Therapy's First Obstacle: Trust My Therapist? No Way!
Thursday, October 31 2013 Tom Cloyd, MS, MA
Effective psychotherapy requires a substantial degree of trust, which can only occur when the client-therapist relationship feels sufficiently safe to both parties. With victims of psychological trauma, achieving this sense of safety and trust can be a truly difficult barrier to productive therapeutic work. Let's look at some of the reasons for this. But, first - why do this? Because it is all but impossible to solve a problem you don't understand, and this problem must be solved. That this is possible is verified by the thousands of people who have actually done it, each in their own manner, but all in the same general sorts of ways. It is important to see a path to the mountain top, if that is where you wish to be. Let's look at how and why that path can be hard to find.
We can begin by doing some "thought experiments" (i.e., considering some imaginary situations), to better grasp some aspects of the problem.
Ambiguity - the problem of not knowing enough
Suppose you travel to a nearby strange town, walk into a building you've never before entered, and then through a door whose identification indicates you have arrived at your destination: the office of someone you have chosen as your psychotherapist. You close the door behind you, and are invited by voice coming from the end of a short hall to "come on back". Entering a modest-sized office, you turn to your left. Someone sitting at a desk in a high-backed chair, with their back to you, turns around. You look at their face, trying to "read" their expression, and find you cannot. You just don't know how they are reacting to you. How do YOU now react?
This is actually fairly predictable. What research tells us is that how you "read" this ambiguous situation will significantly depend on your state of mind, and probably your self-esteem, as well (Smith, 2013). Interpretation of ambiguity such as this depends a lot on context (Bouton, 1988), and part of that context surely is your own mental state.
Anxiety - the problem of negativity bias
Now, let's change the scenario. Suppose that before you entered this building, you were already feeling edgy, uncomfortable, wary. How does that effect your reaction? You can probably correctly guess: It will likely induce you to respond to what you're seeing, as well as the office, the building, and the whole town - all potential sources of threat - as significantly more threatening than a realistic assessment would seem to indicate (Frenkel & Bar-Haim, 2011). Low self-esteem, especially coupled with anxiety, will likely result in your seeing even more threat in the ambiguity of the facial expression you're looking at (Smith, 2013).
Lessons of personal history - the problem of over-generalization from previous experience
Let's tweak our thought experiment further: Suppose that what you see in the chair IS recognizable to you. Suppose that it seems vaguely familiar: a person of power, important to you, who is not clearly trustworthy. After all, while the stranger in the chair surely has not harmed you in any way, you also have little reason at this point to trust them much. In addition, you do bring something special into this ambiguous situation: extensive experience with the most important "powerful people" in your life - your caregivers during childhood, who will usually be your parents.
What if your experience with these powerful people throughout your childhood was that they failed to meet your needs, failed to respond to you when you needed comforting, failed to help you make the world a place you could understand and in which you could be comfortable. I am describing, of course, an incompetent (at best) or abusive parent or caregiver.
In this circumstance, the situation is familiar, not strange. Your brain will predict what happens next, and it isn't something good or desirable. This is not fear of the unknown, but fear of the known. You likely have ways of dealing with this, because you've had a long time to figure out a response. You're also highly likely to USE your accustomed response, which will probably be to distance yourself from what you are already too familiar with - the negative consequences of engaging with a powerful person who you do not have clear reason to trust.
Inability to recognize safety - the problem of impoverished prior experience
Let's suppose that you nevertheless persist in this situation, and try to get it to work for you. And then the situation changes again: the person in the chair, at some point in your meeting with them, invites you begin trusting them, perhaps by talking more about yourself, or by trying some experiential experiments with them. To an outsider, this will probably seem a clear invitation to trust - what will you do with it?
Suppose you have never really known a safe, supportive, caring relationship with a person of power upon whom you depended. It's likely that the invitation to engage in trusting behavior may not even be recognized. Instead you'll see an invitation to move closer to a situation that has almost always let you down, hurt you, left you bewildered and helpless. In other words, you've been invited to do a dance you not only do not know, but which essentially looks like a sure and certain beating, and not a dance at all. This is the only way you can see it, the only thing your experiences tell you is possible.
If you do recognize it, but have no experience of trust in a relationship with an important person, how will you know how it is done? You probably won't. To have seen a tango is not to have learned the steps, much less the style.
The necessity of a solution
That these sorts of problems should exist is not difficult to understand, when you consider the natural variations in human personality, and the considerable variety of lessons people learn from their childhood experience. Each person's ability to enter into trusting relationships varies in ways that mirror the individuality of their personal history, and our inherent desire for relationships with others also varies with the individual. Some of us are inherently gregarious, and some instinctively shy, and all sorts of variations on these two extremes exist.
Yet, a way to achieve sufficient trust must be found, else what is hoped for in entering therapy will never be achieved. Realizing this, however, offers one no solution. We do see, however, two aspects of the problem that look like promising places to focus our attention: the initial ambiguity you have about the other person, and prior experience you bring to this ambiguous situation. Other promising places on which to focus, not yet seen, likely also exist.
What exactly can be done? How can this substantial barrier to the trust needed for psychotherapy be overcome? I will take this up in my next post, and you may be surprised at how many options actually exist for resolving this problem.
These references are all fairly experimental research reports. Non-professional readers can read conclusion sections and summaries in their abstracts and generally understand what the studies are showing us.
Bishop, S. J. (2007). Neurocognitive mechanisms of anxiety: an integrative account. Trends in Cognitive Sciences, 11(7), 307–316. doi:10.1016/j.tics.2007.05.008 [download]
This article offers a good overview of the neuropsychology of anxiety.
Frenkel, T. I., & Bar-Haim, Y. (2011). Neural activation during the processing of ambiguous fearful facial expressions: An ERP study in anxious and nonanxious individuals. Biological Psychology, 88(2-3), 188–195. doi:10.1016/j.biopsycho.2011.08.001 [download]
The literature review in this rather technical article gives one good access to other literature supporting the idea that anxious individuals react to ambiguous stimuli with a negativity bias.
Smith, N. T. (2013). 2013 - The influence of self-esteem level on interpretation of ambiguous stimuli after a rejection experience. In Stander Symposium Posters. Book 348. [download]
This B.A. Honors thesis poster presentation - an accessible, brief summary - is of a study showing that individuals with low self-esteem evaluate both positive and negative communication more negatively than individuals with high self-esteem.
[photo credit: Victor1558]