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Therapists do not always respond at their best when they are confronted with a patient’s humiliated fury, demands and needs, regression, entitlement, sadomasochism, unbearable suffering and loneliness, extreme avoidance and silence, or intense self-harm or suicidality. It is easy to become confused when working with dissociative parts and to be unable to hold the whole person in mind. Even seasoned therapists can become overwhelmed by the basic question How do I stay grounded and steady with my patients?
In order to navigate successfully the many complexities and pressures brought to treatment, therapists must have consistent ways to be aware of, accept, and change our own unhelpful personal reactions, which we all have. We are human and make mistakes; fail to adequately attune, understand, or empathize; get tired and frustrated; are too eager to fix and help without setting important limits; are hurtful; and cross boundaries from time to time. Often we have unrealistic expectations of ourselves as therapists. We may take extraordinary measures, or relentlessly twist ourselves in knots to be better, be more, be different, in the hope that if we change, our patients will change and get better. There may be some small truth in this method when our countertransference or lack of knowledge is in the way and we need to do something about it, but overall it is not an effective strategy. We can only hope for and work toward being a “good enough” therapist for our patients.
The best place to begin therapy is with ourselves, the imperfect but good enough therapist. Who we are and how we are with our patients make a critical difference in helping them make progress. In this chapter of our recent book Treating Trauma-Related Dissociation: A Practical, Integrative Approach we will focus on the person of the therapist, and further in our book we explore the therapeutic relationship—the shared medium in which both therapist and patient can grow and thrive; or conversely, in which they may unwittingly play out unresolved sadomasochistic enactments or rescue fantasies that typically do not end well.
The Good Enough Therapist
The idea of the good enough therapist (Cozolino, 2004) is based on Winnicott’s concept of the good enough mother, who attends to her child in an ordinary, everyday way that does not require perfection, seamless attunement, or constant availability (Winnicott, 1968). Good enough parents are able to take in stride the rapidly shifting states of the infant, providing consistency and security across a wide array of experience. However, even good parents match and attune to their children only about one third of the time (Malatesta, Culver, Tesman, & Shepard, 1989; Tronick & Cohn, 1989).
A natural cycle of relational disruption and repair is even more important and predictive of secure attachment than attunement alone (Tronick & Cohn, 1989). The therapist’s failures to understand or connect with a patient offer opportunities for this essential repair.
Thus, therapists’ attunement to patients is by definition flawed and is only part of the story. The more complex and difficult part of therapy is often in limit setting and in repair and reattunement, without trying to make up for or protect patients from the harsh realities of their lives. Indeed, patients have the task, as do we all, of “mastering the disappointment and pain that comes with the recognition of just how limited, just how unreliable, and ultimately, just how separate, immutable, and unrelenting one’s objects [relationships] (past and present) really are” (Stark, 2006, p. 2). It is avoidance of this realization that, in part, maintains dissociation in our patients and urges them to invite the therapist to relinquish the usual and essential boundaries and limits of psychotherapy. But at the same time, patients also need to experience a consistent and compassionate person who accepts them as they are, yet also supports them in making change.
As with all therapies, we must begin treatment of complex dissociative disorders by reflecting on ourselves as therapists, because our strengths and limitations as human beings can make or break a therapy.
Reenactments and the Good Enough Therapist
Reenactments are unconscious, somatically based relational interactions in which both patient and therapist project onto the other unresolved experiences from the past (e.g., Bromberg, 1998; Davies, 1997; Frawley-O’Dea, 1997; Howell, 2005; Plakun, 1998). Along with others, we propose that reenactments are dissociative in nature (Schore, 2012; Stern, 2010). The enduring traumatic attachment patterns of our patients—and our own attachment patterns, whatever they may be—are the filters through which we see each other in the therapeutic relationship. The patients’ living reenactments of abuse or neglect within dissociative parts of themselves have not yet been fully integrated.
Reenactments are often felt experiences in the bodies of therapist and patient, sensorimotor and emotional encounters that make reflection and therapeutic change difficult, because they are typically not in conscious awareness, or at least are difficult to put into words. Therapists and patients may implicitly take on many unhelpful and interchangeable enactment roles. These we discuss later in our book.
Therapists must be aware of their emotional and somatic experiences with a patient and understand reenactments from the history of the patient that may be playing out.
Patients—or particular dissociative parts—can experience the therapist as being “too much”: too punitive, pushing too hard, setting too many limits, asking too many questions, being too emotional or too cognitive, too silent or too talkative, too fast or too slow, too smart or too uninformed. Patients also may experience the therapist as “too little”: not good enough, not correct in our understanding of them, not responsive or available enough, not kind enough, not helpful enough.
CASE EXAMPLE OF REENACTMENT: MARTHA
Martha experienced her therapist as cold and punitive, even though in reality she was a warm, vibrant, and highly competent therapist. During sessions the therapist would sometimes find herself feeling incompetent and a bit frozen, with a physical feeling like a cold stone in the pit of her stomach weighing her down and a vague sense of being disappointed in herself. She sometimes felt Martha was overwhelming and demanding and, in turn, Martha believed her therapist hated her and found her needs disgusting. Martha turned this disgust inward, and a critical dissociative part of her berated and punished the young parts of herself for being so needy. During these times, Martha was enraged, both toward her therapist for not meeting her needs and toward herself for having them. The reenactment from Martha’s history was of herself as a child encountering her hostile, absent mother, while the reenactment from the therapist’s history was based on an old pattern of believing she could not ever quite live up to her sister’s stellar academic and social reputation.
The Experience of the Therapist in Reenactments. When we are pulled into reenactments with a patient, we may feel differently than usual: harsh, punitive, overwhelmed, too much in our heads when we should be connected with our emotions, too much in our emotions when we need to be reflecting. We may be enraged or humiliated, guilty or ashamed, unable to meet and match the patient’s energy and capacities. We may feel superior in one moment and exceptionally stupid in the next. Sometimes we may feel like an all-embracing earth mother and other times cold and unfeeling as ice. We feel ourselves desperately caring and feeling utterly responsible for a patient’s very life, and then drained and lacking in empathy. But sometimes we are easily caught in reenactments that are much harder to recognize because they are congruent with how we usually think and feel. For example, a very warm therapist may not recognize that a child part is pulling for caretaking, because the therapist normally feels so naturally attentive and giving. Or a somewhat avoidant therapist may not recognize that he is in a reenactment involving a neglectful, absent parent. Or we view our frustration and anger with the very real egregious behavior of a patient as a response to the present situation (which it is), but fail to recognize that we have also been pulled into a reenactment of the punitive, enraged parent.
Our bodies are the playing field for reenactments: We (and our patients) become hyper- or hypoaroused, tense, hot or cold; our gaze averts, our faces freeze, or we frown or smile even when we are tense around the eyes. We slump in our chair or lean forward aggressively, or cross our arms in defense. Our patients project these experiences onto us, and we unconsciously mirror dissociative parts of themselves that they cannot yet tolerate. Our role is to consciously take these experiences on, hoping to recognize and hold them, attenuate them, and hand them gently back to the patient to own at the right time.
As we see from the example of Martha’s therapist above, these experiences are often not just projections from the patient but also come from our own personal experiences, triggered by the dynamics of the patient. They also are very real experiences born of actually dealing with individuals who are greatly suffering, enraged and humiliated, needy and clinging, avoidant and defensive, demanding and entitled, intense and relentless. Our experiences in real time with patients help us understand the difficulties other people have with them, as well as what struggles they themselves have in relationships. Most often, both the patient’s and the therapist’s histories are at play, interacting with the “real” relationship in the present, engendering a highly complex matrix of emotions and behaviors much like a three-dimensional chess game. Of course, we do not always know in the moment whether what we feel is from our own past experience, from the patient, or from the real relationship in the present. A willingness to stay curious and to accept any or all of these possibilities is important.
These byzantine experiences can be enormously challenging for us as therapists, whose best tool is ourselves. Of course, therapeutic success is not always complete or possible, and that is yet another reality we must come to accept. Or, at the least, our idealized version of success does not always happen. Some patients achieve stability, but not much meaning or contentment. Some are never able to fully trust, always remaining guarded. Some are unable to relinquish their fantasies of a magical cure that comes from outside themselves. A few patients will not get better despite our best efforts, and occasionally we ourselves are unable to sufficiently overcome our own personal challenges to be of help to a particular patient. Yet, there is reason for hope, because the majority of the time we are able to navigate ourselves and our patients through difficulties.
Painful reenactments must be acknowledged and shifted via consistent therapeutic boundaries and predictability, by talking about the felt experience in the moment with compassionate relational repair by the therapist, and by growing accountability and realization by the patient. We must remain as steady and nonreactive as possible in the face of our own and our patients’ intense emotions, from euphoria to despair, from delight to rage, from grief to acceptance, from love to hate, from suffering to contented relief. It is the therapist’s own relational capacities, emotional maturity, and high integrative level that can help pull the relationship time and again out of the mire of enactment and back onto the road of progress.
The rewards of being reflective and present in the moment, and offering patients a positive and new experience of being seen and heard—and of learning to see and hear the other—are well worth enduring these challenging times. Indeed, these are the fires in which the good enough therapist is forged.
Excerpted from the book Treating-Trauma Related Dissociation, (c) 2017 by Kathy Steele, Suzette Boon, and Onno van der Hart. Used with permission of the publisher, W. W. Norton.
About the Authors
Kathy Steele, MN, CS is in private practice in Atlanta, Georgia, and is also an Adjunct Faculty at Emory University. Kathy is a Fellow and a past President of the International Society for the Study of Trauma and Dissociation (ISSTD), and is the recipient of a number of awards for her clinical and published works. Ms. Steele consults and teaches intenationally on topics related to trauma, dissociation, attachment, and psychotherapy.
Suzette Boon, PhD, is a clinical psychologist and psychotherapist working in private practice in Maarssen, the Netherlands. She was the co-founder and first President of the European Society for the Study of Trauma and Dissociation and is a Fellow of ISSTD. Dr Boon teaches and consults internationally on dissociative disorders. She as received a number of awards for her work and has published extensively, including three books on dissociative disorders.
Onno van der Hart, Ph.D., is Professor Emeritus of Psychopathology of Chronic Traumatization, Department of Clinical and Health Psychology, Utrecht University, Utrecht, the Netherlands, and a psychologist / psychotherapist in private practice in Amsterdam, the Netherlands. He is a Past President of the International Society for Traumatic Stress Studies (ISTSS) and is a Fellow of ISSTD. Dr. Van der Hart has published over a hundred articles and book chapters, as well as numerous books. He has won many awards for his clinical, research, and written works.
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