NYIPT Template

As helping professionals we want to be empathic and helpful. But we often wind up feeling so powerless with some patients, perhaps invisible, especially with patients who seem to be self-destructive. Why is that?

People who are attracted to painful, self-destructive behaviors live in a foreign world, and when they come into therapy with us, there is no platform for exchange. We can only build a platform by finding a common language in which to communicate.

As therapists we want to understand and find ways to think about what's going on in our patients' minds. This seems meaningless to some of the people who come to us. They want solutions, answers, unquestioning agreement, or they need to act-out and make us feel some of what they may be feeling.

The sadomasochistic person hears pain, feels pain, thinks pain. Or nothingness. They come to us to get rid of all the bad feelings they have. They want a place to dump their bad feelings. Our efforts to empathize and talk seem weak and ineffective. They want to experience something powerful, like the powerful, albeit negative, experiences they had as children, that evoked big feelings. I can imagine that coming to a therapist after years of family sado-masochistic interactions is a little like walking into a normally lit room after being in the blinding sun. It seems dark, but only because the sun was so bright.

We have ample evidence that adolescents who hurt themselves, through whatever method, were involved with parents who related to their children in a primitive manner. Picture a mother who deliberately provokes a child to be scared by saying she's going to leave, and she justifies her behavior by saying it feels good to feel wanted. Picture a scenario where a parent provokes a big feeling, like anger, or sadness, and then laughs. This parent seeks the child's reaction because it helps the parent feel real, connected and (falsely) effectual. The insecure parent’s laugh may be an indication of relief, like, "Thank God, I must really exist, because I can cause this big reaction."

Now picture this same parent being either turned off, or turning away from a toddler's budding independence or competence. This parent cannot imagine enjoying the child’s competence or feeling empathy at the child's struggles and frustration. These parents connect through intrusive care, criticism, or dramatic enactments of their own abuse. In this scenario, there is pain related to connection, or loneliness and deadness.

A number of years ago I worked in a school, in special education. At first I wondered why so many teachers screamed in the classroom, and why they said so many harsh things to their students. I worked with a large number of boys in groups. The boys would find extraordinary ways of finding the wrong thing to do. Climbing up on chairs, throwing things around, running around the school when I was escorting them to the consultation room, making lots of noise, talking about sexual matters in a way that was meant to provoke or embarrass me. In the first couple of years I, too, became hoarse in the first month of every year, raising my voice while telling the boys what they already knew: "It’s time to sit, time to talk, time to keep it down…"

As I got to know the boys, I learned to wait for them to notice me. I would silently walk them down the hallway, ignoring their provocations, quietly preventing them from piling three chairs up so that they could get a paper airplane off a ceiling light fixture. There would usually be a lull, as if they were peeking at me and asking what did I think of all of this? I developed a speech to say to them. "I know how to yell. Did they like it when their teachers yelled? Did their parents yell? Did they like it? Would they like me to yell?" If someone joked, "Yes," I would demonstrate that I knew how. That usually got a laugh. I said, "I don’t want to yell at you." I wanted to see if there was some way I could help them to reach some positive goals. What did they want? What did they want to do? Become a baseball player? Get out of school? How could we reach any of their goals by working together?

People who are living in a primitive or archaic relational matrix are living in a jungle. They live with the thought, kill or be killed, attack or be attacked. If you aren’t attacking, you must be weak. Your “niceness” can be thought of as weakness. In a way, niceness is an acceptance of human weakness. Allowing oneself to be receptive and open comes not only from a sense of safety, but from an acceptance that there are dangers in the world that cannot be defended against or controlled. A constant defensive position not only does not work to prevent danger, it prevents true connection and the possibility for mature competent functioning.

The special ed boys I worked with would cheat at Uno games, and they'd laugh when I lost. I would say "I must seem so stupid to you. When I let myself lose, I must seem so weak to you. But, you must be afraid to find out if you will really win or lose, so that's why you have to cheat. Losing feels terrible, as if there is something wrong with you if you lose." You can probably imagine that it caused a lot of cognitive dissonance for these boys to hear that they were afraid. This was something that they had never considered.

In order to achieve a dialogue in treatment, it is crucial that therapist and patient speak the same language. The first part of treatment with people who are self-destructive consists of demonstrating the differences between the language of being hurt and hurting someone and the language of mutuality.

One of the clincians who attended my talk at the Graduate Society gave a great example of a young woman who wanted to be someone special. When her therapist asked what steps she was taking to reach her goals’ she felt attacked. Helping this young woman understand that she and her therapist were on the same side would require a shift towards speaking the same language. Once a common language can be developed, the dialogue can begin.