Psychotherapy Bulletin

Psychotherapy Bulletin

Lately I’ve been thinking about therapist authenticity. Since moving to private practice three years ago I have worked primarily with adult survivors of childhood sexual, physical, and emotional abuse. Due to years of chronic violence during developmentally important periods, clients’ life experiences are typically characterized by an insecure (often disorganized) attachment style, a chronically activated nervous system, and difficulty with emotion regulation. These complex trauma dynamics adversely affect clients’ ability to form and sustain relationships. The vulnerability required for any form of intimacy is intolerable and, as one of my clients put it plainly, “obviously a really bad idea.”

Not surprisingly—and as most of you know—developing rapport with clients who fear connection is quite challenging. Building relationship with any client requires patience, respect, and consistency. And yet, with a few select clients my typical approach to forming rapport is sorely insufficient. There are simply some important relationship competencies they do not have. It feels more accurate and empathic to conceptualize these clients as having an underdeveloped skill set rather than to consider them resistant. Because I, as the therapist, do have these skills, I see part of my task as being to work in creative ways to help them engage in the task of co-creating our relationship.

What can I do in these circumstances to facilitate a real bond? Might these cases be what Greenson (1967) terms the “special considerations” (p. 223) in which the real relationship between a client and myself is permitted more leeway? What constitutes a “real” relationship, and how do I present aspects of my authentic self in a way that serves the client and not myself? Two clients come to mind as I think through these questions.

Annie is an articulate young woman from rural Maryland. She is bright and funny. Her parents worked long hours and Annie was responsible for the care of her younger siblings. When home, her mother was often drunk, unpredictable, depressed, or sleeping. Several times Annie’s mother “went missing” at night, and Annie recalls searching for her in the middle of the night while Annie was still in grade school. Annie’s depression went unnoticed and her pleas for help unheeded. Her mother’s feelings took precedence at home. Annie was bullied in school, experienced the death of several friends during her adolescence, struggled with an eating disorder and alcohol addiction, and has attempted suicide multiple times. Her parents continue to deny her struggles. Her most important attachment figures have not been attuned to her needs, so much so that she claims that needs are “irrelevant if they are not going to be met.”

Annie has done a lot of work. She has been sober for years, attends AA regularly, and has been successful in both inpatient and outpatient treatment programs. Now Annie requires that people in her life be real. In fact, she demands it. She resents the typical gentle therapist voice and approach because it is patronizing. She wants to know what I think. Unless I am real, she does not participate in therapy. I am challenged to navigate her genuine need for an authentic encounter because when Annie is engaged with me the work she does in therapy is admirable.

William, on the other hand, is more guarded than any other client with whom I’ve worked. He presents as cordial and polite, a highly intelligent man with an impressive vocabulary, a sharp wit, and a high status career. He is a survivor of severe physical and emotional abuse at the hands of a wildly unpredictable mother. His stories of beatings, neglect, and abandonment threats are brutal. He was a victim, but also served as his mother’s emotional partner, mediator to his parents’ fights, and parent and protector of his younger siblings. Nor was school a safe haven; William was severely bullied and placed in remedial classes due to an undiagnosed learning disability.

During the first six months of our work together, William demonstrated little self-understanding. His responses to my probes were nebulous. Often I had little idea what William said or meant. Just when I thought we were forming a connection, he would become formal and distant; from my perspective, it felt as if we had never met. I truly had no idea why he kept his appointments. At one point I wondered if he were, in fact, affectively limited—if perhaps his emotional reservoir is simply shallow. Quite the contrary: It turns out that he possesses an exceptionally deep emotional well, but shields it in a cloak of intellectualized reserve. Connecting with clients fairly quickly is one of my strengths. However, my typical approach did not work with him at all, not because he is resistant but because he is that wounded.

Keeping It “Real”: Building Connection Through Authenticity

I am tasked in different ways to reach these two clients. How do I shift in order to develop the solid therapeutic relationship that I feel is necessary to do the work? I begin by thinking through some questions.

What is the impact on development of early childhood abuse?

I find it helpful to use a framework of a resource loss model to understand the impact of early childhood trauma (Cloitre, Cohen, & Koenen, 2006). Although Annie and William experienced different forms of abuse, for both the abuse happened repeatedly during critical developmental periods. Each lost important resources, including a sense of security and personal safety, the development of self-knowledge, trust in self and others, and an ability to identify and regulate strong affect. Experiences at home affected their attention and concentration at school, both in the classroom and on the playground, and contributed to diminished social development and negative social experiences.

Due to these losses, neither Annie nor William developed the requisite psychological and social resources needed for recovery from abuse. They both continue to struggle to forge relationships characterized by trust and appropriate levels of intimacy (Cloitre, et al., 2006). Despite their different presentations, both Annie and William report feeling damaged and unworthy, alienated from others, and pessimistic about relationship success.

What is the contribution of attachment experience?

We learn to care for ourselves from the way we are cared for (van der Kolk, 2014). An infant naturally seeks the parent when alarmed, but if the parent behavior itself is alarming, the child is placed in the frightening position of wanting to approach and flee simultaneously (Main, 1996). Herein lies the paradox for clients like Annie and William. Both individuals looked to their primary parent to assess safety and/or threat level, and found her to be unpredictable and untrustworthy.

Neither protected nor soothed, Annie and William bring their internal working model of others into childhood, adolescence, and adulthood, and use these templates to guide their relationship expectations. William would like me “take charge” in our work because he does not understand interpersonal objectives. When I process relationship dynamics he seems disoriented and confused by what is happening. His current important relationships follow a similar path; when his partner wants to discuss emotion or conflict in their relationship, he feels numb and unable to think clearly. Annie expresses sadness because her parents are not attuned to her, but becomes angry with me when I ask about her needs and wishes. Similarly, she experiences challenges in her friendships and romantic relationship because she resents when others do not consider her needs, even while she denies the importance of those needs.

My job as a secure base is to be a different sort of anchor than these clients have had before. Annie and William have learned that relationships hurt, that no one will step in to help them because they are not worth saving, and that to be connected means they will be abused. To be a responsive caregiver with clients like Annie and William means I need to be attuned to their needs and adjust my approach if indicated. I hoped that offering these two clients aspects of my authentic self might break the impasse to the development of a trusting therapeutic relationship.

What aspects of the therapy relationship become more salient for clients with attachment trauma?

Most of us agree that the connection between client and therapist is of vital importance to overall therapy process and outcome, though the emphasis each of us places on the therapeutic relationship will vary. It is the real relationship that feels most salient when thinking about authenticity, but defining the real relationship has been challenging (Gelso, 2011). Greenson (1967) proposes that the real relationship consists of genuineness and realistic perceptions; Gestalt therapists emphasize the I-thou relationship; and Rogers (1957) emphasizes congruence, or genuineness, as one therapist-offered condition necessary and sufficient for change. What these general descriptions have in common is a certain willingness in the clinician to be herself.
Rogers’ (1965) concept of transparency particularly resonates with me. While I do not want all of my clients to “see all the way though me” (Rogers, 1965, p. 2), I do want clients to know when they have had an impact on me, particularly when they have learned otherwise in their most significant relationships.

So what about Annie and William, and what does any of this have to do with authenticity?

After nearly a year of working too hard with William, I thought: I just need to have a relationship with this guy. It turns out that reaching William involves simple interpersonal exchanges where we share interests and I demonstrate some vulnerability. He is amused by my fascination with Stonehenge, and he shares the aspects of coin collecting that intrigue him. We exchange and discuss books, although he does not enjoy fiction and reading his nonfiction recommendations feels like homework to me. When he observes a sale tag on the bottom of my new boots his eyes soften, I am slightly embarrassed, and we both laugh.

My willingness to relax boundaries in these ways has helped him to trust me. He begins to take more ownership of the session and spontaneously begins to share his story with me. The nature of our interaction shifted rather dramatically when I decided to be different. He now explores in some depth how certain skills which saved him in childhood are no longer adaptive. For instance, as a child William became skilled at “listening for” openings to de-escalate violence and chaos, but in his current relationships struggles to “listen to” others. His ability to observe and make process interventions helps him in his work, but confirms the childhood message that he is a manipulative liar. When I ask about ways in which he might manipulate me, he became upset and worried about my reaction between sessions. The following week, however, he shared his concerns with me and we processed his feelings and sustained our bond.

Annie is interested in my values. She wants to know my position on gay marriage. What do I think about what is happening in Baltimore? What was my reaction to the Bruce Jenner interview? Do I understand the implications of the wage gap? She wants me to communicate my understanding of the impact that power and privilege have on her daily life. She wants to bring her dog to our sessions.

To be authentic with Annie does not mean that I will answer or gratify all of her questions and demands. However, I will be clear and direct with her. Her need to feel that her therapist is authentic and true is grounded in her real experience that important figures were not attuned to her and that she does not matter. We explore how needs can be affirmed but not always met. She may not bring her dog to my office, although he is awfully cute. We can discuss our similar stance on social issues. I empathized with Annie’s hurt feelings when, at a family gatherings, her girlfriend introduced Annie as simply a good friend. However, when I would not say her girlfriend was “absolutely wrong,” Annie became angry because she felt I was unsupportive. I reminded her that our relationship is grounded in an authentic exchange of thoughts and feelings, and she smiled. She expressed sadness because her mother cannot engage with her in this way, and I expressed my true feeling that I would be proud to have a daughter like her.

As I was gathering my thoughts for this piece I wondered about the necessity of clarifying my relationship approach to clients? As it happened, I was asked to articulate my position the very next day during a consultation with a prospective client. The person stated that he was looking for a therapist like Dr. Malfi from The Sopranos. Dr. Malfi? I was intrigued and, quite honestly, a bit uneasy. He remarked that I was a little too friendly, and that, yes, he would like me to send him some referrals. I considered whether I might be less transparent, but decide that going against my basic nature is inauthentic because I become stiff and unnatural. Instead, I seek to create a connection in which both participants can be real with one another. I strive to be myself in the therapy room to assess what is needed of me so that a productive working relationship can emerge.

[1] All identifying information has been disguised to protect client confidentiality.

Cite This Article

Friedman, S. (2015). Reflections on authenticity in psychotherapy. Psychotherapy Bulletin, 50(2), 30-33.

References

Cloitre, M., Cohen, L. R., & Koenen, K. C. (2006). Treating survivors of childhood abuse: Psychotherapy for the interrupted life. New York, NY: The Guilford Press.

Gelso, C. J. (2011). The real relationship in psychotherapy: The hidden foundation of change. Washington, DC: American Psychological Association.

Greenson, R. R. (1967). The technique and practice of psychoanalysis (Vol. 1). New York, NY: International Universities Press.

Main, M. (1996). Introduction to the special section on attachment and psychotherapy: 2. Overview of the field of attachment. Journal of Consulting and Clinical Psychology, 64(2), 237-243. doi: 10.1037/0022-006X.64.2.237

Rogers, C. R. (1957).  The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95-103. doi: 10.1037/h0045357

Shostrom, E. L. (Producer). (1965). Three approaches to psychotherapy (Part 1-Carl Rogers). [Film]. Orange County, CA: Psychological Films.

van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY: Viking.

1 Comment

  1. Samantha

    Hi there,

    I’m a psychiatrist/therapist and I enjoyed reading your article. Thank you for sharing. I hope you don’t mind if I used your case studies for teaching purposes.

    Reply

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