16. Therapy from Assessment - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Down the Relationship Rabbit Hole, Assessment and Strategy for Therapy
Chapter 16: THERAPY FROM ASSESSMENT


In increasing dysfunctional (greater devolution) order, the following are examples of approaching each stage of relationship condition, the couple or family's process, or each individual's process.
  
Communication training: The therapist will help the individual, couple, or family understand and learn healthy communication.  "This is what this means, this is how I say this; this is what I want you to do."  In a classic gender cultural misunderstanding, Martin was trying to express how much he cared for his wife, by working overtime so he could buy her an expensive present.  Meanwhile Pam was feeling neglected by his physical absence—thinking he didn't want to spend time with her anymore.  Hurt, Pam responded with the silent treatment.  Helping Martin articulate what the symbolism of work (being the loving provider… a model from his father) helped her understand that he did care.  Helping Pam articulate how she experienced his absences helped Martin understand how she felt.  And, then they were able to teach each other how to better communicate the caring they both felt.

Symbolism & empathy:  The therapist elicits and evokes the deeper symbolism of otherwise simple (if clumsy) communications to facilitate empathy.  Rene experienced a great deal of impatience at Kevin's elaborate and slow communication style.  She became anxious and would eventually interrupt him, which upset him.  This set off a chain of reciprocal anger and retribution.  When asked what bothered her so much about his style, Rene rationalized its inefficiency and so forth.  Using a gestalt method, the therapist focused her anxiety physically in its location in her throat.  As she stayed with the anxiety—the stuckness in her throat, the therapist directed her to the holistic experience (not a memory per se) of sound, sight, and smells… from some younger time.  Rene's anxiety became greater and greater and turned into visible fear and distress on her face and body.  She chose to stay with the feelings, and a scene burst upon her consciousness.  She came from a working-class family that was very poor when she was young.  Her father was highly stressed and prone to outbursts of rage as he dealt with his periods of unemployment.  The scene was seeing brother being beaten when Rene was very young.  Her anxiety was that she could not do anything about it.  Being unable…impotent brought her back to this fear.  Being disabled waiting for her husband to complete his elongated discourse had the same effect!

Later, when Rene discussed this therapeutic experience with her mother, her mother confirmed that this incident had indeed occurred.  It happened when Rene was six months old at a time she did not yet have language to speak!  Hence, the stuckness in her throat.  Her father had just been laid off and her brother had just dropped a bottle of milk, shattering it all over the kitchen floor.  When Rene understood this, she was able to disconnect from her anxiety and fear as a baby to better tolerate her long-winded husband.  And, her husband who loved her deeply worked mightily to shorten his "speeches" to more succinct lengths!  And, there were also reasons why he felt compelled to be so elaborate with his communications, but that's another therapeutic issue!  The therapist should be aware that the likelihood of trauma being relevant in a couple or an individual is higher if they come from a family or culture where severe corporal punishment was acceptable.

Injury & healing: The therapist's goal is to help identify the injury, how it occurred, identify how the vulnerability came to be, and help individuals, the couple, or the family experience the healing.  The couple had major stresses in work and family.  Both were overwhelmed.  Mindy worked fulltime and still took major responsibility for the children's needs.  Dietrich- "Dick", a second-generation German-American also worked fulltime and tried to "help" with the children as much as possible.  The logistics of three children, 5 teams, 4 music lessons, three schools, etc. were often overwhelming.  As they are discussing this in therapy, Mindy comments about Dick's demanding work and some of the kids' games he had missed, and says, "…he misses their games all the time.  Dick doesn't even both to check the schedules. "  Dick flew into a rage from an emotional stab he's experienced from her.  "Damn it!  It's all the time, 'all the time', 'he doesn't care.'  I do care.  You don't understand…" Instead of letting this go where it always went, the therapist interrupted and asked, "She really pissed you off there.  What was that jab about?"  While acknowledging the anger, the therapist was pointing him to the injury.  Dick said, "It's always her and the kids.  She makes it sound like I'm the big bad man!  Like they're her kids and not mine too!"  The therapist said, "You mean, she doesn't appreciate you as a father… a dad to the kids?"  BINGO!  He nods to confirm this.  The therapist asked, "How was your father as a model to be a dad?"  Angrily, he spit out, "He was the sperm donor!  He was too busy drinking and chasing skirt."

The therapy shifted from the argument and anger between Mindy and Dick.  The work focused on processing the loss he experienced from his father's emotional abandonment and how he swore never to be a father like him.  In this process, Dick talked about the difficulties his father had as a Polish young immigrant without any English skills struggling to make ends meet in Chicago. He also revealed that the family was very poor when he was young.  A little more work reveals his mother taking her pain out on Dick after his father abandoned the family, by accusing him of "being just like your father!"  The therapeutic interpretation was simple- make the connection from the past to the present… from the old wound to the present pain.  "So when Mindy criticizes the amount of time you spend with the kids, it's like making you like him… like your dad.  That must hurt."  The therapist acknowledged his "goodness"… his moving from the bad model.  The therapist turned to work with Mindy.  If she was able to acknowledge that he is not like his father… he's a good dad… a little stressed… with poor time management… needing to prioritize differently… but a good dad, then healing would begin.  Mindy's ability to do this depended a lot on her own pain or relative health and whether she has an aggressive defensive style.  If the therapy could manage potential emotional competition, so Mindy and Dick could tolerate the other's feelings while asserting his or her own, healing would begin.

Blaming vs. responsibility: The therapist blocks individuals from blame that avoids taking personal responsibility.  In couple therapy, the therapist should block the partner's blaming of the other for his/her vindictive abusive behavior; and confront the choice of being toxic.  Rymond was violently screaming obscenities at Gretchen during a session.  "You f—king bitch!  You knew that's not what I wanted.  What the f—k am I supposed to do!?  I'm so pissed off!  Oh, yeah!  Now you're scared!  I'm the big bad guy scaring the little bitch!  What the f—k else can I do?"  Gretchen was literally quivering with fear as Rymond ranted and raved.  This is a classic and often terrifying situation… for the therapist!  The emotional abuse implies potential physical and/or psychological domestic violence.  It is clearly dysfunctional and toxic, and there is an absolute need to intervene, but how?  A boundary of not yelling doesn't address any of the underlying issues, and probably won't work anyway.  An admonition of the rage's hurtfulness will be (has already been) responded with outraged justification that Gretchen has brought the rage upon her; what's more, she deserves it.  He's asserting there's nothing else he can do.  Basically, Rymond is "justifying being an asshole!"  He's blamed her for his toxic behavior.  He took no responsibility for it.  The foundation of this rage is Rymond's inner sense of impotence that he has lived his entire life as a member of a traditionally oppressed group.  The current battle with his wife evokes all the trauma and frustration of his lifelong battle to have value in work in a racist society.

A powerful therapeutic approach to this dilemma uses the ideal self to bring Rymond back to responsibility and choice.  The ideal self is the self one holds oneself to that completely lives up to the highest and greatest values one holds dear.  It is the perfect self from the self-image and definition a person comes to over time.  The real self, on the other hand, is what the person actually does.  Whenever the real self is able to live up to, that is perform up to the standards and expectations defined by the ideal self, one's self-esteem is confirmed.  If one performs otherwise, self worth goes down.  The therapist should challenge and evoke the ideal self.   In the mix of cultural models and values that one has used to survive, especially in macho traditions are models and values of a powerful and good self.  The therapist interrupted Rymond's rant, purposely using a very aggressive and sarcastic tone, "Let me get this straight… You're telling me, that she can make you be an asshole?  You're telling me, that she can make you become less of a man that you want to be?  That you ain't got no choice?  That's bulls--!  I don't believe you believe that terrifying your wife is an ok thing to do.  That ain't the man you want to be.  I'm not talking about who I want you to be.  I'm talking about who you want to be.  You're telling me that Gretchen can be such a bitch, that you don't have enough balls to be a man?!  That she's so damn powerful, that you lose all your values? … that you're FORCED to be an asshole?!  Let me tell you, there ain't no one and there ain't nothing anyone can do, that should be able to make you descend… become less of a man that you want to be!  Otherwise, you ain't nothing but a wimpy assed… but loud, angry punk!  Screaming like a madman at your shivering wife!"

When someone's anger is getting out of control, attempting to block it often increases the intensity and redirects it at the therapist without gaining any benefit.  Joining the anger initially (or appearing to) is sometimes more effective.  However, as the therapist "joins" the anger, he or she then can re-direct it.  An analogy would be the cowboy in classic western movies, knowing better than to try to jump in front of and stop cold a runaway stagecoach pulled by out of control horses.  It is more effective for the cowboy on his horse to race along with the stagecoach horses, and then grabs the reins or hop onto the horses.  That is, the cowboy joins the energy.  Once joined, the cowboy can gradually redirect the stagecoach horses' energy, or eventually take over control and stop it.  In the face of intense arousal, the therapist often cannot and should not try to stop the energy.  Joining the energy includes being willing to risk the client being furious at the therapist, at least temporarily.  Rymond stared at the therapist with fire in his eyes!  Yup, he was pissed at the therapist now.  The therapeutic intervention had moved him from being pissed at Gretchen to being pissed at the therapist.  She was no longer the target.  Now, he directed his energy and attention to the therapist.  Now that the therapist had his attention, the therapist further directed it towards his choosing verbal aggression and his assertion of self-righteousness.  The therapist  continued,

"What?  You saying it's right to scare the crap out of your wife?  Is that all you can do?"  He was silent for a minute.  The therapist did not let him off the hook.  "What? You gots to be an asshole?  Huh?"  More staring and silence.  Finally, he snapped, What the hell am I supposed to do!?"  Rymond was trying to get the therapist to play his game.  The therapist was supposed to suggest something he could do, so that he could derisively assert its stupidity or impossibility and/or expound further on Gretchen being a bitch.  Instead of providing an answer he can deny, the therapist challenged him, "Find a way to be the man you want to be.  Don't betray yourself.  You make the choice.  Now you're punking out… you've chosen to be an asshole."  He responded with the same tone for a while, continuing to bait the therapist back to the "Gretchen is a bitch" discussion.  The therapist stayed insistent and focused on his ideal self.  "This isn't about Gretchen.  It's about you and who you want to be… who you try to be.  If she's that bad, you shouldn't be with her.  It's about you."  The therapist took care not to offer any alterative behaviors or communications.  Rymond was not ready for suggestions, except to shoot them down if the therapist could be enticed to offer them.  The therapist should be aware that under stress (as Rymond was in this situation), individuals tend to revert back to familiar processes or behaviors.  These are often dysfunctional processes or behaviors, which is why clients are in therapy!  Rymond's intuitive goal was to get the therapist to join in his dysfunctional process as he had regularly gotten Gretchen to join in.  Without the therapist's cooperation, he couldn't stay in his process and feed his self-righteous rage.  The therapist continued to challenge his ideal self.  

"Is this it?  You saying you're doomed to be this limited?"  His affect shifted from anger to frustration to resignation to sadness.  I asked, "Do you think it's possible for you to be the man you want to be?"  He was silent for a long time.   Finally, he said, "I don't know what else to do." This was the therapeutic shift that the therapist had been working for.  His statement encompassed without saying it out loud, that he did not want to be an asshole.  He owned that he did not want to terrorize his wife.  He wanted to be a better man… a better person… and a better husband.  He admitted that he was failing himself with his behavior.  Only now was he ready to consider what the therapist might have to offer.  He had owned his impotence.  The therapist offered a contract to train the real self. I asked, "Do you want to learn?"  He replied, "But it's hard.  She makes me so mad."  With that exchange, the therapy could at least try to move forward with him taking greater responsibility.  Now he was speaking to the difficulty of their process, rather than to its impossibility.  Without having to say "yes," he had responded affirmatively to the therapist's offer.  The therapist had evoked and then offered a new definition of Rymond's ideal self.  His old ideal self was self-righteous, aggressive when challenged, and justified toxic communication and behavior when threatened.  His new ideal self asserted that he could and would choose to be a good person no matter how provoked.  He had accepted a new ideal self offered by the therapist.  Although the therapist offered a "new" definition of an ideal self, it was a definition that evoked from within his cultural experiences and values.  It was based on his desire to be a "man."  Rymond had not explored the nuance and sophistication of what it meant for him to be a "man."  The therapist offered more depth than his simplistic definition.  It stretched his cultural values without breaking them.  Only then did the therapist offer him a contract to develop new skills and options for the real self with the question, "Do you want to learn?"  When he responded, "But it's hard…" he had accepted his responsibility, his previous choices, and the offer.  Cross-cultural training from his former cultural pattern to a new functional pattern that worked for him and for the couple to communicate healthier could begin.  And Gretchen?  Gretchen had watched the exchange.  Later, she said she realized that at least in therapy, there could be in control or at least, the therapist could be in control.  She needed that security to begin to venture taking more responsibility in the relationship.  And that was a therapeutic challenge as well… a different challenge than it had been with Rymond.  

Disconnection & reconnection: The therapist must get the individual, partners, or family members to agree to risk offering vulnerabilities and trust to another, the other, or others again, which means probably and almost certainly hurting each other again.  For the individual client, he or she must risk vulnerability to important other individuals in his or her life and also probably be hurt.  Hurting each other happens while and despite learning better processes.  This is the most difficult type of individual in a relationship, couple, or family to work with.  Reconnection goes against every instinct the disconnected person, partner, family member, or couple or family has developed over the years to survive being hurt.  Disconnection has been the choice for survival.  It may have been the only culturally sanctioned or family modeled alternative.  Although, disconnection came with major harmful consequences (increased loneliness, loss, depression, and so forth), it was experienced as the preferred chronic but usually dull pain over the acute stabbing pain of ongoing battles.  The therapist essentially is teaching an individual how to have a healthy relationship, a couple how to be a couple again, or a family how to be functionally.  Homework might be given to attempt productive unfamiliar behaviors with others in the real world outside of therapy.  The therapist may assign dates for partners; set up to get them to play together; prompt them scheduling time to spend together as a couple- not as parents.  The dates may need to be highly structured with major limits.  They are prompted to allow for tentative interactions since more emotionally substantial and risky interactions force greater connection than the couple can currently tolerate.  Small risks of connection and emotional vulnerability are possible.  The therapist can prompt for small investments of trust.  Interactions would be based on identifying, finding, and experiencing original attractions to see if they still exist, can be rekindled, and built upon.  Similar tasks are given for the family.  These approaches are essentially behaviorally oriented.  A behavioral approach prompts new experiences that allow for the possibility of small incremental emotional vulnerability to grow.  Dating, family meals, and other experiences also allow for each person to see if his or her injuries can tolerate the proximity of the other or others.

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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