Co-Creating Safety
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Co-Creating Safety

Healing the Fragile Patient

Jon Frederickson

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eBook - ePub

Co-Creating Safety

Healing the Fragile Patient

Jon Frederickson

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About This Book

Some patients are crippled by fear and anxiety. To help the 50 percent of patients who drop out of therapy before they have received its full benefits, therapists must know how to make therapy a safe place. Only if patients feel safe in their body and with the therapist can they feel safe enough to change. Co-Creating Safety provides clear, systematic steps for assessing and meeting patients' needs. Every technique is illustrated with a vignette. Representing hundreds of therapeutic impasses taken from actual sessions, the vignettes show therapists what to say so they can assess and respond to patients' needs moment by moment, help patients develop and keep an effective focus that leads to change, help regulate patients' anxiety, deactivate misperceptions of the therapist and therapy, help patients see and let go of defenses that cause their symptoms, help them overcome their fears and face their feelings, and help them let go of insecure attachment strategies to form a healing relationship.

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Building a Secure Attachment



The Signal of Danger

Listen . . . and attend with the ear of your heart.
Recently, a colleague attended a seminar on anxiety. A clinician in the audience asked, “What do you do when the patient is too anxious in the session?” The presenter replied, “I send them home. If they’re too anxious, they can’t do therapy.”
Since when do we send people away until they no longer need our help? My oncologist did not ask me to go home until I no longer had cancer. He understood his role: to help me. At a clinic where I worked years ago, a severely disturbed man came for a consultation. The psychiatrist, Harold Eist, asked, “How can I help you?” “I’m afraid I’m going crazy.” Harold replied, “Well, you came to the right place.” When he said “the right place,” he didn’t mean the clinic but the healing relationship they would co-create.
We start therapy by asking, “What is the problem you would like me to help you with?” It seems like a simple factual request. Yet it is also a complicated question about relating: “Would you like to depend on me?” The fragile patient is not afraid of her problem. She is afraid of depending. As soon as she asks for help, her painful history of depending arises. She wants to depend upon you, yet her body becomes anxious. With her higher mind, she recognizes her therapist. But her lower mind may react as if you are a victimizer. And the more traumatic her past abuse, the more her anxiety rises.


A few fragile patients can declare a problem without being overwhelmed with anxiety. Some flood as soon as you ask about their problem. Or they quake with terror before walking into your office! Nontraumatized people describe an inner house requiring repair. Fragile patients try to flee from an inner house on fire. Yet no matter how fast they run, they never get away from the flames because they are on fire. They first need us to douse those flames by regulating anxiety. In this way, we create a safe place for people who may never have had one. To co-create safety, however, we must know how to regulate anxiety.
Ideally, the mother cuddles the troubled baby in her arms and soothes her. The father hugs his frightened son and comforts him. We would not force a child to climb onto a carnival ride while she is screaming. Likewise, we should not explore the patient’s problems if she feels scared. She is not defying you. She is drowning in anxiety. The therapist might mistakenly think, “This patient is not joining me.” What if anxiety floods her because she is joining you? Through anxiety, her body screams, “Help me!” If you rush ahead without regulating her anxiety, you will become the cause of danger rather than the source of safety. For therapy to be safe, we help her feel safe, bodily, by regulating her anxiety.
She reaches out to a therapist because she needs relief. She tried to solve her problems on her own, but her solutions didn’t work. She requires therapy, yet relying on a therapist conjures up her history of depending. Most fragile patients learned to love while enduring many traumas. People they trusted abandoned, hurt, or abused them. Depending caused pain, not pleasure. No wonder they feel fear when they seek safety. Through anxiety, the body signals that depending was not safe; it was dangerous. Anxiety tells us the history of their suffering.
Our relationship today triggers the patient’s memories of past relationships, pains, and agonies. And the body offers the first memory: overwhelming anxiety (Fox and Hane 2008). Early insecure attachments repeatedly evoked so much anxiety that the toxic shock shaped the patient’s brain and physiology (Jaremka et al. 2013; Landers and Sullivan 2012). And if the parent could not regulate anxiety, the child never learned self-regulation (Adam, Klimes-Dougan, and Gunnar 2007; Schore 2002). In fact, anxiety “in the mothering one, induces anxiety in the infant” (Sullivan 1953a, 41–42). Thus, the future fragile patient does not receive from the parent anxiety regulation but anxiety induction. And through this feedback loop, ever-increasing anxiety leads to somnolent detachment in the infant, the precursor to dissociative patterns later in life. (For more on the interpersonal theory of anxiety, see F. Evans [1996].)
Thus, to co-create a safe place, we regulate anxiety so the patient can depend on a therapist. But first, what is anxiety?

Anxiety Defined

Anxiety is a term widely used yet almost universally misunderstood. Fear refers to our response to an objective, external threat (A. Freud 1936): a car skids into your lane, and your foot slams on the brakes. Your heart pounds and your hands shake. Anxiety refers to our response to a subjective, internal threat: a feeling frightens us (A. Freud 1936). But why would a feeling evoke anxiety?
Many children learn that their feelings make parents anxious and frightened (Bowlby 1969). Then children become afraid of the frightened or frightening parent, fearing the loss of a relationship they require for their survival (Bowlby 1969, 1973, 1980; Main and Solomon 1990). As a result, they try to hide their feelings to decrease the caretaker’s anxiety and to bring security back into their insecure connection (Sullivan 1953b). Through repeated experiences, this link between feelings and danger becomes conditioned, contaminating every invitation to love.
Anxiety is our response to feelings rising within us that endangered the security of earlier relationships. The parents or caretakers are no longer present. But anxiety rises whenever those previously dangerous feelings arise: “Love is dangerous. Stop!”
Anxiety has a specific function. It signals that feelings and impulses rising now could endanger the relationship (Freud 1926/1961b; A. Freud 1936). Fear is “induced by threat of destruction to one’s physical self, and anxiety . . . by perceived threat of destruction of one’s psychological self. . . . [Thus,] all anxiety is ultimately of interpersonal origin” (Cooper and Guynn 2006, 103).
To survive, animals must avoid predators; children must avoid losing relationships. Any emotion that provokes anxiety in the parent puts the child’s security in peril (F. Evans 1996; Sullivan 1953a, 1953b). Therefore, the child learns to hide emotions, desires, and impulses that make parents anxious. And anxiety becomes a signal: “This feeling, thought, or impulse is dangerous.”
To hold onto his parents’ love, the child adopts their defenses (Geleerd 1965). He must imitate their neurotic ways to be admitted to the human community. If he cannot count on his parents to love him, he must use their defenses to cover up what they cannot love. Whatever they hate, he hides. And the ways he hides, his defenses, make him less aware of the feelings that cause anxiety—feelings he doesn’t see, he can’t share so his parents can care for the remainder. But the defenses corrupt his consciousness through the disowning of his inner life, leaving him psychically blinded to his being.
Not all feelings or traumatic experiences will generate anxiety in the future. The pivotal issue is whether we have a loved one with whom we can bear and share our feelings. When the child cannot depend on his caretakers for affect regulation, he has to rely on their defenses for affect dissociation (Schore 2002; Sullivan 1953a, 1953b). In fact, feelings do not fuel the child’s anxiety. The parent’s rejection or even hatred of his feelings fuels his anxiety: “I might lose the person I need to survive!” Thus, the font of anxiety today was fear borne in the past.
Why does anxiety cause so many difficulties? A single traumatic experience can trigger anxiety for a lifetime. Fear memories are forever (Fanselow and Gale 2003). As a result, feelings that remind us of a trauma in the past trigger anxiety and defenses in the present. What was life-threatening then feels dangerous now.

Anxiety: Understanding the Neurobiology

Having described anxiety’s relational origins, let’s examine how the brain produces anxiety symptoms in the body. If you can understand and observe the physical signs of anxiety, you can assess whether it is too high. You will know when to regulate it. And, when you see it, you can examine the client’s previous sentence to discover what triggered anxiety in this second. With this knowledge, you can co-create safety with the fragile patient.
We have inherited our biological anxiety system from the fear system of animals. Animals don’t have time to think. They must flee predators to avoid being eaten. Thus, evolution provided them with brains that nonconsciously assess risk and activate the body without a single thought involved. We have the same mammalian fear systems designed for escaping from predators (Porges 1997, 2001, 2011; Porges and Bazhenova 2006). But, in humans, those systems get activated for both external dangers that threaten our life and internal feelings that could endanger a relationship.
When a threat is perceived, such as a snake, it triggers the amygdala and hypothalamus (Damasio 1999; LeDoux 1998). They activate the autonomic nervous system, producing anxiety symptoms throughout the body. Milliseconds later, the amygdala sends a message to the cortex. The body feels anxious before the prefrontal cortex registers the signal from the amygdala. Only then does the prefront...

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