“IF I CAN GRAPPLE WITH THIS I CAN TRULY BE OF USE IN THE THERAPY ROOM”: USING THE THERAPIST’S OWN EMOTIONAL STRUGGLES TO FACILITATE EFFECTIVE THERAPY Harry J. Aponte and Karni Kissil Drexel University This study premises that self-of-the-therapist work is pivotal in the development of effective therapists. However, therapy models vary in their goals for this work and the means of accomplishing them. This study presents the perspective of the person-of-the-therapist Training (POTT) model that prioritizes the ability to consciously and purposefully use the selfas-is at the moment of contact with the client over the traditional goal of therapists working to resolve their issues. A key underlying assumption of the model proposes that therapists’ core issues (referred to as “signature themes”) are potent resources that can be tapped into to connect, assess and intervene effectively with clients. The study presents the model and illustrates the use of signature themes in clinical work. For what matters above all is the attitude we take toward suffering, the attitude in which we take our suffering upon ourselves (Frankl, 1963, p. 178). Making one’s own wounds a source of healing, therefore, does not call for a sharing of superficial personal pains but for a constant willingness to see one’s own pain and suffering as rising from the depth of the human condition which all men share (Nouwen, 1979, p. 88). When we become aware that we do not have to escape our pains, but that we can mobilize them into a common search for life, those very pains are transformed from expressions of despair into signs of hope (Nouwen, 1979, p. 93). INTRODUCTION We are “wounded healers” (Hanshew, 1998; Nouwen, 1979; Sedgwick, 1994; Stone, 2008), and it is how we therapists use those wounds that makes the difference beyond technique in the human experience called therapy. A wealth of clinical and theoretical writings underscores the critical role that self of the therapist work plays in the training and formation of effective therapists (Baldwin, 2000; Hayes, 2002; Rober, 2011). Beginning with the psychoanalysts (Freud, 1910/1959; Freud, 1937/1964; Reik, 1948) through the humanists/existentialists (Frankl, 1963; Rogers, 1957) to the pioneers in family therapy (Bowen, 1972; Satir, 2000; Whitaker & Keith, 1981) to postmodernists (Hoffman, 1990; White, 1993) to current social commentators (McDowell & Shelton, 2002; McGoldrick & Hardy, 2008; Watson, 1993), there has been recognition that the therapist brings more than theory and technique to the therapeutic process. In the last twenty years, family therapy theorists have started focusing more on the therapeutic relationship within a systemic work and on the use of the family therapist’s self when working with families (e.g., Flaskas, 2004; Lee & Everett, 2004; Rober, 2011). Systemic thinkers view the players Harry J. Aponte, MSW, LCSW, LMFT, Clinical Associate Professor, Department of Couple and Family Therapy, Drexel University; Karni Kissil, Ph.D, LMFT, Adjunct Faculty, Department of Couple and Family Therapy, Drexel University. Address correspondence to Harry Aponte, Couple and Family Therapy Department, Drexel University, 1420 Walnut Street, Suite 920, Philadelphia, PA 19102; E-mail: [email protected]. 152 JOURNAL OF MARITAL AND FAMILY THERAPY April 2014 Journal of Marital and Family Therapy doi: 10.1111/jmft.12011 April 2014, Vol. 40, No. 2, 152–164 in the therapeutic process, therapist and clients, as forming a dynamically evolving ad hoc system with its own boundaries and structure. They view therapists as “unavoidably part of the system as participant observers” (Cheon & Murphy, 2007, p. 5). For systemic thinkers, this active participation of therapists in the therapeutic relationship involves not just their “feelings and attitudes,” that is, their psychological makeup, as some psychoanalytically oriented therapists propose (e.g., Gelso, 2011, p. 5). It also incorporates their “culture, values, and spirituality” (Aponte, et al., 2009, p. 382), as well as their social and political views (McDowell & Shelton, 2002; Watson, 1993), meaning all of who they are because their full humanity is inextricably ensconced in the human-to-human component of their interactions with their clients. Of course, along with this “humanity” of the therapist come the therapist’s personal issues, their struggles with their psyches as analysts have recognized from the beginning, along with their struggles within their families, their communities and their societies (Lappin & Hardy, 1997; Lawless, Gale, and Bacigalupe, 2001; Roche & Leventhal, 2009). From a systemic perspective, we are looking at the therapeutic process from an ecosystemic lens, taking into account the confluence of factors from all facets of the therapist and client’s lives in the arena of the therapeutic encounter. Thus, the therapist, him/ herself, brings a complex personal self that influences the professional persona in the dynamic milieu of the person-to-person engagement that is talking therapy. When most people think of the self-of-the-therapist work, they think of therapists participating in a process that requires introspective work on issues in their own life that have impact on the process of therapy in both positive and negative ways (Timm & Blow, 1999). In this study, we are tightening our focus on one much debated aspect of what a therapist brings to the relationship and work with families—the therapist’s personal struggles and their actual and potential influence on the therapeutic process. Clinicians and scholars who have addressed the relationship of therapists’ personal emotional struggles to their therapy, historically advocated for one of two stances —either to get that personal self out of the way of the professional self (meaning resolution of personal issues) or to learn how to use these emotional struggles to enhance the effectiveness of the professional self (Timm & Blow, 1999). From Freud (1910/1959) to Bowen (1972) and Satir (2000), many have asserted that the therapist cannot take the patient/client further than where he or she is in his/her personal journey. From that perspective, the primary aim in the personal aspect of therapist training is to work continually (Freud, 1937/1964) toward resolution of therapists’ personal issues. Others have put more emphasis on working with and through who the therapist is whenever engaging the client, viewing the therapist in the here-and-now moment of engagement with the client as a “wounded healer”, with ongoing emotional struggles, even as he/she progresses in his/her own indefinite journey toward personal growth (Aponte et al., 2009; Martin, 2011; Sedgwick, 1994). This study enters this discussion from the premise that in our humanity, we therapists all have our personal issues, our wounds, and in our professional role we have an obligation to be conscious of, and work on these issues; issues for which we need to take active, ongoing responsibility in the therapeutic process for the sake of the families with whom we work. We stand with those systemic thinkers who recognize the infusion in virtually all stages of our personal development of the social forces that profoundly influence our complex life context—from our families to our immediate communities to the larger society (Aponte, 1994a; Barnett, 2008; Scaramella, Neppl, Ontai, and Conger, 2008; Smith, 2006). However, what we are proposing here for special consideration is what we view as the unique complex struggle for self-definition, self-valuation, and self-purposefulness that is at the core of each person’s life’s journey. This core struggle elaborates with our growth and development and with the contextualizing of our lives. It attaches to other issues that emerge through life, but is present within us in some form or another to the end. These personal core issues can be analogized to physical vulnerabilities that we all live with—such as who may have been born susceptible to digestive, respiratory, or cardiovascular problems. These physical vulnerabilities may come with our genetic legacies and manifest through life in various forms due to our personal health habits, environmental circumstances and physical stages of aging. They are likely to impact other aspects of our health and physical functioning. They may even motivate us to compensate through extra care for our physical health to the point that we may achieve exceptional conditioning and physical abilities as have some athletes. But deep at the heart of it all there still lives the seed of that original vulnerability. April 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 153 The challenge we face as therapists is what to do about and with our personal psychological and emotional vulnerabilities in the context of our responsibilities for the families for whom we care, given that our work with them is by its very nature so very personal for them and for us. What we present here is a particular focus that is not meant to be exclusive, but rather a perspective that hopefully enriches the conversation we are having about the use of self in therapy. The POTT Model Clearly, models vary in their definition of the goals of the self-of-the-therapist work and the steps included in achieving those goals. The training model, the person-of-the-therapist (POTT) (Aponte, 1982; Aponte & Winter, 2000; Aponte et al. 2009) is the framework through, which we will discuss the above aspects of the use of self in therapy. It is based on the premise that within the therapeutic relationship is a personal process (Aponte, 1994b) that takes place between therapist and client and that that personal process generates a unique character to the various aspects of the therapeutic process specific to each particular case—the development of the relationship, and the exploratory and interventional processes of therapist and family. Furthermore, and most critical to the essence of this training model is the idea that therapists are capable of developing an expertise in how they proactively use themselves personally in all these aspects of the therapeutic process to further the effectiveness of their efforts. These concepts are not unique to the POTT model. Haber (1990) speaks of “the influence of our personhood in the therapeutic system” (p. 7) and further about therapists taking “an active part in the evolutionary process of the therapeutic system” (p. 7). Elka€ım (1997) states, “The meaning and function of the therapist’s feelings in the context of the therapeutic system are the tools both for understanding the system and intervening in it” (p. xxvi). Flaskas (1997) also addresses the active task of therapists pursuing “different levels of intimacy and attachment required for different kinds of therapeutic work” (p. 269). The POTT perspective is built around the recognition of “the interactive nature of personal growth (awareness) and skill development” (Watson, p. 22), and the promotion of the marriage between the two. In the common factors language of Morgan and Sprenkle’s (2007) schema for dimensions of the foci for supervisory roles, the POTT model attempts to bring together within one supervisory/ training framework coaching a supervisee/trainee’s “direct work” with “mentoring activities [that] include working on self-of-the-therapist issues that are related to clinical functioning” (p. 11). However, in this study, we are highlighting the central pillar of the model based on two assumptions: one, that we all carry within us a psychological issue that is at the core of our human woundedness, coloring our emotional functioning throughout our lives; and two, that for therapists to be able to relate most effectively to their clients, they must learn to work with and through this core issue, that we call the therapist’s “signature theme.” The POTT model takes a unique stance regarding the value of these core psychological issues by not just suggesting, as others have carried out from psychoanalysis to family therapy (Reik, 1948; Haber, 1990; Martin, 2011; Rober, 2011; Sedgwick, 1994; Stone, 2008; Timm & Blow, 1999), that these “signature themes” are resources that can enhance therapists’ effectiveness, but by placing learning to work through these signature themes at the very heart of the training of therapists in the use of self. In the POTT model, learning to work with and through these “signature themes” is so vital to therapists’ professional performance that the training revolves around mastering the signature theme in all aspects of the therapeutic process. The three basic components of the model are to train therapists to know themselves (signature theme, personal history, and life-outlook; Aponte & Winter, 2000), achieve the ability to access their inner personal experience in the therapeutic process (Rober, 2010, 2011), and make use of their selves actively and purposefully commensurate with each task of the therapeutic process—connecting with clients, assessing cognitively and intuitively, and intervening in a personal transaction specifically tailored to the client (Aponte & Carlsen, 2009). The POTT approach to work with and through the self is not tied to any one model of therapy. It considers the human connection and process through which all therapies are implemented a common factor of the therapeutic method (Sprenkle, Davis, and Lebow, 2009); however, different models of therapy may vary in their value of its relevance to therapeutic outcomes. It is common sense that all therapists must work with clients from within a relationship that elicits trust and cooperation, and that therapists need to be accountable for how they relate and conduct 154 JOURNAL OF MARITAL AND FAMILY THERAPY April 2014 themselves with clients, which requires self-awareness and self-discipline. That amounts to taking conscious responsibility for the use of self. Supervision models commonly incorporate some form of the use of self as articulated by the integrative family therapists: “One of the most important roles for a supervisor is to help the trainees become alert and flexible observers of themselves in the context of their functioning and roles with their clinical families” (Lee & Everett, 2004, p. 30). Sprenkle, Davis, and Lebow (2009) “believe that ongoing self-of-the-therapist work is an important part of training for both students and educators” (p. 165). However, their approach falls strongly on the side of those whose focus is on “achieving an emotionally healthy therapist” (p. 165). The POTT model’s emphasis on how the therapist uses self in the here-and-now falls closer to Rober’s (2010) “inner conversation” when he talks about the “different kinds of [therapist] reflections” during the therapeutic process: “Observations and evaluations of the client’s process, reflections about trying to make sense out of the client’s story, reflections dealing with the therapist’s own experiencing, and finally reflections about how the therapist can be helpful to the client” (p. 159). While giving primacy to self-management by the therapist in the moment as is, the POTT model does make accommodations for work on resolution of personal issues. The POTT model encourages therapists to work toward resolution of personal issues. However, pragmatically speaking, our clients get who we are today, flaws and all, and not who we aspire to be when our issues may no longer be “issues” for us. Therefore, as therapists, it is our obligation to be prepared to use the whole of who we are today to the benefit of our clients. Nonetheless, it has been our premise, supported by our experience that the trainees progressively gain degrees of freedom and self-mastery vis-a-vis their issues in the very process of their growing more conscious of their signature themes and how they play out in the context of their clinical practice. This is carried out through the most crucial exercises of the training, involving live supervision of clinical cases that are most directly geared toward developing the trainees’ ability to conduct their clinical work through the purposeful use of their personal issues. In the academic setting (Aponte et al, 2009), trainees often spontaneously take home to their families personal issues they are working on in school, but the trainers do not assume responsibility for these efforts of the students except to watch out for repercussions that require guidance and support of the students or referral to personal therapy. The POTT model addresses both sides of these foci in training, while also looking to adapt itself to whatever model of therapy the individual clinician advocates. It does not require trainees to work from a particular approach to therapy. It does, however, expect them to be conscious of the therapeutic approach and strategy they are adopting with a case. Then the trainers attempt to help the trainees take active responsibility for integrating the use of self with whatever model of therapy they are employing. Making reference to White & Russell (1995), Roberto (1997) asserts along the lines of the POTT philosophy: “Use of self is part of the therapist’s individual character or style and has grown so valued in the field that it was recently named as a critical supervisory function independent of supervisor’s orientation” (p. 165). The goals of this study are two, the first being to describe the person of the therapist work according to the POTT model, specifically as it pertains to the use of “signature themes” as pivotal resources in the work of therapy. The second goal of this study is to detail how the POTT model operationalizes the somewhat abstract concept of self-of-the therapist work. The study will illustrate step by step, through case examples, how the POTT model is being applied with trainees in the use of their signature themes to connect, assess and intervene with their clients. THE SIGNATURE THEME Signature themes are the lifelong struggles shaping the person’s relationships with self and others (Aponte & Carlsen, 2009). We all live with our very unique-to-each person signature struggles with ourselves and with life. The signature theme has an underlying core, such as the need for control or fear of vulnerability or fear of rejection or feelings of low self-esteem. These themes are universal enough to enable therapists to identify and empathize with most clients. However, the signature theme has another level more specific to the individual that has to do with how the underlying dynamic surrounding the core theme gets played out habitually in the April 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 155 various contexts of that person’s life. This is at the level of the specific qualities and circumstances of the person’s life. Our biology, our family histories, our gender, race, ethnicity, culture and spirituality, along with the effects of the choices we have made in life, all shape who we are today. Woven into these life experiences are hurts, deprivations, failures and losses that form the core of each person’s lifelong personal emotional vulnerabilities (Aponte et al., 2009). At this operational level, people’s personal issues inevitably are active factors that tend to get triggered or played out in thematically predictable forms in the various contexts of the drama of life, such as people’s family relationships and jobs, which for therapists would include their relationships with clients—individuals and families. These specific qualities and circumstances, as they manifested in the past and do today in our lives allow for the ability of therapists to identify with and differentiate from their clients’ themes at more context specific levels. Self of the Therapist Work Using the Signature Theme The signature themes are not viewed as hindering therapy, but rather as potentially valuable resources enabling therapists to work effectively by identifying with (Stone, 2008) and differentiating from (Bowen, 1972) their clients (individuals or families). An acceptance and valuing of self with all their personal vulnerabilities opens therapists to empathize with their own selves, and to the possibility of working through their personal challenges to evolve and grow. This then facilitates their reaching within themselves to connect through a wound of their own to their client’s wound, which in turn allows for a cognitive and emotional identification that may enable them to better understand and empathize with a client’s woundedness and see in it the potential for change. To the extent, therapists are grounded in the journey of understanding and tackling their own issues, they can differentiate themselves from their clients and their clients’ issues. This differentiation allows them to simultaneously relate intimately to their client’s experience, while standing outside of their engagement with the client, with relative freedom to observe the interaction and draw both insight and the ability to maneuver therapeutically. They can relate to and appreciate their clients’ difficult journeys without overidentifying or suffering from compassion fatigue (Negash & Sahin, 2011). It is noteworthy that our training is conducted in a group context (Aponte & Winter, 2000; Aponte et al., 2009). Although this training can be performed in individual supervision, our experience taught us that the group amplifies the power of the experience exponentially, a phenomenon recognized by many trainers: “The process of the training group must be considered and used to develop a context that can maximize the development of personal and interpersonal resources” (Haber, 1990, p. 4). The group allows the individual trainee to see the humanity of every other trainee, who like their clients and themselves, struggles with life. It helps remove the shame that blinds us to our flaws and vulnerabilities, provides the support of empathic colleagues, and facilitates the ability to observe self by seeing ourselves as others see us. Throughout this process, trainees need to feel the personal acceptance and support of the trainers. In the spirit of the model, the trainers themselves need to be conscious of their own personal issues and be able to use that self-awareness in a conscious and active manner in their interactions with trainees. Part of the training of the trainers is that they have the experience of presenting on their own personal issues as related to their roles as supervisors and trainers (Aponte, 1994b; Aponte et al., 2009). This is carried out either individually or in a group, depending upon how many are up for formation as trainers at a given time. The preference, as with the trainees, is to have at least two in preparation at the same time to provide something of a group experience for them. Following their training and during the course of leading a training group, the training team consults regularly with each other about their process with the trainees, and will address, either in the training group itself and/or outside, with the trainees whatever issues may be arising between them and a trainee with intent to resolve them. Throughout the training, the trainers are available to the trainees for additional support, and for further processing of their experiences. Acknowledging the emotionally challenging nature of this training, the trainers work continuously on creating a safe-holding environment (Aponte, 1994b) by putting in place clear group rules regarding confidentiality and feedback providing, and by facilitating a nonjudgmental and accepting training environment. In addition, the trainees are 156 JOURNAL OF MARITAL AND FAMILY THERAPY April 2014 instructed to present only as much as they feel comfortable sharing given that the emphasis is more on their reactions to their life experiences than the details of these experiences. The trainers clarify from the start that POTT is not therapy. The focus is always, in class discussions, presentations, write-ups, and journals, on how to use the self for the benefit of the clients and how they can apply what they learn to their clinical work. The POTT work itself includes two broad steps. In the first step, trainees take turns to present on what they consider to be their signature theme/s. The trainers are usually two, and preferably male and female. Our experience has been that gender, like race and culture, does matter. The mix in the trainers brings to the experience not only of the trainee presenting, but also to the mix of the group the perspectives and emotional responses of both genders. Where there is a strong representation of a particular ethnic group, we would hope to have one of the two represent the perspectives of that ethnic group along with the universal representation of the two sexes. We believe in the person of the trainer, as well as of the therapist, and aim to draw from the breadth and depth of the diversity of the trainers in working with the trainees. Usually, one of the trainers takes the lead with a trainee, hoping to make the best match for a particular presentation. Moreover, a responsibility of the two trainers is to monitor one another’s process with the trainees, serving to support, complement, and correct one another as indicated by the needs of the trainees. As with the therapist, the work of the trainers on the “self” is an ever, ongoing process, and their partners in the training are explicitly understood to be a vital part of that effort as related to their performance in the training context. The trainers walk the presenters through an initial attempt to identify their signature themes. As part of helping the trainees understand their issues, the trainers walk them through the exploration of the origin of their themes and the histories of their struggles with them. This includes looking at relational and familial patterns and circumstances involved in the creation and maintenance of these themes. Then they look at the trainees’ themes in the context of their clinical work exploring the potential benefits and/or barriers a specific theme presents to their work with clients (Mutchler & Anderson, 2010). Prior to their presentations, the trainees are provided with a guide that includes questions designed to help them identify their signature themes (see Appendix A). Following their presentation, the trainees write up their understanding of what they concluded with the help of a video of their discussion with the trainers that they can view in an emotionally cooler ambiance outside the classroom. Through journaling following each presentation, trainees further expand on their reflections of their theme through identifying with and differentiating from their colleagues’ themes, and through what came up for them as they observed their colleagues’ presentations, thus creating a more coherent and comprehensive understanding of the signature theme. Below is a list of initial attempts by several trainees to identify their signature themes. All trainees were first-year students in a Marriage and Family Therapy master’s program. We are reporting the themes in the trainees’ own words. What follows is a sample of initial attempts during the first POTT presentation of first-year Marriage and Family Therapy students to identify their signature themes. 1. It’s hard for me to stay in my emotions and be vulnerable. 2. I am always thinking the worst; not being able to enjoy the good things but always waiting for the worst to happen. 3. I am afraid that I am alone or that I will be alone. 4. My signature themes are over-functioning and abandonment issues, I’m also afraid to be venerable (sic) because I see it as a sign of weakness. 5. I realized that my signature theme is finding a sense of worth and a purpose in life/my existence. 6. I think that my signature theme is the lack of trust I have in others. 7. My signature theme is control/wanting to be in control of things at all times. 8. Rejection is one of my signature themes. 9. Fear of losing my parents. 10. I have a distorted perception of myself in relation to other people—feeling inadequate, not good enough, and not fitting in. 11. My Signature theme is codependency/low self-esteem. April 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 157 12. Codependency is the need to feel loved and needed by others. 13. My signature themes are my fear of rejection and of not being good enough. 14. My signature themes are my trust and control issues. 15. I’m beginning to realize that most of the tension and anxieties and coping mechanisms that are a part of my life today seem to be centered around my need to be in control or how I react when I feel that I am losing control. The themes that were repeated most often throughout our trainings were four: fear of rejection, need to control, lack of self worth, and fear of being vulnerable. It is obvious that these themes reflect more how the trainees experience themselves than represent distinct unrelated issues. Working on understanding the dynamics and patterns surrounding these themes enabled trainees to see the common struggles they had with their fellow trainees, even though the articulation of their core issues might be different. For example, the need to control often reflected their defense against experiencing rejection. This need to control could also recast as a fear of being vulnerable. Although we often talk about “a signature theme,” some trainees identify more than one issue. The trainers aim to help them recognize one overarching theme that would stitch together all the original signature themes. However, some trainees end up with more than one theme by the conclusion of training. The main point is not the number of themes, but the ability to acknowledge that these themes exist, to be able to discern them when triggered or draw on them as needed, so as to be able to use them to facilitate effective therapy. The trainees progress through three stages during the course of their training. In the first presentation, they look to identify their signature themes. The next two presentations seek to put the signature themes in the context of their clinical work, first by presenting on a case, aiming to recognize how aspects of their lives, including their personal issues, played a part in how they related, thought about and worked with their clients. The third presentation is a live supervised session with a client family simulated by actors that highlights the trainee’s use of self. The trainees are required to write up their experiences in both clinical presentations, and in each reflect on their signature themes to develop a more comprehensive and nuanced understanding of the dynamic surrounding their themes and their manifestations in the therapeutic encounters. Initially, trainees tend to focus more on their signature themes as obstacles to their performance. However, with the help of the trainers and the experience of other trainees’ as having similar struggles, trainees begin to accept their issues and then slowly grow to view them as resources for connecting with clients. Much of this process takes place during the presentations and in the group feedback session following each presentation. The trainers consistently normalize students’ emotional struggles, pointing to the freedom they experience when they can acknowledge and accept their vulnerable humanity. This is a self-acceptance that frees them to come out from hiding and fleeing from their issues, enabling them instead to use their issues to look deeper into their clients’ struggles. Additionally, the trainers themselves share about their use of their own struggles in their therapy with clients, joining in identification with the students and modeling how this self-acceptance works for them. We witness trainees moving from viewing their issues as shameful things to fight and hide from, to resources that give them ever-greater access to the humanity of the families they engage. The following is an example of the beginning of this transition, in which a trainee is moving toward acceptance of her personal vulnerabilities. She wrote: The negativity and frustration that I detailed during my POTT presentation [the case presentation] was me beating up on myself. I wished that I could have felt a more genuine connection to the clients. I wished that I did not feel so resentful by the heavy influence of religion on the session. I wished that I could be less nervous, self-conscious, and timid. But examining these feelings and investigating them and their origins and implications rather than vainly wishing I did not have them in the first place or wishing I could somehow just ‘be better’ is the way I will grow and develop as a therapist. I am beginning to have a better understanding of this following the insight I received during my POTT presentation. 158 JOURNAL OF MARITAL AND FAMILY THERAPY April 2014 Another example shows a trainee who is able to utilize her signature theme to connect with her client. The trainee, who described her signature theme as difficulty being vulnerable and always expecting the worst wrote the following in her case presentation: When I first met with Susan (pseudonym) the first thing that I noticed was her negativity towards life. I tend to not be as optimistic and I am always waiting for the worst to happen instead of enjoying the good because of my experiences. When Susan is talking in this manner I see myself and think, wow so this is what my family and friends have to work with. Because I can relate to the way she thinks about things it helps me to ground myself and give her homework and motivation that is not unreasonable. I approach the situation as if I was her and someone trying to make me see things more optimistic. Helping her in this area is helping me to think more positively. As stated above my signature theme is being comfortable with being vulnerable to myself and others. I feel like if I can grapple with this I can truly be of use in the therapy room with this client. Many of Susan’s issues stem with being comfortable with herself, admitting her true feelings to herself, and being comfortable with telling people her feelings and thoughts. I feel as though I will understand where she is coming from and not get frustrated with her and her own pace of processing things like others have in school, therapy, and home. Putting it All Together – Using the Signature Theme to Connect, Assess and Intervene with Clients: A Clinical Example We present here in greater detail a clinical situation that exemplifies the use of the self, with a special focus on the signature theme in the three essential tasks of the therapeutic process—the relationship, the assessment, and the intervention. This was the trainee’s third presentation, with the first two focused on identifying her signature theme in the contexts of her personal life and in her clinical practice—fear of and, therefore, tendency to shut herself off from the vulnerability of her emotions. The trainers and the trainee would be working with this in mind. We describe a session this trainee had with a simulated family that was supervised by the trainers. The trainee understood that she was to work with this family as if she had the family in ongoing treatment. The trainers observed the trainee through closed circuit TV and also communicated with her through an earphone. The trainers already knew that the trainee-therapist would be anxious and that her signature theme would dictate that she should be “strong,” shutting off any feelings of weakness, that is, any sense of vulnerability. In her words: I have narrowed it down to difficulty being emotionally vulnerable. Vulnerability applies to telling others my feelings and emotions and letting myself accepting these emotions and feelings. Before I am able to be honest with people with the emotions I have, I need to be able to be honest with myself. I have come to the conclusion that I tend to subconsciously correlate vulnerability with weakness. The trainee summed up the clinical issue as: Chloe is the seventeen-year-old adopted daughter of Jack and Mary who have brought her to family therapy to try and figure out what is going on with Chloe. Her grades have gone down, she has been caught smoking marijuana and is not hanging with the people that her parents think are good influences. Chloe, who had been relatively well connected to her parents, has withdrawn from them in the last year, which has them very troubled. The trainee understands that her immediate goal is to help the parents work together to gain their daughter’s trust so they can find out what has gone wrong for her so they can help her right things. As the trainee was about to enter the interviewing room, the instructions the trainers gave her were intended to help her get around her tight self-protective wall so she could see, feel and relate to her clients. They told her that when she entered the room, she should just concentrate on being fully present in the moment and connect with the clients. “Meet them where they are, and do not worry about what to do next.” The supervisors would be with her every step of the way. April 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 159 During the session, the trainers would pull the trainee out of the session three times to help her hold clearly in mind her therapeutic goal, while remaining personally grounded in her own emotional space as she reflected on what was happening with the family, between her and the family, and within herself. The first break would be shortly after the trainee gained her first impressions of the family and was setting a direction for her work with the family, the second break would be in mid-course to review the trajectory of the session and reset if necessary, and the third break would take place as the session was coming to an end to help the trainee bring the session to a close in a way that would leave the family with a sense of what they had accomplished in the session, and where they would be headed as the therapy proceeded. Following the session, the trainee wrote about her experience of the supervision: When I was pulled out the first time I was asked how I felt and why I did not express this. At this moment I realized how much my signature theme played a role in the therapy room. Not expressing my emotions or feelings has been so embedded in me I do not even realize I am holding back. When she returned to the room, she put her heart and head together in a way that fit what she was experiencing emotionally with her understanding that the family needed help to trust and communicate. Conscious that the family’s challenges paralleled the trainee’s issues about trust and communication of her emotions, the trainers worked with her as they would have her work with the family. They attended to her tenseness and elicited the vocalization of her anxiety, while supporting her emotionally and affirming her effectiveness with the family. In the beginning of the session I was feeling a little uneasy and sadden[ed] by what I was feeling in the room. It did not feel like they were a family unit but rather three separate people in the room that happen[ed] to live together. I felt sadden[ed] in the beginning because I sensed all of them felt hopelessness and melancholy. She was coached to use her connection to the sadness she was feeling for them as a means to deepen her connection to the family. Even more poignantly, she could see a reflection of her own life in the family, her own struggle with trust that shuts her out of true intimacy with those she cares about. She reentered the room more emotionally accessible to herself and to them, which became the medium for an intervention meant to open them up to each other. She entered the room and: Expressed with the clients what I was feeling in the room and it felt like it was much easier to do the rest of the session. Expressing what I was feeling in the room seemed to open the door for the clients to speak about their emotions. It seemed as though this brought them closer together and the line of separation had potential to be erased a little now. It was an intervention that was powered by the strength of her emotions. Part of how the trainees were trained to connect with their clients was through a conscious effort to relate what and how their clients presented about their issues to their own life experiences, that is, to find a way to “see and feel” them through the lenses of their own issues. The immediate challenge for the trainee with this family would be Chloe’s sulking and irritable posture. The trainee relates: Chloe would aggravate me at times with her resistance and attitude. I recognize that she was a lot like me when I was younger, very resistant and angry. Relating to that part of who I was is probably why she could aggravate me so much. It made me wonder what is going on beneath that demeanor because I know what it is like to put a wall up when so much is going on inside you and you cannot or feel like you cannot let it out. Because she could recognize herself in this young girl, the trainee (24 years old) intuited that this prickly exterior was hiding a troubled interior. She would not be put off by the girl’s exterior and would reach behind the wall. This bit of intuition formed the basis of a hypothesis, a tentative assessment of what was immediately going on in Chloe. Based on that hypothesis, the trainee formulated her immediate approach to dealing with the girl. Being able to relate to her behavior with what I was going through at that time in my life, I knew that this had to happen within her own time. I also can relate to how she 160 JOURNAL OF MARITAL AND FAMILY THERAPY April 2014 shuts down and tries to distract people with content to avoid revealing what is inside. This is how I can be, so I went with my gut that told me the way to get something workable out of her was to just keep focus on the questions asked and push a little more for the answer. She would work to stay emotionally engaged with Chloe, while not allowing herself to be distracted from the questioning and exploration she was into with her. From her understanding of the case, she had identified one goal, but it was a goal fueled by what she opened herself to feel and recall. She further used her own recollection of her experiences in her family to implement her strategy for beginning to reconnect Chloe to her parents, first through her mother. Having such strong positive feelings about my mother being there for us all the time and seeing Chloe’s pain with her mother not being able to be there was saddening and scary. I asked questions and found out she does want to be there for her daughter more and be home more. After knowing this I continued having her express this to her daughter. However, she did not make this intervention without awareness of the father. Again, her strategy was given emotional depth in its implementation by memories of her own father that she pulled up for herself at that moment. I could feel the intensity of Jack feeling marginalized and left out quite vividly because it pulled out my feelings of empathy I have for my father at times. Validating him and telling him we need to take this one step at a time was how I overcame this challenge [to keep him involved while focusing on the mother–daughter relationship]. When I felt that he was validated and understood why I was going in the direction with mother and daughter, it made it easier to stay focused on them locking the deal to take time out to talk with one another on a specific day. The trainee succeeded in getting the mother and daughter to agree to take some time out before the following week’s session to do some shopping together, with no talk about problems. The trainee was rewarded by the actors of the simulated family who fed back to her that they felt she was really connected to them so that they felt safe to let down some of their guard with each other. She herself was surprised about how emotionally accessible she was to herself and to them. She felt she had accomplished something with them and with herself. At the end of the training, the trainees write a paper summarizing the professional and personal changes they have gone through as a result of the training. The trainee wrote about the ways her work on her signature themes enhanced her clinical work with her clients. She wrote: The more I worked on my signature theme, the more I was able to connect with my clients…Since I have been able to work on myself and know how hard it was/is to open up to people and admit things to myself, I know how hard it can be for my clients to go through it in the therapy room. This allows me to be patient but also know when it was time to push them further. Interestedly enough, I tend to go for the emotions in my session now more than anything… I feel more and more comfortable asking my clients what they are feeling and recognizing it because I am getting more comfortable in doing it with myself. I have allowed myself to be more open with myself and others and it has allowed me to make more human connections with my clients. PERSONAL BENEFITS OF WORKING WITH THE SIGNATURE THEME We have emphasized training therapists to gain mastery of their selves in the therapeutic process, over their resolving personal issues to avoid bad countertransference. This stems from the pragmatic assumption that our clients get who we are today, wherever we are in the process of working on our own emotional wounds. Therefore, our immediate task is to know as much as we can about our whole self and to have as much ability to use all of who we are as positively and proactively as we can. The person-of-the-therapist training model believes in the importance of continually working on gaining greater insight into what we bring of our selves to the table and April 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 161 developing the observing self that not only can see, but also can direct the use of the self to work as needed to effect good therapy. As noted earlier, our experience has been that the very process of working toward the goal of becoming an effective therapist within the POTT model fosters personal change in the trainees. The training environment facilitates the trainees’ acceptance of the vulnerability of their humanity. Acknowledging and accepting the humanity and universality of their issues takes away the shame and reduces the need to hide them from self and others. Consequently, trainees begin to view the training as an opportunity to grow by engaging the challenge of working their personal issues on an ongoing basis. Because trainees are motivated to work on themselves to become better therapists, they experience the palpable advantage of gaining freedom from their own self-restricting and self-blinding issues so they can better see, hear, and feel their clients and their issues. The trainers support these personal efforts on their parts, and the trainees regularly report changes in themselves and in their personal relationships. Focusing on the goals of the POTT training, the trainers help the trainees to harness these new understandings and behaviors and their improved self for the betterment of their clinical work. The emphasis throughout the work remains on the value of the use of the self as is at the moment of the therapeutic encounter. As they continue to develop in the training, trainees can recognize the reciprocal influence and connection between their professional and personal selves. They experience how their personal growth feeds their professional self and vice-verse, which keeps them highly motivated and committed to continue this journey. CONCLUSIONS Our premise is that the self-of-the-therapist work is crucial in the development of effective therapists. While most clinicians, researchers, and academicians in the mental health field support the importance of this work, the practical means and concrete steps needed to increase therapists’ awareness to the ways their whole self-impacts their therapeutic encounters remain fragmented, reflecting the varied perspectives on the subject in the field. In addition, most traditional approaches to the self-of-the-therapist work look at therapists’ emotional issues and personal struggles from the perspective of potentially hindering therapy, and therefore, in therapist formation, prioritize ongoing work toward personal resolution. This study offers a different perspective: first, it puts forward that, however “resolved” we may be, we all carry within us in some form or another our own core issues (signature themes) that color how we see, feel, and function; second, that it is critical for therapists to get hold of that “wounded” part of themselves, and learn to work with and through their signature themes to consciously and purposefully utilize them for their therapeutic tasks. The study attempted to demonstrate a practical, step-by-step approach to how therapists in their training and ongoing formation can harness their inner struggles to facilitate better connections, assessments and interventions with clients. Helping therapists acknowledge and understand their struggles, accept their humanity and feel comfortable “going there” emotionally as needed, positions them not only to gain greater mastery of themselves to implement their therapeutic tasks, but also to free and motivate them to indeed work on their personal issues, which of course makes more of their selves available for the work of therapy. While our experience has provided us with convincing anecdotal evidence that this approach to the use of self is efficacious, we are currently in the process of conducting research on the training model. REFERENCES Aponte, H.J., (1982). The cornerstone of therapy: The person of the therapist. The Family Therapy Networker, 6, 19–21. Aponte, H.J. (1994a). Bread & spirit: Therapy with the new poor. New York: W. W. Norton. Aponte, H.J. (1994b). How personal can training get? Journal of Marital and Family Therapy, 20(1), 3–15. Aponte, H. J., & Winter, J. E. (2000). The person and practice of the therapist: Treatment and training. In M. Baldwin (Ed.), The use of self in therapy (2nd ed., pp. 127–165). New York: Hawthorne. Aponte, H.J., Powell, F.D., Brooks, S., Watson, M.F., Litzke, C., Lawless, J., & Johnson, E. (2009). Training the person of the therapist in an academic setting. Journal of Marital and Family Therapy, 35, 381–394. 162 JOURNAL OF MARITAL AND FAMILY THERAPY April 2014 Aponte, H.J., & Carlsen, J.C. (2009). An instrument for person-of-the-therapist supervision. Journal of Marital and Family Therapy, 35, 395–405. Baldwin, M. (Ed.) (2000). The use of self in therapy (2nd edn). New York: Hawthorne. Barnett, M.A. (2008). Economic disadvantage in complex family systems: Expansion of the family stress models. Clinical Child Family Psychology, 11, 145–161. Bowen, M. (1972). Toward a differentiation of a self in one’s family. In James L. Framo (Ed.), Family interaction (pp. 111–173). New York: Springer. Cheon, H., & Murphy, M.J. (2007). The self-of-the-therapist awakened. Journal of Feminist Family Therapy, 19, 1–16. Elka€ım, M. (1997). If you love me, don’t love me. Undoing reciprocal double binds and other methods of change in couple and family therapy. Northvale, NJ: Aronson. Flaskas, C. (1997). Engagement and the therapeutic relationship in systemic therapy. Journal of Family Therapy, 19, 263–282. Flaskas, C. (2004). Thinking about the therapeutic relationship: Emerging themes in family therapy. Australia and New Zealand Journal of Family Therapy, 25, 13–20. Frankl, V.E. (1963). Man’s search for meaning. New York: Washington Square Press. Freud, S. (1959). Future prospects of psychoanalytic psychotherapy. In J. Strachey (Ed.), Standard edition of the complete psychological works of Sigmund Freud (Vol. 20, pp. 87–172). London: Hogarth Press. (Original work published 1910). Freud, S. (1964). Analysis terminable and interminable. In J. Strachey (Ed. and Trans.) The standard edition of the complete psychological works of Sigmund Freud (Vol. XXIII, pp. 249). London: Hogarth Press. (Original work published 1937). Gelso, C.J. (2011). The real relationship in psychotherapy: The hidden foundation of change. Washington, DC: American Psychological Association. Haber, R. (1990). From handicap to handy capable: Training systemic therapists in use of self. Family Process, 29, 375–384. Hanshew, E. R. (1998). An investigation of the wounded healer phenomenon: Counselor trainees and their self-conscious emotions and mental health. Dissertation Abstracts International, 58 (10-A), Apr 1998, 3846, US: University Microfilms International. Hayes, J.A. (2002). Playing with fire: Countertransference and clinical epistemology. Journal of Contemporary Psychotherapy, 32, 92–100. Hoffman, L. (1990). Constructing realities: An art of lenses. Family Process, 29(1), 1–12. Lappin, J., & Hardy, K.V. (1997). Keeping context in view: The heart of supervisors. In Thomas C. Todd & Cheryl L. Storm (Eds.), The complete systemic supervisor (pp. 41–58). Boston: Allyn and Bacon. Lawless, J.J., Gale, J.E., & Bacigalupe, G. (2001). The discourse of race and culture in family therapy supervision: A conversation analysis. Contemporary Family Therapy, 23(2), 181–197. Lee, R.E., & Everett, C.A. (2004). The integrative family therapy supervisor. New York: Routledge. Martin, P. (2011). Celebrating the wounded healer. Counseling Psychology Review, 26, 10–19. McDowell, T., & Shelton, D. (2002). Valuing ideas of social justice in MFT curricula. Contemporary Family Therapy, 2, 313–331. McGoldrick, M., & Hardy, H.V. (2008). Re-visioning family therapy: Race, culture, and gender in clinical practice. New York: Guilford. Morgan, M.M., & Sprenkle, D.H. (2007). Toward a common factors approach to supervision. Journal of Marital and Family Therapy, 33, 1–17. Mutchler, M., & Anderson, S. (2010). Therapist personal agency: A model for examining the training context. Journal of Marital & Family Therapy, 36(4), 511–525. Negash, S., & Sahin, S. (2011). Compassion fatigue in marriage and family therapy: Implications for therapists and clients. Journal of Marital and Family Therapy, 37(1), 1–13. Nouwen, H.J.M. (1979). The wounded healer. New York: Image. Reik, T. (1948). Listening with the Third Ear: The inner experience of a psychoanalyst. New York: Farrar and Strauss. Rober, P. (2010). The interacting-reflecting training exercise: Addressing the therapist’s inner conversation in family therapy training. Journal of Marital and Family Therapy, 36, 158–170. Rober, P. (2011). The therapist’s experiencing in family therapy practice. Journal of Family Therapy, 33, 233–255. Roberto, L.G. (1997). Supervision: The transgenerational models. In Thomas C. Todd & Cheryl L. Storm (Eds.), The complete systemic supervisor (pp. 156–172). Boston: Allyn and Bacon. Roche, K.M., & Leventhal, T. (2009). Beyond neighborhood poverty: Family management, neighborhood disorder, and adolescents’ early sexual onset. Journal of Family Psychology, 23(6), 819–827. Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Satir, V. (2000). The therapist story. In M. Baldwin (Ed.), The use of self in therapy (2nd edn). (pp. 17–28). New York: Haworth. April 2014 JOURNAL OF MARITAL AND FAMILY THERAPY 163 Scaramella, L.V., Neppl, T.K., Ontai, L.L., & Conger, R.D. (2008). Consequences of socioeconomic disadvantage across three generations: Parenting behavior and child externalizing problems. Journal of Family Psychology, 22, 725–733. Sedgwick, D. (1994). The wounded healer: Countertransference from a Jungian perspective. London: Routledge. Smith, L. (2006). Addressing classism, extending multicultural competence, and serving the poor. American Psychologist, 61, 338–339. Sprenkle, D.H., Davis, S.D., & Lebow, J.L. (2009). Common factors in couple and family therapy. New York: Guilford. Stone, D. (2008). Healing: Exploring the circle of compassion in the helping relationship. The Humanistic Psychologist, 36, 45–51. Timm, T.M., & Blow, A.J. (1999). Self-of-the-therapist work: A balance between removing restraints and identifying resources. Contemporary Family Therapy, 21, 331–350. Watson, M.F. (1993). Supervising the person of the therapist: Issues, challenges and dilemmas. Contemporary Family Therapy, 15(1), 21–31. Whitaker, C.A., & Keith, D.V. (1981). Symbolic-experiential family therapy. In A. Gurman & D. Kniskern (Eds.), Handbook of family therapy (pp. 187–225). New York: Brunner/Mazel. White, M. (1993). Deconstruction and therapy. In S. Gilligan & R. Price (Eds.), Therapeutic conversations (pp. 22– 61). New York: W.W. Norton. White, M., & Russell, C. (1995). The essential elements of supervisory systems: A modified Delphi study. Journal of Marital and Family Therapy, 21, 33–53. APPENDIX A GUIDE TO IDENTIFYING YOUR SIGNATURE THEME In this handout, you will find some questions to help you jumpstart the process of identifying and clarifying your signature theme. These questions are proposed to start your reflection about your wounds, hang-ups, and those ongoing struggles that manifest in your functioning and relationships. Also, we offer some comments that could help you reach more clarity about what a signature theme is, and what the process of identifying it looks like. Questions What is your biggest source of anxiety and/or biggest fear? (e.g., being abandoned, rejected, not being enough, feeling stupid, etc.) Is there something about yourself that you would prefer people not know? What do you do to keep people from knowing this? Is there a characteristic of yours that somehow limits you in your functioning and relationships? (e.g., not wanting to be needy, thus pretending to always being strong and independent, as a result never asking for help and feeling alone when in crisis) How do you usually deal with stress? Is there a reaction to stressful situations or interactions that seems to cause you problems? Looking back at your life, can you recognize a recurrent pattern in your functioning and relationships that doesn’t work well for you? Comments • Remember that signature themes are not specific events (e.g., a parent’s death) or particular relationships (e.g., the relationship with my ex-boyfriend), although meaningful events and relationships can play a role in the development of your signature themes. • Signature themes are personal patterns of feeling, thinking and/or relating that you experience as challenges to your functioning and relating as you would want. • It is fine if at the beginning of this process you identify several signature themes. Through your class presentations, journals and experiences during this program you will most likely consolidate these themes into one or two overarching themes. • Your signature theme grew and developed in a particular environment, under particular circumstances. You will find it there—complex factors that came together to give your signature its very personal character (e.g., your family relationships, your personal relationships, your ethnicity and race, your culture and spirituality, your socioeconomic circumstances, etc.) Look for your signature theme there. 164 JOURNAL OF MARITAL AND FAMILY THERAPY April 2014 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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