Psychotherapeutic Boundaries

One of my lifelong priorities has been to demystify the language of psychotherapy. Academic terms and jargon more often make the therapist sound impressive rather than help the patient get better. “Make it simple and down-to-earth for me,” is something I say a lot – to fellow therapists and to my patients, as well. Vague confusion doesn’t do anyone any good.

So today I want to demystify two terms in the psychotherapy profession. These thoughts come straight out of my thesis of 38 years ago. The terms I’m talking about are the external boundary and the internal boundary.

Part of a psychotherapist’s job is to set and control the external boundary for their patients. This means – as simply as I can put it – that it’s my responsibility to create and maintain a safe and beneficial space for my patients. This setting will give them the best chance to understand and resolve their challenging personal issues. Part of the space is my office. Patients must be able to feel physically safe. This includes the promise to complete privacy and confidentiality.

The other “space” that’s part of the external boundary is the structure of the therapy I provide. Working within their budgets as best I can, I determine how many sessions, lasting how long, and happening how often, are needed to give my patients their best chance for success. I also set up scheduling and payment methods to help my patients be more accountable for their progress and success.

The internal boundary of psychotherapy, however, is less directly under my control. It is more like a delicate partnership with my patient. Patients cross the internal boundary to reveal to me their pain, wounds, struggles, and fears. They reveal their traumas from the past and the present and their hopes for the future. These revelations allow me to get to work – helping them address issues, resolve pain, and create a better life and relationships.

But crossing the internal boundary can be complicated by many, many things. Patients can feel shame and have trouble being honest. Patients can want to blame others or events and deny responsibility for themselves. Patients can be in denial, or disconnected, or just plain don’t know how they feel or why they keep making a mess of their lives.

Over my years in practice, I’ve developed ways to help people cross the internal boundary, discovering and revealing their most deeply held pain and secrets so that they can heal. I believe this is where psychotherapy goes beyond having a toolkit. Yes, tools are necessary, but there is an art to using them. In this area, I can always improve.

Trauma Therapist Podcast

Last week I had the very great pleasure of being interviewed by Dr. Guy MacPherson. Guy is a clinical psychologist and the moving force behind the West Coast Trauma Project, a website dedicated to raising awareness of trauma and helping trauma therapists thrive. “My goal with the West Coast Trauma Project,” Guy explains, “is to help other trauma therapists thrive – through providing actionable information, community building, inspiration and support.”

One of the resources Guy offers on his website is the Trauma Therapist Podcast, a series of recorded interviews with therapists in the field of trauma. My conversation with Guy provided me with an opportunity to share from my heart about my life and work. Follow here, to listen in.

Trauma/Healing 3

Trauma . . .

. . . is a hidden epidemic.

Healing . . .

. . . is possible.

Good Parent, Bad Parent

Last week I wrote about reparenting in psychotherapy. I’ve used it as part of my practice since the beginning, about 45 years ago. Reparenting places a sizable burden of responsibility on a therapist, because it means committing in every way to being a loving parent to often deeply troubled people.

My patients have often grown up in families with neglect or abuse of one kind or another. In crucial ways, they didn’t get the help they needed to become capable adults. They carry around pain from their childhoods combined with pain from their troubled current lives. When I reparent them – become the “good parent” they never had – they have a fresh chance for something better.

With reparenting, something interesting happens. I get to see how my patients were as children. I get to see how they were treated by their parents and the ways they protected themselves, as best they could, from neglect and abuse. Because I take on a parent role (even though I’m the good guy) they get confused and end up thinking I’m just like their true parents were. It doesn’t feel good sometimes, but it’s an important part of the process of healing that they bring this confusion out with me.

Just last week, at the end of a session, I had a patient say, “I know you’re mad at me.” No, I wasn’t, I explained. Why did they think so? “Because I didn’t work hard and I made no progress,” they said. It was clear to me in that moment that as a child, my patient had needed to earn their parent’s love. Most of the time, nothing they did was ever going to be good enough.

So I had the opportunity right then to genuinely acknowledge my patient’s efforts. I stay with the truth. I’m not going to give false praise. My patient is working hard and doing their best. More importantly, they are a person of value and worthy of love and support. I was glad for the opportunity to give them that message.

Trauma/Healing I

Trauma . . .

. . . is a visible or invisible wound.

Healing . . .

. . . repairs the wound, but there will always be a scar.

Reparenting

I think the best description of how I approach being a psychotherapist is to say that I “re-parent” my patients.

When I was training in psychotherapy in the 70s, reparenting was part of the classic model. I believe our profession has moved away from taking on this role but I can’t imagine doing what I do in any other way.

The people who come to see me usually have significant problems. Their traumatic issues and experiences cut deeply into who they are and disrupt their lives and relationships. I would say that every one of them suffers from seriously flawed parenting. Growing up in their families of origin included either harsh discipline, neglect, alcoholism or drug use, or some type of physical, emotional, or sexual abuse.

The people my patients loved and trusted and depended on for their lives – their parents – significantly betrayed them in some way.

There are important things they didn’t learn; they weren’t able to grow up in the right ways. They want their lives to be good but things keep going wrong for them in ways they sometimes understand and sometimes are completely confused about. They need to be reparented.

And I want to say, right off, that this role is a huge one to shoulder. To do it right, with integrity and humility, is very, very hard. The burden of responsibility to reparent my patients is as awesome a responsibility as being an actual parent of a child.

It was in the role of a parent with one of my patients last week that I needed to share one of the most difficult experiences of my life. My patient was at a critical turning point and needed to be able to learn from my example, like a good father helping his kids learn from his mistakes. Believe me, I thought about this very carefully. I don’t like sharing this story and I need to be absolutely sure that by sharing it I’m really going to help someone.

I decided to go ahead. As usual after telling this story, I ended up sweating, drained, and shaking inside. I had trouble sleeping that night.

I hope my patient heard me. Now I’ll see where he goes with it.

Lost

Families of service members killed in the line of duty have suffered the ultimate loss of their loved ones. Their sons or daughters, husbands or wives, fathers or mothers, will never come home. Their loss and grief are real and tangible.

But many families of service members who do return from active duty also feel that they have “lost” their loved one. To a lesser degree – but still significantly – the service man or woman they knew before deployment has changed beyond their recognition.

Military families understand that the experience of combat changes people. They would be concerned if their loved one returned from deployment exactly as they used to be, as though nothing had happened to them. But many families and loved ones are unprepared for the stranger who at long last walks through the door.

Loved ones expect a time of transition. But when time goes on and on and their veteran doesn’t readjust – or is possibly getting even more troubled – they wonder what to do. They can feel pain for the lost relationship, frustrated over how to get help, and worn out at the burden of care placed on them.

Military personnel are changed by their service . . .

. . . physically – by wounds and injuries, and the lingering disabilities they may produce

. . . emotionally – by anxiety, depression, rage, terror, and shame

. . . mentally – by changed attitudes about the world and the people in it, or by the side effects of psychotropic and pain medications prescribed for visible and “invisible” wounds

. . . spiritually – by a loss of hope and faith, by anger at God, by shame for violating deeply held principles of conduct in a hellish theater of war

The Bernstein Institute for Trauma Treatment, with the support of nonprofit Sonoma Coast Trauma Treatment, is in the process of forming a support group for loved ones of veterans struggling with the traumatic effects of their service. If you or someone you know needs our help at this time, please get in touch.

A PTSD Scenario – and a Support Group

A veteran and his wife sleep side by side in their darkened bedroom. The man moves restlessly under the covers. The woman, long familiar with his insomnia and night terrors, is somewhat conscious of his rising agitation. Something happens. It might be a sound from the external world – a passing car, a gust of wind – or a shift in the internal dream world of the man. Suddenly he is on his feet, dragging his stunned wife out of bed. He grabs the knife on his nightstand and braces his wife forcefully against the wall. She knows him as her husband, the man she loves, a troubled veteran with PTSD. But the veteran doesn’t know his wife. She is the enemy. As she pleads with him, he slowly recognizes where he is, who she is. He releases her, flooded with remorse and shame.

A dramatic scenario, I’m sure you’ll agree. Something you might see in a movie, such as the recently released American Sniper. But it’s also a true scenario, as it happened to me. I was that veteran.

My first wife and I are not alone in experiences of that kind. Many patients and people I’ve met over the years share similar stories. Many veterans and their spouses or partners make the decision to sleep apart – many of them eventually break up – because veterans with PTSD often have great difficulty with relationships and intimacy.

Intimate relationships are characterized by vulnerability. With a loved one, we drop our defenses and expose ourselves and our feelings. For veterans struggling with PTSD and other military-related traumas, vulnerability can be terrifying and intolerable. Their partners, paradoxically because they are beloved, become dangerous threats to be avoided. Veterans can fear losing control and hurting those they love. Sometimes they even sufficiently lose touch with reality to believe their partners really are the enemy. Everyone suffers, including the veteran’s loved one.

That’s why I’m in the process of forming a support group for loved ones of veterans struggling with PTSD. I’m reaching out to spread the word that the Bernstein Institute, in partnership with nonprofit Sonoma Coast Trauma Treatment, has help and hope to offer. If you or someone you know is in need of this kind of group, please contact us at 707-781-3335.

Military Suicide and Military Families: Part 3

Military suicides happen far too often.  Alarming statistics from studies of suicide by active duty service members and veterans both paint a tragic picture.  The years of combat in Iraq and Afghanistan, the multiple deployments, have taken their physical and emotional tolls.  Over the last few months, I’ve kept this issue in the forefront of my blog posts.  Lately, I’ve highlighted a side to military suicide about which few studies have been done and statistics are largely unavailable: suicide by military spouses.

I’ve drawn heavily from the words of two military wives:  Ms. Deborah Mullen, wife of former Chairman of the Joint Chiefs of Staff and retired Navy Admiral Mike Mullen, and Kristy Kaufmann, wife of an Army soldier and executive director of the Code of Support Foundation.  I’ve reviewed the symptoms of post-traumatic stress (including suicide and suicide attempts), and the inadequate mental health treatment currently available to military spouses.  Today I’m going to go into more detail about the stresses experienced by military families.  I’ll conclude with Deborah and Kristy’s suggestions for ways the Departments of Defense and Veterans Affairs could better serve the mental health needs of military families.

In January, 2011, Deborah Mullen addressed the Military Health System Annual Conference.  She opened with a direct quote from a letter by a young military spouse.  “It is infinitely worse to be left behind,” she read, “a prey to all the horrors of imagining what may be happening to the one you love.  You slowly eat your heart out with anxiety and to endure such suspense is simply the hardest of all trials that come to an army wife.”

The letter’s young author?  Libby Custer, wife of General George Custer, writing in May of 1876.  “The nature of war changes,” Ms. Mullen observes.  “Weapons get smarter . . . tactics get sharper . . . breakthrough medical advances save more and more lives.  But the stress and the anxiety felt by those who are left behind NEVER changes.”

Besides the agony of waiting, other sources of stress for military spouses and families include reintegration and reunion challenges, Deborah explains.  “A combat tour may last a year, but the effects of that tour on the service member and family may last much longer.”  Spousal and child abuse cases are rising in military families.  Families of service members who’ve sustained serious physical injuries may endure long-term relocation to receive treatment, and children “may be left at home with family or friends”, breaking the immediate family apart.

Or maybe the returning service member has suffered the signature wound of our Iraq and Afghanistan conflicts: an “invisible” wound from PTSD or TBI.  Spouses and children “don’t understand why their parent looks the same, but isn’t the same,” Deborah continues.  And “for those children whose mom or dad died – either by the enemy or by their own hand – this war will never really end.”

How can the DoD and VA better serve the mental health needs of military families?  Deborah Mullen and Kristy Kaufmann, writing for the New York Times, make the following key suggestions:

1. Really listen to military families, look at things through their eyes, to better understand their special needs and challenges.

2. Provide “home-centered” assistance for families in crisis, in which counselors and other assistance personnel come directly into the home to provide needed support.

3. Do a better job of following up on the results of programs currently in place.  New programs are being created all the time, but too often they aren’t reviewed and modified, as necessary, to become truly effective.

4. Develop a more holistic strategy that integrates military families and community support.  Society has a crucial role to play in helping keep military families strong and healthy.

“Ultimately,” Deborah concludes, “spouses tell me they don’t need another program, they don’t need more training.  What they need – what they want – is time.  Time with their spouses.  Time together with their family.  Time with a counselor or a doctor or a minister.  They want time to explore and understand what is happening to them . . . and the patience and understanding of loved ones, friends and the system itself.”

“If you have a broken family,” Kristy warns, “chances are you’re going to have a broken soldier – and vice versa . . . . It will take a nation working together to keep us strong.”

As a young Marine wife told Ms. Mullen, “It doesn’t matter if it’s the first day they’re gone, or the last day before they return home, you’re scared all the time.  You pretend to be happy, but you’re living in fear.”  And, Deborah urges, military spouses should not have to face that fear alone.

Through my work, I’m committed to the health and well-being of our nation’s service members and their families.  I don’t want them to be left alone to struggle with their issues of emotional trauma and post-traumatic stress.  I encourage you to join me, in whatever way you can.

Military Suicide and Military Families: Part 2

In my last post I sought to bring attention to an overlooked aspect of the current tragedy of military suicide – suicide within military families.  While hard statistics are unavailable at this time, anecdotal evidence indicates elevated levels of suicides and suicide attempts by military spouses, due to high levels of stress and secondary trauma.

I quoted two military wives – Ms. Deborah Mullen, wife of former Chairman of the Joint Chiefs of Staff and retired Navy Admiral Mike Mullen, and Kristy Kaufmann, wife of an Army soldier and executive director of the Code of Support Foundation – as they eloquently spoke out about this troubling issue.  Deborah pointed out that stigma still exists against military spouses admitting their mental health challenges and post-traumatic stress.  Depression, anxiety, sleeplessness, panic attacks, and self-medication with alcohol and drugs have become a part of military spouses’ lives, as well as the lives of their active duty and veteran partners.

I ended my last post with the question: What happens for the desperate spouses who do gather the courage to seek treatment within the Department of Defense and Veterans Affairs mental health services?  I draw my information here directly from Ms. Mullen’s address to the 2011 Military Health System Annual Conference.

The experience of spouses who seek help is “disappointing”, Deborah states.  “Misdiagnosis.  Lengthy waiting periods.  Red tape.”  Obstacles that “discourage and indeed damage the healing process”.

At the same military post hospital, she reveals, two spouses who sought treatment for help with classic PTS symptoms – one with suicidal thoughts – were prescribed five and seven medications each, with no followup appointments.  And, “Neither was ever referred for psychological help.”

I’m going to make a very strong statement here.  I believe a system that would allow a general practitioner to prescribe multiple, heavy-duty medications for psychological symptoms and then not see the patient again, is broken.  This is especially true for patients with suicidal thoughts.  Several prescription anti-depressants have been recently shown to create or intensify suicidal thought ideation.  I believe the actions of the doctors at this post hospital were unethical and unconscionable.

But there is even more going wrong for suffering military spouses within the mental health approach of the DoD and VA.  According to Ms. Mullen, spouses refer to it as the “15 and one rule”.

“It goes like this,” she explains.  “No matter WHAT may be bothering you from a health perspective, you are allowed to discuss only one symptom and only then for 15 minutes.  That’s it, no exceptions.  If we accept, as we have, that spouses suffer a PTS all their own . . . and if we know, as we do, that PTS manifests itself in many different ways in many different people, why would we not accept the need to treat the whole person?  Why would we fail to look at the totality of issues confronting a young spouse?  And why would we ask that young spouse not to confront them all herself?”

As a professional in the mental health field, with over 40 years of experience, I’m appalled and angry at what I see as insensitive and unprofessional practice within the military health system.  Patients must have the time and opportunity to reveal an accurate picture of the issues they face and the symptoms they experience.  With suicide as a potential outcome for desperate patients, I would characterize the treatment protocols for military spouses as very irresponsible and dangerous.

Kristy Kaufmann has strong words of her own on an additional obstacle.  “The fact is,” she wrote in a New York Times opinion piece last fall, “even if everything in the Pentagon and the VA were working perfectly, the government simply does not have the resources – or culture, for that matter – to support the level of need after 10 years of war, and it never will.”

Are you angry yet?

Combat and active duty experiences create their own patterns of post-traumatic stress for our service members.  What are the special problems that enter the lives of military spouses and families, leaving trauma in their wake?  I will return to answer that question next week.