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Psychotherapy

The Face with No Expression

As I continue to read Tomkins and Nathanson, focusing on the human face as the seat of our affects, I'm reminded of clients from long ago whom I didn't fully understand at the time. In particular, I think of Noah and the completely deaded facial expression he presented throughout every session. If I were still working with Noah, I would say to him, "You're terrified that I might read your shame in your face, so to stop me, you keep your expession flat and fixed, immobile so it won't give anything away."

Vanessa, one of my current clients, begins her sessions with a flat facial expression that conveys indifference. I don't think it's about hiding shame, not in the way Noah used to do, but it's related. Allowing her face to reveal that she's glad to see me, that she might have been looking forward to our session, feels unbearably vulnerable. She's afraid to smile. What if I didn't smile back? In a microcosm, it's the problem of unrequited love, once again. Core shame results when mother repeatedly fails to reciprocate the baby's joy in her. Could anything be more excruciatingly painful?


Psychotherapy

Book Review: Cinderella, A Tale of Narcissism and Self-Harm


Since Adrienne's snake dream, we've been making gradual progress in tapping into her unconscious anger. I've helped her become more aware of the rage often lurking behind self-pity and on several occasions now, she has been able to detect the hidden rage herself. In discussing her repeated insistence that I'd rather get rid of her and take on a less difficult client at my new (higher) fee, I've pointed out the hidden insult, the hostile suggestion that I'd drop a client to make 25 bucks more an hour. It's a complex message, of course, reflecting her sense of worthlessness, the conviction that no one could truly care about her for who she is. At the same time, she's angry and I feel it. Adrienne's anger feels closer and closer to the surface as time goes on.


Psychotherapy

Online vs. In-Person Psychotherapy — One Major Difference

When I first began working with clients by Skype, I was surprised (and relieved) to find how similar it is to working in person. Once I began learning more about affect theory and how facial expressions communicate feeling states, I came to understand why I'm still able to empathize so well with my clients.

Now that I've been practicing via Skype for over a year now, I'm also understanding one important way that it differs from conventional face-to-face work: psychotherapy relationships via Skype tend to be much more transient. I suppose it's a feature of many "virtual" relationships that are quickly formed and easily ended. Despite all the caveats in my disclosure statements, no matter how clearly I state that I don't do short-term work and believe it takes time for a psychotherapy bond to develop, I still have clients who come for a few weeks and decide to quit because they don't feel they're making sufficient progress.


New Discussion Forum

Over on my personal website After Psychotherapy, I've now opened the first topic thread on a new discussion forum. In this first thread, we'll be discussing the Introduction and first chapter of my new book, Why Do I Do That?, then in subsequent threads we'll take up each of the chapters individually. I view this forum as a place for site visitors who are reading the book to ask questions about what they've read and to share their experience of engaging...

General

Depersonalization Disorder: A Hypothesis

In one of our first sessions, Carl told me that his feelings of depersonalization began several years ago when he was reading a self-help or psychology book (he can no longer remember the name of it) and one of the author's ideas gave him a sudden unpleasant insight into himself. He can't recall exactly what he realized; but at that moment, he felt himself lift out of his body, into his head and out through the top of it where he has remained ever since. He's now more or less constantly preoccupied with attempting to regulate how he appears to other people by mind-reading and "empathy." Other than a pervasive feeling of anxiety, he has little idea about how he feels.


Psychotherapy

From Shame to Self-Esteem

Melissa continues to struggle with the challenges of her new job, vacillating between fear that she won't be able to master the new skills and contempt for how "stupid and trivial" it all seems to her. We talked about her scorn as a defense: when she can't bear the fear of failure, when it all seems so overwhelming to her, she take flight into contempt. The indifference she sometimes expresses is, in fact, a variation on this theme, where "not caring" reflects an underlying scorn which is equally defensive. The challenge, as we often find, is believing that she might grow little by little over time and gradually get better at something; she usually believes that she must know everything already or she's a hopeless failure.


General

Mother-Baby Music

I've always had a problem with the term attachment to describe what happens between mother and baby. Today, in session with Janice, I remembered the word attunement and felt it was a much better, more accurate descriptor.

Janice began the session by talking about her husband's almost complete inability to read her body sexually and to identify what gives her pleasure. The way he had been touching her the night before felt completely unrelated to her own responses; it distressed her so much that she began to cry in the middle of sex. When they talked about it afterwards, he told her he felt there was a very narrow pathway of acceptable behavior and that if he deviated from it, he'd upset her. Janice acknowledged that there was some truth to what he had said. She next talked about how he doesn't pay much attention to his intonation when he plays saxophone, that he often sounds shrill and off-pitch but doesn't seem to notice. Her mother had been like that, too -- interested in music but unable to carry a tune.