Considering Analytic Space

Clinical Practice, Digging Deep... - Therapy, therapy relationship, therapy space - May 30, 2013

Ah, here we are again! Another week. Therapeutic ‘space’ is a topic I’ve been thinking about a lot lately, as I just relocated my office (across the hall from my previous office, which some clients lovingly called either ‘the womb’ or ‘the cave’, as it was a ‘cozy’ interior office without windows). Although I have spent a lot of time considering the physical space over the past month, that seems merely to have served as a metaphor for deeper matters. That said, I thought I would dig up an old essay I composed in grad school on just that topic–from a psychoanalytic / psychodynamic perspective.

We were only allowed six pages and five sources (the only sources we used for this course), and…well, I let you read it. The contents of this essay (barring the citations, of course) is Copyright 2006 D. Michael Coy.

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Considering Analytic Space

Patrick Casement suggests that “the analyst or therapist can be guided towards working more effectively, monitoring the analytic space for what may be intruding upon it and the analytic process for what could disturb it” (1991a, p. 187). As I considered Casement’s meaning here, I found myself reviewing in detail the text from which this quote originates. I will, in this essay, elaborate my understanding of these words through three different yet related dimensions: Casement’s text itself, related course selections, and my own work with clients.

On Learning from the Text

Casement brings together a wide array of concepts in discussing his thoughts about the analytic space and process. He asserts early on in the text that “[t]herapists sometimes have to tolerate extended periods during which they may feel ignorant and helpless” (Casement, 1991b, p. 8). Casement further suggests that “[w]hen a therapist thinks that he sees signs of what is familiar to him, he can become blind to what is unfamiliar and strange” (p. 9). In this case, what might “intrude upon” or “disturb” the analytic space are both the therapist’s own fear of not immediately grasping a client’s situation and the subsequent reliance upon such tools as anecdotal or borrowed knowledge, cliché interpretations, and deflection or reassurance—so to avoid coming in contact with a client’s unpleasant thoughts or feelings, for which the therapist feels unprepared (1991b). Though these approaches can serve as a source of security for the therapist, they can also disturb the analytic space by robbing clients of original, unique insight into their lives. Over time, just as an infant subtly—and not so subtly—cues the parent to an empathic misattunement, so will the client prompt the therapist to attend to their unmet needs in the therapy (1991c). Empathic attunement to these prompts is facilitated by the therapist’s willingness to open himself up emotionally to the client as well as to any resulting countertransference (1991d). Along with this emotional openness comes the need for containment. Casement (1991e) quotes the maxim, “The best containment is a good interpretation” (p. 127). He states, however, that interpretation alone cannot offer holding. This good (i.e., empathically attuned) interpretation must be accompanied by the therapist’s willingness potentially to bear and survive, rather than avoid or retaliate against, the client’s most terrible feelings—else the therapist risks losing the ability, in the client’s eyes, to maintain the integrity of the analysis (1991e; 1991f). Containment is not only, however, a psychological concept. Being mindful of more palpable boundaries also plays an integral part in monitoring the analytic space and process. Here I refer to cases where, for instance, either the client feels the need for particular behaviors (e.g., smoking, etc.), additional sessions, or actual bodily contact within the therapy, or the therapist makes transference interpretations without enough evidence of the transference, offers additional sessions without prompting, or becomes inappropriately directive with the client. Casement himself struggles with what is and is not appropriate for the individual client, always bearing in mind the potential for either disrupting the analysis or traumatizing the client (1991c; 1991f; 1991g).

Casement further notes the importance of being “non-intrusively available” to the client, acting rather as Winnicott’s spatula was available yet not forced upon a child in the therapy space (1991c). This, he later suggests, provides the unobtrusive yet potentially comforting “being alone together” (1991h, discussing Winnicott), which allows the client to engage the therapist’s interpretations “when they are ready” to hear them (1991i). This, again, requires a high level of attunement on the therapist’s part (1991d) and a willingness to allow clients (and themselves) both a certain “playfulness” (1991h) and the flexibility to use the therapy space and the therapist as they will (1991j; 1991k; 1991l), within reasonable limits. On “space,” Casement writes that, “[to] be healthy, every intimate relationship needs space and personal boundaries, and a corresponding respect by each person for the ‘otherness’ of the other” (1991h, p. 341). When the therapy relationship cannot accommodate this, we as therapists lose the ability to protect the client from outside intrusion—namely, ourselves—and the therapy space becomes “tainted” and potentially unsafe as a free space for the client to “be” (1991h).

Other Texts, Other Views

Allowing clients to “be”—by allowing ourselves not to know—is a concern that Coltart (1992) shares. Echoing Casement, Coltart writes, “It is of the essence of our impossible profession that in a very singular way we do not know what we are doing” (p. 2). She illuminates this statement when she suggests that, though training, research, discussions with colleagues, etc., are all extremely important to the “process,” each client is unique. Each presents new mysteries, which we must patiently approach, so to allow the client space to reveal them. We cannot afford, then, to apply premature labels and interpretations to the client’s experience if we wish to avoid impinging upon the freedom that allows this natural revelation to occur. This freedom, Coltart suggests, includes being “in the moment,” which sometimes means blurting something out—sometimes when we least expect it. Class discussion (1-12-2006) has also focused upon this issue, the general consensus being that, though less is usually more when commenting to the client (Casement, 1991b; Coltart, 1992), there are times when blurting is necessary.

Maroda (1999) seems to agree with this. Shocking though some of her comments to clients might be, they are infinitely “human” and often, she feels, necessary to reestablish equilibrium in the therapy space, much as Casement’s physical holding of Joy served the same function when her behavior became untenable (1991j). Maroda’s humorous approach to dealing with “difficult” clients adds a new dimension to Casement’s writing. Maroda’s “battles” to maintain a safe space for her clients to explore themselves are often fought against her inner self and the clients themselves. This is no different than Casement’s work, of course, but Maroda’s admissions of her sometimes painfully honest exchanges with clients in times of stress—and her ability to maintain a sense of humor about these interactions—brings into greater relief Casement’s often rather serious musings (see “Mrs. B,” 1991f). It is not that Casement’s exploration is not compelling, because it is. The differences can perhaps be attributed to issues of style and, one might guess, training. Nevertheless, both Casement and Maroda seem to agree that analytic holding is of extreme importance—they just handle it in ways that are more in line with their respective personalities.

Maroda, however, takes to task therapists who allow their clients free reign to abuse them. She delineates anger from abuse, suggesting that, though anger is certainly valid as a feeling, there is little excuse for abusive behavior in the therapy space. Such abuse, she suggests, is (to use Casement’s words) an intrusion upon the therapy space, and robs the therapist of the ability to maintain the freedom that is so needed in for the therapeutic interaction to “breathe.” The point here seem to be that, even in the best of worlds, the client’s right to “be” has practical limits. Limits in the therapy, however, should not be imposed by the therapist’s ideas about who the client “really” is (Foster, 1998; Schonfeld-Ringel, 2001). Though we all as therapists bring all our experience with us into our work with clients, we must be very careful to mind any “intrusion” of either conscious or unconscious agendas. This is especially true for clients who do not share our ethnicity or cultural experience, among other things. This idea harks back to Casement’s insistence that therapists must not allow themselves to impose their wishes and values upon the client—and this imposition, both Foster and Schonfeld-Ringel might add, includes the assumption of cultural norms and shared experience. What’s more, therapists must remain aware of their own unmet needs when working with clients. Casement (1991m) might here suggest that these unmet needs are more appropriately dealt with in the therapist’s own personal therapy rather than in murky countertransference responses that focus upon, among other traits, race and ethnicity. Foster seems more apt to approach these issues head on with the client as a continuation of the “co-creation” of the therapeutic experience. In any case, it is the act of approaching the unknown rather than avoiding it that remains key in the promotion of an unimpeded analytic space and process.

Reflections and Ruminations

I have discovered much about myself while studying both Casement’s and others’ writings included in this course. I wholeheartedly agree with Casement’s comment on analytic space and process. Agreeing with a statement and finding the resources to adhere to it, however, are two different matters. I have found myself in it twice thus far during this school year for precisely this reason. I have found myself sitting with clients whom I found difficult, wanting very much to speak my mind. I have difficulty holding my tongue when I am frustrated, and I now understand why. I strive to be as present in sessions as I possibly can, and also to feel comfortable with “not knowing.” This has been a real struggle—especially with those clients who so desperately want answers. I think of one particular client who is deeply depressed and suffering from PTSD-related symptoms, who so badly wants to be rid of these unpleasant feelings. Neither he nor I can conceive of how to make that happen, and I can admit to myself that it annoys me. I feel limited by my lack of…whatever it is I feel I lack. A class discussion (3-2-2006) comes to mind when I think of this client and his perhaps unrealistic need to be released from his misery. I wonder that he knows what it was like not to feel this way, pervasive as it seems. Time means little to him, as each day feels very much like every other. The clock may tick on, he feels, but he does not move forward with it. Yesterday, he cried for the first time in our work together, and I avoided saying anything, not wanting to encroach upon this moment of being “alone together.” I felt elated that he was able to express an emotion rather than only talk about it. It was a very odd sensation to feel happy that someone could cry in my presence.

With another client, whom I see in his home, the therapy space has for months been intruded upon by his rather large television. At first, he left the television on, unmuted, for the entire session. This lasted for a couple of months. Around the close of 2005, he began either to turn down the volume significantly or to mute it. All through this time, I never said a word about it, figuring that if it didn’t bother him, then it must serve a purpose. In the past three or so weeks, he has begun to turn off the television, each time describing it as “a distraction.” Yesterday, I mentioned it to him. He replied, “I don’t need it anymore. I used it as a way to not think about things during the session, and now I don’t have to do that. Things are different.” There have been times, working with this client, that I have felt really depressed about seeing him. I often wonder if my presence makes any difference at all. I felt really moved by this experience, partially because it helped me realize that my client is, in fact, taking what he needs from our work together. The effort is not put forth in vain.

I have, through reading Casement, placed much greater faith in my own patience with my clients (and myself) and developed far more respect for the usefulness of interpretations (feeble as mine often seem, to me)—especially when I am able to wait for clients to lead me to them. I look forward with great anticipation to the time, very soon, when I can devote more of my professional energy to developing relationships with those people who choose for me to accompany them down the dark paths that we all so often fear to walk alone.

References

Casement, P. (1991a). Introduction to part two: the analytic space and process. In Learning from
the patient (pp. 187-188). New York: The Guilford Press.

Casement, P. (1991b). Preliminary thoughts on learning from the patient. In Learning from the
patient (pp. 6-28). New York: The Guilford Press.

Casement, P. (1991c). Processes of search and discovery in the therapeutic experience. In
Learning from the patient (pp. 140-157). New York: The Guilford Press.

Casement, P. (1991d). Forms of interactive communication. In Learning from the patient (pp.
64-86). New York: The Guilford Press.

Casement, P. (1991e). Key dynamics of containment. In Learning from the patient (pp. 111-
128). New York: The Guilford Press.

Casement, P. (1991f). Analytic holding under pressure. In Learning from the patient (pp. 129-
139). New York: The Guilford Press.

Casement, P. (1991g). The search for space: an issue of boundaries. In Learning from the patient
(pp. 158-179). New York: The Guilford Press.

Casement, P. (1991h). The analytic space and process. In Learning from the patient (pp. 339-
356). New York: The Guilford Press.

Casement, P. (1991i). Theory rediscovered. In Learning from the patient (pp. 180-184). New
York: The Guilford Press.

Casement, P. (1991j). A child leads the way. In Learning from the patient (pp. 214-247). New
York: The Guilford Press.

Casement, P. (1991k). The experience of trauma in the transference. In Learning from the patient
(pp. 258-272). New York: The Guilford Press.

Casement, P. (1991l). The meeting of needs in the psychoanalysis. In Learning from the patient
(pp. 273-292). New York: The Guilford Press.

Casement, P. (1991m). Internal supervision: a lapse and recovery. In Learning from the patient
(pp. 52-63). New York: The Guilford Press.

Coltart, N. (1992). Slouching towards Bethlehem…or thinking the unthinkable in psychoanalysis.
In Slouching towards Bethlehem (pp. 1-14). New York: The Guilford Press.

Foster, R.P. (1998). The clinician’s cultural countertransference: the psychodynamics of
culturally competent practice. Clinical Social Work Journal, 26, 253-269.

Maroda, K. J. (1999). Reflections on the analyst’s legitimate power and the existence of reality.
In Seduction, surrender, and transformation: emotional engagement in the analytic
process (pp. 161-180). Hillsdale, NJ: The Analytic Press.

Schonfeld-Ringel, S. (2001). A re-conceptualization of the working alliance in cross-cultural
practice with non-Western clients: integrating relational perspectives and multicultural theories. Clinical Social Work Journal, 29, 53-63.

Treating Methamphetamine Addiction Using the EMDR Feeling-State Addiction Protocol

Addictions and Compulsions, Clinical Practice, Digging Deep..., EMDR, Traumatic Experience - addiction treatment, EMDR, Feeling-State Addiction Protocol, FSAP, methamphetamine addiction treatment, Therapy - May 14, 2013

Disclaimer: This blog entry is neither intended to provide a step-by-step guide to using the Feeling-State Addiction Protocol (FSAP) nor is it in any way meant to stand as a scientifically supported statement of effectiveness. The results described herein are merely illustrative of the anecdotal experience of its author when employing the protocol. The FSAP—or any other EMDR treatment protocol—should not be employed by anyone not specifically trained in EMDR and stabilization techniques. The following is meant to represent this writer’s impressions of the protocol and is not meant to supplant writings and research conducted by FSAP developer Robert Miller, PhD. This writer has taken utmost care to ensure that clients participating in this treatment have been fully supportive and desiring of the hoped for results.

It has been such a busy couple of weeks, and I’ve been remiss in posting. It’s nice to be back at the keyboard doing something fun.

I’ve continued to work with clients employing the EMDR Feeling-State Addiction Protocol, and I wanted to offer up a bit more detail of my (and my clients’) experience of it. The client about whom you will read has granted me permission to share this information for training/learning purposes. Please note that names and some details have been changed to protect the confidentiality of the client.

I began working with ‘Tommy’ some months ago, at which point he sought to remain abstinent from methamphetamine use. This was a great struggle for Tommy, owing to the powerful feelings he gained from using, combined with the sex he had enjoyed while high. He acknowledged, though, that he no longer got the same ‘high’ that he experienced very early on in his use, and that, in fact, he rarely if ever had sex anymore when using. The drug had gotten in the way of his enjoyment of the thing he started using for in the first place. Nevertheless, Tommy remained ambivalent about not using. He was in meth’s grip.

After a brief participation in, then an extended hiatus from, therapy, and finding that his life was falling apart around him, Tommy made the decision to go into a rehab program and get ‘clean’. Tommy did just that for a number of weeks, then transitioned into an intensive outpatient program (IOP) and living in a recovery home. It was during this period that Tommy reconnected with me.

The quality and degree of engagement in this second period of work has been very different, and this is when I began to discuss with Tommy the possibility of employing EMDR to address long-standing, unhealed traumatic experience (physical, emotional, and sexual) that appeared to have informed his later use of substances. I already knew that I’d be attending Robert Miller’s Feeling-State Addiction Protocol training in March 2013, and Itold Tommy so. He seemed enthusiastic about possibly being one of the first clients with whom I would try to use it once I returned.

Oh, and before we begin, a ‘key’ for the uninitiated:

BLS = bi-lateral stimulation
EM = eye movements

SUDs = subjective units of disturbance
VOC = validity of (positive) cognition
FS = feeling-state (emotion+sensation+cognition+addictive/compulsive behavior)
PFS = positive feeling-state (the FSAP version of the SUDs)
PC = positive cognition
NC = negative cognition

FSAP processing commenced on April 12, 2013, in a 60 minute session, which progressed as follows:

EMDR FSAP Processing – FSAP Phase III

FS Processing – Session 1

Target Behavior: Methamphetamine Use
Most Intense Part(s): Preparing syringe for injection

Feeling State #1: Euphoria+preparing syringe
Starting PFS: 6
Location in Body: chest

Notes: EM used to facilitate BLS in this session. PFS for FS#1 dropped to 0 after 1 set of BLS. Tommy could identify no other positive feelings connected to preparing to use.

—————————-
Deficit Processing

Wanted Feeling #1: Euphoria
SUDs: 9
Location in Body: upper chest

Notes: Intensity of WF#1 dropped from 9 to 0 after 2 sets of BLS.

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Future Template

Tommy wanted to be motivated in his life, and feel that he ‘belongs’ there, working, attending school, etc. Tommy reported somatic blocks in his chest and stomach, as well as feelings of sadness, in successive sets of BLS, and reported that the initial ‘scene’ felt clear of disturbance after 3 sets of BLS and that it felt totally try that he was motivated and belonged in his life. Tommy was able to proceed through his imaginal ‘film’ of living his life and dealing with potential barriers feeling motivation and a believing that he belongs to life, and responded well to reinforcement of this situation with BLS.

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May 19, 2013 (45 min session)

FS/Behavior Evaluation Since Last Session: Tommy reported that he was unable to ‘conjure up’ any experience of euphoric recall related to preparing to use methamphetamine (the identified initial target) since last session. Tommy reported ‘feeling different’, as well, although he could not necessarily quantify this. Tommy reported two additional triggers: a) Drawing back the syringe after shooting up; b) Imagining someone else using, seeing someone have that ‘first rush’. The second target was addressed first in today’s session. Session progressed exactly as documented below, without any breaks in the 45 minute session.

EMDR FSAP Processing – FSAP Phase III

FS Processing – Session 2

Target Behavior A: Methamphetamine use
Most Intense Part(s): Seeing someone else injecting meth and witnessing their ‘first rush’

Feeling State #1: Feeling free+witnessing another person’s rush
Starting PFS: 5 – 6
Location in Body: Behind eyes; chest

Feeling State #2: Relief+watching
Starting PFS: 4 – 5
Location in Body: Behind eyes; chest

Notes: EM used to facilitate BLS in this session. PFS for FS#1 dropped from 5 – 6 to 0 after 2 sets of BLS. PFS for FS#2 dropped from 4 – 5 to 0 after 1 set of BLS

Although, most of the time, relief is not the core feeling, thus not part of a feeling-state, in this case Tommy appeared very much to be seeking a sense of relief from emotional pain, etc.

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Deficit Processing

Wanted Feeling #1: Feeling free [from mother]
SUDs: 9
Location in Body: Back of head

Notes: SUDs dropped from 9 to 0 after 3 sets of BLS.

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EMDR FSAP Processing – FSAP Phase IV

NC Underlying Feeling: I’ll never amount to anything
Float Back Target: Mother saying this to him when he was younger

EMDR Reprocessing – Target #1

Target: Feeling that he won’t amount to anything

Most Disturbing Part: Mother saying this to him as a child and later in life

NC: I’ll never amount to anything
PC: I can achieve what I put my mind to
VOC: 3

Emotions: sadness; disappointment

SUDs: 9

Location in Body: chest/heart

Processing Notes: Tommy reported SUDs of 0 after 6 sets of EM; adaptive processing began almost immediately. After initial reprocessing, VOS increased from 3 to 5. After 1 additional set of EM, VOC increased to 7. In body scan, Tommy reported no disturbance at all, with no EM necessary. Positive feelings reinforced with BLS. At this point, moved on to addressing Target Behavior B.

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Target Behavior B: Methamphetamine use
Most Intense Part(s): Seeing someone else injecting meth and witnessing the ‘first rush’

Feeling State #1: Excitement+witnessing another person’s rush
Starting PFS: 2
Location in Body: Behind eyes; chest

Notes: When initially asssessed at beginning of session, PFS=4. After processing Target Behavior A, PFS dropped to 2, which was reprocessed at this pointin session. PFS for FS#1 dropped from 2 to 0 after 1 set of BLS.

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Deficit Processing

Wanted Feeling #1: Excitement
SUDs: 0 with no BLS

Notes: Nothing remarkable observed. Identification and processing of NC not undertaken for this cluster, as the session concluded.

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April 26, 2013 (60 min session)

FS/Behavior Evaluation Since Last Session: Tommy reported having a meth using dream where nothing would give him his desired high–at least, not anywhere near to the degree he was used to experiencing it. Tommy reported experiencing a ‘mild rush of heat’ in his body, but he recalled getting angry in the dream because he wasn’t getting his high.

Tommy also reported that a friend who recently relapsed (on meth) offered client a graphic retelling of his relapse experience, and Tommy experienced no triggering at all.

EMDR FSAP Processing – Phase III

FS Processing – Session 3

Target Behavior: Using methamphetamine
Most Intense Part(s): Could not identify

Notes: Client experienced no triggering, but expressed a strong desire for a feeling of relief. No processing on FS, as no positive feelings could be identified.

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Deficit Processing

Wanted Feeling #1: Relief
SUDs: 6
Location: heart/chest

Notes: EM used to facilitate BLS in this session. Desire for relief dropped from 6 to 0 after 1 set of BLS. Processing moved on to FSAP Phase IV from here.

—————————-
EMDR FSAP Processing – FSAP Phase IV

NC Underlying Feeling: If I put my guard down, I’ll get hurt
Float Back Target: Volatility at home growing up

EMDR Reprocessing – Target #2

Target: Volatility at home growing up

Most Disturbing Part: same as above

NC: If I put my guard down, I’ll get hurt
PC: Putting my guard down opens me up for love
VOC: 3

Emotions: sadness

SUDs: 6

Location in Body: chest

Processing Notes: Processing on this target was rather brief, due to time constraint. However, after 6 sets of BLS, Tommy reported feeling much more accepting of the general situation at home growing up, yet realizing how much pain and suffering was there for him and his siblings. Tommy experienced a revelation in processing: ‘It was so much to process [back then]. When I found drugs and alcohol, I didn’t have to process anything’.

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May 3, 2013 (45 minute session)

In this session, Tommy asked to ‘take a break’ from EMDR/FSAP processing to reflect on the work done in the past three sessions. When I asked Tommy about his desire/urge to use methamphetamine, this was his response:

“It would be like if someone said [to me], ‘Let’s go for a swim in the sewer’…it’s like, ‘No thanks. Not today’.”

Tommy reported no evidence at all of cravings or urges to use methamphetamine and no using dreams. Tommy also reported no experiences of feeling triggered to use, explaining by way of the quote noted above. Tommy explored what it has been like for him not to experience cravings.

Summary

At this point, Tommy continues to experience no cravings or urges to use methamphetamine, and we are delving more into the underlying trauma that created the needs that made the development of the feeling-state(s) possible. The final phase of treatment will include reprocessing the negative beliefs Tommy developed as a result of his meth use (the final phase in FSAP processing) remain.

Tackling the EMDR Feeling-State Addiction Protocol

Addictions and Compulsions, Digging Deep..., EMDR - Addictions. Compulsions, EMDR, Feeling-State Addiction Protocol, FSAP, Therapy, Treatment - April 17, 2013

Disclaimer: This blog entry is neither intended to provide a step-by-step guide to using the Feeling-State Addiction Protocol (FSAP), nor is it in any way meant to stand as a scientifically supported statement of effectiveness. The results described herein are merely illustrative of the anecdotal experience of its author when employing the protocol. The FSAP—or any other EMDR treatment protocol—should not be employed by anyone not specifically trained in EMDR and stabilization techniques. The following is meant to represent this writer’s impressions of the protocol and is not meant to supplant writings and research conducted by FSAP developer Robert Miller, PhD. This writer has taken utmost care to ensure that clients participating in this treatment have been fully supportive and desiring of the hoped for results.

After addressing such a challenging topic in last week’s blog post, I decided to take up a lighter subject in my second blog entry: Addictions and compulsions.

My observations have suggested to me that, for some therapists, regardless of their particular bent, addictions are often something that ‘other therapists deal with’. Addictions can feel overwhelming and scary, not only for the person experiencing them first hand, but for the therapist in the room with them. So often in treatment, it seems, there are far more questions than answers in addressing addictions. One of the most prominent questions, in my experience of conducting both group and individual therapy, is, ‘Why does knowing something not translate into feeling/believing it and result in changed behavior?’

As a social worker who employs EMDR rather frequently, I have become very comfortable with addressing the varied reasons why, by helping people move through the emotional barriers that prevent the ‘knowing’ from agreeing with the ‘feeling’—at least when it comes to negative irrational beliefs. (For an explanation of EMDR treatment, please click here.)

Although there are also ways of targeting irrational positive affect via EMDR (Knipe, 2005), until more recently, there seems not to have been an explanation of why someone might keep going back to the same behavior, over and over, even when the person knows that it is hurting them or others in their life. In March 2013, I attended a two-day, intensive workshop training that introduced the Feeling-State Addiction Protocol (FSAP). The FSAP is undergirded by the Feeling-State Theory of Addiction and Compulsion. Both the theory and the treatment protocol were developed by Robert Miller, PhD, based on the EMDR standard protocol developed by Francine Shapiro, PhD. According to Dr. Miller,

The feeling-state theory (FST) of [impulse control disorders (ICDs)] was developed by this author. The theory postulates that ICDs are created when positive feelings, linked with specific objects or behavior, form a state-dependent memory. This state-dependent memory, composed of feelings and the event, form a unit called a “feeling-state” (FS). The FS is hypothesized to be the cause of ICDs (Miller, 2010).

A ‘feeling’ is not the same as an ’emotion’ in this way of looking at things. Here, a feeling is the combination of an emotion, the physical experience of that emotion, and a positive cognition that accompanies them. For example, someone could experience happiness, feel it in their chest, head, and arms, and experience a thought such as, ‘Wow, I really belong with these people’. The three combine into, ‘I feel like I belong’.

The implications of this theory are pretty heady. Just as negative feelings that ‘won’t go away’ can be the result of a state-dependent memory (i.e., the state a person was in when the experience got emotionally ‘stuck’), so can positive feelings. This isn’t just any positive experience we’re talking about, though. This has to have been an overwhelmingly positive feeling for the person, rooted in a strong, unmet (and perhaps hidden) emotional need to feel whatever that feeling is (feeling powerful, feeling like a winner, feeling in control, etc.). The ‘feeling-state’ is a combination of the powerful, positive feeling(s) essentially fused with the behavior that gave the person that feeling. It appears that addictions and many compulsions are not done for the sake of the behavior, according to this theory, but as a deeply felt, emotionally driven desire to experience the overwhelming positive feeling(s) again. For more detailed information, please refer to Dr. Miller’s website.

So, always up for something that might help my clients move through their difficulties more swiftly (if possible), I’ve begun employing this protocol with clients. It’s not easy. (Well, sometimes it is, actually.) However, the key is to accurately identify with the client the feeling states they are experiencing connected to the specific behavior (or part(s) of the behavior) that yield the strongest positive feeling. Without having correctly identified those feeling-states, the protocol doesn’t work. The initial processing phase of the protocol is where the separation of the target behavior and the feeling-state(s) occurs.

I’ve not gotten all the way through the full protocol with any client yet. I’ve only begun employing the thing in the past three weeks, and I’m still getting a ‘feel’ for it (pitfalls, dead-ends, and all) but my clients and I have already seen some really impressive results. Examples include:

Client with a history of polysubstance dependence, focusing on past intravenous cocaine use. After one session, client reported no longer being able to trigger the craving to use cocaine.

Client with history of cutting behaviors. After two sessions (one focusing on the cutting itself, another focusing on the feeling of relief after cutting), client no longer finds cutting—or even other, harm reduction inspired alternatives—desirable or appealing.

Client with history of binge eating of both savory and sugary foods. After one session, client reported that she was able to choose to eat only two small pieces of chocolate rather than eating the whole chocolate bar—and still felt satisfied. Client reported that she had no additional urge to eat more than she wanted.

A single behavior can have multiple feelings attached, so the real trick for me has been to identify all those feeling-states. Also, different aspects of the behavior can been attached to different positive feelings for the client. The key is to weed all of them out at the root. The person does not even need to remember the original, powerful experience. However, it does require that the person be willing to engage in what is known as ‘euphoric recall’ in order to elicit those feelings. Also, if the targeted behavior has become one of a person’s primary coping strategies, then the therapist is potentially pulling the rug out from under their client if they blow through this treatment without a good amount of prep work and resource development, as should be standard with any employment of EMDR as a treatment.

According to Dr. Miller in the training, he has also seen success in taking what I would consider a harm reduction approach to addressing behaviors: Not entirely eliminating the feeling state, but reducing it slightly, so that the client feels a bit more in control and maybe feels that there is a bit more room in their life for other things. Some people may also be happy with reduced rather than entirely eliminated use or behavior.

The examples described above are but a few. However, it appears that this protocol can be used on most any behavior with an emotional compulsion component, including ‘process’ addictions, including relationship co-dependence, and substance abuse/dependence issues. Evidence offered by Dr. Miller in training suggested that this protocol is not effective with features that are specifically linked to Obsessive-Compulsive Disorder, owing to confounding factors.

For more information about the FSAP and Dr. Miller’s work and research, as well as training opportunities for EMDR clinicians, please direct your browser here.

References
Knipe, J. (2005). Targeting positive affect to clear the pain of unrequited love, codependence, avoidance, and procrastination. In R. Shapiro (Ed.). EMDR solutions: Pathways to healing (pp. 189-212). New York: W W Norton & Co.

Miller, R. (2010). The Feeling-State Theory of Impulse-Control Disorders and the Impulse-Control Disorder Protocol, 16(3), 2-10.

Grieving the Death of a Client

Clinical Practice, Digging Deep..., Grief and Loss - April 11, 2013

Well, after being nudged by a social worker colleague of mine who maintains a blog, I decided to do the same—well over a year after creating the space for it on my website, and after a few false starts. Why did it take me so long, I asked myself? Well, for the longest time, I just didn’t have room in my brain for it. Now, well, there’s a bit more room. It was time to edge in and have a seat at the keyboard, I supposed.

I pondered on how to begin the blog, as well, and something happened some months ago that I have felt strongly compelled to share with others. I experienced the sudden, unexpected death of a client, and I imagined writing about the particular way that I grieved the loss. Digging deep, indeed. I hope this entry is of value for therapists and those seeking therapy alike.

Tom (not his real name) and I worked together for about a year, focusing on long-term substance use and emotional attachment difficulties. Tom experienced isolated health scares during the year, some related to lapsing back into substance use, some not. I loved working with Tom, and I saw him make wonderful, if at times very emotionally painful, progress. We met weekly, sharing a cup of tea and exploring his social-emotional terrain. As a new year arrived, so did illness for Tom. We were uncertain what the future held, but Tom was committed to continue our work. Tom expressed concerns about mortality, but we had no reason to believe that his time on this plane of existence was limited.

One week, Tom did not arrive for a scheduled session, and he did not call ahead to notify me of a late arrival or absence. Recently, Tom had missed a couple of sessions out of concern about going out in the cold while still on the mend from illness. Nevertheless, he always called ahead to let me know. The only other instance when Tom hadn’t called ahead was in the midst of an unexpected hospitalization. I feared something was very wrong.

I placed a couple of courtesy calls to Tom over the next two days, and none were returned. This was not characteristic for Tom and, rational or not, I began to wonder if Tom had died. Via an online resource—Tom had a web presence of which I was aware—I discovered a single post from a self-identified friend of Tom stating that Tom had died suddenly and unexpectedly, but in apparent peace.

I had never lost a client to death before. I had lost others close to me, but…this felt different. I experienced a profound numbness that felt very much present but also very distant at the same time. The only word that comes to mind in describing the feeling is, ‘Blecch’. I reached out to a couple of colleagues throughout the day, but most of them were otherwise occupied. I tried to be circumspect in explaining why I seemed so ‘down’ to those close to me, and I spoke with my clinical consultant. Online, I read what I could about coping with client terminations resulting from death, but most of the therapists who posted seemed focused on loss of a client to suicide. I found a couple of articles about maintaining boundaries when participating (or whether to participate at all) in a public celebration or remembrance of the deceased client’s life.

I struggled to decide how I wished to honor this person and the work we had undertaken. I continued to sit with the feelings of loss, but went so far as to re-arrange my office, thinking it would feel a bit better not to look at the sofa from the same perspective. I happened to send photos of the new layout to a close friend who is highly attuned to energy (and to whom I had alluded the recent death of a client). She responded to the photos, saying, ‘There’s someone in your office, and he wants a final session. Could that be the client who died?’ Admittedly, I felt a bit baffled, but then I realized how much sense my discomfort made in this context.

Sitting at the desk in my office then, I immediately turned to the sofa, and said, ‘All right, Tom, I’m scheduling us for our regular time this week. Let’s have our final session’.

That day, at our appointed time, I closed my office door and said, ‘Tom, this is our final session. If you are here, then I hope you’ll acknowledge your presence at some point in the next 45 minutes’. I prepared a cup of Tom’s favorite tea and placed it on the coffee table at his usual spot.

It was as if I were conducting a regular session, with all the periods of talk and silence that one would expect in a comfortable, therapeutic working relationship as I enjoyed with Tom. About ten or fifteen minutes into the session, in a room that is typically about 75 degrees, I felt a distinct chill, to the point that I actually began to shiver. I rolled down the sleeves of my sweater to stay warm.
I continued the session, telling Tom what our collaboration had meant for me and reviewing the progress that I’d seen Tom make in his life since the beginning of therapy—all the while maintaining the same therapeutic tone, the same boundaries, that I’d always maintained when Tom was physically present. I thought I might cry (which would have been fine with me), but the tears never came. I read aloud a couple of remembrances and anecdotes posted online about Tom from others who had responded to the friend’s original post about Tom’s passing.

As the session neared its end, I thanked Tom for allowing me the honor of participating in his life in such a capacity, and I wished him well. I re-iterated that this would, indeed, be our last session, that I needed to make room in the therapeutic space for others’ emotional energy. I opened the door, ushered Tom out with a farewell, and, to my satisfaction, ended a treasured collaboration.

A few moments later, I myself stepped out of my office to clear my head. When I returned, I no longer sensed a chill. I instead felt a sense of both freedom and closure, and I was able to move forward, to return to serving the needs of the living.

Digging Deep…