Kindle Notes & Highlights
In sessions, the timing of the responses is all-important: sensing when to speak and when to hold back and let the client ‘get there’ for herself.
Good therapists are able to pick up and use clients’ language and metaphors in their turn-taking side of the conversation.
In addition, therapists are aware of the arc of a session; they hold back near the beginning, allow intensity to build up, and wind things down as the end comes into view.
When therapy is in trouble, therapist and client seem to be on parallel tracks, each with their own agenda.
Or therapists’ anxiety leads them to cram in interpretations or instructions; the client is not receptive
and cannot ‘hear’ what is being said.
Therapist comments take the form of ‘lectures’ or are jargon-ridden, rather than usin...
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In psychotherapy, early trauma will, one way or another, be ‘re-played’. Unavoidable or inevitable holiday breaks, minor mistakes and failures on the part of the therapist will re-evoke egregious traumata from the patient’s past (absence, exploitation, neglect, seduction, etc.). As for a theatre audience, this helps patients ‘see’, mentalise, re-work, move on from, forgive, and contextualise ‘effigies’ from the past’ (Freud, 1900).
‘Good’ sessions are not necessarily those that are obviously happy or hopeful; misery or sadness or rage may
surface, but in ways that feel satisfying, worked through, co-regulated, as though something important has been accomplished.
‘work’ – work that is, in fact, play.
the foundation for effective and enduring psychological treatments.
Therapists need to cultivate a light touch, helping clients to see their miseries objectively, even with a degree of ‘laughing through tears’, while at the same time not being infected with denial and other manic defences.
Gestalt therapists play with the ‘empty chair’,
Effective therapy, we argue, entails re-establishing a sensitive period in clients’ lives so that the suffering patient is open to the anxiety-modulating presence of a caregiver.
Both biobehavioural synchrony and the reawakening of a sensitive period can lead to the functional and structural brain changes that are the ultimate objectives of psychotherapy.
Full-blown explicit (i.e., conscious or self-aware) mentalising is a three-stage process. It is experiential in that its starting point is an ‘automatic’ affective response – a ‘thought’ often accompanied by somatic sensations and/or images. This is followed by awareness or ‘noticing’ what one is thinking. Lastly, and only in explicit as opposed to implicit mentalising, thinking about what one has found oneself thinking about (cf. Holmes, 2014b).
stressed, and therefore with her mentalising capacities inactivated,
Stress is the enemy of mentalisation: when anxiety reaches a certain level the mentalising brain goes ‘off line’, and the mind moves into ‘survival mode’
Trauma not only inflicts mental harm but inhibits the mentalising that is integral to recovery. The role of attachment-informed therapy is to counteract that process in vivo through the therapeutic relationship. But there is a caveat. Faced with acute danger, mentalising can be disadvantageous. About to be eaten by a lion, one doesn’t want to spend too much time imagining what’s going on in the feline’s mind. Mentalising is inherently ‘slow’; arousal activates fast thinking and inhibits mentalising (cf. Kahneman, 2011).
From an evolutionary perspective, this range of attachment patterns provides the variation that natural selection needs to ‘work on’ in order to maximise the chances of species survival
three key psychotherapy-relevant features of resilience: agency, relationship-competence, and mentalising.
Secure attachment does not equate to continuous uninterrupted mother–baby harmony and proximity.
maltreatment and high levels of accumulated socioeconomic risk (low maternal education, young maternal age at childbirth, single parenthood, minority group status, and substance use) predict high rates of disorganised attachment
The pathological manifestations of self-destructiveness – identification with hostile caregivers – turn this round and so bring the trauma within the subject’s control.
the pain and terror of trauma, if re-enacted in the ‘playspace’
of therapy, comes within the patient’s control and choice, thereby helping redress the sense of victimhood.
Secure therapists will make efforts to contact recalcitrant avoidant patients who miss all or part of sessions, rather than let such people slip away as ‘drop-outs’. Insecure therapists, complacently telling themselves they have been ‘sacked’ or that a patient is ‘unsuitable for treatment’ are letting their own defensiveness get the better of them.
the therapist needs to stand firm to ‘radical acceptance’, seeing apparent self-destructiveness (including ‘attacks’ on therapy) as defensive means of survival and self-soothing in a hostile internal and external environment.
The prospect of oblivion has become the balm, the all-accepting soothing other, so notably absent in their life. In this quasi-delusional zone, ‘half in love with easeful Death’ (Keats, 1819/2007), death itself becomes the secure base, a ‘heaven-haven’ (Hopkins, 1918/2008) where pain and suffering are finally assuaged. Suicide beckons when all attachments feel to have failed, turning out-of-control helplessness into action, providing a kind of mastery, both horrific and compelling. Acknowledging all this is part of any attachment-informed ‘risk assessment’.
The problem with the ‘life-coach’ stance is that the client’s active self becomes lodged in the therapist, while they themselves continue in the passive, victimised position.
the disadvantage is that it leaves clients permanently prey to exploitation.
therapists draw
on their own feelings – e.g. ‘sounds horribly bleak’ – to speculate about what might have been going through the client’s body-mind.
Outcome research in psychotherapy needs to take account of this tendency to remission, posing tricky methodological problems.
the ‘gold standard’ of double blind controlled trials is inherently unattainable in psychotherapy.
When the Nazis arrived in Vienna in the 1938 ‘Anschluss’, his fame meant he could have escaped to the USA. But his secure attachment pattern meant that he chose to stay with his beloved parents. All three were interred in a concentration camp, where his parents died. Frankl’s secure attachment also saved his life, however. On the march to a lethal work detail he would listen to an unhappy guard’s troubles, who repaid him with lighter duties and more food (Frankl, 1946/2006).
Those most likely to benefit most from psychological therapies will have high levels of neuroplasticity, possibly mediated via 5-HTT.
patients coming for psychotherapeutic help are likely
to have been traumatised by adverse developmental experiences, but are also more able to respond to the fav...
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Change in the less neuroplastic group will be slower ...
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here ‘radical acceptance’ is often the best psychotherapeutic strategy as it avoids the implied criticisms associated with a more ‘interpretive’ approach, which can merely lower already rock-bottom self-esteem.
‘perish the thought’ – healthy repression and narcissistic bounce-back,
The theme of change-promotion in psychotherapy has been implicit in our discussion so far. Here, with some inevitable recapitulation, we carve the topic into three aspects: corrective experiences, skill acquisition, and the emergence of new psychological constellations.
Without trust, no matter how clever, well-qualified, or knowledgeable the therapist, the patient will be unable to profit from the relationship.
The attachment figure – caregiver or spouse – becomes an extension of the self, vicariously undertaking the threat response on behalf of the subject.
Without a secure base, exploration of mental pain is almost inevitably inhibited.8 Negative affect-regulation is one of the prime functions of a secure base – helping to cope with fear, panic, misery, depression, confusion, low self-esteem, sense of failure, impotence, victimhood. Difficulties in processing and transcending these emotions are central to many psychological illnesses.
Therapeutic change re-awakens sensitive periods where the client is open to the influence of an intimate other.
The analyst’s job is to mount a benign interpretive challenge to these assumptions, confronting patients with their transferential misperceptions, while neither blaming nor distancing them.
Secure attachment allows for improbability: uncertainties are tolerable, because they can be resolved through action, either on one’s own or with the help of an attachment figure.
