Case study
Introduction
I have been working with this client for just over two years. In terms of cultivating a clinical relationship it’s in the early phases. The presenting problem was anxiety, trouble relaxing and limited self-care. The main focus of the work so far has been to start establishing basic rapport and trust within an intersubjective relational context. My approach so far has been to focus on the client’s initial concerns specially anxiety around their work as a way to initiate interventions and start building a relationship. Taking into consideration the client’s description of his challenges and noticeable affect I have tried to focus on self-regulation from an attachment perspective (Beebe & Lachmann, 2002). In formed by Somatic Experiencing perspective, part of my work has been to support parasympathetic nervous system functioning by allowing deactivation and relaxation in experiential work in sessions to help balance and reset the effects of sympathetic arousal (Levine, 1997). The initial goal has been to start creating enough resources in their nervous system to counter the effects of long-term experience of anxiety. These physiological resources, I feel are necessary for the client to engage underlying psychodynamic material in longer-term therapy.
Background
The client is thirty-one and recently moved to back to the bay area after a break of a few years. Client grew up on the east coast, has good work in the residential and small business construction industry. He is one of three children in his family, an older brother who was adopted and a younger brother who was born female and went through a gender change at 19. His parents were married for 13 years and didn’t conceive any children that led to their decision to adopt his older brother. Shortly after the parents had gone through the adoption, his mother became unexpectedly pregnant with him so after not having any children they had two young children in a year. From initial, limited conversations that I have had with the client about his family, he feels considerable sadness about his family and is very conscious about his apparent privilege as a Caucasian male, although there is a sense of guilt that seems to be present for the client since he feel that his siblings may have had more struggles in their life. I feel that his early attachment environment was inconsistent and may be unpredictable owing partly to his adopted, older brothers difficulty in adjusting to his the environment.
Somatic Experiencing Theory
SE is a nervous system based trauma healing approach that emphasizes the importance of the autonomic nervous system in symptoms and healing of trauma. The approach emphasizes the importance of working with the bodily felt sense in stabilizing and resourcing the nervous system as well as in renegotiating the traumatic reactions and backlog stored in the body (Levine, 1997). The key understanding is that traumatic experiences overwhelm the body’s natural self-regulatory capacities, leaving the in the system, depending on the nature or magnitude of trauma, with unprocessed survival responses need to be released in a titrated manner in order to restore the nervous system back to its natural self-regulating capacity. The unprocessed energy in the body not only hinders the normal enjoyment of life but also sets up the out of whack nervous system for repetition of trauma responses out of sync with the actual conditions the person is in.
Felt Sense: In working with this client, the use of felt sense awareness to get in touch with the feeling states has been key. The client has come into most sessions complaining about the feeling of anxiousness during the day or the previous week. My approach has been to listen and reflect on the client’s experiences and then proceed to in the moment experiential work. The main component of this work has been breath awareness and tuning into the bodily felt sense that is present for the client. In one particular session the client came in describing a feeling of wanting to “give up”, I sensed this as a desperate attempt on behalf of his nervous system for help but also as an arising awareness that he had some choice although it seem to be couched in bleak terms. In this session I invited him to recline on the couch while using additional cushions for his back and neck to come to a more comfortable and supported posture. He reported feeling a level of anxious all through his body - tension in his chest, arms and legs. As we started to shift focus to his breath and allowing the tensions to be there and be met by the breath, he started to feel a little more at ease. As he stayed with his breath and turned his attention to the feeling of physical support of the couch and a level of comfort that was available he started registering more the relaxing elements of his experience. At first he started remember things that he needed to take care of at work. In an effort to help him tune in I decided to externalize the “to do” list by setting a couple of objects on the floor in front of him to represent the work responsibilities. I noticed that the inner critic was a very key component of what drove his anxiety. I recognized the importance of his work responsibilities and their connection to his sense of being able to support himself. I felt it was important to recognize the inner critic’s role in helping him to cope with the more functional aspects of his life and the fact that our relationship is still new, the alternative ways of being with himself and performing well at work have not been explored yet. As we were able to assuage the “self critical” aspect of his experience he was able to tune into the relaxation he was in touch with reclining on the couch. In a couple of minutes he seemed to be dosing off, his hands in a fist would tremble a little as if his arms were releasing wound up energy in his chest. After a few minutes I wasn’t sure how to proceed since he wasn’t saying anything and I didn’t want to wakeup him up to surprise him if he was in fact falling asleep or in deeper relaxation. I decided to give it more time and trust the process. I started to breathe more deeply myself so that I might catch his attention without surprising him. I then cleared my throat and waited for another couple of minutes as I asked him in a soft voice what he was feeling. He opened his eyes a little to look at me, as if to check to see if I was there. He said that he was on the edge of falling asleep multiple times, he felt relaxed and the tension in his body had subsided replaced by sense of relaxation.
Renegotiation: The key understanding in my approach to client’s renegotiation of anxious responses is to provide a safe, empathic and attuned relational environment where the client can feel held. The invitation for the client to take on a relaxed posture and turn their attention to their sensorial experience has been a way to shift attention back to the body, this has not only helped to bring attention to the hear and now but also to the relative sense of safety and comfort that is available. The resource of ease, comfort and attuned presence of another are key components in starting to renegotiate attachment as well as other sources of trauma and accumulated deregulation in the nervous system leading to Hypervigilance and symptoms of anxiety (Siegel, Solomon, 2003).
Clinical Relationship
The challenge that has been part of the work here for me, especially as a training clinician is being with a certain level of not knowing. This being a clinical relationship, a certain level of not know seems a natural part of the process. At the same time, I am aware of the limits of my knowledge as well as experience. It feels important to name the ways that I have experienced not knowing in working with this client:
Not knowing client’s capacity to be with difficult emotions like sense of loss, sadness, regret, guilt and frustration.
Client’s inner process beyond what is apparent and/or communicated.
My own capacity to perceive, discern, relate and understand the client and their process
I have tried to bring this not knowing to help make room for the uniqueness of the client’s experience as well as their expertise in being the source of knowledge about their experience (Anderson, 1992). At the same time, I have tried to create an empathic and affectively attuned environment for the client. At the same time my goal now is to widen the focus of the work to early developmental and attachment experiences. The focus is starting to cultivate right brain communication and attunement as a foundation for therapeutic work (Siegel, 1999). Furthermore, caring and empathy as informed by theorists of intersubjectivity (Mitchell, Storlow), are informing my work in trying to create a reparative and supportive relational environment for the client. My effort is to create a secure attachment environment for the client so that his experience can be held and related to while forming a long-term therapeutic relationship. My sense is that the client has trouble attuning to his self-states (Bromberg 1998) that causes more anxiety. Complementing the SE work with affect attunement and self-regulation would foster self-integration and greater capacity for self-attunement.
References
Anderson, H. (1990) Then and now: From knowing to not knowing. Contemporary Family Therapy Journal. 12:193-198.
Anderson, H. & Goolishian, H. (1992) The client is the expert: A not-knowing approach to therapy. In. S. McNamee & K. Gergen (Eds.). Social Construction and the Therapeutic Process. Newbury Park, CA: Sage.
Bremner, J. D., & Brett, E. (1997). Trauma-related dissociative states and long-term psychopathology in posttraumatic stress disorder. Journal of Trauma Stress, 10, 37–49. Bromberg, P. M. (2006). Awakening the dreamer: Clinical journeys. Mahwah, NJ: The Analytic Press.
Bromberg, P.M. (1998). Standing in the spaces: Essays on clinical process, trauma, and dissociation. New Jersey: Analytic Press.
Levine, Peter, (1997) Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences, North Atlantic Books, Berkeley, CA
Siegel, Daniel J, 1999, The Developing Mind: How Relationships and the Brain Interact to Shape who We are, Guilford Press
Siegel, Daniel J; Solomon, Marion, 2003, Healing Trauma: Attachment, Mind, Body and Brain