I'm Danielle Kurzweil.

I'm honored to join Alex Virchus as co-host for this podcast, an important resource for therapists interested in growing their understanding of and ability to treat CPTSD and dissociative disorders.

I've benefited gratefully from this podcast, being able to join this discussion rather than just passively learning through books and workshops, interacting with the information, asking questions, sharing our own real-time experiences and creating community to pool knowledge.

Like with our guest today, Kathy Steele.

Kathy has contributed substantially to the work of improving therapist competency and providing effective trauma treatment, which you can read about in her website that's linked below.

Today we'll be discussing her work, which builds upon the work of Paul Gilbert and Giovanni Ligati to create clear and practical guidelines for therapists and utilizing a collaborative treatment model alongside their clients.

Kathy is compassionate, impressively clear about very difficult topics and brings to us immediately actionable and practical tips for connecting compassionately with our clients and ourselves as we do this highly challenging work.

Enjoy.

I was wondering if you could also give our listeners an overview of this collaborative model of therapeutic alliance that you talk about.

Relationship between therapist and their client.

Right.

And I came upon this just through my own struggles as a therapist to help that subset of clients.

It's not every client, but a small subset of clients that really struggled with dependency.

It's like they needed the therapist all the time.

And sometimes, you know, the more available the therapist became, the more dysregulated the client became and just needed the therapist more and more.

And so it was a vicious cycle.

So that's what got me interested in what are we trying to do in creating attachment with clients and what can go wrong with that.

And there are other, there's lots of things that could go wrong, but I want to focus on this particular thing because I think it's something that many therapists struggle with because by our nature, we are helpers.

And by our nature, we respond with compassion and sometimes with urgency when somebody's in distress.

And so how to manage something that's very natural for us, but yet not get into a role where there's so much dependency on the therapist for the client that the client is becoming dysregulated.

And the reason that more extreme dependency is not good, well, there are many reasons, but one of them is because in trauma, a client not only wants to be connected, but also needs to defend against relationship because relationship was what was and so when we're just paying attention to the needs of the client to connect, we're not always paying attention to the needs of the client to protect, right?

And the general thinking has been, well, if they can connect enough, this will gradually, this need for defense will gradually go down, but that often doesn't happen because there is often dissociation between the part of the self that's trying to connect and the part of the self that's going, oh no, that's too dangerous, right?

And so it's very important, I think, for the therapist to modulate the intensity of the relationship as best we can.

And we do that through a kind of collaborative model.

Now, that is not my own work.

That work comes from several people in the field.

The two that come to mind are Paul Gilbert, who wrote a lot about compassion-focused therapy, and Giovanni Liotti, who was an Italian psychologist and researcher, psychiatrist, who did, both of them did a lot of work on the idea that in addition to attachment, there are other ways to connect that are built in for us.

They're evolutionary prepared, right?

And so, for example, for parents, there is this intuitive sense of caring for infants.

We may not know exactly what to do, but we've got the instinct to care for young children and infants in the same way that animals have that instinct.

So this idea of caretaking is built in, and that's a way of connecting, but it's not about really attachment.

It's about kind of rescue and caregiving.

And there are other ways, like you can connect relationally through playfulness, or through sexuality, or through competition, where you're sort of judging, am I better than or less than everybody else, kind of putting yourself on a ladder.

And all of those are built in evolutionary prepared ways of organizing ourselves in relationships and in groups.

And when traumatized clients have difficulty with attachment, when attachment doesn't work for them because it's dangerous, they may move to some of these other strategies.

And one of the strategies that I hope that therapists can use is a collaborative strategy.

And that strategy is about basic understanding of each other.

Now, we think about understanding each other and sharing and working on goals.

We can think of, well, a team at work collaborates on a goal, right?

But there's a lot of other things that are going on besides explicitly cognitively saying we have this goal in mind that we're working toward.

Collaboration at its most basic level is about do I feel safe with you or not, right?

Because if I don't feel safe, I can't collaborate.

And so we could think about what Stephen Porges talks about with the polyvagal theory, and his idea of activating the ventral vagal system as being important in collaboration, because collaboration does activate the ventral does.

And so if we think about collaboration, again, it's not only explicit, let's work on these therapeutic goals together.

But it's about the felt sense of do I get you?

Do I understand you?

And do you get me?

And on that nonverbal level, and then we build the more explicit, let's together work in therapy based on that.

The reason we want to use collaboration is because the client's attachment system is really over activated in some way, whether that is through desperately seeking attachment, or whether that is sort of desperately avoiding attachment.

Clients get triggered when their attachment system is activated.

So the idea is to try not to further activate the client's attachment system, because it's really dysregulated already, but to use the collaborative approach to kind of calm it down a little bit, right?

And I don't know if this is super different than the way we really approach attachment in a with a lot of clients.

But I think we have to really understand when we're thinking about attachment, what is the goal of attachment?

The goal of attachment is to have a felt sense of security, so that I can come and go, whether my attachment figure is in front of me, or away on a my grandmother, who I was very close to, she's been dead for 20, 30 years, a long time.

But I still hold her, right?

I still have that figure internally.

And so the idea is not to have the therapist there literally all the time, but to be able to take that, that representation in.

And a lot of that I had a felt sense of my own grandma.

That's right.

That's right.

Many of us have a felt sense of lots of other people.

Right?

And sometimes we have a felt sense that's really bad.

And that's difficult.

Right?

But the felt sense of a positive enough figure is what secure attachment is really about.

And sometimes we get confused, we, we think, well, I need to be available all the time, call me when you need me.

Right?

That's not really how secure attachment works.

Secure attachment is saying, I'll be here when I say I'll be here.

So it's consistent.

It's predictable.

And it helps the client.

Let's together, here's the collaborative model.

Let's together figure out what makes it so hard for you when I'm not here.

And let's help you build some skills around that.

So that's a, that's a beginning structure.

And then my guess is you have some questions about that.

I do.

I do.

I was wondering, um, what does consultation with therapists around this issue look like?

Um, I know that you work with therapists directly and help them with this.

And, um, you know, for, for therapists out there who were looking for this kind of guidance, also other, other consultants who might want to support in this way.

Um, you know, what are some of those elements?

What are some of those conversations that, um, come up some of the typical conversations and, you know, and I'm also thinking about those therapists who don't have access to consultation to give the type of things that they can do on their own.

Yeah.

Yeah.

Well, I, I think that, you know, therapists come in with this issue and they feel distressed.

They feel guilty because they don't think they're giving enough or they feel exhausted because they feel like I'm giving all I can give and the client still isn't getting better.

And so therapists, uh, be become distressed and they, they may feel urgent.

I've got to do something.

And I think when those three things, one of those three things happens that it's a, it's a flag.

It's a red flag for me to say, Ooh, I'm getting activated in my caretaking system.

Right.

Um, so it's a matter of really learning to stop and reflect.

Where am I?

Am I feeling burnt out?

Well, maybe I'm giving too much or maybe I'm giving too much of one thing and not or relatively constant is not helpful.

And, and that's the thing.

If it were helpful, maybe we could go with it and tolerate it and, and, and work with it a bit.

But, um, in general, it actually, uh, creates this, what, um, John Bowlby called insecure dependency where, um, any sign that the therapist is going to go away or not be available, the client gets more and more panicked.

Right.

And so it doesn't calm it down.

It actually activates it.

So when I feel the urge to caretake, to rescue, to be more available than I'm available for other clients, um, when my family might complain, you're, you're never here.

You're is aware.

Um, when you feel, when I feel burnt out, like I don't want to do this work anymore, it's not enjoyable.

Um, and sometimes when I feel trapped, like I can't stop what I'm doing because I think the client needs it, but I can't tolerate continuing to do it.

Right.

So you get this trapped sort of double bind.

I think those are the things to look out for.

Are there different sensations when it's, um, the other, um, sort of side of that coin, when someone, um, might be more rejecting or avoidant?

You mean the therapist or the client?

Client.

The client.

Yeah.

I mean, that's the opposite.

It feels like the opposite of the, the, the pulling in.

It is, um, you know, I might show up to every session, but you, you can't possibly help me.

That's right.

Um, that is a different issue, but again, collaboration is important because if somebody comes in and says, I'm desperate, I'm suicidal, but nothing has ever helped me.

And I don't think you can help me.

What happens in the therapist?

The therapist thinks I'm a, I'm a trauma therapist.

I can help where nobody else has helped.

So we get a little narcissistic.

Yeah.

Or we, we get, you know, if not narcissistic, we get our caretaking, uh, activated, like, well, I'll work really, really hard and try to find a way.

And so it becomes the therapist work rather than the client's work.

So what I might say to a client like that is, well, I can imagine that you don't think I can help you.

I don't know if I can help you, but what's really important is that we find a way to work together toward your goals.

So tell me something about what you want to accomplish.

And then I can get curious about what hasn't worked and why.

And then I can figure out, is there, uh, an internal lock to getting the work done or, uh, what, what actually is happening there?

That's such wonderful language.

Um, I do something similar.

Uh, my consultant, one of the first things that he recommended that I do when I started working with him was to keep a little notebook by the side of my table for things that went sideways in therapy.

Ah, yeah.

Great idea.

That was such like a flood of relief.

Like, okay, they're supposed to go sideways.

I'm supposed to make mistakes.

Things are supposed to feel awkward.

Um, I'm supposed to get confused, lost.

I don't know what I'm doing half the time or where we're going.

And I've been doing this work 40 years and I still don't know where we're going half the time.

Right.

And I think it's really important to take the pressure off about getting it right because it's about relationship and relationship is, you know, just being human.

Of course we want to do a good job.

Of course we do.

That's not the question, but not to beat ourselves up when things go sideways because, um, we can't be prepared for it.

Sometimes we can't even control our own reactions and it's really normal in a therapist.

You use a lot of really, um, wonderful language, you know, especially when you're talking about curiosity and getting curious with both with yourself and on our own, or maybe as we're preparing for a session and also in session with clients.

I'm wondering, is that something in consultation that you, um, even role play with therapists or is that something that, I know that we can, we can certainly over plan and that's not helpful.

It's not helpful to go into a session with a script.

Some of that language might not be accessible, especially since we, I mean, I think a lot of us have, um, you know, sort of maybe not so helpful responses to the feeling of conflict, for example, or there might be some automatic words that come out and we're like, well, that's not exactly how I meant to phrase it, but to have at the ready because we've this session, but to have some of those, um, and you, I mean, and I am, I am thinking about some of the graphs and the tables that you have, but you know, I wonder if there's, um, uh, a way, you know, that, that therapists can, can practice that outside of session as well as in session.

So we're not always sort of floundering.

Yeah.

Right.

I mean, I, I think floundering is part of the process.

And I think as you do therapy longer, you learn ways of saying things that are empathic, but perhaps also limit setting, um, uh, something like that.

Um, yeah, that fits for you.

Yeah.

Yeah.

You don't want to talk about Kathy Steele because it would come across as, is not genuine.

You have to find your, your own way, but, but this idea of compassionate curiosity, I think can really shape our language like being, uh, it's almost like rising above the situation and looking at it and go, Oh, is that interesting?