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HI Everyone !!
Just getting the conversation started for Workshop 3…we talked about providing the patient with Validation, Hope and Understanding early in the process of evaluation and how this is the first step and a critical step in recovery. In fact, if we skip this, we will likely have a resistant patient who feels judged, misunderstood or that we are on the fringe of medicine and don’t know what we are talking about.
I made this mistake just last week !!……a man came to me with decades of whole body pain….all the doctors, tests, treatments, etc. that one has. His ultimate diagnosis was chronic back pain from failed back syndrome and fibromyalgia. I thought he knew what I did and had come to see me to try a new path. In the first hour, I jumped in with this new approach to chronic pain and maybe it could help him – thinking he would be so relieved and excited. However, I had skipped the validation piece. I had read all of his medical records prior to his appointment, but from his perspective, I didn’t listen to his stories. He said I had not listened to him, that I had judged him, that I didn’t know the details of his pain and his experiences and how this had destroyed his life. I went too fast and didn’t listen enough. I had miscalculated how quickly I could go from Validation and Hope to Understanding…I felt really bad. He left my care, so I didn’t get a redo on that one. In hindsight, I should have seen how much pain he was in and been more sensitive to where he was in the first visit – I should have put more testers out there to explore how ready he was to hear the good news and developed the relationship more before diving into it.In fact, I think some patients aren’t really ready to hear there is even HOPE ! After all they have been through, how could there be? and if there were any hope at all, wouldn’t that mean that they had needlessly suffered? And, if they had needlessly suffered, that could, of course, be ENRAGING and too much to bare.
Here is the Live Workshop 3 Recording:
https://us06web.zoom.us/rec/share/Nj90pr7rJB02H-Q37h6cC8HrPYs1B56qujcElIiWCPtMXAJfU69uUivDIx57Cy_0.Qn06-6CKm7ACQYLp?startTime=1678298111000
Passcode: =4wcz+F#Hi everyone. I have a question about regulating anxiety in the moment and how it might relate to validation.
I am working with a 40 year old married father of two young children who is dealing with an episode of depression / anxiety for the first time. He sought treatment with me for “physical symptoms of anxiety.” He has been experiencing disabling migraines. During our last session he mentioned his sensitivity to other people’s emotions and feelings and I commented to him, “you are a very caring person.” He began to get choked up and some tears came. I asked him, what is happening , what are you feeling ? And he said that it felt very unusual, unlike him, different, and I could sense his anxiety rising. So I proceeded to ground him, mentioning his feet were on the floor, he was supported by the chair, I drew attention to a deep breath that he took, and mentioned that “you are safe.” I was pleased that he experienced this wave of emotion during our session. We returned to our conversation.
After we had finished and were making plans for our next session, he told me that what I had said about him “being safe” had made him angry. I was caught off guard as we were done with our session but I felt that I needed to address this. I told him that I was really glad that he told me this (my impression is that he does not do anger— I think he has many situations in his life that make him angry but he keeps it bottled up). He seemed more interested in figuring out why that particular comment “you are safe” made him angry , to which I said that he should give some thought to before next session when we can explore this further. I will be seeing him again later this week.
I am wondering what reactions people may have to this story and whether there might have been a better way to regulate my patient’s anxiety in the moment. I suspect that he did not feel that he was under threat and my comment about his safety may have suggested that he was weak. At the same time, I viewed this as a success as my patient was able to experience both sadness and anger in our session and he shared these feelings with me. I wonder how I might approach future episodes of anxiety with him without evoking feelings of anger – or maybe this is part of the process? Thanks!
Great work, Aaron.
The fact that he was able to express that something made him angry is a great sign. I would explore what about your relationship led to that feeling and allow him to express directly to you anything that he can and is important about that. It will model for him that he can allow anger and express it in a safe and healthy way (with you).
Then you can also explore what might be underlying this; what in his life has led to him being angry. He may have been told that he was safe when he really wasn’t by people who had power over him. There was probably something like that that triggered his reaction. Then you can do emotional processing work (EAET) with him on that situation from the past.
It’s also great that you helped him to tolerate being anxious without fearing it. That is the PRT approach to anxiety (and pain).
Excellent stuff!!
HowardHi Aaron,
Ditto on everything Howard said.
I would not consider a rising of anger as something to avoid or something that went wrong. I would view it as great material to work with and to begin to crack the egg, the hard shell of his emotions. My suspicion is that weakness and vulnerability led to lack of safety in his experience – perhaps, he was ridiculed for his empathy, made fun of, got in trouble in some way, mocked or beat up. I wonder if he can remember a time when he had a similar feeling in the past. Sometimes abusers will look for a persons weakness or try to elicit it and then pounce with they see it – like a tiger seeing blood. Next time you see him, it might be helpful to revisit the situation, see if anger arises again, ask him where he feels that anger in his body, ask him if it has a voice, what it wants to say, what it wants to do, etc.
I thought you did a great job.
AliciaI also wanted to say that anxiety is not always something that needs to be regulated – especially when you are trying to work with a therapist. I think our job is not to regulate it – in a way, that is repression – I think we need to understand what is causing it and to do that, we have to allow it to be for the moment. The rising of anxiety is a sign the danger signal has been turned on. We can use that to explore why that is – what was the thought, the emotion, the thing that was said or done or not said or not done or seen – that made the danger signal sense danger? If we focusing on repressing the anxiety we might miss the opportunity to see what is underneath it. Of course, if the patient’s anxiety is too high, you can’t do the work either….so regulation is necessary. It is an art to know when to help the patient regulate and when to help them explore it.
Agree with Howard and Alicia. I have some other thoughts that the anger might be from the anger toward his parents (or other caregivers) for not making him feel safe as a child. I learned this from Howard as well as Allan Abbass from ISTDP training. That often the repressed anger that is there toward our parents (Allan often specifically said mother) for not treating us as we deserved as a child is always bubbling under the surface and behind everything. When anger comes up, it is often the anger that was created because of the parents’ treatment of the child that the unconscious brain learned was too dangerous to express and therefore the person spends the rest of their lifetime repressing. Tears can often be a protective mechanism to hide the true emotion of anger. A person goes straight to tears and sadness and becomes a weak victim, rather than going to the true underlying emotion of anger which represents more power, strength and a positive core belief of worthiness. A person thinks they are very expressive of emotion because they cry a lot, but it is really covering up the anger. Particularly common in women (this was an aha moment for myself in the training). If you can do the EAET work to process and release that anger, which teaches his brain it is not dangerous to feel the emotion of anger, then it doesn’t surface so much and take over current situations. He can then feel safe because his unconscious brain is not afraid of feeling the anger. Howard taught me love, compassion and understanding is always behind the anger, which is why we don’t need to fear it. Then leaning in to the sensations of the anxiety and welcoming them through the lens of safety with PRT, rather than pushing them away can be helpful. Allan Abbass teaches that the anxiety sensations are produced because of not allowing oneself to feel the underlying emotion. If they allow themselves to feel the emotion, the anxiety will go away. Feel free to chime in Howard and Alicia. This was my take home message.
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