14 Feb Creating a Holding Environment: A Case Study in Utilizing Individual and Group Therapy, the Internet, and Multiple Therapists in the Treatment of the Traumatized Patient.

Posted at 10:32 pm in Individual Therapy by jlbworks

Differentiation…propels the developing child to grow to be an emotionally separate person, with the ability to think, feel, and act for himself…The more entangled and intense the emotional atmosphere a person grows up in, the more his life is governed by his own and other people’s feelings…Increasing one’s ability to distinguish thinking from feeling, in oneself and others, and learning to use that ability to direct one’s life and solve problems is the central guiding principle of family psychotherapy. (Kerr, Michael E., “Chronic Anxiety and Defining a Self,” Atlantic Monthly, September, 1988, pp. 41-42)

Lack of differentiation is a key to understanding both males and females who desperately return to destructive relationships…Adults with poor developmental histories also seek out and remain in undifferentiated relationships because it makes them feel less empty and alone…The normal healthy sense of self has a firm boundary around it that cannot be breached. The empty, emotionally abandoned individual invites others ‘on the outside’ to come ‘inside’ in order to make them feel whole. (Celani, David P., The Illusion of Love: Why the Battered Woman Returns to Her Abuser. New York: Columbia University Press, 1994, pp. 41-42)

A poorly integrated ego leaves the unfortunate person on the brink of chaos. This is yet another ‘key’ reason… that the poorly reared child develops into an adult who is confused, chaotic, and easily taken over by others. The poorly integrated individual has so many contradictory views of himself, and of others, that he loses all confidence in his perceptions, feelings, and opinions. He is easy prey for people who (to him forcefully) present another version of reality, for he is so unsure of his own shifting and chaotic view. (Celani, pp. 60-61)

The struggle between the newly internalized memories (from the psychotherapy hour) and the enormous pressures from inner emptiness turns out to be a David and Goliath battle, as is seems impossible for the fifty-minute hour to compensate for a lifetime of neglect. (Celani, p. 191)

I would like to thank Marsha Robertson, Dr. Tom Campbell, Christina Oliver, and my wife, Dr. Nilufer Yalman, for reading the first draft of this talk and making helpful suggestions. Nilufer was particularly helpful in suggesting how to organize a great deal of clinical material.

Today I would like to present an ongoing psychotherapy case which I believe highlights the challenges we face as psychotherapists in working with traumatized patients. I have her permission to talk about her treatment. If you recognize this case in some way, I ask that you maintain strict confidentiality regarding this material.

I have chosen this case partly because there are a number of email exchanges with the patient which illustrate my effort to maintain an adequate “holding” environment for her, while at the same time trying to keep to a psychotherapy frame which would dictate that therapy takes place in the office, and not over the Internet.

This is also a case which illustrates my belief that with many patients, especially those with traumatic histories, we need to provide multiple modalities and sessions per week, as we seek to provide as many “newly internalized memories” as possible in the “David and Goliath battle” with the patient’s years of neglect and/or trauma.

While you will note a number of thoughts and behaviors in this case which suggest a borderline level of personality organization, I find it more useful to approach this case from the perspective of the impact of severe neglect and trauma on this individual’s personality and coping skills.

This case begins with an email from the prospective patient, whom I shall call Ashley, almost four years ago. She writes, on May 3, 2012:

Dr. Chanin,
“I stumbled upon your page while looking for a therapist/psychologist online. I have been thinking for quite a few years about possibly talking to someone, like you. I have been on antidepressant medications (off and on) since I was 18. While I feel that they have provided some relief, I think I could benefit even more from individual therapy.”

I call Ashley in response to her email and learn that she is 29 years old, married, and lives an hour away from Nashville, TN. We schedule the initial consultation.

At the first appointment, her response to my question, “How can I help you?,” is that she wants help with her confidence and self-esteem, wants to not feel depressed all the time, and she says that she is struggling with anxiety at work and out in the public. She also complains about fighting with her husband a lot because of his not helping her enough. They have two sons, aged 9 and 7, whom I shall call Bailey and Alex. She has had no prior experience in individual psychotherapy.

With all new patients, I try to take a detailed history. Ashley was the only girl, with three brothers. They lacked parental guidance and involvement from an early age. Their mother worked the night shift, and their father left for work at 4:30 a.m. Ashley states, “We made our own lunches and we walked to school—my mother wasn’t there”

I ask Ashley to describe each of her parents, as they were during her childhood. Of her mother, Ashley states,

“She worked nights as a nurse and slept a lot in the daytime. Mostly I didn’t tell her anything—I worried I’d get in trouble or that she’d be mad about it. She was unhappy with my father. She had a daycare in the house—a bunch of kids everywhere. She was busy with the four of us and all the other kids. Her own father never talked to her—maybe one or two sentences in her whole life.

When I ask what would happen when her father got home, Ashley relates:

“He yelled and spanked us with belts or hangers. It happened a lot, and left marks. I was afraid of him—an Army guy. He was in the military for 25 years—an authoritative parent—kind of mean. I learned how to not make him angry. If we made a mess, we’d get whippings, until somebody admitted it. I would be the one to admit it. He drank every day. When my older brother got caught drinking, my father told him, ‘You shouldn’t drink—it turns you into an asshole.’ My father added, ‘I’ve been drunk for thirty years.’”

When patient’s mother married her father, she did not know that he had already been married six times, and that these relationships had supposedly ended due to the father’s infidelities. Once her mother found out, she was often suspicious that he was cheating on her. One time, her mother drove with Ashley, then aged 18, to the house of a woman with whom she suspected her husband was having an affair. Later, her father admitted to having an “emotional affair” with the woman. Ashley says to me, “I couldn’t imagine him having an emotional relationship with anybody!”

As Ashley’s story unfolds, the parental neglect from her childhood is obvious. The trauma becomes evident more gradually—the fact that her father shot her with a bb gun from the front porch when she was out in the yard, and that he would also shoot and kill dogs, cats, and other small animals from the porch.

Ashley enjoyed grammar school and made good grades. She did not like high school, saying, “I was really shy, and didn’t have many friends.” Though she never had a date in high school, her father thought she was promiscuous because he found cigarettes in her car. He said to her, “Sluts smoke—that’s what you are!”

After graduating in the top 15% of her high school class, Ashley enrolled in a nearby state university. Having moved out of her parents’ home at age 18, she experienced her first bout of depression, suggesting significant separation/individuation issues, as is common with children of neglect and abuse. She went on Zoloft, which helped with the depression, but she self-medicated extensively with alcohol and marijuana.

Ashley met a man, whom I will call Steve, during her first semester, and he became her first and only boyfriend. They never used birth control, and yet she was shocked, in her 3rd or 4th college semester, to find out that she was pregnant. Once she was pregnant, Ashley and Steve began living together. After the birth of her son, she went on birth control, but got pregnant again two months after starting a job training program. At that point she and Steve did marry.

After the birth of her first child, Ashley experienced severe post-partum depression, likely re-experiencing the loneliness and lack of support of her childhood. She went on Lexapro, which helped her pull out of the depression. Describing the current state of her relationship with Steve, now 10 years later, Ashley relates that they are still fighting, that she gets little help from him, and that she experiences her husband as being like her father.

At her second appointment, Ashley demonstrates, as David Celani has written, “her lack of confidence in her perceptions, feelings, and opinions.” She felt guilty about what she had told me, in her first session, about her parents, and had called her brother to ask him, “What were Mom and Dad like when we were growing up?” Her brother confirmed her memories about their parents.

During this hour I take a sexual history. Sex was never talked about in Ashley’s family, and her mother never prepared her for menstruation. When she had her first period, she sneaked into her mother’s bathroom for pads, having heard girls at school talk about their periods. Ashley recounted, “It was rough—I didn’t know what I was doing. There were accidents at school–I didn’t tell my mother.

Steve had been Ashley’s first sexual partner. She had other partners, usually one night stands while drinking alcohol. At age 19, on New Year’s Eve, she had gone to a bonfire alone, drank way too much, and asked to stay in an available room at the party. Someone came in during the night and had sex with her. When I asked if she’d been raped, Ashley replies, “I didn’t know to call it that—I tried to stop it.”

When I ask if she ever has nightmares about it, she says, “Sometimes—every once in awhile. I wake up really scared, trying to get away from somebody. If I’m sleeping and my husband tries to put his arm around me, I’ll wake up and fight him a little bit. I always sleep with the light on. I don’t like to be in the dark. I don’t want to have sex as much as he does. If I could never have sex, I’d be happy.”

Ashley became pregnant while using an IUD in 2009, and suffered an emotionally traumatic miscarriage at 9 weeks, having to carry the fetus that she knew had no heartbeat for another week. She describes being depressed for several months afterward, and continues to be terrified of getting pregnant again.

I gave Ashley a depression screening test, in which she scored in the positive range for all nine DSM IV diagnostic criteria for Major Depression. I had also administered the Substance Abuse Subtle Screening Inventory (SASSI), which results suggested that she had a “High Probability of having a Substance Dependence Disorder.” I referred her for a medication evaluation with psychiatrist Scott Ruder, M.D.

Though she has largely refrained from using marijuana due to fears about random urine screens at work, Ashley has continued to abuse alcohol. She states:

“I will drink most nights, after the kids go to bed. Usually it’s vodka straight, 3 or 4 or 5 drinks a night. I drink it right down. I don’t really like it—it doesn’t taste good. But it makes me feel more relaxed and I can stop thinking about things.”

In her third session, we now begin to focus on such areas as her depression, her alcohol abuse, and her difficult relationship with her husband. Ashley states, “He seems like he is the one who is always right and I’m always wrong.” (Remember again the opening quote in this talk about the individual who “loses all confidence in his perceptions, feelings, and opinions.”) I say to Ashley, “It sounds as though you don’t have a lot of power,” to which she agrees. I ask whether this might be contributing to her depression, and she emphatically answers, “Yes!” We might hypothesize that Ashley’s depression is related to the fact that she has so much feeling that she can’t express, and she is so uncertain of her right to express her feelings.

Between the 3rd and 4th psychotherapy sessions, Ashley meets with Dr. Ruder, who starts her on Wellbutrin. She makes a concerted effort to reduce her alcohol consumption. She begins to read a number of books I suggest related to her experience in what I would call her narcissistic family, meaning that the children’s needs were subordinate to parental needs. Dr. Volney Gay might speak of her experience in an inverted self object family environment.

Following her 7th session, she takes her first ever airplane trip by herself. Ashley recounts that she and her husband have been fighting ever since she returned, and that he has forced her to have sex. Ashley states, “There is no point in telling Steve how I think about things.” I ask if this is similar to how it was with her mother. Ashley answers,

“It reminds me more of my Dad—the boss of the house. Steve makes me feel like I’m the kid and he’s the parent. I get in trouble, like a kid gets in trouble. I told him, ‘We should be separated for awhile. It would give you some time to be away from me. Maybe you’d be better without me around.”

After her 15th session, Ashley sends me her first email:

“Sorry, I don’t know if it is okay to email or not. I am really sorry I kept the fact I had been drinking again from you. I am disgusted with myself. I will dump all that I have out, and will be more honest with you. I hope emailing you doesn’t make me seem like a crazy person, I just wanted to apologize.”

I email her back, saying, “As I said, don’t beat yourself up about it. Setbacks are all part of the process. I think you are doing great work in your therapy.”

In the following session, Ashley describes ideas of reference, meaning that she imagines others are thinking negative things about her. She states,

“Work has gotten worse. I keep thinking about what other people are thinking about me. I’m trying to tell myself, ‘These are just my thoughts.’ But I imagine that they are saying things like ‘I’d rather have somebody else work on the floor. I don’t like being around her. She doesn’t fit in very well.’”

In her 20th session, Ashley reports a dream she had after her previous psychotherapy session:

“It’s scary—I’m in my parent’s closet. I’m looking through it—clothes from a long time ago. I’m getting choked—there are hairballs in my throat—it’s so gross—like out of a drain—cockroaches coming out of my mouth.”

When I ask Ashley to associate to her dream, she responds, “There are things I need to be talking about in therapy.”

In her 21st session, Ashley again begins to talk about her relationship with her father. She references her ½ sister, who grew up away from their father:

“She thought she was missing out on something—we didn’t get his attention either! He was always in his own world, watching television, sitting in the same spot. He wouldn’t talk to anybody. At supper, nobody could talk. He’d get mad if you didn’t eat everything on your plate. We couldn’t make any noise when we ate. We couldn’t drink anything when we ate. I’d have to sit there until 10 or 11:00 p.m. if my plate wasn’t clean.”

In her 30th session, Ashley continues to talk about her marriage and the impact of her psychotherapy:

“Steve is smoking in the house again. I’m not saying anything—it’s best if we’re not fighting right now. Everything is easier if I keep doing what I’ve always done. Coming to therapy makes everything harder. It makes me think that I should expect something different from people.”

I respond by saying: “Therapy challenges your living with familiar unhappiness.”

We also begin to explore Ashley’s extreme social anxiety, which I have found to often be part of the clinical picture with patients with extremely low self-esteem. I administer the Social Phobia Inventory, in which she scores in the severe range of symptomotology. Ashley relates her efforts in presenting and maintaining a False Self:

“I have a hard time at work, being around those people, with no time to myself. I’m having to pretend that I’m normal. I don’t like going to the grocery store. I dread going to a graduation party.”

In her 32nd session, now 6 months into therapy, Ashley tells me for the first time about her self-mutilating:

“I cut myself with a razor blade, about 2 inches long. I got really anxious about things. I knew if I cut, I’d calm down. Last night, my husband saw it—was really mad at me. It started when I was 12—I was in trouble and got sent to my room. I saw a pencil on the floor—did it on my arm—it calmed me down.”

I ask Ashley about why she has not told me before about her cutting. She answers, “I didn’t want you to know it. I could stop doing it and then you wouldn’t think bad of me for doing it.” I ask her what she thinks about her cutting. She says, “It’s a coping mechanism for some people.” “Like alcohol?,” I ask. Ashley responds, “It’s similar. Friday I thought, “I need alcohol or to cut—either will work.”

When I ask about what precipitated the cutting episode, Ashley replies,

“I was worried about things between me and Steve. What if I’m not telling Dr. Chanin the right things? I’m anxious about starting group therapy, and sitting in here. I wish it wasn’t a problem to sit in a group. My husband says, ‘You are mentally ill.’ If I am, I’m not seeing things straight—I’m seeing things through a crazy person’s eyes.”

Here we see another illustration of David Celani’s idea that the victim of childhood trauma and neglect “is easy prey for people who forcefully present another version of reality, for she is so unsure of her own shifting and chaotic view.” Ashley clearly has major identity issues and is so unclear about who she is and what she actually experiences.

After seven and ½ months of weekly individual therapy, I had invited Ashley to become a member of my women’s group, for adult children of narcissistic families, which I now co-lead with Julia Marx, M.F.A., M.A. All of the women in the group have at least one narcissistic parent. I anticipate that group will be challenging for Ashley. The night after the first group meeting, I receive a 2nd email from Ashley:

“Hi Dr. Chanin. I was pretty upset after group yesterday. I know I did terrible, but I promise I did the best I could. I’m afraid I won’t be able to contribute. I’m embarrassed. Do you think it will get better? Or do you think I shouldn’t be in the group after all?”

I write Ashley back: “You did fine. Please don’t worry about it. Everyone was happy to have you there. Everyone is anxious at the beginning. You spoke very clearly when you talked. Just give yourself some compassion and patience. Group can be very hard because we go back to the same behaviors we used to survive in our families.”

In her individual session the following week, Ashley speaks again about her struggles with her husband: “Steve was mad that I didn’t clean all day. He said, ‘You don’t need to go to therapy.’”

The evening of her 42nd individual session, I add two members to the group therapy, taking it from seven to nine members. Ashley sends me her 3rd email the next morning:

“Dear Dr. Chanin,
For some reason, group is harder with more people. I understand the need to be challenged. I have a lot in common with the other girls. I know they wouldn’t judge me for anything I say. It feels like when I am in group a wall comes up. I can’t put my thoughts together well. I’m busy trying to cover up my emotions. I left feeling inadequate, stupid, and alone. I really hate myself right now. I have a prescription for clonazepam from Dr. Ruder, which I took. It is helpful, but it can’t fix a personality defect. I messed up last night. On the way home I purchased alcohol and drank it while driving. I’ve never done that. After getting home, I had sex with Steve—the kind where I let him be mean to me. I already regret sending this, but if I don’t I’ll come back Tuesday and pretend that things are alright.”

When Ashley is desperate for relief from her own “inner critic” voice, she turns to alcohol. And she allows her husband to mistreat her sexually.

In her 44th session, Ashley continues to talk about her struggles with her husband:

“Steve says he is worried about my salvation and that I should be reading the Bible more. He calls everything but the Bible ‘Devil Books.’ He says it is his mission to save me.”

Three weeks later, Ashley relates recent problems with Steve:
“He is giving me ‘The Silent Treatment.’ He wanted to do something sexually that I didn’t want to do. Then he got all mad and said, ‘Forget it!” The next day he ignored me and is still ignoring me.”

Here Ashley may be externalizing her own conflicts, as she gives me “The Silent Treatment” also, is often unable to tell me things during her sessions, and then does so by email instead.

The morning after her 48th individual session and group meeting, I receive her 4th email:

“I had a dream that I was getting on a boat with a group of people, and all of a sudden I find myself in the middle of the ocean, alone and in the midst of a storm. I am afraid that I will be all alone, and that the support and trust I have in you is an illusion. I feel like I am going to get myself into something I can’t handle, and I’ll be abandoned.”

The dream makes evident Ashley’s struggle with object constancy. She is fearful that I will disappear and let her down like the other people in her life, past and present.

In her next session, Ashley recounts at length the recent conflicts with her husband:

“I told Steve, ‘Stop telling me that my perception is wrong.’ He said, ‘I’m never going to therapy. I hate your therapist—he’s filling your head with a bunch of relationship crap!’ He keeps trying to make out like I’m crazy! He said, “You want a gay man—then you’d be happy. Straight men don’t talk about their feelings!’”

After her 53rd individual session and group meeting, Ashley sends me her 5th email:
“Dear Dr. Chanin,
I feel like the girls in group don’t like me. I think you don’t like me. I feel like I don’t belong anywhere. I feel like a stupid little girl. I can’t risk ever losing Steve. He kept me safe when everything around me was terrifying. My mom and dad hated me. What do I do to fix that?”

Her emails suggest that Ashley is struggling to contain her feelings within the boundaries of her therapy hours. She has experienced so much neglect and trauma at the hands of her parents and is terrified of being alone and unwanted.

On the morning after her 55th individual session and group meeting, Ashley sends me her 6th email:

“Let me start by telling you this dream. I am in grade school sitting alone under the slide. A group of boys taunt me and throw rocks at me, and I do nothing. Then I find myself in a dark room, the boys are now men, and they continue throwing rocks. All the rocks are yellow. Then two of the men hold my arms down and I can’t move. And I’m crying. And I’m asking them to please stop. They shove rock after rock in my mouth. Then they shove more rocks into my vagina. And I am in pain. And then I wake up. I’ve been drinking the past couple of weeks. Before sleep and before sex.”

In the dream, Ashley is unable to stand up for herself, and then is horribly violated. I begin to suspect that there is incest or other sexual abuse about which Ashley has as yet been unable to tell me. I also believe that she is so afraid to talk about this because she fears retaliation or abandonment or that I will think she is a horrible person.

I email Ashley back the following morning: “Ashley, I’m glad you were able to share all of this with me now. While your dream is certainly very disturbing, it shed’s light on some of the work that needs to be done in therapy and in EMDR.

At this point, I suggest to Ashley that she would benefit from EMDR, and I make a referral to NPI member Christina Oliver, M.A., for EMDR treatment.

In her 58th individual session and also in group, Ashley talks about a bachelorette party she’d attended over the weekend, in which she drank a lot, partly to cope with her extreme social anxiety. That evening she sends me the 7th email:

“Dr. Chanin,
Now everyone knows that I’m an unfit mother. I’m like my Dad. I’m feeling really bad. As well I should, I deserve to feel like the piece of shit that I am. I just tucked the children in bed. I don’t deserve them. I’m going to ruin them. I’ve brought my troubles on myself. Who do I think I am? I’m ashamed for you and everyone else to know that all I am is a fat, disgusting, alcoholic. I’m feeling really bad. Please tell me everything is ok and to stick with therapy.”

Ashley projects her own intense Inner Critic onto others, is so afraid that the other members won’t like her, and that I too will reject her.

The evening after her 59th session, I receive her 8th email:

“Dr. Chanin,
I was dishonest in our therapy session today, and I’m sorry. I told you that I didn’t do anything self destructive last week, but I did. I used a curling iron and burned myself on my hip. I couldn’t bring myself to tell you because I am embarrassed that I’m the kind of person that does that sort of thing. I’m just sorry I lied about it today.”

It is often hard for Ashley to be forthcoming with me in her therapy sessions, and she feels more able to unburden herself by email. My therapeutic challenge continues to be how to help Ashley reveal more to me during her face-to-face therapy sessions. As her therapy deepens, her anxiety increases that neither her therapists nor the group can tolerate her.

After her 64th session, Ashley sends me the 9th email. After 14 months of therapy, she tells me about another self-destructive behavior:

“I caught myself telling a lie today. I have binged and purged, sometimes just purged. I guess it started around 7th grade maybe? I only did it occasionally and haven’t done it in like 9 years. Laxatives and diuretics have taken its place, when I’m feeling guilty over eating too much. What a disgusting thing to do.” In her 68th session, Ashley relates that her struggles with her husband continue. Her 10th email is sent several days later:

“Dr. Chanin,
Yesterday I had a hard time. I think my inner critic got to me. I couldn’t calm myself down. I started having suicidal thoughts. I wouldn’t do that to my children. But it wouldn’t go away. I knew cutting would help, and after awhile, decided to go ahead with it. I used a razor and cut my upper leg until I felt better. I am okay now. The thoughts were just thoughts, I could never do it. I am sure I wouldn’t be able to tell you about this during our session, so I am telling you now. I’m trying not to email you. I guess I just want to feel less alone.”

Ashley again reveals by email her deep despair and hopelessness that she feels unable to share with me face to face.

In her 80th session, Ashley returns to her conflicts with her husband:

“Steve is ignoring me again. He acts like I did something wrong, like he’s angry, like he’s aggravated. He woke me up at 3:00 a.m. Sunday morning, saying, ‘I have needs. You’re not fulfilling my needs.’ I told him, ‘The only time you’re nice to me is when you want sex. Then he said, ‘If you want me to be nice to you, you have to have sex.’”

Here Ashley may be attributing to her husband the anger she must feel that she has to be so accommodating to others for them to be nice to her.

One morning the following week, Ashley sends me the 11th email:

“Dr. Chanin,
I have really messed up this week. My children cried for about an hour telling me how mean their daddy has been to them. I realized then that I have to keep Steve happy for their sake, too. So I’ve been drinking more, mostly to make having sex easier. I should be able to handle this. It’s getting so hard to pretend like everything is okay. I feel alone.”

In her 85th session, I tell Ashley that I will soon be going out of network with all insurances, including hers. That afternoon she sends the 12th email:

“Dr. Chanin,
I feel so sad. I looked it up. I can’t afford it. Steve will not let me spend that much. I don’t know what I will do. Of course you are worth the amount I would need to pay, I just can’t afford it. I thought I had more time. You have really helped me, but there’s more I need to do. I can’t go to someone else. I made Christina mad last week and now I find out I can’t come to you either. I’m trying to avoid listening to the voice in my head that says you want to get rid of me because that’s not the way it is, right? I feel like such an idiot right now. I think I will be lost if I can’t come see you anymore.”

My telling Ashley that I will be going out of network triggers abandonment panic. That evening I email her back: “When we meet next week, let’s talk about what’s affordable for you. You and I have more work to do, and I know that will take time. The good thing about having my own practice is that I have the flexibility to work with what people can afford.”

In her 90th session, Ashley talks about her conflicts with her husband that week, in the midst of a cold winter, over heating their home:

“It’s been a rough week—last night the heat stopped working. It was 50 degrees in our house this morning. Steve just went to work—he didn’t want me to call anybody to fix the heat. He didn’t want me to even get a space heater. He said, ‘We could sleep outside with blankets—it’s silly to think that heat is important.’”

In her 97th session, Ashley makes a statement that suggests the progress she has been making in her therapy. Remember the opening quote in this talk about the critical importance of “increasing one’s ability to distinguish thinking from feeling, in oneself and others?” Ashley states, “I’m getting better about dealing with guilt. Even if I feel guilty, it doesn’t mean I am guilty. Like about Steve’s clothes not being clean for a week, after I’ve just worked 3 12-hour days.”

Four months later, following her 110th individual session and group meeting, I receive the 13th email:

“Dr. Chanin,
I can’t relate like the others. I have too much to hide. What if I just said everything? How bad it is, how bad it was. Then what? Then I’ll be left with a whole bunch of garbage that I won’t know what to do with. I really will be all alone. What about your judgment of me? Could I even stand it? I care more about what you think than any other now. What if things I remember aren’t true? What if I really am the sicko I’ve told myself I was all these years. I wish one day I could come to your office and tell you everything. But then what? What if you think I’m a bad person? What if you hate me? Things would never be the same. Did I bring all of this on myself? All the bad, I brought on myself. I asked for it. I really did. Because I’m weak. I need your help. But I need to be honest. What if I face the past and you don’t want to hear about it? No one wants to hear it. I know that. It’s me that is stuck with it. But how do I move past it? You’ve most likely heard it a thousand times. But I need you to tell me you want to hear anything I have to say.”

Three weeks later, in her 123rd session, I decide to return to her words in this email, and remind Ashley of her wish to “one day come to my office and tell me everything.” And I say that I do “want to hear anything she has to say.” She then begins to try to tell me about incest with her father, though she mostly goes silent and can share only that she had nightmares around ages 6 to 8, and would go to her parent’s bed. In her session the following week she tries again to tell me, but again is unable to say very much about what happened. The morning after this session, I receive another email:

“Dr. Chanin, I was wondering if I could email you about it. If not, I understand, I know it’s better to do it during the therapy session. I just think it would be easier.” I write her back, saying, “I think it would be better to write everything down and then share with me at a therapy session. I know that’s harder for you.”

Three weeks later, in her 126th session, Ashley tries again to tell me about the incest with her father, but again is unable to tell me anymore. I decide to tell her that is would be okay to email me about what happened. Two days later I receive the following email:

“I come to his room because I am scared. Mom gets really mad when I come in. She sends me back sometimes but Dad lets me stay. One night she is so angry,she goes to the couch, and never comes back. He touches me down there. His hands are rubbing me, I feel his fingers down there. I pretend to be asleep. He was nicer to me then. I knew it wasn’t right, and I felt guilty, but I kept coming back. Then, I think it was 5th grade, Dad was in the shower, and I hear him calling my name. He’s standing in the shower with the door open. I feel shocked, seeing him with no clothes on. Everything he is saying sounds far away, like we’re under water, and I feel far away, like I might pass out. I look out the window. The bars. I’m in prison. I tell him I don’t want to, I’m crying. I think he’s mad. I’m scared. I hate when he’s mad. I tell myself just do it, get it over with. He wants me to. He tells me to give him a kiss. Put it in my mouth. I do what I’m told. Later I tell myself over and over, ‘You’re sick. You’re a sicko. You’re a liar. Stop thinking about it! There’s something wrong with you. They’re all gonna know what a sick twisted person you are!’ I keep telling myself I made it up in my sick and twisted and perverted mind. My Dad never touched me again unless he was hitting me or choking me or slapping me or pushing me or throwing me down.”

Several years ago, in an EMDR session, NPI member Janis Christenson said to another of my patients, “This memory has been feeding you those (negative) beliefs about yourself—you’ve been carrying them around, all these years.”

As I believe is clear from this recounting of Ashley’s work over a two and a half year period, psychotherapy with an individual with her level of neglect and trauma is indeed a “David and Goliath battle.” On the Goliath side is her internalized “wounded self,” filled with the neglect and abuse of her parents, including incest with her father, and complicated by her adult history of rape and the interactions with a controlling husband. At a very deep level she believes that she is bad and that no one could possibly really like her or care about her. Overwhelmed by her shame, emptiness, and rage, she repeatedly turns to self-destructive actions such as alcohol abuse, self-mutilation, and eating disorder behaviors to obliterate the feelings she cannot bear.

On the David side is her native intelligence and her determination to pursue her psychotherapy even against the repeated opposition of her husband and despite having to commute an hour each way to get to therapy. She rarely misses an individual or group therapy session. Also on the David side is her willingness to make the time and spend the money for multiple sessions of therapy per week, including her individual sessions with me, her group sessions with Julia Marx and me, and her EMDR and trauma work with Christina Oliver.

Ashley was often more able to reveal herself to me by email than in the office. When I discussed this case with Dr. Tom Campbell, he suggested to me that in fact Ashley’s emails have an adaptive function. Given her history with an abusive father and a difficult husband, it seems likely that she has a powerful transference resistance to me as a male therapist, meaning that she emotionally shields herself from sharing more personal and intimate details of her life when with me in the office. The emails give her a way to speak about these details and thereby bypass the resistance she feels so strongly when with me face to face.

In my emails back to her, I consistently sought to reassure her, validate her experience, and tried to help her to remain hopeful about her work with me and in the group. I believe that this repeated validation is critical in Ashley’s becoming more able to internalize a supportive view of herself.

In an email to me following a reading of the initial draft of this presentation, Christina Oliver made the following observations about the progress she has seen in her work with Ashley:
“She has made some behavioral changes, like attending social functions at work and saying no rather than yes to requests for help that are too much for her. She questions her projections of negative judgments that she puts on others, reminding herself that others probably aren’t thinking of her at all. She gradually has allowed her husband to manipulate her less, and questions her own sanity less as he tries to convince her that her depression is the result of her own problems rather than the imbalance of power in their relationship. While he is punishing her by ignoring her, she has started to make plans for herself and her kids, to keep herself busy and her spirits up, rather than isolating herself and staying in the house feeling badly about her marriage.”

I will close with another quote from David Celani. While he is referring to battered women, and Ashley is not actually being physically battered, I believe that she fits the profile. He writes:

“When the therapeutic process goes well, it is possible to restructure the ego of many battered women in three to five years of individual psychotherapy / individual counseling. This assumes that the therapist has a good working model. It also assumes that the patient has the insurance or financial resources to pay for the long course of treatment. It is a venture that has many obstacles in its way because of the sheer amount of time it takes to repair characterological disorders. Long-term treatment of the abused woman demands that the patient think of the future rather than the present and lead a stable life that allows her to stay in one geographical area for many years. (Celani, pp. 205-206)