by Thérèse Hicks
I have been working as a psychotherapist for over twenty years. For the first ten of those years, I worked in psychiatric services, first in Massachusetts for seven years, and then for the first three years of my life in Ireland. Over these years, I have been accumulating a very varied box of tools, most of which were first pressed into service for my own personal healing, before then being honed for use by others. Most recently, I have been working as a Counsellor/Therapist on a primary care team. In preparing my interview for the post, I knew I would have to formulate an approach to a service that would be time sensitive so that it could cope with a high number of referrals, yet which would also be capable of providing in-depth healing for those who wished to avail of such a journey. For the past five years, the service, which I have designed, has gradually evolved to fulfil this vision. This is how it happened.
Initially, when referrals were still few in number, I would meet with a person and reflect with them on their situation from a developmental point of view. This involves looking at how experiences in their early years have shaped how they are responding to their current difficulties. It was unclear how many sessions I could offer people at that time, since I didn’t know how quickly the press of referral numbers would become an issue. Fortuitously, at that time, a friend lent me a copy of Mindfulness Based Cognitive Therapy of Depression (Segal et al. 2001). I have been meditating for over 40 years, again, as a way of maintaining and energizing my own life. The entry of mindfulness into the psychotherapy repertoire is something I very much welcome. I held my first mindfulness group in the autumn of 2007 with six participants.
As the tide of referrals began to rise, I would meet with the person once or twice, and then ask them to attend the start of the next mindfulness group. In a small town and its environs, this is a challenging proposition. The overriding concern of people is, ‘who will I meet there?’ Obviously, how well I presented the evolving treatment package, as well as offering them a plausible analysis of their predicament, and relevant solutions, were key to whether or not they would opt-in to the service. Without a persuasive and credible presentation, they would not take the risk of being in a group. I am happy to report that I have held twenty-four mindfulness groups since that initial effort, and, depending on the size of the room available, have had group numbers ranging into the mid-twenties. Those who have attended the groups have found them extremely helpful for a number of reasons.
In order to deepen the therapeutic experience, I then organized the Personal Development Course, which happens every January/February. (All the groups I offer are eight weeks in length.) In my previous post as the Counsellor for the Gay Men’s Health Project, I was fortunate to be on a team with an Occupational Therapist and Outreach Workers. They had put together a Personal Development Course and they generously allowed me to take it with me to my current post. It explores the process of change, assertiveness, negative thinking, and self-esteem. It performs the dual purpose of increasing group coherence and strengthening participants’ sense of self.
After two years, there were enough people who had attended the Personal Development Course for me to consider what would be the next most useful group. In my experience, the deepest level of healing is with the ‘inner child’. This is an intervention based on developmental psychology which allows a person to move through a very deep healing process in a fairly brief period of time. John Bradshaw had published Homecoming (1992) not long after I started working as a psychotherapist. When I first saw it, I immediately recognized it as the more focused path to the healing it had taken me five and a half years to come to in thrice weekly Jungian analysis. I have been making use of this book (or at least the first nine chapters of it) for most of my time as a psychotherapist. Using his basic structure, I then designed the Developmental Healing Group, which gives the participants the information they need to do the inner child work. However, I do not attempt to actually do that work in the group, finding that some months of individual work provide a better holding container for a person’s process.
When I worked for the Gay Men’s Health Project, inner child work, using Homecoming, was my primary approach. In that post, I had the luxury of giving each client up to two years of intensive work, if they wanted it. However, after a few years of doing inner child work with quite a few people, I noticed that it didn’t seem to work very well with some of them. When I reflected on the commonalities of each of those people, I noticed that they had had very severe trauma backgrounds. That spurred me on to explore training in trauma work. I decided to do the year-long course given by the Sensorimotor Psychotherapy Institute in Dublin, which I found extremely useful. It has transformed how I perceive what clients are talking about, and how I respond to them.
Now, when I meet someone for the first session, after exploring their history, I outline what I call the four stages, or levels, of emotional healing. The first step is to stop addictive behaviours. This generally means that a person needs to stop all drinking or use of pot (and obviously other drugs, though not prescribed medications apart from benzodiazepines). Some people object to this request, but I have found that alcohol has an interfering effect. Those who use it while trying to do this work have a poor outcome. In my perception, there is a significant underestimation in Ireland of the impact of alcohol on the therapeutic process.
The next step is to learn a healthy coping skill. This is where mindfulness comes in. For the vast majority of referrals, when I send them the letter acknowledging that they have been referred to my service, I suggest that they get a copy of The Mindful Way through Depression (Williams et al. 2007). If they are not said to be depressed on the referral, I point out that the important part of this book is learning mindfulness, and that they can skip the first chapter on depression if they wish. Interestingly, this book was only published a few months before I started using mindfulness as a therapeutic intervention. I will often do some mindfulness in the first session, just to give a person a feel for it. They can do the mindfulness group as many times as they wish and those who use it the most, generally have the best outcomes.
In a recent article, Ron Siegel (2012) notes that, while mindfulness is generally very useful for most people, for those suffering from significant trauma it can be counter-productive. This is because the level of agitation in the body from trauma can override a person’s best efforts to sit still with an internal focus. Whether or not this is the case for a person can only be determined by their actually trying to do some mindfulness practice. Sometimes an external focus, away from the body, can be tolerated, or perhaps something like mindful walking allows the person to give adequate expression to a flight reaction. However, if neither of these options works, then it is necessary for the person to do some trauma processing before they can do mindfulness practice.
Initially, I had been suggesting to clients that they get Waking the Tiger (1997), Peter Levine’s exploration of trauma, which includes a few exercises for people to use. However, more recently, I have found that his later work, Healing Trauma (2008), is much better as a self-help book, which clients can use at home, with guidance in sessions. His format makes use of frightening examples, which the reader then processes using the three trauma response behaviours of the body – fight, flight, and collapse. In the context of the process I engage in with clients, I find it even more helpful if we make a list of the traumatic events in their lives, which they then process with the same work. Just this intervention alone has an amazing impact on a person’s presentation. A sense of calmness replaces what has often been an anxious or worried body. (Recently, a colleague has identified Levine’s most recent work, Freedom from Pain (2012), as excellent for those suffering from chronic pain, so I am looking forward to putting it to good use as well.)
Most trauma work is done either before or after the Personal Development Course, depending on the person’s level of distress. That course gives an excellent boost to a person’s ability to set and defend boundaries with other people in their lives. Inadequate boundaries can happen for a number of reasons. The most obvious of these is sexual abuse in childhood, but other kinds of abuse – verbal, emotional, and physical – can be nearly as damaging. Other causes can be enmeshed families, in which the identified caretaker is expected to give and give and give, with no option of saying ‘no!’ Such demands can be made by both siblings and parents. The other big benefit of the Personal Development Course is the freedom to feel good about oneself. When the word ‘self-esteem’ is first explored in the group, it is amazing how many people think that it is the same as being prideful or stuck up. The idea that it is OK to like oneself is novel, and sometimes takes a lot of getting used to.
I generally meet with each client once between each of the three groups. It is interesting how people continue to come only for a long as they feel a need to. Some find that one eight session mindfulness group is enough. Others persist through the Personal Development Course, and perhaps do some trauma processing. Only about ten to fifteen per cent of all clients referred come to the Developmental Healing Group, and only about half of those go on to do the inner child work. In one way, this is just as well, because the individual weekly sessions of the inner child work would take up too much of my time in a week if a lot of people were to avail of this option.
The inner child work can take from about five to eight to nine months, depending on the person. Over all, the entire process can take as little as thirteen or fourteen months to complete, depending upon the time of year that they begin. Interestingly, it is not entirely possible to predict ahead of time who will go the whole way. Some very shy or depressed and hugely traumatized people can display surprising courage and perseverance, while others who present with a lot of insight initially don’t find their way to this deeper level of learning to love one’s self. Most importantly from my point of view is that it allows me to respond to a very high number of referrals in a year (it works with up to one hundred and fifty or so; two hundred collapses it). At the same time, I am doing some in-depth work with some clients so that I am not deskilled or demotivated by doing only symptom-focused or short-term work. Attempting to see too many new people in a week is emotionally overwhelming due to the amount of new material and, generally, the high level of distress in people’s stories. Too many referrals makes it difficult not to get caught up in this.
While some people find the Personal Development Course quite challenging, nearly everyone finds the Developmental Healing Group quite arduous. This in-depth look at the emotional needs of children from birth through adolescence often reveals to the participants the level of emotional neglect that they suffered. Neglect is much more difficult to detect because it is what didn’t happen that has caused the wounding, rather than the more readily identifiable abuse. Nevertheless, it has been found to be just as disabling. On more than one occasion, I have met with someone who has had previous experience of counselling, who has come away with the conclusion that there is ‘nothing wrong’ with them, even though they are deeply unhappy. The great benefit of encountering developmental psychology in a group is that participants become aware that most people have some kind of wounding in their childhood. They are normal.
Indeed, the benefit of group work (and these are psycho-educational groups, not psychotherapy groups), even in the minimal sharing of a mindfulness group, soon alerts people to the fact that nearly everyone is coping with something. This is identified as a huge relief by most participants. Their sense of isolation or abnormality is often much more of a problem for them than their specific difficulty. This is, to some extent, due to the prevalence of negative thinking, which amplifies all of our worst fears connected with the past and the future. Mindfulness starts to challenge negative thinking, and then the Personal Development Course deepens this, providing people with a number of ways to counteract it. Becoming more assertive helps a person take better care of themselves and feel more empowered. This in turn, reduces negative thinking and increases self-esteem. The whole system becomes an upward spiral rather than a downward one.
The actual doing of inner child work takes a bit of getting used to. Basically, a person engages in a dialogue with younger parts of their being. It can feel a bit confusing, talking to different aspects of oneself, but once gotten used to, it provides a very powerful tool for self-reflection and self-compassion. The biggest challenge is for a person to allow a feeling of compassion for him or herself. The internalized self-hatred encountered in abusive or neglectful parenting patterns can leave a person blaming themselves for things that they would never accuse other children of. However, once a person has embraced their own pain, and given him or herself the love and approval every child needs, they discover a sense of contentment that cannot be achieved without a deep level of self-acceptance.
It is important to have done the inner child work yourself if you are intending to use it with clients. It is very common for clients to actually repeat what was done to them as children with themselves as they are doing this work. Without being aware of this, it would be easy enough to miss what was happening, and so the process would be ineffective.
As anyone knows who is engaged with their own healing process, there is no one ‘magic bullet’ that settles things once and for all. Despite the thoroughness of the above approach, its primary strength is that it gives a person a basic foundation for a healthy self- relationship as well as a number of tools that they can continue to use to cope with future distress. I have found myself that there are levels of distress that cannot be reached in the present moment. It is only as life unfolds that they gradually surface and present themselves for processing. Letting clients know that future bouts of deep sadness, or intense emotional pain, can be expected, helps them to see it as normal rather than a failure of their earlier work.
As you can imagine, interacting with such a high number of people who are in distress, year in and year out, is extremely emotionally challenging for me personally. I find it very important to actively pursue my own healing at every level. I routinely go for massage, osteopathy/cranio-sacral work, visit my own therapist about once a month, and engage in mindfulness daily. If I don’t ‘walk the talk’, I wouldn’t last long in the job. Adequate support in the job – clinical supervision, peer supervision, and continuing professional development – is also crucial to being able to sustain this level of work.
I have written this article both because it helps my own reflective process on my work, as well as sharing possible approaches for others to consider. The approach has been driven by the need to respond to a high number of referrals. I am aware that many psychotherapists in private practice are struggling more with a lack of numbers than too many. However, perhaps you may find some of the things which I have discovered in the process of my own development as a psychotherapist might be useful to you as well.
Thérèse Hicks, MA(CP), MIAHIP, works in the public service as part of a Primary Care Team.
Bradshaw, J. (1992) Homecoming. New York: Bantam.
Levine, P. (1997) Waking the Tiger. Berkeley CA: North Atlantic Books.
Levine, P. (2008) Healing Trauma. Louisville CO: Sounds True.
Levine, P. (2012) Freedom from Pain: Discover Your Body’s Power to Overcome Physical Pain. Louisville CO: Sounds True, Inc.
Segal, Z. V., Williams, M., Teasdale, J. (2001) Mindfulness Based Cognitive Therapy of Depression. New York: The Guildford Press.
Siegel, R. (2012) ‘How Is the Popular Mix of Meditation and Psychotherapy Changing the Way We See the World?’ Psychotherapy Networker. Vol: January. http://www.alternet.org/story/153651/how_is_the_popular_mix_of_meditation_and_p sychotherapy_changing_the_way_we_see_the_world
Williams, M., Teasdale, J., Segal, Z. V., Kabat-Zinn, J. (2007) The Mindful Way through Depression. New York: The Guildford Press.