Tuesday, December 30, 2014

Understanding sleep

Sleep is a multi-system brain/body cascade effect. It may be best understood in deep sleep with Rapid Eye Movement associated with dreaming. The wave patterns are smooth and rhythmic. Dreaming happens during this time. A sufficient amount of coordination between sections of the brain/body are required to achieve deep sleep. Two of the brain sections I know about related to sleep are the frontal lobe and the limbic system. The lack of coordination between these two sections seems to be at the root of sleep problems with many of the patients I have had with anxiety problems.

One type of medicine prescribed to help sleep is Benzodiazapines. The psychoactive component of these drugs is a frontal lobe suppressant. When taken at an effective dose, this dampening of activity in the frontal lobe can help the observing part of the brain not react to stimuli generated from the limbic system. Anxious people have an exaggerated sense of endangerment, which sends an exaggerate signal to the frontal lobe. For optimum healthy sleep anxious people need to include the frontal lobe inhibitory effect on the limbic system. 90% of the function of the tissue in the pre-frontal cortex is designed to inhibit impulses coming from the brain stem. Including the frontal lobe is easier said than done. When sleep gets compromised frontal lobe activity is challenged to stay coordinated; therefore, inhibiting fear impulses is not as effective. When fear impulses aren't modulated the frontal lobe can get more active. The tireder the system gets the more this coordination can be impaired.

Benzodiazapine can allow at least some level of sleep and dreaming. This can be a tremendous benefit to breaking long-standing sleep deficits. The trouble with this is Benzodiazapines compromise the very part of the brain we need to influence to lower brain/body fear impulses that are interfering with sleep.

Quality of life and continued improvement in sleep hygiene are how to make decisions about using medicine for sleep. Many of the patients I have worked with have two choices; 1) Do not take Benzodiazapines and have a continually decreasing ability to get refreshing sleep, or 2) Use Benzodiazapines and strengthen their frontal lobe abilities to modulate impulses in their waking life. Either way enhancing the ability to see fear stimuli and soothe the multi-systems needs to be the target. These medicines will soothe the frontal lobe and maybe enough to not need ever increasing doses. I don't view Benzodiazapines as physically very addicting, however it is easy to become dependent on them in ways that aren't useful. Close coordination with a competent medical person is mandatory. Having someone like me who has a lay understanding of these processes can help make decisions more likely to be useful.

Tuesday, April 2, 2013

PTSD The Approach/Avoidance Disorder

As I look at each symptom of PTSD in this section I will repeatedly bring that symptom back the varying attachment dynamics that can be precursors to the approach/avoidance strategy.

B-1) Recurring distressing recollections of the traumatic event or events.

This symptom is more inclusively stated by saying; having an over-powering need to talk to someone about an intrusive, distressing memory, along with the seemingly intuitive sense it will be painful to relive it. This need to tell gets stronger over time if not expressed, with a felt sense of attunement from the listener. The sufferer believes the memories will get less intense over time. This phenomenon has some components similar to a frog not noticing the difference in temperature increases in a pan of water until they boil to death. If you drop frogs into boiling water they jump out so fast their skin hardly gets scalded. As the person fights off the memories it is hard to notice they are getting more emotionally intense. It seems natural and intuitive to expect them to lessen. This “hallmark” symptom of re-experiencing thoughts and feelings of the traumatic event may also seem to stand alone to the sufferer. When he or she finds out this symptom has lend to the rest of the symptoms it is a great relief for most people.

I use the example of how compelled you feel to tell anyone you can find about the big fish you have caught. The compulsive need to tell about experience outside the usual range of human experience is natural. We seek out people who are likely to attune to our feelings, either by knowing us or knowing what it is like to catch a big fish. After about the twelfth telling the need to tell the story has diminished. Now drop yourself in the middle of a desert where you don't know anyone and they have almost no experience with fish. The compulsion to tell someone may not get satisfied. Without the telling it is likely, and healthy to continue have the need to tell “the big fish story” no matter how long you are in the desert.

The need to tell is somewhat centered in our body-based sense of ourselves. Developmentally it is the child rushing into the living room saying to her parents, "Look at me! Look at me!" Healthy parents make sure the child knows they attended to her. She goes away from that experience knowing it is natural to express feelings stronger than usual. If instead the parents ignore her she eventually bottles up the need to tell someone her feelings. If these two girls go through the same traumatic event their probability of seeking soothing from outside themselves is very different. In one of them the need to tell about the trauma resurfaces and is expressed until it is relatively exhausted. With the other girl the need to tell only shows up when she can't stop the compulsion to tell. Even if she does tell someone who could be attuned to her, she has learned to not look for cues of someone attuning to her. With one girl the story of the trauma becomes integrated inside her with the felt sense of being attuned to by her support system. With the other girl the need to tell about the trauma wars with the known fact of feeling more alone with the story if she does ever tells someone.

Consider a 19 year old medic in Vietnam in 1967. His training is condensed into eight months. In his first three months he has the need to perform two tracheotomies, both of whom die. On the second one he remembers some subtlety of his training he wasn't doing. Even if his saves 100 soldiers through performing great tracheotomies the next nine months, the part of him that feels less than others fixates on the two deaths.

When a person’s developing psyche comes upon an extreme life event there is a tendency to retreat to an earlier survival based coping strategy. The younger the disturbing situation the more problematic the reactions to it can be. The infant or toddler who learned to survive the lack of an attuned response to their affective states may develop a strategy to compensate for the lack of attunement. When later life traumas happen the individual will likely use the same coping mechanism as they did in their youth. There may be a short term gain to this strategy, however in the long run it is necessary to seek and find affective attunement to the disturbing feelings. PTSD has been proven to be developed from the lack of an attuned response, rather than the effects of the trauma.

There is an accumulation of factors bringing a client into my office for distress from symptoms of PTSD. These factors need to be observed from the perspective of representing strengths in the individual’s ability to hold their identity together. An example would be a combat veteran who was physically abused as a very young child by their parent. He may develop a Disorganized Attachment, because the person he needs to be soothed by is the one who is causing the distress. Soothing means a felt sense of attunement. Another example is the rape survivor who was ignored as a child, especially when in distress. She may develop an Avoidant Attachment imagining she will never be attuned to. Both examples create internal tension with no avenue for action. For the Avoidant person they can predict their environment won’t attune to their distress. The Disorganized person keeps finding attunement in people who feel abusive to him. We are neurologically organized to seek out attachment. It requires massive energy to block the need to feel soothed.

This is the "hallmark" symptom of PTSD. The other re-experiencing symptoms can almost always be related distressing to memories and thoughts of the trauma, or distressing memories and thoughts of the other re-experiencing symptoms developed after the traumatic experience. We know a lot about healthy expression of distress over critical life events of loss. We call it the grieving process. Depending on the degree of attachment, suddenness of the loss and the temperament of the griever the intensity, frequency and duration of out-pourings of distress take place. It is healthy for these out-pourings to continue with decreased frequency, intensity and duration for at least a year. The anniversary of the loss is a particularly likely time for the feelings to re-surface. Two years is not considered overlong to feel swept up in the feelings of a critical life event.

In the original description of PTSD the stressful event needed to be something as life threatening as a bullet hitting the wall behind your head. Integrating the experience of being centimeters away from sure death into your self-story, requires you to relinquish fantasies of immortality and omnipotence. Freud and I agree we all harbor these fantasies. In a sense, those healthy parents responding to the "Look at me" are perpetuating the child's fantasy of their felt sense of importance in the world. This healthy nugget, around which the developing psyche organizes itself, is highly challenged by the stark reality of the dangers of the world. It takes the time and the processing of the internal tension of the felt sense of increased endangerment. PTSD can only be diagnosed when the felt sense of endangerment remains exaggerated for a long enough time and leads to distress for the client. Reconciling the infantile sense of being omnipotent with the mature realization of the dangers of the world is part of growing up. Retreating to an earlier strategy for coping with distressing feelings is the opposite of maturation. The earlier the strategy developed the less likely we are to know we are using it. It feels intuitive to isolate and push away the distressing memories. The fact that we blow up easily or can’t sleep does necessarily feel related. Short-term it works better to deny the memories access to our consciousness. Long-term we want to be able to access the memories and feelings when we want to and not be over-powered by them. Learning when we are capable of allowing the feelings to go through us is maturity.

Another internal tension that we all carry which feeds into feeling an exaggerated sense of endangerment is "rapprochement". This is the tension between a desire for independence and a desire for dependence. It is exemplified in the moment the exploring toddler notices his mother walking out of the room. Does the child respond to his internal need to explore, or the internal need to have mother caring for him. If either he or his Mom is omnipotent he thinks he will be okay. As the reality sets in that she can't be two places at once, or join him in all his explorations, a sort of disbelief in the parameters of his existence sets in. This really never gets reconciled in us. Therefore, when a traumatic event happens in life there is more fuel for this tension. The subliminal dialog might go something like this: "I can't survive without someone taking these horrible feelings away from me", or "I have to be able to hold onto these horrible feelings by myself".

PTSD recovery is allowing the person's development to take place. This requires the person developing a felt sense of being attuned to in their most challenged states. The states of coming to terms with the immediate, practical dangers of the world, and the irreconcilable needs for independence and dependence are two of these ongoing challenges. If you have ever been the care giver for a child going through a tantrum you have experienced some of what a therapist needs to be able to do. The client's emotional expression is seldom as dramatic as a childhood tantrum. The client does need a feeling of having survived an "affect storm" in the presence of another. This survival of self and the therapy (therapist as respecting other) is essential for the integration of memories that are outside of the parameters of what we have learned to expect from our world.

Friday, March 22, 2013

Anxiety Attacks

Panic Attacks—Most of the clients I have seen have had at least one Anxiety Attack in their lives. They find tremendous relief in the first session finding out what is physically happening to them. (see section on A Handy way to see the Brain). My job is to be sure the client knows they are experiencing an activation of the Flight, Fight, Freeze and Flop (FFFF) response. Prior the 1995 revision of the Diagnostic and Statistical Manual (DSM-IV) two types of acute anxiety reactions were differentiated. I still find the difference useful because of the likely difference in the recovery process. A Panic Attack generally comes on quickly, lasted from 1-20 minutes and ends abruptly. People report the end being so sudden it takes their breath away. An Anxiety Attack comes on gradually, lasts up to two hours and slowly loses its force. People reporting Panic Attacks almost always say they felt like they were going to die. Both types of episodes have residual effects.

The worst part of Anxiety Attacks is their chronicity. People become worn-out from the effects of the last one and fear of the next one. The worst part of a Panic Attack is its intensity. Sufferers will be exhausted afterwards and may remain afraid of the next one for years or decades. The sudden onset of a Panic Attack often gives us an advantage of having a recognizable set of circumstances we can help the client illuminate. Recognition at an ever earlier moment is the primary part of recovery. When the client can notice precursors and relax before the Frontal Lobe turns itself off, they have a much greater likelihood of the FFFF response not being initiated.

With all forms of Anxiety Disorders the thinking leading up to and during the episode will include a declarative internal statement of: “I can’t__, but I must_”, or “ I have to, but I don’t want to_____”. The most frequently reported place people experience this trap in their thinking is in the grocery store. The etymology of the word Agoraphobia (one of the types of Anxiety Disorders in the Diagnostic Manual) is fear of the market place. I always imagine a herder coming over the rise to see the longed-for market place. He has been alone with his animals and thoughts. On many levels he wants to go into the market place. His business and resupply need to be done there. He wants involvement with people. On the other hand he is afraid of being taken advantage of, or be ridiculed or criticized. The worst fear comes if he has experienced some type of anxiety reaction in the past. His biggest fear is he will have an attack. The modern day person has to go get their groceries to survive. It is a perfect setup for an Anxiety or Panic Attack. “I have to go to the store, but I can’t do it if I have a Panic Attack”. If they don’t go they increase their desperateness and add more tension to the next attempt. If they do go and have an attack they get nothing accomplished they increase their desperateness and add more tension to the next attempt. The word, “but” is used here as a contradiction. The only way out of this dilemma is to consciously choose one side of the equation or the other.

If the herder chooses to not go into the market he will slowly starve to death, besides becoming less capable of being around people. If he prepares by relaxing himself thoroughly and survives the encounters with others he can repeat this ritual the next time. Most exaggerated fear of endangerment is built by avoiding the repetition of historical situations and feelings leading up to an episode of exaggerated fear of endangerment. This self-fulfilling cycle only gets interrupted when the sufferer becomes aware of the cycle and relaxes.

Anti-anxiety medications have cause as much trouble as they have provided relief for anxiety. They are a class of medicines called Benzodiazepines. Benzodiazepine is the depressant chemical released when alcohol is broken down in the body. It is particularly active as a Frontal Lobe depressant. The Frontal Lobe will have diffuse activity and less over-all activity. In order to modulate impulses from the brain stem, like anxiety, concentrated Frontal Lobe activity is required. The benefit of these medicines comes because it is harder to be aware of brain stem impulses if you are compromised in your Frontal Lobe.

Valium was the first developed benzodiazepine. It had a half-life of longer than a day. A person took it to go to the grocery store and had a depressed Frontal Lobe for the rest of the day. Xanax, one of the later developed benzodiazepines, has a much shorter half-life, which may mean the next dose needs to be taken sooner. The ability to observe an exaggerate sense of endangerment returned fairly abruptly. People tended to need to take the fast dissipating benzodiazepines more frequently, or face the same feelings they avoided a few hours ago. This cycle can lead to a type of dependency. Any prolonged use of a benzodiazepine challenges the Frontal Lobe’s inhibitory function of anxiety. In the short-term, seven to ten days, benzodiazepines allow a person to not notice the anxiety welling up from their brain stem.

Recovery is definite if you are treated by a knowledgeable practitioner. At the bare minimum the client will learn the phrase, “This too shall pass”. Hippocrates, the father of medicine, wrote about Anxiety Attacks. In all our document history since, no one has died yet of a Panic Attack. People do build-up fatal musculature around their hearts because of the rapid heartbeat of FFFF. Either type of attack is a built-in survival mode to deal with a life-threatening situation. This built-in reaction won't kill you. It is very unfamiliar and if you are afraid of it, it gets magnified.

In a psychoanalytic sense anxiety is caused by a lack of an attuned response to a felt sense of endangerment. By feeling attuned to by a therapist who seems to understand their anxious feelings, the client is no longer alone with the unbearable affect. The “I can’t, but I must” situation can be looked at objectively. Recovery is about make a choice of which side of this contradiction to act on. The beauty of the recovery process is related to the repetitive nature of the problem. If the client can develop a realistic response to thinking they are trapped, they can use the same response in many other situations.

Wednesday, March 20, 2013

DEPRESSION & THE CINGULATE GYRUS

Depression---Anger turned inward—cingulate gyrus

In between the left and right and just below hemispheres of the human brain is a group of nervous about as long and thick as a hotdog. Its primary purpose is to switch our focus from one thing to another. When we are focusing on a client we are accessing many areas of our memories of them, our disciplines as therapists, their histories and the current session’s interactions. If they ask us about the plant we have in the office our Cingulate Gyrus will quickly activate to gather relevant data of the history of our plant. The Cingulate’s job is meant to be short-lived, like a switch. I point to the light switch. It turns the attention to the plant, then stops functioning until we want to switch back to our clinical awareness. The Cingulate Gyrus is located above the Limbic Cortex and Corpus Callosum. It is high enough up in the brain to utilize language, however when it operates the brain reduces the use of the frontal lobe. The logic circuitry isn’t nearly as important as the complex process of creating memory images.

This is all well and good, however what does it have to do with anger turned inward? The Cingulate has the capability of having a thought over and over again without the need to filter it through the logic circuitry. Thought distortions are what David Burns, MD, in his 1980 book Feeling Good, called the core of being depressed. There is some hopeless, helpless exaggerated thought that resonates with the feelings in the Limbic System. Without regulation from the Frontal Cortex the emotional low brain/body and repetitive thought re-enforce one-an-other. The more we think our situation is hopeless the more it feels hopeless. The more we feel hopeless the more we think the hopeless thought over again. This Cingulate Gyrus/Limbic Cortex feedback allows the impulse centers of the brain/body to operate without the modulation the Frontal Cortex is responsible for.

If we experience anger toward ourselves or others while we are thinking and feeling hopeless we are compromised in our ability to modulate those feelings and thoughts. As the seconds and moments develop into days and weeks a feeling of lethargy sets in. *****An aside about Shame/Narcissism. Even when the Frontal Lobe can get involved, it is important to remember its default setting is to worry about what people are thinking and feeling about us. Our shame dynamic tells us there is something wrong with us and other people know it. During moments of depression there IS something wrong with us, so rather than helping us become more realistic about our thoughts and feelings, the False Self turns the reigns back over to the Cingulate Gyrus and the Limbic Cortex. ******The diagnostic manual for mental disorders states that an essential criterion to meet the diagnosis of a Depressive episode is: a person must experience a feeling like hopelessness most of the hours, for most of the days, for at least two weeks. Many people who have come to me for therapy have been experiencing thoughts and feelings of hopelessness almost every day for years.

So how do we get the logic circuitry back involved? This is where Dr. Burns clarified for us Cognitive Behavioral Therapy. One, identify the distorted thoughts. Two, determine the type of exaggeration it is. Three, develop a realistic thought about the same thing without the exaggeration; and practice all three steps when able to notice depressive thoughts or feelings. This process of recognition of the distressing component requires the observation ability that only can come from the Frontal Lobe. 90% of the function of the cells in the Frontal Lobe is to inhibit impulse coming from the Limbic Cortex. By being logical and starting an action of thinking differently, automatically the emotions are being modulated. This may not be powerful enough to inhibit the process of the emotions controlling the thoughts, however it is likely to be a useful component of most people's recovery from Depression.

Wednesday, February 13, 2013

Pain and psychotherapy

All felt pain has physical and psychological components. Sensory and emotional signals are sent up and down the body/brain systems. Suffering and agony are fear related to pain. They are intrinsic to pain. Fear, in a deep body/brain sense, is a requirement. It manifests as muscle guarding which tenses the muscle areas surrounding the pain. This increased tension can cause more mechanical pain, leading to more muscle guarding, and more pain. I will explain pain in the brain/body, its relationship to involuntary contraction of muscle, and what to do about it to suffer less.

First let me clarify the basic working components of the nervous system. I have found my clients need this information in order to understand anxiety, depression, pain, medicines, anger, and impulsive behavior.

Nerves have three different types of dendrite receptors: mechanical, thermal and chemical. The brain interprets pain signals. Psychological processes have physical effects. Physical processes have psychological effects. There is no separation between psychological and biological. The cell wall of a neuron is made up of proteins, large molecules, whose shape and content determine the character and function of each protein. The outfacing end of the long cell wall protein can be thought of as a key hole, it is the receptor site. Neurotransmitters are the keys that fit in these locks. Overly simplified, when a neurotransmitter lodges in these proteins they bond changing the electrical potential of the whole cell a tiny bit. The nerve cell generally sets at -70 millivolts, when it reaches -40 millivolts it triggers the cell wall proteins to flip over, bring the cell to +30 millivolts. Neurotransmitters are discharged out of the axon end of the nerve, into the synapse between that axon and the dendrite of the next cell. They diffuse into the area where the dendrite end of the next nerve has many receptor sites for them. The electrical process causes the protien to flip, (actual Sodium-Na and Potassium-K, negatively charged (-) chemicals are pushed out while Chloride-Cl, positively charged (+) is drawn in). Those two nerves are now wired together.

The more a pathway in the nervous system is used the more it becomes resupplied with the necessary chemicals for it to operate. Blood veins, arteries and the muscles that surround them are strengthened and developed. It gets easier and easier to use that pathway. This is part of the way chronic pain gets habituated in the body/brain.

As a pain sensation is felt in the body it sends a signal of the pain to the spinal column. As the signal arrives, the spinal column quickly makes available more receptor sites for noticing pain. The surrounding neural dendrites are quickly tuned to receive the same pain signal. Therefore, the signal is amplified, literally increasing magnitude of the pain signal. The brain can also send signals back down the spinal column to interfere with the use of some of the receptor sites or add more. After the spinal column has processed it, the pain signal heads up to the brain. There the signal goes through an amazing and complex matrix of receiving areas.

The following brain areas are some of important functions in the way we experience pain:

SENSORY CORTEX
This is a strip of brain tissue on both sides of the brain about the width of your index finger. It processes our body sensations. How pain is felt depends on how cells in these strips are organized. Every part of our body has an area represented on the brain’s sensory strip. It is a mini version of our body mapped onto our brain. The size of the space dedicated for different body parts is related to that area’s degree of sensitivity. Therefore the mouth, face, finger, genitals and feet are related to much bigger areas than their physical size is. This increased sensitivity allows us to feel two toothpicks pressed on our fingertip a quarter of an inch apart and it will feel like one toothpick on our backs. These areas can all get bigger or smaller depending on use. If you have chronic pain in your right elbow the space related to it in the sensory strip enlarges and becomes more sensitive. (In recovery from suffering from pain the reverse of this process will be utilized. The client learns many systems to focus on the non-painful areas of their life.)

LIMBIC SYSTEM

One of the first and most powerful matrixes for pain identification is located in the Amygdala. The Amygdala can decide to pass the signal on up to more complex areas for evaluation, or the Amygdala can take over if it determines the signal to be life threatening. If it feels life threatening all of the smooth muscles contract to force all the blood near the heart for rapid use where need. This creates a lot more tension throughout the body. At the same time in 40-60 milliseconds directions are sent to the heart to speed up, lungs to work faster using only the top parts that are closer to the heart, the stomach and other organs to shut off, the adrenal gland to secrete adrenaline, and many other systems
If a person has an exaggerated sense of endangerment due to life threatening experiences in their past, it is easier for the Amygdala to take over. So, when the body sends a signal that is similar to the signal sent during an earlier life threatening event it is more likely a fear response will be initiated.

SITTING WITH THE RIGHT AMOUNT OF PAIN

So, how can we talk to someone about all of these complications with pain? I have never explained all of these concepts to any one client. Even though several of my client knew more about some the pain related processes in their body/brain. Many of them have been much smarter than I am. Joining the client in where they are at with their knowledge of their pain and their hard fought strategy for dealing with, is the answer. In a sense I am a knowledgeable person they are bouncing their plans off of. My job with either depression or anxiety is to help the client relax in many layers of their organization of themselves. When their pain coping strategies sound and feel like the way they dealt with the deficits in their early life care-giver environment, I need to help them soften those ideas. These defensive strategies invariably make pain worse in the long run, so helping them see what ideas help them and what ideas hurt them illuminates relaxing with the pain and focusing on how they want their life to be.

The problem and solution with chronic pain is neural plasticity. Nerves. being able to add new connections to other nerves, leads to ever greater intensity, frequency and duration of suffering. Allowing the overgrown areas to atrophy is facilitated by growing new more dynamic connections in other areas.

Knowing the overall cascade effect, that is most obviously demonstrated by the either/or bifurcated functioning of the Amygdala, (flight or fight triggered on the left; empathy and frontal lobe connection on the right) helps patientss plan ways incremental progress in many areas of pain modulation, rather than looking for a quick fix.

Thursday, January 17, 2013

Relational Therapy for Recovery from Trauma

BILL MAIER, LCSW #5259

1675 SW Marlowe, Ste 315

Portland, OR 97225

360-670-5844

Let me help you trace the developmental roots of your anxiety. You will find the strength in your 'Shadow' and the purpose of the'Shame' you carry.

DISCLAIMER

I am using this forum in a casual manner to clarify the language I use for talking about psychotherapy. The people I have learned from have been rigorously thorough in quoting sources and justifying their opinions. I will seldom do that here. I will be paraphrasing many of the statements of the people listed in the resources. This is not presented as an argument, only an illumination of what I have found useful. I want it to be helpful for you.

INTRODUCTION

After twenty years of practice I became interested in the idea of working with my client’s feelings of shame as early as possible in psychotherapy. After nine years of using this approach with clients from eight-75 years old, I feel a need to share my approach to dealing with attachment and trauma challenges. As D. W. Winnicott said better than I will here, if I have anything important to explain with this work, it has been portrayed by artists for thousands of years far better than I will. I specialized in the treatment of post-traumatic stress disorder for over 26 years. In the past ten years I have also successfully worked with school aged children and teenagers. Therapeutic intervention focusing on shame helps clients unravel patterns causing them distress their whole lives. Creating new options evolving out of their innermost value system provides maximum flexibility.

CREATING A HOLDING ENVIRONMENT

The ambiance of safety to explore previously buried feelings is primary to PTSD therapy. The fact is PTSD definitely gets better with a knowledgeable treatment provider and enough involvement. Utilizing tools like; Eye Movement Desensitization and Reprocessing, Cognitive Behavioral Therapy, Energy Psychologies, Reality Therapy and many other approaches can be helpful, however it is the client’s felt sense of being attuned to that is required in the long run. Symptom reduction is wonderful and is necessary as part of any effect PTSD therapy, however the client needs to be able to call up a deep felt inner sense of facing their turmoil and calming down. This allows the client to make meaning from their experience. Meaning of themselves and their experience is what they transport into the world outside of therapy.

“Transportability of a felt sense of a co-developed feeling of mastery matches our wiring inclusively.” What does that sentence mean? “Transportability” is the function of carrying inside ourselves the image of being able to soothe ourselves while being with a caring other. It means to transport a sense of being seen into the blind, uncaring world. As our early wiring forms up inutero, and throughout life, it organizes itself by feelings of connection to others and who we think we are. "Transportability" is imagining someone is holding you in mind when you are apart from them. “Matches our wiring inclusively”, means to reform memories to include feeling understood. Many matrices of our brain/body coordinate their development around their impact on the people around them. “A felt sense of a co-developed feeling of mastery” is surviving as a client and a knowledgeable therapist to an agreed upon level of ability in the client to utilize the feelings associated with the memories of the trauma. As a graduating client is walking out of my door we both need to have the internal image of having influenced one-another about his or her feelings of the trauma.

Client’s Presenting Problem

From the first phone call explore the possible strengths that have developed from the problem the person is telling you about. With PTSD, ask the prospective client to imagine their current life without the trauma having happened. What strengths do they have now that would be gone? The therapy process will help assure they keep those assets gained by surviving the trauma.

PTSD The Approach/Avoidance Disorder

As I look at each symptom of PTSD in this section I will repeatedly connect that symptom back to the varying attachment dynamics that can be precursors to the approach/avoidance strategy.

B-1) Recurring distressing recollections of the traumatic event or events.

This symptom is more inclusively stated by saying; having an over-powering need to talk to someone about an intrusive, distressing memory. This need to tell gets stronger over time. The sufferer believes the memories will get less intense over time. This phenomenon has some of the components similar to a frog not noticing the difference in temperature increasing in a pan of water until they boil to death. If you drop frogs into boiling water they jump out so fast their skin hardly gets scalded. As the person fights off the memories it is hard to notice they are getting more emotionally intense. It seems natural and intuitive to expect them to lessen. This “hallmark” symptom of re-experiencing thoughts and feelings of the traumatic event may also seem to stand alone to the sufferer. When he or she finds out this symptom has lead to the rest of the symptoms it is a great relief for most people.

Consider a 19 year old medic in Vietnam in 1967. His training is condensed into eight months. In his first three months in combat he has the need to perform two tracheotomies, both of whom die. On the second one he remembers some subtlety of his training he wasn't doing. Even if he saves 100 soldiers through performing great tracheotomies the next nine months, the part of him that feels less than others fixates on the two deaths.

There are an accumulation of factors bringing a client into my office for distress from symptoms of PTSD. These factors need to be observed from the perspective of representing strengths in the individual’s ability to hold their identity together. An example would be a combat veteran who was physically abused as a very young child by their parent. He may develop a Disorganized Attachment, because the person he needs to be soothed by is the one who is causing the distress. Soothing means a felt sense of attunement. Another example is the rape survivor who was ignored as a child, especially when in distress. She may develop an Avoidant Attachment imagining she will never be attuned to. Both examples create internal tension with no avenue for action. For the Avoidant person they can predict their environment won’t attune to their distress. The Disorganized person keeps finding attunement in people who feel abusive to him. We are neurologically organized to seek out attachment. It requires massive energy to block the need to feel soothed.

This is the "hallmark" symptom of PTSD. The other re-experiencing symptoms can almost always be related to distressing memories and thoughts of the trauma, or distressing memories and thoughts of the other re-experiencing symptoms developed after the traumatic experience. We know a lot about healthy the expression of distress over critical life events of loss. We call it the grieving process. Varying levels of intensity, frequency and duration of out-pourings of distress will take place depending on the degree of attachment, the suddenness of the loss and the temperament of the griever. It is healthy for these out-pourings to continue with decreased frequency, intensity and duration for at least a year. The anniversary of the loss is a particularly likely time for the feelings to re-surface. Two years is not considered overlong to feel swept up in the feelings of a critical life event.

In the original description of PTSD the stressful event needed to be something as life threatening as a bullet hitting the wall behind your head. Integrating the experience of being centimeters away from sure death into your self-story, requires you to relinquish fantasies of immortality and omnipotence. Freud and I agree we all harbor these fantasies. In a sense, those healthy parents responding to the "Look at me" are perpetuating the child's fantasy of their felt sense of importance in the world. This healthy nugget, around which the developing psyche organizes itself, is highly challenged by the stark reality of the dangers of the world. It takes the time and the processing of the internal tension of the felt sense of increased endangerment to develop a realistic sense of self. PTSD can only be diagnosed when the felt sense of endangerment remains exaggerated for a long enough time and leads to distress for the client. Reconciling the infantile sense of being omnipotent with the mature realization of the dangers of the world is part of growing up. Retreating to an earlier strategy for coping with distressing feelings is the opposite of maturation. The earlier the strategy developed the less likely we are to know we are using it. It feels intuitive to isolate and push away the distressing memories. The fact that we blow up easily or can’t sleep does not necessarily feel related. Short-term it works better to deny the memories access to our consciousness. Long-term we want to be able to access the memories and feelings when we want to and not be over-powered by them. Learning when we are capable of allowing the feelings to go through us is maturity.

Panic Attacks

Most of the clients I have seen have had at least one Anxiety Attack in their lives. They find tremendous relief in the first session finding out what is physically happening to them. (see section on A Handy way to see the Brain). My job is to be sure the client knows they are experiencing an activation of the Flight, Fight, Freeze and Flop (FFFF) response. Prior the 1995 revision of the Diagnostic and Statistical Manual (DSM-IV) two types of acute anxiety reactions were differentiated. I still find the difference useful because of the likely difference in the recovery process. A Panic Attack generally comes on quickly, lasted from 1-20 minutes and ends abruptly. People report the end being so sudden it takes their breath away. An Anxiety Attack comes on gradually, lasts up to two hours and slowly loses its force. People reporting Panic Attacks almost always say they felt like they were going to die. Both types of episodes have residual effects.

The worst part of Anxiety Attacks is their chronicity. The client becomes worn-out from the effects of the last one and fear of the next one. The worst part of a Panic Attack is its intensity. The client will be exhausted afterwards and may remain afraid of the next one for years or decades. The sudden onset of a Panic Attack often gives us an advantage of having a recognizable set of circumstances we can help the client illuminate. Recognition at an ever earlier moment is the primary part of recovery. When the client can notice precursors and relax before the Frontal Lobe turns itself off, they have a much greater likelihood of the FFFF response not being initiated.

With all forms of Anxiety Disorders the thinking leading up to and during the episode will include a declarative internal statement of: “I can’t__, but I must_”, or “ I have to, but I don’t want to_____”. The most frequently reported place people experience this trap in their thinking is in the grocery store. The etymology of the word Agoraphobia (one of the types of Anxiety Disorders in the Diagnostic Manual) is fear of the market place. I always imagine a herder coming over the rise to see the longed-for market place. He has been alone with his animals and thoughts. On many levels he wants to go into the market place. His business and resupply need to be done there. He wants involvement with people. On the other hand he is afraid of being taken advantage of, or be ridiculed or criticized. The worst fear comes if he has experienced some type of anxiety reaction in the past. His biggest fear is he will have an attack. The modern day person has to go get their groceries to survive. It is a perfect setup for an Anxiety or Panic Attack. “I have to go to the store, but I can’t do it if I have a Panic Attack”. If they don’t go they increase their desperateness and add more tension to the next attempt. If they do go and have an attack they get nothing accomplished they increase their desperateness and add more tension to the next attempt. The word, “but” is used here as a contradiction. The only way out of this dilemma is to consciously choose one side of the equation or the other.

If the herder chooses to not go into the market he will slowly starve to death, besides becoming less capable of being around people. If he prepares by relaxing himself thoroughly and survives the encounters with others he can repeat this ritual the next time. Most exaggerated fear of endangerment is built by avoiding the repetition of historical situations and feelings leading up to an episode of exaggerated fear of endangerment. This self-fulfilling cycle only gets interrupted when the sufferer becomes aware of the cycle and relaxes.

Anti-anxiety medications have cause as much trouble as they have provided relief for anxiety. They are a class of medicines called Benzodiazepines. Benzodiazepine is the depressant chemical release when alcohol is broken down in the body. It is particularly active as a Frontal Lobe depressant. The Frontal Lobe will have diffuse activity and less over-all activity. In order to modulate impulses from the brain stem, like anxiety, concentrated Frontal Lobe activity is required. The benefit of these medicines comes because it is harder to be aware of brain stem impulses if you are compromised in your Frontal Lobe.

Valium was the first developed benzodiazepine. It had a half-life of longer than a day. A person took it to go to the grocery store and had a depressed Frontal Lobe for the rest of the day. Xanax, one of the later developed benzodiazepines, has a much shorter half-life that then caused more of other problems. The ability to observe an exaggerated sense of endangerment returned fairly abruptly. People tended to need to take the fast dissipating benzodiazepines more frequently, or face the same feelings they avoided a few hours ago. This cycle can lead to a type of dependency. Any prolonged use of a benzodiazepine challenges the Frontal Lobe’s inhibitory function with anxiety. In the short-term, seven to ten days, benzodiazepines allow a person to not notice the anxiety welling up from their brain stem.

Recovery is definite if you are treated by a knowledgeable practitioner. At the bare minimum the client will learn the phrase, “This too shall pass”. Hippocrates, the father of medicine, wrote about Anxiety Attacks. In all our documented history since, no one has died yet of a Panic Attack. People do build-up fatal musculature around their hearts because of the rapid heartbeat of FFFF. Either type of attack is a built-in survival mode to deal with a life-threatening situation. This built-in reaction won't kill you. It is very unfamiliar and if you are afraid of it, it gets magnified.

In a psychoanalytic sense anxiety is caused by a lack of an attuned response to a felt sense of endangerment. By feeling attuned to by a therapist who seems to understand their anxious feelings, the client is no longer alone with the unbearable affect. The “I can’t, but I must” situation can be looked at objectively. Recovery is about making a choice of which side of this contradiction to act on. The beauty of the recovery process is related to the repetitive nature of the problem. If the client can develop a realistic response to thinking they are trapped, they can use the same response in many other situations.

Anger

Working with a person with impulse control problems is made most difficult by the person’s belief that controlling themselves is their answer. “The answer” is actually discovering the underlying feeling of fear and manifesting a new response from there. They are afraid they won’t get something they want, or afraid they will get something they don’t want. This work can be done in as few as 10 sessions with most people. The underlying pattern of their familial practice of unhealthy angry behavior can require in-depth long-term psychodynamic work. In both short-term and long-term work the beginning process is the same. The primary task for the client is to prove to himself and me he can walk away from situations where he would have acted angrily in the past. I call this, “Vote with your feet” and point to my foot. In a few weeks this process may be replaced by taking two deep breathes, if the client has truly grasped the idea of needing to reengage their frontal lobe when the impulse centers of their brain have developed an ability to override their judgment.

The first step is, physical action, walk away, the next step is the physical and mental actions of staying present and breathing. The final step is mental and the more complex emotional response. Let’s start with an example. A common example is the father who comes into therapy because he acts angrily toward his children. It is an example that has many similarities to the fellow who is overly aggressive with people, the teen who has outbursts of anger and the woman who can’t understand why she gets so upset about things. The father will usually tell me that he needs to step in when it is important to control his children. It is important to have nonjudgmentally gathered the facts about how he acts that he doesn’t like before him telling you why it is important he acts that way. Most therapists have experienced the defensive structure of the person with anger problems. “I’m not angry”, is said in a harsh defensive tone. Quite often this person will appear tense and ready to find fault with the counselor. The client needs to know this work is well known, has a degree of predictability and can’t be done overnight.

By the third session there is usually an opportunity to compare the client’s defensive statement of their need to act angrily with their first session’s statement about their problem with the way they act. I look back in my notes and read their statement to them with the pretext of getting their opinion about their behavior accurate, rather than proving them to be in denial. Once dialogue is established we can begin to explore the underlying feelings. I help them explore their feelings by explaining how quickly a low brain reaction, like anger, can dominate all other feelings, 40-60 milliseconds. I encourage the client to guess at what their feelings are. Then the next time they are angry they might be better able to see if that feeling was there or not. We want to find an underlying emotion we can use to motivate a healthy response.

The client’s ability to use mentalization is the best predictor of success as we go on to sophisticate their internal state before, during and after a moment of anger. They will be using their brain/body the way it was designed, if they can imagine how the person is feeling they are with when their anger develops. Those milliseconds can become rich and powerful in redefining who the person sees themselves to be. Of course, mentalization is where the long-term psychodynamic work is often necessary. If the client has severe deficits in their ability to perceive cues and formulate mental pictures of the people they are around the responses they can develop will be limited. Their internalized shame structure will be too pervasive to do the sophisticated process of picking up and interpreting cues. Helping these people is explained in the sections on Shame and on Forgiveness and Letting Go.

Pain and psychotherapy

All felt pain has physical and psychological components. Sensory and emotional signals are sent up and down the body/brain systems. Suffering and agony are fear related to pain. They are intrinsic to pain. Fear, in a deep body/brain sense, is a requirement. It manifests as muscle guarding which tenses the muscle areas surrounding the pain. This increased tension can cause more mechanical pain, leading to more muscle guarding, and more pain. Most people who explain the brain/body leave out the part I find the most central for understanding the processes. I will clarify the basic working components of the nervous system. I have found my clients need this information in order to understand anxiety, depression, pain, medicines, anger, and impulsive behavior. Knowing the overall cascade effect, most obviously demonstrated by the either/or bifurcated functioning of the Amygdala, (flight or fight triggered on the left; empathy and frontal lobe connection triggered on the right) helps clients to plan ways to make incremental progress in many areas, rather than looking for a quick fix.

Nerves have three different types of dendrite receptors: mechanical, thermal and chemical. The brain interprets pain signals. Psychological processes have physical effects. Physical processes have psychological effects. There is no separation between psychological and biological. The cell wall of a neuron is built with protein, large molecules, their shape and their contents determine the character and function of each protein. The outfacing side of the long cell wall protein can be thought of as a key hole. Neurotransmitters are the keys that fit in these locks. Overly simplified, when a neurotransmitter lodges in these proteins they bond changing the electrical potential of the whole cell a tiny bit. The nerve cell generally sets at -70 millivolts, when it reaches -40 millivolts it triggers the cell wall proteins to flip over, bring the cell to +30 millivolts. Neurotransmitters are discharged out of the axon end of the nerve, into the synapse between that axon and the dendrite of the next cell. They diffuse into the area where the dendrite end of the next nerve has many receptor sites for them. The more this relationship operates the more receptors site are built. Those two nerves are now wired together. The protein’s flipping is caused by the electrical process, (actual Sodium-Na and Potassium-K, negatively charged (-) chemicals are pushed out while Chloride-Cl, positively charged (+) is drawn in. It is the transfer of electrons that we call electricity.

The more a pathway in the nervous system is used the more it becomes resupplied with the necessary chemicals for it to operate. Blood veins, arteries and the muscles that surround them are strengthen and developed. It gets easier and easier to use that pathway. This is part of the way chronic pain gets habituated in the body/brain.

Another way pain signals get increased for survival alerts is in its recognition at the spinal column. As a pain sensation is felt it sends a signal of the pain to the spinal column. As the signal arrives, the spinal column quickly makes available more receptor sites for noticing pain. The surrounding neural dendrites are quickly tuned to receive the same pain signal. Therefore, the signal is amplified, literally increasing magnitude of the pain signal. The brain can also send signals back down the spinal column to interfere with the use of some of the receptor sites or add more. After the spinal column has processed it, the pain signal heads up to the brain. There the signal goes through an amazing and complex matrix of receiving areas.

When we experience pain the following brain areas provide important functions:

SENSORY CORTEX

This is a strip of brain tissue on both sides of the brain about the width of your index finger. It processes our body sensations. How pain is felt depends on how cells in these strips are organized. Every part of our body has an area represented on the brain’s sensory strip. It is a mini version of our body mapped onto our brain. The size of the space dedicated for different body parts is related to that area’s degree of sensitivity. Therefore the mouth, face, fingers, genitals and feet are related to much bigger areas than their physical size would suggest. This increased sensitivity allows us to feel two toothpicks pressed on our fingertip a quarter of an inch apart and it will feel like one toothpick on our backs. These areas can all get bigger or smaller depending on use. If you have chronic pain in your right elbow the space related to it in the sensory strip enlarges and becomes more sensitive. (In recovery from suffering from pain the reverse of this process will be utilized. The client learns many systems to focus on the non-painful areas of their life.)

LIMBIC SYSTEM

One of the first and most powerful matrixes for pain identification is located in the Amygdala. The Amygdala can decide to pass the signal on up to more complex areas for evaluation, or the Amygdala can take over if it determines the signal to be life-threatening. If it feels life-threatening all of the smooth muscles contract to force all the blood near the heart for rapid use where needed. This creates a lot more tension throughout the body. At the same time in 40-60 milliseconds directions are sent to the heart to speed up, lungs to work faster using only the top parts that are closer to the heart, the stomach and other organs to shut off, the adrenal gland to secrete adrenaline, and many other systems to be activated or shut down.

If a person has an exaggerated sense of endangerment due to life threatening experiences in their past, it is easier for the Amygdala to take over. So, when the body sends a signal similar to the signal sent during an earlier life-threatening event it is more likely a fear response will be initiated.

SITTING WITH THE RIGHT AMOUNT OF PAIN

How can we talk to someone about all of these complications with pain? I have never explained all of these concepts to any one client. Even though several of my client knew much more than I about some of the pain related processes in their body/brain. Many of them have seemed much smarter than I am. Joining the client where they are at with their knowledge of their pain and their hard fought strategy for dealing with it, is the answer. In a sense I am a knowledgeable person they are bouncing their plans off. My job with either depression or anxiety is to help the client relax in many layers of their organization of themselves. When their pain coping strategies sound and feel like the way they dealt with the deficits in their early life care-giver environment, I need to help them soften those ideas. These defensive strategies invariably make pain worse in the long run, so helping them see what ideas help them and what ideas hurt them illuminates relaxing with the pain and focusing on how they want their life to be.

The problem and solution with chronic pain is neural plasticity. Nerves being able to add new connections to other nerves, leads to ever greater intensity, frequency and duration of suffering. Allowing the overgrown areas to atrophy is facilitated by growing new more dynamic connections in other areas.

Cutting---

The client’s inner world doesn’t bridge to the outer world. They focus their understanding of actions in terms of physical, as opposed to mental, outcomes. Only action that has physical impact is felt as able to alter mental states in both self and others. Physical acts, like self-harm, seem the only way to change moods.

As a therapist I want to verify my client’s perception of me through self-disclosure to increase mentalization. Mentalization refers to the capacity to envision mental states in the self and others.

Bodily awareness and health are the foundations of humans being able to imagine what others are thinking and feeling, and imagining others knowing what they are thinking and feeling. People with secure attachments carry around this knowledge of being seen and felt by others. Deficits in attachment can lead to a reduced ability to feel seen or felt by the world around one. As a person with disturbed attachment moves through development they learn to focus on understanding actions in terms of their physical, rather than mental outcomes. Only action that has physical outcomes is felt to be able to alter the mental state in both self and others. Physical acts, like self-harm, reinforce this strategy. When feeling acutely invisible the person looks forward to a known sensation. The buildup, the ritual and the act change the way the person feels.

By violating the physical boundary of her body with a needle or a knife, she dramatizes the very existence of that boundary. This reestablishes a sense of her embodied self-hood. In addition the stinging sensation and the droplets of blood produced by the delicate cutting provide her with concrete sensory evidence of continuing aliveness. In her more vulnerable states the ever increasing draw toward the repetitive action to repudiate the lack of attunement she expects and receives becomes greater. Similarly for a male when he proves to himself he is alive by pulling his hair, picking at himself or reckless behavior he feels somewhat soothed in the moment of high distress.

These are horrible secrets that they want everyone, and no one, to know. One of the challenges in therapy is that the structures that foreshadow self-harm rituals are established quite young. In healthy development the defense against not being seen or felt is matured through many avenues of early play. Therapy needs to provide enough of a holding environment to allow the client to experiment with infantile acting out to get their feelings across. It is difficult to develop a light, playful attitude in the dyad toward these life-threatening feelings. As they don’t feel punished for existing, they may create a communicative behavior that they consider, “good enough”. This often takes years of weekly psychotherapy.

Mentalization refers to the capacity to envision mental states in the self and others.

Capture the moment of healthy grandiosity. She says, “You are going to take cutting away from me.” I ask,” What will happen to you if you quit cutting? What would that look like?”

Depression—

Why can’t a depressed person use the Power of Positive Thinking? Many people who have come to me for treatment have tried various self-help techniques first. These techniques are great for the vast majority of people, however for people who meet the depressive or anxious diagnoses they are a set up. Depressed and anxious people often get better for a little while. Then they fall back into their habitual pattern of thinking, proving they are hopeless. It actually hurts worse after feeling a little better. This repetitive thinking is deeply entrenched and difficult to be aware of.

Therapy needs to start with developing an ability to recognize unrealistic repetitive thoughts and then move toward thinking realistically about their lives and circumstances. Once these skills are successfully in use, the Power of Positive Thinking can be of great additional benefit.

Depression---Anger turned inward—cingulate gyrus

In between the left and right and just below hemispheres of the human brain is a group of nerves about as long and thick as a hotdog. Its primary purpose is to switch our focus from one thing to another. When we are focusing on a client we are accessing many areas of our memories of them, our disciplines as therapists, their histories and the current session’s interactions. If they ask us about the plant we have in the office our Cingulate Gyrus will quickly activate to gather relevant data of the history of our plant. The Cingulate’s job is meant to be short-lived, like a switch. I point to the light switch. It turns the attention to the plant, then stops functioning until we want to switch back to our clinical awareness. The Cingulate Gyrus is located above the Limbic Cortex and Corpus Callosum. It is high enough up in the brain to utilize language, however when it operates the brain reduces the use of the frontal lobe. The logic circuitry isn’t nearly as important as the complex process of creating memory images.

This is all well and good, however what does it have to do with anger turned inward? The Cingulate has the capability of having a thought over and over again without the need to filter it through the logic circuitry. Thought distortions are what David Burns, MD, in his 1980 book Feeling Good, called the core of being depressed. There is some hopeless, helpless exaggerated thought that resonates with the feelings in the Limbic System. Without regulation from the Frontal Cortex the emotional low brain/body and repetitive thought re-enforce one-another. The more we think our situation is hopeless the more it feels hopeless. The more we feel hopeless the more we think the hopeless thought over again. This Cingulate Gyrus/Limbic Cortex feedback allows the impulse centers of the brain/body to operate without the modulation the Frontal Cortex is responsible for maintaining.

How do we get the logic circuitry back involved again? This is where Dr. Burns clarified for us Cognitive Behavioral Therapy. One, identify the distorted thoughts. Two, determine the type of exaggeration it is. Three, develop a realistic thought about the same thing without the exaggeration; and practice all three steps when able to notice depressive thoughts or feelings. This process of recognition of the distressing component requires the observation ability that only can come from the Frontal Lobe. 90% of the function of the cells in the Frontal Lobe is to inhibit impulse coming from the Limbic Cortex. By being logical and starting an action of thinking differently, automatically the emotions are being modulated. This may not be powerful enough to inhibit the process of the emotions controlling the thoughts, however it is likely to be a useful component of most people's recovery from Depression.

Relational Context.

Who does the client live with? What do they have for social support systems? What type of relationships with people at work/school? What is their proximity to extended family?

In utero during the last trimester the baby and at least the mother have started to resonate in their Amygdals. We now know this from using functional Magnetic Resonance Imaging, fMRI. The right orbital frontal has started to coordinate new patterns of connection in brain areas. These are some of the early relational contexts for the innermost design of the developing being. Regulating mutually, resonance, requires a level of complexity. As an example, think of a moment when the mother feels a sense of abandonment. If the feeling of abandonment persists and develops into a pattern for the mother the fetus may develop a compensatory pattern to be prepared for the lack of resonance with the mother. The lack of resonance may manifest as its own way of dealing with the fact the world isn't safe. In moments of resonance and harmony for mom and fetus the natural course of development proceeds. This resonance, and the periods of time in utero it is lacking, are likely to be re-played after the baby is born. Now the mother/infant primary involvement takes on the added complexity of integrating perceptions, sense of self and sense of the other. Fantasies of: “I am all of this”, and “She controls all of this”; develop their life long tension. By toddlerhood it is, “ I want to do my thing and I don’t have to have a parent’s attention” battling with,"I can’t get along without the parent”. If the toddler chooses to play with her toys as mom walks out of the room, she at least temporarily, organizes around the fact she is able to continue to exist with the parent’s immediate impact being removed.

The core of the developing self is a tension between the above-mentioned journeys toward independence and dependence. When and if other siblings and the father get involved, we add to the complexity and therefore the tension. In harmony and natural development the ever present knowledge that the world isn’t safe is survivable. The organizing principles of the child have less need to hide from the terror of the world not being safe. The child can better trust in her ability to manifest what she wants or feel what she feels. The holding environment is enriched and more dynamically carried inside the child. Ultimately this is put to the test when the child feels unbearable affect and doesn't feel attuned to. This highly disorganized state needs to be exhausted, so a new more flexible confidence will be more likely in the next disorganized state.

When the mother is experiencing a feeling of abandonment after the baby is born the mother may be too needy of her child, or sulkingly indifferent. The child has two poor choices: one, learn to auto regulate while ignoring the natural tendency to resonate with their mother; or two, suffer from the known pattern their mother is going through. This is an early time of auto-regulation that can develop as a deficit in the ability to mutually regulate.

All of our relationships are based around our authentic sense of ourselves and our world, including the knowledge the world is a scary place; and our need for external validation. We need to feel a sense of being attuned to. What this means is when we manifest a unique new pattern we seek out and move closer to someone being influenced by us. Maybe they give us a smile, maybe they appear to relax, or maybe they get excited. Generically we require them to notice and respond to our individuality.

As a therapist I am helping the client explore their relational context in the present along with the knowledge of the background information of how they construct their individuality and seek for approval from important figures inside and outside of them.

History—Earliest remembered feeling of shame

Eight years old is the most common.

Shame and the Ego Ideal---Morrison, 1995

P38” I believe the ego ideal—and particularly the ideal self—provides a framework for understanding shame from an internal perspective. The values, idealizations, and internalized parental expectations of perfection, which form the content of the ego ideal, have been structuralized and no longer require the presence of the external object as guide. The shape of the ideal self is determined by this internal perspective. It is failure to live up to this ideal self—experienced as a sense of inferiority, defeat, flaw, or weakness—that results in the feeling of shame.

…………..It is the affective response to that failure, the searing shame, that is experienced clinically (even when that failure is defensive), and that therefore should be the first focus of therapeutic intervention”

Imagine a healthy infant who has learned to do the dance of interacting with her mother. Imagine that child preoccupied with entertaining herself. Now the mother comes to initiate the familiar pleasurable activity. The baby must choose. One, give up on its attention to itself and connects with mother. Or two, stay attuned to her own activity and disappoint her mother. Either choice can set up a replicating pattern. Mother and baby begin to expect baby will either drop what she is doing or will ignore mother.

Let’s structuralize the baby’s choices: Choice One—where the baby gives up on its attention to itself. As development progresses this practiced choice and it consequences get easier, more familiar. As the young child begins to interact with other children, she is highly attractive to the friend who wants her to pay attention to him. She is good at setting herself aside. He may be a child who made Choice Two and finds it is easy to not pay attention to his playmate’s needs in deference to his own needs. We all made this kind of choice before our hippocampus was mylonated. Therefore, drawing it into awareness is unlikely. Becoming aware of its later developing manifestations is “the first focus of the therapeutic intervention”.

Medicines and Psychotherapy

Make sure you are aware of the “Black Box” warning for newer antidepressant medication. There is an increased risk for suicide, especially in teenagers, as lethargic symptoms are reduced. It is as if the lethargic person is so exhausted by their repetitive thinking they don’t have the energy for killing themselves. The Selective Serotonin Reuptake Inhibitors, SSRI’s and their cousins the Selective Non-Serotonin Reuptake Inhibitors, SNSRI’s make it more difficult for the brain to keep thinking the same thought over and over again. This inhibition allows the brain to operate the way it was designed, not stuck in a perpetual loop. This facilitates more goal oriented actions. The trouble comes if the goal is to stop going-on-being. (see Suicide section)

It is wonderful to have established a working relationship with a person who can’t make a dent in their repetitive thinking and work with a prescriber to get on the right amount of antidepressant medication. I always explain that efficacy of these medicines alone is about 10%, psychotherapy alone is about 10% and combining both gives you a 30% chance of making a change in the way your depression affects you. For the people who find these medicines helpful about 5% take them for three to six months and it is like a light went on in their heads and they never are depressed again. On the other end of the spectrum are 5% of people who find good effect from antidepressants seem to need to stay on them for life. This 5% can be catching and changing their repetitive thoughts with the best of us with Prozac on board and shortly after weaning off are trapped in their depressive thinking again. Most clients take from one to five years. The times when it is most important to have a knowledgeable therapist is coming on and off the medicine. As the client is getting better be sure to help them notice any changes in their thinking. Often they will say, “I started to think the old thoughts and they simply disappeared”. Also common is they don’t notice any difference. Then ask, “If you asked your partner (other family members or friend) would they say you are different?” Ideally you, as the therapist know some of their recurrent thoughts. Ask them about specific thoughts. In the next several months keep track of the ebbs and flows of the Thought Distortions and develop strategies for identifying the type of distortions each is and create realistic substitute thinking. As the person weans off of the medicines make expectable the return of repetitive thinking. I say, “You have about three weeks where these old thoughts are fairly noticeable, and then they began to fade into the background of your awareness”. The client needs to get better and better at noticing and replacing these thoughts. The depressive patterns can be as deeply engrained as the Grand Canyon. A couple of months or years of new thinking doesn’t develop enough of a habit to keep from falling into the old habits. The client must learn to fall into cyclic thoughts, see where they are, and establish new thinking for the rest of their lives.

A ‘handy’ way to get an image of brain structure

The peanut just to the right of center in the frontal lobe lights up when looking for and giving facial cues. Two peanuts further to the right lights up when differentiating tone of voice, (prosody). In between is the second section, the Right Orbital Frontal, (ROF) cortex. The ROF is helping to coordinate brain development in the last trimester in utero. The right side of the Amygdala is dominant in coordinating brain development during this time. Once language is developed to a point of 2,000-3,000 words the ROF becomes more and more dominant in the coordination of brain development. The Amygdala continues to coordinate new brain connections, however not as dynamically as the ROF. An impulse comes up through the brain stem, sensory receptor sites, vagus nerve (contolling the heart and facial muscles), or gut feeling to the Amygdala. It is routed through the Hippocampus. The Hippocampus is a striated, caterpillar looking thing about the size your thumb from the second knuckle up to the tip. With your fist closed over your thumb you get a very nice approximation of the locations of these nerve structures. The brain stem is represented by your wrist and lower part of the palm. The Amygdala is the second knuckle on your thumb, with the Hippocampus the rest of the thumb. The fingers curl around the thumb the same way the frontal lobe reaches almost to the anterior of the brain. This proximity allows numerous, short connections with these areas. The Hippocampus stores our body based memories. When the message from the Amygdala reminds the Hippocampus of something life-threatening, a rapid response is sent back to the Amygdala to tell the Frontal Lobe to turn itself off. The Basil Ganglia are activated to move our bodies around (Flight, Fight, Flop or Freeze). With the Frontal Lobe disengaged these processes quickly build momentum. The adrenal gland then secretes adrenaline. This whole activity can be completed in 40-60 milliseconds. This is how an Anxiety Attack begins.

The overall function of 90% of the tissue in the Frontal cortex is to inhibit impulses coming from the brain stem. These inhibitory processes allow us to be familial social beings. Being the most executive of these processes, the ROF operates in two modes. One, the story of self in relation and resonance to the surround. Two, what are other people thinking and feeling about me. Both processes are essential.

Dissociation

Dissociation is experienced by the client as a lack of a feeling of going-on-being. It is a massive, energetic attempt to auto-regulate. In all cases it starts early in life. Dissociation is always an attachment dynamic developed in the maternal interaction. When a discontinuity of going-on-being in the client happens in the session it makes little difference what you do or say. Your client does not need to see an action or hear words, they need to sense a being, to know someone else exists as they go-on-being. They need a glimmer of attunement and confidence in their ability to co-survive the terrible affect they have blocked since childhood. That mutual gaze recognition, where both people see the other is present, constructs an environment for them going-on-being. The result is the generation of more complex psychoneurobiological models of change of brain/mind/body, not only in the earliest but in all subsequent stages of the development. This internal state for the client permits them to hold their previously patterned action in abeyance allowing an inner confidence to generate behavior. This abeyance of action manifests a vacuum. In the moment of vacuum the self can be rhythmic, harmonic, and spontaneous in action. This is a moment of useful self-interest, surety. Behavior congruent with the deep values is performed with less restriction, therefore less energy is used. Through each stage of development, and the phases between, change forms around the earlier stages. Our job is to help the client change the form of their current development based on their innermost value systems.

DEVELOPMENT

Development will happen naturally with my connection to my being. Age is not a barrier to development. I need to give myself what I thought the world would give me. It begins at the moment we are all at now.

As I am consistent and responsible, I will manifest my journey. "It means holding ambiguity and holding complexity, so that our traumatized patients can have the chance to unfreeze." Donna Orange, The Suffering Stranger 2011, Routledge.

I can find ways to ignore the connection to my being. If this pattern of ignoring my inner self seems to make it easier for me to dealing with the things happening around me I am more likely to use it the next time. Unhealthy habits of my caregivers keep happening through out my development, so it keeps getting easier and easier to put out the energy necessary to ignore my connection to my innermost self. Development then takes on the semblance of the dysfunction of my caregiver environment.

As an adult redoing development the process seems similar to the layers of an onion. The depth of awareness I have of defensive strategies will be determined by what I can be aware of and still survive. My psyche won't allow me to recognize the next deeper level until I can survive looking at it. The path of least resistance is to go on not looking. I think it is healthy to spend more time not looking than looking. We need time to learn to soothe at each level.

At each level of recovery I enhance the repair I have done with the later developing defensive structures I have already worked on. The template of repair is often similar and reusable, so easier to repeat, however each earlier level is more difficult to unravel. I can only hold onto as much complexity as I can.

An example is when I stopped having tears at 15. I was able to catch any feeling before an emotion could generate. I used two different equally successful strategies: one; I didn't want their pity or condemnation, and two; there was something wrong with me for feeling this way. At age 35 I learned to cry again. At 50 I cried long and hard for several days in a very supportive secure environment. Now at 65 crying is a natural part of my life. There are several warm/fuzzy situations I usually cry in and many emotional ones. My tears pre-50 were mostly about early adult traumas. Since 50 the tears in recovery have been about redoing my early development.

Learning to see that my father and mother could see me as lovable is the ongoing evolution of my development. When my father was 85 I could often see the gleam in his eye about his son, me. I know, intellectually, it was there in my youth also. I still am able to block it from my awareness. It is dangerous territory because I felt unsafe emotionally. He was gone a lot working and my mother unavailable. She was overwhelmed with the responsibilities of running a family and often sat at the kitchen table staring for hours. My colic was bad and two years later my brother was born and she was less able to cope.

Hopefully this helps you see the need for awareness of increased complexity at each earlier organization of development. Development after adult traumas is massively complex and influence greatly by earlier chooses related to deficits in the caregiver environment.

Development will happen naturally with my connection to my being. Age is not a barrier to development. I need to give myself what I thought the world would give me. It begins at the moment we are all at now.

As I am consistent and responsible, I will manifest my journey.

Story of Self (versus) What are they thinking and feeling about me?

How the client creates a felt sense of attunement during moments of useful self-interest, surety.

As a child matures they come to the unattractive fact that no one person’s potency is unlimited. The infantile state is one of primary omnipotence or grandiosity. The fantasy that one is in control of the world is normal. This naturally shifts, as the child matures, to a phase of secondary or derived omnipotence in which one or more primary caregivers are believed to be all powerful. Eventually the child tolerates a tension inside themselves of the need for dependence and the need for individuation, neither of which work perfectly.

All of us idealize. We carry remnants of the need to impute special values and power to people on whom we depend emotionally. In some people the need to idealize seems relatively unmodified from infancy. Their behavior shows evidence of the survival of archaic and rather desperate efforts to counteract internal terror by the conviction that someone to whom they can attach is omnipotent, omniscient, and omnibenevolent, and that through psychological merger with this wonderful Other, they are safe. They also hope to be free of shame.

A structural way of construing the psychology of people with distress caused by their tendencies toward Narcissism is in terms of their dependence on the defense of primitive idealization. Primitive devaluation is only the inevitable downside of the need to idealize. Since nothing in human life is perfect, archaic modes of idealization are doomed to disappointment. The more an object is idealized, the more radical the devaluation to which it will eventually be subject. Therapists working in the Borderline spectrum can ruefully attest to the damages that ensue when the client who has thought that his or her therapist could walk on water decides instead that he or she cannot walk and chew gum at the same time.

Therapy needs to move from a consciousness of all-good or all-bad, to a healthy integration of good and bad. We must come to the crossroads of idealizing and devaluing, and explore that moment in therapy. The client must endure, and go beyond, the threat of the therapy dissolving in order to change. Exploring the clinician’s own foibles is a great place to start. The suffering person experiences the worst of their fears and their co-explorer remains confident and imperfect. Can you help the person explore how your imperfections make you their persecutor, and them your victim? This concerned objectivity creates an investigatory dyadic agreement in the room to get to the bottom of these stressful moments.

The bottom of these moments is the position from which the client needs to know they can go-on-being. It carries some of the potency of the moment the infant is having a tantrum and the caregiver stays available to her. When a tantrum or episode of dysregulation coupled with recognition of an attuned support person, the infant will have more new neural growth than any other time during development. The tension inside the client of feeling she is all powerful, hoping you are all powerful and the disquieting fact that neither of us is, has to be experienced

“Affect Storms” in the therapy room and their study are signs of movement in this process. They need to occur naturally in an ambiance of consistent, supportive interaction. If the client feels attuned to, explore and enhance that. If there is an absence of attunement explore your reaction, the countertransference to the “Storm”. Psychologically healthy people never stop exploring deeper into their Narcissistic core. Suicidality is the ultimate of passivity and ends the exploration into the narcissistic. Remember, “cutting” is always done as an answer to these storms.

Acknowledge their awareness of improvement and enhanced functioning. Enliven any image the client has of you as being both bad and good.

The Care-taker (Protective Self) Self & Authentic Sense of Self (Glimmer)

Cognitive Therapy and Reality Therapy

Forgiveness—Guilt, letting go and acceptance

Forgiving others is necessary to feel forgiven

Being judgmental toward self and others can manifest a lot of stress. Forgiveness is a process of becoming less and less attached to your need to be right. Say someone maliciously harmed you. By being right about holding onto resentment and anger toward them you get to continue the suffering they caused you. Even if you are aware of the wounding every minute you can learn hold it as comfortably integrated into your past as possible. Their misdeed has now lost its power over you. Holding onto a resentment is literally swallowing poison because you want someone else to suffer. Squeezing tighter on a hot chunk of coal increases the wound. Letting it go you will still have a burn, however you won’t be making it worse. Treatment is about airing out, cleaning (integration) and soothing (mutual recognition of the strengths gained). Forgiveness is not forgetting, it is integrating. Anger feels like you are holding the hurt away by blaming it on the other. Guilt for you or blame for them allows the suffering to grow. The choice is quit doing guilt and blame. They must have been a sick individual. You did the best you could with the information you had at the time. Myself I let my mind go to the law. “Am I going to attempt to get the law to punish this person?” If not, my continuing to imagine hurting them is very likely to hurt me. Are they worth me getting hurt more. Not likely. At the least the imagining and resulting anger secretes chemicals into my system that make it difficult for me to function. Now I have more to be upset at them about. And on and on it goes. Pain is the result of a wound and is a given. The amount of suffering is optional. Without letting go of resentment (re=do again, sentment=thought) suffering gets greater the more energy you put into it.

If I imagine myself a hundred years from now how much poison do I want to be drinking to punish my perpetrator.

Addiction to substances an obvious example of external locus of control

Internal Locus of Control—Glasser—What do I want? How do I feel? (versus) External Locus of Control

Anger

Working with a person with impulse control problems is made most difficult by the person’s belief that controlling themselves is their answer. “The answer” is actually discovering the underlying feelings of fear and manifesting a new response from there. They are afraid they won’t get something they want, or afraid they will get something they don’t want. This work can be done in as few as 10 sessions with most people. The underlying pattern of their familial practice of unhealthy angry behavior can require in-depth long-term psychodynamic work. In both short-term and long-term work the beginning process is the same. The primary task for the client is to prove to himself and me he can walk away from situations where he would have acted angrily in the past. I call this, “Vote with your feet” and point to my foot. In a few weeks this process may be replaced by taking two deep breathes, if the client has truly grasped the idea of needing to reengage their frontal lobe when the impulse centers of their brain have developed an ability to override their judgment.

The first step is, physical action, walk away, the next step is the physical and mental actions of staying present and breathing. The final step is mental and the more complex emotional response. Let’s start with an example. A common example is the father who comes into therapy because he acts angrily toward his children. It is an example that has many similarities to the fellow who is overly aggressive with people, the teen who has outbursts of anger and the woman who can’t understand why she gets so upset about things. The father will usually tell me that he needs to step in when it is important to control his children. It is important to have nonjudgmentally gathered the facts about how he acts that he doesn’t like before him telling you why it is important he acts that way. Most therapists have experienced the defensive structure of the person with anger problems. “I’m not angry”, is said in a harsh defensive tone. Quite often this person will appear tense and ready to find fault with the counselor. The client needs to know this work is well known, has a degree of predictability and can’t done overnight.

By the third session there is usually an opportunity to compare the client’s defensive statement of their need to act angrily with their first session’s statement about their problem with the way they act. I look back in my notes and read their statement to them with the pretext of getting their opinion about their behavior accurate, rather than proving them to be in denial. Once dialogue is established we can begin to explore the underlying feelings. I help them explore their feelings by explaining how quickly a low brain reaction, like anger, can dominate all other feelings, 40-60 milliseconds. I encourage the client to guess at what their feelings are. Then the next time they are angry they might be better able to see if that feeling was there or not. We want to find an underlying emotion we can use to motivate a healthy response.

The client’s ability to use mentalization is the best predictor of success as we go on to sophisticate their internal state before, during and after a moment of anger. They will be using their brain/body the way it was designed, if they can imagine how the person is feeling they are with when their anger develops. Those milliseconds can become rich and powerful in redefining who the person sees themselves to be. Of course, mentalization is where the long-term psychodynamic work is often necessary. If the client has severe deficits in their ability to perceive cues and formulate mental pictures of the people they are around the responses they can develop will be limited. Their internalized shame structure will be too pervasive to do the sophisticated process of picking up and interpreting cues. Helping these people is explained in the sections on Shame and on Forgiveness and Letting Go.

Depression---Anger turned inward—cingulate gyrus

How do we get the logic circuitry back involved? This is where Dr. Burns clarified for us Cognitive Behavioral Therapy. One, identify the distorted thoughts. Two, determine the type of exaggeration it is. Three, develop a realistic thought about the same thing without the exaggeration; and practice all three steps when able to notice depressive thoughts or feelings. This process of recognition of the distressing component requires the observation ability that only can come from the Frontal Lobe. 90% of the function of the cells in the Frontal Lobe is to inhibit impulse coming from the Limbic Cortex. By being logical and starting an action of thinking differently, automatically the emotions are being modulated.

Dissociation is always an attachment dynamic developed in the maternal interaction.

Delayed Gratification—Self-soothing healthfully rather than reacting on impulse

Opposite Action—Develop a Self-Story communicable to the therapist

Entitlement confusion

Underlying feeling being flawed

DBT

Amygdala---Attachment/Separation—is about regulation in the brain.

Affect in the therapy session.

Can the client use something besides their internal loops to self soothe? Can they use intersubjective cues? Auto-regulate compared interactive regulation? For a lifetime the client has been doing the exhausting blocking of the terror of an inability to take in interactive comfort. Stern’s moment of meaning is at the unexpected. The disturbed client has an expectation of what the object (therapist) will do as they move toward dissociation. What is familiar for self-soothing, even if it isn’t very effective and requires a lot of energy (dissociation,) is what the client will use. During dissociation blood flow is inhibited to the higher centers of the body/brain and shunted to survival systems in the brain/body. These moments create Dorsal Motor Vagal low oxygen use and therefore reduce complex, dynamic development. Therapy can increase this complex, dynamic development by “a moment of meaning”. When something unexpected, non-intrusive or non-abandoning, a felt sense of attunement, can happen for the client.

Narrative and Procedural Memory

**Lyons-Ruth (1999) offers a concise definition of implicit processes, and ties its early development into current psychoanalytic models. “Both psychoanalysis theory and cognitive science agree that meaning systems include both conscious (e.g. verbalizable or attended to) aspects of experience and unconscious or implicit processed aspects of experience. Implicit processing in modern cognitive science is applied to mental activity that is repetitive, automatic, provides quick categorization and decision-making, and operates outside the realm of focal attention and verbalized experience. Although not discussed in the cognitive literature, implicit processing may be particularly relevant to the quick and automatic handling of non-verbal affective cues, which are recognized and represented early in infancy in complex ‘proto-dialogues’ (Trepriorvarthen, 1980) and so have their origins to the availability of symbolic communication” (Schore, 2005)

Implicit and Explicit Memory

“There exist in our brain two memory systems, each with different functions. One system concerns explicit (or declarative) memory. It concerns specific events of one’s life and allows, through remembering, a reconstruction of one’s personal experience. Implicit memory, in contrast is not conscious and concerns data that can be neither remembered or verbalized. It presides over the learning of various skills: a) priming, which is the ability of an individual to choose an object to which he/she has previously been exposed subliminally; b) procedural memory, which concerns cognitive and sensormotor experiences such as motor skill learning, everday activities, playing instruments or certain sports; c) emotive and affective memory, which concerns emotional experiences, as well as the phantasies and defenses linked to the first relations of the child with the environment and in particular with the mother (Mancia, 2005)

“Both research and clinical studies are now describing in detail how the affective basic core of the nascent self actively communicates its subjective psychobiological states with the primer object in intersubjective proto-conversations of coordinated visual-facial, tactile-gestural and auditory-prosodic mutual signaling (Schore, 2001a).

The most significant relevant basic interactions between mother and child usually lie in the visual area: the child’s bodily display is responded to by the the gleam in the mother’s eye” (Kohut, 1971).

“Implicit processing in modern cognitive science is applied to mental activity that is repetitive, automatic, provides quick categorization and decision-making, and operates outside the realm of focal attention and verbalized experience. Although not discussed in the cognitive literature, implicit processing may be particularly relevant to the quick and automatic handling of non-verbal affective cues, which are recognized and represented early in infancy in complex ‘proto-dialogues’ (Trepriorvarthen, 1980) and so have their origins to the availability of symbolic communication” (Schore, 2005).

“Self-organizing systems evolve hierarchically, they move from one level of development to another. Each new level builds on the previous one and is increasingly complex and differentiated” (Carroll, 2001).

What’s happening in the brain?

“The right hemisphere, particularly the right frontal region, under normal circumstances plays a crucial role in establishing the appropriate relationship between the self and the world” (Schore, 2006).

“Although the right brain reorganizes later in life and retains its plasticity, conditions affecting its initial stages of evolution have enormous impact on its subsequent development (Schore, 2005).

”Right brain increases in ‘implicit relational knowledge’ store in the nonverbal domain (Stern et al., 1998) thus lie at the core of the psychoanalytic change process.

Complexity theory and creating safety for trauma survivors.

Therapy is a bridging function which allows the client to put into narrative, and a felt sense, the unconscious traumatic experiences of the past. She/he is then able to think of, verbalize and transform the memories of such experiences, conferring on them a new meaning developed out of the dyad.

Grandiosity---Healthy & Defensive types

Shadow- Malevolent, Pre-Ruth, Sheva---Destruction/Creation

Pathological Accommodationn/mind/body

Three Attachment deficit styles

1. Avoidant

2. Dependent

3. Disorganized—

Bodily awareness and health are the foundation of humans being able to imagine what others are thinking and feeling, and imagining others knowing what they are thinking and feeling. People with secure attachments carry around this knowledge of being seen and felt by others. Deficits in attachment can lead to a lack of an ability to feel seen or felt by the world around one. As a person with disturbed attachment moves through development they learn to focus on understanding actions in terms of their physical, rather than mental outcomes. Only action that has physical outcomes is felt to be able to alter the mental state in both self and others. Physical acts, like self-harm, re-enforce this strategy. When feeling acutely invisible the person looks forward to a known sensation. The buildup, the ritual and the act change the way the person feels.

By violating the physical boundary of her body with a needle or a knife, she dramatizes the very existence of that boundary. This reestablishes a sense of her embodied self-hood. In addition the stinging sensation and the droplets of blood produced by the delicate cutting provide her with concrete sensory evidence of continuing aliveness. In her more vulnerable states the ever increasing draw toward the repetitive action to repudiate the lack of attunement she expects and receives becomes greater. He also when he proves to himself he is alive by pulling his hair, picking at himself or reckless behavior he feels somewhat soothed in the moment of high distress.

These are horrible secrets that they want everyone, and no one, to know. One of the challenges in therapy is that the structures that foreshadow self-harm rituals are established quite young. The defense against not being seen or felt is matured through many avenues of early play. Therapy needs to provide enough of a holding environment to allow the client to experiment with infantile acting out to get their feelings across. It is difficult to develop a light, playful attitude in the dyad toward these life-threatening feelings. As they don’t feel punished for existing, the client may create a communicative behavior that they consider, “good enough”. This often takes years of weekly psychotherapy.

Real (v) Unreal—Basketball with Third Graders

Dreams

Dreamer as the expert in discovering meaning. The “Ah ha” feeling will guide dreamer

Process takes at least 30 minutes

Ideally the dream is written out

First time reading or telling the dream, the therapist doesn’t ask many questions, the dreamer give as much surrounding information as possible—no detail is too small. Always, after first reading or telling of a dream ask the dreamer how they felt when they first remembered the dream upon waking. If this feeling is anger, frustration, fear, terror, etc; don’t add or subtract any value to that feeling. The goal is to help the dreamer wake in an investigatory mood. When other feelings are reported, use them as a guide to finding details during the second reading

Second reading or telling---Is the dreamer seeing out of their own eyes or floating above the scene as an observer of themselves. Every image in every dream represents some aspect of the dreamer.

Dreams appear for a multi-purposes. The dream psyche will include the information that the two of you discussed this dream in the next dream you have.

This process is my interpretation of Dream Reflection defined by Richard Jones in the 1970’s. In the 1960’s there were two leading dream research institutes across the street from one-an-other in New York City. They were using computers to store the analyst’s interpretation of the symbols in their patient’s dreams. Everyone was sure computers would quickly solidify the meanings of aspects of dreams. Instead, things got less clear the more data they acquired. One of the two decided to start over with new data collection using the dreamer as the expert. The meaning of a symbol only got fed into the computer if the dreamer said, “Ah ha! I see how it ties together with the other symbols”. Very quickly the universality of many symbols began to take shape. An example is ‘water’. Water in a dream is often found to represent the dreamer’s emotions, moods and flow of feeling energy. My clients with PTSD have often dreamt of a thin layer of water on the sidewalk or street they are walking on. This matches their tightly controlled emotions that seem to have little depth. They keep the variation of their emotions narrow for fear of them being out of control. A dream of a stagnant pool, rhythmic warm waves, a raging river, or a deep clear pond seems to have easily relatable meanings.

If my client dreams about water, rather than asking a question about emotions, it is my job to continue to explore the details. This is where it is important that you asked the dreamer how they felt when they first remembered the dream upon waking. This feeling my lead them to understand the water.

Differentiation and Individuation

Closure

What brought you into therapy? What did you do? What’s left to be done?

Ideally both parties look at one-an-other and say we don’t need to do therapy any longer. The client and I have made an early therapy agreement to do three months therapy for the separation process. Sometimes one or the other of us announces they think the need for therapy together has been completed. By earlier agreement we wait for the other person to come into agreement.

Value-Driven Obligations---The client lists their values in order of importance. Their whole course in therapy is reviewed in relation to these values. We discuss plans and the client begins to develop activities to continue enhancing their abilities to act on their values

Follow-up

Three free phone calls, return session if needed

FUTURE SUBJECTS

If I imagine myself a hundred years from now how much poison do I want to be drinking.

Internal Locus of Control—Glasser—What do I want? How do I feel? (versus) External Locus of Control

Addiction to substances an obvious example

Anger

Depression---Anger turned inward—cyginulate gyrus

Dissociation is always an attachment dynamic developed in the maternal interaction.

Delayed Gratification—Self-soothing healthfully rather than reacting on impulse

Opposite Action—Develop a Self-Story communicable to the therapist

Entitlement confusion

Underlying feeling being flawed

DBT

Amygdala---Attachment/Separation—is about regulation in the brain.

Affect in the therapy session. Can the client use something besides their internal loops to self soothe? Can they use intersubjective cues? Auto-regulate compared interactive regulation? For a lifetime the client has been doing the exhausting blocking of the terror of an inability to take in interactive comfort. Stern’s moment of meaning is at the unexpected. The disturbed client has an expectation of what the object (therapist) will do as they move toward dissociation. What is familiar for self-soothing, even if it isn’t very effective and requires a lot of energy (dissociation,) is what the client will use. During dissociation blood flow is inhibited to the higher centers of the body/brain and shunted to survival systems in the brain/body. These moments create Dorsal Motor Vagal low oxygen use and therefore reduce complex, dynamic development. Therapy can increase this complex, dynamic development by “a moment of meaning”. When something unexpected, non-intrusive or non-abandoning, a felt sense of attunement, can happen for the client.

Narrative and Procedural Memory

Implicit and Explicit Memory

What’s happening in the brain?

”Right brain increases in ‘implicit relational knowledge’ store in the nonverbal domain (Stern et al., 1998) thus lie at the core of the psychoanalytic change process.

Complexity theory and creating safety for trauma survivors.

Grandiosity---Healthy & Defensive types

Shadow- Malevolent, Pre-Ruth, Sheva---Destruction/Creation

Pathological Accommodationn/mind/body

Three Attachment deficit styles

1. Avoidant

2. Dependent

3. Disorganized—

These are horrible secrets that they want everyone, and no one, to know. One of the challenges in therapy is that the structures that foreshadow self-harm rituals are established quite young. The defense against not being seen or felt is matured through many avenues of early play. Therapy needs to provide enough of a holding environment to allow the client to experiment with infantile acting out to get their feelings across. It is difficult to develop a light, playful attitude in the dyad toward these life-threatening feelings. As the don’t feel punished for existing, the client may create a communicative behavior that they consider, “good enough”. This often takes years of weekly psychotherapy.

Real (v) Unreal—Basketball with Third Graders

Dreams

Dreamer as the expert in discovering meaning. The “Ah ha” feeling will guide dreamer

Process takes at least 30 minutes

Ideally the dream is written out

Second reading or telling---Is the dreamer seeing out of their own eyes or floating above the scene as an observer of themselves. Every image in every dream represents some aspect of the dreamer.

Dreams appear for a multi-purposes. The dream psyche will include the information that the two of you discussed this dream in the next dream you have.