How I Work as a Therapist
I entered the field of clinical psychology because I wanted to make a meaningful and helpful connection with people who are struggling and wanting to grow.
My psychotherapeutic work is guided by three central tenets:
Firstly, we are to a very large degree a product of our relational history. Genetics do play a role in temperament differences, vulnerabilities for some psychological disorders, and they are heavily weighted in the occurrence of others (i.e., schizophrenia, bipolar disorder). When it comes to our psychological and emotional life, there is no past and present. If painful feelings or beliefs have not been addressed in psychotherapy, they are still alive and present within us, whether suppressed or in the form of emotional reactivity, and they take their toll on our functioning (i.e., depression, anxiety, social and primary relationship problems, underachievement, substance abuse).
The second principle is that emotional and psychological problems (excluding any biological influence) come through human relationships and therefore the healing must also come through human relationships (i.e., the psychotherapeutic relationship); we do not heal in isolation.
My third guiding tenant is that our self-experience, though long-standing and embedded, is not fixed or objective, but rather how we feel about ourselves from early life experiences. Therefore, our self-experience is subjective and fluid. I have seen in my practice that at any age we all are capable, and in fact poised, for change and growth once the immediate psychotherapeutic environment provides the necessary ingredients to do so. In the same manner, a wilting and dying plant will come to life once it is given food and water and is moved next to a sun filled window.
The strength and cohesion of our self-experience is the result of the quality of our parental (or caretaker) relationships and how well our developmental needs are met. From my training in Self Psychology and Intersubjective Systems Theory, the universal developmental needs found to be essential throughout the lifespan, but most critically in early life are 1) the need for emotional, psychological, and physical safety (when young) from a parent we look up to and trust, 2) the need to delineate a boundary and exercise autonomy, 3) the need to feel loved unconditionally, 4) the need to have at least one friend and cohort to move through life‘s challenges and share in its joys. To these universal needs, I add an additional developmental requirement, 5) the need to feel validated for our achievements and competency. Parents can fully provide unconditional love, however if they cannot validate and celebrate a child’s first steps or his learning to balance on a bicycle- something will be critically missing.
Regardless of love, motivation, or intentionality, parents or caregivers fall on a large spectrum of psychological health and emotional intelligence and their ability to foster these capabilities within their children. When our early emotional and psychological needs are not met and certainly when we are directly injured (i.e., verbal, physical, and sexual abuse, and traumatic loss, betrayal, and rejection), our self-esteem and self-cohesion suffers leaving us vulnerable to anxiety and panic, depression, emotional reactivity, a lack of healthy assertiveness, relationship and intimacy struggles, social isolation, compulsive, impulsive behavior, addictions and other psychological problems.
From my early training as a gestalt therapist I emphasize the importance of self-awareness in the present moment. Though the present moment is a simple and obvious concept, it is elusive to many of us as we find ourselves much of the time ruminating about the past or worrying about the future. The present moment is the only time frame where we truly have leverage and effectiveness and only with self-awareness of our thoughts, feelings, our body and physical functioning (i.e., breathing, muscle tension, or rigidity) do we truly have a choice to be or function differently.
Another very important concept in gestalt therapy is boundary. As mentioned above, the ability to delineate a boundary with others (i.e., to say “no”) is a universal developmental need. However, beyond this function boundary activities are more complex and also indicative of psychological health or psychopathology.
Our boundary is necessary for both for separateness and contact with others such as the function of our skin that acts to both keep out pathogens and at the same time allowing us to touch and connect with others. From a psychological perspective, we need our boundary in certain situations to be firm (i.e., in response to somebody who is intrusive or manipulative) and at other times one that is permeable allowing us to take in and assimilate from the environment such as appreciating another person’s perspective, absorbing new knowledge, or learning a new skill. There are occasions where a high level of permeability or even a temporary absence of boundary are necessary for the enriched participation in a romantic, sexual, or spiritual experience.
In treatment, I address boundary disturbances such as projection or placing or attributing what is inside us (anger, self-loathing) onto others, introjection or the swallowing whole from others without chewing or assimilating (an extreme case would be followers of a cult leader), and confluence (never delineating a boundary and thus being chronically agreeable and accommodating to the point where one’s needs never become realized and eventually not even self-recognized.
As a psychologist, I work in three equally important spheres of human functioning: emotional, cognitive, and behavioral.
Parents or caregivers who create an environment leading to unmet needs, injury, or who are not capable of modeling the healthy expression of feelings such as sadness, fear, or joy will not be able to consistently and successfully perform the important task of helping their children to name, tolerate and integrate the painful feelings that result within the family experience as well as life in general. These painful feelings will either have to be suppressed or repressed or they will become destructively reactive and rogue. I help individuals safely bring forth suppressed or repressed painful feelings, where they have become more toxic, into the healing relationship and I help those with reactive and rogue emotions learn how to regulate, calm and soothe themselves. One of my primary functions as a therapist is to help individuals I am working with become emotionally integrated so that our emotions serve to support and enrich us as people.
The cognitive dimension of therapy is gaining insight and understanding of the important early relationships that shaped us as individuals. As mentioned above, our self-experience is subjective and a direct reflection of the quality of the early relationships we had with our parents and other important people. The more we understand what we had to do to navigate our development as a dependent child, the more we realize the differences in our current environment as an adult and that we have a choice to be different and relate to others differently.
Additionally, if our developmental needs are not met and when we are injured we form unhealthy beliefs about ourselves that crystallize into the formation of an internalized critic that continually shames and instills unhealthy guilt within us. Unhealthy guilt is differentiated from healthy guilt that arises when we actually do something wrong or harmful to others. I help the individuals I am working with understand that the internalized critic’s source is external (we are not born with an internalized critic) and has to be challenged and ultimately dissolved so that healthy self-esteem, worthiness, confidence can begin to grow.
The final sphere of functioning that I attend to is the behavioral or experiential learning. As we learn to regulate and integrate painful feelings and begin to understand the forces that shape us as individuals when we were young it is time to begin behavioral experiments. We ultimately change through successful experiments that truly demonstrate that we are not the children we once were. We now realize that we possess far more life experience, abilities, and resources, and that we and our environment are not the same as when we were young.
The importance of experiential learning can best be demonstrated with the following vignette. A child falls into a swimming pool by accident and experiences what feels like an interminable period of time in a bona fide panic. Following this incident that person experiences anxiety and dread at the thought of going near a swimming pool. Following the emotional and cognitive work of therapy, the injured adult in gradual experiments will see that at the end of the pool there are steps. She next can then incrementally take one step at a time and then can feel the concrete of shallow end. As she ventures to a deeper part of the pool she realizes that there is also a ledge to hold on to. The new swimmer can begin to kick and practice arm strokes all of within the safety of both the shallow end and within reach of the pool ledge. It is only after this successful experiential learning, that she will feel safe to master and enjoy swimming and create a contemporary relationship with the pool.
Whether it is a swimming pool, going to a social function where many are strangers, or initiating a conversation with someone with whom we have a romantic interest, the necessity of incremental experiential learning is necessary.
In conclusion, the therapy I conduct is both an art and a science. A quality psychotherapist must not only have compassion and a desire to help others, but also must be interested and fascinated with the person they are working with. As one of my mentors said, “every person’s life is worth a novel.” I provide an emotionally safe and supportive therapy environment and I know intuitively and empathically when to listen and allow time and space for the individual I am working with to reflect and feel, when to challenge unhealthy beliefs systems, to provide psychological education, to introduce alternate ways of seeing oneself and the world, and when to introduce behavioral experiments both within the therapy relationship and for the individual to do outside the office in order to galvanize change.
Copyright © 2012 Bruce A. Howard, Ph.D. All rights reserved.