest comfortably in your lap.
It is important to create a climate of safety especially for those clients who may have a history of abuse or trauma. I tell clients what I am going to do and the order in which I am
going to do it so there are no surprises. I say the following to them:
Now I would like to lead you in a deep muscle progressive relaxation exercise. I want you to get comfortable in your chair. You may want to put both
of your feet on the floor and let your hands rest comfortably in your lap.
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Would you like me to dim the lights? If it feels comfortable, I invite you to
close your eyes. If at any time you wish to open your eyes and check out your
surroundings or move your body, feel free to do so. If you wish to stop doing
the relaxation exercise at any point, please feel free to tell me. I want you to
breathe normally throughout the exercise — in through your nose and out
through your mouth breathing into the diaphragm area while you do the
tensing and relaxing exercises. When we have walked through each muscle
group, I will ask you to imagine the numbers 10 through 1 on a movie
screen, and then we will come to the end of the relaxation exercise. Do you
have any questions? Do you have any concerns?
Would you like me to dim the lights? If it feels comfortable, I invite you to
close your eyes. If at any time you wish to open your eyes and check out your
surroundings or move your body, feel free to do so. If you wish to stop doing
the relaxation exercise at any point, please feel free to tell me. I want you to
breathe normally throughout the exercise — in through your nose and out
through your mouth breathing into the diaphragm area while you do the
tensing and relaxing exercises. When we have walked through each muscle
group, I will ask you to imagine the numbers 10 through 1 on a movie
screen, and then we will come to the end of the relaxation exercise. Do you
have any questions? Do you have any concerns?
Address any questions or concerns before proceeding.
Address any questions or concerns before proceeding.
I follow the script using a normal voice. I remind them to breathe (in through their nose
and out through their mouth breathing into the diaphragm area) several times
throughout the relaxation exercise, although it is not in the script. As I walk through
the exercise with clients, I observe how they are responding to the directions. I am particularly interested in whether they are breathing diaphragmatically or from their chest. If they
are falling asleep, I make my voice a little louder and invite them to stay fully alert and
awake as they do these exercises. They may fall asleep anyhow, and if they do, I just keep
walking through the relaxation until the end. Sometimes clients move around a lot, and
sometimes they stay perfectly still. I want to give them lots of permission to figure out what
is right for them without any judgment or shaming on my part. Practice makes perfect!
They will gradually do it better and better if they continue to practice. I want them to have
a feeling of success if at all possible. At the end of the relaxation exercise, it is important
to give clients a couple of minutes to reorient themselves back into the room.
I follow the script using a normal voice. I remind them to breathe (in through their nose
and out through their mouth breathing into the diaphragm area) several times
throughout the relaxation exercise, although it is not in the script. As I walk through
the exercise with clients, I observe how they are responding to the directions. I am particularly interested in whether they are breathing diaphragmatically or from their chest. If they
are falling asleep, I make my voice a little louder and invite them to stay fully alert and
awake as they do these exercises. They may fall asleep anyhow, and if they do, I just keep
walking through the relaxation until the end. Sometimes clients move around a lot, and
sometimes they stay perfectly still. I want to give them lots of permission to figure out what
is right for them without any judgment or shaming on my part. Practice makes perfect!
They will gradually do it better and better if they continue to practice. I want them to have
a feeling of success if at all possible. At the end of the relaxation exercise, it is important
to give clients a couple of minutes to reorient themselves back into the room.
When they seem fully alert and awake, I ask them to rate themselves on the General Tension Record before we talk. Once again, how clients rate themselves is an arbitrary measurement.
When they seem fully alert and awake, I ask them to rate themselves on the General Tension Record before we talk. Once again, how clients rate themselves is an arbitrary measurement.
What Was It Like For You? (Time needed: 3-5 minutes)
What Was It Like For You? (Time needed: 3-5 minutes)
I ask clients the following questions to see what the progressive relaxation exercise was like
for them:
• Was there any difference between the rating you gave yourself before and now?
• What were the measurements?
• How did it feel to do this exercise?
• What did you like?
• What did you not like?
• Was there anything that felt good?
• Was there anything that did not feel good?
• Was there anything that was difficult in the process?
• Were there any surprises?
• Were there any new insights?
• Are there any questions?
• Overall, how do you feel about doing this exercise?
I ask clients the following questions to see what the progressive relaxation exercise was like
for them:
• Was there any difference between the rating you gave yourself before and now?
• What were the measurements?
• How did it feel to do this exercise?
• What did you like?
• What did you not like?
• Was there anything that felt good?
• Was there anything that did not feel good?
• Was there anything that was difficult in the process?
• Were there any surprises?
• Were there any new insights?
• Are there any questions?
• Overall, how do you feel about doing this exercise?
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Normalizing Feelings (Time needed: 3-5 minutes)
Normalizing Feelings (Time needed: 3-5 minutes)
I say the following kinds of things to clients to normalize feelings:
• If your mind wanders, just pull it back.
• You may feel light, heavy, tingling, or floating. (All are very normal feelings.)
• You may feel tense.
• You may feel nothing.
• It is okay to feel whatever you feel.
• The goal is not to go to sleep but rather to stay fully awake and alert.
• You may use this exercise before trying to sleep. It may help to bring down your anxiety or tension level enough to allow you to drift into sleep.
I say the following kinds of things to clients to normalize feelings:
• If your mind wanders, just pull it back.
• You may feel light, heavy, tingling, or floating. (All are very normal feelings.)
• You may feel tense.
• You may feel nothing.
• It is okay to feel whatever you feel.
• The goal is not to go to sleep but rather to stay fully awake and alert.
• You may use this exercise before trying to sleep. It may help to bring down your anxiety or tension level enough to allow you to drift into sleep.
Example
Example
A young woman was diagnosed with severe muscle tension. When other
treatments failed, she chose to be treated with biofeedback (BFB) coupled
with a progressive relaxation exercise. When she was attached to a BFB machine, she promptly went to sleep. The machine gave a biological readout
that showed her tension level to be very high as indicated by a shrill auditory
output. This was her normal sleep pattern. She stated that she would wake
up feeling as though she had fought the war on both sides and lost. She
often had headaches on awakening and always had a backache. She never
felt rested or calm. Over time, she learned to distinguish the difference between tension and relaxation in her body. Gradually, she learned how to relax her body so that she could lead a healthy life once again.
A young woman was diagnosed with severe muscle tension. When other
treatments failed, she chose to be treated with biofeedback (BFB) coupled
with a progressive relaxation exercise. When she was attached to a BFB machine, she promptly went to sleep. The machine gave a biological readout
that showed her tension level to be very high as indicated by a shrill auditory
output. This was her normal sleep pattern. She stated that she would wake
up feeling as though she had fought the war on both sides and lost. She
often had headaches on awakening and always had a backache. She never
felt rested or calm. Over time, she learned to distinguish the difference between tension and relaxation in her body. Gradually, she learned how to relax her body so that she could lead a healthy life once again.
Eustress vs. Distress (Time needed: 3-5 minutes)
Eustress vs. Distress (Time needed: 3-5 minutes)
After I have normalized their feelings I say the following kinds of things to clients:
Eustress is the good kind of stress. Eustress allows us to gear up to do a task.
If the task is setting the table, we probably do not need very much eustress.
If I am going to teach a class this afternoon, my level of eustress will be
higher. If I am still feeling a lot of stress tonight or tomorrow, I may have
moved into distress. If I stay distressed long enough, my body may move into
a state of panic. The goal is to bring our stress level down as a way of relaxing the body and mind. Ideally, we need to bring our stress level down
when it moves from eustress to stress. It is preferable to do this on a daily
basis by doing a relaxation exercise for 20 to 30 minutes. Doing relaxation
exercises helps keep the level of stress at a reasonable level and prevents a
state of distress or panic.
After I have normalized their feelings I say the following kinds of things to clients:
Eustress is the good kind of stress. Eustress allows us to gear up to do a task.
If the task is setting the table, we probably do not need very much eustress.
If I am going to teach a class this afternoon, my level of eustress will be
higher. If I am still feeling a lot of stress tonight or tomorrow, I may have
moved into distress. If I stay distressed long enough, my body may move into
a state of panic. The goal is to bring our stress level down as a way of relaxing the body and mind. Ideally, we need to bring our stress level down
when it moves from eustress to stress. It is preferable to do this on a daily
basis by doing a relaxation exercise for 20 to 30 minutes. Doing relaxation
exercises helps keep the level of stress at a reasonable level and prevents a
state of distress or panic.
(I draw a diagonal line on the board showing that when the stress level goes high enough,
it may become distress or panic. I draw a second diagonal line half as high and then draw
it coming back down as a way of symbolizing that we can keep our stress level out of the
distress or panic level by doing the relaxation training during the day - [Figure 3].) Stress
levels may go back up but not to a distress level.
People who maintain a continuously high level of tension in their bodies will
often experience a physiological withdrawal that may manifest itself as depression when they attempt to bring down their stress level. They can
(I draw a diagonal line on the board showing that when the stress level goes high enough,
it may become distress or panic. I draw a second diagonal line half as high and then draw
it coming back down as a way of symbolizing that we can keep our stress level out of the
distress or panic level by doing the relaxation training during the day - [Figure 3].) Stress
levels may go back up but not to a distress level.
People who maintain a continuously high level of tension in their bodies will
often experience a physiological withdrawal that may manifest itself as depression when they attempt to bring down their stress level. They can
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actually become addicted to the adrenalin high. If letting go or relaxing feels
like depression, they may choose to stay addicted to the adrenalin high.
People using relaxation exercises on a regular basis reap the benefits long
after they can no longer feel the effects in their body. When used regularly,
it is like having a nap and may feel even better. People often report that they
have higher energy and do not require as much sleep.
Panic
Distress
s
res
St
sin
Ri
actually become addicted to the adrenalin high. If letting go or relaxing feels
like depression, they may choose to stay addicted to the adrenalin high.
People using relaxation exercises on a regular basis reap the benefits long
after they can no longer feel the effects in their body. When used regularly,
it is like having a nap and may feel even better. People often report that they
have higher energy and do not require as much sleep.
g
s
res
St
sin
Ri
g
Do Relaxation
res
St
Do Relaxation
St
re
s
g
sin
i
sR
Panic
Distress
sF
all
in
g
Figure 3
res
St
St
re
s
g
sin
i
sR
sF
all
in
g
Figure 3
Homework Assignment (Time needed: 3-5 minutes)
Homework Assignment (Time needed: 3-5 minutes)
I then ask clients:
• Are you willing to do this relaxation exercise at home on a regular basis?
I then ask clients:
• Are you willing to do this relaxation exercise at home on a regular basis?
If the answer is affirmative, I usually say these kinds of things:
• It is helpful to practice relaxation daily if possible. There is no right time. It could be
in the morning, mid-day, evening, or before going to bed.
• When do you think would be a good time for you to practice?
• 20-30 minutes is enough but you can take longer if you wish. It is okay to spend longer on a muscle group. It is okay to go back to any muscle group if you want to relax it
more. Also, if you forget a muscle group, you can go back to it. There is no set order
for doing the exercises. Some people start at their feet and work up, which is the opposite of how I have taught to you.
• Some clients like to do these exercises lying down. It is okay to do them this way.
The neck and back exercises are a little more difficult to do, but you can figure out
what you can and cannot do in that position.
• Where is a good place for you to practice the relaxation exercises?
If the answer is affirmative, I usually say these kinds of things:
• It is helpful to practice relaxation daily if possible. There is no right time. It could be
in the morning, mid-day, evening, or before going to bed.
• When do you think would be a good time for you to practice?
• 20-30 minutes is enough but you can take longer if you wish. It is okay to spend longer on a muscle group. It is okay to go back to any muscle group if you want to relax it
more. Also, if you forget a muscle group, you can go back to it. There is no set order
for doing the exercises. Some people start at their feet and work up, which is the opposite of how I have taught to you.
• Some clients like to do these exercises lying down. It is okay to do them this way.
The neck and back exercises are a little more difficult to do, but you can figure out
what you can and cannot do in that position.
• Where is a good place for you to practice the relaxation exercises?
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• It is helpful to find a safe, quiet place at home and/or in your workplace to practice
the relaxation exercises. I would recommend a room where you can close the door.
However, this is not always possible. It is often helpful to turn on the answering machine and turn down the volume so you will not be disturbed. If others are home, ask
them not to disturb you.
• I would like you to rate yourself on the General Tension Record before and after you
do the relaxation exercise at home.
• Next week we will spend about 35-40 minutes doing the relaxation in the room and
answering any questions. The rest of the time we will have for talking.
• The week after that I will teach you the progressive relaxation exercise called Creating a Safe Place and invite you to create a safe place inside of you.
• When you can relax at home as well as you do here, then you do not need me to lead
you through it.
• Are there any questions?
• It is helpful to find a safe, quiet place at home and/or in your workplace to practice
the relaxation exercises. I would recommend a room where you can close the door.
However, this is not always possible. It is often helpful to turn on the answering machine and turn down the volume so you will not be disturbed. If others are home, ask
them not to disturb you.
• I would like you to rate yourself on the General Tension Record before and after you
do the relaxation exercise at home.
• Next week we will spend about 35-40 minutes doing the relaxation in the room and
answering any questions. The rest of the time we will have for talking.
• The week after that I will teach you the progressive relaxation exercise called Creating a Safe Place and invite you to create a safe place inside of you.
• When you can relax at home as well as you do here, then you do not need me to lead
you through it.
• Are there any questions?
If there are no questions, and there is any time left (which is unlikely) in the session, I direct
their attention back to the issues that brought them to therapy.
If there are no questions, and there is any time left (which is unlikely) in the session, I direct
their attention back to the issues that brought them to therapy.
When I have taught clients the relaxation process, I ask if they would like to try using an
audio tape. Some clients like a tape, as it helps to keep them focused. Other clients feel that
using a tape gets in their way. Some therapists like to make a relaxation tape for their clients
who prefer this modality. Clients often like to hear their therapist’s voice on tape. I have
provided scripts for the two progressive relaxation exercises used in this chapter (Appendices C and D). Appendix C offers a script that invites clients to actually tense and relax
each muscle group. Appendix D invites clients to mentally focus on relaxing each muscle
group as well as developing their safe place. Some therapists charge for their tapes; others
do not. I tell clients that they are welcome to try one of my tapes, and if they do not like it,
they can bring it back.
When I have taught clients the relaxation process, I ask if they would like to try using an
audio tape. Some clients like a tape, as it helps to keep them focused. Other clients feel that
using a tape gets in their way. Some therapists like to make a relaxation tape for their clients
who prefer this modality. Clients often like to hear their therapist’s voice on tape. I have
provided scripts for the two progressive relaxation exercises used in this chapter (Appendices C and D). Appendix C offers a script that invites clients to actually tense and relax
each muscle group. Appendix D invites clients to mentally focus on relaxing each muscle
group as well as developing their safe place. Some therapists charge for their tapes; others
do not. I tell clients that they are welcome to try one of my tapes, and if they do not like it,
they can bring it back.
THIRD TEACHING SESSION DETAILS (Time needed: 35-40
THIRD TEACHING SESSION DETAILS (Time needed: 35-40
minutes)
minutes)
CHECKING ON PRACTICE AT HOME (Time needed: 3-5 minutes)
CHECKING ON PRACTICE AT HOME (Time needed: 3-5 minutes)
I ask clients the following:
• Did you do the relaxation exercise?
I ask clients the following:
• Did you do the relaxation exercise?
If the answer is negative, I explore without judgment what that is about.
• Do you want to do it?
If the answer is negative, I explore without judgment what that is about.
• Do you want to do it?
Sometimes I have clients who have decided that they do not wish to do it. Many of my very
anxious clients have not been able to do the exercise initially. However, over time, I often
can get them to incorporate the diaphragmatic breathing or a few minutes of relaxation by
doing it in the room when they are very anxious.
• How often did you do the exercise?
• I hope you give yourself strokes for the times you did it. Good for you!
• When did you do it?
Sometimes I have clients who have decided that they do not wish to do it. Many of my very
anxious clients have not been able to do the exercise initially. However, over time, I often
can get them to incorporate the diaphragmatic breathing or a few minutes of relaxation by
doing it in the room when they are very anxious.
• How often did you do the exercise?
• I hope you give yourself strokes for the times you did it. Good for you!
• When did you do it?
160
160
• What was that like for you?
• Did you find you were able to relax?
• Did you have any problems?
• Do you have any thoughts or feelings about doing the relaxation exercise?
• What was that like for you?
• Did you find you were able to relax?
• Did you have any problems?
• Do you have any thoughts or feelings about doing the relaxation exercise?
DEEP MUSCLE RELAXATION EXERCISE (Time needed: about 20 min-
DEEP MUSCLE RELAXATION EXERCISE (Time needed: about 20 min-
utes)
I say the following to clients so they will know what to expect in the session:
utes)
I say the following to clients so they will know what to expect in the session:
As we did last time, I will ask you to rate your tension level before and after
you do the relaxation exercise. After we walk through the exercise, we will
talk about what that was like for you. Are there any questions?
As we did last time, I will ask you to rate your tension level before and after
you do the relaxation exercise. After we walk through the exercise, we will
talk about what that was like for you. Are there any questions?
I have clients rate themselves on the General Tension Record. (See Appendix A, this chapter.) Then I lead them through the Deep Muscle Relaxation exercise once again. (See Appendix C, this chapter.) At the close of the relaxation exercise, I ask clients to again rate
themselves on the General Tension Record. I am wanting to see if there is any movement
towards a more relaxed state.
I have clients rate themselves on the General Tension Record. (See Appendix A, this chapter.) Then I lead them through the Deep Muscle Relaxation exercise once again. (See Appendix C, this chapter.) At the close of the relaxation exercise, I ask clients to again rate
themselves on the General Tension Record. I am wanting to see if there is any movement
towards a more relaxed state.
I sometimes find it useful to repeat some of the questions or comments from the following
two sections.
I sometimes find it useful to repeat some of the questions or comments from the following
two sections.
What Was It Like For You?
What Was It Like For You?
Note: This section, coupled with the next section, takes about 3-5 minutes as you may not
use all of these questions this time.
• Was there any difference between the rating before and now?
• What were the measurements?
• How did it feel to do this exercise?
• What did you like?
• What did you not like?
• Was there anything that felt good?
• Was there anything that did not feel good?
• Was there anything that was difficult in the process?
• Were there any surprises?
• Were there any new insights?
• Are there any questions?
• Overall, how do you feel about doing this exercise?
Normalizing Feelings
• If your mind wanders, just pull it back.
• You may feel light, heavy, tingling, or floating. (All very normal feelings)
• You may feel tense.
• You may feel nothing.
Note: This section, coupled with the next section, takes about 3-5 minutes as you may not
use all of these questions this time.
• Was there any difference between the rating before and now?
• What were the measurements?
• How did it feel to do this exercise?
• What did you like?
• What did you not like?
• Was there anything that felt good?
• Was there anything that did not feel good?
• Was there anything that was difficult in the process?
• Were there any surprises?
• Were there any new insights?
• Are there any questions?
• Overall, how do you feel about doing this exercise?
Normalizing Feelings
• If your mind wanders, just pull it back.
• You may feel light, heavy, tingling, or floating. (All very normal feelings)
• You may feel tense.
• You may feel nothing.
161
• It is okay to feel whatever you feel.
• The goal is not to go to sleep but rather to stay fully awake and alert.
• You may use this exercise before trying to sleep. It may help to bring down your anxiety or
tension level enough to allow you to drift into sleep.
Homework Assignment (Time needed: 3-5 minutes)
I would invite you to take the time to practice the Deep Muscle Relaxation exercise
several times this week.
I would like you to rate yourself on the General Tension Record before and after you
do the relaxation exercise at home.
Next week we will spend about 30-35 minutes doing the relaxation exercise called
Creating a Safe Place. In this progressive relaxation exercise, I will ask you to focus
on the different muscle groups and tell them to relax. I will ask you to say two different affirmations to yourself. Then, I will invite you to create a safe place inside
of yourself. If you are doing okay at that point, we will not do any more practicing
in our sessions. Do you have any questions?
161
• It is okay to feel whatever you feel.
• The goal is not to go to sleep but rather to stay fully awake and alert.
• You may use this exercise before trying to sleep. It may help to bring down your anxiety or
tension level enough to allow you to drift into sleep.
Homework Assignment (Time needed: 3-5 minutes)
I would invite you to take the time to practice the Deep Muscle Relaxation exercise
several times this week.
I would like you to rate yourself on the General Tension Record before and after you
do the relaxation exercise at home.
Next week we will spend about 30-35 minutes doing the relaxation exercise called
Creating a Safe Place. In this progressive relaxation exercise, I will ask you to focus
on the different muscle groups and tell them to relax. I will ask you to say two different affirmations to yourself. Then, I will invite you to create a safe place inside
of yourself. If you are doing okay at that point, we will not do any more practicing
in our sessions. Do you have any questions?
Then, I direct their attention back to the issues that brought them to therapy.
Then, I direct their attention back to the issues that brought them to therapy.
FOURTH TEACHING SESSION DETAILS (Time needed: 30-35
FOURTH TEACHING SESSION DETAILS (Time needed: 30-35
minutes)
minutes)
In this session I check in with clients to see how they did the past week on the relaxation exercise.
I repeat Checking On Practice at Home in much the same way as I did in the Third Teaching Session.
In this session I check in with clients to see how they did the past week on the relaxation exercise.
I repeat Checking On Practice at Home in much the same way as I did in the Third Teaching Session.
CHECKING ON PRACTICE AT HOME (Time needed: 3-5 minutes)
CHECKING ON PRACTICE AT HOME (Time needed: 3-5 minutes)
• Did you do the relaxation exercise?
• Do you want to do it?
• How often did you do it?
• I hope you give yourself strokes for the times you did it. Good for you!
• When did you do it?
• What was that like for you?
• Did you find that you were able to relax?
• Did you have any problems?
• Which exercise did you do?
• Did you listen to the other exercise?
• Do you have any thoughts or feelings about the process?
• Did you do the relaxation exercise?
• Do you want to do it?
• How often did you do it?
• I hope you give yourself strokes for the times you did it. Good for you!
• When did you do it?
• What was that like for you?
• Did you find that you were able to relax?
• Did you have any problems?
• Which exercise did you do?
• Did you listen to the other exercise?
• Do you have any thoughts or feelings about the process?
CREATING A SAFE PLACE RELAXATION EXERCISE (Time needed: 15-18
CREATING A SAFE PLACE RELAXATION EXERCISE (Time needed: 15-18
minutes)
minutes)
Again, I ask clients to rate themselves on the General Tension Record. (See Appendix A, this
Again, I ask clients to rate themselves on the General Tension Record. (See Appendix A, this
162
162
chapter.) I then introduce and teach them the relaxation exercise called Creating a Safe Place.
(See Appendix D, this chapter.) This is a full script that can be photocopied and used to lead
clients through the relaxation exercise. I usually do not give it to clients. This script takes approximately 18 minutes if it is put on tape.
chapter.) I then introduce and teach them the relaxation exercise called Creating a Safe Place.
(See Appendix D, this chapter.) This is a full script that can be photocopied and used to lead
clients through the relaxation exercise. I usually do not give it to clients. This script takes approximately 18 minutes if it is put on tape.
Note: Clients who do not choose to participate in the relaxation exercises may be able to develop
a safe place in other ways. See Alternative Ways of Developing a Safe Place later in this chapter.
Note: Clients who do not choose to participate in the relaxation exercises may be able to develop
a safe place in other ways. See Alternative Ways of Developing a Safe Place later in this chapter.
I say the following kinds of things to clients so they will know what to expect as we do this
exercise:
In this exercise I will invite you to focus on your breathing and then ask you, in
turn, to relax each muscle group. Then I will ask you to create an image of a
safe place inside your mind. It may be somewhere you have or have not been. It
can be indoors or outside. Just see what comes to you.
I say the following kinds of things to clients so they will know what to expect as we do this
exercise:
In this exercise I will invite you to focus on your breathing and then ask you, in
turn, to relax each muscle group. Then I will ask you to create an image of a
safe place inside your mind. It may be somewhere you have or have not been. It
can be indoors or outside. Just see what comes to you.
Note: Some clients will already have a safe place that they go to inside of themselves. If they
are willing to share it with me, I then invite them to go to that place as I lead them through the
relaxation exercise.
Note: Some clients will already have a safe place that they go to inside of themselves. If they
are willing to share it with me, I then invite them to go to that place as I lead them through the
relaxation exercise.
Finally, I will invite you to say the following two affirmations to yourself:
Every day in every way I am getting better.
I accept myself completely here and now.
(Feel free to substitute different affirmations. See Suggestions for Using Affirmations later in this chapter.) Then the relaxation will come to a close.
Finally, I will invite you to say the following two affirmations to yourself:
Every day in every way I am getting better.
I accept myself completely here and now.
(Feel free to substitute different affirmations. See Suggestions for Using Affirmations later in this chapter.) Then the relaxation will come to a close.
When I have finished leading them through the relaxation exercise, I ask them to rate themselves on the General Tension Record. Then I ask how they felt about doing this exercise.
When I have finished leading them through the relaxation exercise, I ask them to rate themselves on the General Tension Record. Then I ask how they felt about doing this exercise.
Evaluating the Exercise Experience (Time needed: 5-10 minutes)
Evaluating the Exercise Experience (Time needed: 5-10 minutes)
I ask the following questions:
• What was that like for you?
I ask the following questions:
• What was that like for you?
• Did you like thinking the muscles tense and relaxed or actually tensing and relaxing
them?
• Did you like thinking the muscles tense and relaxed or actually tensing and relaxing
them?
In the future, whenever I do a relaxation exercise with clients, I use the exercise they prefer. If
there is no preference, I may use either one depending on the time factor and their need. Additional questions that I ask regarding their ability to create a safe place are:
• Were you able to create a safe place for yourself?
• Would you be comfortable sharing your safe place with me?
In the future, whenever I do a relaxation exercise with clients, I use the exercise they prefer. If
there is no preference, I may use either one depending on the time factor and their need. Additional questions that I ask regarding their ability to create a safe place are:
• Were you able to create a safe place for yourself?
• Would you be comfortable sharing your safe place with me?
Note: It is important to be respectful if the client’s response is negative. The therapist does not
have to know the details of the safe place to lead clients through a relaxation exercise. Usually,
clients are comfortable sharing their safe place.
Note: It is important to be respectful if the client’s response is negative. The therapist does not
have to know the details of the safe place to lead clients through a relaxation exercise. Usually,
clients are comfortable sharing their safe place.
• Could you engage your senses?
• What could you touch or feel tactilely?
• What sounds did you hear?
• What did you see?
• Were there things you could taste?
• Could you engage your senses?
• What could you touch or feel tactilely?
• What sounds did you hear?
• What did you see?
• Were there things you could taste?
163
• Were there any smells?
• How did it feel to be in this safe place?
• How old were you? Were you your present age or younger?
• Were you alone or with someone?
• Did that person feel safe to you?
163
• Were
• Were
there
there
anyany
smells?
smells?
• How
• How
did did
it feel
it feel
to be
to in
bethis
in this
safesafe
place?
place?
• How
• How
old old
were
were
you?
you?
Were
Were
youyou
youryour
present
present
ageage
or younger?
or younger?
• Were
• Were
youyou
alone
alone
or with
or with
someone?
someone?
• Did
• Did
thatthat
person
person
feelfeel
safesafe
to you?
to you?
Examples of Safe Places
Examples
Examples
of Safe
of Safe
Places
Places
Sometimes clients include people in their safe place with whom they do not feel safe and thus
sabotage themselves. If this happens, you can suggest that they choose someone with whom
they do feel safe. Sometimes, clients have someone with them like a wise old woman or man,
an animal, a beloved pet, God or Christ, a grandparent, or favorite relative. Often they choose
to be alone. It is frequently helpful for clients to image the child part of themselves in this safe
place. Some of the locations that clients have created for themselves are as follows:
• meadows
• mountains
• forests
• beside a lake, river, or stream
• the ocean
• mountain caves
• penthouse apartment
• safe room inside of a house
• room with a fireplace
• sitting on a rock
Sometimes
Sometimes
clients
clients
include
include
people
people
in their
in their
safesafe
place
place
withwith
whom
whom
theythey
do not
do not
feelfeel
safesafe
andand
thusthus
sabotage
sabotage
themselves.
themselves.
If this
If this
happens,
happens,
youyou
cancan
suggest
suggest
thatthat
theythey
choose
choose
someone
someone
withwith
whom
whom
theythey
do feel
do feel
safe.safe.
Sometimes,
Sometimes,
clients
clients
havehave
someone
someone
withwith
them
them
likelike
a wise
a wise
old old
woman
woman
or man,
or man,
an animal,
an animal,
a beloved
a beloved
pet,pet,
GodGod
or Christ,
or Christ,
a grandparent,
a grandparent,
or favorite
or favorite
relative.
relative.
Often
Often
theythey
choose
choose
to be
toalone.
be alone.
It isItfrequently
is frequently
helpful
helpful
for clients
for clients
to image
to image
the the
child
child
partpart
of themselves
of themselves
in this
in this
safesafe
place.
place.
Some
Some
of the
of the
locations
locations
thatthat
clients
clients
havehave
created
created
for for
themselves
themselves
are are
as follows:
as follows:
• meadows
• meadows
• mountains
• mountains
• forests
• forests
• beside
• beside
a lake,
a lake,
river,
river,
or stream
or stream
• the• the
ocean
ocean
• mountain
• mountain
caves
caves
• penthouse
• penthouse
apartment
apartment
• safe
• safe
room
room
inside
inside
of aofhouse
a house
• room
• room
withwith
a fireplace
a fireplace
• sitting
• sitting
on aonrock
a rock
At first, clients may have difficulty creating a safe place. However, with practice, they are usually able to create a safe place inside themselves.
At first,
At first,
clients
clients
maymay
havehave
difficulty
difficulty
creating
creating
a safe
a safe
place.
place.
However,
However,
withwith
practice,
practice,
theythey
are are
usu-usuallyally
ableable
to create
to create
a safe
a safe
place
place
inside
inside
themselves.
themselves.
Homework Assignment (Time needed: 3-5 minutes)
(Time
(Time
needed:
needed:
3-5 3-5
minutes)
minutes)
Homework
Homework
Assignment
Assignment
I then ask clients if they would like to create a safe place as a regular part of their relaxation
process. If the answer is affirmative, I ask/say:
• Which relaxation exercise do you wish to use?
• Would you like to practice more in further sessions or are you feeling comfortable on
your own? (If clients are feeling comfortable doing the relaxation on their own, we do no
further development of a safe place in session.)
• I would encourage you to take time on a daily basis to do the relaxation exercises coupled with creating a safe place on your own.
I then
I then
ask ask
clients
clients
if they
if they
would
would
likelike
to create
to create
a safe
a safe
place
place
as aasregular
a regular
partpart
of their
of their
relaxation
relaxation
process.
process.
If the
If the
answer
answer
is affirmative,
is affirmative,
I ask/say:
I ask/say:
• Which
• Which
relaxation
relaxation
exercise
exercise
do you
do you
wishwish
to use?
to use?
• Would
• Would
youyou
likelike
to practice
to practice
more
more
in further
in further
sessions
sessions
or are
or are
youyou
feeling
feeling
comfortable
comfortable
on on
youryour
own?
own?
(If clients
(If clients
are are
feeling
feeling
comfortable
comfortable
doing
doing
the the
relaxation
relaxation
on their
on their
own,
own,
we do
we no
do no
further
further
development
development
of aofsafe
a safe
place
place
in session.)
in session.)
• I would
• I would
encourage
encourage
youyou
to take
to take
timetime
on aondaily
a daily
basis
basis
to do
to the
do the
relaxation
relaxation
exercises
exercises
cou-coupledpled
withwith
creating
creating
a safe
a safe
place
place
on your
on your
own.
own.
From time to time in future sessions, I check in and see how they are doing. In times of crisis,
I especially want to check in with them. When under stress, we regress. It can be helpful to get
them jump-started again.
From
From
timetime
to time
to time
in future
in future
sessions,
sessions,
I check
I check
in and
in and
see see
howhow
theythey
are are
doing.
doing.
In times
In times
of crisis,
of crisis,
I especially
I especially
want
want
to check
to check
in with
in with
them.
them.
When
When
under
under
stress,
stress,
we regress.
we regress.
It can
It can
be helpful
be helpful
to get
to get
them
them
jump-started
jump-started
again.
again.
ADDITIONAL WAYS OF CREATING SAFETY
ADDITIONAL
ADDITIONAL
WAYS
WAYS
OFOF
CREATING
CREATING
SAFETY
SAFETY
ALTERNATIVE WAYS OF DEVELOPING SAFE PLACES
ALTERNATIVE
ALTERNATIVE
WAYS
WAYS
OFOF
DEVELOPING
DEVELOPING
SAFE
SAFE
PLACES
PLACES
Creating an Actual Safe Place
Creating
Creating
an an
Actual
Actual
Safe
Safe
Place
Place
Therapists can encourage clients to create an actual safe place where clients can go when they
feel scared, out of control, or very vulnerable. Usually, this safe place is in the client’s home.
For some clients, their safe place might be their bedroom or a favorite room in their home. It
can be any place where they can create a sanctuary for themselves. Some clients can do this,
Therapists
Therapists
cancan
encourage
encourage
clients
clients
to create
to create
an actual
an actual
safesafe
place
place
where
where
clients
clients
cancan
go when
go when
theythey
feelfeel
scared,
scared,
out out
of control,
of control,
or very
or very
vulnerable.
vulnerable.
Usually,
Usually,
thisthis
safesafe
place
place
is inisthe
in the
client’s
client’s
home.
home.
ForFor
some
some
clients,
clients,
theirtheir
safesafe
place
place
might
might
be their
be their
bedroom
bedroom
or aorfavorite
a favorite
room
room
in their
in their
home.
home.
It It
cancan
be any
be any
place
place
where
where
theythey
cancan
create
create
a sanctuary
a sanctuary
for for
themselves.
themselves.
Some
Some
clients
clients
cancan
do this,
do this,
164
164
and some cannot. I might ask clients the following:
• Is there a safe place that you can go to inside your home?
• Are you willing to take the child within you to this safe place when you are feeling scared,
out of control, or fearful of what you might do?
• What kinds of things can you do for yourself in this safe place?
andand
some
some
cannot.
cannot.
I might
I might
askask
clients
clients
thethe
following:
following:
• Is• there
Is there
a safe
a safe
place
place
thatthat
youyou
cancan
go go
to inside
to inside
your
your
home?
home?
• Are
• Are
youyou
willing
willing
to take
to take
thethe
child
child
within
within
youyou
to this
to this
safe
safe
place
place
when
when
youyou
areare
feeling
feeling
scared,
scared,
outout
of of
control,
control,
or or
fearful
fearful
of of
what
what
youyou
might
might
do?do?
• What
• What
kinds
kinds
of of
things
things
cancan
youyou
do do
forfor
yourself
yourself
in this
in this
safe
safe
place?
place?
Example
Example
Example
A therapist saw a young woman who had a lot of abandonment issues from
childhood. When they first began to work together, the client engaged in behaviors that put her at risk. She lived with her family. Her bedroom became
her place of sanctuary. She utilized a number of things to soothe herself.
She often did a relaxation exercise. Sometimes she played music that
soothed her. She frequently journaled about her feelings. There were times
she held her favorite stuffed animal and talked to the child within her. These
kinds of exercises often soothed her enough to be able to get through her
day. Occasionally, when she was in a fragile place emotionally, she would
call and ask for support. Being able to soothe herself kept her from engaging
in destructive or dangerous behaviors. It also allowed her to need less support from the therapist outside of sessions.
A therapist
A therapist
saw
saw
a young
a young
woman
woman
who
who
hadhad
a lot
a lot
of abandonment
of abandonment
issues
issues
from
from
childhood.
childhood.
When
When
they
they
first
first
began
began
to work
to work
together,
together,
thethe
client
client
engaged
engaged
in bein behaviors
haviors
that
that
putput
herher
at risk.
at risk.
SheShe
lived
lived
with
with
herher
family.
family.
HerHer
bedroom
bedroom
became
became
herher
place
place
of sanctuary.
of sanctuary.
SheShe
utilized
utilized
a number
a number
of things
of things
to to
soothe
soothe
herself.
herself.
SheShe
often
often
diddid
a relaxation
a relaxation
exercise.
exercise.
Sometimes
Sometimes
sheshe
played
played
music
music
that
that
soothed
soothed
her.her.
SheShe
frequently
frequently
journaled
journaled
about
about
herher
feelings.
feelings.
There
There
were
were
times
times
sheshe
held
held
herher
favorite
favorite
stuffed
stuffed
animal
animal
andand
talked
talked
to the
to the
child
child
within
within
her.her.
These
These
kinds
kinds
of exercises
of exercises
often
often
soothed
soothed
herher
enough
enough
to to
be be
able
able
to to
getget
through
through
herher
day.
day.
Occasionally,
Occasionally,
when
when
sheshe
was
was
in ainfragile
a fragile
place
place
emotionally,
emotionally,
sheshe
would
would
callcall
andand
askask
forfor
support.
support.
Being
Being
able
able
to soothe
to soothe
herself
herself
kept
kept
herher
from
from
engaging
engaging
in destructive
in destructive
or or
dangerous
dangerous
behaviors.
behaviors.
It also
It also
allowed
allowed
herher
to need
to need
lessless
supsupport
port
from
from
thethe
therapist
therapist
outside
outside
of sessions.
of sessions.
For some clients herbs, incense, or rituals are important to use to clear or cleanse their safe place
or for healing purposes. It may be helpful to explore with clients whether there are cultural or spiritual activities in which they might engage that would increase their safety level. Doing this kind
of exploration shows interest in their world and may bring forth powerful symbols of healing that
clients can use to increase their safety level.
ForFor
some
some
clients
clients
herbs,
herbs,
incense,
incense,
or or
rituals
rituals
areare
important
important
to use
to use
to clear
to clear
or or
cleanse
cleanse
their
their
safe
safe
place
place
or for
or for
healing
healing
purposes.
purposes.
It may
It may
be be
helpful
helpful
to explore
to explore
with
with
clients
clients
whether
whether
there
there
areare
cultural
cultural
or spiror spiritual
itual
activities
activities
in which
in which
they
they
might
might
engage
engage
thatthat
would
would
increase
increase
their
their
safety
safety
level.
level.
Doing
Doing
thisthis
kind
kind
of exploration
of exploration
shows
shows
interest
interest
in their
in their
world
world
andand
may
may
bring
bring
forth
forth
powerful
powerful
symbols
symbols
of healing
of healing
thatthat
clients
clients
cancan
useuse
to increase
to increase
their
their
safety
safety
level.
level.
Note: For clients who are currently being abused or battered and have not decided to permanently
leave their significant other, having a place where they can go outside their home is very important
(shelters, friends, malls, etc.).
Note:
Note:
ForFor
clients
clients
whowho
areare
currently
currently
being
being
abused
abused
or battered
or battered
andand
have
have
not not
decided
decided
to permanently
to permanently
leave
leave
theirtheir
significant
significant
other,
other,
having
having
a place
a place
where
where
theythey
cancan
go outside
go outside
theirtheir
home
home
is very
is very
important
important
(shelters,
(shelters,
friends,
friends,
malls,
malls,
etc.).
etc.).
Drawing a Safe Place
Drawing
Drawing
a Safe
a Safe
Place
Place
Sometimes, I have clients who do not choose to use the relaxation process or create a safe place
inside of themselves that they can go to in time of need. I may invite them to draw a safe place for
themselves by asking the following:
• Would you be willing to draw a safe place?
Sometimes,
Sometimes,
I have
I have
clients
clients
who
who
do do
notnot
choose
choose
to use
to use
thethe
relaxation
relaxation
process
process
or or
create
create
a safe
a safe
place
place
inside
inside
of themselves
of themselves
thatthat
they
they
cancan
go go
to in
to time
in time
of need.
of need.
I may
I may
invite
invite
them
them
to draw
to draw
a safe
a safe
place
place
forfor
themselves
themselves
by by
asking
asking
thethe
following:
following:
• Would
• Would
youyou
be be
willing
willing
to draw
to draw
a safe
a safe
place?
place?
If the answer is affirmative, I say to them:
• I would like you to draw a safe place for yourself.
• I would like you to do this drawing in any way that feels comfortable to you.
• I would like you to be aware of any feelings that come up as you make this drawing.
• Would you be comfortable sharing with me what you have drawn?
If the
If the
answer
answer
is affirmative,
is affirmative,
I say
I say
to them:
to them:
• I •would
I would
likelike
youyou
to draw
to draw
a safe
a safe
place
place
forfor
yourself.
yourself.
• I •would
I would
likelike
youyou
to do
to do
thisthis
drawing
drawing
in any
in any
way
way
thatthat
feels
feels
comfortable
comfortable
to you.
to you.
• I •would
I would
likelike
youyou
to be
to be
aware
aware
of of
anyany
feelings
feelings
thatthat
come
come
up up
as as
youyou
make
make
thisthis
drawing.
drawing.
• Would
• Would
youyou
be be
comfortable
comfortable
sharing
sharing
with
with
meme
what
what
youyou
have
have
drawn?
drawn?
If, the answer is affirmative, then the following questions are helpful:
• Can you tell me about what you have drawn?
• Is this a place you have been to or one that only exists inside of you?
• What did you feel as you drew it?
• What was it like to draw a safe place?
• How did it feel to tell me about it?
If, If,
thethe
answer
answer
is affirmative,
is affirmative,
then
then
thethe
following
following
questions
questions
areare
helpful:
helpful:
• Can
• Can
youyou
telltell
meme
about
about
what
what
youyou
have
have
drawn?
drawn?
• Is• this
Is this
a place
a place
youyou
have
have
been
been
to or
to or
oneone
thatthat
only
only
exists
exists
inside
inside
of of
you?
you?
• What
• What
diddid
youyou
feelfeel
as as
youyou
drew
drew
it? it?
• What
• What
waswas
it like
it like
to draw
to draw
a safe
a safe
place?
place?
• How
• How
diddid
it feel
it feel
to tell
to tell
meme
about
about
it? it?
165
• Is there any way you can use this image to help you increase your safety level?
165
• Is• there
Is there
anyany
way
way
youyou
cancan
useuse
thisthis
image
image
to help
to help
youyou
increase
increase
your
your
safety
safety
level?
level?
The following process could be used to further engage clients’ senses in creating an internal safe
place. Or, clients could be invited to imagine a safe place without any reference to the drawing exercise.
TheThe
following
following
process
process
could
could
be be
used
used
to further
to further
engage
engage
clients’
clients’
senses
senses
in creating
in creating
an an
internal
internal
safe
safe
place.
place.
Or,Or,
clients
clients
could
could
be be
invited
invited
to imagine
to imagine
a safe
a safe
place
place
without
without
anyany
reference
reference
to the
to the
drawing
drawing
ex-exercise.
ercise.
Imaging a Safe Place
Imaging
Imaging
a Safe
a Safe
Place
Place
I ask clients if they would be comfortable closing their eyes and imaging the safe place that they
drew on paper. I want to see if they can engage their senses as fully as possible. If clients are able
to get an image, then I invite them to tell me about it. If they seem to be having difficulty, I might
say the following kinds of things:
Take a few moments and look around and enjoy seeing what is in your safe place.
Let yourself hear the sounds in this safe place that you have created. Allow yourself
to be aware of any smells or scents, and let yourself smell them. Notice if there are
any textures that you can touch or that are touching your body. Let your body feel
them. Be aware of what you are feeling inside as you image yourself in this safe
place. Allow yourself to feel warm, comfortable, and safe. If this is a place that feels
safe, you can return whenever you choose to recapture these feelings. Open your
eyes and give yourself a moment to re-orient yourself in the room.
I then ask the following kinds of questions:
• What are you feeling?
• Were you able to get an image of the safe place that you drew?
• What was that like for you?
• Could you engage each of your senses?
• Do you feel comfortable telling me about your image?
I ask
I ask
clients
clients
if they
if they
would
would
be be
comfortable
comfortable
closing
closing
their
their
eyes
eyes
andand
imaging
imaging
thethe
safe
safe
place
place
thatthat
they
they
drew
drew
on on
paper.
paper.
I want
I want
to see
to see
if they
if they
cancan
engage
engage
their
their
senses
senses
as fully
as fully
as possible.
as possible.
If clients
If clients
areare
able
able
to get
to get
an an
image,
image,
then
then
I invite
I invite
them
them
to tell
to tell
meme
about
about
it. If
it. they
If they
seem
seem
to be
to be
having
having
difficulty,
difficulty,
I might
I might
saysay
thethe
following
following
kinds
kinds
of of
things:
things:
Take
Take
a few
a few
moments
moments
andand
look
look
around
around
andand
enjoy
enjoy
seeing
seeing
what
what
is in
is your
in your
safe
safe
place.
place.
LetLet
yourself
yourself
hear
hear
thethe
sounds
sounds
in this
in this
safe
safe
place
place
thatthat
youyou
have
have
created.
created.
Allow
Allow
yourself
yourself
to be
to be
aware
aware
of any
of any
smells
smells
or or
scents,
scents,
andand
let let
yourself
yourself
smell
smell
them.
them.
Notice
Notice
if there
if there
areare
anyany
textures
textures
thatthat
youyou
cancan
touch
touch
or or
thatthat
areare
touching
touching
your
your
body.
body.
LetLet
your
your
body
body
feelfeel
them.
them.
BeBe
aware
aware
of what
of what
youyou
areare
feeling
feeling
inside
inside
as as
youyou
image
image
yourself
yourself
in this
in this
safe
safe
place.
place.
Allow
Allow
yourself
yourself
to feel
to feel
warm,
warm,
comfortable,
comfortable,
andand
safe.
safe.
If this
If this
is aisplace
a place
thatthat
feels
feels
safe,
safe,
youyou
cancan
return
return
whenever
whenever
youyou
choose
choose
to recapture
to recapture
these
these
feelings.
feelings.
Open
Open
your
your
eyes
eyes
andand
give
give
yourself
yourself
a moment
a moment
to re-orient
to re-orient
yourself
yourself
in the
in the
room.
room.
I then
I then
askask
thethe
following
following
kinds
kinds
of of
questions:
questions:
• What
• What
areare
youyou
feeling?
feeling?
• Were
• Were
youyou
able
able
to get
to get
an an
image
image
of of
thethe
safe
safe
place
place
thatthat
youyou
drew?
drew?
• What
• What
waswas
thatthat
likelike
forfor
you?
you?
• Could
• Could
youyou
engage
engage
each
each
of of
your
your
senses?
senses?
• Do
• Do
youyou
feelfeel
comfortable
comfortable
telling
telling
meme
about
about
your
your
image?
image?
If there was a feeling of success, I then ask clients if they are willing to take a few minutes each
day to imagine their safe place.
If there
If there
waswas
a feeling
a feeling
of of
success,
success,
I then
I then
askask
clients
clients
if they
if they
areare
willing
willing
to take
to take
a few
a few
minutes
minutes
each
each
dayday
to imagine
to imagine
their
their
safe
safe
place.
place.
SELF-SOOTHING ACTIVITIES
SELF-SOOTHING
SELF-SOOTHING
ACTIVITIES
ACTIVITIES
Creating a List of Self-Soothing Activities
Creating
Creating
a List
a List
of of
Self-Soothing
Self-Soothing
Activities
Activities
It is particularly useful to help clients develop a list of self-soothing activities that they can engage
in to care for themselves on a regular basis. It has been my experience that clients usually need to
do this in session with the therapist offering appropriate input. I normally ask clients what kinds
of things they are doing to self-soothe or comfort themselves. I affirm what they are already doing
to care for themselves. I give them a pencil and piece of paper and ask them to write down these
self-soothing activities. Then, I ask them what else they could do or would like to do to soothe
themselves. As they think of things, I offer suggestions with the hope that they will expand their
repertoire. Some clients come up with a number of self-soothing activities to add to their list. I have
found it helpful to have a list of activities in front of me when I am working with clients to create
their own list. I have included a suggested list of self-soothing activities that has been compiled
over the years. (See Appendix E, this chapter.) This list may be copied and sent home with clients.
It has been my experience that when clients need to self-soothe, they often experience difficulty
remembering ways they might soothe themselves.
It isItparticularly
is particularly
useful
useful
to help
to help
clients
clients
develop
develop
a list
a list
of self-soothing
of self-soothing
activities
activities
thatthat
they
they
cancan
engage
engage
in to
in care
to care
forfor
themselves
themselves
on on
a regular
a regular
basis.
basis.
It has
It has
been
been
mymy
experience
experience
thatthat
clients
clients
usually
usually
need
need
to to
do do
thisthis
in session
in session
with
with
thethe
therapist
therapist
offering
offering
appropriate
appropriate
input.
input.
I normally
I normally
askask
clients
clients
what
what
kinds
kinds
of things
of things
they
they
areare
doing
doing
to self-soothe
to self-soothe
or comfort
or comfort
themselves.
themselves.
I affirm
I affirm
what
what
they
they
areare
already
already
doing
doing
to care
to care
forfor
themselves.
themselves.
I give
I give
them
them
a pencil
a pencil
andand
piece
piece
of of
paper
paper
andand
askask
them
them
to write
to write
down
down
these
these
self-soothing
self-soothing
activities.
activities.
Then,
Then,
I ask
I ask
them
them
what
what
elseelse
they
they
could
could
do do
or or
would
would
likelike
to do
to do
to soothe
to soothe
themselves.
themselves.
AsAs
they
they
think
think
of of
things,
things,
I offer
I offer
suggestions
suggestions
with
with
thethe
hope
hope
thatthat
they
they
willwill
expand
expand
their
their
repertoire.
repertoire.
Some
Some
clients
clients
come
come
up up
with
with
a number
a number
of self-soothing
of self-soothing
activities
activities
to add
to add
to their
to their
list.list.
I have
I have
found
found
it helpful
it helpful
to have
to have
a list
a list
of activities
of activities
in front
in front
of me
of me
when
when
I am
I am
working
working
with
with
clients
clients
to create
to create
their
their
own
own
list.list.
I have
I have
included
included
a suggested
a suggested
listlist
of of
self-soothing
self-soothing
activities
activities
thatthat
hashas
been
been
compiled
compiled
over
over
thethe
years.
years.
(See
(See
Appendix
Appendix
E, this
E, this
chapter.)
chapter.)
This
This
listlist
may
may
be be
copied
copied
andand
sent
sent
home
home
with
with
clients.
clients.
It has
It has
been
been
mymy
experience
experience
thatthat
when
when
clients
clients
need
need
to self-soothe,
to self-soothe,
they
they
often
often
experience
experience
difficulty
difficulty
remembering
remembering
ways
ways
they
they
might
might
soothe
soothe
themselves.
themselves.
It is a good idea for clients to have at least a half dozen activities they can engage in to self-soothe.
I make a copy for their file so I can refer back to it as a gentle way of supporting them in their
It isItaisgood
a good
idea
idea
forfor
clients
clients
to have
to have
at least
at least
a half
a half
dozen
dozen
activities
activities
they
they
cancan
engage
engage
in to
in self-soothe.
to self-soothe.
I make
I make
a copy
a copy
forfor
their
their
filefile
so so
I can
I can
refer
refer
back
back
to ittoas
it as
a gentle
a gentle
way
way
of of
supporting
supporting
them
them
in their
in their
166
166
self-care. I send the original list home with them. I often recommend that clients put this list on their
refrigerator or some place where they can see it frequently. Initially, I check in with them each week
to see how they are doing on self-soothing. Once routines are in place, I only check in when it seems
appropriate. In times of crises, clients may stop soothing themselves. At these times, I always check
on their self-soothing and encourage and support their getting back on track as a way of caring for
themselves.
self-care.
self-care.
I sendI send
the original
the original
list home
list home
with with
them.them.
I often
I often
recommend
recommend
that clients
that clients
put this
putlist
thison
listtheir
on their
refrigerator
refrigerator
or some
or some
placeplace
where
where
they they
can see
canitsee
frequently.
it frequently.
Initially,
Initially,
I check
I check
in with
in with
themthem
eacheach
weekweek
to seetohow
see how
they they
are doing
are doing
on self-soothing.
on self-soothing.
OnceOnce
routines
routines
are inare
place,
in place,
I onlyI only
checkcheck
in when
in when
it seems
it seems
appropriate.
appropriate.
In times
In times
of crises,
of crises,
clients
clients
may may
stop stop
soothing
soothing
themselves.
themselves.
At these
At these
times,
times,
I always
I always
checkcheck
on their
on their
self-soothing
self-soothing
and encourage
and encourage
and support
and support
theirtheir
getting
getting
backback
on track
on track
as a way
as a way
of caring
of caring
for for
themselves.
themselves.
Creating a Customized Tape
Creating
Creating
a Customized
a Customized
TapeTape
Sometimes, I make a tape in the room using the relaxation exercise that clients prefer, or we create
one together. (See Appendices C and D, this chapter.) I may choose to customize the tape to meet
their needs by having them tell me things that are helpful for them to hear. I may remind them of
things they have told me that they can do to care for and soothe themselves. This kind of tape can
be helpful in between sessions. I have found it to be especially helpful for clients who have experienced a lot of loss and abandonment. This clientele often find it comforting to use a personalized
tape when I am on vacation.
Sometimes,
Sometimes,
I make
I make
a tapea tape
in theinroom
the room
usingusing
the relaxation
the relaxation
exercise
exercise
that clients
that clients
prefer,
prefer,
or weorcreate
we create
one together.
one together.
(See (See
Appendices
Appendices
C and
C D,
andthis
D, chapter.)
this chapter.)
I mayI may
choose
choose
to customize
to customize
the tape
the tape
to meet
to meet
theirtheir
needsneeds
by having
by having
themthem
tell me
tellthings
me things
that are
thathelpful
are helpful
for them
for them
to hear.
to hear.
I mayI may
remind
remind
themthem
of of
things
things
they they
havehave
told me
toldthat
me they
that they
can do
cantodo
care
to care
for and
for soothe
and soothe
themselves.
themselves.
This This
kind kind
of tape
of tape
can can
be helpful
be helpful
in between
in between
sessions.
sessions.
I have
I have
foundfound
it to be
it toespecially
be especially
helpful
helpful
for clients
for clients
who who
havehave
expe-experienced
rienced
a lot aoflot
loss
of and
loss abandonment.
and abandonment.
This This
clientele
clientele
oftenoften
find it
find
comforting
it comforting
to usetoause
personalized
a personalized
tape tape
whenwhen
I am Ion
amvacation.
on vacation.
Listed below are some self-soothing activities that clients with abandonment issues may find helpful to be reminded of on their customized tape:
• Quiet your body by breathing in through your nose and out through your mouth breathing
into the diaphragm area.
• Take time to jog several days a week as a way of caring for yourself.
• Take some time daily to journal about your thoughts and feelings.
• Give yourself some time to listen to music as a way of calming yourself.
• Remember the people who love and care for you and wrap their love around you.
• Reach out and connect with the people who love and care for you.
• Attend a 12-Step meeting or call your sponsor if you need to talk.
As a way of empowering clients to take responsibility for themselves, I say the following:
• I trust that you will do everything that you can to care for yourself healthfully.
I often use the following affirmations on tapes:
• You have a right to be here.
• You have a right to exist.
• Whatever you feel is okay.
• It is okay to ask for what you need.
• Say to yourself on a daily basis the affirmations that you have chosen for yourself. (See Suggestions for Using Affirmations, this chapter.) Some affirmations clients have chosen are:
• I deserve to be happy.
• I deserve to have people in my life who treat me well.
• I deserve to take time to play.
Listed
Listed
below
below
are some
are some
self-soothing
self-soothing
activities
activities
that clients
that clients
with with
abandonment
abandonment
issues
issues
may may
find helpfind helpful toful
betoreminded
be reminded
of onoftheir
on their
customized
customized
tape:tape:
• Quiet
• Quiet
youryour
bodybody
by breathing
by breathing
in through
in through
youryour
nosenose
and out
andthrough
out through
youryour
mouth
mouth
breathing
breathing
into the
intodiaphragm
the diaphragm
area.area.
• Take
• Take
time time
to jogtoseveral
jog several
daysdays
a week
a week
as a way
as a way
of caring
of caring
for yourself.
for yourself.
• Take
• Take
somesome
time time
dailydaily
to journal
to journal
aboutabout
youryour
thoughts
thoughts
and feelings.
and feelings.
• Give
• Give
yourself
yourself
somesome
time time
to listen
to listen
to music
to music
as a way
as a way
of calming
of calming
yourself.
yourself.
• Remember
• Remember
the people
the people
who who
love love
and care
and care
for you
for and
you wrap
and wrap
theirtheir
love love
around
around
you. you.
• Reach
• Reach
out and
out connect
and connect
with with
the people
the people
who who
love love
and care
and care
for you.
for you.
• Attend
• Attend
a 12-Step
a 12-Step
meeting
meeting
or call
or your
call your
sponsor
sponsor
if you
if need
you need
to talk.
to talk.
As a As
way
a way
of empowering
of empowering
clients
clients
to take
to take
responsibility
responsibility
for themselves,
for themselves,
I sayIthe
sayfollowing:
the following:
• I trust
• I trust
that you
that will
you do
willeverything
do everything
that you
that can
you to
can
care
to care
for yourself
for yourself
healthfully.
healthfully.
I often
I often
use the
usefollowing
the following
affirmations
affirmations
on tapes:
on tapes:
• You• You
havehave
a right
a right
to betohere.
be here.
• You• You
havehave
a right
a right
to exist.
to exist.
• Whatever
• Whatever
you feel
you is
feel
okay.
is okay.
• It is• okay
It is okay
to ask
tofor
askwhat
for what
you need.
you need.
• Say• to
Say
yourself
to yourself
on a on
daily
a daily
basisbasis
the affirmations
the affirmations
that you
that have
you have
chosen
chosen
for yourself.
for yourself.
(See (See
Sug-Suggestions
gestions
for Using
for Using
Affirmations,
Affirmations,
this chapter.)
this chapter.)
SomeSome
affirmations
affirmations
clients
clients
havehave
chosen
chosen
are: are:
• I deserve
• I deserve
to betohappy.
be happy.
• I deserve
• I deserve
to have
to have
people
people
in myinlife
mywho
life who
treat treat
me well.
me well.
• I deserve
• I deserve
to take
to take
time time
to play.
to play.
For adults who were abused as children, I sometimes say one of the following:
• You didn’t do anything wrong.
• It wasn’t your fault.
• You’re not going to die.
For adults
For adults
who who
werewere
abused
abused
as children,
as children,
I sometimes
I sometimes
say one
say of
one
theoffollowing:
the following:
• You• You
didn’t
didn’t
do anything
do anything
wrong.
wrong.
• It wasn’t
• It wasn’t
youryour
fault.fault.
• You’re
• You’re
not going
not going
to die.
to die.
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I usually develop a script that meets the needs of that client as in the following example:
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I usually develop a script that meets the needs of that client as in the following example:
Client Example
Client Example
A client had major abandonment issues and was quite fearful that the therapist would not return from her vacation. She asked the therapist to promise
her that she would return. The therapist told her that she could not make
that promise. The therapist felt comfortable saying to the client: “I will do
everything within my power to return.” This statement was acceptable to
the client.
A client had major abandonment issues and was quite fearful that the therapist would not return from her vacation. She asked the therapist to promise
her that she would return. The therapist told her that she could not make
that promise. The therapist felt comfortable saying to the client: “I will do
everything within my power to return.” This statement was acceptable to
the client.
Partial Sample Script
Partial Sample Script
“I invite you to take time to play on a daily basis. You deserve to play. Taking
time daily to go for walks will help you to feel better. When thoughts and
feelings come up, it may be helpful to journal about them. Remember, you
can call your sponsor and talk to her. It is okay to put your painful feelings
in a box and put them on the shelf until you feel safe enough to deal with
them. The abuse was not your fault. You did not do anything wrong or bad.
Think of all the people in your life who love and care for you. I invite you to
wrap their love and caring around you. I trust that you will do everything
that you can to care for yourself. I will do everything within my power to
return.”
“I invite you to take time to play on a daily basis. You deserve to play. Taking
time daily to go for walks will help you to feel better. When thoughts and
feelings come up, it may be helpful to journal about them. Remember, you
can call your sponsor and talk to her. It is okay to put your painful feelings
in a box and put them on the shelf until you feel safe enough to deal with
them. The abuse was not your fault. You did not do anything wrong or bad.
Think of all the people in your life who love and care for you. I invite you to
wrap their love and caring around you. I trust that you will do everything
that you can to care for yourself. I will do everything within my power to
return.”
Use of Transition Objects as a Way of Creating Safety
Use of Transition Objects as a Way of Creating Safety
Clients who have experienced a lot of abandonment issues in their lives frequently have difficulty staying attached to the therapist at an emotional level. Often, these clients never got
to experience healthy attachment as a child. An important part of the healing in therapy is
getting healthfully attached to the therapist. A healthy dependency can be created that allows clients to begin to trust that someone cares about them and can provide a level of containment for their healing journey. Of course, this process is always balanced with supporting the client’s independence as well.
Clients who have experienced a lot of abandonment issues in their lives frequently have difficulty staying attached to the therapist at an emotional level. Often, these clients never got
to experience healthy attachment as a child. An important part of the healing in therapy is
getting healthfully attached to the therapist. A healthy dependency can be created that allows clients to begin to trust that someone cares about them and can provide a level of containment for their healing journey. Of course, this process is always balanced with supporting the client’s independence as well.
I have a menagerie of stuffed animals in my office that I have collected and my clients have
brought me. Often clients will be drawn to a particular stuffed animal that they hold, stroke,
or talk to in the room. During periods when clients are experiencing heightened emotional
distress, one of these stuffed animals may go home with them. Sometimes the animal becomes beloved like The Velveteen Rabbit and, by mutual agreement, never returns. I have
had clients take a stuffed animal with them when they were facing surgery. Small stuffed
animals that fit into purses may go to court or places where clients are under heavy stress.
Stuffed animals go out when I go on vacation and wander back at some later time. I have
given out goddess figures that have served as transition objects to a number of clients. I still
have a Mexican Ojo De Dios (a God’s Eye) that my initial therapist gave me. He gave me
a rock that I had in my desk drawer for many years. The transition objects serve as a bridge
or a symbol of the attachment that we have together. They serve to remind clients of my
caring and support when they need it. Children have their cherished blanket or stuffed animal that serves to help them hold on to their primary caregiver. Eventually the object wears
out, gets lost and/or is no longer needed in the same way. Equally so, transition objects are
useful with some clients at certain stages of therapy. A number of clients never use them at
all. I tend to take my lead from my clients, or I get an intuitive sense that offering a transition object might be helpful.
I have a menagerie of stuffed animals in my office that I have collected and my clients have
brought me. Often clients will be drawn to a particular stuffed animal that they hold, stroke,
or talk to in the room. During periods when clients are experiencing heightened emotional
distress, one of these stuffed animals may go home with them. Sometimes the animal becomes beloved like The Velveteen Rabbit and, by mutual agreement, never returns. I have
had clients take a stuffed animal with them when they were facing surgery. Small stuffed
animals that fit into purses may go to court or places where clients are under heavy stress.
Stuffed animals go out when I go on vacation and wander back at some later time. I have
given out goddess figures that have served as transition objects to a number of clients. I still
have a Mexican Ojo De Dios (a God’s Eye) that my initial therapist gave me. He gave me
a rock that I had in my desk drawer for many years. The transition objects serve as a bridge
or a symbol of the attachment that we have together. They serve to remind clients of my
caring and support when they need it. Children have their cherished blanket or stuffed animal that serves to help them hold on to their primary caregiver. Eventually the object wears
out, gets lost and/or is no longer needed in the same way. Equally so, transition objects are
useful with some clients at certain stages of therapy. A number of clients never use them at
all. I tend to take my lead from my clients, or I get an intuitive sense that offering a transition object might be helpful.
Therapists can also help clients create a portable haven to take with them anywhere. It can
Therapists can also help clients create a portable haven to take with them anywhere. It can
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be an object that they slip into their purse, pocket, or small bag or a basket of things that
they can keep close to them. Each object should have some symbolic or comforting value.
It may be something that makes the space they are in very special. Portable havens that can
be used as transition objects include poems, small stones, stuffed animals, incense, candles,
herbs, pictures of loved ones, god or goddess figures. (See source of god or goddess figures
under Recommended Resources, this chapter.) The portable haven could be something clients create for themselves or something a therapist or treasured friend has given them.
be an object that they slip into their purse, pocket, or small bag or a basket of things that
they can keep close to them. Each object should have some symbolic or comforting value.
It may be something that makes the space they are in very special. Portable havens that can
be used as transition objects include poems, small stones, stuffed animals, incense, candles,
herbs, pictures of loved ones, god or goddess figures. (See source of god or goddess figures
under Recommended Resources, this chapter.) The portable haven could be something clients create for themselves or something a therapist or treasured friend has given them.
Example
Example
When I teach, I have a smooth flat blue plastic heart in my pocket that a
dear friend gave to me. I touch it and rub it and use it as a self-soothing
way of carrying that person’s love and caring with me.
When I teach, I have a smooth flat blue plastic heart in my pocket that a
dear friend gave to me. I touch it and rub it and use it as a self-soothing
way of carrying that person’s love and caring with me.
One of my colleagues keeps Hindu mala beads in his pocket so he can reach
in and feel them. They remind him of the prayer he chants to soothe himself.
One of my colleagues keeps Hindu mala beads in his pocket so he can reach
in and feel them. They remind him of the prayer he chants to soothe himself.
Example
Example
A female client had experienced major abandonment issues as a child. She
had been adopted at birth into an emotionally abusive home. She grew up
feeling very unsafe and fearful of trusting anyone. The therapist noticed her
touching and stroking a little stuffed rabbit during a session. She invited her
to take the rabbit home with her as a way of helping her to self-soothe. The
client took the rabbit with her. Sometime later a miss occurred between the
therapist and the client. The client was hurt and angry so she brought the
rabbit back. The therapist and the client worked through the miss. The therapist invited her to take the rabbit back home with her. The therapist was
sure that when she left she would leave the rabbit behind. When the therapist looked, the rabbit was gone. Subsequently, the client concluded therapy. The client kept the rabbit as a helpful way of reconnecting with what she
had learned in therapy.
A female client had experienced major abandonment issues as a child. She
had been adopted at birth into an emotionally abusive home. She grew up
feeling very unsafe and fearful of trusting anyone. The therapist noticed her
touching and stroking a little stuffed rabbit during a session. She invited her
to take the rabbit home with her as a way of helping her to self-soothe. The
client took the rabbit with her. Sometime later a miss occurred between the
therapist and the client. The client was hurt and angry so she brought the
rabbit back. The therapist and the client worked through the miss. The therapist invited her to take the rabbit back home with her. The therapist was
sure that when she left she would leave the rabbit behind. When the therapist looked, the rabbit was gone. Subsequently, the client concluded therapy. The client kept the rabbit as a helpful way of reconnecting with what she
had learned in therapy.
Example
Example
A female client dated a man a couple of times. She decided that she did not
want to see him again. The man started stalking her and continued to stalk
and harass her for some time. The therapist gave her a small teddy bear to
carry in a bag that she took to her frequent court appearances. It was particularly helpful to her while she was taking legal action to stop the stalking.
A female client dated a man a couple of times. She decided that she did not
want to see him again. The man started stalking her and continued to stalk
and harass her for some time. The therapist gave her a small teddy bear to
carry in a bag that she took to her frequent court appearances. It was particularly helpful to her while she was taking legal action to stop the stalking.
Use of Imagery to Create Safety
Use of Imagery to Create Safety
There are three processes used in imagery: visual, auditory, and kinesthetic. Approximately
60% of people are primarily visual, and the rest are auditory or kinesthetic. Often, clients
major in one and minor in another. The therapist can use this knowledge to increase the
safety level for the client in the room as well as in clients’ significant relationships.
There are three processes used in imagery: visual, auditory, and kinesthetic. Approximately
60% of people are primarily visual, and the rest are auditory or kinesthetic. Often, clients
major in one and minor in another. The therapist can use this knowledge to increase the
safety level for the client in the room as well as in clients’ significant relationships.
Visual clients often use words like, “I see what you mean.” They tend to watch and observe
their surroundings. These clients take in information through their eyes. Doing things for
them that can be seen may be important. Clients who image visually will be very attuned
to the nonverbal body language. The eyes and expression on the face will be very important. Congruence of facial expression with words that are spoken will be duly noted.Visual
clients are most often soothed by what they see in the body language of the other. It may
Visual clients often use words like, “I see what you mean.” They tend to watch and observe
their surroundings. These clients take in information through their eyes. Doing things for
them that can be seen may be important. Clients who image visually will be very attuned
to the nonverbal body language. The eyes and expression on the face will be very important. Congruence of facial expression with words that are spoken will be duly noted.Visual
clients are most often soothed by what they see in the body language of the other. It may
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be helpful for therapists to use their own body language to reflect or mirror nonverbally the
client’s feeling state.
169
be helpful for therapists to use their own body language to reflect or mirror nonverbally the
client’s feeling state.
Example
Example
A female client experienced trauma as a result of being physically and emotionally abused by a brutal father. Her mother used her for a confidante and
surrogate parent. The mother completely denied the abuse of her daughter.
When the client came into therapy, she made it very clear that she had never
been seen and heard as a child. Words had deeply wounded her so they
meant nothing to her. The client needed the therapist to contain her by
mostly staying silent. However, she was very attuned to the therapist’s nonverbal body language and facial expression.
A female client experienced trauma as a result of being physically and emotionally abused by a brutal father. Her mother used her for a confidante and
surrogate parent. The mother completely denied the abuse of her daughter.
When the client came into therapy, she made it very clear that she had never
been seen and heard as a child. Words had deeply wounded her so they
meant nothing to her. The client needed the therapist to contain her by
mostly staying silent. However, she was very attuned to the therapist’s nonverbal body language and facial expression.
The therapist’s primary work was to mirror and reflect nonverbally her empathy and caring for the client. This process allowed the client to experience
a healthful attachment relationship. It also allowed her to begin to reconnect
with herself. Since the client was very knowledgeable about her psychological journey, lots of words on the therapist’s part were not necessary. Insights were shared by the therapist at the close of each session, and these
seemed to be acceptable.
The therapist’s primary work was to mirror and reflect nonverbally her empathy and caring for the client. This process allowed the client to experience
a healthful attachment relationship. It also allowed her to begin to reconnect
with herself. Since the client was very knowledgeable about her psychological journey, lots of words on the therapist’s part were not necessary. Insights were shared by the therapist at the close of each session, and these
seemed to be acceptable.
Examples
Examples
Some therapists send cards to their clients with words of encouragement
that clients have asked for or that the therapist thinks may be helpful for
them to read.
Some therapists send cards to their clients with words of encouragement
that clients have asked for or that the therapist thinks may be helpful for
them to read.
Therapists may choose to send notes when they go on vacation.
Therapists may choose to send notes when they go on vacation.
Therapists may write affirmations in their own handwriting and hand them
to clients to take home with them.
Therapists may write affirmations in their own handwriting and hand them
to clients to take home with them.
Auditory clients use words like, “I hear.” They listen carefully to what is being said or not
said. They are attuned to inflection and tone of voice. Auditory clients are soothed by what
they hear, not by what they see. Mirroring or reflective listening are more important for
these clients rather than body language.
Auditory clients use words like, “I hear.” They listen carefully to what is being said or not
said. They are attuned to inflection and tone of voice. Auditory clients are soothed by what
they hear, not by what they see. Mirroring or reflective listening are more important for
these clients rather than body language.
Example
Example
A female client grew up in a home where no one listened to her. She had
experienced a lack of healthy attachment and emotional abandonment. She
was primarily auditory. She kept finding men to be in relationship with who
did not listen to her. Gradually, she became clear how important her need to
be mirrored and reflected was to her and how hurt and angry she felt when
she was not heard. She entered a relationship with a man who could mirror
and reflect her feelings.
A female client grew up in a home where no one listened to her. She had
experienced a lack of healthy attachment and emotional abandonment. She
was primarily auditory. She kept finding men to be in relationship with who
did not listen to her. Gradually, she became clear how important her need to
be mirrored and reflected was to her and how hurt and angry she felt when
she was not heard. She entered a relationship with a man who could mirror
and reflect her feelings.
Kinesthetic clients may use phrases such as “I’m getting in touch with,” “I can’t get in touch
with,” “I feel,” “I have a gut feeling.” They tend to have a deep need for physical contact
either in touching or being touched. Soothing is most likely to happen through some kind
of physical touch. They are often more aware of what is happening in their body. They
Kinesthetic clients may use phrases such as “I’m getting in touch with,” “I can’t get in touch
with,” “I feel,” “I have a gut feeling.” They tend to have a deep need for physical contact
either in touching or being touched. Soothing is most likely to happen through some kind
of physical touch. They are often more aware of what is happening in their body. They
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sometimes somatize their feelings. Various bodily symptoms may be preferable to an emotional state. For some kinesthetic clients, the opposite may be true. Kinesthetic clients may
be very cut off from what their body needs, especially if they feel that their body has betrayed them.
sometimes somatize their feelings. Various bodily symptoms may be preferable to an emotional state. For some kinesthetic clients, the opposite may be true. Kinesthetic clients may
be very cut off from what their body needs, especially if they feel that their body has betrayed them.
Clients who have experienced trauma from physical or sexual abuse may have a more difficult time healing at a physical level. With physical and sexual abuse, the body has been
violated. Healthy, appropriate physical touch may help facilitate healing. (See Chapter 9.)
Often kinesthetic clients who have been sexually abused believe that their bodies have betrayed them. There may be a skin hunger for the kinesthetic client who has experienced
physical, sexual, or emotional abuse, especially if there was a lack of healthy attachment
with the primary caregiver. Both female and male clients may engage in sexual activity
when what they need is to be held and comforted.
Clients who have experienced trauma from physical or sexual abuse may have a more difficult time healing at a physical level. With physical and sexual abuse, the body has been
violated. Healthy, appropriate physical touch may help facilitate healing. (See Chapter 9.)
Often kinesthetic clients who have been sexually abused believe that their bodies have betrayed them. There may be a skin hunger for the kinesthetic client who has experienced
physical, sexual, or emotional abuse, especially if there was a lack of healthy attachment
with the primary caregiver. Both female and male clients may engage in sexual activity
when what they need is to be held and comforted.
Example
Example
A female client who was sexually abused as a child had a deep kinesthetic
need to be held and touched. When she began to date someone new, the
hunger to be touched and held so overwhelmed her that she always had sex
immediately. When the therapist asked her what she needed to feel loved
and cared for, she was clear that she wanted to be touched or held by her
boyfriend. Over the course of the therapy process, the client was able to
differentiate her sexual needs from her need for healthy touch. She learned
how to get her need for touch met without always having to be sexual.
A female client who was sexually abused as a child had a deep kinesthetic
need to be held and touched. When she began to date someone new, the
hunger to be touched and held so overwhelmed her that she always had sex
immediately. When the therapist asked her what she needed to feel loved
and cared for, she was clear that she wanted to be touched or held.
held by
Over
her
the course Over
boyfriend.
of thethe
therapy
courseprocess,
of the therapy
the client
process,
was able
thetoclient
differentiate
was ableher
to
sexual needsher
differentiate
from
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her need
needs
forfrom
healthy
her need
touch.forShe
healthy
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howShe
to get
learned
her
needto
how
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needwithout
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always
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withouttoalways
be sexual.
having to be sexual.
Example
Example
A male client had been emotionally abused by his father and parented his
mother from the time he was very young. He found women who were emotionally abusive to him. He kept trying to get his kinesthetic needs met by
engaging in sexual activity. Over time he was able to understand that his
need for healthy touch was not being met by being abused or sexual. At that
point, he was able to set some healthy boundaries for himself that did not
automatically include sex.
A male client had been emotionally abused by his father and parented his
mother from the time he was very young. He found women who were emotionally abusive to him. He kept trying to get his kinesthetic needs met by
engaging in sexual activity. Over time he was able to understand that his
need for healthy touch was not being met by being abused or sexual. At that
point, he was able to set some healthy boundaries for himself that did not
automatically include sex.
It is very helpful for clients to understand which of their senses is most important for taking
in love and caring, thereby increasing their safety level. When clients understand which
modes of self-soothing feel best to them, they can teach their significant other. It is particularly helpful when partners can understand the ways their significant other will and will
not take in love or caring. When a female client is primarily auditory, she can tell her partner that she needs to hear him say the words “I love you” to her. If her partner is primarily
visual, previously he may have tended to respond by doing things for her that she could see.
He may not have understood why the visual things that he had done for her did not have the
same effect on her that they would have had on him.
It is very helpful for clients to understand which of their senses is most important for taking
in love and caring, thereby increasing their safety level. When clients understand which
modes of self-soothing feel best to them, they can teach their significant other. It is particularly helpful when partners can understand the ways their significant other will and will
not take in love or caring. When a female client is primarily auditory, she can tell her partner that she needs to hear him say the words “I love you” to her. If her partner is primarily
visual, previously he may have tended to respond by doing things for her that she could see.
He may not have understood why the visual things that he had done for her did not have the
same effect on her that they would have had on him.
Example
Example
A female client’s partner had cleaned the kitchen floor as a way of showing
her he loved and cared about her. Since she was both kinesthetic and auditory, she wanted him to hold her in his arms and tell her he loved her. Her
partner gave her something that she could see because he was very visual
and took in love that way. He gave her love the way he wanted to feel loved
and cared for.
A female client’s partner had cleaned the kitchen floor as a way of showing
her he loved and cared about her. Since she was both kinesthetic and auditory, she wanted him to hold her in his arms and tell her he loved her. Her
partner gave her something that she could see because he was very visual
and took in love that way. He gave her love the way he wanted to feel loved
and cared for.
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This kind of situation occurs a great deal with couples, and it is often helpful to address this
issue in couple therapy. It enables both partners to see what they need to feel loved and cared
for which can deepen their level of safety in the relationship. It takes the blame off of each partner and helps partners be supportive of each other.
This kind of situation occurs a great deal with couples, and it is often helpful to address this
issue in couple therapy. It enables both partners to see what they need to feel loved and cared
for which can deepen their level of safety in the relationship. It takes the blame off of each partner and helps partners be supportive of each other.
Example
Example
If a female client is primarily visual, she may have a need to see her partner’s eyes and facial expression. She is likely to check and see if her partner
is smiling and looking at her in a loving and caring way. If her partner tells
her he loves her but his facial expression and/or bodily language are not
congruent, she may not find his words believable.
If a female client is primarily visual, she may have a need to see her partner’s eyes and facial expression. She is likely to check and see if her partner
is smiling and looking at her in a loving and caring way. If her partner tells
her he loves her but his facial expression and/or bodily language are not
congruent, she may not find his words believable.
AFFIRMATIONS
AFFIRMATIONS
I have found affirmations to be useful in creating safety within the client and in their daily lives
and relationships. Affirmations are useful to counter negative self-talk. A great deal of the negative self-talk comes from old thought patterns or mental tapes that clients have had all of their
lives. When clients project positive expectations through the affirmation process, they begin to
create a new reality for themselves. Using affirmations is a wonderful way to create a more positive self-image.
I have found affirmations to be useful in creating safety within the client and in their daily lives
and relationships. Affirmations are useful to counter negative self-talk. A great deal of the negative self-talk comes from old thought patterns or mental tapes that clients have had all of their
lives. When clients project positive expectations through the affirmation process, they begin to
create a new reality for themselves. Using affirmations is a wonderful way to create a more positive self-image.
Definition of Affirmations
Definition of Affirmations
An affirmation is a verbal statement of a desired outcome. It is a statement of what a person
wants to have happen in the future. It essentially helps the person to create a positive expectancy of a particular outcome. It can be very specific or general in nature. I usually find it helpful
to make affirmations more specific in nature. Positive energy begets positive energy. Clients
are inviting the universe to provide for them that which they need to heal, grow, flourish, etc.
Inviting the universe to provide for them taps into their spirituality. It addresses questions like
“Do I deserve?” and “Can I expect to be provided for?” Clients draw to themselves, a step at a
time, that which they strive for. Out of their positive affirmations, they begin to create a new
reality for themselves. It can help clients to see the glass as half full rather than half empty.
An affirmation is a verbal statement of a desired outcome. It is a statement of what a person
wants to have happen in the future. It essentially helps the person to create a positive expectancy of a particular outcome. It can be very specific or general in nature. I usually find it helpful
to make affirmations more specific in nature. Positive energy begets positive energy. Clients
are inviting the universe to provide for them that which they need to heal, grow, flourish, etc.
Inviting the universe to provide for them taps into their spirituality. It addresses questions like
“Do I deserve?” and “Can I expect to be provided for?” Clients draw to themselves, a step at a
time, that which they strive for. Out of their positive affirmations, they begin to create a new
reality for themselves. It can help clients to see the glass as half full rather than half empty.
Working With Affirmations
Working With Affirmations
I usually teach affirmations to a client when I repeatedly hear negative self-talk in session. I
invite clients to come up with a positive statement that they want to affirm in order to counter
the negative self-talk they are saying to themselves or others. I may suggest an affirmation, but
it needs to be an exact fit for the client. I give the client a sheet of paper and a pencil. The client
may need to write the affirmation several times until it is specific, positive, and short enough
to remember and write down. The affirmation needs to be powerful enough to counter the negative self-talk. When clients have chosen an affirmation, I ask them to write it at the top of the
page. Then, I ask them to check in with the internal committee or the internal critic in their
brain to see what sentence or phrase comes up in response to this affirmation. I ask them to verbalize the response and write it down. I invite them to be aware of what they are feeling as each
response comes up. I tell them to note if any images come up for them. I ask them to write the
affirmation again and see what the committee has to say. I have them keep doing this until they
get 10 responses (or run out of responses) from the internal critic. I have them conclude with
writing the positive affirmation one more time.
I usually teach affirmations to a client when I repeatedly hear negative self-talk in session. I
invite clients to come up with a positive statement that they want to affirm in order to counter
the negative self-talk they are saying to themselves or others. I may suggest an affirmation, but
it needs to be an exact fit for the client. I give the client a sheet of paper and a pencil. The client
may need to write the affirmation several times until it is specific, positive, and short enough
to remember and write down. The affirmation needs to be powerful enough to counter the negative self-talk. When clients have chosen an affirmation, I ask them to write it at the top of the
page. Then, I ask them to check in with the internal committee or the internal critic in their
brain to see what sentence or phrase comes up in response to this affirmation. I ask them to verbalize the response and write it down. I invite them to be aware of what they are feeling as each
response comes up. I tell them to note if any images come up for them. I ask them to write the
affirmation again and see what the committee has to say. I have them keep doing this until they
get 10 responses (or run out of responses) from the internal critic. I have them conclude with
writing the positive affirmation one more time.
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Sample Affirmation Exercise
Client: I have a right to give myself pleasure each day.
Internal Critic: There’s work to be done.
Client: I have a right to give myself pleasure each day.
Internal Critic: What gives you the right to do nothing?
Client: I have a right to give myself pleasure each day.
Internal Critic: You don’t have any rights.
Client: I have a right to give myself pleasure each day.
Internal Critic:........................................................................
Client:.......................................................................
Internal Critic:.........................................................................
Client: I have a right to give myself pleasure each day.
Sample Affirmation Exercise
Client: I have a right to give myself pleasure each day.
Internal Critic: There’s work to be done.
Client: I have a right to give myself pleasure each day.
Internal Critic: What gives you the right to do nothing?
Client: I have a right to give myself pleasure each day.
Internal Critic: You don’t have any rights.
Client: I have a right to give myself pleasure each day.
Internal Critic:........................................................................
Client:.......................................................................
Internal Critic:.........................................................................
Client: I have a right to give myself pleasure each day.
I invite them to read aloud the affirmation followed by each response and ending with the
affirmation. I invite them to make the affirmation a part of their daily life.
I invite them to read aloud the affirmation followed by each response and ending with the
affirmation. I invite them to make the affirmation a part of their daily life.
I then process with them what it was like to do this exercise by asking the following:
• What was it like for you to do this exercise?
• Were there any new insights or understandings that you gained?
• Were there any feelings that came up for you as you did this exercise?
• What were the responses from the internal committee that jumped out at you?
• How did these responses come to be a part of your life?
• Is there any person in your life that comes to mind in connection with these responses?
• Is there anyone in your life who can support you in responding to this affirmation?
• Are there any other thoughts or feelings that you have?
I then process with them what it was like to do this exercise by asking the following:
• What was it like for you to do this exercise?
• Were there any new insights or understandings that you gained?
• Were there any feelings that came up for you as you did this exercise?
• What were the responses from the internal committee that jumped out at you?
• How did these responses come to be a part of your life?
• Is there any person in your life that comes to mind in connection with these responses?
• Is there anyone in your life who can support you in responding to this affirmation?
• Are there any other thoughts or feelings that you have?
Suggestions for Using Affirmations
Suggestions for Using Affirmations
1. Write affirmations on a piece of paper, a notebook, or a card and put on a refrigerator, a mirror, a desk, a car dashboard, a telephone, a wallet, etc., where they can be
easily seen and read daily.
2. Speak, write, draw, sing, or chant affirmations as you go about your daily life.
3. Say your affirmations as part of your relaxation process.
4. Engage any of the five senses of touch, taste, sight, sound, or smell that you imagine
fit your affirmations.
5. Spend five minutes a day imaging in your mind the desired outcome and allowing
yourself to experience a sense of joy in the process. Engage your five senses as much
as you can.
6. Look into the mirror and say the affirmation aloud to yourself. Give yourself permission to have a pleasant, relaxed expression on your face as you say the affirmation.
7. Tape yourself while repeatedly verbalizing the affirmation so you can listen to it
when you are in the car, working, or going to sleep.
1. Write affirmations on a piece of paper, a notebook, or a card and put on a refrigerator, a mirror, a desk, a car dashboard, a telephone, a wallet, etc., where they can be
easily seen and read daily.
2. Speak, write, draw, sing, or chant affirmations as you go about your daily life.
3. Say your affirmations as part of your relaxation process.
4. Engage any of the five senses of touch, taste, sight, sound, or smell that you imagine
fit your affirmations.
5. Spend five minutes a day imaging in your mind the desired outcome and allowing
yourself to experience a sense of joy in the process. Engage your five senses as much
as you can.
6. Look into the mirror and say the affirmation aloud to yourself. Give yourself permission to have a pleasant, relaxed expression on your face as you say the affirmation.
7. Tape yourself while repeatedly verbalizing the affirmation so you can listen to it
when you are in the car, working, or going to sleep.
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8. Repeat the affirmation first thing in the morning or the last thing at night. (The mind
is very open to the use of affirmations early in the morning or just before sleep.
8. Repeat the affirmation first thing in the morning or the last thing at night. (The mind
is very open to the use of affirmations early in the morning or just before sleep.
9. Write each affirmation five times daily.
9. Write each affirmation five times daily.
10. Affirm daily even if you do not feel like it.
10. Affirm daily even if you do not feel like it.
11. Affirm daily even it your family thinks you are weird.
11. Affirm daily even it your family thinks you are weird.
12. Affirm daily even if you do not feel it is doing you any good. Change takes time.
12. Affirm daily even if you do not feel it is doing you any good. Change takes time.
13. Set aside a particular time to do your affirmation even if something else does not
get done.
13. Set aside a particular time to do your affirmation even if something else does not
get done.
14. Affirm even when you are discouraged and are feeling down.
14. Affirm even when you are discouraged and are feeling down.
15. Take a few minutes to image your entire day in your mind. Imagine that your affirmation is true for the entire day.
• What would you be doing?
15. Take a few minutes to image your entire day in your mind. Imagine that your affirmation is true for the entire day.
• What would you be doing?
• What would that be like?
• What would you be feeling?
• What would you say about yourself?
• What would that be like?
• What would you be feeling?
• What would you say about yourself?
The more you can image your affirmation, the more likely it is to become a reality.
The more you can image your affirmation, the more likely it is to become a reality.
I invite clients to say and write each affirmation to themselves in the first, second, and third
person as follows.
I invite clients to say and write each affirmation to themselves in the first, second, and third
person as follows.
Example
I, Cheryl, am a person of worth.
You, Cheryl, are a person of worth.
Cheryl is a person of worth.
Example
I, Cheryl, am a person of worth.
You, Cheryl, are a person of worth.
Cheryl is a person of worth.
Most of our negative messages have come to us from what others have said to us or about
us.
Most of our negative messages have come to us from what others have said to us or about
us.
Some examples of affirmations are:
Some examples of affirmations are:
• I accept myself completely here and now.
• I accept myself completely here and now.
• Every day in every way I’m getting better and better.
• Every day in every way I’m getting better and better.
• I am a person of worth.
• I am a person of worth.
• I deserve to play.
• I deserve to play.
• I deserve love.
• I deserve love.
• All my feelings are good.
• All my feelings are good.
REFERENCES
REFERENCES
Selye, H. (1956). The Stress of Life. New York: McGraw-Hill.
Selye, H. (1956). The Stress of Life. New York: McGraw-Hill.
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RECOMMENDED RESOURCES
RECOMMENDED RESOURCES
This section includes: self-soothing, relaxation, meditation, affirmations, guided imagery,
and journaling
This section includes: self-soothing, relaxation, meditation, affirmations, guided imagery,
and journaling
Bell Pine Art Farm, Inc., 82535 Weiss Road, Creswell, OR 97426. (800)439-6556 http://
www.bellpineartfarm.com (They sell small clay figures, i.e., Mother Goddess,
Birthing Goddess, Father Spirit, all of which have a removable baby figure. These
make nice gifts for clients who are working on reparenting issues. See their website for other figures available.)
Bell Pine Art Farm, Inc., 82535 Weiss Road, Creswell, OR 97426. (800)439-6556 http://
www.bellpineartfarm.com (They sell small clay figures, i.e., Mother Goddess,
Birthing Goddess, Father Spirit, all of which have a removable baby figure. These
make nice gifts for clients who are working on reparenting issues. See their website for other figures available.)
Benson, H. (1975). The Relaxation Response. New York: William Morrow & Co., Inc.
Benson, H. (1975). The Relaxation Response. New York: William Morrow & Co., Inc.
Capacchione, L. (1979). The Creative Journal: The Art of Finding Yourself. Athens, OH:
Swallow Press.
Capacchione, L. (1979). The Creative Journal: The Art of Finding Yourself. Athens, OH:
Swallow Press.
Capacchione, L. (1990). The Picture of Health: Healing Your Life with Art. Santa Monica,
CA: Hay House, Inc.
Capacchione, L. (1990). The Picture of Health: Healing Your Life with Art. Santa Monica,
CA: Hay House, Inc.
Gawain, S. (1995). Creative Visualization. Novato, CA: New World Publishing.
Gawain, S. (1995). Creative Visualization. Novato, CA: New World Publishing.
Gawain, S. (1995). The Creative Visualization Workbook. Novato, CA: New World Publishing.
Gawain, S. (1995). The Creative Visualization Workbook. Novato, CA: New World Publishing.
Hart, A. D. (1986). Adrenalin & Stress: The Exciting New Breakthrough That Helps You
Overcome Stress Damage. Waco, TX: Word Books Publisher.
Hart, A. D. (1986). Adrenalin & Stress: The Exciting New Breakthrough That Helps You
Overcome Stress Damage. Waco, TX: Word Books Publisher.
Kabat-Zinn, J. (1994). Wherever You Go There You Are: Mindfulness Meditation in
Everyday Life. New York: Hyperion.
Kabat-Zinn, J. (1994). Wherever You Go There You Are: Mindfulness Meditation in
Everyday Life. New York: Hyperion.
McCloud, A. (2003). Meditation: Simple Steps for Health and Well Being. San Francisco:
Chronicle Books.
McCloud, A. (2003). Meditation: Simple Steps for Health and Well Being. San Francisco:
Chronicle Books.
Naparstek, B. (1994). Staying Well with Guided Imagery: How to Harness the Power of
Your Imagination for Health and Healing. New York: Warner Books, Inc.
Naparstek, B. (1994). Staying Well with Guided Imagery: How to Harness the Power of
Your Imagination for Health and Healing. New York: Warner Books, Inc.
Pelletier, K. (1977). Mind as Healer, Mind as Slayer. New York: Dell Publishing Co.
Pelletier, K. (1977). Mind as Healer, Mind as Slayer. New York: Dell Publishing Co.
Ryan, R. S., & Travis, J. W. (1981). The Wellness Workbook. Berkeley, CA: Ten Speed
Press.
Ryan, R. S., & Travis, J. W. (1981). The Wellness Workbook. Berkeley, CA: Ten Speed
Press.
Tulku, T. (1997). Gesture of Balance: A Guide to Awareness, Self Healing, and Meditation. Berkeley, CA: Dharma Publications.
Tulku, T. (1997). Gesture of Balance: A Guide to Awareness, Self Healing, and Meditation. Berkeley, CA: Dharma Publications.
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Chapter 5 Appendix A
Chapter 5 Appendix A
General Tension Record
General Tension Record
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General Tension Record
General Tension Record
Use this rating guide before and after you do your relaxation exercise. Enter your score in
the chart below.
1
2
3
4
5
Completely
Very
Moderately
Fairly
Slightly
relaxed
relaxed
relaxed
relaxed
relaxed
Use this rating guide before and after you do your relaxation exercise. Enter your score in
the chart below.
1
2
3
4
5
Completely
Very
Moderately
Fairly
Slightly
relaxed
relaxed
relaxed
relaxed
relaxed
6
Slightly
tense
Week of
____________
7
Fairly
tense
“Before”
Exercise
Score
8
Moderately
tense
“After”
Exercise
Score
9
Very
tense
10
Completely
tense
Comments/Remarks
6
Slightly
tense
Week of
____________
MONDAY
MONDAY
TUESDAY
TUESDAY
WEDNESDAY
WEDNESDAY
THURSDAY
THURSDAY
FRIDAY
FRIDAY
SATURDAY
SATURDAY
SUNDAY
SUNDAY
Week of
____________
“Before”
Exercise
Score
“After”
Exercise
Score
Comments/Remarks
Week of
____________
MONDAY
MONDAY
TUESDAY
TUESDAY
WEDNESDAY
WEDNESDAY
THURSDAY
THURSDAY
FRIDAY
FRIDAY
SATURDAY
SATURDAY
SUNDAY
SUNDAY
7
Fairly
tense
8
Moderately
tense
“Before”
Exercise
Score
“After”
Exercise
Score
“Before”
Exercise
Score
“After”
Exercise
Score
9
Very
tense
10
Completely
tense
Comments/Remarks
Comments/Remarks
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178
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Chapter 5 Appendix B
Chapter 5 Appendix B
Tensing and Relaxing Muscle
Group Exercises
Tensing and Relaxing Muscle
Group Exercises
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Tensing and Relaxing Muscle Group Exercises
Tensing and Relaxing Muscle Group Exercises
Forehead - Tense the muscles of your forehead by frowning.
Forehead - Tense the muscles of your forehead by frowning.
Eyes - Gently close your eyelids. Move your eye muscles upward, then downward, to one
side, then to the other.
Eyes - Gently close your eyelids. Move your eye muscles upward, then downward, to one
side, then to the other.
Face - Tense the muscles around your eyes and face by grimacing or wrinkling up your face
in an exaggerated manner.
Face - Tense the muscles around your eyes and face by grimacing or wrinkling up your face
in an exaggerated manner.
Jaw - Tense the muscles by yawning.
Jaw - Tense the muscles by yawning.
Neck - Tense the muscles on the right side of your neck by moving your neck toward your
right shoulder. Do the same on the opposite side.
Neck - Tense the muscles on the right side of your neck by moving your neck toward your
right shoulder. Do the same on the opposite side.
Tense the muscles at the front of your neck by hyperextending your head towards
your back.
Tense the muscles at the front of your neck by hyperextending your head towards
your back.
Tense the muscles at the back of your neck by bending your head towards your
chest as far as feels comfortable.
Tense the muscles at the back of your neck by bending your head towards your
chest as far as feels comfortable.
Starting with your chin pressed against your chest, rotate your head in a complete
circle clockwise. Do it very smoothly and slowly. Now rotate your head in a complete circle counterclockwise.
Starting with your chin pressed against your chest, rotate your head in a complete
circle clockwise. Do it very smoothly and slowly. Now rotate your head in a complete circle counterclockwise.
Slowly and smoothly move your head in a figure eight pattern.
Slowly and smoothly move your head in a figure eight pattern.
Shoulders - Tense the muscles of your right shoulder by bringing your shoulder up towards
your ear. Do the same on the opposite side.
Shoulders - Tense the muscles of your right shoulder by bringing your shoulder up towards
your ear. Do the same on the opposite side.
Tense the muscles of both shoulders by bringing them up simultaneously towards
your ears.
Tense the muscles of both shoulders by bringing them up simultaneously towards
your ears.
Move both shoulders simultaneously in a rolling motion.
Move both shoulders simultaneously in a rolling motion.
Biceps - Tense the muscles in your right arm by flexing them in an exaggerated manner.
Do the same on the opposite side.
Biceps - Tense the muscles in your right arm by flexing them in an exaggerated manner.
Do the same on the opposite side.
Forearm, Wrist, Fingers - Tense the muscles in your right forearm, wrist, and fingers by
first hyperextending your hand to tense the forearm, rotating and counterrotating at
the wrist, by flexing your fingers and making a fist, exaggerating it. Do the same on
the opposite side.
Forearm, Wrist, Fingers - Tense the muscles in your right forearm, wrist, and fingers by
first hyperextending your hand to tense the forearm, rotating and counterrotating at
the wrist, by flexing your fingers and making a fist, exaggerating it. Do the same on
the opposite side.
Back - Tense the muscles in your upper back in a way that is comfortable for you.
Back - Tense the muscles in your upper back in a way that is comfortable for you.
Tense the muscles in your lower back in a way that is comfortable for you.
Tense the muscles in your lower back in a way that is comfortable for you.
Chest - Take a deep breath into your chest. As you slowly let it out, say the word “relax.”
Chest - Take a deep breath into your chest. As you slowly let it out, say the word “relax.”
Diaphragm - Take a deep breath into your diaphragm. As you slowly let it out, say the
word “relax.”
Diaphragm - Take a deep breath into your diaphragm. As you slowly let it out, say the
word “relax.”
Abdomen - Tense the muscles of your abdomen as if you were to be lightly tapped.
Abdomen - Tense the muscles of your abdomen as if you were to be lightly tapped.
Buttocks and Genitals - Tense the muscles in your buttocks and genitals.
Buttocks and Genitals - Tense the muscles in your buttocks and genitals.
Thigh and Calf Muscles - Simultaneously tense the muscles in your right thigh and calf.
Do the same on the opposite side.
Thigh and Calf Muscles - Simultaneously tense the muscles in your right thigh and calf.
Do the same on the opposite side.
Foreleg, Ankle, and Foot - Tense the muscles of your left foreleg, ankle, and foot by first
hyperextending your foot, rotating and counterrotating your ankle, by flexing your
toes, and curling them under. Do the same on the opposite side.
Foreleg, Ankle, and Foot - Tense the muscles of your left foreleg, ankle, and foot by first
hyperextending your foot, rotating and counterrotating your ankle, by flexing your
toes, and curling them under. Do the same on the opposite side.
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Chapter 5 Appendix C
Chapter 5 Appendix C
Deep Muscle Relaxation Script
Deep Muscle Relaxation Script
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184
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185
Deep Muscle Relaxation Script
Deep Muscle Relaxation Script
Allow your body to become comfortable.
Allow your body to become comfortable.
Closing your eyes helps to tune out distractions.
Closing your eyes helps to tune out distractions.
Breathe in through your nose and out through your mouth.
Breathe in through your nose and out through your mouth.
As you become aware of your breathing, take in a few deep breaths; as you slowly
let out each breath, mentally say the word relax. Pause
As you become aware of your breathing, take in a few deep breaths; as you slowly
let out each breath, mentally say the word relax. Pause
Relax Pause Relax Pause
Relax Pause Relax Pause
Now, tense the muscles of your forehead.
Pause
Relax them.
Pause
And feel the relaxation.
Now, tense the muscles of your forehead.
Pause
Relax them.
Pause
And feel the relaxation.
Pause
Pause
With your eyelids gently closed, move your eye muscles upward, then downward, to one
side, then to the other.
Pause
Feel the difference between the tension and the relaxation as you let them rest.
Pause
Feel the relaxation.
With your eyelids gently closed, move your eye muscles upward, then downward, to one
side, then to the other.
Pause
Feel the difference between the tension and the relaxation as you let them rest.
Pause
Feel the relaxation.
Pause
Pause
Become aware of the muscles around your eyes and face.
Pause
Tense the muscles by grimacing or wrinkling them in an exaggerated manner.
Pause
Allow these muscles to relax and let your face become soft like a baby's skin.
Pause
Enjoy the relaxation as it occurs.
Become aware of the muscles around your eyes and face.
Pause
Tense the muscles by grimacing or wrinkling them in an exaggerated manner.
Pause
Allow these muscles to relax and let your face become soft like a baby's skin.
Pause
Enjoy the relaxation as it occurs.
Pause
Pause
As you focus on the tension in your jaw, tense the muscles by yawning or tightening them.
Pause
Then relax these muscles and allow your body to feel more deeply relaxed.
As you focus on the tension in your jaw, tense the muscles by yawning or tightening them.
Pause
Then relax these muscles and allow your body to feel more deeply relaxed.
Pause
Pause
Allow a wave of relaxation to flow from the top of your head down through your
eyes, face, and jaw.
Allow a wave of relaxation to flow from the top of your head down through your
eyes, face, and jaw.
Pause
Pause
Moving to your neck, tense the muscles on the right side of your neck by moving your neck
toward your left shoulder as far as feels comfortable.
Moving to your neck, tense the muscles on the right side of your neck by moving your neck
toward your left shoulder as far as feels comfortable.
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Pause
Then relax these muscles by returning your neck to its normal position.
Pause
Feel the difference between the tension and the relaxation as you let go.
Pause
Then relax these muscles by returning your neck to its normal position.
Pause
Feel the difference between the tension and the relaxation as you let go.
Pause
Pause
Tense the muscles on the left side of your neck by moving your neck toward your
right shoulder as far as feels comfortable.
Pause
Allow these muscles to relax by returning your neck to its normal position.
Pause
Feel the relaxation in contrast to the tension.
Tense the muscles on the left side of your neck by moving your neck toward your
right shoulder as far as feels comfortable.
Pause
Allow these muscles to relax by returning your neck to its normal position.
Pause
Feel the relaxation in contrast to the tension.
Pause
Pause
Tense the muscles at the front of your neck by hyperextending your head towards
your back.
Pause
Give these muscles permission to relax by returning your head to its normal position.
Pause
Enjoy the relaxation as it replaces the tension in your body.
Tense the muscles at the front of your neck by hyperextending your head towards
your back.
Pause
Give these muscles permission to relax by returning your head to its normal position.
Pause
Enjoy the relaxation as it replaces the tension in your body.
Pause
Pause
Tense the muscles at the back of your neck by bending your head towards your
chest as far as feels comfortable.
Pause
Then allow these muscles to relax as you return your head to its normal position.
Pause
Feel the relaxation as it spreads through your body.
Tense the muscles at the back of your neck by bending your head towards your
chest as far as feels comfortable.
Pause
Then allow these muscles to relax as you return your head to its normal position.
Pause
Feel the relaxation as it spreads through your body.
Pause
Pause
Starting with your chin pressed against your chest, rotate your head in a complete
circle clockwise. Do it very smoothly and slowly.
Pause
Return your head to its normal position for a moment or two.
Pause
Now, starting with your chin pressed against your chest, rotate your head in a complete
circle counterclockwise. Do it very slowly and smoothly.
Pause
Return your head to its normal position.
Pause
Feel your body relax and let go.
Starting with your chin pressed against your chest, rotate your head in a complete
circle clockwise. Do it very smoothly and slowly.
Pause
Return your head to its normal position for a moment or two.
Pause
Now, starting with your chin pressed against your chest, rotate your head in a complete
circle counterclockwise. Do it very slowly and smoothly.
Pause
Return your head to its normal position.
Pause
Feel your body relax and let go.
Pause
Pause
Now slowly and smoothly move your head in a figure eight pattern.
Pause
Return your head to its normal position.
Pause
Allow your body to feel even more deeply relaxed.
Now slowly and smoothly move your head in a figure eight pattern.
Pause
Return your head to its normal position.
Pause
Allow your body to feel even more deeply relaxed.
Pause
Pause
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Enjoy any feelings of warmth, heaviness, or lightness as they may occur.
Enjoy any feelings of warmth, heaviness, or lightness as they may occur.
Pause
Pause
Moving down your body, tense the muscles of your right shoulder by bringing it up
towards your ear.
Pause
Then relax these muscles by returning your shoulder to its normal position.
Pause
Give yourself permission to feel the relaxation.
Moving down your body, tense the muscles of your right shoulder by bringing it up
towards your ear.
Pause
Then relax these muscles by returning your shoulder to its normal position.
Pause
Give yourself permission to feel the relaxation.
Pause
Pause
Tense the muscles of your other shoulder by bringing it up towards your ear.
Pause
Now, let these muscles relax by returning your shoulder to its normal position.
Pause
Allow yourself to feel the relaxation.
Tense the muscles of your other shoulder by bringing it up towards your ear.
Pause
Now, let these muscles relax by returning your shoulder to its normal position.
Pause
Allow yourself to feel the relaxation.
Pause
Pause
Tense the muscles in both shoulders by bringing them up simultaneously towards
your ears.
Pause
Allow the muscles in your shoulders to relax and let go by returning them
to their normal position.
Pause
Feel the difference between the tension and the relaxation.
Pause
Enjoy any feelings of warmth, heaviness or lightness as you relax more deeply.
Tense the muscles in both shoulders by bringing them up simultaneously towards
your ears.
Pause
Allow the muscles in your shoulders to relax and let go by returning them
to their normal position.
Pause
Feel the difference between the tension and the relaxation.
Pause
Enjoy any feelings of warmth, heaviness or lightness as you relax more deeply.
Pause
Pause
Now move both shoulders simultaneously in a rolling motion.
Pause
Give your shoulders permission to relax as you return them to their normal position.
Pause
Let a feeling of calmness and serenity envelop you.
Now move both shoulders simultaneously in a rolling motion.
Pause
Give your shoulders permission to relax as you return them to their normal position.
Pause
Let a feeling of calmness and serenity envelop you.
Pause
Pause
Moving to the biceps muscle, tense the muscles in your right arm by flexing
the muscle in an exaggerated manner.
Pause
Allow these muscles to relax by returning your arm to its resting position.
Pause
Feel the relaxation.
Moving to the biceps muscle, tense the muscles in your right arm by flexing
the muscle in an exaggerated manner.
Pause
Allow these muscles to relax by returning your arm to its resting position.
Pause
Feel the relaxation.
Pause
Pause
Tense the biceps muscle in your other arm by flexing the muscle in an exaggerated
manner.
Pause
Allow these muscles to relax by returning your arm to its resting position.
Tense the biceps muscle in your other arm by flexing the muscle in an exaggerated
manner.
Pause
Allow these muscles to relax by returning your arm to its resting position.
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Pause
Enjoy the feelings of deeper relaxation.
Pause
Enjoy the feelings of deeper relaxation.
Pause
Pause
Tense the muscles in your right forearm, wrist, and fingers by first hyperextending your
hand to tense the forearm — rotating and counterrotating at the wrist — by flexing your
fingers — and making a fist, exaggerating it.
Pause
Give these muscles permission to relax by returning your hand to its resting
position with no resistance to gravity.
Pause
Feel your body becoming more and more relaxed.
Tense the muscles in your right forearm, wrist, and fingers by first hyperextending your
hand to tense the forearm — rotating and counterrotating at the wrist — by flexing your
fingers — and making a fist, exaggerating it.
Pause
Give these muscles permission to relax by returning your hand to its resting
position with no resistance to gravity.
Pause
Feel your body becoming more and more relaxed.
Pause
Pause
Tense the muscles in your left forearm, wrist, and fingers by first hyperextending
your hand to tense the forearm — rotating and counterrotating at the wrist — by flexing
your fingers — and making a fist, exaggerating it.
Pause
Give these muscles permission to relax by returning your hand to its resting
position with no resistance to gravity.
Pause
See if you can no longer distinguish where your hand ends and your lap or chair begins.
Pause
Feel the relaxation.
Tense the muscles in your left forearm, wrist, and fingers by first hyperextending
your hand to tense the forearm — rotating and counterrotating at the wrist — by flexing
your fingers — and making a fist, exaggerating it.
Pause
Give these muscles permission to relax by returning your hand to its resting
position with no resistance to gravity.
Pause
See if you can no longer distinguish where your hand ends and your lap or chair begins.
Pause
Feel the relaxation.
Pause
Pause
Allow a feeling of warmth and tingling to permeate your body as you become more deeply
relaxed.
Allow a feeling of warmth and tingling to permeate your body as you become more deeply
relaxed.
Pause
Pause
Moving to your back, tense the muscles in your upper back in a way that is comfortable for
you.
Pause
Then relax these muscles.
Pause
Feel the relaxation and feeling of warmth spread through your body.
Moving to your back, tense the muscles in your upper back in a way that is comfortable for
you.
Pause
Then relax these muscles.
Pause
Feel the relaxation and feeling of warmth spread through your body.
Pause
Pause
Now tense the muscles of your lower back in a way that is comfortable for you.
Pause
Then relax these muscles.
Pause
Enjoy the feelings of deeper and deeper relaxation.
Now tense the muscles of your lower back in a way that is comfortable for you.
Pause
Then relax these muscles.
Pause
Enjoy the feelings of deeper and deeper relaxation.
Pause
Pause
Focusing on your chest, take in a deep breath. As you slowly let it out say
the word “Relax.”
Pause
Allow your body to relax more and more deeply.
Focusing on your chest, take in a deep breath. As you slowly let it out say
the word “Relax.”
Pause
Allow your body to relax more and more deeply.
Pause
Pause
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Now, take in a deep breath into your diaphragm area. As you slowly let it out,
say the word “Relax.”
Pause
Feel your body going deeper and deeper into relaxation.
Now, take in a deep breath into your diaphragm area. As you slowly let it out,
say the word “Relax.”
Pause
Feel your body going deeper and deeper into relaxation.
Pause
Pause
Tense the muscles in your abdomen as if you were to be lightly tapped.
Pause
Give these muscles permission to relax.
Pause
Enjoy any feelings of warmth, heaviness, or lightness as you become more deeply
relaxed.
Tense the muscles in your abdomen as if you were to be lightly tapped.
Pause
Give these muscles permission to relax.
Pause
Enjoy any feelings of warmth, heaviness, or lightness as you become more deeply
relaxed.
Pause
Pause
Tense the muscles in your buttocks and genitals.
Pause
Allow these muscles to relax.
Pause
Feel the relaxation.
Pause
Give yourself permission to feel a sense of calmness and serenity.
Tense the muscles in your buttocks and genitals.
Pause
Allow these muscles to relax.
Pause
Feel the relaxation.
Pause
Give yourself permission to feel a sense of calmness and serenity.
Pause
Pause
Simultaneously tense the muscles in your right thigh and calf respectively.
Pause
Let these muscles relax by returning to their resting position.
Pause
Enjoy the relaxation.
Simultaneously tense the muscles in your right thigh and calf respectively.
Pause
Let these muscles relax by returning to their resting position.
Pause
Enjoy the relaxation.
Pause
Pause
Now, simultaneously tense the muscles in your left thigh and calf.
Pause
Allow these muscle to relax by returning to their resting position.
Pause
Feel yourself relax deeper and deeper.
Now, simultaneously tense the muscles in your left thigh and calf.
Pause
Allow these muscle to relax by returning to their resting position.
Pause
Feel yourself relax deeper and deeper.
Pause
Pause
Allow yourself to feel very calm and peaceful .
Allow yourself to feel very calm and peaceful .
Pause
Pause
Now tense the muscles of your right foreleg, ankle, and foot by first — hyperextending
your foot — rotating and counterrotating your ankle — by flexing your toes and — curling
them under.
Pause
Then relax these muscles by returning your foot to its normal position — with no
resistance to gravity.
Pause
Feel the relaxation and feeling of warmth.
Now tense the muscles of your right foreleg, ankle, and foot by first — hyperextending
your foot — rotating and counterrotating your ankle — by flexing your toes and — curling
them under.
Pause
Then relax these muscles by returning your foot to its normal position — with no
resistance to gravity.
Pause
Feel the relaxation and feeling of warmth.
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Pause
Pause
Tense the muscles of your left foreleg, ankle and foot by first — hyperextending your foot,
— rotating and counterrotating your ankle, — by flexing your toes, and — curling them
under.
Pause
Then relax these muscles by returning your foot to its normal position with no resistance to
gravity.
Pause
See if you can no longer distinguish where your feet end and the floor begins.
Tense the muscles of your left foreleg, ankle and foot by first — hyperextending your foot,
— rotating and counterrotating your ankle, — by flexing your toes, and — curling them
under.
Pause
Then relax these muscles by returning your foot to its normal position with no resistance to
gravity.
Pause
See if you can no longer distinguish where your feet end and the floor begins.
Pause
Pause
Allow a feeling of relaxation to permeate every muscle group of your body from your forehead to your toes.
Allow a feeling of relaxation to permeate every muscle group of your body from your forehead to your toes.
Pause
Pause
As you relax more deeply, I want you to imagine the numbers 10 through 1 as they
are projected on a movie screen or as I say them, one number at a time.
Pause
With each number, allow yourself to feel more deeply relaxed.
Pause
When you reach the number 1, you will feel completely relaxed.
As you relax more deeply, I want you to imagine the numbers 10 through 1 as they
are projected on a movie screen or as I say them, one number at a time.
Pause
With each number, allow yourself to feel more deeply relaxed.
Pause
When you reach the number 1, you will feel completely relaxed.
Pause
Pause
Image the number10
You are feeling calm and peaceful.
9
A feeling of serenity is enveloping you.
8
You are at peace with yourself.
7
You are relaxing deeper and deeper.
6
Your arms and legs feel very light or heavy.
5
You are feeling safe and comfortable.
4
You are relaxing more and more deeply.
3
Your mind is connecting with your inner self as you relax deeper and deeper.
2
You are feeling calm inwardly as well as outwardly,
1
You are completely relaxed.
You are at one with the universe.
Image the number10
You are feeling calm and peaceful.
9
A feeling of serenity is enveloping you.
8
You are at peace with yourself.
7
You are relaxing deeper and deeper.
6
Your arms and legs feel very light or heavy.
5
You are feeling safe and comfortable.
4
You are relaxing more and more deeply.
3
Your mind is connecting with your inner self as you relax deeper and deeper.
2
You are feeling calm inwardly as well as outwardly,
1
You are completely relaxed.
You are at one with the universe.
Pause
Pause
Mentally pat yourself on the back for entering into this experience.
Mentally pat yourself on the back for entering into this experience.
Pause
Pause
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As the muscles of your eyelids slowly lighten, allow a feeling of deep refreshment, high
energy, and positiveness to stay with you.
Pause
As the muscles of your eyelids slowly lighten, allow a feeling of deep refreshment, high
energy, and positiveness to stay with you.
Pause
Open your eyes, look around the room, and stretch your body. Engage your senses for a few
moments and allow yourself to see the things in the room. Notice the sounds that are
present. Let yourself feel the chair you are sitting on. Orient yourself to this space and time.
Open your eyes, look around the room, and stretch your body. Engage your senses for a few
moments and allow yourself to see the things in the room. Notice the sounds that are
present. Let yourself feel the chair you are sitting on. Orient yourself to this space and time.
Note: For those clients who are primarily auditory, it might be useful to substitute “hear” for
“image” on the previous page where the client is invited to imagine the numbers 10 through
1 on a movie screen.
Note: For those clients who are primarily auditory, it might be useful to substitute “hear” for
“image” on the previous page where the client is invited to imagine the numbers 10 through
1 on a movie screen.
Note: The hyphens used in the arm and leg muscle groups are used to delineate each exercise and give clients time to do each part before proceeding.
Note: The hyphens used in the arm and leg muscle groups are used to delineate each exercise and give clients time to do each part before proceeding.
Note: To delineate each separate muscle group in the script I have separated them with extra space and a Pause. It also makes it easier to keep your place when you are using this
with a client.
Note: To delineate each separate muscle group in the script I have separated them with extra space and a Pause. It also makes it easier to keep your place when you are using this
with a client.
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Chapter 5 Appendix D
Chapter 5 Appendix D
Creating a Safe Place Script
Creating a Safe Place Script
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Creating a Safe Place Script
Creating a Safe Place Script
I would like you to become comfortable in your chair with your feet on the floor and your
arms resting comfortably on your lap.
I would like you to become comfortable in your chair with your feet on the floor and your
arms resting comfortably on your lap.
Closing your eyes can help to tune out distractions.
Become aware of your breathing.
Pause
Closing your eyes can help to tune out distractions.
Become aware of your breathing.
Pause
As you become aware of your breathing, take in a few deep breaths, as you slowly let out
each breath, mentally say the word “relax.” Pause
Relax Pause Relax Pause
Focus on the tension in your forehead.
Pause
As you tell your forehead to relax, feel the relaxation spread throughout your body.
As you become aware of your breathing, take in a few deep breaths, as you slowly let out
each breath, mentally say the word “relax.” Pause
Relax Pause Relax Pause
Focus on the tension in your forehead.
Pause
As you tell your forehead to relax, feel the relaxation spread throughout your body.
Pause
Pause
Note the tension around the muscles of your eyes and face.
Note the tension around the muscles of your eyes and face.
Pause
Pause
Tell these muscles to relax.
Tell these muscles to relax.
Feel the relaxation.
Feel the relaxation.
Pause
Pause
Focus on the tension in your jaw.
Focus on the tension in your jaw.
Pause
Pause
Now allow your jaw to feel relaxed.
Now allow your jaw to feel relaxed.
Pause
Pause
Enjoy a feeling of relaxation.
Enjoy a feeling of relaxation.
Pause
Pause
Be aware of the tension in your neck.
Be aware of the tension in your neck.
Pause
Pause
Allow your neck to relax.
Allow your neck to relax.
Pause
Pause
Give yourself permission to relax more and more deeply.
Give yourself permission to relax more and more deeply.
Pause
Pause
Moving down your body, tell your shoulders to release their tension.
Moving down your body, tell your shoulders to release their tension.
Pause
Pause
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Allow yourself to feel very calm and peaceful.
Allow yourself to feel very calm and peaceful.
Pause
Pause
Give the muscles in your upper and lower back permission to release their tension.
Give the muscles in your upper and lower back permission to release their tension.
Pause
Pause
Feel the relaxation.
Feel the relaxation.
Pause
Pause
As you feel more deeply relaxed, allow your upper arms to relax.
As you feel more deeply relaxed, allow your upper arms to relax.
Pause
Pause
Feel the relaxation and warmth as they spread throughout your body.
Feel the relaxation and warmth as they spread throughout your body.
Pause
Pause
Note the tension in your lower arms and hands.
Note the tension in your lower arms and hands.
Pause
Pause
Give them permission to relax and let go.
Give them permission to relax and let go.
Pause
Pause
Enjoy any feelings of heaviness, - lightness, - warmth, - or tingling as they may occur.
Enjoy any feelings of heaviness, - lightness, - warmth, - or tingling as they may occur.
Pause
Pause
Focus on the tension in your abdomen.
Focus on the tension in your abdomen.
Pause
Pause
Tell these muscles to relax and become warm and comfortable.
Tell these muscles to relax and become warm and comfortable.
Pause
Pause
Let a feeling of calmness and serenity envelop you.
Let a feeling of calmness and serenity envelop you.
Pause
Pause
Focus on the tension in your buttocks.
Focus on the tension in your buttocks.
Pause
Pause
Allow these muscles to relax and let go.
Allow these muscles to relax and let go.
Pause
Pause
Feel the relaxation.
Feel the relaxation.
Pause
Pause
Moving to your thighs, be aware of any tension there.
Moving to your thighs, be aware of any tension there.
Pause
Pause
Allow them to relax.
Allow them to relax.
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Pause
Pause
Feel your body becoming warmer and more deeply relaxed.
Feel your body becoming warmer and more deeply relaxed.
Pause
Pause
Let any tension in your legs go.
Let any tension in your legs go.
Pause
Pause
Enjoy the feelings of warmth and relaxation as they flow through your body.
Enjoy the feelings of warmth and relaxation as they flow through your body.
Pause
Pause
As you tell your ankles and feet to relax, feel the warmth and relaxation.
As you tell your ankles and feet to relax, feel the warmth and relaxation.
Pause
Pause
Bask in this feeling of warmth and relaxation as it permeates your entire body.
Bask in this feeling of warmth and relaxation as it permeates your entire body.
Pause
Pause
This is a time to be good to yourself.
This is a time to be good to yourself.
You may even feel a need to smile as you enjoy this time for you!
You may even feel a need to smile as you enjoy this time for you!
Pause
Pause
In a moment — an image can come to mind of one of your favorite places. Pause As it
does, you may image yourself in this place. Pause As the image becomes clearer to
you, take notice of the surroundings. Pause You may be seeing sand, - water lapping at
your feet, - trees, - mountains, - grass, - rain, - sun in your face. Pause It could be anywhere. Pause You may be hearing the sounds of birds singing, - wind blowing, - rain
falling, - leaves rustling. Pause You may be smelling fresh grass, - flowers, - salt water,
- pine needles. Pause You may feel the textures of flowers, - the earth, - water, - leaves,
- trees. Pause Take notice of the time of day Pause and what you are wearing. Pause
There may be other people present Pause or you may prefer to be alone in this favorite
place of yours. Pause Take notice of the good feelings you have when you are in this
place Pause and let yourself enter it fully and feel those feelings even more Pause
really enjoying your favorite place Pause just taking all the time in the world and
enjoying it.
In a moment — an image can come to mind of one of your favorite places. Pause As it
does, you may image yourself in this place. Pause As the image becomes clearer to
you, take notice of the surroundings. Pause You may be seeing sand, - water lapping at
your feet, - trees, - mountains, - grass, - rain, - sun in your face. Pause It could be anywhere. Pause You may be hearing the sounds of birds singing, - wind blowing, - rain
falling, - leaves rustling. Pause You may be smelling fresh grass, - flowers, - salt water,
- pine needles. Pause You may feel the textures of flowers, - the earth, - water, - leaves,
- trees. Pause Take notice of the time of day Pause and what you are wearing. Pause
There may be other people present Pause or you may prefer to be alone in this favorite
place of yours. Pause Take notice of the good feelings you have when you are in this
place Pause and let yourself enter it fully and feel those feelings even more Pause
really enjoying your favorite place Pause just taking all the time in the world and
enjoying it.
Pause
Pause
You have created a favorite place where you can feel warm, Pause safe, Pause comfortable, Pause at peace, Pause and deeply relaxed.
You have created a favorite place where you can feel warm, Pause safe, Pause comfortable, Pause at peace, Pause and deeply relaxed.
Pause
Pause
You can return here whenever you choose to recapture these feelings.
You can return here whenever you choose to recapture these feelings.
Pause
Pause
Remember that every thought has its own energy and that it attracts like thoughts.
Remember that every thought has its own energy and that it attracts like thoughts.
Pause
Pause
As you take in a deep breath and slowly let it out — say to yourself,
As you take in a deep breath and slowly let it out — say to yourself,
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“Every day in every way I am getting better and better.”
“Every day in every way I am getting better and better.”
Repeat.
Repeat.
Pause
Repeat.
Pause
Pause
Repeat.
Pause
As you take in a deep breath and slowly let it out - say to yourself,
As you take in a deep breath and slowly let it out - say to yourself,
“I accept myself completely here and now.”
“I accept myself completely here and now.”
Repeat.
Repeat.
Pause
Repeat.
Pause
Pause
Repeat.
Pause
Mentally pat yourself on the back for entering into this experience.
Mentally pat yourself on the back for entering into this experience.
As the muscles of your eyelids slowly lighten up – allow a feeling of deep refreshment high energy - and positiveness to stay with you.
As the muscles of your eyelids slowly lighten up – allow a feeling of deep refreshment high energy - and positiveness to stay with you.
Pause
Pause
Open your eyes, look around the room, and stretch your body. Engage your senses for a
few moments and allow yourself to see the things in the room. Notice the sounds that are
present. Let yourself feel the chair you are sitting on. Orient yourself to this space and
time.
Open your eyes, look around the room, and stretch your body. Engage your senses for a
few moments and allow yourself to see the things in the room. Notice the sounds that are
present. Let yourself feel the chair you are sitting on. Orient yourself to this space and
time.
Note: When asking clients to image a safe place where they are asked to engage their senses, it may be helpful to use the senses that clients are most attuned to in creating a safe
place.
Note: When asking clients to image a safe place where they are asked to engage their senses, it may be helpful to use the senses that clients are most attuned to in creating a safe
place.
Note: The hyphens are used to indicate a pause.
Note: The hyphens are used to indicate a pause.
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Chapter 5 Appendix E
Chapter 5 Appendix E
Self-Soothing Activities List
Self-Soothing Activities List
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Self Soothing Activities List
Self Soothing Activities List
• petting an animal (Some clients may trust animals more than they trust people. Petting and
caring for animals will often calm clients.)
• hugging or holding a stuffed animal. (Sometimes clients will hold a favorite stuffed animal and talk to it as if it were the child within them.)
• lighting a fire in the fireplace
• lighting candles
• listening to music
• doing aerobic exercise (For clients who are depressed, exercise is an incredibly important
activity to engage in on a regular basis. It helps kick in the neurotransmitters and lowers
depression. For clients who are anxious, it helps to bring down their hyperarousal and calm
them.)
• stretching
• walking
• bicycling
• doing yoga
• hiking
• calling a friend
• praying
• doing relaxation exercise or some form of meditation
• watching a funny movie (Sometimes it's helpful to have a repertoire of funny movies as
deep belly laughing is a wonderful way to relax.)
• reading joke books
• eating a favorite food
• buying something nice for yourself
• doing aroma therapy
• redecorating the house
• changing the furniture around
• buying some flowers
• taking yourself out to lunch
• getting a massage
• doing self massage
• getting your hair done
• petting an animal (Some clients may trust animals more than they trust people. Petting and
caring for animals will often calm clients.)
• hugging or holding a stuffed animal. (Sometimes clients will hold a favorite stuffed animal and talk to it as if it were the child within them.)
• lighting a fire in the fireplace
• lighting candles
• listening to music
• doing aerobic exercise (For clients who are depressed, exercise is an incredibly important
activity to engage in on a regular basis. It helps kick in the neurotransmitters and lowers
depression. For clients who are anxious, it helps to bring down their hyperarousal and calm
them.)
• stretching
• walking
• bicycling
• doing yoga
• hiking
• calling a friend
• praying
• doing relaxation exercise or some form of meditation
• watching a funny movie (Sometimes it's helpful to have a repertoire of funny movies as
deep belly laughing is a wonderful way to relax.)
• reading joke books
• eating a favorite food
• buying something nice for yourself
• doing aroma therapy
• redecorating the house
• changing the furniture around
• buying some flowers
• taking yourself out to lunch
• getting a massage
• doing self massage
• getting your hair done
• getting a manicure, pedicure
• having someone watch the children and doing something for yourself
• going to a thrift shop
• going to a museum
• getting a manicure, pedicure
• having someone watch the children and doing something for yourself
• going to a thrift shop
• going to a museum
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• taking a drive in the car to a nice place
• attending a 12-Step meeting such as ACA, CODA, AA, Al ANON, SAC
• calling a sponsor and talking to them
• drinking a cup of tea
• having a glass of wine
• listening to tapes
• volunteering
• engaging in big muscle activity, housework, etc.
• taking a bubble bath or a hot bath
• journaling (For some clients it is very important to write about their feelings.)
• painting
• dancing to music
• going dancing
• going to the park and walking, sitting, or swinging on the swings
• working hard at some project that one has interest in or needs to do
• working at crafts or hobbies that are interesting (woodworking, tole painting, etc.)
• gardening
• walking the dog
• sorting and organizing stuff (cleaning closets, drawers, files, etc.)
• picking flowers from the garden and arranging them in the house
Note: It is important to choose a number of things that do not cost anything to prevent lack
of funds being used as an excuse.
• taking a drive in the car to a nice place
• attending a 12-Step meeting such as ACA, CODA, AA, Al ANON, SAC
• calling a sponsor and talking to them
• drinking a cup of tea
• having a glass of wine
• listening to tapes
• volunteering
• engaging in big muscle activity, housework, etc.
• taking a bubble bath or a hot bath
• journaling (For some clients it is very important to write about their feelings.)
• painting
• dancing to music
• going dancing
• going to the park and walking, sitting, or swinging on the swings
• working hard at some project that one has interest in or needs to do
• working at crafts or hobbies that are interesting (woodworking, tole painting, etc.)
• gardening
• walking the dog
• sorting and organizing stuff (cleaning closets, drawers, files, etc.)
• picking flowers from the garden and arranging them in the house
Note: It is important to choose a number of things that do not cost anything to prevent lack
of funds being used as an excuse.
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6
Exploring and Addressing Trust
Issues to Increase Safety
Exploring and Addressing Trust
Issues to Increase Safety
Chapter Outline
Chapter Outline
A. Theory of Attachment
A. Theory of Attachment
1. Secure Attachment
1. Secure Attachment
2. Avoidant Attachment
2. Avoidant Attachment
3. Ambivalent Attachment
3. Ambivalent Attachment
4. Disorganized/Avoidant Attachment
4. Disorganized/Avoidant Attachment
B. Maintaining Attachment When a Rupture of Trust Has Occurred
B. Maintaining Attachment When a Rupture of Trust Has Occurred
C. Developmental Stage Where Rupture of Trust Took Place
C. Developmental Stage Where Rupture of Trust Took Place
D. Loss of A Basic Sense of Self
D. Loss of A Basic Sense of Self
E. Connection and Disconnection
E. Connection and Disconnection
F. Creating Healthy Dependence That Leads to Independence
F. Creating Healthy Dependence That Leads to Independence
G. Exercises to Increase the Client’s Support System
G. Exercises to Increase the Client’s Support System
1. A Living Security Blanket
1. A Living Security Blanket
a. Inner Circle
a. Inner Circle
b. Middle Circle
b. Middle Circle
c. Outer Circle
c. Outer Circle
2. Basics of a Healthy Relationship
2. Basics of a Healthy Relationship
3. How Clients Get Tangled in Relationships
3. How Clients Get Tangled in Relationships
6
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204
Exploring and Addressing Trust Issues to
Increase Safety
Exploring and Addressing Trust Issues to
Increase Safety
One way of thinking about trust is to frame it as a normal developmental process. There are
various tasks that each person needs to accomplish to lead a healthy life. According to Eric
Erikson’s psychosocial stages, the first stage of life is trust vs. mistrust (1963). This stage
takes place in the first one to two years of life. Infants must rely on others for all of their
needs. If children receive healthy nurturance during these years, then they learn to trust and
rely on their caregivers and will feel secure and dependent. A problem arises when children
get inconsistent care. Children who do not receive healthy nurturing may not learn to trust
others in their environment. Children who are mistreated often feel angry, frustrated, mistrustful, suspicious, and fearful as adults. They may experience depression and/or anxiety
as a result of the lack of healthy nurturance. Trust develops in the relationship that children
have with their parents or caregivers. This sense of trust provides children with a healthy
foundation for developing relationships as well as their sense of spirituality throughout
their life.
One way of thinking about trust is to frame it as a normal developmental process. There are
various tasks that each person needs to accomplish to lead a healthy life. According to Eric
Erikson’s psychosocial stages, the first stage of life is trust vs. mistrust (1963). This stage
takes place in the first one to two years of life. Infants must rely on others for all of their
needs. If children receive healthy nurturance during these years, then they learn to trust and
rely on their caregivers and will feel secure and dependent. A problem arises when children
get inconsistent care. Children who do not receive healthy nurturing may not learn to trust
others in their environment. Children who are mistreated often feel angry, frustrated, mistrustful, suspicious, and fearful as adults. They may experience depression and/or anxiety
as a result of the lack of healthy nurturance. Trust develops in the relationship that children
have with their parents or caregivers. This sense of trust provides children with a healthy
foundation for developing relationships as well as their sense of spirituality throughout
their life.
Attachment Theory has many aspects and can be useful in understanding how a client functions around issues of trust. I have included a brief overview of the theoretical underpinnings of this theory here because I feel it is particularly useful in developing an empathic
relationship with clients. In Ainsworth’s research, on Bowlby’s attachment theory it was
found that several patterns of attachment occur between children and their caregivers. The
different patterns of attachment they have suggested are secure attachment, avoidant attachment, and ambivalent attachment. In addition, I have summarized Main and Solomon’s
proposal of avoidant-disorganized attachment, which is a combination of the avoidant and
ambivalent pattern.
Attachment Theory has many aspects and can be useful in understanding how a client functions around issues of trust. I have included a brief overview of the theoretical underpinnings of this theory here because I feel it is particularly useful in developing an empathic
relationship with clients. In Ainsworth’s research, on Bowlby’s attachment theory it was
found that several patterns of attachment occur between children and their caregivers. The
different patterns of attachment they have suggested are secure attachment, avoidant attachment, and ambivalent attachment. In addition, I have summarized Main and Solomon’s
proposal of avoidant-disorganized attachment, which is a combination of the avoidant and
ambivalent pattern.
These patterns of attachment have helped us understand that infants who are securely attached to their primary caregivers develop a sense of safety and trust. When infants experience caregivers who tend to avoid or reject them, they do not get their safety and trust
needs met through healthy dependence and may develop an avoidant pattern. When infants
experience caregivers who are unpredictable and chaotic, they tend to be fearful and cling
out of their lack of safety and trust and may develop an ambivalent pattern. When infants
experience trauma, abuse, or extensive neglect with their caregiver, they may develop an
avoidant-disorganized pattern as mentioned above.
These patterns of attachment have helped us understand that infants who are securely attached to their primary caregivers develop a sense of safety and trust. When infants experience caregivers who tend to avoid or reject them, they do not get their safety and trust
needs met through healthy dependence and may develop an avoidant pattern. When infants
experience caregivers who are unpredictable and chaotic, they tend to be fearful and cling
out of their lack of safety and trust and may develop an ambivalent pattern. When infants
experience trauma, abuse, or extensive neglect with their caregiver, they may develop an
avoidant-disorganized pattern as mentioned above.
Bowlby (1988) believed that secure attachment is a life long need. It is a need that people
never outgrow. Even when people have healthy attachment in their relationship(s), they will
still experience times of stress or vulnerability. If people feel only slightly stressed, a look
across the room at a significant other may suffice. If people feel moderate stress, they may
need to experience some form of touch. With severe stress, they may need to be held for
awhile and comforted. Having healthy attachment and/or connections with others enables
people throughout their lifetime to build ways to deal with stressors as they arise.
Bowlby (1988) believed that secure attachment is a life long need. It is a need that people
never outgrow. Even when people have healthy attachment in their relationship(s), they will
still experience times of stress or vulnerability. If people feel only slightly stressed, a look
across the room at a significant other may suffice. If people feel moderate stress, they may
need to experience some form of touch. With severe stress, they may need to be held for
awhile and comforted. Having healthy attachment and/or connections with others enables
people throughout their lifetime to build ways to deal with stressors as they arise.
A metaphor that is sometimes helpful when thinking of the effects of healthy and unhealthy
attachment is that of healing a physical injury. When a person with a compromised immune
system has cuts or scrapes, it is far more traumatic than it is for the person who has a healthy
A metaphor that is sometimes helpful when thinking of the effects of healthy and unhealthy
attachment is that of healing a physical injury. When a person with a compromised immune
system has cuts or scrapes, it is far more traumatic than it is for the person who has a healthy
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immune system. People with a healthy immune system will not think much about a cut or
scrape. They have learned to trust that their immune system will deal with it and that they
will be okay. Children without healthy attachment do not have any system to heal the cuts
or abrasions of life. These children get much worse, as they cannot attach to get those needs
met from other people. When people cannot attach healing becomes more difficult.
immune system. People with a healthy immune system will not think much about a cut or
scrape. They have learned to trust that their immune system will deal with it and that they
will be okay. Children without healthy attachment do not have any system to heal the cuts
or abrasions of life. These children get much worse, as they cannot attach to get those needs
met from other people. When people cannot attach healing becomes more difficult.
THEORY OF ATTACHMENT
THEORY OF ATTACHMENT
It is important to understand the patterns of attachment in order to create safety in the therapeutic relationship. Having this knowledge allows therapists to begin to assess the level of
safety clients have within themselves, with others, and at an existential level. These attachment patterns manifest themselves through the transference, dependency, and trust issues
that come up in session. The lack of healthy attachment shows itself in the level of shame
clients experience in the therapeutic relationship as well as in their lives outside of therapy.
It is extremely important for therapists to understand their own pattern of attachment and
how this may affect the therapeutic relationship in positive or negative ways. (See How
Therapists May Block Themselves from Dealing with Clients’ Feelings, Chapter 4.)
It is important to understand the patterns of attachment in order to create safety in the therapeutic relationship. Having this knowledge allows therapists to begin to assess the level of
safety clients have within themselves, with others, and at an existential level. These attachment patterns manifest themselves through the transference, dependency, and trust issues
that come up in session. The lack of healthy attachment shows itself in the level of shame
clients experience in the therapeutic relationship as well as in their lives outside of therapy.
It is extremely important for therapists to understand their own pattern of attachment and
how this may affect the therapeutic relationship in positive or negative ways. (See How
Therapists May Block Themselves from Dealing with Clients’ Feelings, Chapter 4.)
It is particularly useful to understand how the various patterns of attachment manifest themselves over the life cycle from infancy to adulthood. It is helpful to look at the patterns relative to particular clients to ascertain what pattern(s) of attachment they seem to have
experienced. It is assumed that most clients may have characteristics of more than one pattern of attachment.
It is particularly useful to understand how the various patterns of attachment manifest themselves over the life cycle from infancy to adulthood. It is helpful to look at the patterns relative to particular clients to ascertain what pattern(s) of attachment they seem to have
experienced. It is assumed that most clients may have characteristics of more than one pattern of attachment.
Attachment, trust, and safety are intimately connected. There is a great deal of cutting edge
research being done in the area of attachment and trauma at a neurobiological level (Main
& Solomon, 1986; Schore, 2002a,b; Siegel, 1999; Stern, 1995). A brief review of the different patterns (as originally proposed by Ainsworth, Blehar, Waters, & Wall, 1978) of attachment in infancy and how they look across the life span is provided.
Attachment, trust, and safety are intimately connected. There is a great deal of cutting edge
research being done in the area of attachment and trauma at a neurobiological level (Main
& Solomon, 1986; Schore, 2002a,b; Siegel, 1999; Stern, 1995). A brief review of the different patterns (as originally proposed by Ainsworth, Blehar, Waters, & Wall, 1978) of attachment in infancy and how they look across the life span is provided.
SECURE ATTACHMENT
SECURE ATTACHMENT
Infants who are securely attached have caregivers who are sensitive, warm, and caring.
These caregivers promptly attend to the cries of their infants. Caregivers serve as a secure
base to come back to while their infants are freely exploring the environment. These infants
can explore on their own when their caregivers are present. They may or may not be unhappy when their caregivers are absent. They will greet their caregivers in a positive fashion
when their caregivers return. These infants actively seek out their caregivers in times of distress and are easily comforted. They happily return to play after being comforted. When
these children reach preschool age, they tend to make friends easily and are well-liked.
They have good self esteem. They are flexible and handle stress well. They are able to be
open and engage in meaningful interchange. They are comfortable with physical contact.
They are warm and happy most of the time. In middle childhood, they continue to make
close friends and keep them while they engage in bigger groups of their peers. As adults,
they are able to access a broad range of feelings with ease. They are able to tap into many
of their memories regardless of whether they are positive or negative. They have a fairly
accurate picture of who their parents are; and if they experienced discomfort with them,
then they have resolved most of the pain or anger. Secure adults usually have children who
securely attach to them.
Infants who are securely attached have caregivers who are sensitive, warm, and caring.
These caregivers promptly attend to the cries of their infants. Caregivers serve as a secure
base to come back to while their infants are freely exploring the environment. These infants
can explore on their own when their caregivers are present. They may or may not be unhappy when their caregivers are absent. They will greet their caregivers in a positive fashion
when their caregivers return. These infants actively seek out their caregivers in times of distress and are easily comforted. They happily return to play after being comforted. When
these children reach preschool age, they tend to make friends easily and are well-liked.
They have good self esteem. They are flexible and handle stress well. They are able to be
open and engage in meaningful interchange. They are comfortable with physical contact.
They are warm and happy most of the time. In middle childhood, they continue to make
close friends and keep them while they engage in bigger groups of their peers. As adults,
they are able to access a broad range of feelings with ease. They are able to tap into many
of their memories regardless of whether they are positive or negative. They have a fairly
accurate picture of who their parents are; and if they experienced discomfort with them,
then they have resolved most of the pain or anger. Secure adults usually have children who
securely attach to them.
AVOIDANT ATTACHMENT
AVOIDANT ATTACHMENT
Infants who are avoidantly attached appear to have little interest in their primary caregivers.
They busily explore the environment. They seem to avoid their caregivers whenever the
Infants who are avoidantly attached appear to have little interest in their primary caregivers.
They busily explore the environment. They seem to avoid their caregivers whenever the
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caregivers return after a brief absence. These caregivers are often unavailable at an emotional level and may seem to reject the infant. These caregivers are frequently uncomfortable with the extensive emotional needs of the infant. They can affirm the infant being
independent but not support the infant’s dependent needs. When these infants are a year old,
they will likely seek little physical contact with the caregiver. These infants may show anger from time to time without any provocation. They do not respond to being comforted
by the caregivers. These infants are upset when they are put down. When these infants are
feeling discomfort or stress, they will avoid their caregivers and appear as though everything is fine. In preschool these children will often show anger, aggression, and appear defiant. These children may not be liked by their peers. They tend to spend a lot of time
around teachers. When they are hurting, they tend to isolate and withdraw. By school age,
these children tend to have short, neutral interchanges with their parents. There is an absence of warm physical contact. In middle childhood, these children may not have close
friends. There is little evidence of them experiencing jealousy or wanting a friend all to
themselves. They may be isolated by their peers. They tend to put their parents on a pedestal
and look up to them. Their actual experience of being parented is incongruent with the idealization of their parents. They have little, if any, ability to self-reflect. These avoidantly
attached children often become dismissive adults who discount warm, loving connections
with others. Dismissive adults usually have avoidantly attached children.
caregivers return after a brief absence. These caregivers are often unavailable at an emotional level and may seem to reject the infant. These caregivers are frequently uncomfortable with the extensive emotional needs of the infant. They can affirm the infant being
independent but not support the infant’s dependent needs. When these infants are a year old,
they will likely seek little physical contact with the caregiver. These infants may show anger from time to time without any provocation. They do not respond to being comforted
by the caregivers. These infants are upset when they are put down. When these infants are
feeling discomfort or stress, they will avoid their caregivers and appear as though everything is fine. In preschool these children will often show anger, aggression, and appear defiant. These children may not be liked by their peers. They tend to spend a lot of time
around teachers. When they are hurting, they tend to isolate and withdraw. By school age,
these children tend to have short, neutral interchanges with their parents. There is an absence of warm physical contact. In middle childhood, these children may not have close
friends. There is little evidence of them experiencing jealousy or wanting a friend all to
themselves. They may be isolated by their peers. They tend to put their parents on a pedestal
and look up to them. Their actual experience of being parented is incongruent with the idealization of their parents. They have little, if any, ability to self-reflect. These avoidantly
attached children often become dismissive adults who discount warm, loving connections
with others. Dismissive adults usually have avoidantly attached children.
AMBIVALENT ATTACHMENT
AMBIVALENT ATTACHMENT
Infants who are ambivalently attached engage in little exploration when their caregivers are
present. They appear to seek out, yet push away, caregivers upon their return. These infants
can be difficult to soothe or comfort. These caregivers are not predictable or are emotionally chaotic. They are often attentive but more on their own terms rather than to the infant’s
needs. These caregivers tend to be most responsive to the infant’s fear. As a result, these
infants cry a lot, tend to cling, and demand a great deal of attention. They are easily angered
and become upset when their caregivers leave even for a short amount of time. They will
exhibit a great deal of chronic anxiety in relationship to their caregivers. Exploration of
their environment is limited due to their anxiety about leaving their caregivers. It is difficult
for them to take in soothing after being separated from their caregivers, as they experience
both anger and comfort at the same time. In preschool, these children tend to be very easily
overwhelmed by anxiety, and their lack of maturity is obvious. They frequently depend on
their teacher for soothing and containment. They may become victimized by peers who are
aggressive. By school age, they may confuse intimacy and hostility in their relationship
with their parents. They can alternately be cute or ingratiating. They are anxious about their
caregivers when they are separated from them. In middle childhood, these children have
difficulty getting along with their peer group. They may find it hard to hold onto friendships
when they are participating in their larger peer group. These children often become preoccupied adults who have a lot of pain and anger at their parents. They have little ability to
take responsibility for their own actions in relationships. There is a tremendous fear of
abandonment. Preoccupied adults usually have ambivalently attached children.
Infants who are ambivalently attached engage in little exploration when their caregivers are
present. They appear to seek out, yet push away, caregivers upon their return. These infants
can be difficult to soothe or comfort. These caregivers are not predictable or are emotionally chaotic. They are often attentive but more on their own terms rather than to the infant’s
needs. These caregivers tend to be most responsive to the infant’s fear. As a result, these
infants cry a lot, tend to cling, and demand a great deal of attention. They are easily angered
and become upset when their caregivers leave even for a short amount of time. They will
exhibit a great deal of chronic anxiety in relationship to their caregivers. Exploration of
their environment is limited due to their anxiety about leaving their caregivers. It is difficult
for them to take in soothing after being separated from their caregivers, as they experience
both anger and comfort at the same time. In preschool, these children tend to be very easily
overwhelmed by anxiety, and their lack of maturity is obvious. They frequently depend on
their teacher for soothing and containment. They may become victimized by peers who are
aggressive. By school age, they may confuse intimacy and hostility in their relationship
with their parents. They can alternately be cute or ingratiating. They are anxious about their
caregivers when they are separated from them. In middle childhood, these children have
difficulty getting along with their peer group. They may find it hard to hold onto friendships
when they are participating in their larger peer group. These children often become preoccupied adults who have a lot of pain and anger at their parents. They have little ability to
take responsibility for their own actions in relationships. There is a tremendous fear of
abandonment. Preoccupied adults usually have ambivalently attached children.
DISORGANIZED/AVOIDANT ATTACHMENT
DISORGANIZED/AVOIDANT ATTACHMENT
Subsequent to Ainsworth’s original three patterns of attachment, Main and Solomon (1986)
have proposed a fourth pattern called disorganized/avoidant attachment that can develop in
childhood. This pattern of attachment appears to result from traumatic experiences children
have with caregivers and others. Aspects of avoidant and ambivalent attachment are
present. The trauma, abuse, or extensive neglect can occur in infancy or at some later time
in the person’s life. These infants seem to manifest disorganized and disoriented behavior
Subsequent to Ainsworth’s original three patterns of attachment, Main and Solomon (1986)
have proposed a fourth pattern called disorganized/avoidant attachment that can develop in
childhood. This pattern of attachment appears to result from traumatic experiences children
have with caregivers and others. Aspects of avoidant and ambivalent attachment are
present. The trauma, abuse, or extensive neglect can occur in infancy or at some later time
in the person’s life. These infants seem to manifest disorganized and disoriented behavior
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in the presence of their caregivers. They do not seem to know how to be close when stressed
or fearful. Disorganized children do not appear to have a strategy of staying close to their
caregivers. When they are upset, they tend to show both the tendency to move toward their
caregivers and yet want to avoid them. They may look dazed, frozen, or appear apprehensive. They both need the contact with their caregivers and yet are fearful of that contact. It
is like their caregivers are both the people who can help or hurt them. These children tend
to take care of their parents in order to control them or may become depressed or disorganized (not able to make contact). Not infrequently, these caregivers have had a background
of trauma or sexual abuse and so appear frightened or frightening to the child. Adults who
have a history of betrayal and abuse by the caregivers they were dependent upon may have
considerable difficulty trusting the therapeutic process or attachment. These adults may also
struggle with regulating their feelings.
in the presence of their caregivers. They do not seem to know how to be close when stressed
or fearful. Disorganized children do not appear to have a strategy of staying close to their
caregivers. When they are upset, they tend to show both the tendency to move toward their
caregivers and yet want to avoid them. They may look dazed, frozen, or appear apprehensive. They both need the contact with their caregivers and yet are fearful of that contact. It
is like their caregivers are both the people who can help or hurt them. These children tend
to take care of their parents in order to control them or may become depressed or disorganized (not able to make contact). Not infrequently, these caregivers have had a background
of trauma or sexual abuse and so appear frightened or frightening to the child. Adults who
have a history of betrayal and abuse by the caregivers they were dependent upon may have
considerable difficulty trusting the therapeutic process or attachment. These adults may also
struggle with regulating their feelings.
MAINTAINING ATTACHMENT WHEN A RUPTURE
OF TRUST HAS OCCURRED
MAINTAINING ATTACHMENT WHEN A RUPTURE
OF TRUST HAS OCCURRED
Painful childhood experiences can cause a tremendous sense of abandonment. At an existential level, they must find some way to make sense out of what they have experienced.
Most children do not know that whatever they experienced of a negative nature at the hands
of their caregiver is not normal. This is the only family they have, and until they get much
older, they do not have information about what happens in other families. If the abuse or
neglect are severe enough, it will feel like a life and death issue for the child. Children will
go to any lengths to survive physically and emotionally. They will do whatever they have
to do to preserve their attachment to their primary caregiver. As an attempt to keep this attachment, the child must reject the idea that the caregiver is bad or is not being a responsible
caregiver. Day after day children must ignore behaviors that are directed their way that are
of a negative nature. Children learn how to engage their defenses to wall off from consciousness whatever they have experienced of an abusive or neglectful nature. They learn
to minimize, rationalize, or make excuses for what has occurred including the following:
• I deserved the punishment I got.
Painful childhood experiences can cause a tremendous sense of abandonment. At an existential level, they must find some way to make sense out of what they have experienced.
Most children do not know that whatever they experienced of a negative nature at the hands
of their caregiver is not normal. This is the only family they have, and until they get much
older, they do not have information about what happens in other families. If the abuse or
neglect are severe enough, it will feel like a life and death issue for the child. Children will
go to any lengths to survive physically and emotionally. They will do whatever they have
to do to preserve their attachment to their primary caregiver. As an attempt to keep this attachment, the child must reject the idea that the caregiver is bad or is not being a responsible
caregiver. Day after day children must ignore behaviors that are directed their way that are
of a negative nature. Children learn how to engage their defenses to wall off from consciousness whatever they have experienced of an abusive or neglectful nature. They learn
to minimize, rationalize, or make excuses for what has occurred including the following:
• I deserved the punishment I got.
• My parents did the best they could.
• My parents did the best they could.
• I don’t think what happened to me was abusive.
• I don’t think what happened to me was abusive.
• I believed that I caused the abuse.
• I believed that I caused the abuse.
• I believe that I seduced my brother.
• I believe that I seduced my brother.
• My parents never really hurt me.
• My parents never really hurt me.
From an attachment perspective, the goal of therapy is to help clients to begin to form secure
attachments with the emphasis being on the therapeutic relationship as a basis for change.
It is the role of the therapist to provide this secure base (Bowlby, 1988) or a healthy holding
environment. (Winnicott, 1988). Clients can then explore their past and present experiences
both with the therapist and others.
From an attachment perspective, the goal of therapy is to help clients to begin to form secure
attachments with the emphasis being on the therapeutic relationship as a basis for change.
It is the role of the therapist to provide this secure base (Bowlby, 1988) or a healthy holding
environment. (Winnicott, 1988). Clients can then explore their past and present experiences
both with the therapist and others.
For therapists who are working extensively with clients who have a childhood history of
trauma or physical, sexual, or emotional abuse, I strongly encourage reading some of the
excellent books available on this subject. See References and Recommended Resources, this
chapter.
For therapists who are working extensively with clients who have a childhood history of
trauma or physical, sexual, or emotional abuse, I strongly encourage reading some of the
excellent books available on this subject. See References and Recommended Resources, this
chapter.
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DEVELOPMENTAL STAGE WHERE RUPTURE OF
TRUST TOOK PLACE
DEVELOPMENTAL STAGE WHERE RUPTURE OF
TRUST TOOK PLACE
Therapists need to be aware of Erikson’s psychosocial stages and understand the developmental tasks for each stage. This sets a framework or backdrop for conceptualizing how the
ruptures of trust have affected the normal, healthy developmental process. Children experience a different kind of injury if a rupture of trust occurs at a preverbal stage vs. experiencing a rupture of trust at a time when they are able to put words on experiences. The
cognitive developmental level of children also influences how they conceptualize a rupture
of trust. There can be multiple losses or traumas that occur at any age. However, we know
that the brain stores memories at a bodily, skin, and sensory level. Adults abused as very
young children may be able to access memories concerning these experiences in response
to sensory stimulation. These losses are sometimes referred to as a person having body
memories. Preverbal trauma or abuse is much harder to work on as the words were not
there.
Therapists need to be aware of Erikson’s psychosocial stages and understand the developmental tasks for each stage. This sets a framework or backdrop for conceptualizing how the
ruptures of trust have affected the normal, healthy developmental process. Children experience a different kind of injury if a rupture of trust occurs at a preverbal stage vs. experiencing a rupture of trust at a time when they are able to put words on experiences. The
cognitive developmental level of children also influences how they conceptualize a rupture
of trust. There can be multiple losses or traumas that occur at any age. However, we know
that the brain stores memories at a bodily, skin, and sensory level. Adults abused as very
young children may be able to access memories concerning these experiences in response
to sensory stimulation. These losses are sometimes referred to as a person having body
memories. Preverbal trauma or abuse is much harder to work on as the words were not
there.
When a client is wanting to heal a particular stage of their life, it may be helpful to have
them image themselves at that age.
When a client is wanting to heal a particular stage of their life, it may be helpful to have
them image themselves at that age.
Example
Example
A male client told the therapist that he wanted to work on what happened
to him when he was 4 years old. The therapist invited him to get an image
of being 4 years old.
A male client told the therapist that he wanted to work on what happened
to him when he was 4 years old. The therapist invited him to get an image
of being 4 years old.
Example
Example
A male client began to talk about something painful that happened during
the week. The therapist sensed there was a deep connection to the past.
When it seemed appropriate, the therapist asked the client how old he was
feeling at that moment. The client stated that he was feeling about 4 years
old.
A male client began to talk about something painful that happened during
the week. The therapist sensed there was a deep connection to the past.
When it seemed appropriate, the therapist asked the client how old he was
feeling at that moment. The client stated that he was feeling about 4 years
old.
The therapist might say the following kinds of things to clients as a way of exploring their
experience of a particular time in their life:
The therapist might say the following kinds of things to clients as a way of exploring their
experience of a particular time in their life:
• Tell me about being __ years old.
• What was happening at __ years old?
• Tell me about that time.
• What were you feeling?
• What is/was happening in your body?
• What did you do with your feelings?
• What are/were you experiencing?
• What decisions did you make about yourself?
• How does this experience still affect you?
• Do you see any connections between what happened then and your response now?
• Are there any new insights that you gained?
• Tell me about being __ years old.
• What was happening at __ years old?
• Tell me about that time.
• What were you feeling?
• What is/was happening in your body?
• What did you do with your feelings?
• What are/were you experiencing?
• What decisions did you make about yourself?
• How does this experience still affect you?
• Do you see any connections between what happened then and your response now?
• Are there any new insights that you gained?
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LOSS OF A BASIC SENSE OF SELF
LOSS OF A BASIC SENSE OF SELF
A basic sense of self is eroded at an emotional, physical, and spiritual level when ruptures
of trust occur. People who have experienced ruptures of trust lose their trust in themselves,
in other people, and whatever they might conceive of as an all-powerful other. Close relationships are difficult due to their intense feelings of need and fear.
A basic sense of self is eroded at an emotional, physical, and spiritual level when ruptures
of trust occur. People who have experienced ruptures of trust lose their trust in themselves,
in other people, and whatever they might conceive of as an all-powerful other. Close relationships are difficult due to their intense feelings of need and fear.
Early in my work with clients who have major ruptures of trust, I teach information on the
concept of self. (I put a circle on the board. I write the word self in the circle - [Figure1].) I
then say the following:
Early in my work with clients who have major ruptures of trust, I teach information on the
concept of self. (I put a circle on the board. I write the word self in the circle - [Figure1].) I
then say the following:
I want you to imagine that this is the “self” you were born with. It was intact
and whole at the time of your birth. All the “self” needed was healthy, consistent nurturance for normal development to take place. This in turn would
have allowed each developmental task to be accomplished as you grew and
matured into an adult and lived out a normal life cycle.
I want you to imagine that this is the “self” you were born with. It was intact
and whole at the time of your birth. All the “self” needed was healthy, consistent nurturance for normal development to take place. This in turn would
have allowed each developmental task to be accomplished as you grew and
matured into an adult and lived out a normal life cycle.
SELF
SELF
Figure 1
Figure 1
Sometimes it is helpful to think of the “self” as a puzzle. When the woundedness or ruptures of trust began, it took pieces of that “self” away or never
let them develop normally. (I draw this on the board.) Healing takes place
when the pieces of the puzzle begin to be repaired and put into place where
they belong. Another way of thinking of this concept is that the “self” got
bashed in as a result of the woundedness or ruptures of trust. The healing
work is to begin to push those pieces back out. (I draw this on the board.) It
is about recovering what was lost. It may also be about creating parts or
pieces that never got to develop in the first place.
Sometimes it is helpful to think of the “self” as a puzzle. When the woundedness or ruptures of trust began, it took pieces of that “self” away or never
let them develop normally. (I draw this on the board.) Healing takes place
when the pieces of the puzzle begin to be repaired and put into place where
they belong. Another way of thinking of this concept is that the “self” got
bashed in as a result of the woundedness or ruptures of trust. The healing
work is to begin to push those pieces back out. (I draw this on the board.) It
is about recovering what was lost. It may also be about creating parts or
pieces that never got to develop in the first place.
Clients may want to know how they can accomplish the task of rebuilding a self. This is a
healthy, thoughtful question on their part. I tell them that it is a long and gradual process
and that there are no quick fixes. The primary task is to create enough safety between us,
within themselves, and in relationship to others. I affirm that they have already begun this
process by having reached out and asked for help. If they want specifics, I tell them that a
place to begin is for them to identify what they feel and what they need in response to what
they feel. (See Exercises for Identifying Feelings, Chapter 4.) Many times children who
have experienced ruptures of trust have not had healthy mirroring by their caregiver and,
as a result, often do not know what they feel or what they need.
Clients may want to know how they can accomplish the task of rebuilding a self. This is a
healthy, thoughtful question on their part. I tell them that it is a long and gradual process
and that there are no quick fixes. The primary task is to create enough safety between us,
within themselves, and in relationship to others. I affirm that they have already begun this
process by having reached out and asked for help. If they want specifics, I tell them that a
place to begin is for them to identify what they feel and what they need in response to what
they feel. (See Exercises for Identifying Feelings, Chapter 4.) Many times children who
have experienced ruptures of trust have not had healthy mirroring by their caregiver and,
as a result, often do not know what they feel or what they need.
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CONNECTION AND DISCONNECTION
CONNECTION AND DISCONNECTION
Another theory that can enhance the understanding of the therapeutic relationship has been
proposed by Jordan and Dooley (2001) from the Stone Center at Wellesley College. They
note in Relational Practice in Action that shaming experiences often lead clients to a sense
of disconnection from themselves and others. They do not see themselves as deserving of
love or understanding from another. To heal this sense of separateness, clients need to experience reconnection. Reconnection can happen more easily in a safe environment. Creating safety through the therapeutic attachment enables clients to begin to move out of isolation and disconnection by nature of the therapeutic relationship. It creates enough safety
for them to begin to trust their ability to reclaim or build a self. The therapeutic attachment
enables or promotes the clients’ process of holding onto themselves in relationship. Clients
can begin to feel a sense of vitality, are more able to act, and have a more accurate sense of
themselves, the other person, and the relationship. They may also feel a greater sense of
worth and feel more connected to and drawn toward others.
Another theory that can enhance the understanding of the therapeutic relationship has been
proposed by Jordan and Dooley (2001) from the Stone Center at Wellesley College. They
note in Relational Practice in Action that shaming experiences often lead clients to a sense
of disconnection from themselves and others. They do not see themselves as deserving of
love or understanding from another. To heal this sense of separateness, clients need to experience reconnection. Reconnection can happen more easily in a safe environment. Creating safety through the therapeutic attachment enables clients to begin to move out of isolation and disconnection by nature of the therapeutic relationship. It creates enough safety
for them to begin to trust their ability to reclaim or build a self. The therapeutic attachment
enables or promotes the clients’ process of holding onto themselves in relationship. Clients
can begin to feel a sense of vitality, are more able to act, and have a more accurate sense of
themselves, the other person, and the relationship. They may also feel a greater sense of
worth and feel more connected to and drawn toward others.
It is important for therapists to understand how disconnection occurs for a client. Miller and
Stiver (1997) from the Stone Center at Wellesley College propose in The Healing Connection that clients need to feel that the connection or therapeutic attachment is safe. They can
then begin to explore how they have disconnected in the past and what brought about those
disconnections. The more therapists can connect empathically and genuinely with their clients as they share their experiences, the more likely clients are to further engage themselves
in healing ruptures of trust.
It is important for therapists to understand how disconnection occurs for a client. Miller and
Stiver (1997) from the Stone Center at Wellesley College propose in The Healing Connection that clients need to feel that the connection or therapeutic attachment is safe. They can
then begin to explore how they have disconnected in the past and what brought about those
disconnections. The more therapists can connect empathically and genuinely with their clients as they share their experiences, the more likely clients are to further engage themselves
in healing ruptures of trust.
From an attachment theory perspective, the yearning for connection is a basic building
block of life and continues throughout the life span. When children experience a secure
base or connection with their primary caregiver, they can develop a healthy self and are able
to maintain that self in relationship. Maslow talks about the need for affiliation after the
need for safety has been met (Everly & Lating, 1995). Miller and Stiver (1997) further propose that when disconnection is experienced on a continuous basis as a result of ruptures
of trust, the yearnings increase in intensity and often are seen as dangerous and something
to be avoided. When disconnection occurs in clients’ lives, they have to find ways to stay
connected and protect themselves at the same time. Disconnection serves the purpose of
preserving safety. Ways people frequently disconnect include:
• keeping their thoughts or feelings to themselves (shutting down emotionally)
• shaming themselves
• becoming silent so as not to be seen
• living adaptive, inauthentic lives
• playing out a role by pleasing or taking care of others
• talking so much that others cannot respond
• withdrawing and isolating
• engaging in addictive behaviors
• working too much
• repeating old destructive behaviors or patterns from past traumatic experiences
From an attachment theory perspective, the yearning for connection is a basic building
block of life and continues throughout the life span. When children experience a secure
base or connection with their primary caregiver, they can develop a healthy self and are able
to maintain that self in relationship. Maslow talks about the need for affiliation after the
need for safety has been met (Everly & Lating, 1995). Miller and Stiver (1997) further propose that when disconnection is experienced on a continuous basis as a result of ruptures
of trust, the yearnings increase in intensity and often are seen as dangerous and something
to be avoided. When disconnection occurs in clients’ lives, they have to find ways to stay
connected and protect themselves at the same time. Disconnection serves the purpose of
preserving safety. Ways people frequently disconnect include:
• keeping their thoughts or feelings to themselves (shutting down emotionally)
• shaming themselves
• becoming silent so as not to be seen
• living adaptive, inauthentic lives
• playing out a role by pleasing or taking care of others
• talking so much that others cannot respond
• withdrawing and isolating
• engaging in addictive behaviors
• working too much
• repeating old destructive behaviors or patterns from past traumatic experiences
Many clients have experienced these ruptures of trust in their lives before entering therapy.
Clients with deep ruptures of trust often feel very alone and believe that they cannot have
healthy relationships, satisfying work, etc. People who are disconnected frequently experience depression, confusion, lost productivity, low self-worth, and withdrawal. This may
Many clients have experienced these ruptures of trust in their lives before entering therapy.
Clients with deep ruptures of trust often feel very alone and believe that they cannot have
healthy relationships, satisfying work, etc. People who are disconnected frequently experience depression, confusion, lost productivity, low self-worth, and withdrawal. This may
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result in poor work performances, mood disorders, anxiety disorders, eating disorders,
substance abuse, aggression, and various other difficulties.
result in poor work performances, mood disorders, anxiety disorders, eating disorders,
substance abuse, aggression, and various other difficulties.
Just as it is useful to observe how clients have disconnected, it is also valuable for therapists
to understand how connected or disconnected they are from their clients in their sessions
with them. It may be helpful to review Chapter 4 on identifying feelings. (See How Therapists Block Themselves from Dealing with Client’s Feelings, Chapter 4.) The more therapists are in touch with their own feelings the more they can use them in the room with the
client. It is important that therapists do not distance themselves from the strong and powerful feelings that come up in them in response to their clients. These feelings make therapists open and vulnerable in such a way that clients are able to feel connected to them and
therapists to their clients. It often allows clients to touch their own feelings for the first time
as they experience this authentic mirroring process. When therapists can be fully present
clients can see and feel that they can have an impact on the therapist. Experiencing healthy
empathy in response to their feelings is often something clients have feared could never happen. When this happens, it results in a greater capacity for empathy in both the
client and therapist. Over time, clients may begin to generalize their experience of empathic attunement to create healthy relationships outside of therapy.
Just as it is useful to observe how clients have disconnected, it is also valuable for therapists
to understand how connected or disconnected they are from their clients in their sessions
with them. It may be helpful to review Chapter 4 on identifying feelings. (See How Therapists Block Themselves from Dealing with Client’s Feelings, Chapter 4.) The more therapists are in touch with their own feelings the more they can use them in the room with the
client. It is important that therapists do not distance themselves from the strong and powerful feelings that come up in them in response to their clients. These feelings make therapists open and vulnerable in such a way that clients are able to feel connected to them and
therapists to their clients. It often allows clients to touch their own feelings for the first time
as they experience this authentic mirroring process. When therapists can be fully present
clients can see and feel that they can have an impact on the therapist. Experiencing healthy
empathy in response to their feelings is often something clients have feared could never happen. When this happens, it results in a greater capacity for empathy in both the
client and therapist. Over time, clients may begin to generalize their experience of empathic attunement to create healthy relationships outside of therapy.
Example
Example
When a female client shared her pain about being abused by her father, the
therapist got an image of a child being beaten, and she began to feel a deep
sense of sadness. Tears rolled down her face. Since her client did not like
her to respond when she was sharing feelings, the therapist let the tears
speak for themselves. When the client saw the tears, she felt understood
and that her pain was important to someone. They both experienced a deep
connection.
When a female client shared her pain about being abused by her father, the
therapist got an image of a child being beaten, and she began to feel a deep
sense of sadness. Tears rolled down her face. Since her client did not like
her to respond when she was sharing feelings, the therapist let the tears
speak for themselves. When the client saw the tears, she felt understood
and that her pain was important to someone. They both experienced a deep
connection.
The purpose of the therapeutic attachment is to encourage and support the healing of clients
by helping them move away from the disconnection of suffering and pain into connection
and a healthy, satisfying life. It is the responsibility of the therapist to create enough safety
for clients to feel and think about their feelings without being shamed for them.
The purpose of the therapeutic attachment is to encourage and support the healing of clients
by helping them move away from the disconnection of suffering and pain into connection
and a healthy, satisfying life. It is the responsibility of the therapist to create enough safety
for clients to feel and think about their feelings without being shamed for them.
CREATING HEALTHY DEPENDENCE THAT
LEADS TO INDEPENDENCE
CREATING HEALTHY DEPENDENCE THAT
LEADS TO INDEPENDENCE
Although there are many different theoretical opinions on the value of dependency in the
therapeutic relationship, I believe that a healthy dependence in the therapeutic relationship
is necessary for healing. It allows clients to begin to complete the unfinished developmental
tasks experienced as a result of lack of healthy attachment and/or ruptures of trust. The role
of the therapist is one of constantly checking in with clients, helping them become aware
of what feels right to them, what changes they want to make, supporting them in the changes they make, and empowering them so that they can learn to trust themselves and the
choices they make. If the therapeutic relationship continues over a long period of time, then
the therapist will be fostering more and more independence.
Example
Although there are many different theoretical opinions on the value of dependency in the
therapeutic relationship, I believe that a healthy dependence in the therapeutic relationship
is necessary for healing. It allows clients to begin to complete the unfinished developmental
tasks experienced as a result of lack of healthy attachment and/or ruptures of trust. The role
of the therapist is one of constantly checking in with clients, helping them become aware
of what feels right to them, what changes they want to make, supporting them in the changes they make, and empowering them so that they can learn to trust themselves and the
choices they make. If the therapeutic relationship continues over a long period of time, then
the therapist will be fostering more and more independence.
Example
A therapist was working with a client who had been sexually abused by her
brother. She was stabilized on medications and was managing her anxiety
more effectively. The client told her mother that she needed to talk to her
brother about being abused. Her mother agreed with her. The client shared
with the therapist that she had such a good feeling afterwards. She told the
therapist that she knew she “was going to make it.”
A therapist was working with a client who had been sexually abused by her
brother. She was stabilized on medications and was managing her anxiety
more effectively. The client told her mother that she needed to talk to her
brother about being abused. Her mother agreed with her. The client shared
with the therapist that she had such a good feeling afterwards. She told the
therapist that she knew she “was going to make it.”
The therapist and client had worked on trying to strengthen the healthy
adult part of the client so that she could begin to care for the very anxious,
abused child part of her.
The therapist and client had worked on trying to strengthen the healthy
adult part of the client so that she could begin to care for the very anxious,
abused child part of her.
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Clients may appear as though they trust the therapist completely. A part of trusting is feeling safe. When clients begin to feel safe in the therapeutic attachment, they are often able
to gradually trust and hold onto themselves. When clients have abuse, trauma, or neglect in
their background, trust has been disrupted. They can create safety in their lives by the
choices they make. They can learn to trust themselves and trust others who are trustworthy.
Clients can learn to feel good about themselves, have healthy friendships, significant love
relationships, and achieve their goals or dreams. However, they will probably find they
need to continue to work on increasing their ability to trust themselves especially when they
are feeling very vulnerable.
Clients may appear as though they trust the therapist completely. A part of trusting is feeling safe. When clients begin to feel safe in the therapeutic attachment, they are often able
to gradually trust and hold onto themselves. When clients have abuse, trauma, or neglect in
their background, trust has been disrupted. They can create safety in their lives by the
choices they make. They can learn to trust themselves and trust others who are trustworthy.
Clients can learn to feel good about themselves, have healthy friendships, significant love
relationships, and achieve their goals or dreams. However, they will probably find they
need to continue to work on increasing their ability to trust themselves especially when they
are feeling very vulnerable.
Often clients ask themselves the following questions regarding trust:
• If I do not know and trust myself, how can I have a relationship?
• How can I know if you are trustworthy?
• How can I set healthy boundaries for myself?
• How can I feel safe with you and still hold onto myself?
Often clients ask themselves the following questions regarding trust:
• If I do not know and trust myself, how can I have a relationship?
• How can I know if you are trustworthy?
• How can I set healthy boundaries for myself?
• How can I feel safe with you and still hold onto myself?
Therapists develop healthy connections in the therapeutic attachment in several ways.
When therapists are present to the client verbally and nonverbally in a respectful manner,
they indicate they care about the relationship that is developing between the two of them.
Therapists indicate their interest by being curious and asking questions, and maintaining a
nonjudgmental attitude toward their clients.
Therapists develop healthy connections in the therapeutic attachment in several ways.
When therapists are present to the client verbally and nonverbally in a respectful manner,
they indicate they care about the relationship that is developing between the two of them.
Therapists indicate their interest by being curious and asking questions, and maintaining a
nonjudgmental attitude toward their clients.
Therapists give empathy by listening and reflecting clients’ feelings. Therapists need to understand or validate clients’ experiences by seeing them from their clients’ perspective. In
the process of giving validation, the therapist needs to understand and appreciate how the
client arrived at this feeling or thinking place.
Therapists give empathy by listening and reflecting clients’ feelings. Therapists need to understand or validate clients’ experiences by seeing them from their clients’ perspective. In
the process of giving validation, the therapist needs to understand and appreciate how the
client arrived at this feeling or thinking place.
Sample Responses
Sample Responses
“It must have been very scary for you to be only 6 years old and have to
take care of your brother while your mother was at work.”
“You must have been exhausted being up all night taking care of your sick
child.”
“I can understand that when your wife pushes you into doing something
that you do not want to do, and you comply with her, you become the little
boy who did not dare say ‘no’ to your father. You feel angry and become silent just like you did then.”
“It must have been very scary for you to be only 6 years old and have to
take care of your brother while your mother was at work.”
“You must have been exhausted being up all night taking care of your sick
child.”
“I can understand that when your wife pushes you into doing something
that you do not want to do, and you comply with her, you become the little
boy who did not dare say ‘no’ to your father. You feel angry and become silent just like you did then.”
EXERCISES TO INCREASE THE CLIENT’S
SUPPORT SYSTEM
EXERCISES TO INCREASE THE CLIENT’S
SUPPORT SYSTEM
A LIVING SECURITY BLANKET
A LIVING SECURITY BLANKET
The following is a model that I use with clients who do not appear to have a healthy support
system. It helps me assess who, if anyone, is in their support system. Using the model gives
clients some criteria for evaluating their support systems. It is helpful for both the therapist
and the client to understand who is in their inner and middle circles and why the client has
put each person there. Sometimes clients have people who really care about them and have
not accessed them for support. Other times, clients have been too fearful and distrustful due
The following is a model that I use with clients who do not appear to have a healthy support
system. It helps me assess who, if anyone, is in their support system. Using the model gives
clients some criteria for evaluating their support systems. It is helpful for both the therapist
and the client to understand who is in their inner and middle circles and why the client has
put each person there. Sometimes clients have people who really care about them and have
not accessed them for support. Other times, clients have been too fearful and distrustful due
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to the level of disconnection in their lives to develop a support system. There may be people
in the inner circle who are not trustworthy. This model allows clients to look at these people
and evaluate whether or not they want to keep them in their inner circle. I say the following
kinds of things to clients:
to the level of disconnection in their lives to develop a support system. There may be people
in the inner circle who are not trustworthy. This model allows clients to look at these people
and evaluate whether or not they want to keep them in their inner circle. I say the following
kinds of things to clients:
I would like to teach you a model. I want to remind you that models are idealized, but they give us a way to think about something that can be useful.
This model of a healthy support system talks about the inner circle, the middle circle, and the outer circle. Having a strong support system, or a “living
security blanket,” will allow you to trust more easily and feel safer in the
world.
I would like to teach you a model. I want to remind you that models are idealized, but they give us a way to think about something that can be useful.
This model of a healthy support system talks about the inner circle, the middle circle, and the outer circle. Having a strong support system, or a “living
security blanket,” will allow you to trust more easily and feel safer in the
world.
Then, I move to the following statements and/or questions under each circle.
Then, I move to the following statements and/or questions under each circle.
Inner Circle
Inner Circle
Ideally, it is helpful to have 4-7 friends in the inner circle. Sometimes clients have no one
in their inner circle. I like to ask clients the following questions:
• Who do you fully trust?
• Who can you call at any time, day or night, that would be there for you unequivocally?
• Does this friend live nearby or a long distance away?
• What makes you put this friend in your inner circle?
• Does this friend call you if he/she is hurting as well?
• Do you have other friends in your inner circle?
• What are their names?
• Can you tell me about them?
Ideally, it is helpful to have 4-7 friends in the inner circle. Sometimes clients have no one
in their inner circle. I like to ask clients the following questions:
• Who do you fully trust?
• Who can you call at any time, day or night, that would be there for you unequivocally?
• Does this friend live nearby or a long distance away?
• What makes you put this friend in your inner circle?
• Does this friend call you if he/she is hurting as well?
• Do you have other friends in your inner circle?
• What are their names?
• Can you tell me about them?
Each time they give me a name I put it in the inner circle I have drawn on the white board.
When there is no one in their inner circle, it is helpful to begin to explore how they could
begin to get a support system for themselves and what they might be willing to do to make
that happen one step at a time. When all their friends are a long distance away, it is important to start building a support system that is close by.
Each time they give me a name I put it in the inner circle I have drawn on the white board.
When there is no one in their inner circle, it is helpful to begin to explore how they could
begin to get a support system for themselves and what they might be willing to do to make
that happen one step at a time. When all their friends are a long distance away, it is important to start building a support system that is close by.
Middle Circle
Middle Circle
Ideally, there would be 10-15 friends in the middle circle. I say the following things to clients:
Ideally, there would be 10-15 friends in the middle circle. I say the following things to clients:
The friends in the middle circle are there for you in some ways, but you may
not fully trust them. They may be there for you sometimes, but they may let
you down other times. Over time, these friendships may grow to the point
that you can put them in your inner circle. Some of these friends will never
be put there. These are friends that you can do things with and enjoy in various ways from time to time. Your interests and values may be somewhat different from each other.
The friends in the middle circle are there for you in some ways, but you may
not fully trust them. They may be there for you sometimes, but they may let
you down other times. Over time, these friendships may grow to the point
that you can put them in your inner circle. Some of these friends will never
be put there. These are friends that you can do things with and enjoy in various ways from time to time. Your interests and values may be somewhat different from each other.
I ask clients the following questions:
• Who are the friends in your middle circle?
I ask clients the following questions:
• Who are the friends in your middle circle?
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• Can you tell me about them?
• Can you tell me about them?
• What makes you put this friend here?
• What makes you put this friend here?
• How are they there for you?
• How are they there for you?
• How are they not there for you?
• How are they not there for you?
• Who else is in this circle?
• Who else is in this circle?
• Can you tell me about them?
• Can you tell me about them?
• Is there anyone in this circle that could be cultivated enough to move into your inner
circle?
• Is there anyone in this circle that could be cultivated enough to move into your inner
circle?
• What would you need to make that happen?
• What would you need to make that happen?
• What could you do to make that happen?
• What could you do to make that happen?
Outer Circle
Outer Circle
Ideally there would be 30-50 people in the outer circle. I say the following things to my
clients:
Ideally there would be 30-50 people in the outer circle. I say the following things to my
clients:
The people in the outer circle are people in your life that you interact with
on a daily, weekly, or monthly basis. They might be office staff at work, the
postman, a grocery clerk, a hair stylist, colleagues in your field, a supervisor, a garage mechanic, fellow employees, etc. Pleasantries might be exchanged, you might eat together, work on a task, laugh and joke, make small
talk, exchange empathy for some event that has occurred, etc. Normally, intense sharing at a deep personal level does not occur, but there is a sense of
seeing and being seen at some level that can be comforting. Sometimes this
level of support is all clients have in their life.
The people in the outer circle are people in your life that you interact with
on a daily, weekly, or monthly basis. They might be office staff at work, the
postman, a grocery clerk, a hair stylist, colleagues in your field, a supervisor, a garage mechanic, fellow employees, etc. Pleasantries might be exchanged, you might eat together, work on a task, laugh and joke, make small
talk, exchange empathy for some event that has occurred, etc. Normally, intense sharing at a deep personal level does not occur, but there is a sense of
seeing and being seen at some level that can be comforting. Sometimes this
level of support is all clients have in their life.
I continue this discussion by stating that all of us need friends in our life who can listen,
comfort, hear us when we cry, reach out to us, and give us hope. I then ask the following
questions:
• Would you like to increase your support system?
• What are you willing to do to build up a support system?
• What is one step that you can take this week to make that happen in your life?
I continue this discussion by stating that all of us need friends in our life who can listen,
comfort, hear us when we cry, reach out to us, and give us hope. I then ask the following
questions:
• Would you like to increase your support system?
• What are you willing to do to build up a support system?
• What is one step that you can take this week to make that happen in your life?
BASICS OF A HEALTHY RELATIONSHIP
BASICS OF A HEALTHY RELATIONSHIP
Clients who do not have healthy relationships with their parents may not know how to form
healthy relationships. They may never have experienced a sense of engagement with their
parents in an empathic process that occurs normally in a healthy parent/child relationship.
Some children have had parents who do not engage in empathic relationships with their
peers. Children need to both experience empathy with their parents and see their parents
engaging empathically with others to learn the healthy process of connection or socialization.
Clients who do not have healthy relationships with their parents may not know how to form
healthy relationships. They may never have experienced a sense of engagement with their
parents in an empathic process that occurs normally in a healthy parent/child relationship.
Some children have had parents who do not engage in empathic relationships with their
peers. Children need to both experience empathy with their parents and see their parents
engaging empathically with others to learn the healthy process of connection or socialization.
I often teach clients what a healthy relationship looks like. I say to them the following:
I often teach clients what a healthy relationship looks like. I say to them the following:
Healthy relationships are reciprocal in nature. You share a little bit about
yourself and see if the other listens and seems genuinely interested and
Healthy relationships are reciprocal in nature. You share a little bit about
yourself and see if the other listens and seems genuinely interested and
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accepting. Then the other shares something about them. If each person feels
safe enough, the risking continues until both are safe enough to share their
innermost thoughts and feelings with the other. If one talks all the time and
shows no interest in the other’s life, it is not a healthy relationship. If one
“dumps” on the other a continuous tale of woe, it is clearly not going to lead
to a healthy relationship.
accepting. Then the other shares something about them. If each person feels
safe enough, the risking continues until both are safe enough to share their
innermost thoughts and feelings with the other. If one talks all the time and
shows no interest in the other’s life, it is not a healthy relationship. If one
“dumps” on the other a continuous tale of woe, it is clearly not going to lead
to a healthy relationship.
The exercise that follows can be done in several ways:
• Clients can be verbally asked to describe the basics of a healthy relationship while
the therapist is putting their answers on a white board.
• It can be done by giving clients a sheet of paper to list the characteristics of a healthy
relationship and then talk about their answers with them.
• Clients can be asked to do this at home and bring it next time so it can be discussed
together.
The exercise that follows can be done in several ways:
• Clients can be verbally asked to describe the basics of a healthy relationship while
the therapist is putting their answers on a white board.
• It can be done by giving clients a sheet of paper to list the characteristics of a healthy
relationship and then talk about their answers with them.
• Clients can be asked to do this at home and bring it next time so it can be discussed
together.
When exploring with clients the basics of a healthy relationship, I begin by asking them the
following question and then I write their responses on a white board:
• How would you describe the characteristics of a healthy relationship?
When exploring with clients the basics of a healthy relationship, I begin by asking them the
following question and then I write their responses on a white board:
• How would you describe the characteristics of a healthy relationship?
Then I usually teach them the basics of healthy relationships by putting them on the board.
It can serve to expand their thinking about what constitutes a healthy relationship.
• In relationships that grow deeper in nature, there is a need to go slowly and take plenty of time for the relationship to develop.
• There are two people in the relationship. There needs to be a fit for each of you.
• When sharing at an emotional level, it is important to note the kind of response you
get to your sharing so that you can respond at a similar level of intensity.
• When a relationship is lost, there needs to be a time of grieving. Grieving the loss
allows for the energy to develop new relationships.
• Some persons will not respond favorably when you attempt to establish a relationship. Each person has their own needs that they bring to a relationship. You cannot
know what their lack of response means to them. It is important that you do not personalize their response.
• Multiple experiences with others are necessary to find out what you desire in a relationship.
• A successful relationship requires initiative, self-assertion, refining, picking up after
failure, learning from mistakes, and trying again. To succeed in relationships, “Don’t
give up.” When things go wrong, analyze the situation and look for the lessons to be
learned.
• It is important to ascertain how safe and comfortable you are before sharing something that makes you vulnerable. You need to be able to trust that the other person will
not deny, devalue, minimize, pity, or shame you in some way. You need to be able to
trust that they will keep your confidence.
Then I usually teach them the basics of healthy relationships by putting them on the board.
It can serve to expand their thinking about what constitutes a healthy relationship.
• In relationships that grow deeper in nature, there is a need to go slowly and take plenty of time for the relationship to develop.
• There are two people in the relationship. There needs to be a fit for each of you.
• When sharing at an emotional level, it is important to note the kind of response you
get to your sharing so that you can respond at a similar level of intensity.
• When a relationship is lost, there needs to be a time of grieving. Grieving the loss
allows for the energy to develop new relationships.
• Some persons will not respond favorably when you attempt to establish a relationship. Each person has their own needs that they bring to a relationship. You cannot
know what their lack of response means to them. It is important that you do not personalize their response.
• Multiple experiences with others are necessary to find out what you desire in a relationship.
• A successful relationship requires initiative, self-assertion, refining, picking up after
failure, learning from mistakes, and trying again. To succeed in relationships, “Don’t
give up.” When things go wrong, analyze the situation and look for the lessons to be
learned.
• It is important to ascertain how safe and comfortable you are before sharing something that makes you vulnerable. You need to be able to trust that the other person will
not deny, devalue, minimize, pity, or shame you in some way. You need to be able to
trust that they will keep your confidence.
HOW CLIENTS GET TANGLED IN RELATIONSHIPS
HOW CLIENTS GET TANGLED IN RELATIONSHIPS
The Drama Triangle
The Drama Triangle
Much of the time we use our theoretical orientation(s) as ways to think about what is happening to clients, not as something we teach them. However, I have found it valuable to
Much of the time we use our theoretical orientation(s) as ways to think about what is happening to clients, not as something we teach them. However, I have found it valuable to
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teach all of my clients the Drama Triangle as defined in Transactional Analysis (Stewart &
Joines, 1987). Many clients are in unhealthy relationships and may have little awareness of
how to get out of them due to what they learned in their family of origin. I want them to
understand how they may enter the Drama Triangle and what happens after they do. As previously mentioned in Chapter 4, capital letters are used to clarify when a person is in the
role of Rescuer, Victim, or Persecutor. I use a white board to draw the three points of the
Drama Triangle and then talk about each point as follows:
teach all of my clients the Drama Triangle as defined in Transactional Analysis (Stewart &
Joines, 1987). Many clients are in unhealthy relationships and may have little awareness of
how to get out of them due to what they learned in their family of origin. I want them to
understand how they may enter the Drama Triangle and what happens after they do. As previously mentioned in Chapter 4, capital letters are used to clarify when a person is in the
role of Rescuer, Victim, or Persecutor. I use a white board to draw the three points of the
Drama Triangle and then talk about each point as follows:
I would like to teach you about the Drama Triangle as it is talked about in
Transactional Analysis or TA. It is called the Drama Triangle because it
describes the drama in people’s lives. There are three roles you might play
in the Drama Triangle. One is Rescuer, another is Victim, and the third one
is Persecutor. We tend to major in one role and minor in another. Once you
enter from one position, you never stay there. You go around the entire triangle and feel or respond from each of those positions as does the other you
are interacting with.
I would like to teach you about the Drama Triangle as it is talked about in
Transactional Analysis or TA. It is called the Drama Triangle because it
describes the drama in people’s lives. There are three roles you might play
in the Drama Triangle. One is Rescuer, another is Victim, and the third one
is Persecutor. We tend to major in one role and minor in another. Once you
enter from one position, you never stay there. You go around the entire triangle and feel or respond from each of those positions as does the other you
are interacting with.
It is helpful to write some of the characteristics for the three roles of the Drama Triangle on
the white board as you teach them this material.
It is helpful to write some of the characteristics for the three roles of the Drama Triangle on
the white board as you teach them this material.
The Rescuer
The Rescuer
Characteristics of the Rescuer role are:
1. They do what they don’t want to do.
2. They help without being asked.
3. They do more than half the work when asked for help.
Characteristics of the Rescuer role are:
1. They do what they don’t want to do.
2. They help without being asked.
3. They do more than half the work when asked for help.
Some additional characteristics of the Rescuer role are:
• have a need to be needed
• define their self-worth by being needed
• have learned to take care of others
• are usually parentified children
• are very adaptive and tend to people please
• are often overly responsible
• often are overly sensitive to the pain of others
• do not have good boundaries
• often have a need to control
People who choose the role of Rescuer often come from a family system
where they have learned to take care of other persons in the family in order
to get the care they needed. Some clients will have cared for a sibling. Others may have taken care of their parent at an emotional or physical level.
They have often carried the pain of the family. When Rescuing they frequently have a sense of grandiosity. This grandiosity often contributes to their
feeling that they can make others feel okay. They may have no conscious
awareness of doing this. If they took care of others in their family system,
their boundaries were violated as children. Rescuers sometimes come from
families where there are drugs or alcohol. There may have been physical,
sexual, or emotional abuse present. Rescuers have often experienced a great
deal of abandonment.
Some additional characteristics of the Rescuer role are:
• have a need to be needed
• define their self-worth by being needed
• have learned to take care of others
• are usually parentified children
• are very adaptive and tend to people please
• are often overly responsible
• often are overly sensitive to the pain of others
• do not have good boundaries
• often have a need to control
People who choose the role of Rescuer often come from a family system
where they have learned to take care of other persons in the family in order
to get the care they needed. Some clients will have cared for a sibling. Others may have taken care of their parent at an emotional or physical level.
They have often carried the pain of the family. When Rescuing they frequently have a sense of grandiosity. This grandiosity often contributes to their
feeling that they can make others feel okay. They may have no conscious
awareness of doing this. If they took care of others in their family system,
their boundaries were violated as children. Rescuers sometimes come from
families where there are drugs or alcohol. There may have been physical,
sexual, or emotional abuse present. Rescuers have often experienced a great
deal of abandonment.
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Rescuers come from a stance that says “I’m ok. I’ll try to help you out.”
They come from a “one up” position. “I know what you need and I am going
to tell you.” The role of the Rescuer is a powerful role but not a healthy one.
Trying to fix someone usually backfires and frequently leaves them feeling
hurt, angry, and victimized when the other person refuses their aid. Traditionally, Rescuers find Victims who need to be fixed. Rescuers may also control by being overprotective of others around them. When they overprotect,
it may be an attempt to keep the other from experiencing pain, making a
mistake, etc. Rescuers are often sensitive, caring individuals and are unable
to differentiate between being loving and caring vs. taking over the other
person’s life. Clearly, the world needs loving, caring people. So, how can
you tell whether you are being loving and caring or a Rescuer? It changes
daily depending on your fatigue level, your time constraints, whether you
want to do it, how it affects your life, etc.
Rescuers come from a stance that says “I’m ok. I’ll try to help you out.”
They come from a “one up” position. “I know what you need and I am going
to tell you.” The role of the Rescuer is a powerful role but not a healthy one.
Trying to fix someone usually backfires and frequently leaves them feeling
hurt, angry, and victimized when the other person refuses their aid. Traditionally, Rescuers find Victims who need to be fixed. Rescuers may also control by being overprotective of others around them. When they overprotect,
it may be an attempt to keep the other from experiencing pain, making a
mistake, etc. Rescuers are often sensitive, caring individuals and are unable
to differentiate between being loving and caring vs. taking over the other
person’s life. Clearly, the world needs loving, caring people. So, how can
you tell whether you are being loving and caring or a Rescuer? It changes
daily depending on your fatigue level, your time constraints, whether you
want to do it, how it affects your life, etc.
Example
Example
A client shared with her therapist that she had slept well the night before
and was feeling rested. She felt good emotionally. She had no major time
constraints. When a friend called who always had a tale of woe to share with
her, she was able to listen and be empathic without trying to fix her or take
away her pain. She decided after 20 minutes that she needed to bring the
conversation to a close and told her friend that she needed to hang up. The
client felt good because she had not been Rescuing. She did not feel resentful of her friend for having called. She did not give more than she wanted to
give. She did not violate her own boundaries.
A client shared with her therapist that she had slept well the night before
and was feeling rested. She felt good emotionally. She had no major time
constraints. When a friend called who always had a tale of woe to share with
her, she was able to listen and be empathic without trying to fix her or take
away her pain. She decided after 20 minutes that she needed to bring the
conversation to a close and told her friend that she needed to hang up. The
client felt good because she had not been Rescuing. She did not feel resentful of her friend for having called. She did not give more than she wanted to
give. She did not violate her own boundaries.
Example
Example
A male client had worked late the night before. He had slept poorly and
awakened feeling exhausted. He had a report due that afternoon, and he
had stayed home to finish it. His friend called and wanted him to listen to
what had happened to him. He did not tell his friend that he had a deadline
and did not have time to talk. He continued to listen and violated his own
boundaries. A half hour later he hung up feeling victimized and angry at
himself for not telling his friend what he needed. He started out as Rescuer,
moved to Victim, and then felt like he wanted to Persecute someone. He did
not get his report done as quickly as he wanted. When he got to work, he
yelled at the secretary because he was still angry at his friend for taking his
time and angry at himself for giving it.
A male client had worked late the night before. He had slept poorly and
awakened feeling exhausted. He had a report due that afternoon, and he
had stayed home to finish it. His friend called and wanted him to listen to
what had happened to him. He did not tell his friend that he had a deadline
and did not have time to talk. He continued to listen and violated his own
boundaries. A half hour later he hung up feeling victimized and angry at
himself for not telling his friend what he needed. He started out as Rescuer,
moved to Victim, and then felt like he wanted to Persecute someone. He did
not get his report done as quickly as he wanted. When he got to work, he
yelled at the secretary because he was still angry at his friend for taking his
time and angry at himself for giving it.
Example
Example
A mother who had sexual abuse in her background was overprotective in her
parenting style. Her mother had been very critical of her. She tended to be
critical of her daughter as an attempt to keep her from making mistakes and
to keep her safe. As a result, her daughter was afraid to try new ventures
or think on her own and consequently did not learn to trust herself. The
daughter would become angry with the mother, and the mother would become defensive. After the mother worked on her own issues in therapy, she
was able to see that when she tried to protect her daughter and was critical
of her, she was playing the role of Rescuer by controlling her. Later in life
when her daughter came to her asking for advice or counsel, she was more
often able to help her explore her options and make decisions for herself.
When she stayed out of the Drama Triangle, she was able to care for herself
and be supportive of her daughter.
A mother who had sexual abuse in her background was overprotective in her
parenting style. Her mother had been very critical of her. She tended to be
critical of her daughter as an attempt to keep her from making mistakes and
to keep her safe. As a result, her daughter was afraid to try new ventures
or think on her own and consequently did not learn to trust herself. The
daughter would become angry with the mother, and the mother would become defensive. After the mother worked on her own issues in therapy, she
was able to see that when she tried to protect her daughter and was critical
of her, she was playing the role of Rescuer by controlling her. Later in life
when her daughter came to her asking for advice or counsel, she was more
often able to help her explore her options and make decisions for herself.
When she stayed out of the Drama Triangle, she was able to care for herself
and be supportive of her daughter.
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The following questions can be asked of clients to ascertain whether they are playing the
role of Rescuer:
• When did you listen when you didn’t want to listen?
• When did you give more than you had energy to give?
• Would the other person have survived if you had chosen to take care of yourself?
• Was the other person truly helpless like an elderly person or a child?
The following questions can be asked of clients to ascertain whether they are playing the
role of Rescuer:
• When did you listen when you didn’t want to listen?
• When did you give more than you had energy to give?
• Would the other person have survived if you had chosen to take care of yourself?
• Was the other person truly helpless like an elderly person or a child?
Rescuers recognize or appear to know more about the others’ feelings than their own. Clients caught in Rescuing may operate at an unconscious level from the following kinds of
scripts:
• I have to do this or the world will end.
• I have to do this or mother will die.
• I have to do this or the company will fail.
• I have to do this or the family will break up.
Rescuers recognize or appear to know more about the others’ feelings than their own. Clients caught in Rescuing may operate at an unconscious level from the following kinds of
scripts:
• I have to do this or the world will end.
• I have to do this or mother will die.
• I have to do this or the company will fail.
• I have to do this or the family will break up.
When young children have to take care of their caregiver, they have to dissociate their own
needs, which necessitates a complete chemical change. The cost of the chemical switch is
the inability to know what they feel emotionally. An additional cost of this switch, beyond
the loss of emotional awareness, is the loss of the physical sensations of fatigue, pain, hunger, or other bodily needs. Ultimately, the cost may result in getting sick, becoming exhausted, or experiencing some kind of collapse. Depression is also a frequent result of this
process.
When young children have to take care of their caregiver, they have to dissociate their own
needs, which necessitates a complete chemical change. The cost of the chemical switch is
the inability to know what they feel emotionally. An additional cost of this switch, beyond
the loss of emotional awareness, is the loss of the physical sensations of fatigue, pain, hunger, or other bodily needs. Ultimately, the cost may result in getting sick, becoming exhausted, or experiencing some kind of collapse. Depression is also a frequent result of this
process.
Example
Example
A child came home from school and wanted to share about his day but became clear that his mother was distraught and overwhelmed. He listened to
her and did not share about his day for fear of distressing her further. He
discounted his own needs and took on the role of Rescuer.
A child came home from school and wanted to share about his day but became clear that his mother was distraught and overwhelmed. He listened to
her and did not share about his day for fear of distressing her further. He
discounted his own needs and took on the role of Rescuer.
When I am working with clients who favor the role of Rescuer, some additional things I
find useful are:
• helping them develop an awareness of their body by teaching them breathing and/or
relaxation exercises (See Chapter 5.)
• teaching them to frequently check in with what they are feeling (mad, sad, glad,
scared)
• teaching them to ask themselves what they need in response to what they are feeling
• helping them decide whether they can meet that need themselves or ask someone else
to meet that need (See Exercises for Identifying Feelings, Chapter 4.)
• helping them to become aware of their self-care (See Chapter 5.)
• helping them learn to recognize what they can really control and change
When I am working with clients who favor the role of Rescuer, some additional things I
find useful are:
• helping them develop an awareness of their body by teaching them breathing and/or
relaxation exercises (See Chapter 5.)
• teaching them to frequently check in with what they are feeling (mad, sad, glad,
scared)
• teaching them to ask themselves what they need in response to what they are feeling
• helping them decide whether they can meet that need themselves or ask someone else
to meet that need (See Exercises for Identifying Feelings, Chapter 4.)
• helping them to become aware of their self-care (See Chapter 5.)
• helping them learn to recognize what they can really control and change
I may ask clients who favor the role of Rescuer questions like:
• What are you feeling right now?
• How do you identify what you need from your family or a friend?
I may ask clients who favor the role of Rescuer questions like:
• What are you feeling right now?
• How do you identify what you need from your family or a friend?
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• When you feel overwhelmed, what can you do to take care of yourself (take a break,
go for a walk, call a friend)? (See Chapter 5.)
• Are you aware of when you get anxious? What makes you anxious? What are you
supposed to do with your anxiety based on your family scripts?
• In what situations do you find yourself taking care of others rather than caring about
them?
• In what situations do you find yourself taking responsibility for someone else?
• When you feel overwhelmed, what can you do to take care of yourself (take a break,
go for a walk, call a friend)? (See Chapter 5.)
• Are you aware of when you get anxious? What makes you anxious? What are you
supposed to do with your anxiety based on your family scripts?
• In what situations do you find yourself taking care of others rather than caring about
them?
• In what situations do you find yourself taking responsibility for someone else?
In a healthy relationship I am responsible to you rather than for you, and I am honest with
my own feelings as is appropriate. I take care of myself so I can participate in the relationship. Assuming you are not literally helpless, I am able to balance your needs with my own.
In a healthy relationship I am responsible to you rather than for you, and I am honest with
my own feelings as is appropriate. I take care of myself so I can participate in the relationship. Assuming you are not literally helpless, I am able to balance your needs with my own.
The Victim
The Victim
Characteristics of the Victim role are:
1. They ask questions when they already know the answer.
2. They don’t ask directly for what they want.
3. They don’t take responsibility for their own feelings, needs, wants, or actions.
Characteristics of the Victim role are:
1. They ask questions when they already know the answer.
2. They don’t ask directly for what they want.
3. They don’t take responsibility for their own feelings, needs, wants, or actions.
When teaching clients about the role of Victim, I often say something like the following:
People learn how to play the Victim role in a family system when there are
dysfunctional relationships. There may be substance abuse in the family.
Sometimes they may have actually been victimized physically, sexually, or
emotionally. They may have been singled out for scapegoating. Later they
may choose to be Victims. Sometimes it makes it hard to take new suggestions and they find themselves defending what they have been doing by saying “Yes, but.” Victims find Rescuers to help them feel better. When
Rescuers get hooked into taking care of Victims, they usually feel victimized
themselves which promotes a shift from Victim into Persecutor. The Victim
is in a “one down” position with a “woe is me” kind of stance. They feel
sad, helpless, and hopeless that life will change for them.
One of the common ways people in the Victim role can confuse themselves
is by assuming that if someone loves or cares about them, they will know
what they need or want. When people are in the Victim role, they equate being loved with the other person’s ability to read their mind and know what
they want.
When teaching clients about the role of Victim, I often say something like the following:
People learn how to play the Victim role in a family system when there are
dysfunctional relationships. There may be substance abuse in the family.
Sometimes they may have actually been victimized physically, sexually, or
emotionally. They may have been singled out for scapegoating. Later they
may choose to be Victims. Sometimes it makes it hard to take new suggestions and they find themselves defending what they have been doing by saying “Yes, but.” Victims find Rescuers to help them feel better. When
Rescuers get hooked into taking care of Victims, they usually feel victimized
themselves which promotes a shift from Victim into Persecutor. The Victim
is in a “one down” position with a “woe is me” kind of stance. They feel
sad, helpless, and hopeless that life will change for them.
One of the common ways people in the Victim role can confuse themselves
is by assuming that if someone loves or cares about them, they will know
what they need or want. When people are in the Victim role, they equate being loved with the other person’s ability to read their mind and know what
they want.
They will frequently say or think things like:
• If you really loved me, you would know what I feel, need, and want without my needing to tell you or ask.
• If you really cared about me, you would do what I want.
• If you really loved me, I wouldn’t have to ask for what I want or need.
They will frequently say or think things like:
• If you really loved me, you would know what I feel, need, and want without my needing to tell you or ask.
• If you really cared about me, you would do what I want.
• If you really loved me, I wouldn’t have to ask for what I want or need.
Example
Example
A client came into therapy and proceeded to talk about everything that was
wrong with his life (Victim). Over the course of therapy, a number of alternative actions were suggested by the therapist (Rescuer), but he found reasons week after week to not make any changes. He felt less and less
powerful, and the therapist felt more and more frustrated (Persecutor).
A client came into therapy and proceeded to talk about everything that was
wrong with his life (Victim). Over the course of therapy, a number of alternative actions were suggested by the therapist (Rescuer), but he found reasons week after week to not make any changes. He felt less and less
powerful, and the therapist felt more and more frustrated (Persecutor).
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Frequently, what happens is that clients move from Rescuer to Victim. This happens when
they have exhausted the adrenal system that supports the rescuing. Subsequently, they feel
lethargic, sad, even whiny (Victim) hoping that someone else will take care of them the way
they have chosen to take care of others. This is not a conscious process, and, frequently,
clients will deny the reality of this process in their lives until they have more awareness of
their feelings. This process often translates into Rescuing behaviors such as the following:
• overscheduling themselves
• overstressing their bodies
• being driven to do things whether or not anything gets accomplished
Frequently, what happens is that clients move from Rescuer to Victim. This happens when
they have exhausted the adrenal system that supports the rescuing. Subsequently, they feel
lethargic, sad, even whiny (Victim) hoping that someone else will take care of them the way
they have chosen to take care of others. This is not a conscious process, and, frequently,
clients will deny the reality of this process in their lives until they have more awareness of
their feelings. This process often translates into Rescuing behaviors such as the following:
• overscheduling themselves
• overstressing their bodies
• being driven to do things whether or not anything gets accomplished
If I ascertain that clients are stuck in a Victim role (by offering several suggestions and getting a “Yes, but” response or its equivalent), I realize that they need to stay where they are
for whatever reason. At this point I try to join them in their stuckness and be present to it
by saying something like:
• It sounds like you need to be right where you are at this moment and time. (Often
clients will agree.)
If I ascertain that clients are stuck in a Victim role (by offering several suggestions and getting a “Yes, but” response or its equivalent), I realize that they need to stay where they are
for whatever reason. At this point I try to join them in their stuckness and be present to it
by saying something like:
• It sounds like you need to be right where you are at this moment and time. (Often
clients will agree.)
In addition I might say the following kinds of things as an attempt to empower them:
• I trust that if and when you are ready to make a change, you will make that happen
in a way that is right for you.
• I trust that you will figure out what is best for you.
In addition I might say the following kinds of things as an attempt to empower them:
• I trust that if and when you are ready to make a change, you will make that happen
in a way that is right for you.
• I trust that you will figure out what is best for you.
Another approach that sometimes is useful is to ask the following questions:
• How does it feel to be in this place and not be able to make any change?
• What would make you want to change?
• How did it feel when I encouraged you to explore alternatives?
• What would need to happen for you to be able to make changes in your life?
• How did it feel to have me ask these questions instead of pushing you to make a
change?
• Do you have any new insights from doing this exploration?
Another approach that sometimes is useful is to ask the following questions:
• How does it feel to be in this place and not be able to make any change?
• What would make you want to change?
• How did it feel when I encouraged you to explore alternatives?
• What would need to happen for you to be able to make changes in your life?
• How did it feel to have me ask these questions instead of pushing you to make a
change?
• Do you have any new insights from doing this exploration?
Because people tend to move from the role of Rescuer to Victim, I suggest you review the
previous section under Rescuer for additional ideas in working with clients who favor a
Victim role.
Because people tend to move from the role of Rescuer to Victim, I suggest you review the
previous section under Rescuer for additional ideas in working with clients who favor a
Victim role.
The Persecutor
Characteristics of the Persecutor role are:
The Persecutor
Characteristics of the Persecutor role are:
1. They project their feelings of not okayness onto others.
1. They project their feelings of not okayness onto others.
2. They can be shaming by being sarcastic, cruel, and demeaning in an attempt to disempower others.
2. They can be shaming by being sarcastic, cruel, and demeaning in an attempt to disempower others.
3. They point out differences as a way of indicating their superiority.
3. They point out differences as a way of indicating their superiority.
I teach the following:
The Persecutor comes from a “one up” position of “I’m ok. You’re not ok.”
Persecutors are usually very willing to tell you how “not okay” you are.
I teach the following:
The Persecutor comes from a “one up” position of “I’m ok. You’re not ok.”
Persecutors are usually very willing to tell you how “not okay” you are.
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Persecutors act angry and can become abusive when they feel victimized. It
is a position of choice when a person is no longer able to maintain either the
Rescuer or Victim role. Persecutors also have learned this role by identifying with parents who criticized, judged, or hurt them. It can feel much better
to be angry and critical than sad and helpless.
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Persecutors act angry and can become abusive when they feel victimized. It
is a position of choice when a person is no longer able to maintain either the
Rescuer or Victim role. Persecutors also have learned this role by identifying with parents who criticized, judged, or hurt them. It can feel much better
to be angry and critical than sad and helpless.
Example
Example
Adolescents who feel controlled by their parents may feel like Victims. As a
result, they frequently feel that they have no power in their family. In response to feeling controlled, adolescents may move to the role of the Persecutor by lying. They may also persecute their parents by getting arrested,
doing poorly in school, or engaging in other acting out behaviors, knowing
at some level that this will humiliate their parents.
Adolescents who feel controlled by their parents may feel like Victims. As a
result, they frequently feel that they have no power in their family. In response to feeling controlled, adolescents may move to the role of the Persecutor by lying. They may also persecute their parents by getting arrested,
doing poorly in school, or engaging in other acting out behaviors, knowing
at some level that this will humiliate their parents.
Example
Example
A boss wanted an employee to perform in a particular controlling way. The
boss began to feel victimized when his orders were not followed by his employee. He became critical, threatened to fire him, and found other ways of
persecuting the employee.
A boss wanted an employee to perform in a particular controlling way. The
boss began to feel victimized when his orders were not followed by his employee. He became critical, threatened to fire him, and found other ways of
persecuting the employee.
When working with clients who favor the role of Persecutor, it is helpful to explore the following:
When working with clients who favor the role of Persecutor, it is helpful to explore the following:
• look at the hurt child part that is underneath the need to persecute the other
• explore how clients feel helpless or when they feel like a Victim and how that triggers
them into the Persecutor role. Often, it is because clients have experienced being
shamed, so they attempt to shame another person.
• look at the hurt child part that is underneath the need to persecute the other
• explore how clients feel helpless or when they feel like a Victim and how that triggers
them into the Persecutor role. Often, it is because clients have experienced being
shamed, so they attempt to shame another person.
It has been my desire to share some of what I have found valuable from several of the theories that particularly address the therapeutic relationship. I have not intended to present
any one theory in its fullness. Many therapists find the concepts from multiple theoretical
orientations useful in their practice.
It has been my desire to share some of what I have found valuable from several of the theories that particularly address the therapeutic relationship. I have not intended to present
any one theory in its fullness. Many therapists find the concepts from multiple theoretical
orientations useful in their practice.
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RECOMMENDED RESOURCES
RECOMMENDED RESOURCES
This section includes: attachment, self, healthy relationships, and connection
This section includes: attachment, self, healthy relationships, and connection
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Bucklin, L., & Keil, M. (1999). Come Rain or Come Shine: Friendships Between Women.
Holbrook, MA: Adams Media Corporation.
Bucklin, L., & Keil, M. (1999). Come Rain or Come Shine: Friendships Between Women.
Holbrook, MA: Adams Media Corporation.
Goldberg, S., Muir, R., & Kerr, J. (Eds.). (1995). Attachment Theory: Social Developmental and Clinical Perspectives. Hillsdale, NJ: The Analytic Press. (This is a good
overview of research and clinical applications.)
Goldberg, S., Muir, R., & Kerr, J. (Eds.). (1995). Attachment Theory: Social Developmental and Clinical Perspectives. Hillsdale, NJ: The Analytic Press. (This is a good
overview of research and clinical applications.)
Karen, R. (1994). Becoming Attached: Unfolding the Mystery of the Infant-Mother Bond
and Its Importance on Later Life. New York: Warner Books.
Karen, R. (1994). Becoming Attached: Unfolding the Mystery of the Infant-Mother Bond
and Its Importance on Later Life. New York: Warner Books.
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Lerner, H. (2001). The Dance of Connection: How to Talk to Someone When You’re Mad,
Hurt, Scared, Frustrated, Insulted, Betrayed, or Desperate. New York: Harper
Collins.
Lerner, H. (2001). The Dance of Connection: How to Talk to Someone When You’re Mad,
Hurt, Scared, Frustrated, Insulted, Betrayed, or Desperate. New York: Harper
Collins.
Masterson, J. F. (1985). The Real Self: A Developmental, Self, and Object Relations
Approach. New York: Brunner/Mazel Publishers.
Masterson, J. F. (1985). The Real Self: A Developmental, Self, and Object Relations
Approach. New York: Brunner/Mazel Publishers.
Siegel, D. J., & Hartzell, M. (2003). Parenting from the Inside Out. New York: Penguin
Putnam, Inc.
Siegel, D. J., & Hartzell, M. (2003). Parenting from the Inside Out. New York: Penguin
Putnam, Inc.
Smith, M. J. (1975). When I Say No I Feel Guilty. New York: Bantam Books.
Smith, M. J. (1975). When I Say No I Feel Guilty. New York: Bantam Books.
Solomon, M., & Siegel, D. J. (2003). Healing Trauma: Attachment, Mind, Body and
Brain. New York: W.W. Norton & Co.
Solomon, M., & Siegel, D. J. (2003). Healing Trauma: Attachment, Mind, Body and
Brain. New York: W.W. Norton & Co.
Stern, D. N. (1998). Diary of a Baby: What Your Child Sees, Feels, and Experiences. New
York: Basic Books.
Stern, D. N. (1998). Diary of a Baby: What Your Child Sees, Feels, and Experiences. New
York: Basic Books.
Stern, D. N., & Bruschweiler-Stern, with Freeland, A. (1998). The Birth of a Mother: How
the Motherhood Experience Changes You Forever. New York: Basic Books.
Stern, D. N., & Bruschweiler-Stern, with Freeland, A. (1998). The Birth of a Mother: How
the Motherhood Experience Changes You Forever. New York: Basic Books.
Whitfield, C. L. (1987). Healing the Child Within. Deerfield Beach, FL: Health Communications, Inc.
Whitfield, C. L. (1987). Healing the Child Within. Deerfield Beach, FL: Health Communications, Inc.
Whitfield, C. L. (1990). A Gift To Myself. Deerfield Beach, FL: Health Communications.
Whitfield, C. L. (1990). A Gift To Myself. Deerfield Beach, FL: Health Communications.
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7
Maintaining Safety While
Dealing with Trauma - Initial
Stages
Maintaining Safety While
Dealing with Trauma - Initial
Stages
Chapter Outline-
Chapter Outline-
A. Intrusiveness
1. Recurrent Intrusive Recollections of the Event
A. Intrusiveness
1. Recurrent Intrusive Recollections of the Event
a. What It Looks Like in the Client’s Life
a. What It Looks Like in the Client’s Life
b. Some Ways of Working with Intrusiveness
b. Some Ways of Working with Intrusiveness
2. Recurrent Nightmares of the Event
2. Recurrent Nightmares of the Event
a. What It Looks Like in the Client’s Life
a. What It Looks Like in the Client’s Life
b. Some Ways of Working with Nightmares
b. Some Ways of Working with Nightmares
3. Acting or Feeling as If the Event Were Recurring (Flashbacks)
3. Acting or Feeling as If the Event Were Recurring (Flashbacks)
a. What It Looks Like in the Client’s Life
a. What It Looks Like in the Client’s Life
b. Some Ways of Working with Flashbacks
b. Some Ways of Working with Flashbacks
B. Avoidance and Numbing
B. Avoidance and Numbing
1. Dissociative Issues
1. Dissociative Issues
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a. BASK Model of Dissociation
a. BASK Model of Dissociation
b. Signs and Symptoms of Possible Dissociation
b. Signs and Symptoms of Possible Dissociation
2. Teaching Clients About Dissociation
C. Hyperarousal
2. Teaching Clients About Dissociation
C. Hyperarousal
1. What It Looks Like in the Client’s Life
1. What It Looks Like in the Client’s Life
2. Some Ways of Working with Hyperarousal
2. Some Ways of Working with Hyperarousal
D. Role of the Amygdala in the Fear Response
D. Role of the Amygdala in the Fear Response
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Maintaining Safety While Dealing with Trauma
- Initial Stages
Maintaining Safety While Dealing with Trauma
- Initial Stages
When dealing with past trauma, there are special issues concerning the maintenance of
safety. Everything we have previously talked about when working with ruptures of trust is
generally applicable and is even more important to address.
When dealing with past trauma, there are special issues concerning the maintenance of
safety. Everything we have previously talked about when working with ruptures of trust is
generally applicable and is even more important to address.
Trauma can be a result of many different short-term events including:
Natural Disasters - floods, earthquakes, hurricanes, tropical storms, tornadoes, volcanoes
Accidental Disasters - car, plane, or boat accidents; explosions; fires
Interpersonal Violence - rape, assaults, robbery, terrorist attacks, hostage-taking,
bombing, shooting
Trauma can be a result of many different short-term events including:
Natural Disasters - floods, earthquakes, hurricanes, tropical storms, tornadoes, volcanoes
Accidental Disasters - car, plane, or boat accidents; explosions; fires
Interpersonal Violence - rape, assaults, robbery, terrorist attacks, hostage-taking,
bombing, shooting
These short-term events may cause long-term changes in affect, stress related behavior,
physiological functioning, and mental health.
These short-term events may cause long-term changes in affect, stress related behavior,
physiological functioning, and mental health.
Trauma can be a result of many different long-term events including:
Natural and Technological Disasters - nuclear accidents and toxic spills
Interpersonal Violence - being a hostage, political prisoner, POW, victim of childhood
sexual and/or physical abuse, battered syndrome, Holocaust victim, sexual harassment, refugee
Medical Procedures - surgeries, being immobilized, invasive procedures, etc. (These
can be particularly traumatic for children.)
Violence, Persecution/Marginalization - racism, sexism, or heterosexism
Trauma can be a result of many different long-term events including:
Natural and Technological Disasters - nuclear accidents and toxic spills
Interpersonal Violence - being a hostage, political prisoner, POW, victim of childhood
sexual and/or physical abuse, battered syndrome, Holocaust victim, sexual harassment, refugee
Medical Procedures - surgeries, being immobilized, invasive procedures, etc. (These
can be particularly traumatic for children.)
Violence, Persecution/Marginalization - racism, sexism, or heterosexism
For posttraumatic stress disorder (PTSD) to be diagnosed, the person must meet the following two distinct criteria as defined by the DSM-IV-TR (2000):
1. The person must have experienced, witnessed, or been confronted with an event or
events that involve actual or threatened death or serious injury or a threat to the
physical integrity of self or others.
2. The person’s response involved intense fear, helplessness, or horror.
For posttraumatic stress disorder (PTSD) to be diagnosed, the person must meet the following two distinct criteria as defined by the DSM-IV-TR (2000):
1. The person must have experienced, witnessed, or been confronted with an event or
events that involve actual or threatened death or serious injury or a threat to the
physical integrity of self or others.
2. The person’s response involved intense fear, helplessness, or horror.
If these two criteria are met, then the three symptom clusters of posttraumatic stress disorder are evaluated. These three clusters are:
1. Intrusiveness
2. Avoidance and Numbing
3. Hyperarousal
If these two criteria are met, then the three symptom clusters of posttraumatic stress disorder are evaluated. These three clusters are:
1. Intrusiveness
2. Avoidance and Numbing
3. Hyperarousal
It is important that therapists be familiar with each cluster as well as what is needed to maintain client safety. It is the task of the therapist to maintain safety when dealing with clients
who have experienced trauma. There are many excellent resources on trauma. Therefore, I
will not attempt to duplicate the experts in the field. I strongly encourage you to attend
workshops or read further in this area so as to fully inform yourself of the importance of
these issues. I will give descriptions of what acute stress or PTSD looks like either in the
It is important that therapists be familiar with each cluster as well as what is needed to maintain client safety. It is the task of the therapist to maintain safety when dealing with clients
who have experienced trauma. There are many excellent resources on trauma. Therefore, I
will not attempt to duplicate the experts in the field. I strongly encourage you to attend
workshops or read further in this area so as to fully inform yourself of the importance of
these issues. I will give descriptions of what acute stress or PTSD looks like either in the
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client’s life or in the clinical setting and some practical suggestions about maintaining safety and working with these symptoms of trauma.
client’s life or in the clinical setting and some practical suggestions about maintaining safety and working with these symptoms of trauma.
Many clients present with anxiety symptoms, depression, or relationship issues that are disguised PTSD. Having an accurate diagnosis makes it more likely that clients will receive
appropriate treatment. I have seen a large percentage of clients with physical or sexual
abuse that have PTSD, chronic, delayed. Therefore, I routinely do an assessment for PTSD.
If clients are experiencing PTSD, then adequate stabilization is important to reduce symptoms such as poor, unrestful sleep, irritability, hyperarousal, eating disturbances or disorders, and/or the inability to self-soothe.
Many clients present with anxiety symptoms, depression, or relationship issues that are disguised PTSD. Having an accurate diagnosis makes it more likely that clients will receive
appropriate treatment. I have seen a large percentage of clients with physical or sexual
abuse that have PTSD, chronic, delayed. Therefore, I routinely do an assessment for PTSD.
If clients are experiencing PTSD, then adequate stabilization is important to reduce symptoms such as poor, unrestful sleep, irritability, hyperarousal, eating disturbances or disorders, and/or the inability to self-soothe.
It may be useful for therapists to carefully review the symptom clusters for PTSD (intrusiveness, avoidance and numbing, and hyperarousal) when they suspect a client may have
been traumatized in the past. These criteria can be used as a way of checking which, if any,
of the symptoms may be applicable to the client. Many clients are relieved to know that
what they are experiencing is something that has a name and that others have experienced
it. However, some clients will see it as a negative label and may use it as a way to shame
themselves. Regardless of whether or not the diagnosis is shared with the client, the treatment is the same. As noted in Chapter 1, PTSD is a result of traumatic experiences. Everyone who has experienced trauma may not meet the criteria for PTSD but may have some of
the symptoms of PTSD like anxiety, depression, and dissociation. Clients may meet the criteria for an anxiety disorder, a mood disorder, and/or a dissociative identity disorder. A
number of clients who have sexual or physical abuse in their background experience higher
levels of intrusiveness, avoidance and numbing, and hyperarousal without meeting the criteria for PTSD. Nightmares are a form of intrusiveness. Numbing is a way to avoid contact
and can lead to depression. Another avoidance behavior is hyperarousal. Self-inflicted violence can be used as a way to dissociate or to stop dissociation. Eating disorders can be
another way of avoiding or numbing out feelings. If clients appear to have depressive
symptoms, it is important to get a depressive history both in the past and present. The ultimate goal is to create enough safety to stabilize the client and then to work toward mutually
agreed upon goals.
It may be useful for therapists to carefully review the symptom clusters for PTSD (intrusiveness, avoidance and numbing, and hyperarousal) when they suspect a client may have
been traumatized in the past. These criteria can be used as a way of checking which, if any,
of the symptoms may be applicable to the client. Many clients are relieved to know that
what they are experiencing is something that has a name and that others have experienced
it. However, some clients will see it as a negative label and may use it as a way to shame
themselves. Regardless of whether or not the diagnosis is shared with the client, the treatment is the same. As noted in Chapter 1, PTSD is a result of traumatic experiences. Everyone who has experienced trauma may not meet the criteria for PTSD but may have some of
the symptoms of PTSD like anxiety, depression, and dissociation. Clients may meet the criteria for an anxiety disorder, a mood disorder, and/or a dissociative identity disorder. A
number of clients who have sexual or physical abuse in their background experience higher
levels of intrusiveness, avoidance and numbing, and hyperarousal without meeting the criteria for PTSD. Nightmares are a form of intrusiveness. Numbing is a way to avoid contact
and can lead to depression. Another avoidance behavior is hyperarousal. Self-inflicted violence can be used as a way to dissociate or to stop dissociation. Eating disorders can be
another way of avoiding or numbing out feelings. If clients appear to have depressive
symptoms, it is important to get a depressive history both in the past and present. The ultimate goal is to create enough safety to stabilize the client and then to work toward mutually
agreed upon goals.
INTRUSIVENESS
INTRUSIVENESS
Note: It is worth noting that intrusiveness has such a powerful impact on people that the
DSM-IV-TR (2000) only requires one of the following symptoms to be present in a person’s
life in order to meet criteria for PTSD in this category. Clients may be persistently experiencing any or all of these symptoms, or they may experience them intermittently in response to
certain triggers.
Note: It is worth noting that intrusiveness has such a powerful impact on people that the
DSM-IV-TR (2000) only requires one of the following symptoms to be present in a person’s
life in order to meet criteria for PTSD in this category. Clients may be persistently experiencing any or all of these symptoms, or they may experience them intermittently in response to
certain triggers.
The first symptom cluster for PTSD involves the consistent reexperiencing of the traumatic
event. This intrusiveness may take a number of different forms. The most common forms
of intrusiveness I see are recurrent distressing recollections of the event, nightmares, occasionally sleepwalking, and dissociative flashbacks. Presented here are how these experiences express themselves in the client’s life. In addition, some practical techniques for
working with intrusiveness in the office and in the client’s life are offered.
The first symptom cluster for PTSD involves the consistent reexperiencing of the traumatic
event. This intrusiveness may take a number of different forms. The most common forms
of intrusiveness I see are recurrent distressing recollections of the event, nightmares, occasionally sleepwalking, and dissociative flashbacks. Presented here are how these experiences express themselves in the client’s life. In addition, some practical techniques for
working with intrusiveness in the office and in the client’s life are offered.
RECURRENT DISTRESSING RECOLLECTIONS OF THE EVENT
RECURRENT DISTRESSING RECOLLECTIONS OF THE EVENT
What It Looks Like in the Client’s Life
What It Looks Like in the Client’s Life
Clients frequently have images, thoughts, or perceptions of the traumatic event as they go
Clients frequently have images, thoughts, or perceptions of the traumatic event as they go
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about their daily lives or in session. These distressing recollections are a common occurrence when there is unresolved trauma. At this level of intrusiveness, clients are not acting
or feeling as though they are reliving the experience. However, the recollections are disruptive in nature and tend to make clients uncomfortable.
about their daily lives or in session. These distressing recollections are a common occurrence when there is unresolved trauma. At this level of intrusiveness, clients are not acting
or feeling as though they are reliving the experience. However, the recollections are disruptive in nature and tend to make clients uncomfortable.
Some Ways of Working with Intrusiveness
Some Ways of Working with Intrusiveness
Initially, I assess clients’ level of discomfort around their intrusive experience or recollections. When clients are safe enough to explore the primary experience of the trauma and
have images, feelings, or thoughts that begin to surface, I invite them to share what their
memory was, and we explore it together. Clients need to be empowered to have as much
control as possible. Based on the work of Courtois (1988), the following suggestions are
useful in handling intrusive images or recollections:
Initially, I assess clients’ level of discomfort around their intrusive experience or recollections. When clients are safe enough to explore the primary experience of the trauma and
have images, feelings, or thoughts that begin to surface, I invite them to share what their
memory was, and we explore it together. Clients need to be empowered to have as much
control as possible. Based on the work of Courtois (1988), the following suggestions are
useful in handling intrusive images or recollections:
• Put the memories in a box and place them on a high shelf until you are ready to take
them down.
• Put the memories in a box and place them on a high shelf until you are ready to take
them down.
• Put the memories in a room, close the door, and lock it until you are safe enough to
deal with them.
• Put the memories in a room, close the door, and lock it until you are safe enough to
deal with them.
• Put the memories in a safe place and allow yourself to bring up a positive image in
your mind.
• Put the memories in a safe place and allow yourself to bring up a positive image in
your mind.
• Go to a safe place inside of yourself.
• Go to a safe place inside of yourself.
Further suggestions I make for handling intrusive images or recollections are:
• thought stopping
• substituting another thought in its place
• distraction by thinking about something else
• getting an image of something positive or pleasurable
• talking about the feelings with someone who can just listen and be with the client
• journaling about their recollections
• breathing or relaxation exercises
Further suggestions I make for handling intrusive images or recollections are:
• thought stopping
• substituting another thought in its place
• distraction by thinking about something else
• getting an image of something positive or pleasurable
• talking about the feelings with someone who can just listen and be with the client
• journaling about their recollections
• breathing or relaxation exercises
Clients need to have a sense of safety or stability and the ability to self-soothe before any
intensive memory work is done. In other words, they need to be able to work, care for themselves, and fulfill their normal daily responsibilities. As it is appropriate to do the integrative memory work, additional images, thoughts, or feelings may come up. I then have
clients tell me about their images, thoughts, or feelings at an intellectual level. When they
are comfortable at this level and can stay present without dissociating, I invite them to share
their memory attaching their affect and feel the traumatic experience at a bodily or sensory
level. Sharing the recollections might be done in any number of ways. Some of the techniques I find useful with clients include:
Clients need to have a sense of safety or stability and the ability to self-soothe before any
intensive memory work is done. In other words, they need to be able to work, care for themselves, and fulfill their normal daily responsibilities. As it is appropriate to do the integrative memory work, additional images, thoughts, or feelings may come up. I then have
clients tell me about their images, thoughts, or feelings at an intellectual level. When they
are comfortable at this level and can stay present without dissociating, I invite them to share
their memory attaching their affect and feel the traumatic experience at a bodily or sensory
level. Sharing the recollections might be done in any number of ways. Some of the techniques I find useful with clients include:
Writing
• Make a written narrative of their entire history.
• Write out a time line from birth to the present. (It can help them to put painful or traumatic events in the context of what was going on in their life.)
• Do a written time line of the losses experienced. (Often there are unresolved losses
that may still affect them.)
Writing
• Make a written narrative of their entire history.
• Write out a time line from birth to the present. (It can help them to put painful or traumatic events in the context of what was going on in their life.)
• Do a written time line of the losses experienced. (Often there are unresolved losses
that may still affect them.)
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• Write or journal about a painful or traumatic memory that is bothering them.
• Write with the non-dominant hand about a memory, feeling, and/or experience. (Using the non-dominant hand often helps to access painful memories from the child part
of them.)
• Write or journal about a painful or traumatic memory that is bothering them.
• Write with the non-dominant hand about a memory, feeling, and/or experience. (Using the non-dominant hand often helps to access painful memories from the child part
of them.)
When I ask clients to write about their history, their losses, a painful memory, etc., I usually
ask them to read what they have written. I am always looking for the affect when they share
their narrative with me. This allows me to gain additional insights into their process. I keep
a copy of their life history or a loss history in their file since we may want to refer back to it.
When I ask clients to write about their history, their losses, a painful memory, etc., I usually
ask them to read what they have written. I am always looking for the affect when they share
their narrative with me. This allows me to gain additional insights into their process. I keep
a copy of their life history or a loss history in their file since we may want to refer back to it.
Subsequent to a client completing an exercise, it is often useful and enriching to use the following questions:
• Was it helpful or not helpful to do this exercise?
• What were your feelings while doing this exercise? (mad, sad, glad, scared)
• Is there anything that you became aware of or learned about yourself?
• Are there any additional insights that you gained from doing this exercise?
Subsequent to a client completing an exercise, it is often useful and enriching to use the following questions:
• Was it helpful or not helpful to do this exercise?
• What were your feelings while doing this exercise? (mad, sad, glad, scared)
• Is there anything that you became aware of or learned about yourself?
• Are there any additional insights that you gained from doing this exercise?
It is helpful to see if there is a particular theme that seems to recur in what clients have written. If clients are safe enough, it is important to explore the meaning of the memory for
them. Questions such as the following can be used:
It is helpful to see if there is a particular theme that seems to recur in what clients have written. If clients are safe enough, it is important to explore the meaning of the memory for
them. Questions such as the following can be used:
• What did this mean to you?
• What did this mean to you?
• What were you feeling?
• What were you feeling?
• How has this affected your life?
• How has this affected your life?
• In what ways has this affected your life?
• In what ways has this affected your life?
• What did you decide about you?
• What did you decide about you?
Drawing
• Draw on a sheet of paper or a sketch pad what you are feeling at this particular moment.
• Draw your memory of a particular event in either your dominant or non-dominant
hand. (Some clients find it useful to do the drawing with their non-dominant hand as
a way of accessing feelings they had as a child.)
• Assign clients to do a drawing in the room or at home and bring it in so it can be
talked about together. (I invite them to be aware of what they are feeling as they do
the drawing.)
Drawing
• Draw on a sheet of paper or a sketch pad what you are feeling at this particular moment.
• Draw your memory of a particular event in either your dominant or non-dominant
hand. (Some clients find it useful to do the drawing with their non-dominant hand as
a way of accessing feelings they had as a child.)
• Assign clients to do a drawing in the room or at home and bring it in so it can be
talked about together. (I invite them to be aware of what they are feeling as they do
the drawing.)
When I ask clients about what they have drawn I might ask or say to them the following:
• Tell me about your drawing or picture.
• What is going on in the drawing? (I want to be sure I understand what the various
symbols, colors, lines mean.)
• Is there any particular reason that you chose this color?
• What did you feel when you drew this picture?
• Tell me about the feeling.
• Is there anything that you learned about yourself?
When I ask clients about what they have drawn I might ask or say to them the following:
• Tell me about your drawing or picture.
• What is going on in the drawing? (I want to be sure I understand what the various
symbols, colors, lines mean.)
• Is there any particular reason that you chose this color?
• What did you feel when you drew this picture?
• Tell me about the feeling.
• Is there anything that you learned about yourself?
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• Were there any new insights that you gained from doing this exercise?
• If you had to choose a name or a title, what would you name it? (use a phrase or word)
• How did it feel to share this drawing with me?
• Were there any new insights that you gained from doing this exercise?
• If you had to choose a name or a title, what would you name it? (use a phrase or word)
• How did it feel to share this drawing with me?
Working with Clay
Working with Clay
When clients are appropriately angry or enraged, I tell them that I am not afraid of their anger. I also tell them that it makes sense to me that they would feel anger or rage based on
what happened to them. Clients are often afraid of their anger or rage and may be fearful
they will get lost in it, turn it on themselves, hurt themselves, or hurt someone else. Some
clients had rageaholics in their families, were never allowed to be angry, or were shamed
for their anger. The rules I share with clients who want to access their rage in the room are:
“As long as you are aware of what you are doing, don’t hurt yourself, don’t hurt me, or
break stuff in the room, it’s okay to be angry or feel the rage.”
When clients are appropriately angry or enraged, I tell them that I am not afraid of their anger. I also tell them that it makes sense to me that they would feel anger or rage based on
what happened to them. Clients are often afraid of their anger or rage and may be fearful
they will get lost in it, turn it on themselves, hurt themselves, or hurt someone else. Some
clients had rageaholics in their families, were never allowed to be angry, or were shamed
for their anger. The rules I share with clients who want to access their rage in the room are:
“As long as you are aware of what you are doing, don’t hurt yourself, don’t hurt me, or
break stuff in the room, it’s okay to be angry or feel the rage.”
Clients may access or work through their feelings by working with clay. I have found this
technique to be particularly helpful to access anger or rage.
• I use a square of masonite or linoleum that can be bought at the store. I buy clay in
a half dozen colors that I store in plastic bags. I use a cheap plastic shower curtain or
shower liner to keep it off the floor. Clients work with the clay on the shower curtain.
Sometimes clients ask for things that they can pound, poke, or cut the clay with. I have
used small hammers, large nails, or scissors for this. It is not uncommon for them to
shape the clay into their abuser and anatomically act out their rage on them. I have
never had a client act out their anger inappropriately in this fashion. However, I would
not recommend giving clients scissors or knives if you are not certain they have the
ability to control their actions.
• Clients may choose to work silently with the clay and then talk after they have finished. I remind them to be aware of what they are feeling as they work with the clay.
I usually encourage them to share what they are feeling.
• Clients usually verbalize their feelings while they are working with their hands. I
may encourage them to stay with their feelings. I sit quietly and observe both their verbal and nonverbal responses.
Clients may access or work through their feelings by working with clay. I have found this
technique to be particularly helpful to access anger or rage.
• I use a square of masonite or linoleum that can be bought at the store. I buy clay in
a half dozen colors that I store in plastic bags. I use a cheap plastic shower curtain or
shower liner to keep it off the floor. Clients work with the clay on the shower curtain.
Sometimes clients ask for things that they can pound, poke, or cut the clay with. I have
used small hammers, large nails, or scissors for this. It is not uncommon for them to
shape the clay into their abuser and anatomically act out their rage on them. I have
never had a client act out their anger inappropriately in this fashion. However, I would
not recommend giving clients scissors or knives if you are not certain they have the
ability to control their actions.
• Clients may choose to work silently with the clay and then talk after they have finished. I remind them to be aware of what they are feeling as they work with the clay.
I usually encourage them to share what they are feeling.
• Clients usually verbalize their feelings while they are working with their hands. I
may encourage them to stay with their feelings. I sit quietly and observe both their verbal and nonverbal responses.
We process what that experience was like for them afterwards. Questions I might ask include:
We process what that experience was like for them afterwards. Questions I might ask include:
• What was it like for you to do this?
• What was it like for you to do this?
• What did you feel as you worked with the clay?
• What did you feel as you worked with the clay?
• How did it feel to touch the rage?
• How did it feel to touch the rage?
• How did it feel to get angry?
• How did it feel to get angry?
• How did it feel to touch the sadness?
• How did it feel to touch the sadness?
• How did it feel to touch the fearful or scared feelings?
• How did it feel to touch the fearful or scared feelings?
• Are there any other feelings that you experienced?
• Are there any other feelings that you experienced?
• What are you feeling right now?
• What are you feeling right now?
• Did you break any family rules by letting yourself feel the anger, rage, sadness, or
fear?
• Did you break any family rules by letting yourself feel the anger, rage, sadness, or
fear?
• How does it feel to have broken the family rules?
• How does it feel to have broken the family rules?
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• Is there anything that you learned about yourself?
• Are there any additional insights that you gained from doing this exercise?
• Is there anything that you learned about yourself?
• Are there any additional insights that you gained from doing this exercise?
Beating a Foam-filled Pillow
Beating a Foam-filled Pillow
Clients who are feeling a lot of anger or rage often find it helpful to beat on a pillow with
a smaller one while imagining the pillow to be their abuser. I have a large, 36-inch square
foam-filled pillow that I keep in a corner of my office. I have a small pillow that clients can
use to beat on the larger pillow. Some clients prefer to use their fists. It is often helpful to
get some big muscle activity going when attempting to access a great deal of anger or rage.
I invite them to stay with their feelings. Otherwise, I sit quietly and observe their responses,
both verbal and nonverbal. There may be a great deal of yelling or screaming as feelings
are accessed. This is a normal process when accessing very painful feelings. However, it is
important to watch for dissociation as the exercise is rendered ineffective when this happens. (See Dissociative Issues, this chapter, for further understanding on this topic.)
Clients who are feeling a lot of anger or rage often find it helpful to beat on a pillow with
a smaller one while imagining the pillow to be their abuser. I have a large, 36-inch square
foam-filled pillow that I keep in a corner of my office. I have a small pillow that clients can
use to beat on the larger pillow. Some clients prefer to use their fists. It is often helpful to
get some big muscle activity going when attempting to access a great deal of anger or rage.
I invite them to stay with their feelings. Otherwise, I sit quietly and observe their responses,
both verbal and nonverbal. There may be a great deal of yelling or screaming as feelings
are accessed. This is a normal process when accessing very painful feelings. However, it is
important to watch for dissociation as the exercise is rendered ineffective when this happens. (See Dissociative Issues, this chapter, for further understanding on this topic.)
Afterwards we process their experience. Questions I might ask include:
• What was it like for you to do this exercise?
• How did it feel to get angry?
• How did it feel to touch the rage?
• Were there any scary feelings in allowing yourself to get angry?
• Are there any other feelings that you experienced?
• What are you feeling right now?
• Did you break any family rules by letting yourself feel the anger, rage, sadness, fear?
• How does it feel that you broke the family rules?
• Is there anything that you learned about yourself?
• Were there any additional insights that you gained from doing this exercise?
Afterwards we process their experience. Questions I might ask include:
• What was it like for you to do this exercise?
• How did it feel to get angry?
• How did it feel to touch the rage?
• Were there any scary feelings in allowing yourself to get angry?
• Are there any other feelings that you experienced?
• What are you feeling right now?
• Did you break any family rules by letting yourself feel the anger, rage, sadness, fear?
• How does it feel that you broke the family rules?
• Is there anything that you learned about yourself?
• Were there any additional insights that you gained from doing this exercise?
Paper and Scissors, Markers, or Pencils
Paper and Scissors, Markers, or Pencils
Clients who are feeling a lot of rage may be able to access the rage by drawing their abuser
and cutting him/her to pieces. I ask the same kinds of questions as when working with clay.
Clients who are feeling a lot of rage may be able to access the rage by drawing their abuser
and cutting him/her to pieces. I ask the same kinds of questions as when working with clay.
Ripping a Phone Book
Ripping a Phone Book
Clients who are feeling a lot of rage may be able to access the rage by manually ripping up
a phone book. I ask the same kinds of questions as when working with clay.
Clients who are feeling a lot of rage may be able to access the rage by manually ripping up
a phone book. I ask the same kinds of questions as when working with clay.
Wringing a Hand Towel
Wringing a Hand Towel
Clients who are feeling a lot of rage may be able to access the rage by taking a hand towel
and twisting and wringing it in their hands. I ask the same kinds of questions as when working with clay.
Clients who are feeling a lot of rage may be able to access the rage by taking a hand towel
and twisting and wringing it in their hands. I ask the same kinds of questions as when working with clay.
Imaging a Painful Memory in Their Mind
Imaging a Painful Memory in Their Mind
Some clients prefer to sit quietly and get an image in their mind of a painful memory. They
are able to access the feelings and say the things they want to say. I ask them to tell me about
Some clients prefer to sit quietly and get an image in their mind of a painful memory. They
are able to access the feelings and say the things they want to say. I ask them to tell me about
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the experience and what they felt afterwards. I ask the same kinds of questions as when
working with clay.
Note: When these types of exercises are used to access painful feelings, it is important to
look for a sense of relief or release within the clients. Do they feel any lighter or more hopeful? Usually clients experience some level of relief. If they do not, then it is useful to explore
what they are experiencing.
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the experience and what they felt afterwards. I ask the same kinds of questions as when
working with clay.
Note: When these types of exercises are used to access painful feelings, it is important to
look for a sense of relief or release within the clients. Do they feel any lighter or more hopeful? Usually clients experience some level of relief. If they do not, then it is useful to explore
what they are experiencing.
RECURRENT NIGHTMARES OF THE EVENT
RECURRENT NIGHTMARES OF THE EVENT
What It Looks Like in the Client’s Life
What It Looks Like in the Client’s Life
Nightmares often have a recurring theme of victimization. It is often useful to identify the
theme. The theme may be a script the client lives out of such as the following:
• a fear of not being seen
• invisibility
• having no voice
• feeling powerless
• helpless
• no way to make a difference
• out of control
Nightmares often have a recurring theme of victimization. It is often useful to identify the
theme. The theme may be a script the client lives out of such as the following:
• a fear of not being seen
• invisibility
• having no voice
• feeling powerless
• helpless
• no way to make a difference
• out of control
The client may not be aware of the theme of the nightmare, but with increased awareness
may be able to access this information. In the case of childhood trauma, the theme of the
nightmares has usually been there for a long time. Nightmares of being brutalized, raped,
murdered, assaulted, chased, pursued, stalked, etc. are common especially for clients who
have sexual or physical abuse in their background. The nightmares may be a way of reenacting the trauma over and over. Some nightmares may be a literal replaying of events that
occurred. Other nightmares are symbolic in nature, and it is helpful to understand the symbolism. Sometimes the people in the dreams are faceless; sometimes they have faces of
people known to the client. Often, the feeling in the nightmare or afterwards is one of fear
or terror. The body frequently experiences a heightened state of hyperarousal as a result of
the nightmare. Sleep is disrupted, and the person often feels the effect of the nightmare the
next day. Clients will not always remember a nightmare the following day.
The client may not be aware of the theme of the nightmare, but with increased awareness
may be able to access this information. In the case of childhood trauma, the theme of the
nightmares has usually been there for a long time. Nightmares of being brutalized, raped,
murdered, assaulted, chased, pursued, stalked, etc. are common especially for clients who
have sexual or physical abuse in their background. The nightmares may be a way of reenacting the trauma over and over. Some nightmares may be a literal replaying of events that
occurred. Other nightmares are symbolic in nature, and it is helpful to understand the symbolism. Sometimes the people in the dreams are faceless; sometimes they have faces of
people known to the client. Often, the feeling in the nightmare or afterwards is one of fear
or terror. The body frequently experiences a heightened state of hyperarousal as a result of
the nightmare. Sleep is disrupted, and the person often feels the effect of the nightmare the
next day. Clients will not always remember a nightmare the following day.
Intrusiveness can also manifest itself as sleepwalking. Clients may have no awareness of
doing this, but their significant other may tell them when it happens. Sometimes they wake
themselves up and realize what has happened. When there are major disturbances in the
area of sleep, a medication to lessen anxiety or depression may be indicated. A referral for
sleeping medication may be helpful during the stabilization phase when safety is being established. As healing takes place over time, the intrusiveness of the nightmares usually begins to recede. Intrusiveness in the form of nightmares and sleepwalking may be initiated
at an unconscious level, as the unconscious attempts to heal the trauma. Because the intrusiveness is happening out of conscious awareness, it makes it more difficult to heal symptoms of trauma.
Intrusiveness can also manifest itself as sleepwalking. Clients may have no awareness of
doing this, but their significant other may tell them when it happens. Sometimes they wake
themselves up and realize what has happened. When there are major disturbances in the
area of sleep, a medication to lessen anxiety or depression may be indicated. A referral for
sleeping medication may be helpful during the stabilization phase when safety is being established. As healing takes place over time, the intrusiveness of the nightmares usually begins to recede. Intrusiveness in the form of nightmares and sleepwalking may be initiated
at an unconscious level, as the unconscious attempts to heal the trauma. Because the intrusiveness is happening out of conscious awareness, it makes it more difficult to heal symptoms of trauma.
Some Ways of Working with Nightmares
Some Ways of Working with Nightmares
Note: This material can also be utilized when working with dreams.
If it seems appropriate in terms of clients’ safety level, it can be helpful to have them write
down their nightmares and begin to work with them. I suggest the following:
Note: This material can also be utilized when working with dreams.
If it seems appropriate in terms of clients’ safety level, it can be helpful to have them write
down their nightmares and begin to work with them. I suggest the following:
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• Tell yourself during the day that you are going to remember your dreams.
• Tell yourself during the day that you are going to remember your dreams.
• It is helpful to place a pad of paper and a pencil beside your bed.
• It is helpful to place a pad of paper and a pencil beside your bed.
• When you get in bed, tell yourself that you will remember your dreams.
• When you get in bed, tell yourself that you will remember your dreams.
• It is helpful to keep your eyes closed and stay in the same body position when you
awaken from a dream while you review its contents.
• It is helpful to keep your eyes closed and stay in the same body position when you
awaken from a dream while you review its contents.
• Train yourself to write down your dreams immediately on awakening, even if they
occur in the middle of the night.
• Train yourself to write down your dreams immediately on awakening, even if they
occur in the middle of the night.
• On first awakening in the morning, record your dreams on paper.
• On first awakening in the morning, record your dreams on paper.
• Sharing your dream with others helps to retain it in your mind.
• Sharing your dream with others helps to retain it in your mind.
After awakening from a nightmare, you may find it helpful to say to yourself the following
kinds of statements:
After awakening from a nightmare, you may find it helpful to say to yourself the following
kinds of statements:
• I am safe.
• I am safe.
• No one is hurting me.
• No one is hurting me.
• This is not happening to me except in my mind.
• This is not happening to me except in my mind.
• This is not real.
• This is not real.
A distraction can be useful to help you get your mind off a nightmare. (Often clients are
able to go back to sleep after finding some way(s) to self-soothe.)
A distraction can be useful to help you get your mind off a nightmare. (Often clients are
able to go back to sleep after finding some way(s) to self-soothe.)
• You may find it useful to wake yourself up when nightmares occur.
• You may find it useful to wake yourself up when nightmares occur.
• Sometimes it is helpful to ask to be held if that is available.
• Sometimes it is helpful to ask to be held if that is available.
• You may find that you benefit from talking about the nightmare with someone close
to you as a way of letting it go.
• You may find that you benefit from talking about the nightmare with someone close
to you as a way of letting it go.
• Writing about the nightmare may be helpful in allowing you to let it go.
• Writing about the nightmare may be helpful in allowing you to let it go.
• At some point, it is important to work on separating the nightmare from reality and
find ways to soothe yourself.
• At some point, it is important to work on separating the nightmare from reality and
find ways to soothe yourself.
Some ways of exploring clients’ dreams are:
Some ways of exploring clients’ dreams are:
• After asking clients to tell me about their dream, I ask them to identify what they felt
in response to the dream. I also want to know what the feeling was in the dream. We
look at the process that was going on in the dream and see how that might be happening in their life at a literal or symbolic level.
• After asking clients to tell me about their dream, I ask them to identify what they felt
in response to the dream. I also want to know what the feeling was in the dream. We
look at the process that was going on in the dream and see how that might be happening in their life at a literal or symbolic level.
• Another approach to dream work is to ask clients to tell me about their dream.We
explore how each of the characters in the dream might be parts of themselves, and then
we look at the process in the dream and how that might be going on in their life.
• Another approach to dream work is to ask clients to tell me about their dream.We
explore how each of the characters in the dream might be parts of themselves, and then
we look at the process in the dream and how that might be going on in their life.
Some clients seem to easily access the unconscious by doing dream work and are able to
see the healing work reflected in their lives. Their nightmares decrease, or the content
changes in ways that seem healthy. Some clients do a great deal of dream work interspersed
with topics that come up for them on a weekly basis. Other clients are not amenable to
dream work, and different avenues of healing need to be utilized.
Some clients seem to easily access the unconscious by doing dream work and are able to
see the healing work reflected in their lives. Their nightmares decrease, or the content
changes in ways that seem healthy. Some clients do a great deal of dream work interspersed
with topics that come up for them on a weekly basis. Other clients are not amenable to
dream work, and different avenues of healing need to be utilized.
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ACTING OR FEELING AS IF THE EVENT WERE RECURRING
(FLASHBACKS)
ACTING OR FEELING AS IF THE EVENT WERE RECURRING
(FLASHBACKS)
What It Looks Like in the Client’s Life
What It Looks Like in the Client’s Life
When a client experiences flashbacks, there is a sense of actually reliving the experience.
Clients often experience a great deal of discomfort when this occurs. These recollections or
memories tend to be extremely painful and often interfere with their ability to go about their
daily functions. These experiences are not psychotic episodes. They may have no awareness of being in the here and now. They usually do not feel safe. Clients may feel that there
is no one with whom they can share their experience. They may feel utterly alone. When a
flashback happens, they may experience high levels of anxiety or hyperarousal. Additionally, depression may be experienced as a normal response to feeling helpless and hopeless
to stop the flashbacks. Clients can experience these episodes at any time, which makes it
more difficult to guard against them happening. Flashbacks often happen in response to a
triggered event in the present. The feelings that were present in the original trauma such as
terror, rage, not being heard, not being seen, or being abused are re-experienced as the
flashback is occurring. Clients may not be aware what the stimulus is in the present that has
caused the flashback.
When a client experiences flashbacks, there is a sense of actually reliving the experience.
Clients often experience a great deal of discomfort when this occurs. These recollections or
memories tend to be extremely painful and often interfere with their ability to go about their
daily functions. These experiences are not psychotic episodes. They may have no awareness of being in the here and now. They usually do not feel safe. Clients may feel that there
is no one with whom they can share their experience. They may feel utterly alone. When a
flashback happens, they may experience high levels of anxiety or hyperarousal. Additionally, depression may be experienced as a normal response to feeling helpless and hopeless
to stop the flashbacks. Clients can experience these episodes at any time, which makes it
more difficult to guard against them happening. Flashbacks often happen in response to a
triggered event in the present. The feelings that were present in the original trauma such as
terror, rage, not being heard, not being seen, or being abused are re-experienced as the
flashback is occurring. Clients may not be aware what the stimulus is in the present that has
caused the flashback.
Some clients respond well to being touched or held by someone who cares for them. This
may help them to feel safer and more grounded in the present. When a significant other is
willing to hold the client, it should be done carefully and only with the client’s permission
ahead of time. When there is a history of physical or sexual abuse or assault, the client can
confuse a significant other with the perpetrator.
Some clients respond well to being touched or held by someone who cares for them. This
may help them to feel safer and more grounded in the present. When a significant other is
willing to hold the client, it should be done carefully and only with the client’s permission
ahead of time. When there is a history of physical or sexual abuse or assault, the client can
confuse a significant other with the perpetrator.
It is important that a client’s significant other be educated about how flashbacks work.
When partners are loving and supportive, this can serve to increase the client’s safety. Support can help a client to get grounded and stay oriented in the here and now.
It is important that a client’s significant other be educated about how flashbacks work.
When partners are loving and supportive, this can serve to increase the client’s safety. Support can help a client to get grounded and stay oriented in the here and now.
Some Ways of Working with Flashbacks
Some Ways of Working with Flashbacks
Since flashbacks are a common occurrence for many clients with PTSD, it is helpful to
teach them how to work with a flashback. Clients need to be taught that flashbacks are a
normal response to trauma. Flashbacks tend to decrease over time as healing of the trauma
takes place. Courtois (1988) suggests the following reassuring statements might be used
with clients having flashbacks:
• You may not have control over when a flashback occurs.
• The goal is to help you control what happens when a flashback occurs.
• We need to help you develop better coping skills to lower your anxiety when a flashback occurs.
• You need to take whatever steps necessary to keep you safe when a flashback occurs.
• When you understand the triggers for a flashback, you may choose to avoid certain
activities or change them in some way to accommodate your need for safety.
Since flashbacks are a common occurrence for many clients with PTSD, it is helpful to
teach them how to work with a flashback. Clients need to be taught that flashbacks are a
normal response to trauma. Flashbacks tend to decrease over time as healing of the trauma
takes place. Courtois (1988) suggests the following reassuring statements might be used
with clients having flashbacks:
• You may not have control over when a flashback occurs.
• The goal is to help you control what happens when a flashback occurs.
• We need to help you develop better coping skills to lower your anxiety when a flashback occurs.
• You need to take whatever steps necessary to keep you safe when a flashback occurs.
• When you understand the triggers for a flashback, you may choose to avoid certain
activities or change them in some way to accommodate your need for safety.
Example
Example
If a client is engaging in lovemaking and a flashback occurs, she may need to
change positions, get up, create physical distance between herself and her
partner, and remind herself of who is with her in the present.
If a client is engaging in lovemaking and a flashback occurs, she may need to
change positions, get up, create physical distance between herself and her
partner, and remind herself of who is with her in the present.
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Whether clients are alone or with someone, there are steps that they can take to care for
themselves when a flashback occurs (Courtois, 1988). These steps are as follows:
Whether clients are alone or with someone, there are steps that they can take to care for
themselves when a flashback occurs (Courtois, 1988). These steps are as follows:
• Acknowledge to yourself and/or share with someone close that you are having a
flashback.
• Acknowledge to yourself and/or share with someone close that you are having a
flashback.
• Talk about what you are experiencing.
• Talk about what you are experiencing.
• Reorient or ground yourself in the present. (See grounding exercises below.)
• Reorient or ground yourself in the present. (See grounding exercises below.)
• Write down or draw your experience.
• Write down or draw your experience.
• Tell yourself or be told by someone close to you that you are safe.
• Tell yourself or be told by someone close to you that you are safe.
• Tell yourself or be told by someone close to you that you are not in the situation you
are reliving in your mind.
• Tell yourself or be told by someone close to you that you are not in the situation you
are reliving in your mind.
When a flashback happens during a session, I encourage clients to ground themselves in the
here and now. This means to fully experience the physical place of their body in the world
in the present. Grounding exercises can help clients feel a sense of control and assist them
in differentiating the past from the present. At this point, I tend to become very directive
when I am helping clients to get grounded. The following are behaviors which I find useful
in helping clients. I might gently make some or all of these suggestions to get clients
grounded in their body in the present:
When a flashback happens during a session, I encourage clients to ground themselves in the
here and now. This means to fully experience the physical place of their body in the world
in the present. Grounding exercises can help clients feel a sense of control and assist them
in differentiating the past from the present. At this point, I tend to become very directive
when I am helping clients to get grounded. The following are behaviors which I find useful
in helping clients. I might gently make some or all of these suggestions to get clients
grounded in their body in the present:
• Stand up and walk around.
• Stand up and walk around.
• Feel your feet on the floor.
• Feel your feet on the floor.
• Feel your bottom on the chair
• Feel your bottom on the chair
• Slowly take some breaths in through your nose and out through your mouth breathing into the diaphragm area.
• Slowly take some breaths in through your nose and out through your mouth breathing into the diaphragm area.
• Look around and notice where you are.
• Look around and notice where you are.
• Notice the sounds you hear around you.
• Notice the sounds you hear around you.
• See the pictures on the walls
• See the pictures on the walls
• Reach out and touch the chair or the table.
• Reach out and touch the chair or the table.
If clients still appear to be unsafe, I may do a longer relaxation exercise and invite them to
relax their bodies until they feel sufficiently calm. If they are proficient at relaxation, I may
invite them to slowly breathe in through their nose and out through their mouth breathing
into the diaphragm area and experience themselves in their safe place. When clients are
well grounded in the present I may ask them if there is anything that they would like from
me. I do not recommend a therapist do any holding if a flashback occurs during a session.
When there is a history of physical or sexual abuse or assault, the client can confuse a therapist with the perpetrator. This is more likely to happen when the therapist is the same gender as the perpetrator. If confusion occurs, use the grounding exercises previously
mentioned. (See Touch with Sexually Abused Clients, Chapter 9.)
If clients still appear to be unsafe, I may do a longer relaxation exercise and invite them to
relax their bodies until they feel sufficiently calm. If they are proficient at relaxation, I may
invite them to slowly breathe in through their nose and out through their mouth breathing
into the diaphragm area and experience themselves in their safe place. When clients are
well grounded in the present I may ask them if there is anything that they would like from
me. I do not recommend a therapist do any holding if a flashback occurs during a session.
When there is a history of physical or sexual abuse or assault, the client can confuse a therapist with the perpetrator. This is more likely to happen when the therapist is the same gender as the perpetrator. If confusion occurs, use the grounding exercises previously
mentioned. (See Touch with Sexually Abused Clients, Chapter 9.)
How a therapist responds to a flashback occurring in session should be dependent on
whether or not a client has an awareness of what has just happened. See the following examples:
How a therapist responds to a flashback occurring in session should be dependent on
whether or not a client has an awareness of what has just happened. See the following examples:
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Example
Example
Vignette: A male client with physical abuse in his history knew a flashback was
occurring in session and proceeded to tell the therapist.
Client: “I just had a flashback of being beaten by my father.”
Intervention: The therapist and the client then explored what that was like for
him. The therapist chose whether or not she was going to explore what the
original scene was like for him. She asked the client what it was like to have
the flashback with her present. She also asked what it was like for him to share
this experience with her.
Vignette: A male client with physical abuse in his history knew a flashback was
occurring in session and proceeded to tell the therapist.
Client: “I just had a flashback of being beaten by my father.”
Intervention: The therapist and the client then explored what that was like for
him. The therapist chose whether or not she was going to explore what the
original scene was like for him. She asked the client what it was like to have
the flashback with her present. She also asked what it was like for him to share
this experience with her.
Example
Example
Vignette: A female client with sexual abuse in her history had not learned to
recognize a flashback and/or tell her therapist that she had experienced one.
However, the therapist became aware that something had just occurred with
his client. He responded to her by asking her some questions.
Intervention: The therapist asked the client, “What just happened?” “Tell me
about what just happened?”
Client: “I felt like I was little again and being sexually abused by my father.”
Intervention: At this point the therapist normalized the flashback by saying to
the client, “You are experiencing a flashback. Flashbacks are a form of intrusiveness that usually come in response to experiencing a traumatic event at
some prior time.”
The therapist did the grounding exercises previously mentioned to be sure that
his client was back in the here-and-now and feeling safe physically and emotionally.
Vignette: A female client with sexual abuse in her history had not learned to
recognize a flashback and/or tell her therapist that she had experienced one.
However, the therapist became aware that something had just occurred with
his client. He responded to her by asking her some questions.
Intervention: The therapist asked the client, “What just happened?” “Tell me
about what just happened?”
Client: “I felt like I was little again and being sexually abused by my father.”
Intervention: At this point the therapist normalized the flashback by saying to
the client, “You are experiencing a flashback. Flashbacks are a form of intrusiveness that usually come in response to experiencing a traumatic event at
some prior time.”
The therapist did the grounding exercises previously mentioned to be sure that
his client was back in the here-and-now and feeling safe physically and emotionally.
Further things I might say when clients are feeling grounded and safe both physically and
emotionally include:
Further things I might say when clients are feeling grounded and safe both physically and
emotionally include:
Based on your history of abuse (sexual, physical, emotional) or trauma, it
makes sense to me that you would experience this kind of intrusiveness.
Flashbacks often come when one is beginning to move closer to touching the
pain of the trauma. The gift of flashbacks are that they give us a window into
the memories. The nongift is that they often touch painful feelings. Flashbacks are usually in response to a stimulus or trigger in the present. Sometimes, we are able to figure out what the trigger is and sometimes not.
Based on your history of abuse (sexual, physical, emotional) or trauma, it
makes sense to me that you would experience this kind of intrusiveness.
Flashbacks often come when one is beginning to move closer to touching the
pain of the trauma. The gift of flashbacks are that they give us a window into
the memories. The nongift is that they often touch painful feelings. Flashbacks are usually in response to a stimulus or trigger in the present. Sometimes, we are able to figure out what the trigger is and sometimes not.
I invite clients to tell me more about the memory by asking the following:
• What are you remembering?
• What are you feeling?
I invite clients to tell me more about the memory by asking the following:
• What are you remembering?
• What are you feeling?
Talking about the memory may help lessen its impact on the client and often increases the
safety level.
Talking about the memory may help lessen its impact on the client and often increases the
safety level.
As appropriate, I might verbalize any of the following kinds of statements as a way of offering reassurance and support to the client:
• I want you to know that you are safe.
• He/she can’t hurt you anymore.
As appropriate, I might verbalize any of the following kinds of statements as a way of offering reassurance and support to the client:
• I want you to know that you are safe.
• He/she can’t hurt you anymore.
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• I want you to tell yourself that you are safe.
• You are not back in the situation where you were being abused.
• This memory is in your mind.
• Thinking and feeling it in your mind and body does not make it a reality.
• I want you to tell yourself that you are safe.
• You are not back in the situation where you were being abused.
• This memory is in your mind.
• Thinking and feeling it in your mind and body does not make it a reality.
If it feels like clients can stay grounded in the present and process what took place in the
room, I tell them that I would like for us to process what happened. I then ask if they feel
comfortable enough to do that. If the answer is affirmative, I may ask the following:
• What are your feelings about having had a flashback?
• What did you say to yourself about this experience?
• Did you experience any shame in response to the flashback?
• What did that shame look like?
• How did it feel to have me tell you it was a flashback and that it happens normally
in response to trauma?
• How did it feel to tell me about the memory?
• Did it increase or decrease your safety level to tell me?
• How did it feel to have me invite you to ground your body?
• Was there any grounding exercise that was particularly helpful? Which one?
• Is there anything I might have done to increase your safety level during this time?
• Was there anything that you could have done to increase your safety level during this
time?
• What did you learn about yourself from having this flashback?
• Did you gain any new insights from this experience?
• Do you have any idea what the trigger or stimulus in the present might have been?
If it feels like clients can stay grounded in the present and process what took place in the
room, I tell them that I would like for us to process what happened. I then ask if they feel
comfortable enough to do that. If the answer is affirmative, I may ask the following:
• What are your feelings about having had a flashback?
• What did you say to yourself about this experience?
• Did you experience any shame in response to the flashback?
• What did that shame look like?
• How did it feel to have me tell you it was a flashback and that it happens normally
in response to trauma?
• How did it feel to tell me about the memory?
• Did it increase or decrease your safety level to tell me?
• How did it feel to have me invite you to ground your body?
• Was there any grounding exercise that was particularly helpful? Which one?
• Is there anything I might have done to increase your safety level during this time?
• Was there anything that you could have done to increase your safety level during this
time?
• What did you learn about yourself from having this flashback?
• Did you gain any new insights from this experience?
• Do you have any idea what the trigger or stimulus in the present might have been?
Note: There is often a feeling in the present that is experienced just before the flashback
occurs. The feeling in the flashback is usually the same.
Note: There is often a feeling in the present that is experienced just before the flashback
occurs. The feeling in the flashback is usually the same.
AVOIDANCE AND NUMBING
AVOIDANCE AND NUMBING
Avoidance and numbing are indicative of the second symptom cluster for PTSD. They are
like denial in that clients frequently do not know they are using these defenses. Clients are
even less aware of how they avoid than when they numb themselves. They may be able to
rationalize why they avoid. For instance, these clients may say they do not want a close relationship in order to avoid the anxiety that intimacy might arouse in them. The better clients are at avoiding, the less awareness they have of doing it. It is a difficult task for a
therapist to discern if clients are using avoidance or merely prefer to live their life a particular way.
Avoidance and numbing are indicative of the second symptom cluster for PTSD. They are
like denial in that clients frequently do not know they are using these defenses. Clients are
even less aware of how they avoid than when they numb themselves. They may be able to
rationalize why they avoid. For instance, these clients may say they do not want a close relationship in order to avoid the anxiety that intimacy might arouse in them. The better clients are at avoiding, the less awareness they have of doing it. It is a difficult task for a
therapist to discern if clients are using avoidance or merely prefer to live their life a particular way.
Note: It is helpful to note that approximately half of the symptoms listed under the category
of avoidance and numbing are also depressive symptoms. When there is significant avoidance and numbing, it may be useful to assess for depressive disorders. It is important to remember that PTSD includes symptoms of anxiety, depression, and dissociation.
Note: It is helpful to note that approximately half of the symptoms listed under the category
of avoidance and numbing are also depressive symptoms. When there is significant avoidance and numbing, it may be useful to assess for depressive disorders. It is important to remember that PTSD includes symptoms of anxiety, depression, and dissociation.
Avoidance and numbing may be evident in a number of client behaviors. Clients may avoid
Avoidance and numbing may be evident in a number of client behaviors. Clients may avoid
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and numb by engaging in addictive behaviors. When clients do not want to feel the vulnerability of their sadness, they may work extra hours. Clients who are not comfortable being
sexually intimate with their significant other may use alcohol or drugs to avoid and numb
themselves. Numbing is a result of avoiding feelings. Anything that is done to avoid feelings leads to being numb. When clients are numb, they do not experience the rewards of
empathic connections with others, and this enhances their chances of becoming depressed,
anxious, or lonely. They may learn to avoid situations or circumstances that either might
trigger a flashback or some other kind of uncomfortable feeling.
and numb by engaging in addictive behaviors. When clients do not want to feel the vulnerability of their sadness, they may work extra hours. Clients who are not comfortable being
sexually intimate with their significant other may use alcohol or drugs to avoid and numb
themselves. Numbing is a result of avoiding feelings. Anything that is done to avoid feelings leads to being numb. When clients are numb, they do not experience the rewards of
empathic connections with others, and this enhances their chances of becoming depressed,
anxious, or lonely. They may learn to avoid situations or circumstances that either might
trigger a flashback or some other kind of uncomfortable feeling.
It is interesting to note how the symptom clusters interact with each other. Clients can become hypervigilant and then respond to these intense feelings by avoiding feelings, people,
etc. and becoming numb. Likewise they may have intrusive experiences which can also
lead to the avoidance and numbing cycle.
It is interesting to note how the symptom clusters interact with each other. Clients can become hypervigilant and then respond to these intense feelings by avoiding feelings, people,
etc. and becoming numb. Likewise they may have intrusive experiences which can also
lead to the avoidance and numbing cycle.
Example
Example
A female client had been sexually abused as a child. As an adult, she chose to
work long hours to avoid intimate contact with her partner. This allowed her
to avoid unresolved fears around her sexuality that were residuals of what she
had experienced.
A female client had been sexually abused as a child. As an adult, she chose to
work long hours to avoid intimate contact with her partner. This allowed her
to avoid unresolved fears around her sexuality that were residuals of what she
had experienced.
Courtois (1988) suggests that numbing reactions sometimes occur in therapy and may serve
the following functions for clients:
• numb the self against the anxiety associated with the therapy issues or the therapy
relationship itself
• avoid recall of memories
• avoid painful feelings
• avoid integrating the learning of therapy
• maintain safety when what is being discussed is upsetting
• defend against shame (pp. 296-297)
Courtois (1988) suggests that numbing reactions sometimes occur in therapy and may serve
the following functions for clients:
• numb the self against the anxiety associated with the therapy issues or the therapy
relationship itself
• avoid recall of memories
• avoid painful feelings
• avoid integrating the learning of therapy
• maintain safety when what is being discussed is upsetting
• defend against shame (pp. 296-297)
DISSOCIATIVE ISSUES
DISSOCIATIVE ISSUES
One of the functional ways that clients avoid and numb is through dissociation. Dissociation can be a normal healthy process. Everyone uses it when they fantasize, daydream, or
tune out. People do it when driving on the freeway, when they are bored, in emergencies,
in times of trauma. Some degree of dissociation is always present in normally functioning
humans. Dissociation is simply an exaggeration of normal ways of modulating thinking,
feeling, and behaving. Dissociation may be used spontaneously or sporadically, but with
repeated victimization, it can become a habitual way of responding to stress. It makes sense
to use dissociation when faced with an intolerable situation. Clients who as children experienced betrayal by a caregiver may have needed to dissociate the information about the betrayal in order to maintain their attachment to the caregiver.
One of the functional ways that clients avoid and numb is through dissociation. Dissociation can be a normal healthy process. Everyone uses it when they fantasize, daydream, or
tune out. People do it when driving on the freeway, when they are bored, in emergencies,
in times of trauma. Some degree of dissociation is always present in normally functioning
humans. Dissociation is simply an exaggeration of normal ways of modulating thinking,
feeling, and behaving. Dissociation may be used spontaneously or sporadically, but with
repeated victimization, it can become a habitual way of responding to stress. It makes sense
to use dissociation when faced with an intolerable situation. Clients who as children experienced betrayal by a caregiver may have needed to dissociate the information about the betrayal in order to maintain their attachment to the caregiver.
However, dissociation may become pathological. It can lead to interpersonal problems and
cause disruptions of awareness or memory even as it serves to sustain the individual. It becomes a survival mechanism. The degree of dissociation in a given individual is influenced
by genetic proclivity, age, and early developmental experiences, particularly episodes of
trauma and stress. In the context of severe trauma, dissociation may serve as an effective
However, dissociation may become pathological. It can lead to interpersonal problems and
cause disruptions of awareness or memory even as it serves to sustain the individual. It becomes a survival mechanism. The degree of dissociation in a given individual is influenced
by genetic proclivity, age, and early developmental experiences, particularly episodes of
trauma and stress. In the context of severe trauma, dissociation may serve as an effective
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defense insulating the individual from overwhelming experience and affect. However, it
can generalize to lesser stresses and become a chronic maladaptive process.
defense insulating the individual from overwhelming experience and affect. However, it
can generalize to lesser stresses and become a chronic maladaptive process.
If clients appear to be dissociating consistently such that they may have a total loss of memory for periods of time in their current life, then they may be diagnosed as having a Dissociative Identity Disorder. Diagnosing this disorder is very complex, and additional training
and supervision are needed in order to do it adequately.
If clients appear to be dissociating consistently such that they may have a total loss of memory for periods of time in their current life, then they may be diagnosed as having a Dissociative Identity Disorder. Diagnosing this disorder is very complex, and additional training
and supervision are needed in order to do it adequately.
If a full screening for dissociation seems appropriate, then the SCID-D, Revised is an excellent instrument. (See Posttraumatic Stress History, Chapter 1 for more information on
this instrument.) For further information you might consult The Stranger in the Mirror,
Dissociation - The Hidden Epidemic by Steinberg and Schnall (2000). Dr. Steinberg developed the SCID-D, Revised and is considered a leading expert in the field.
If a full screening for dissociation seems appropriate, then the SCID-D, Revised is an excellent instrument. (See Posttraumatic Stress History, Chapter 1 for more information on
this instrument.) For further information you might consult The Stranger in the Mirror,
Dissociation - The Hidden Epidemic by Steinberg and Schnall (2000). Dr. Steinberg developed the SCID-D, Revised and is considered a leading expert in the field.
BASK Model of Dissociation
BASK Model of Dissociation
Braun (1988a,b), in the journal Dissociation, discusses the BASK Model that he developed
as a way to describe what happens when dissociation occurs. The BASK Model notes four
different ways an individual may dissociate: behavior, affect, sensation, and knowledge.
Clients may use any one of these ways, some combination, or all of them to dissociate.
Since children have difficulty integrating traumatic experiences, they may have dissociated
from one or more aspects of the trauma.
Braun (1988a,b), in the journal Dissociation, discusses the BASK Model that he developed
as a way to describe what happens when dissociation occurs. The BASK Model notes four
different ways an individual may dissociate: behavior, affect, sensation, and knowledge.
Clients may use any one of these ways, some combination, or all of them to dissociate.
Since children have difficulty integrating traumatic experiences, they may have dissociated
from one or more aspects of the trauma.
It is the responsibility of the therapist to ascertain which of these aspects might be missing
from the client’s experience. Behaviors, affects, sensations, and knowledge need to be consciously integrated whenever possible. Consider the following:
• A client who drove very fast on the freeway was unable to make a connection between feeling suicidal and his high risk behavior.
• A client calmly reported being brutally beaten by his father, and it became clear that
the missing piece was clearly affect.
• A client began to talk about being sexually abused and stated that she could not feel
her body. The missing piece was sensation.
• A client that was experiencing amnesia would point to missing knowledge or memory.
• A client reported that she was experiencing a burning sensation on her leg which was
a sensory clue. She started to feel a great deal of fear which was an affect clue. In following these clues, she remembered being burned by her perpetrator as a child to force
her silence about the abuse. Because of the complicated ways that our memory system
works, sometimes all or part of the cognitive memory of an event may never become
available. In this case, you may have to work with what is available in terms of body
memory or other forms of recall.
It is the responsibility of the therapist to ascertain which of these aspects might be missing
from the client’s experience. Behaviors, affects, sensations, and knowledge need to be consciously integrated whenever possible. Consider the following:
• A client who drove very fast on the freeway was unable to make a connection between feeling suicidal and his high risk behavior.
• A client calmly reported being brutally beaten by his father, and it became clear that
the missing piece was clearly affect.
• A client began to talk about being sexually abused and stated that she could not feel
her body. The missing piece was sensation.
• A client that was experiencing amnesia would point to missing knowledge or memory.
• A client reported that she was experiencing a burning sensation on her leg which was
a sensory clue. She started to feel a great deal of fear which was an affect clue. In following these clues, she remembered being burned by her perpetrator as a child to force
her silence about the abuse. Because of the complicated ways that our memory system
works, sometimes all or part of the cognitive memory of an event may never become
available. In this case, you may have to work with what is available in terms of body
memory or other forms of recall.
Note: Remember, our memory system is more complicated that we ever dreamed. Be sure
to keep up-to-date with the brain research that is regularly published in both popular and
professional journals. We are continuing to find new ways to address the difficulties in memory retrieval.
Note: Remember, our memory system is more complicated that we ever dreamed. Be sure
to keep up-to-date with the brain research that is regularly published in both popular and
professional journals. We are continuing to find new ways to address the difficulties in memory retrieval.
Behavior has to do with an observable action like running, skipping, or jumping. It is something people do (usually with their bodies). Clients may walk in a seductive manner and
have no awareness of what they are doing. Lack of awareness of their behaviors often translates into lack of awareness of the behaviors of others, which may lead to revictimization.
Thus, they miss important cues that would enhance their ability to keep themselves safe.
Behavior has to do with an observable action like running, skipping, or jumping. It is something people do (usually with their bodies). Clients may walk in a seductive manner and
have no awareness of what they are doing. Lack of awareness of their behaviors often translates into lack of awareness of the behaviors of others, which may lead to revictimization.
Thus, they miss important cues that would enhance their ability to keep themselves safe.
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Example
Example
A woman dressed in a sexually provocative manner and did not understand
when men acted sexually inappropriate with her. She had no awareness that
her behavior (in this case how she dressed and moved) may have been suggesting she was open to sexual encounters. She was unaware of the behavioral cues men gave her concerning their interest.
A woman dressed in a sexually provocative manner and did not understand
when men acted sexually inappropriate with her. She had no awareness that
her behavior (in this case how she dressed and moved) may have been suggesting she was open to sexual encounters. She was unaware of the behavioral cues men gave her concerning their interest.
Sample Behaviors
Sample Behaviors
Clients may be looking or acting aggressively and be unaware of it.
Clients may be looking or acting aggressively and be unaware of it.
Clients may behave in a threatening manner like shaking their fist and have no
awareness of it.
Clients may behave in a threatening manner like shaking their fist and have no
awareness of it.
Clients may kick their foot in a distinctive manner without being aware of doing it.
Clients may kick their foot in a distinctive manner without being aware of doing it.
Clients may constantly smile and not be aware of it.
Clients may constantly smile and not be aware of it.
Example
Example
A man was in an auto accident and jumped out of a car in an aggressive manner preparing to blame the other driver. He had no awareness that his fists
were clenched, his jaw was tight, or that his shoulders were hunched forward
in an aggressive manner.
A man was in an auto accident and jumped out of a car in an aggressive manner preparing to blame the other driver. He had no awareness that his fists
were clenched, his jaw was tight, or that his shoulders were hunched forward
in an aggressive manner.
Affect has to do with feelings such as mad, sad, glad, or scared.When people numb, they
frequently cut off awareness of these feelings. They become unable to acknowledge or express clearly what they feel emotionally. In times of trauma, people frequently dissociate
or cut off their affect which allows them to function more effectively at that time. Everyone
has had this experience in terms of such national tragedies as September 11th and personal
disasters.
Affect has to do with feelings such as mad, sad, glad, or scared.When people numb, they
frequently cut off awareness of these feelings. They become unable to acknowledge or express clearly what they feel emotionally. In times of trauma, people frequently dissociate
or cut off their affect which allows them to function more effectively at that time. Everyone
has had this experience in terms of such national tragedies as September 11th and personal
disasters.
Example
Example
Ten years ago, my husband and I were in a fire that resulted in 125 homes
being lost. Initially, I felt a great deal of fear as I saw the flames coming closer
and closer. Since no fire crews were available to fight the fire near us, it became necessary to dissociate from all affect so that we could deal with the crisis at hand. It is a healthy response to dissociate from all affect when you think
your house could burn down. I was able to think with heightened awareness.
I made decisions as to what needed to be put in our cars in preparation to
leave. Though I functioned at top efficiency, the sequence of events, people
present, etc. all became a blur in my mind. Later when the feelings I had about
the fire had been processed, I could say I had felt extremely scared about being in the fire, and I continued to be scared for a long time. Now I don’t have
to avoid reminders of the fire. When a friend lost her home in a recent fire, I
was able to go to the site and be with her without becoming overly anxious.
Ten years ago, my husband and I were in a fire that resulted in 125 homes
being lost. Initially, I felt a great deal of fear as I saw the flames coming closer
and closer. Since no fire crews were available to fight the fire near us, it became necessary to dissociate from all affect so that we could deal with the crisis at hand. It is a healthy response to dissociate from all affect when you think
your house could burn down. I was able to think with heightened awareness.
I made decisions as to what needed to be put in our cars in preparation to
leave. Though I functioned at top efficiency, the sequence of events, people
present, etc. all became a blur in my mind. Later when the feelings I had about
the fire had been processed, I could say I had felt extremely scared about being in the fire, and I continued to be scared for a long time. Now I don’t have
to avoid reminders of the fire. When a friend lost her home in a recent fire, I
was able to go to the site and be with her without becoming overly anxious.
When a child has been abused on an intermittent or regular basis, it may be necessary for
the child to dissociate from the feelings or affect. Under these circumstances, these feelings
do not get processed and worked through. Normally when memories are processed, the
When a child has been abused on an intermittent or regular basis, it may be necessary for
the child to dissociate from the feelings or affect. Under these circumstances, these feelings
do not get processed and worked through. Normally when memories are processed, the
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event(s) remembered are not affect laden. When an event is traumatic, individuals may do
any number of things to avoid reexperiencing the feelings from that traumatic experience.
This process of avoidance of certain feelings or circumstances may continue into adulthood. At the time of the fire, it was a good thing for me to dissociate. I experienced a number of feelings, but I spontaneously cut off all awareness of them. However, until that affect
resurfaced, the trauma could not be processed. If I had never recalled the memories of the
fire, I would likely have had to avoid any number of things that might bring up the feelings
about the trauma. I might have had a lot of physical and psychological symptoms. Traumatic memories are like a wet garbage bag that begins to rip and spill its contents when something bumps into it. Bumping into the trauma of the fire would have been very uncomfortable, so I would have had to go to great lengths to avoid that happening.
event(s) remembered are not affect laden. When an event is traumatic, individuals may do
any number of things to avoid reexperiencing the feelings from that traumatic experience.
This process of avoidance of certain feelings or circumstances may continue into adulthood. At the time of the fire, it was a good thing for me to dissociate. I experienced a number of feelings, but I spontaneously cut off all awareness of them. However, until that affect
resurfaced, the trauma could not be processed. If I had never recalled the memories of the
fire, I would likely have had to avoid any number of things that might bring up the feelings
about the trauma. I might have had a lot of physical and psychological symptoms. Traumatic memories are like a wet garbage bag that begins to rip and spill its contents when something bumps into it. Bumping into the trauma of the fire would have been very uncomfortable, so I would have had to go to great lengths to avoid that happening.
Example
Example
When a recently married young woman with a history of sexual abuse began
to have regular sexual experiences, she started to have memories and feelings
because these experiences tapped into the dissociated feelings. Instead of enjoying sexual contact she felt scared and angry.
When a recently married young woman with a history of sexual abuse began
to have regular sexual experiences, she started to have memories and feelings
because these experiences tapped into the dissociated feelings. Instead of enjoying sexual contact she felt scared and angry.
As previously mentioned, avoidance can be difficult to treat because people who avoid do
it well. People who avoid fool themselves so that they do not know that they are avoiding
something. When clients are avoiding situations where affect memories may be triggered,
they may say things like the following:
As previously mentioned, avoidance can be difficult to treat because people who avoid do
it well. People who avoid fool themselves so that they do not know that they are avoiding
something. When clients are avoiding situations where affect memories may be triggered,
they may say things like the following:
Sample Responses
Sample Responses
“Oh, it doesn’t have anything to do with that.”
“Oh, it doesn’t have anything to do with that.”
“I don’t see any connection between being abused and my inability to have a
healthy relationship.”
“I don’t see any connection between being abused and my inability to have a
healthy relationship.”
“I don’t see a connection between my shutting down and becoming angry
when my wife demands something of me and my father beating me into compliance as a child.”
“I don’t see a connection between my shutting down and becoming angry
when my wife demands something of me and my father beating me into compliance as a child.”
The hard part for therapists is to be aware of the importance of the traumatic event, because
clients frequently will deny that there is a problem. Clients have dissociated from their affect, because the feelings about the experience were too painful.
The hard part for therapists is to be aware of the importance of the traumatic event, because
clients frequently will deny that there is a problem. Clients have dissociated from their affect, because the feelings about the experience were too painful.
Sensation has to do with being numb and not feeling at a bodily level. When people numb
out, they may have no awareness of pain, body temperature (cold or warm), or their senses
(taste, touch, sight, sound, smell). Sometimes people talk about being numb and not feeling
their body. One of the major ways of leaving or dissociating is at a sensory or bodily level.
Sometimes people lose their ability to speak as they literally cut off their own voice. They
may lose their ability to move any of their limbs. The following are statements that I have
used with clients:
Sensation has to do with being numb and not feeling at a bodily level. When people numb
out, they may have no awareness of pain, body temperature (cold or warm), or their senses
(taste, touch, sight, sound, smell). Sometimes people talk about being numb and not feeling
their body. One of the major ways of leaving or dissociating is at a sensory or bodily level.
Sometimes people lose their ability to speak as they literally cut off their own voice. They
may lose their ability to move any of their limbs. The following are statements that I have
used with clients:
You just described to me a scene where you felt like you could not feel your
body at all and were numb all over. At that time you were missing sensory
or bodily feelings. Your body checked out in response to whatever you were
thinking or feeling at that moment.
You just described to me a scene where you felt like you could not feel your
body at all and were numb all over. At that time you were missing sensory
or bodily feelings. Your body checked out in response to whatever you were
thinking or feeling at that moment.
You know when things happen that are really awful, we do not always
You know when things happen that are really awful, we do not always
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remember what we experience emotionally or what happened. You are telling me that you cannot feel your body when you get really tense or upset.
When you numb out in response to this level of stress, you are dissociating
from your body at a sensation level. Otherwise, you would be able to feel
your body right now.
remember what we experience emotionally or what happened. You are telling me that you cannot feel your body when you get really tense or upset.
When you numb out in response to this level of stress, you are dissociating
from your body at a sensation level. Otherwise, you would be able to feel
your body right now.
You might not be conscious of your leg when you are talking to me, but if I
ask you what your leg feels like and you tell me, “I don’t know it’s there. I
can’t feel it,” you have left, so to speak, or you have dissociated at a sensation or bodily level.
You might not be conscious of your leg when you are talking to me, but if I
ask you what your leg feels like and you tell me, “I don’t know it’s there. I
can’t feel it,” you have left, so to speak, or you have dissociated at a sensation or bodily level.
Example
Example
A female client remembered being physically abused as a little girl by her father. The abuse went on for many years and became more severe in intensity.
At some point she remembered leaving her body and floating just below the
ceiling. She had cut off all feelings of the physical abuse at a sensation, bodily,
or physical level. By looking down and seeing it happening to someone else,
she had been able to endure the severe pain. She had dissociated from that
which was beyond her ability to endure and comprehend.
A female client remembered being physically abused as a little girl by her father. The abuse went on for many years and became more severe in intensity.
At some point she remembered leaving her body and floating just below the
ceiling. She had cut off all feelings of the physical abuse at a sensation, bodily,
or physical level. By looking down and seeing it happening to someone else,
she had been able to endure the severe pain. She had dissociated from that
which was beyond her ability to endure and comprehend.
Note: Self-inflicted violence can be a symptom of dissociation at a sensory level.
Note: Self-inflicted violence can be a symptom of dissociation at a sensory level.
Example
Example
A woman became aware as she was talking about sexual abuse in session that
she could not feel the whole lower half of her body. She knew it was there but
had no sensation or bodily feelings. She had dissociated at a sensory level.
A woman became aware as she was talking about sexual abuse in session that
she could not feel the whole lower half of her body. She knew it was there but
had no sensation or bodily feelings. She had dissociated at a sensory level.
Knowledge has to do with remembering the event. It is about what people commonly think
of as memory. People can dissociate from short-term memory or long-term memory. For
instance, in short-term memory people may not remember where they just put their keys.
Long-term memory often has to do with some affect or sensation which is so uncomfortable
or disturbing that they may block the knowledge of that experience from memory. A person
may not remember being sexually abused as a child, which is an example of long-term
memory.
Knowledge has to do with remembering the event. It is about what people commonly think
of as memory. People can dissociate from short-term memory or long-term memory. For
instance, in short-term memory people may not remember where they just put their keys.
Long-term memory often has to do with some affect or sensation which is so uncomfortable
or disturbing that they may block the knowledge of that experience from memory. A person
may not remember being sexually abused as a child, which is an example of long-term
memory.
A person may walk through a room and bump into something that bruises them. Later they
may have no memory of what caused the bruise, as the knowledge, behavior, and the sensation are missing. It is common for us to lose that knowledge when we have our mind on
something else.
A person may walk through a room and bump into something that bruises them. Later they
may have no memory of what caused the bruise, as the knowledge, behavior, and the sensation are missing. It is common for us to lose that knowledge when we have our mind on
something else.
Example
Example
A woman walked through a room and someone touched her inappropriately.
She had no sensation or bodily feeling in response to being touched inappropriately. She did not remember or had no knowledge or memory of being
touched inappropriately.
A woman walked through a room and someone touched her inappropriately.
She had no sensation or bodily feeling in response to being touched inappropriately. She did not remember or had no knowledge or memory of being
touched inappropriately.
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Example
A female client with sexual abuse in her history went jogging late at night
which put her at risk of revictimization. She had numbed herself from the
knowledge of what was dangerous and thus put herself at risk.
Example
A female client with sexual abuse in her history went jogging late at night
which put her at risk of revictimization. She had numbed herself from the
knowledge of what was dangerous and thus put herself at risk.
Dissociation from knowledge is often what sets up the survivors of abuse or trauma for the
possibility of further victimization. They may have dissociated from the knowledge that
some men are dangerous and can hurt them. Since they are dissociated from that piece of
information, they cannot use it as a way to filter information about where they should be
late at night. When children are growing up, they may learn danger signals about who is
and is not safe. When children are being abused or traumatized in their own home, that
knowledge may not be available to them. Clients may be revictimized because they have
dissociated from the knowledge of what is dangerous. Child victims of trauma and abuse
have to retain their attachment behavior to the person who has abused them, so they stop
seeing people as dangerous.
Dissociation from knowledge is often what sets up the survivors of abuse or trauma for the
possibility of further victimization. They may have dissociated from the knowledge that
some men are dangerous and can hurt them. Since they are dissociated from that piece of
information, they cannot use it as a way to filter information about where they should be
late at night. When children are growing up, they may learn danger signals about who is
and is not safe. When children are being abused or traumatized in their own home, that
knowledge may not be available to them. Clients may be revictimized because they have
dissociated from the knowledge of what is dangerous. Child victims of trauma and abuse
have to retain their attachment behavior to the person who has abused them, so they stop
seeing people as dangerous.
Example
Example
A female client had been sexually abused as a child by several men in her family. She had to dissociate from that knowledge and continue to engage in behavior that kept her attached in the family system. As an adult, her pastor
abused her sexually. She told the church authorities about it. While it was being investigated, she continued to be alone with the pastor and still saw him
as someone who was trustworthy. She had dissociated herself from the knowledge that some apparently trustworthy people can and do hurt you. She continued to dissociate from the knowledge that an important person in her life
that she had trusted had hurt her.
A female client had been sexually abused as a child by several men in her family. She had to dissociate from that knowledge and continue to engage in behavior that kept her attached in the family system. As an adult, her pastor
abused her sexually. She told the church authorities about it. While it was being investigated, she continued to be alone with the pastor and still saw him
as someone who was trustworthy. She had dissociated herself from the knowledge that some apparently trustworthy people can and do hurt you. She continued to dissociate from the knowledge that an important person in her life
that she had trusted had hurt her.
Signs and Symptoms of Possible Dissociation
Signs and Symptoms of Possible Dissociation
I cannot express or state strongly enough how important it is to recognize the dissociative
process in the room. It is also important to never assume a particular symptom is an indication of dissociation, but it is wise to check out the possibility. When clients are dissociating in one or more of the previously noted ways, they are not able to fully make use of
the therapeutic process. There are also indicators in clients’ lives that they are experiencing
dissociation.
I cannot express or state strongly enough how important it is to recognize the dissociative
process in the room. It is also important to never assume a particular symptom is an indication of dissociation, but it is wise to check out the possibility. When clients are dissociating in one or more of the previously noted ways, they are not able to fully make use of
the therapeutic process. There are also indicators in clients’ lives that they are experiencing
dissociation.
Some of these indicators that are frequently seen in the office when clients are dissociating
include:
• staring or spacing out
• the body becoming rigid
• agitation
• restlessness
• sighing
• inability to talk or sudden loss of voice
• headaches
• using a child’s voice or posture
• changes in facial expression that are different from what is normally seen
Some of these indicators that are frequently seen in the office when clients are dissociating
include:
• staring or spacing out
• the body becoming rigid
• agitation
• restlessness
• sighing
• inability to talk or sudden loss of voice
• headaches
• using a child’s voice or posture
• changes in facial expression that are different from what is normally seen
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• some kind of repetitive movement such as rocking back and forth
• some kind of repetitive movement such as rocking back and forth
• tapping a pencil
• tapping a pencil
• constantly moving a limb
• constantly moving a limb
• inability to remember what is happening in session
• inability to remember what is happening in session
• a feeling of detachment in response to the subject matter being discussed
• a feeling of detachment in response to the subject matter being discussed
• coming into a session with a sense of detachment
• coming into a session with a sense of detachment
• restricted range of affect
• restricted range of affect
• affect that is not congruent with the experience being shared or has greater intensity
than seems to be warranted
• affect that is not congruent with the experience being shared or has greater intensity
than seems to be warranted
• suddenly switching from an affective level in session to a cognitive level
• suddenly switching from an affective level in session to a cognitive level
• voice tone changes
• voice tone changes
• changing from first person to third person (use of “I” to “He” or “She”)
• changing from first person to third person (use of “I” to “He” or “She”)
Other symptoms of dissociation that clients are likely to report when talking about traumatic experiences include:
“I left my body while he was raping me.”
“I knew that I was being beaten, but I thought about something else.”
“It must have been scary, but I don’t remember feeling anything.”
“What did you say? I’m sorry, I tuned out.”
“I remember watching my brother being beaten, but I didn’t feel anything.”
Other symptoms of dissociation that clients are likely to report when talking about traumatic experiences include:
“I left my body while he was raping me.”
“I knew that I was being beaten, but I thought about something else.”
“It must have been scary, but I don’t remember feeling anything.”
“What did you say? I’m sorry, I tuned out.”
“I remember watching my brother being beaten, but I didn’t feel anything.”
Because addictive behaviors may come from the attempt to avoid feeling shame, it makes
sense that trauma might be a part of that shame. Therefore, there might be a need to dissociate from the trauma by engaging in addictive behaviors such as the following:
• substance abuse
• shoplifting
• gambling
• sexually acting out
• bingeing or purging
• overworking
• overeating
Because addictive behaviors may come from the attempt to avoid feeling shame, it makes
sense that trauma might be a part of that shame. Therefore, there might be a need to dissociate from the trauma by engaging in addictive behaviors such as the following:
• substance abuse
• shoplifting
• gambling
• sexually acting out
• bingeing or purging
• overworking
• overeating
Other signs of possible dissociation that may be seen in the lives of clients can include:
• inability to organize or complete a task
• lack of understanding of why one has behaved in a particular way
• difficulty concentrating in order to accomplish a task
• anxiety attacks
• lack of understanding how or why one got in a particular place or location
• a sense of being outside one’s body
Other signs of possible dissociation that may be seen in the lives of clients can include:
• inability to organize or complete a task
• lack of understanding of why one has behaved in a particular way
• difficulty concentrating in order to accomplish a task
• anxiety attacks
• lack of understanding how or why one got in a particular place or location
• a sense of being outside one’s body
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• a sense of unreality
• lack of understanding how certain items got in one’s possession
• difficulty remembering events or parts of events that happened
• unexplained lapses of time
• self-inflicted violence
• being prone to accidents
• promiscuity
Most people who have experienced trauma or physical, sexual, or emotional abuse over a
long period of time learn to use dissociation as a coping mechanism. They use dissociation
even when they do not need to use it. Any level of anxiety may bring on a dissociative response, even though the anxiety is not connected with anything having to do with the trauma. Therefore, it becomes important to find out what caused the dissociation. Was it just
the level of anxiety the person experienced? Or, was the dissociation in response to a stimulus of some kind? It is helpful to ask clients the following question:
• What caused you to leave or dissociate just now?
• a sense of unreality
• lack of understanding how certain items got in one’s possession
• difficulty remembering events or parts of events that happened
• unexplained lapses of time
• self-inflicted violence
• being prone to accidents
• promiscuity
Most people who have experienced trauma or physical, sexual, or emotional abuse over a
long period of time learn to use dissociation as a coping mechanism. They use dissociation
even when they do not need to use it. Any level of anxiety may bring on a dissociative response, even though the anxiety is not connected with anything having to do with the trauma. Therefore, it becomes important to find out what caused the dissociation. Was it just
the level of anxiety the person experienced? Or, was the dissociation in response to a stimulus of some kind? It is helpful to ask clients the following question:
• What caused you to leave or dissociate just now?
It is important to be very sensitive to what is happening with the client right there in front
of you. Therapists need to help clients become aware of and understand their own process
of dissociation and begin to identify the triggers or stimulus that bring the dissociation
about.
It is important to be very sensitive to what is happening with the client right there in front
of you. Therapists need to help clients become aware of and understand their own process
of dissociation and begin to identify the triggers or stimulus that bring the dissociation
about.
It may take a very long time for clients to experience enough safety to explore their dissociative process. I may not teach about dissociation for several months or years, but when it
seems appropriate, I try to normalize the process by saying the following:
It may take a very long time for clients to experience enough safety to explore their dissociative process. I may not teach about dissociation for several months or years, but when it
seems appropriate, I try to normalize the process by saying the following:
What is going on with you has a name. It happens to lots of people. Things that
have names have happened to lots of people. It is called dissociation.
What is going on with you has a name. It happens to lots of people. Things that
have names have happened to lots of people. It is called dissociation.
Example
Example
A severely traumatized client was dissociating in the room. The therapist
asked, “Where did you go?” The client was not able to tell her and answered,
“I don’t know.” She was so used to dissociating and had no awareness that
she had left the room. The therapist’s work with her was to create enough
safety so that she could become aware of her dissociative process. It took
years before she was safe enough to be able to stay present when a memory
was being triggered.
A severely traumatized client was dissociating in the room. The therapist
asked, “Where did you go?” The client was not able to tell her and answered,
“I don’t know.” She was so used to dissociating and had no awareness that
she had left the room. The therapist’s work with her was to create enough
safety so that she could become aware of her dissociative process. It took
years before she was safe enough to be able to stay present when a memory
was being triggered.
Example
Example
A female client had been sexually abused as a child. She became her mother’s
caretaker. She developed an eating disorder in adolescence. She learned to
rescue others at her own expense. She had dissociated from the affect laden
memory of her childhood abuse. She seemed to have intermittently dissociated from the sadness and the anger at this happening. In the present, she told
herself it was okay to let others victimize her. Her therapist began to explore
with her what kinds of experiences led to her being victimized and what feelings those experiences evoked in her in the present. She moved in and out of
denial and dissociation. It was the therapist’s task to address it when she saw
it in the room.
A female client had been sexually abused as a child. She became her mother’s
caretaker. She developed an eating disorder in adolescence. She learned to
rescue others at her own expense. She had dissociated from the affect laden
memory of her childhood abuse. She seemed to have intermittently dissociated from the sadness and the anger at this happening. In the present, she told
herself it was okay to let others victimize her. Her therapist began to explore
with her what kinds of experiences led to her being victimized and what feelings those experiences evoked in her in the present. She moved in and out of
denial and dissociation. It was the therapist’s task to address it when she saw
it in the room.
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TEACHING CLIENTS ABOUT DISSOCIATION
TEACHING CLIENTS ABOUT DISSOCIATION
I try to teach clients about what is happening within them so the two of us can work with
their dissociative experience. I want them to understand that their adult thinking part and
my adult thinking part can help to work on the dissociated aspect of themselves in a much
more powerful way. It may take awhile, depending on how much they bring to me.
I try to teach clients about what is happening within them so the two of us can work with
their dissociative experience. I want them to understand that their adult thinking part and
my adult thinking part can help to work on the dissociated aspect of themselves in a much
more powerful way. It may take awhile, depending on how much they bring to me.
The reason it is important to teach clients about the dissociative process is so that the therapist and the client can work in that in-between place between denial of the event and dissociation from any or all aspects of the experience. Clients can learn to tell their therapist
when they have dissociated. Therapists will recognize the denial much quicker as clients
are able to tell them.
The reason it is important to teach clients about the dissociative process is so that the therapist and the client can work in that in-between place between denial of the event and dissociation from any or all aspects of the experience. Clients can learn to tell their therapist
when they have dissociated. Therapists will recognize the denial much quicker as clients
are able to tell them.
I say the following kinds of things to clients when teaching them about dissociation:
• Dissociation occurs healthfully in all of us.
• We dissociate when we are bored.
I say the following kinds of things to clients when teaching them about dissociation:
• Dissociation occurs healthfully in all of us.
• We dissociate when we are bored.
• We dissociate when we fantasize.
• We may dissociate when we are on the freeway.
• We may tune out in a meeting or class that we are in.
• We dissociate when we fantasize.
• We may dissociate when we are on the freeway.
• We may tune out in a meeting or class that we are in.
Further statements I may make to clients when teaching them about the dissociative process
are:
Further statements I may make to clients when teaching them about the dissociative process
are:
Dissociation is a reasonable response to an unreasonable situation. When
something really painful happens to us, we tend to dissociate as the only
way to stay connected to the person we cared about. We make ourselves bad
and the other person good. When we experience a traumatic event like a fire
or an earthquake, we dissociate as a way of dealing with what has happened
to us. When we dissociate, feelings do not get processed, and the memories
are often stored differently. We may remember but not with affect. The feelings are too painful to touch, so we wall them off.
Dissociation is a reasonable response to an unreasonable situation. When
something really painful happens to us, we tend to dissociate as the only
way to stay connected to the person we cared about. We make ourselves bad
and the other person good. When we experience a traumatic event like a fire
or an earthquake, we dissociate as a way of dealing with what has happened
to us. When we dissociate, feelings do not get processed, and the memories
are often stored differently. We may remember but not with affect. The feelings are too painful to touch, so we wall them off.
It is important to remember that dissociation can happen at the time the
event or trauma occurs. It is like typing in an “E” that does not work. You
are typing away, and you look back at what you have typed. You see that all
the “E’s” are missing because the “E” key is not typing. The story looks different than it would if all the “E’s” had typed. Dissociation is like the “E”
key not typing.
It is important to remember that dissociation can happen at the time the
event or trauma occurs. It is like typing in an “E” that does not work. You
are typing away, and you look back at what you have typed. You see that all
the “E’s” are missing because the “E” key is not typing. The story looks different than it would if all the “E’s” had typed. Dissociation is like the “E”
key not typing.
It is important for clients to understand why certain pieces are missing and why they continue to repeat certain behaviors. The key not being typed can be for sensory or bodily feelings such as when a child dissociates from her ability to smell when her abuser ejaculates
on her abdomen after abusing her. The key can be for knowledge so the child does not let
herself know that her uncle has abused her so that she can engage in behaviors that keep
her attached to him.
It is important for clients to understand why certain pieces are missing and why they continue to repeat certain behaviors. The key not being typed can be for sensory or bodily feelings such as when a child dissociates from her ability to smell when her abuser ejaculates
on her abdomen after abusing her. The key can be for knowledge so the child does not let
herself know that her uncle has abused her so that she can engage in behaviors that keep
her attached to him.
The goal is to have clients teach you how they dissociate so that they can eventually tell
you when it is happening in the room. Typical client responses include:
• “I went away.”
• “I’m not here.”
The goal is to have clients teach you how they dissociate so that they can eventually tell
you when it is happening in the room. Typical client responses clients
include:include:
• “I went away.”
• “I’m not here.”
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• “I spaced out.”
• “I left.”
• “I just went numb.”
Clients can be asked the following kinds of questions. I almost always start with the two in
bold type:
• “I spaced out.”
• “I left.”
• “I just went numb.”
Clients can be asked the following kinds of questions. I almost always start with the two in
bold type:
• What just happened?
• What just happened?
• Where did you go?
• Where did you go?
• What happened just before you left?
• What happened just before you left?
• What did you feel just before you left?
• What did you feel just before you left?
• What do you think triggered that feeling? What was that about?
• What do you think triggered that feeling? What was that about?
• What is happening now?
• What is happening now?
• How do you know that you dissociated?
• How do you know that you dissociated?
• What is happening in your body? Describe it for me.
• What is happening in your body? Describe it for me.
• Where is it happening in your body? Describe it for me.
• Where is it happening in your body? Describe it for me.
• If you gave it a voice, what would it say?
• If you gave it a voice, what would it say?
• Does it have a shape?
• Does it have a shape?
• What are you feeling?.
• What are you feeling?.
In working with clients there is a need to go back to what triggered their response. Consider
using the following:
In working with clients there is a need to go back to what triggered their response. Consider
using the following:
• What were the triggers?
• What were the triggers?
• What did you experience?
• What did you experience?
• What images (pictures, sounds, tastes, touches, smells, feelings) are coming up for
you?
• What images (pictures, sounds, tastes, touches, smells, feelings) are coming up for
you?
• Can you begin to let yourself feel any of these now? (This process begins to move
them out of the denial and dissociation.)
• Can yo