Eating Disorders Articles

How A Psychotherapist Listens

by Joanna Poppink, M.F.T.

Reference: Poppink, J. (1997). Chaos and complexity as theoretical grounding for psychotherapeutic listening:
Psychotherapist's presence with patient in flooding stage of post traumatic stress disorder. Paper presented to The Society for Chaos Theory in Psychology Life Sciences, Seventh Annual International Conference, Marquette University, Milwaukee, Wisconsin, July 31 - Aug 3.

The principles, images and metaphors within chaos and complexity can provide useful strategies in a psychotherapist's clinical work.

I'm a psychotherapist in ongoing practice since 1980, and I've incorporated chaos and complexity awareness into my theoretical and experiential grounding. I'm presenting these thoughts and experiences so that we may begin a dialogue, and because you may find something in this discussion that triggers a useful idea or perspective for your own work.

When I was an intern working with young psychotics in a residential treatment center in 1977, I had a learning experience with a 25 year old male patient. I was becoming adept in the use of guided imagery and thought I would offer this black haired, open faced, intelligent, psychotic young man an imagery experience. At this stage in my training, I had been taught not to use these methods with psychotics unless we were in a protected setting, and so I thought, here was an opportunity for both of us.

The imagery process I used at the time usually took from 20 to 45 minutes. The young man and I sat under a tree on a lovely spring day in Los Angeles. He closed his eyes, and I suggested that he be in a meadow. In 90 seconds, this man whirled through a series of horrific misadventures, three dimensional, vivid, in Technicolor, full of scents, sounds, and texture, with blood, murder, torture, and mayhem in full detail. I later wondered if his process was in any way similar to what people describe as their entire life passing before their eyes in a flash.

In the moment, he took my breath away. Nothing I had been taught, nothing in my experience, equipped me to process this material with him. He looked like he was in a state of alert shock after this sudden trauma.

I said, drawing on I don't know what, "Okay. Now let's do it again, except this time we'll do it slowly." He said, "Oh, no. I could never go through that again. I said, "I'll be with you."

We did it again and took about 30 minutes to review the terrain. He was more calm as he described the details of his sudden and terrifying experience. Then we parted.

Because it was a residence, we were both still on the premises. A few hours later he came looking for me. He looked serious, thoughtful, aware and clear. He looked straight into my face and said, "Thank you."

I looked at him and smiled. Then quite seriously I asked, "What are you thanking me for?" He said, "For staying with me."

That was my lesson. The more I understood, could analyze and interpret phenomena, the more theories and options I had in my repertoire, the more capable I would be as a therapist. But the most basic key in working with someone was my ability to remain present for their experience.

Often, it's the therapist's internal emotional limits which stop a patient's exploration. It can be therapist fear which interrupts a patient's process, particularly when the process is emotionally charged and sustained. The frightened, unsure therapist may bring in interpretations too early, offer appeasing explanations, directions, attempts to soothe, critical judgements and perhaps medication. I was so new when I had this experience, I didn't know enough to even attempt these strategies. Now that I know them, I have to work harder not to use them.

When a patient is internally flooded by a cacophony of thoughts and emotions and the flood pours out, his or her internal chaos becomes more visible. It's seems formless at first to both therapist and patient, but in my mind set now, I hold a certainty that structure exists within this chaos. I'm familiar with the rushing forces on the edge of chaos which may diminish and the tumult of chaos out of which a new emergence can eventually arise. I have a certainty that a deep structure, not necessarily in the patient's conscious awareness, is working to establish itself.

When I have this certainty it helps my emotional center stay present and even calm sometimes. When a patient is in a torrent of emotion, perhaps especially then, the patient is acutely sensitive to the inner life of the therapist. Fear, including therapist fear, is catching and can make a patient's turbulence even more frightening to himself.

I believe my task is to ride out the turbulence with the patient, not trying to shape it but allowing the shape to emerge. I have no template, but I am becoming more familiar with the process. The emotional fractals, the bits and pieces of a fractured, fragmented mind and spirit, are attempting to find their own way to each other and create a form, reveal the integrity of the person, in a way no theory or therapist I know of could shape or predict.

To me, this is the stuff of healing. It's tough to sit through this chaos and be present, solid and non-interfering. I suggest that knowledge and appreciation, if not deep understanding, of chaos theory, chaos in nature, and complex systems can extend to an awareness and trust in the life forces of emotional chaos. With this can come a confidence that within emotional chaos lies structure. This structure is unpredictable regarding exactly when, and where it will take shape or what it will look like. But if the process is given a chance both the patient and therapist can be confident that it will emerge.

Remember when someone sat down with you and helped you to see a world you never knew existed? And it was right there in front of your eyes, all along?

Watching ants, exploring snowflakes, looking at the details of a flower or better yet, watching how a frightening bee transformed itself into a benign, graceful industrious creature sucking nectar from a daffodil? Remember how amazing it was to see a strand of your own hair through a magnifying glass or how you felt the first time you saw a drop of water under a microscope?

We all probably share these or similar moments from our early awakening experiences. We were discovering the fascinating wonder and surprise in a world we thought was ordinary. And what made these discoveries all the mere wonderful was the fact that they didn't come from any make believe place. This was all real.

Such events, precious in our lives, help us to be more present and aware in the world around us. Chaos and complexity theory can do that for us too, if we'll let it. At least, it does that for me. And it helps me stay present with patients, especially in the most taxing experiences with a person with PTSD in a flooding stage.

I'll share with you my own process of getting to this place in my thinking and clinical experience.

I met chaos theory through Gleick's book, Chaos: The Making of a New Science, in 1988 or 1989. I heard about it at a psychology conference at the Saybrook Institute in Northern California. I bought the book. It was my companion for a week out of ordinary time as I drove from Half Moon Bay to Los Angeles through the magnificence of the California coast through Big Sur.

It's strange and wonderful that we never know what little thing we may do or experience that will have a powerful impact on the rest of our lives. There is so much that is sensitively dependent on initial conditions. The book changed the way I saw the world.

In Chaos Gleick introduced me to Manlbrot's question: How long is the coast line of Great Britain? I walked on the beaches of Half Moon Bay thinking about how long the coast was. I could measure by straight lines and get one number, or go through each bay and inlet and get another, or carefully climb over each grain of sand and get another. My way of measuring and evaluating was arbitrary and subject to challenge from an infinite number of differing perspectives. Wow.

I sat on the beach and watched the sea glitter with twisting and colliding currents under the sun and wondered about unpredictable yet orderly chaos.

I saw long, faint, orderly dark lines in the sand and couldn't identify them. Yet they made me think of fractals. I followed the shoreline and saw the lines become more sharply defined until I saw leaf patterns, all almost identical, but not quite. I saw that the waves lifted the kelp and dropped it on the soft wet sand. Then other waves rolled in, lifted the kelp and brought it back to the sea.

Strips of kelp outlines remained and developed the etched pattern on the beach. I was fascinated with the steady repetition of movement and shapes and the low lush sound which all were never quite the same and familiar and unpredictable at the same time.

I drove down coast slowly. I'd stop the car, read a few pages and then look around to see if I could find what these nonlinear scientists were talking about. I sat at the base of a 30 foot waterfall deep in the redwoods and watched the water cascade into a calm, black water pool. I marveled at the simplicity of knowing that all the water up there would wind up at the bottom, down there, but that no one could tell where one particular drop would be at any given moment. I marveled at the sudden change between the torrent hitting the water and the calmness of the pool.

And it being 1989 or so, with people still smoking in public, I watched steady rhythm break into unpredictable turbulence in cigarette smoke.

I returned home with new eyes. Over time I found myself enjoying the comfort and reliability of fractals, chaos and turbulence, and simple beginnings leading to complex behavior. It was as if nature had been playing this wonderful game all around me, and I just found out about it.

I began painting, experimenting with inks, watercolors and paper to see what kind of flows and repetitions, turbulence and organization would happen when I played with the materials.

And somewhere along this immersion process I began to think abut all living organisms being complex adaptive systems. And from this came the thought that the workings of the mind may follow the principles nonlinear science was discovering.

That thought led me to a more expanded, calm and even joyful approach to the seemingly chaotic, turbulent emotional experiences of my patients, particularly when they were in a flooding stage of PTSD. I was getting listening and presence training from kelp, waterfalls, cigarette smoke, waves crashing on the rocks in Malibu and more.

I looked at the stem of a rose and examined the leaves, so similar and yet each different and each with the potential for change. I wondered at what point did a stem change its energy and form a leaf? At what point did a leaf reach its maximum size? When did a rose burst forth, and at what particular place? And what was going in the invisible but present root structure that affected what I saw. Everything around me - I have a full and varied garden - looked familiar and unknown. Each plant was following it's own inner integrity yet developing as it interacted and adapted with everything else in the garden including the light, temperature, humidity, animal life, me and forces I don't know about. And the other forms were interacting and adapting to everything else at the same time: cooperation, competition, coevolution.

The more I thought about this the more I felt that it would be very odd if the workings of the mind were not following these same basic principles in nonlinear science.

The person, the fragments of the mind, full of life energy, adapting within itself and with the external world, yet following some inner integrity of the uniqueness of the particular human, was working continually to protect itself, nourish itself, create itself and evolve. Like anything alive it had to cope with inner and outer environmental forces, adjusting, adapting and influencing within its abilities to survive.

Perhaps it sounds simple when I say it. But steeping myself with natural images and appreciation of turbulence and fractals, holding the element of surprise and wonder, feeling the certainty that I can know and yet not predict, becoming aware of the existence and patterns of strange attractors, all help me to remain present for my patient's experience.

When a therapist can genuinely stay present that certainty of presence is communicated to the patient. Then patients can stay present a bit longer for themselves as well. Their tolerance for their own experience increases.

In the experience of being present the therapist can listen more fully and deeply not just to the words but to the meanings behind breathing, movement, inflection, pauses, facial expressions. The therapist can listen to the surface and the possibilities which may be coming from a deeper structure with the patient.

The point at which memories and feelings from past trauma threaten to overwhelm a person's everyday consciousness is a critical and sometimes extended period in recovery from PTSD. It is a challenging time as patients go through strong and fast changing expressions of terror, sorrow, rage and often dip or sink into irrationality and age regression.

Imagery can be helpful in metaphorically seeing moving and interacting forms in a patient's inner experience. When I look at computer drawing of fractals and solitons, I see various schematics of one human mind. A soliton moving as a complete entity within a larger framework is like an archetype, a complex, or an identity fragment existing as a whole in a vast inner life space. Tiny fractal formations, like gossamer dust, are like bits and pieces of diffused identity in protective retreat. There is beauty and organization in these structures which often were created so the system, the psyche, the person could cope with stressful stimuli and survive. Because survival issues were the forces behind the creation of these structures, they are strongly entrenched.

Immersing oneself in the concepts and images of chaos and complexity can open a realm of possibilities to a clinician. Our patients are human and thus, familiar. Our patients are unique individuals and thus, unknown. Concepts of chaos and complexity can help us hold the tension between the familiar and the unknown. This can help us be present for what is, what is in the process of becoming, and to hold back our own desires to shape a definition into something we expect, anticipate or worse, prefer.

My discussion concerns working with people who have lived under chronic stress and traumatic conditions. These people grew up often accepting as normal rather drastic life situations, i.e. minimizing their traumatic experiences - "He never broke any bones." (despite the fact that he regularly beat the boy). "I always had food to eat" (despite the fact they she was sexually violated from age 3 to 11). "We stayed together and slept on a feather bed." (minimizing adversities during the flight from Poland to Russia as the family fled the Nazis). They developed dissociative methods for coping with this world. Or more usually, they used a combination both strategies.

Their dissociation protects them from unbearable emotional pain. Their psyches divide. Some various parts carry awareness of emotional trauma. Some parts are oblivious to that experience. Sometimes they live primarily through parts of themselves which are oblivious to most feelings. They may have occasional outbursts of feeling which seem (to others) to be unconnected to current life situations. These outbursts can be bewildering to friends, co-workers and family and cause intolerable disruptions which neither the patients nor their associates understand.

At varying points in therapy some of these strong feelings will emerge in temper tantrums, rages, bewildered terror episodes and grief. Early outbursts can be wild, dramatic and short-lived. Patient are often convinced that their feelings are about something that has occurred in their here and now life. Expressions can be intense and particularly remarkable in that they seemingly resolve rather quickly. In fact, when a strong outburst dissolves quickly with no resolution that I can see I wonder if we are getting a glimpse into what has been a dissociative style.

My personal relief that the stress is over and the patient's relief that the stress is over may actually run the risk of colluding with a dissociative style. Yet it seems natural to feel relief after a storm passes. In the aftermath of such turbulence, depending on timing and the stage we are in within the therapy as a whole, I may ask the patient, "What was that like for you? Being so angry with me, or being so noisy, or letting me see you cry so hard and long?"

A variety of memories and associations can come with their answer. But the most prevalent answer among patients and the most recurring answer in each patient is: "I can't believe you're still here." or "I thought you'd throw me out after that." Or, "No one ever heard me go through that. I didn't think I could ever let anyone see that."

We will often marvel together about how the room, the furniture, our bodies and our relationship are still intact. Then the patient discovers that we can continue to work with this episode supposedly behind us. It usually will be my job to bring it up as an association to something in the future so it becomes an integrated and remembered piece of our shared history. I know we are making headway when sometime in the future they can with ease and thoughtfulness, relate it to something on their own initiative. And so, we chip away gradually at the powerful defense of dissociation.

The patients' challenge is to learn that they can tolerate their feelings, that they can feel and stay alive and maintain a relationship all at the same time. It's a challenge because in the traumatic environment they lived through in the past they believed with their very cells that self awareness and basic survival were incompatible. Therefore knowing themselves, honoring themselves, living a life based on self-respect and self-awareness is unimaginable. When it is imaginable we may be looking at the new attractor that will lead the psyche to a new organization.

The therapist's task - one of many - is to develop and strengthen a stance in which the patient and the therapist, separately and together can learn to creatively adapt to the changing inner and external environment. The therapist and then the therapist and patient together, create this co-evolutionary stance by increased toleration of feeling, developing understanding, boundary testing and self-awareness.

Using concepts and images of flowing fractals helps me to follow a patient's seemingly disjointed reasoning. Holding the concept of possibility space and phase space is a way of listening and quietly reflecting genuine wholeness back to a person who feels and is fragmented.

Knowing with certainty that there are various patterns and structures within chaotic behavior and that chaotic behavior is sometimes necessary for needed transformation helps me stay present and able to listen better through a patient's uproar and demands.

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The raging or weeping is real and powerfully felt. Under these feelings is another kind of awareness within my patient which may be the attractor in this emotional chaos. Resolving the patient's need for the old structure is part of freeing energy locked in an old coping pattern. This can allow a new distribution of energy and form to assemble. So the therapist, when the time is right, can affirm the existence of that new inner attractor when the patient begins to become aware of it himself.

Increased therapist awareness can help the therapist recognize the patient's awareness. The blind cannot notice when someone makes a subtle visual discovery. We need to expand our vision and conceptual possibility range to encompass our patient's experience.

I affirm that staying present and listening through chaos is essential for healing. I had a supervisor, Lars Lofgren, who once said to me, "Anytime you think your work is easy, you are doing something wrong." I understand that comment more all the time.

For those of you who are interested in exploring these ideas in your own work, I recommend image immersion. Intellectual understanding is important, but alone it won't get us through the storms.

Look at photographs, find examples in life. I like painting to get close to natural formations. To me clouds are three-dimensional watercolor paintings alive with chaos and complexity. But we all find our own medium. These concepts are alive in sound, in texture, perhaps in scent. They abound in the natural world. I suggest that we work and play with fractals and turbulence. I suggest that we learn to recognize co-evolution in action. Let these concepts become so familiar to us that our senses and emotions can recognize and stay present longer for the tension between what is simultaneously familiar and unknown.

This process can add silent and confident appreciation to our listening. It can help us follow energy shapes at times when we know the words are irrelevant. I believe this can help us and our patients negotiate or just plain survive the flood and reach a new and more cohesive awareness of the present.

Then our task becomes accepting, with grace, flexibility and courage the new organization which emerges.

And that, as the storytellers say, is another presentation.

References

• Buckley, P. (Ed.) (1986). Essential papers on object relations. New York: New York University Press.
• Hedges, L. (1994). In search of the lost mother of infancy. Northvale, New Jersey: Jason Aronson Inc.
• Gell-Mann, M. (1994). The quark and the jaguar. New York: Freeman and Co.
• Gleick, J. (1987). Chaos: Making a new science. New York: Penguin Books, New York.
• Gleick, J. (1992). Genius: The life and science of Richard Feynman. New York. Vintage Books, Division of Random House, Inc.
• Kernberg, O. (1983). Borderline conditions and pathological narcissism. New York: Jason Aronson, Inc.
• Kohut, H. (1977). Restoration of the self. New York: International Universities Press, Inc.
• Kohut, H. (1984). How does analysis cure? Chicago: University of Chicago Press.
• Kuhn, T. (1962). The structure of scientific revolutions. Chicago: International Encyclopedia of Unified Science, University of Chicago Press.
• Lindsay, K., Vergo, P. (Eds.). (1994). Point and line to plane. In Kandinsky, Complete writings on art. New York: Da Capo Press, Inc.
• Ruelle, D. (1991). Chance and chaos. Princeton, New Jersey: Princeton University Press.
• Russek, J. (Ed.). (1990). Nature's chaos. Photographs by Eliot Porter. Text by James Gleick. New York: Viking Press.
• Thomas, L. (1975). Lives of a cell. New York: Bantam Books.
• Van der Kolk, B. (1987). Psychological trauma. Washington, D.C.: American Psychiatric Press, Inc.
• Waldrop, M. M. (1992). Complexity: The emerging science at the edge of order and chaos. New York: Touchstone Publishers.
• Young, N. (Ed.). (1982). The paintings of Henry Miller: Paint as you like and die happy. San Francisco: Chronicle Books.

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