Mothering

In the U.S., today is Mother's Day, the day set aside each year for honoring mothers. It's natural, right? After all, each of us owes our lives to a woman who spent 9 months bearing us, labored to give us birth, fed and nurtured us...etc.

Many of us also have incredibly complex relationships with our mothers. After all, family life is stressful, and we often end up hurting the people closest to us, intentionally in a fit of anger, or unintentionally. So, we come to adulthood with a mixed bag of memories and associations that make up our relationships with our mothers. Mother's Day tends to be a day to focus on the good and might light of the bad, but I'd like to reflect instead upon the imperfect nature of mothering.

Winnicott, famed attachment theorist, introduced an extraordinary concept into psychological discourse on the role of parents in mental well-being. In an era when mothers were often blamed for their children's mental illness (e.g., the "schizophrenogenic mother," whose behavior supposedly caused schizophrenia), Winnicott suggested that the most well-adjusted children have mothers who are imperfect. They are "good enough," in that they love and nurture their children, but inevitably, there are failures in attunement, and times the mother's response hurts or frustrates the child. Winnicott thought that these frustrations, when they are within the child's ability to cope ("optimal frustrations") play a crucial role in helping the child gradually develop self-regulation skills.

Of course, mothers being human and imperfect, with their own histories and issues, not all frustration will be "optimal." However, I see that, too, as an opportunity, because often there are other people in our lives who step in and fill the gaps - that meet the needs our own mothers may not always be able to meet. These others enrich our lives and expand our horizons, helping us grow into adulthood with a broader perspective. They also help to form the blueprint for adult support networks - which tend to be a wider web, rather than isolated to the family unit.

I will be forever grateful to all the women who mothered me - my biological mother, and those who have been like mothers in ways small and large. I could never adequately thank them, but hopefully I will be able to pay it forward.

When is a Crisis Evaluation More Than a Crisis Evaluation?

One of my clients, who has OCD, sometimes has intrusive thoughts (i.e., obsessions) about hurting himself or someone else. In the past, he has acted on compulsions to non-suicidal self-injury, but never harmed anyone else, nor attempted suicide. Most of the time, he has the thoughts without acting on them.

Instead, he tends to present to emergency rooms for crisis evaluation and level of care assessment. He went through a period a few years ago, before I met him, of frequent hospitalizations. Then he transitioned to frequent partial hospitalization program admissions. Now, he's usually just referred back to his outpatient providers.

In spite of the steady decrease in his rate of admission to higher levels of care, he's  been getting evaluations with increased frequency over the last few months, creating something of a puzzle for me: If these evaluations are not about being admitted to a higher level of care, then what are they about?

I have a few theories on the matter, or course. For one thing, I have been somewhat less available during this time, with holidays and a new full-time job, so the role of his attachment to me (and related transference) in helping him feel safe could be a factor. He declined a referral to a therapist with more availability (again likely due to attachment), but perhaps occasionally needs a "booster" intervention, which he seeks out via crisis evaluation.

Whether or not my own availability has played a role, it seems clear that the crisis evaluation plays some sort of symbolic role for him. It's not a specific crisis service or clinician, since he presents at various local emergency/crisis locations, so it must be the process itself. One possibility is that the crisis evaluation serves as a kind of transitional object representing the treatment relationship with me and his psychopharmacologist.

Another possibility is that the crisis evaluation itself has become part of the compulsion - perhaps a kind of sublimation of the initial compulsion to harm self/others. In other words, the compulsion to harm is diffused by acting on the compulsion to seek crisis services. Alternatively, getting a crisis evaluation may also be a kind of "safety behavior" diffusing the anxiety in another way: he doesn't trust himself to 1) stay safe, and/or 2) know whether or not he can stay safe. Having a clinician and doctor tell him he's safe to go home provides the reassurance he needs to actually go home and be safe.

Normally, the treatment of choice with safety behaviors is exposure and response prevention - however, the risks of that treatment are considerably higher when the compulsion is about risk. While I'm pretty sure someone can not wash their hands and still come out in one piece, interrupting this safety behavior could result in harm to self or others. I'd rather he get the evaluation than act on a dangerous compulsion!

Instead, I'm thinking that harm-reduction may be the way to go. Since he has needed less and less intensive treatment over time, continuing the work will hopefully lead to less need for evaluations as he trusts himself more to stay safe. If anyone has another idea, though, I'm all ears!

Therapists Take Vacations Too

When you're a therapist, taking time off isn't as simple as putting in a request for vacation. Because the primary tool of the trade is the therapeutic relationship, we have to consider the implications of our absence for each of our clients. Of course, that doesn't mean that we should avoid taking time off because of a client's possible reactions - time off is necessary for self-care, to prevent burn out and keep us available to our clients during the many weeks we're not on vacation.

However, it does mean that we should prepare for our clients' possible responses to our absence, using both preparatory empathy (imagining by ourselves how the client may think, feel, and act), and in-session processing of clients' reactions. (And, of course, be sure we have emergency coverage available for clients during our absence).

For some clients, a vacation may cause minimal disruption or anxiety. These clients tend to have a secure attachment style, and are therefore able to maintain a sense of connection even in the therapist's absence. With these clients, there may be some loss of momentum due to the therapist's vacation (a longer time between sessions means less clear recollection of the conversation, and longer breaks may get clients out of the "habit" of self-reflection), but no loss of trust.

However, many clients have insecure attachment styles. These clients experience more uncertainty and anxiety about relationships, and may therefore have a stronger reaction to the therapist's absence. Clients with dismissive attachments may minimize the significance of the disruption...but may simultaneously demonstrate the disruption by becoming distant, picking a fight, and/or missing sessions. The intervention may be naming the dismissiveness, validating the insecurity the client is feeling about the relationship, and reaffirming the continuity of the relationship in spite of the break.

Clients with preoccupied attachment styles are more likely to become anxious about whether the relationship will withstand an interruption like a vacation. They may appear or express anxiety directly, or may seem less certain of the therapist's availability or interest before or after the break. They may seem needier, with more urgent needs, questions and requests, more frequent calls, and more need for reassurance or encouragement - all subconscious ways to test the strength and continuity of the relationship. The intervention is to name the anxiety, provide reasonable (but not excessive) reassurance, and demonstrate continuity by having established appointments before and after the break, a consistent level of availability and empathy.

Clients with unresolved attachment styles may demonstrate a mix of the above responses, and are the most likely to regress before and after an interruption in treatment (though others may also show some regression). The best response may be to name and validate the mixed response (anger, anxiety, dismissiveness, etc), provide concrete reassurance about the stability of the relationship, and be available, reliable and consistent before and after the break.

How do you handle clients' responses to vacations? Are there responses or difficulties your clients have that I haven't included? What seems to minimize the disruption for clients?

Attachment in Therapy

Underneath the theory and technique, the heart of therapy is the relationship - a special kind of relationship that is formed between therapist and client. The incredibly personal nature of what is shared in therapy gives the relationship a very intimate quality. As a result, clients tend to relate to the therapist in a way that reflects the patterns and expectations they bring to intimate relationships. 

We call it "transference" when the client layers a specific relationship from their past or present life onto the therapeutic relationship - for example, relating to the therapist as if she were the client's actual parent/partner/child, etc. However, even without this kind of transference, we are getting flavors of how the client feels about and relates to important other people. 

This process is both incredibly important and incredibly complicated for clients who have experienced relational traumas - when they have been hurt by those who were most supposed to love and protect them. Particularly when these traumas occur early in life, people may develop enduring patterns of "insecure attachment" - basically, relational templates that assume instability, unpredictability, and/or threat within close relationships. 

While there has been plenty written about attachment styles, I have been thinking more about how insecure attachment styles reveal themselves in therapy, and wanted to write a bit about the subject from this perspective. There are three kinds of insecure attachment, described in adults as preoccupied, dismissive, and unresolved:

1. Persons with a preoccupied attachment style are anxious about relationships, and cope with their anxiety by seeking reassurance. In romantic relationships, they may call often, ask if their partners love them or are mad at them, and so on. In therapy, they may need frequent reassurance that the therapist is "there," and will continue to be there. For example, one client of mine needs reassurance that each new adjunct service (case management, day treatment, etc) is not going to replace therapy, and is not an attempt to "get rid of her." Clients with this attachment style tend to find vacations and other cancellations or disruptions in treatment especially distressing and anxiety-provoking. They may also hold back what they consider to be the most unacceptable parts of themselves for an unusually long time, believing the therapist wouldn't continue working with them if they "really" knew them. As a result, continuity and unconditional positive regard in treatment can be immensely healing.
2. In contrast, people with dismissive attachment styles cope with their anxiety about relationships by dismissing the importance of relationships in general, and by minimizing the significance of particular relationships by leaving the other person before that person can leave them. These clients may be extraordinarily reluctant to engage in the therapeutic relationship. For example, I have one client with some risk issues who didn't want to schedule a follow-up appointment. She needs treatment, but I was sure that encouraging her to come would be the surest way to prevent that from happening. I waited two weeks, but she finally did call to request an appointment, and I am much more confident that she will come precisely because I stepped back and didn't try to pull her in. These clients may also be inclined to drop out without warning if things start to feel too intense. However, if they can hang in their through whatever is triggering the impulse to bolt, it's another potential for significant healing.
3. Finally, individuals with unresolved attachment styles are not consistent in a pattern of relating - they are (predictably) unpredictable. Sometimes preoccupied, sometimes dismissive, sometimes clinging while dismissing...you get the general idea. One client of mine copes with her fear of her partners leaving her by holding them hostage, or by leaving them first, depending on relative size and power. She abruptly dropped out of treatment with her last therapist when she sensed that the therapist was "tired" of her. The challenge for the therapist is to both be predictable in the face of unpredictability, and NOT realize the negative predictions (abandonment, rejection, or whatever).

As this last example suggests, I find it incredibly informative to ask about clients' past experiences with therapy, and how they ended. If someone seems to have dropped out just when they were getting to the heart of thing, I talk to them about relationship patterns, and how they may at some point feel like doing the same thing with me - but that they can make some real progress if they can stick with our relationship anyway. 

How do you assess for and understand the relational patterns that your clients bring to therapy? What have been the best and worst examples for you?