Sunday, August 28, 2016

Below is a link to my thoughts on a recent article in THE NEW YORK TIMES about self- help groups for individuals who hear voices.  I thought the article did not cover all bases.

Please let me know what you think about it, maybe on the Huffington Post's comment page.
Thanks for reading.

Wednesday, July 27, 2016

How I became a trauma therapist 

may benatar


For two years I spoke to a nearly mute woman.  Much of the time I was just trying to guess what she was feeling and reflecting it  back to her.  I just talked.  I didn’t really know what was wrong.  I knew that she had a history of sexual abuse but I did not know who had abused her, the nature of the abuse, or details of the family she came from. I had only the vaguest notion what the issues were for her or why she wouldn’t talk.  I didn’t know what she needed.  I just talked.
Later she told me, much to my surprise, that a (imagined) little girl hid behind my chair while we were in session, a split off, very separate, part of her.  Her terror and her trauma were personified by this mute child. This was my first highly dissociated client. But I did not know it at the time.  I didn’t know it for a long, long time.
Frances came to me in the early 80’s after I had attended an inspiring conference in Boston on the psychology of women.  The counseling center where I was on staff paid for a colleague and I to attend the conference at Harvard University.  One paper on sexual violence against women stood out among the many wonderful talks.  Judith Lewis Herman asked of the 900 (mostly) female psychotherapists how many had been mugged.  People raised their hands.  She went on to say that she could not ask for a show of hands of victims of sexual violence, rape or childhood sexual abuse,  as victims of these crimes are stigmatized.    The victim is the one left with the shame, silenced by the shame, damaged by the shame.  The perpetrator is mostly unknown, mostly unmarked. 
This paper turned out to be life changing for me; it was a key moment in shaping my identity as a psychotherapist.   My colleague, soon to become my friend, and I stood together during the break sipping tea, munching croissants and sharing bits and pieces of our life story, intimate pieces.  We were moved by both the paper and by Judith Herman’s tribute to her recently deceased mother who had been scheduled to deliver a paper at this conference as well.  At the break there were dozens of women flocking to the pay phones to call their mothers.  Women and mothers were being honored and the wounds of women were being witnessed in an open and even welcoming way. 
Both the women’s movement of the 70’s and the anti-war movement of that time had both fueled the interest and investigation of the twin issues of  the trauma effects of war and violence against women.  Judy Herman inspired me to carry the torch and the impassioned message to the mental health staff with whom I worked, the town in which I lived, the people that I knew.  Eventually I taught this material to graduate students but it started with my presentation at a staff meeting.
At the time I was a member of a mostly male staff at a pastoral counseling center.  This material was new and perhaps not particularly welcome to that group.  I brought my experience of the conference and Herman’s meticulously researched paper to the staff.  I was excited about what I had learned and somehow empowered by it as well.  I was taken aback when I got a lot of questions like: “Is this really true, that one in three women have been sexually abused by the age of 18?”   In the early 1980’s the notion that large numbers of women and children might be victims of sexual trauma and suffering from its aftereffects was not quite mainstream.  I distinctly remember one staff member asking me, chuckling, “how could one actually rape one’s wife?”  In other words is it rape if you are married?  I could linger on my outrage, but I won’t. 
The upshot of that presentation was that I became known as the resident “expert” on sexual abuse. 
Frances was referred to me shortly after that staff meeting.  A staff member who was seeing a couple learned in the first session or two that Frances had a history of sexual abuse.  He referred her to me.  “We have someone who is an expert on sexual abuse,” he told Frances. I knew the truth: no one on that all male staff wanted to touch this.  But I was new at the counseling center and I was game.  
It actually turned out to be very challenging.  The marriage that had brought her into the treatment, failed rather quickly.  We didn’t talk much about the marriage or the sexual abuse history.  We didn’t talk about much.  She barely spoke to me for 2 years.  Frances was young,  mid-20’s, tall, thin, and sad. Very sad.  She held herself  tightly, rigid with suspicion. When she did speak her sentences were short and typically unrevealing.  The “shame” that Herman spoke of seemed to leak from her pores.  She looked terrified.
Frances cancelled appointments more often than not.  Maybe I wasn’t busy at the time, and I certainly was interested in her and drawn to her sadness, her silent suffering, so I called her each time she cancelled.  She always showed up the following week.   She asked me, many years later: “Why did you always call me?”  Truthfully, I have no idea.
But pursue her I did.  I think back on that time and wonder how I managed all that silence.  I did strive to “know” her in some way even though she was too frightened to tell me who she was.  I knew enough not to let the silence stretch on.  So I talked about fear, her fear,  about safety and how unsafe it might have felt to her to be in the office with me.  Her gaze was either downcast or wide-eyed. 
Today I would know so much better how to do this then I did then.  Today I would  consult what was going on in my own mind and body for clues for how she was feeling: where was I tense?  did I notice pain or strong sensation one place or another within me?  did my breath quicken? was how unmoored I felt in that situation a reflection of how lost she felt? how was my posture mirroring hers and what did it tell me about what was going on?
In retrospect I think she probably was as bewildered as I, as to how to proceed.  Today I know that there is an invisible force that we call “resonance” that tells us a lot about our companions if we “listen” in the right way. There is resonance between us all.  Today therapists are more familiar with concepts having to do with interpersonal energy and silent communication, right brain to right brain.  Affect is communicated silently.  We just have to listen differently.  But, alas, all that knowledge was decades away, way into my future as a clinician.
At that time my chatter was more about not leaving her alone with her fear and dread.  The content was less important than that there were words of some sort.  I was groping for a connection, some thread, a bridge that we could construct together.  She never became much of a talker, always dropping in and out of therapy at critical moments in the treatment.  But we did construct a bumpy bridge over time and most importantly, the little girl, who I did not initially know  was there,  listened in to what we were doing together and grew.
Frances started and finished college, the first in her very large family to do this.  She became a professional and a single parent.  She did a good job of raising her son, alone, and providing for herself.  She bought and restored a house.   She survived a severe illness, and a near fatal car accident and rehabbed herself from both.
In the years to come I was to treat several more severely traumatized women who had many sequestered part-selves.  Frances and two others remained in treatment for decades.
Like most therapists of that time I did not  recognize the phenomena of multiple self states until it screamed in my face.  I was among the throngs of therapists who believed that Multiple Personality Disorder, as it was then known, was a rare condition.  I remember saying to a client who was a criminal lawyer and felt that many of her imprisoned clients had “multiple personalities,” that that was “highly unlikely, it’s a very rare condition” I stated with authority.  Ha!
Today the idea of multiple selves does not make us uneasy.  This was not always so. When I was starting out in my work with individuals with much early trauma in their life histories, over 30 years ago, the concept of multiple self-states was not part of common/shared wisdom.  Today we have a Pixar movie about animated self- states in the head of a joyous 11 year girl, Inside Out
Today we easily grasp the notion that there is the work-self, the part that shows up at home, distinct from the part that shows up at parties, or sporting events, or with intimate friends.  My daughter, like many of us, has three different voice mail messages: work, home, cell phone.  At work the pitch of her voice is low, she is professional, deliberate and someone to be taken seriously.  On her cell she is casual, the pitch a little higher.  The home voice mail  sounds like a different person altogether: peppy, cheerful, the pitch at least an octave above the work email.  That woman/girl is young, energetic and fun.  This is both different and not different from having multiple selves.  Each voice mail message conveys the circumstance and the  state of being that she occupies in each setting. My daughter has easy access to each “self -state.”  She remembers what is going on at work when she is at home, and if she has to take a work call at home, amidst preparing dinner and directing the children, she can do so fairly easily. There is fluidity. 
The difference between individuals who have sharply segregated “selves” that cause the kind of serious problems that lead them into therapy and more functional individuals is that the former do not have easy access to all the states that my daughter, described above, has.  Some “parts” go to work, some parts parent, many parts hold the trauma memories, not all the parts go to therapy, at least initially.  Frequently the parts do not know each other, or only some do; communication across the system is typically poor.
In Dissociative Identity Disorder (the new designation for Multiple Personality Disorder) parts of experience, the really awful bits, are sequestered in sections of the overall personality so that literally the left hand doesn’t know what the right hand knows.  Tommy the rock opera, written in the 60’s captures some of what this looks like.  Tommy, was a Rock album by The Who, a movie, and a musical on Broadway.  Tommy is a traumatized little boy who becomes deaf,  mute, blind and a wizard at “pinball”.   A boy who cannot see becomes a champ at a sport where participants generally have keen sight. 
Tommy was born with all his senses intact.   When quite small he witnesses the  murder of his father at the hands of his mother’s lover.  The boy is the only witness.  The mother sings to her son:
You didn't hear it
You didn't see it.
You won't say nothing to no one
ever in your life….
You won't say nothing to no one
Never tell a soul
What you know is the Truth.

Little Tommy manages to go blind, deaf, and mute to conform with the pleas and commands of his parents,   But he holds to the truth deep within.  It turns out that there is a great way to do this: its call “dissociation.”
Sickness will surely take the mind
Where minds can't usually go.
Come on the amazing journey
And learn all you should know.

And I did, I went on the journey and it changed me.




Wednesday, April 6, 2016

Posted this awhile ago on Huffington. About my father and a lost history of trauma.



http://www.huffingtonpost.com/may-benatar-phd-lcsw/disappeared-david-trauma-_b_8239002.html

Saturday, January 31, 2015

YOUR CHILDREN ARE NOT YOUR CHILDREN


Your children are not your children.
They are the sons and daughters of Life's longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them,
but seek not to make them like you.
For life goes not backward nor tarries with yesterday.



Some of you may know these words from a poem by Kahlil Gibran.  Some of you may know the lyrics from its adaptation by “Sweet Honey in the Rock,”  an all-woman, African-American, a cappella, gospel-inflected, ensemble.  Their music was featured in our home (on our record player!)  when my children were growing up in the early 80’s.  They loved the music.  So did I.
The lyrics of this particular song… not so much.
If my children are not my children, then whose are they?  And what do you mean they are not mine?!   Or so it went.
When I first became a parent I found it difficult to let go of my own aims, my own rhythms.  I felt the loss of my unencumbered life, or at least mostly unencumbered life.  The physical demands and the confinement were challenging.   For me, it was a bumpy process becoming a parent, hard work,  and to be presented with the idea that they were not truly mine, I was merely a mid-wife, was not welcome.
 I’ve been thinking about this notion of “possession” of children since I read  Andrew Solomon’s wonderful, door stop-erish tome: Far From the Tree. 
This is a  beautifully written,  compassionate,  tender and nuanced examination of the implications for parental identity  when  offspring are starkly different from their parents, when parents cannot find their own image or influence in the eyes, the bodies, and the values of their children.  Parents of autistic children, transgendered children, handicapped children, criminal children, schizophrenic children, dwarfs and deaf children as well as many others, were interviewed (over 300 families).   Solomon  thinks deeply about their trials and their triumphs.   There are those who reject their “variant” children and those who embrace them happily.
                 I think Solomon would have us think a little harder about the illusion of our children being “our children” in the more ordinary situation. The first sentence of Solomon’s book reads: “There is no such thing as reproduction.”  We call it reproducing—having children.  We search our infant’s faces and cannot resist comparing them to our own, our partner’s or at least great-aunt Bertha’s.  And their sweet temperament must be a reflection of our own.  Their colicky nature, surely from the other side.   Are we reproducing or are we mostly ­­producing? a grand accomplishment  in and of itself.  Maybe in all cases children are not merely a “chip off the old block,” but a completely new, unique, beloved “chip”
As I reflect on the obsessive involvement with my own children in the early years and how alien the idea of their not being “mine,” I see how adaptive it was at the time, to see them as extensions of myself, a more beautiful, perfected, unblemished extension at that.   And I think in the early years, it was highly adaptive to cling to this illusion.  Loving my children was a form of “self-love.”  Not the malignant kind, but the benign and necessary kind. 
Generally we think of  “parental narcissism” (in so far as we think of this at all) as a toxic quality.  We picture characters like the mother in the movie “Ordinary People” (played so expertly by Mary Tyler Moore)  who do not truly see their children as real people but only as characters in a play of  their own design, there to serve the parental hero and heroine’s needs.  There is a ruthlessness about them.
Parental narcissism is natural, ubiquitous and serves a serious purpose.  Narcissism is generally associated with selfishness and associated with a disorder. But there is pathological narcissism and appropriate or healthy narcissism.   Without some degree of self-love we are in trouble.  It is a developmentally necessary quality, both to love yourself and to enlarge the circle of self - love to include your children and others.  Insofar as we see ourselves in their eyes or in their sweetness, their scent we are in love with our off spring.  It is a serious problem when this fails to happen.   
Things go awry when the individuality, the uniqueness of the child is denied in the service of meeting the needs of the parent.  That’s the kind of narcissism we generally think of when speaking of parental narcissism.  The miracle is balancing the enormous gratification of seeing ourselves in our beloved children and restraining ourselves. When I speak of the benign sort of parental narcissism,  I have in mind something less ruthless, more loving, and flexible.  It has lots of room for empathy. 

 As the children grow the illusion of  “they are us”  needs to fade.  If we don’t begin to see them as who they are and not a deep reflection of ourselves we start to do them a disservice.  They may have preferences that are quite alien.
            I think of the child who comes back from camp and wants to be a vegetarian, or now needs Kosher meals to be prepared by their secular parents.  I think of children who choose a different religion, perhaps a fundamentalist religion to follow and observe.  The son of left wing parents who wants to become a marine,  or the daughter of right wing parents who comes out as a lesbian and lobbies for marriage equality.  These are challenges for parents,  challenges that need to be negotiated with a relinquishment of the earlier narcissistic  investment.   We produce,  not reproduce.
           
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams











Thursday, August 28, 2014

I'M SORRY


Many years ago I viewed a documentary, on a PBS channel that addressed the effects of
the Holocaust  on the second generation, children born of concentration camp survivors.    Much has been written and studied on the effects on the second and even third generation of survivors of the Holocaust.  The secondary wounding of  offspring of trauma survivors, whether they be survivors of war, concentration camp or childhood trauma are well documented.

It must have been in the mid 80’s that I watched a PBS documentary on the relationship beween adult children and their parents, Holocaust survivors all.   It was fascinating and heartbreaking.  Engraved on my memory over the intervening decades is one scene in particular.

In the film, adult “children” were discussing with their parents what it had been like for them to be shut out of their parents’ experience and/or to be victimized secondarily by it.  There were poignant dialogues between the generations.  Among other things, the younger adults had felt that their own suffering, their own experiences of pain were never quite as valid, as the horrors and loss that their parents had suffered.  Some felt it fell to them to redeem, to heal their parents.  

The scene that has stayed with me was a unique one.  One daughter, tearfully addressed her mother with her suffering.  The mother, who had been a child during the Holocaust, and clearly unaware of the effect her experiences had had on her daughter, was at a loss, initially, as to how to respond. Finally she said “I’m sorry, I’m really, really sorry.”   More than any other words intoned in those dialogues, those words held the most power.
Viewers witnessed the potential for repair in that very moment.

I’ve held on to this scene in the intervening decades and even shared the story with patients who clearly were in need of having this kind of validation in their own lives.  It is both a phrase that I have not heard enough in my own life, and one that I have employed far too sparingly myself.  Two words that we all long for.

We read and hear a lot about the importance of the balm of forgiveness, how it heals the giver and as well as the given too.  But I think we don’t think enough about the power of of  asking for forgiveness, to knit together what feels irretrievably broken. Forgiveness is a hard nut to crack—that is, offering forgiveness that isn’t a thinly disguised form of denial.   But we can all apologize for wrongs we have committed.   An attuned apology is not  necessarily asking for forgiveness but rather an expression of empathy, compassion, “heart feeling” for the person we have wronged in some way, or at least they have perceived a wrong and have been wounded.


It happens  sometimes in my clinical practice that an angry client confronts me with some way in which I have hurt them.  Maybe I have been too blunt, insensitive, or just plain wrong. My timing has been lousy.  Sometimes I’m not guilty, but more often than not I am.  At least a little.  After years of trying to explain, clarify, interpret, really to defend myself,  I have come to realize that it is all a waste of time.  A simple, but “attuned” apology is what is called for here.  Whatever my motive or the context for my misstep, I have hurt someone.

This is sometimes difficult in the midst of an attack—an angry, no holds bar, maybe even abusive client is not someone easy to apologize to.  But there is always time for the interpretation, the exploration, and the meaning of the attack.  In the moment “I’m sorry” may be the only way to get back on track.

Recently a client shared with me what was a pivotal moment for him.  He was berating me for a misstep, which he had done before, and hinted strongly that he was seriously considering leaving therapy.  I asked: do you want to repair the rent in our relationship?  Stopped in his tracks by the question he had to admit that that was indeed a novel idea, “repair.”  He had never witnessed it within his own family.  Either a violent argument was forgotten, denied, disowned or it “broke” the relationship forever.  The notion of repair was alien.  Eventually he replied in the affirmative, yes he wanted to see if this relationship could be fixed.  I offered an apology and he was able to re-join  the collaboration and let go of the all too familiar role of wounded adversary.

Dan Siegel, the interpersonal neurobiology psychiatrist, clinician, and researcher makes the important point in a recent publication: the ability to initiate repair requires a certain humility, an acceptance that we are inperfect. 

It is part of being human to contribute to disruptions in connections with others.  Yet processes like shame can keep us from freely acknowledging our role and making a repair to reconnect with the other person.  These impediments to repair can severely constrain the health of a relationship (The Pocket Guide to Interpersonal Neurobiology).”

In other words my general tendency to defend my actions was probably rooted in an expectation of myself that I would never wrong a patient.  “Mistakes might be made,” but never by me!

I will let Rumi, the 13th Century Sufi poet summarize for me:

Out beyond ideas
of wrongdoing and rightdoing
There is a field.
I’ll meet you there.









Monday, May 5, 2014

MUSINGS OF THE LONG DISTANCE THERAPIST

  

In a few months, I will turn 70.  It will be over 40 years that I have been in clinical practice.

That sentence is actually a pretty shocking one to compose.  It hardly seems possible.  Forty years is a very long time.  So many of my colleagues from the early days no longer practice psychotherapy.  They left the field for various reasons, some very early on.  Being a clinical social worker, or a family and marriage therapist doesn’t pay very well.  The working conditions are not always pleasant, clients are disappointed, they are angry, they lash out, they fire you without notice and sometimes even explanation.  You are sitting still much of the day absorbing the pain, the shame, the trauma, the fury of your clients.  If you work in an agency you can be subject to crushing piles of paperwork and a remarkable lack of respect.

And then there is the weight of responsibility, or felt responsibility, for the well-being of others.  There is always the prospect that you will fail.  There is the dire prospect that the client will harm themselves or others. 

But like the song says, “I’m still here.” 

Quite a surprise.  Starting out I thought I would never make it, that my high level of anxiety would kill me.  But as I client once scolded me, I am persistent, “like a dog with a bone” is the way she put it: not pretty, but apt.
  
I’ve never been much good at puzzles, either crossword puzzles, picture puzzles, or Sudoku.   You can always have the puzzle page of the New York Times out of my newspaper anytime you want. 

But the puzzle of a personality I find intensely engaging.  Without exception every new client is a new puzzle, an original.  Why this symptom and not that?  What happened? Why (seek treatment) now and not before. Why did he survive and she didn’t?  Why did this sibling make it through an abusive childhood and the other one, not so much?

And the key to the puzzle is not written in a book anywhere, there is no standard protocol, the way I work anyhow.  It’s always a new task to figure it out, how to treat this person.  What’s going to work?

Then there is my fascination with the story, the narrative of a life. I spent a lot of time as a child with the “orange biographies,” biographies of “great Americans.”  Our small town library had what seemed liked hundreds of them.  I took a stack out every two weeks.  I consumed everything thing from the story of Davy Crockett, frontiersman, to Florence Nightingale, Mary Todd Lincoln, Jane Addams, George Washington.  So was it the history that I loved so much, or the prospect of greatness?   Perhaps if I read enough of them, maybe I could join their ranks?   No, I think it was the story of lives, lived.  And I’m still here, with those stories.

It is a privileged perch, the perch of the therapist.  One gets to witness all the lives not lived: what it’s like being related to the mob, or to be the neglected child of great wealth.    I get a taste of growing up in Lake Woebegone, Garrison Keillor’s fictitious small Midwestern town, without having ever been to Minnesota.  I get to talk to the voices that populate the inner world of seriously traumatized individuals.

The “privileged perch” can be hazardous.  There is no doubt that if you work with trauma, as so many of us do, that your world view is darkened thereby.   The tales of ritualistic abuse and sadistic cruelty toward children are often hard for people to believe, even therapists.  A supervisee, new to the treatment of the long term effects of extreme trauma, once asked if I believed the tales of multiple rapes and torture that her patients and mine recalled.    I really cannot, of course, offer a definitive answer in any particular case. No one can. But we did live through a century when state sanctioned murder and torture and rape were applied on a mass scale, so why not? 

Here are a few things I have learned from being a therapist:

1.       Motivation counts more than the extent of pathology. People who desperately want to get better, generally do.

2.      Safety counts more than anything.  Anything one can do to help a client feel safe with you and in your office facilitates the healing.  Maybe it is the healing.

3.      Chemistry counts. Who you are is what counts:  “The person of the therapist is the converting catalyst, not his order or credo…not his exquisitely chosen words or denominational silences” (from A General Theory of Love, Lewis, T.,Amini, F., Lannon, R., p.187).

4.       Spirit often arises from the extremities of suffering.  It’s almost uncanny how those who have survived early and extreme trauma and make it into my office, arrive with rather robust spiritual lives.  Not conventionally religious, they are still believers in the transcendent and credit those experiences with their survival.  These patients have taught me a lot about resilienc, spirit and spirituality.
  
Over 40 years of almost continuous practice: it is hard to really comprehend that amount of time. I do comprehend, though, what a blessing it is to have been part of a profession that has brought richness and meaning to so many days of my life.  I am grateful.