Making the most of therapy
You’ve come a long way. Misdiagnoses, mistreatment, maltreatment even—but eventually you’re here. You’ve found a therapist willing to work with you—either privately or on the NHS—and so now you’re expecting it just to happen. Right?
Wrong! Getting good therapy is an essential step in recovery from complex trauma and dissociative disorders but just turning up doesn’t, in and of itself, make things ‘better’. Therapy is not something that is ‘done’ to us, like radio therapy. It’s not a case of sitting comfortably and letting the therapist do the work. In fact, in many ways, it’s exactly the opposite. For therapy to be effective, we need to actively engage in it. But however much we know we might need it, however much we hope it will be effective, it’s still the case that therapists have been to ‘therapy school’ to know what they’re doing but we haven’t been to ‘client school’ to know how to make best use of it.
And, let’s face it—there’s not much of it. It might be for just an hour or two a week, minus holidays, minus cancelled sessions due to illness or bereavement or accident. It may last just six weeks or six months or two years—however long it’s for, invariably it’s not long enough. So it’s imperative we make the most of those precious hours we have, however few there are. Because, ultimately, research shows (Brand et al, 2012) that therapy is effective and for many of us it’s not only our best chance but our only chance to get life back together again.
So what can we do to make the most of therapy?
1. MAKE IT A PRIORITY
The first session or two can seem vitally important but it’s easy to slip into an easy complacency once we’re underway. We have a lot of reasons, unconsciously, to want to avoid it—we’re vulnerable, we’re talking about difficult subjects, it’s bringing up painful feelings—and occasionally that means that we don’t give it the priority in our week that it deserves. Right from the off, I put my sessions in my calendar weeks or even months in advance and everything else had to flow around it, even working full time. It was over seven years before I first voluntarily skipped a session—and that in itself was therapeutic because I was going on my first ‘proper’ holiday. But apart from that, my sessions take priority over everything else in my calendar. However ill I am feeling, however badly I slept, however busy I am at work—my sessions take priority. Everything else can wait: healing cannot.
2. GET IN THE ZONE
My sessions don’t start at 10.30am on a Tuesday morning. My sessions ‘start’ in one sense on a Monday evening. These evenings too are usually sacrosanct—time to journal, to think, to plan how I’m going to use the session. And the next morning, I try wherever possible to allow myself space before the session starts, and after it has ended. When I had young children, that space was created by leaving early and going to sit in a coffee shop for an hour beforehand to ‘get my head together’. I would read through my journals from the week before, my journals from during the week, I would sketch out things I needed to focus on. Whenever I skimped on this, whenever I didn’t take the time to pull myself out of ‘normal’ life and allow myself some time in this emotional airlock, the sessions were never as productive. Sometimes, out of avoidance, I would find myself getting busy with stuff that I really didn’t need to be busy with, and then, finding myself running late, I would speed to therapy and turn up in a hyperaroused state. It was never the best way to start, to already be out of my window of tolerance.
Punctuality is key. When my therapy was an hour’s journey away and accessible only via The World’s Busiest Road, I would leave two hours for the journey, just in case. Occasionally, an accident or hold-up meant that I did only arrive with minutes to spare—if I hadn’t left so early, I would have missed my session entirely. Most of the time I had an hour to kill but I could use it productively sat somewhere with my journal, planning my session. Better early than never.
3. PLAN HOW TO SPEND YOUR SESSION AND TAKE THE DRIVER’S SEAT
It can be galling to realise that your therapist is not omniscient and even more galling if they operate on a ‘led by the client’ basis and are waiting for you to kick things off. Before I understood it, sometimes it struck me that perhaps my therapist was senile—could she not remember what we talked about last week? Sometimes I thought it was because she was disgusted—she could remember only too clearly what we had talked about last week. Sometimes it seemed that she was lazy—why couldn’t she make more of an effort and think up something to say rather than always relying on me?! And sometimes I thought that she was just clueless and didn’t know what to say.
All of those assumptions were wrong. She was waiting to see what I would bring. Grasping that helped enormously because then I realised that the responsibility to plan was mine, or at least jointly mine. And so it became a matter of priority for me to spend my time between the sessions figuring out how I was going to make best use of the session—not sitting passively by, waiting for the therapist to ‘magic’ me better. It became a collaborative effort, which in turn reduced the power differential between us. I wasn’t in ‘child’ mode, waiting for the ‘grown up’ to know what to do, no matter how ‘child-like’ I felt at times, especially when switched to traumatised parts of myself. I was responsible for my own recovery and so I had to take seriously each week the issue of what I wanted to accomplish and how best I wanted to use the time. I had to see myself as the driver and use the therapist as the navigator. I was deciding where we were going and I was putting my foot down to get us there. The therapist was there to guide me and shout directions. When we worked like this, it was a productive journey.
4. RESPECT THE ‘THERAPEUTIC FRAME’
It’s not a phrase that we are taught about in the normal course of events: the ‘therapeutic frame’. It’s most definitely part of the ‘therapy school curriculum’ (for at least some schools of thought) but it’s an important concept for us as clients to grasp too. It can be thought of as the ‘implicit rules’ for therapy but some of the rules are explicit too, such as the session times and days. In our culture of CityLink vans and Tesco deliveries, we are used to selecting our ‘slot’ and then changing it up to 24 hours beforehand if it no longer suits. But therapy doesn’t work like that. We need to respect the frame: when it happens, where it happens, how often it happens, how it happens. This isn’t a hair appointment that we can rearrange at a moment’s notice. It’s a good thing that we allow it to be a fixed point in our week, and for everything else to flow around it, because it establishes within us what is important, and perhaps for the first time we value ourselves by valuing our therapy. And it’s a good thing that we keep the boundaries of this set-aside time: this is our time to talk in a way that we don’t talk the rest of the week. This isn’t a social chat, nor a stiff, professional interaction. This is a relational encounter where we have a different set of rules, where it’s okay to disclose, where it’s okay to be self-focussed, where it’s okay for parts to come to the fore, where it’s okay to feel and express emotions. But there are a thousand ways that we can sabotage this therapy and attack the frame—we can be late, we can be distracted, we can be sulky, we can fail to pay, we can ‘forget’ to come, we can attack the therapist, we can leave early, we can refuse to engage, we can pretend to be open, we can mess about and play a role. But none of that will help us to recover. If we respect the frame, we respect ourselves.
5. ENCOURAGE OTHERS TO RESPECT YOUR THERAPY
At first, before he trained to become a therapist, my husband didn’t have a clue what it was all about. He was left at home, literally holding the baby, while I went off to ‘do drawings’ and ‘have a nice a chat’. He simply couldn’t imagine what went on in my sessions. During a period of huge stress for both of us, at times he succumbed to thinking that it was all a bit self-indulgent. Fortunately, he loves me and fortunately he is quick and eager to learn and once he began to understand the nature of the work—a ‘cosy chat’ is as far from reality as possible—he began to be supportive of my need for therapy and he began actively to protect this time too. Not everyone will have such understanding and supporting partners or family and it’s a tough battle to have to face, albeit a necessary one. It is vital, where possible, to construct boundaries around your therapy times and to elicit the support of everyone and anyone in doing that. It’s hard enough to face your own ambivalence at going back to that scary room with the scary therapist to talk about the scary things…it’s even harder if a partner has ‘accidentally’ stayed late at work and won’t be home in time to babysit. Difficult conversations need to take place, a commitment from both of you (including, where old enough, your children) that this is important, that this matters, that it will help, that it’s a priority, and that it’s okay for you to commit the time to it. Feeling guilty, feeling ‘selfish’ for taking out this time, doesn’t benefit anyone.
6. DO THE HARDEST WORK BETWEEN SESSIONS
In our avoidance, how often do we get to the end of a session and sigh with relief that that’s over with for another week, and we can put it all out of mind again? It’s a helpful tool to be able to segment our experiences like that—to a point. But recovery comes through challenging our habitual avoidance of all things traumatic, in order to resolve them. And contrary to popular belief, that resolution doesn’t come in the therapy session alone. If you have a two-hour session, or two one-hour sessions during the week, that still leaves you with 166 hours where you can make progress. So much of the therapeutic work is about changing the wiring of our brains, these neural networks of habits and automatic responses that we have lived with for decades. The therapy session itself can be a catalyst for that change but new neural networks get laid down through repetition. Saying once in a therapy session, ‘It wasn’t my fault’ will make a difference, but not as much as will saying it a hundred times during the ensuing week. Journalling, thinking, writing, drawing, meditating, considering, dreaming…our brains can be busy and creating new connections all week long. We can do the work of therapy outside the session by implementing what we have discovered in the session, by reinforcing those new truths and realities.
In one Sensorimotor Psychotherapy session, I enjoyed the benefit for the first time of standing up straight, lengthening my spine, and feeling strength and power and competence in my body. It was a striking experience, as my therapist guided me to mindfully notice the different parts of my body and to imagine myself strong and capable. Previously, when I stood up, I felt weak and helpless and panicky. This was a simple exercise and yet it was a breakthrough moment for me. But the real progress was through my reinforcing it dozens of times the following week, by practising ‘standing’, by doing the exercise over and over and over again. I practised it for weeks and months and years, until I had a habit ingrained in my neural networks, a resource that I could draw on at any moment. I could stand up in front of a room of people—in front of a whole auditorium of people!—and feel strong, and capable and competent. And all because I had taken that initial spark in that one single therapy session and repeated and reinforced it again and again and again until the change was there, in my body, as a memory, as a habit.
The same is true for journalling. Very often I would leave a session with one dominating thought from the session to consider in the following week. ‘It wasn’t my fault.’ There was this magical moment in therapy, this moment of revelation, a peeling away of my worldview and the sneak peek of a new vista. But I had to reinforce it afterwards. So I would go away and journal. I would write reams and reams and reams on whether it was my fault or not, what the arguments for and against were, what it felt like to think it wasn’t, what the reality of my innocence made me feel. Thousands of words, thinking it through, considering it, contemplating it, turning it over in my mind. And when I hit a hurdle, when something jarred and would not lie flat and smooth within me, that then became the focus for the following week, and that session would have fresh impetus and direction. Each week, building on the next, by laying foundations and fetching bricks, so that at the start of every session the materials were at hand, the ground was prepared, and I was ready to build.
7. HONOUR AND GUARD YOUR RELATIONSHIP WITH YOUR THERAPIST
It’s easy to think of your therapist as a ‘professional’, where ‘professional’ means they are not really human, and it’s just a job, and they don’t really care, and they have no feelings to hurt. Certainly, you’re not responsible for your therapist’s feelings, and you shouldn’t hold back on talking about what you need to, for fear of upsetting them. But they are still a human being. You can’t build a relationship of collaboration and mutuality unless you treat them fairly. You expect confidentiality of them but how many times do you slag them off to your friends or undermine them or mock them? How many times does your disdain for them leak out like gravy from a pie? Do you make it hard for them to work with you? Do you turn the therapy into a battle? Are you goading them to reject you?
There may be many understandable reasons—not least your trauma, not least a background of disorganised attachment, not least the stress of your current circumstances—why at times you hate your therapist with passion. But they are just a human being too and, regardless of their efforts to show ‘unconditional positive regard’, it’s so much easier for them to help you if you don’t fight them all the way. If you can honour your relationship with them, if you can guard it by treating them with dignity and respect, if you can be quick to apologise and quicker to forgive, you will gain in the end.
I’m not talking about turning a blind eye or being abused by a bad therapist, an unprofessional or an exploitative one. I’m talking about meeting the good one halfway and showing them that you respect them and that you’re not out to destroy them. They hold a lot of anxiety much of the time in this work—the anxiety of your self-harm or suicidality, the anxiety of whether they’re retraumatising you by going too fast or too slow, the anxiety over whether they’ve said the right thing or done the right thing…I see it from both sides, with a husband who is now a therapist. Everyone works better and relates better from a place of safety and one of the first mentalising exercises you can do—without going overboard and taking responsibility for them and worrying about them or caretaking them—is to consider how you are with your therapist, and whether you’re making it safe for them to work with you, or whether they’re distracted or on edge because of your threats.
Nor can we do the work unless we’re willing to relate. We can’t hang around at the edges, wearing a mask, saying what we think will please or placate. This is therapy. This is where things get said, feelings get felt, reality is faced. It’s not a place for emotional snakes and ladders, playing games with the therapist, trying to avoid saying anything real, trying to hide all emotion, trying to keep one step ahead. That was the way I had to be as a child, to survive. But therapy required that I was willing to engage, that I was willing to be honest—with the therapist and myself—and that I was willing to be challenged. Admittedly, it was something that took me a while to learn. But the therapeutic relationship was something that I had to commit to, to stick with, to be honest about, rather than picking it up and discarding it after a few sessions or months because I didn’t feel it was working. Why wasn’t it working? What was going on? Had I talked about it? Had I tried to work it through? Some relationships, of course, can’t be worked through. But many of them can, and we need to learn how.
8. DON’T UNDERMINE THERAPY BY CONTRADICTING IT THE REST OF THE TIME
We want to live free from abuse, but we continue to abuse ourselves. We want to develop secure attachment, but we continue to be pulled around in insecure-ambivalent relationships. We want to put up boundaries with our abusers, but then we invite them to stay. And we go back into our session the following week, and we hang our head in shame, and we feel the full force of our self-frustration as we say, ‘I’m not making any progress.’
I used to think that I would be able to get something sorted in therapy, and that it would spill magically over into ‘real’ life. I would talk about some trauma, understand what distorted belief it had led me into, and then the ‘ping!’ moment would magic into being wonderful new behaviours. But eventually I realised that the ‘ping!’ moment in therapy is often just the start. I had to make active choices to reinforce that by my actions the rest of the week. I had to start choosing not to abuse myself, not to let my abusers near, and to distance myself from people who sought to control and use me. Very often I had to change my behaviours first, whilst still struggling with the concept, before the ‘ping!’ moment really landed.
But what never worked was pursuing one course of action in therapy, whilst undermining it elsewhere. I didn’t want to live in the hyperarousal of attachment insecurity, the up-down, love-hate of borderline relationships. I didn’t like how I became around certain people—the pull they had on me, the submission they tricked out of me, the way my mind got fixed on where they were and what they were doing. I tried compromising and tried just talking about it in therapy, without doing anything about it. But of course it didn’t work. And it infected my therapeutic relationship, making me nervous and twitchy about that, making me ‘see’ abandonment when it wasn’t there. It affected the work I was trying to achieve. I had to make hard decisions, cut off dead branches, steer clear of the nettles. Anything else would undermine what the sessions were for. There had to be congruence between my intentions in therapy and my actions in the rest of life.
Psychoeducation helps. It really, really helps. At the time of the abuse, did you freeze and do you feel bad now that you didn’t do anything to fight back or escape? You need to understand the freeze response. Is your heart pounding and your brain has gone blank and you can’t find your words? You need to understand about triggers and the front and back brain. Does your therapist’s holiday feel like a threat to your very existence and when she comes back are you both delighted to see her and a ball of rage? You need to understand about disorganised attachment.
So much of the time, we beat ourselves up because we don’t understand trauma, we don’t understand about dissociation, and we don’t understand about attachment. And yet almost all of our behaviours and beliefs are logical in the light of these three subjects. I felt powerless when night after night I couldn’t get to sleep because I couldn’t seem to calm down. Once I understood about hyperarousal and the sympathetic nervous system, I stopped feeling so bad about it. It didn’t instantly solve the insomnia, but it stopped me ‘fearing the fear’—the vicious cycle of anxiety that keeps us locked into a fight-or-flight response. Once I understood that dissociation is a normal and natural response to trauma, I stopped feeling that I was such a freak. Once I understood that the out-breath activates the parasympathetic nervous system and helps to regulate our arousal, I began to feel that there was something that I could do to manage my distress.
Often we go into therapy with the expectation that it will be like visiting the hospital or the GP—that the expert, the white coat, will know what they are talking about, and we just have to give blood, or flex our knee, or say ‘aaah’, and everything will be alright. But therapy isn’t like that. The more we understand about dissociation, the more we understand about trauma, the more we understand about attachment, the easier we will find it to understand ourselves. And the more we understand ourselves, the more we will value ourselves as ingenious survivors who are courageous and resourceful, rather than as the screw-ups that we so often think we are. Psychoeducation helps teach us to have self-respect, and it teaches us tools for managing our distress that we didn’t learn as we grew up. Sometimes that education comes within a therapy session, from the therapist, but we have 166+ hours a week where we can work on this stuff for ourselves, and keep the sessions for the application of that knowledge. Knowledge is power, and power is what we need to overcome the disempowerment of trauma.
10. DON’T LET GO OF THE REST OF LIFE
It’s important to prioritise therapy but it’s important to keep it in balance, too. Therapy is there to help you re-engage with life and conquer the world. It’s not there as a substitute for life. Don’t give up supportive friendships because now you have therapy; don’t quit work because you want to focus exclusively on therapy; don’t stop going out and having fun because every night you’re journalling for your session. Keep everything in balance, and everything in perspective. You don’t want to spend five years in therapy, and then at the end of it look up and realise that you’ve lost the life you’ve been trying to build. It’s good to keep focused on the work that you’re doing in therapy, but don’t become so problem-saturated that there’s no outlet for your steam. The things that you work through in therapy need to be worked out in real life; therapy is where you get to practice and figure out your relating, but you need real relationships in real life to put it into action.
Therapy is our springboard for life. It’s important that we use it to launch ourselves into real living. Sometimes our therapy becomes all we have, because our lives are so deprived. But then it is through therapy that we must increase our relational and experiential wealth, because therapy won’t last forever and it’s only a poor imitation of the rich life that we have ahead of us.