12. Therapist DepAnxiety - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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I Don't… You Don't… It Don't Matter, Depression and Anxiety in Couples and Couple Therapy
Chapter 12: THERAPIST ANXIETY & DEPRESSION


A common therapeutic truism shared among therapists, is that the client will make the therapist feel or experience what the client feels or experienced.  As a result, the therapist may absorb client anger, hurt, pain, loss, and especially, anxiety and depression.  Since human services and perhaps, therapy at a higher degree is the offering and acceptance of an intimate and purposeful relationship between a professional and a client, the therapist will often or inevitably have his or her emotions powerfully evoked.  While certain theoretical orientations recommend using and simultaneously resisting such feelings (named as counter-transference, for example), humanistic-existential orientations often emphasize the therapist's emotional experiences as foundational to therapy.  The person of the therapist will not only react to the humanity of his or her clients, but also from his or her humanity.  As a result, theories about clients often have relevance about the therapist.  For example, the therapist may experience the anxious resistant attachment pattern, when a child feels uncertain whether his or her attachment figure will be available and responsive.  The inconsistency of availability and absence causes anxiety and despair.  The child has persistent separation anxiety and becomes clingy and insecure about venturing out to explore.  "Adults who have experienced this type of attachment style often become compulsive caregivers. They never felt sufficiently cared for, but were not disappointed enough to give up trying."  In their research on the person of the therapist, Lackie (1983) and Goldklank (1986) found that therapists were often in caretaker roles in their families of origin.  Indeed, it is no wonder that, for many therapists, their early attachment experiences predisposed them to continue their caretaker roles (Hill, 2009, page 6-7).

The therapist may experience that his or her words, interventions, directives, suggestions, or authority, wisdom, education, and experience may not matter to clients.  They may be rejected and/or he or she as the therapist may be rejected.  Anxiety and depression in the clients be infectious affecting the therapist, causing a sense of impotence, helplessness, and ineffectualness from trying and failing to help.  Thus, clients may evoke anxious and depressive symptoms in the therapist.  Accumulation and continued acquisition of knowledge, experiences, theories, techniques, skills, strategies, and interventions would serve to lower therapist anxiety.  Repeated experiences with successful outcomes for clients in therapy would increase therapist confidence and lower anxiety.  However, years of experience, wisdom, and skills may not in themselves significantly reduce therapist anxiety if the anxiety is psychologically, emotionally, or developmentally based.  Hill (2009) states that the attachment experiences of the therapist predispose potential vicarious identification with the client's anxiety.  Interpersonal conflicts between the therapist and the client often create an intrapersonal form of anxiety.  It can be overtly or covertly expressed.  Recognizing the different ways his or her anxiety is expressed, allows the therapist to understand and use it in therapy.  Therapist responses may be described in five strategies or responses:

1. The therapist may habitually bind anxiety- that is try to gain control of personal anxiety by providing premature and unrealistic reassurance to clients.

2. The therapist may try to avoid anxiety by inadvertently avoiding discussing or recognizing possibly provocative or emotionally latent issues.  While the therapist does not reassure clients prematurely, he or she is unable to hear and be with the clients- that is remain open and available.

3. The therapist absorbs the anxiety and takes it upon him or herself.  He or she becomes overwhelmed and finds it increasingly difficult to stay emotionally present.

4. The therapist escalates the anxiety.  This is relatively rare.  The escalating therapist appears to enjoy exacerbating clients' conflict and anxiety.  He or she may be vicariously enjoying the ensuing fight or "slow burn."

5. The therapist approaches the anxiety within him/herself as well as within and between the persons in therapy.  Approaching anxiety provides a therapeutic context for conversation and exploration without contamination from the therapist's latent anxiety.

The first four therapist approaches to anxiety do not support clients under stress or in crisis or effectively deal with conflicts and anxieties (Hill, 2009, page 7-8).  The therapist must create a secure base for therapy.  He or she should create a non-anxious therapeutic context- or perhaps, an environment able to handle anxiety without the therapist losing control or becoming overwhelmed.  The stable therapeutic container needs to hold the clients and the process that enables growth and change.  The calm confidence of the therapist prompts an environment, that "promotes and encourages therapeutic conversations, interactions and experiences that facilitate new cognitive, emotional and relational experiences, enabling the client(s) to create new meanings and understandings for the experience and management of anxiety, thus creating new avenues for therapeutic change" (page 8).  The therapist's ability to provide empathy, warmth, and genuineness, which is consistent with attachment theory appears critical to therapeutic progress.  When individuals are in conflict, joining with a therapist creates the alliance or attachment base to examine their dysfunctional relationships and individual intrapersonal dynamics.  The secure parent-child attachment is essentially the same as the secure adult partner attachment and essentially the same as the secure client-therapist attachment.  As securely attached individuals and clients experience less anxiety, risk, and threat approaching, so also would securely attached therapists.

Anxious resistant, ambivalent and avoidant attached individuals, clients, or therapists are more likely to avoid, bind, escalate or absorb anxiety as they try to cope with internal cognitive and emotional experiences.  If clients respond erratically or unpredictably to therapist and session activities and/or life stresses, the therapist may feel anxious or threatened.  His or her sense of importance, self-respect, power and control, competence, and identity or self-definition as an effective therapist may be damaged by client communications or actions.  During the course of therapy clients can become enraged, hostile or accusatory, get depressed and become suicidal, become overwhelmed and anxious- including having panic attacks, or have a psychotic break.  Anger and blame may be directed at individuals in and outside of therapy (for example, partners, children, parents, peers or friends, or bosses or colleagues), groups (for example, women, blacks, or immigrants), or institutions (for example, school, work, the government), or it may be directed at the therapist.  Unsure of when or how a client may go off on him or her, the therapist's anxiety may be provoked.  This may be exceedingly difficult if the therapist has personal anxiety or depression issues, and/or attachment style insecurity about availability or rejection.  The dyadic relationship of an individual with an anxious attachment style or family-of-origin distress with his or her partner often instigates problematic relationship experiences or issues that bring a couple to therapy.  The same issues may manifest in the dyadic relationship of therapist with a client, with each dyadic relationships with each partner, and/or the dyadic relationship with the couple within the triadic relationship of partner-partner-therapist.

The therapist could anticipate and address that problematic dynamics between the partners may well be duplicated with problematic dynamics between a partner and the therapist or between the couple and the therapist.  The intimacy of the therapeutic relationship can be threatening to clients.  Reis and Grenyer (2004) found that high levels of fearful attachment impede a client's progress particularly in the first six sessions of psychotherapy.  After ten sessions, later in therapy a preoccupied attachment style interfered with reduction of symptoms.  In the critical early stages of therapy when the therapist seeks establishment of rapport, fearful attachment has an important effect.  Early therapy emphasizes developing client's trust in the therapist while establishing the goals of the work.  "Clients who fearfully avoid open interaction with others may be expected to find this early period more difficult as it requires a degree of disclosure that they may not initially be comfortable with" (Reis and Grenyer, 2004, page 420).  Thus, fearful attachment, which causes or is intricately related to depression/anxiety and relationship distress may also predict poor therapeutic outcomes.  Attachment issues may manifest in significant therapeutic transference.  Prior experiences of being rejected and betrayed by others may cause clients to such negative experiences, feelings, and expectations to the therapy and the therapist.  As a result, therapist words or actions that may be ambiguous or emotionally neutral or intended to be benign may be misinterpreted to match up with highly persistent and set models of rejection.  Such misinterpretations of the therapist's intentions, feelings, and thoughts would affect the client's attention and can circumcise his or her responses and ability to be candid.  Negative self-perceptions and perceptions of others can intensify any difficult and uncomfortable themes or experiences in therapy.  Hyper-vigilant and hypersensitive to criticism and fearful of being rejected again, such clients may emotionally or intellectually withdraw and/or eventually physically quit therapy.  Since "…'fearful' clients are thought to experience conflict between the desire for relationships and their reluctance to trust others, in times of stress they may appear to vacillate between so-called 'approach' behaviours (seeking reassurance and proximity) and 'avoidant' behaviours (withdrawal from interpersonal interactions).  For this reason, others (including the therapist) may view 'fearful' clients as unpredictable in their reactions, and respond in a disengaged or aloof manner, confirming the expectations of the client (Lopez, 1995).  Bartholomew (1990) has similarly suggested that fearful attachment is maintained and perpetuated in a similar cyclical way.  Others are seen as rejecting and untrustworthy, so relationships with them are avoided" (Reis and Grenyer, 2004, page 421).

With avoidance of closeness and of self-revelation, interactions or relationships including with the therapist tend to be also avoided.  Avoidance predicts further avoidance and thus, there is little possibility of gaining alternative rewarding intimacy experiences that dispute the negative model.  "The apparent damaging nature of fearful attachment within psychotherapy may therefore be attributable to the theorized inflexibility of the negative-other working model."  Despite their aversion intrinsic to fearful attachment, establishing a relationship and perhaps, especially the highly vulnerable, intimate, and invested therapeutic relationship, such individuals still desire close relationships.  Therapy may become a safety zone because of its confidentiality with the establishment and assertion of comforting boundaries by the therapist.  With strong therapeutic containment enforced by the therapist, an anxious partner may be able to venture a tentative experiment to be more forthcoming and risk the therapeutic alliance.

Maurice had initiated therapy and clearly took the lead in the initial sessions of therapy.  He could cite chapter and verse of the issues, they experienced.  He described his choices and behaviors as well as Colton's.  Maurice speculated… no, he presented as unadulterated reality both his and Colton's underlying motivations, psychology, and family influences on behavior.  When the therapist asked Colton about his thoughts, feelings, or perceptions, Colton spoke slowly and carefully with frequent glances at Maurice to see how reacted to his words.  In actuality, Colton looked at Maurice to see if he approved of his perceptions and interpretations.  When Maurice interrupted to correct him, "Actually, this is what happened…" Colton quickly deferred to his rendition of the "facts."  The therapist tried to lead Colton with prompts such as "What is your experience…?" "How did you feel…?"  "What was your reality…?"  "Tell me how you saw it differently from Maurice?" or "That's what Maurice thought you meant.  What did you really mean?"  Despite these prompts and a short therapist speech about how each person having their own experience and reality is valid, Colton continued to carefully avoid contradicting Maurice.  When the therapist saw Colton for an individual session without Maurice's presence, the therapist anticipated that Colton would be more forthcoming with his own interpretations and perspectives.  Instead, the therapist discovered that Colton spoke and then looked anxiously at the therapist for approval.  Extending or clarifying questions seemed to make him anxious.  He acted as if the questions meant the therapist did not approve of the original response.  When the therapist reflected back to Colton that he seemed to be fearful of displeasing the therapist and being rejected, Colton was horribly chagrined and started to apologize.  The therapist reassured him that the feedback was not criticism.  Specifically, Colton was not being a "bad" client and that he was not going to be punished with rejection, Colton was able to identify the origins of this anxiety and behavior from a childhood with a very harsh set of parents.  With frequent reassurances that the therapist was not going to condemn and reject him, Colton could talk about fearing being condemned and rejected by the important people in his life: first his parents, then Maurice, and now the therapist.

With the fearful or anxious attachment of someone like Colton, establishing the therapeutic alliance becomes challenging for the therapist.  The therapist would have to manage any anxiety or hurt- that is, personal issues with rejection or abandonment.  Managing anxiety or rejection can be difficult with individual clients- in particular those with borderline or narcissistic features.  However, individual therapy is a two-person or dyadic dynamic, which often is significantly less complex than the triadic dynamic in couple therapy.  Another layer of difficulty can arise in the couple's dynamic.  The anxious partner may fear that non-anxious partner will view aligning and developing trust in the therapist as betrayal.  Although, the anxious partner may want to be accepted by and trust the therapist, his or her primary investment may be to not risk rejection by the non-anxious partner.  Despite being insecurely attached to and having a problematic relationship with the non-anxious partner, preserving that relationship (however unfulfilling) would likely still be more important than a tentative relationship with the therapist.  If an anxiously attached partner such as Colton becomes more trusting of the therapist, in the couple session such a partner would be torn between aligning with his or her partner versus the therapist.  In the therapy with Colton and Maurice, the therapist discussed Colton's attachment style and his anxious motivations and behavior with both partners.  Although, Maurice had a dominating style, he deeply cared for Colton and sensed that Colton censored himself frequently.  The therapist was able to enlist Maurice in reassuring Colton and encouraging him to speak his true feelings and thoughts.  The next phase of therapy involved the therapist "refereeing" Colton and Maurice communication exchanges.  The therapist had to frequently remind Maurice to allow Colton to speak openly, and frequently direct Colton to speak authoritatively from his experiences.  Therapy included ongoing reminders of the previous problematic communication dynamics and examination of the process when Colton's anxiety prevented honest expression or Maurice's authoritative habits blunted it.  Work alternated between the current process between Colton and Maurice and the family-of-origin and attachment experiences that influenced the current process.

Clients with avoidant or dismissive attachment present a different therapeutic challenge.  Individuals with avoidant or dismissive attachment have little overt motivation to seek intimate relationships.  They hold a self-perceived positive model of the self, which becomes a functional model that denies attachment needs and deems close relationships unnecessary.  "In this case there would be no motivation to even attempt closeness or bonding within the therapeutic context, and it could be expected that the development of a strong alliance would be hindered" (Reis and Grenyer, 2004, page 422).  Such individuals, if they ever enter into therapy may be the most provocative to therapist anxiety and depression.  Whatever the therapist attempts to do would not matter to the dismissive client.  Whatever the therapist offers for a trusting intimate relationship would not matter to the client who avoids relationships.  The kindness, sensitivity, caring, and other qualities of the therapist would not matter.  The therapist's respect, guidance, perspective, and wisdom would not matter.  The avoidant or dismissive attached client would provide and provoke every interpersonal social justification for the therapist to reject the client as difficult or intractable- intractably resistant to change and therapy.  The therapist would have every interpersonal social justification to terminate the relationship with the client.  In other words, the therapist would have experienced and reacted as the client's previous formative relationships had and current attachment intimates may again.

When the therapist gives up on the avoidant or dismissive individual, it can lead to the therapist also giving up on the individual's relationship with the partner.  Therapist withdrawal or hopelessness confirms for the individual his or her unlovability and/or intimate others' inability to be present and caring.  The challenge to the therapist can be profound.  He or she will experience the hurt and loss, along with the anxiety and depression of the client.  For some clients and partners, the anxiety and depression will be intense and overwhelming.  For others, the anxiety and depression will be buried deep and hidden by embedded defense mechanisms, negative attributions or interpersonal models, and problematic attachment styles.  The therapist must not assume that his or her openness, availability, experience, wisdom, or other qualities or skills will always suffice to build client-therapist rapport- the therapeutic trust that is foundational to therapy.  Rather than working from that assumed foundation and then working through relevant issues, the therapist should work on creating the foundation of trust.  That is done by fundamentally working on their complex but identifiable issues.

Perhaps, the challenge is for the therapist to get the insecurely attached, depressed, and anxious individual with negative attributions and poor communication and conflict skills to feel he or she matters.  This may only occur when he or she experiences mattering to the therapist.  This would require the therapist to be personally and professionally mature, wise, and skilled to do so despite often feeling not mattering to the individual.  The therapist must convey regard and caring while getting little or no reward, while possibly being punished for the effort.  The therapist may feel that despite best intentions and best efforts, his or her therapeutic actions: feedback, interpretations, caring, sensitivity, wisdom, interventions, and suggestions do not matter to affect the partners individually and collectively.  However, the therapist must remember that the dyadic relationship between an anxious and depressed partner with the persistent caring and skillful therapist may become the reparative model of attachment that facilitates the reparative model of couple's intimacy.  If an individual feels he or she matters to the therapist, it may give him or her the reparative attachment experience to risk attachment to his or her partner.  "You matter to me" from the therapist becomes to the individual, "I matter to one person- the therapist.  And, maybe I may matter to my partner.  Maybe I can take the risk.  Maybe it… maybe my actions do matter… happiness and fulfillment together can happen."  The skilled and knowledgeable therapist really does matter to the depressed or anxious client and the couple.  The therapist can know he or she personally/professionally matters, matters to the partners, and what he or she does clinically matters to the healing and growth of the relationship.  The therapist challenges the partners' personal maxims of "I don't… You don't… It don't matter" and "I can't…" and "We can't do anything to prevent bad things."  Mutually reinforced depression and anxiety in the couple can be challenged through the empowerment of partners and the couple to heal and grow their intimacy.  "I do… You do… It does matter" can become their new experience.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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