Mirroring: A calculated therapeutic technique or just conversation?
Understanding how and why a shiny reflective surface might heal.

(Download this article as a PDF)

By Jason N. Camu, Psy.D.

licensed clinical psychologist

dr.camu@fuelforemotionalhealth.com

Perhaps there is more debate about the definition of, and use of “mirroring” in psychotherapy than might first be apparent. As I have posited in previous articles, we (psychologists) sometimes appear to be in agreement about terms we use, e.g., he was being defensive, or I was mirroring him, but we may actually not share the same applied dictionary. When we use such language in our vernacular, unless accepted as synonymous, we run the risk of diluting our work and communication with one another. Not surprisingly the very same process of misunderstanding is possible when we communicate with our patients; hence the use of mirroring as a tool for clarification and confirmation. Yet the “act of mirroring” may not only serve in our understanding of people but function as a potent intervention as well.

By mirroring a patient we might just be making our best efforts to understand his or her presentation. Why then do we mirror some patients more than others? Why might we never, or rarely choose to mirror certain individuals? Why intervention (with the use of a mirror) is different from person to person may help to illuminate the efficacy of this as a part of treatment. Furthermore, we may also more thoroughly understand the mechanism of cure for a patient.

A closer inspection of what we mean by mirroring and how and why this activity may or may not be helpful is germane to informed practice. I forward the following operational definition.

Mirroring:

An attempt by the psychologist during a therapeutic interaction/setting/context, via verbal communication with a patient, and perhaps the purposeful inclusion of nonverbal gestures (animation/expression), to repeat, reflect, and represent a patient’s remembered emotional, cognitive, and historical experience with great accuracy and true reflection of the real (subjective), remembered experience by the patient. 

I emphasize, “attempt” because mirroring is a proximal attempt on the part of the clinician. By better understanding a person with a mirror, we may choose specific interventions, for example the use of Dialectical Behavior Therapy (DBT) for those who become emotionally upset or disorganized after mirroring. For many other patients I posit that the act of trying to understand can be an effectual instrument in creating change and growth by itself. Thus, I suggest in the above definition that mirroring is actually an intervention and at times part of our method of providing treatment, not just an instrument for understanding and assessment.

For the purposes of this commentary if we can agree that mirroring as an activity is actually an intervention, then questions arise as to why and how it works. If we provide a reflection of a person, back to that person, why would it help? Furthermore, what happens during that interaction that makes a reflective image result in improvement?

What function is served by providing a reflection from which the patient may then view him or herself? As with much of our work, we may want and need to believe that treatment is helpful. But as with any intervention, i.e., antibiotics, surgery, we bear the responsibility of explaining why and how we believe treatment is curative. For the day-to-day practitioner, our starting point of understanding is usually theoretical orientation. We rely on theoretical tenets to describe the mechanism of improvement for a patient.

For myself, an interest in this subject matter was sparked while lecturing to a youthful and energetic audience of first year graduate students. During this Introduction to Psychotherapy lecture, some students had strong reactions to the concept of mirroring. Students’ reactions varied and for some it included irritation or even dismissal of the concept. I became curious about what was happening in the classroom and why such reactions surfaced.

The following hypotheses of how and why mirroring might be useful, may also help to illuminate why the aforementioned trainees expressed mixed feelings when presented with the concept of mirroring in a lecture. The brief diagnostic conceptualizations in the following text might also help to discern who may and may not benefit from the use of mirroring.

Identifying and Labeling Affect

As psychologists one of the first reasons we might mirror a patient is to help the person identify feelings. The assumption, practical and theoretical, is that some people develop and grow throughout their lives without forming a sufficient vocabulary for feelings. The belief is that such individuals are unable to adequately articulate and describe their experiences because they are unfamiliar with feelings. If you are not an electrician, you are likely unfamiliar with the tools and materials associated with the trade. Some people never receive formal training in feelings.

A stereotypic example is the patient that looks mechanical. He describes factual detailed information but never identifies feelings. As he continues, his description of events might lead many to assume angry feelings but the patient never actually says, “I’m angry.” The therapist might then introduce affect words so the patient has a new language to describe his or her experience. For example, “You look frustrated. I could see how that could have made you resentful? (questioning tone).” There are many variations of possible presentations by the clinician, which is a topic of a paper in itself—said variations are well beyond the scope of this discussion. With the above application of mirroring, I suggest the following mechanism of action for improvement for this patient.

Mechanism: By providing language and vocabulary to describe feelings, individuals can then use that language to better manage, regulate, and modulate feelings. It is hypothesized that the mechanism of change is the identification of feelings. As an example, if the individual above can more rapidly and accurately identify the feeling “resentment” he can then make decisions based upon that identification, for example leaving a job, addressing a conflict in a relationship, etc. The assumption would further that he would then experience greater mastery of his life because he can negotiate problems and conflicts with awareness and clarity. Consequently, he would feel more in control, confident, and secure—arguably positive improvements.

Uncovering Affect

Related to the simplified example above is the use of mirroring to uncover buried, hidden, or defended affect. For this patient, the assumption is that he or she has troubling feelings that are morally unacceptable or too painful to acknowledge. A key difference from the individual who cannot identify feelings is that this patient has vocabulary for feelings but is unable or unwilling to use that lexicon. To infuse this commentary with more precise theory, the Structural (Id-Ego-Superego) model of psychoanalytic theory might forward that a person has feelings that are inconsistent or in conflict. For example, a man that is highly selfish but needs to see himself as considerate and compassionate, must deny (conceal) any awareness of his egocentric desires. By denying such unacceptable and intolerable impulses he tries to reduce tension; of course, the conflict will likely surface in daily living, e.g., a romantic relationship, leading the person to therapy. In this situation the clinician is mirroring various aspects of the patient’s presentation, some of which is highly contradictory and charged. An example might look like the following: “You seem really disappointed that she says you are so self-centered. I also heard you saying that you feel the relationship is unfair, because you can’t do the things you enjoy (selfish desires).” Ultimately the use of confrontation as a technique may also be included.

Mechanism: In the above example, the achievement of insight (beginning with awareness via a mirror) is proposed as a mechanism of improvement. When the patient becomes aware of these conflicting parts of the mind he not only has a more comprehensive and accurate view of himself, but he may also choose different ways of managing these newly identified parts. For example, after having his selfish desires mirrored in the language of the therapist, he may later agree and accept this as real and accurate. Consequently he may need to leave a relationship, choose another partner, or try to become more considerate and less self-centered.

Reducing Defensiveness

I respect with great care, that defenses are in place for protection. Defenses are designed to limit pain for the individual. When defenses—for example denial—cause problems in the person’s life and create more pain or prolong suffering, then their utility becomes questionable in the present. By making an effort to understand a person, by verbalizing an approximation of his or her experience (without apparent judgment) we appear non-threatening. I am not suggesting that we consciously manipulate others by appearing to agree with their values, but simply articulating their experience can for a time be separate from critically judging the experience (which may occur later). When feelings are discussed openly and understanding is attempted and established, it is hypothesized that for many people a sense of safety is experienced.

Mechanism: When we feel safe we tend to share more of ourselves, we become less defensive. When we feel genuinely understood by others we are probably more willing to look at weakness, fault, and vulnerability because the investigator appears non-threatening. Said more succinctly, when it appears that another person understands our perspective without a judgment attached we may believe that he or she is less focused on harming us.

Consequently, mirroring may reduce defensiveness allowing the clinician to learn more about the whole person. As noted previously, when we have the privileged position of seeing all parts of a patient we are better equipped to also use other interventions. It should be noted at this juncture that reducing defensiveness with the use of mirroring may also converge and synergize with other therapeutic benefits, i.e., insight.

Constructing a Sense of Self

Depending upon your diagnostic impression and how you think about people and psychological development, you might employ the technique of mirroring in a slightly different way with a certain patient. I forward that some patients come to us with an incomplete sense of identity. The construction of their personal identity is either in disrepair and was never finished, or the building process scarcely began. Some patients in this category describe experiences like feeling “empty” or they appear vacant to the psychologist. When asked how they feel they are sometimes sad, but have a limited and poor understanding of much more. If they do have an image of who they are, it can be vague and imprecise. To use a mirror in a metaphor describing the above patient, consider the following. When people look into a mirror they see a reflection. They see their appearance and along with the physical image that is visible, a host of impressions, judgments, and values began to circulate in the mind. For example, one patient sees the reflection and decides, “I am a bit overweight, I’m getting old?” Another wonders, “I wish I were taller like my brother.” Yet another decides, “I just feel worthless.” For others who look in the mirror they see very little reflected back; the image that is returned is ghost-like, shadowy, like the reflection in a mirror after a steamy shower. Said in a different way, when these patients self reflect they see a poorly formed sense of who they are; a few features might be clear, but much of the image is without detail. This patient might assert, “Well I know I’m smart, but I’m not sure about what’s important in my life, or even what I’m doing.” When in relationships, these patients sometimes even serve as an excellent net for unstable or volatile partners. Or they are sometimes tenuously bound with a fragile attachment. Because they do not have a sense of who they are, they are unable to describe a sense of self. The language does not exist for the patient because nothing exists to describe. Therefore, mirroring takes on a new quality.

How can a clinician mirror or reflect nothingness. Well certainly the initial attempts might include such statements like, “It sounds like you feel a void,” or “It’s like you just feel like nothing?” I reiterate that the person with an incomplete self may be partially constructed, consequently the psychologist could mirror the visible components. A modified version of mirroring can occur in this context as well. Psychological mirroring in a clinical context almost always involves estimations, approximations, and inferences—unless you are parroting verbatim the person. When working with a person who is lacking in self-definition, the clinician is forced to rely more upon a range of “expected human reactions.” What I mean is that we might assume or suggest a range of feelings or experiences. The patient then considers the list of suggestions, sometimes remaining very unsure and indecisive. This process of consideration can be key in treatment as the person eventually commits to an identity by choosing from the list, or he or she has enough self-definition to alter the suggestion. For example, the psychologist might offer, “Well given the way you were treated when your employer took your commission, I could see how a person could be pretty angry about that.” The patient is then charged with exploring why “a person” would be angry. For illustration, “Is this immoral or an injustice, was I mistreated, do I have values that were challenged, and if so, what are my/those values?”

Mechanism: The above description of an incomplete person has straightforward implications for the use of mirroring. When we provide a reflection we are providing the building materials for the construction of an identity. As a hypothetical example, a woman enters treatment and shares that she feels sadness, but also feels uncertain and sometimes empty, unsure about her purpose in life. Her boyfriend believes she is depressed, has poor self-esteem, and lacks confidence. He does however love her accommodating nature and ease of being when they spend time together. The psychologist’s early interventions might include, “You seem like you are lacking purpose or direction in life?” The clinician might elaborate, “like you are not really sure about why you are here, or where you are going.” Further discussion reveals some basic moral values that are present. The psychologist might suggest, “You said that you think honesty is a good quality to have?” With each exchange, and repetition of this process, it is hypothesized that the person begins the construction process. Because the person is participating in a reflection feedback system they begin to retain the proposed parts of the self. The patient might then report, “I really do believe I am an honest person based on our conversations—because of that I think I might need to choose a different type of work.” In actual practice I have suggested a couple concrete metaphors for patients. The first is to imagine that they are a building or structure. Some parts of the building were started, but because the building is incomplete we are uncertain what it looks like, or how it will function. A second example is like that of an early-model instant camera. When a picture was taken, it required a few moments for the image to surface on the photography paper. For this type of person the image is always indistinct, blurry, and with poor definition, as if the photograph never materialized.

Validation-Fulfilling Dependency Needs and Providing Narcissistic Repair

One of the most widely accepted assumptions about not just patients seeking treatment in our office but all people is that we need and want validation—to have our feelings confirmed. With equal popularity it seems that validation is accepted as an essential part of most talk therapies. Certainly in my work over the years, I have seen people relieved and even tearful feeling a deep sense of satisfaction when their perspective was reflected. Mirroring was the specific tool used to provide the experience of validation. However, underlying this therapeutic interaction is the notion that validating a person’s feelings somehow helps them in the psychotherapy context. The question surfaces: What is helpful about validating a person’s feelings? If a person has an emotional experience, why does it need to be confirmed, or validated? One hypothesis is that a subgroup of individuals seeking treatment are in need of, at least in part, the confirmation or validation of feelings to repair early developmental invalidation. This assumes that the patient has experienced feelings in life but because he or she is not confident of the reality, importance, or normalcy of such feelings, it results in damage to their person—more precisely, narcissistic wounds result in feelings of insecurity, inadequacy, and lack of self-efficacy. For these patients, it appears they have a desire to know that other people might also share their experience (as suggested by the psychologist’s provision of a mirror). When they are more certain that their feelings are worthwhile and valuable, they may then feel a greater sense of personal worth, confidence, and emotional security.

Mechanism:When we validate someone’s feelings we are supporting the notion that what is felt is indeed important and has worth. It’s as if we are saying and agreeing to the idea that, “Your feelings are worthwhile.” When this is communicated by mirroring it seems the mechanism of improvement is a change in self-concept, “If my feelings matter and are important, than I suppose I matter and have worth—even when others disagree.”

If you are able to imagine a person with dents, scrapes, and broken parts, then you might imagine ways in which to repair the damage. The patient with narcissistic injuries (dented parts) may experience a type of repair when emotions are reflected back. As described briefly above, mirroring appears to add worth to a person via validation, ultimately resulting in a more resilient and less defensive personal identity. The mechanism of improvement/repair appears subtly different for some others with prominent narcissistic injuries. The attention and effort expended by the therapist seems to be the healing ointment. When the psychologist mirrors, he or she is giving attention, recognition, and acknowledgement of the person. If the patient has a deep need to feel special, than the therapist’s interest in understanding, and the provision of undivided attention, is reparative.

The Unwanted Reflection

If mirroring as a technique has so much utility, is there a time that we should not use the intervention, or a time when even worse, it is contraindicated? Mirroring may be damaging when delivered to the wrong patient at the wrong time. Foremost, a therapeutic alliance with shared goals and trajectory may become askew.

Assessment and diagnostic impressions will be the underlying assumptions guiding treatment and identifying the wrong candidates for mirroring. Consequently, when a person has been assessed as having a more complete and secure sense of identity, and he or she is mirrored, I predict the result will be poor. When an individual knows and values his or her own experience, it is likely not necessary or helpful to reflect that experience. Feeling patronized, the person may become angry. Having a professional parrot your feelings when it is not needed can feel infantilizing or belittling, or in the least like the speaker doesn’t know you at all. An exception is when a relatively stable and secure person is significantly weakened due to life stressors, for example following a loss. At that point, a mirror designed precisely for that person and his or her circumstances might be experienced as supportive. When in therapy such individuals typically improve quickly.

In a nonclinical example, take a close friend who reports that he is upset due to a recent minor auto accident. Knowing this person (assessment of sorts) as a friend, you would likely be able to discern how to be supportive. For some the response would be, “Are you going to have your car fixed?” For others the response might be, “Oh my gosh, that sounds awful—even scary.” Yet for others it might even be, “I bet that made you mad, the guy wasn’t even paying attention.” All of the above rather natural responses are only appropriate for the right audience. I argue that assessment may occur in many subtle and less conspicuous ways. As clinicians (not friends) we may be operating from unidentified sources of information when choosing if, and how to mirror.

So the reason some students found the concept of mirroring upsetting? They revealed with their reactions that for their unique personality and psychological makeup, they did not want or need a reflection from another person, and rather found it contrived, disrespectful, and patronizing. Said differently, these students already knew how they felt, and saw no benefit in having a professional repeat it back. Consequently, when they imagined themselves as recipients of the mirror (patients), the intervention seemed insulting. To correspond regarding this or other articles, please contact me, Dr. Jason Camu via email at:  dr.camu@fuelforemotionalhealth.com.

[twocol_one]

By Dr. Jason N. Camu

licensed clinical psychologist

dr.camu@fuelforemotionalhealth.com

In a field seen perhaps more for mystery and art than science, as psychologists we sometimes struggle to explain our methods and procedures. This is especially true when our own emotional experience is used as a less than scientific tool in the moment.

Our patients want to believe and trust that we can help and that we know how to help. Sometimes the notion that you are a very “intuitive” person is reassuring to a particular type of patient—maybe the person who needs to believe in something bigger and more impressive than the tested hypothesis. For others it means the doctor is not bound by reason and the rules of the social sciences, but rather is flakey and magical. After all, other professions like medicine and law make it clear; because it is in fact clear. I wanted an x-ray for my broken elbow, not the physician’s intuitive sense that it was shattered.

“Intuition” may conjure images of a well-timed intervention that freed a patient from his or her internal prison. Conversely it may sound imprecise, affected, and unskilled. Like any of our tools, if intuition is to be judged as useful, discussion of what it actually is may be beneficial.

What then does “intuitive” mean? I posit the following regarding intuition as it applies to clinical work. Many psychologists are remarkably sensitive people with wonderful gifts in terms of reflective capacity, observation, and detail. This natural or innate predisposition of strong affect is then sifted and structured through education and professional training. Consequently, in addition to all of our scientifically derived skills as psychologists we also aim to use of our own feelings and reactions to further understand people—for example, the confusion that occurs at a staff meeting regarding a psychotic patient (parallel-process), or the schoolgirl crush that is privately experienced by a female intern for the handsome and just charming enough young sociopath. These are examples of countertransference in some form or another. When we fail to acknowledge and explain the experience of countertransference or projective identification, the feelings may be priming the inevitable build up of something that becomes intuitive.

Thus the collision between projected material that is felt (identified with) and our own life experience that also results in an intuitive action by the psychologist, is unique because it escapes understanding or articulation, e.g., “I don’t know it just felt intuitive.”

Intuition in clinical practice may be defined as the following:

The accumulation of powerful emotional data gathered via profound sensitivity and attention to both verbal and non-verbal cues and all of the senses known and unknown, that simultaneously elicits feelings in the recipient that are not articulated or understood in the moment, yet may be translated to action or intervention.

The inability to clearly articulate the source of the intuition should spark interest for those of us in the business of introspection and insight. Action without understanding could be risky. Conversely, it could be just what a patient needed, or doctor ordered for that matter.

Dissection of these keen moments of emotional

[/twocol_one] [twocol_one_last]

experience—whether you acted on your intuition or not—may yield incredibly meaningful information about your patient, and maybe more importantly about you. A colleague of mine described a feeling that one of his psychotic patients was in fact safe to have to his home for dinner. Arguably, this patient’s treatment needs included socialization and interpersonal skills. But what of his history I asked. He could be impatient and verbally aggressive and had poor frustration tolerance, including a formal thought disorder. So what was it that my colleague felt that made him so certain this man would be safe with his family? And my colleague by all measures of performance, including treatment outcome, is an excellent psychologist and not foolish. Maybe this was a terrible lapse of judgment, a boundary violation, and a dangerous empathic fantasy to help. I knew I would never do it. Rather than judge and blame, I wondered.

So I had to wonder about the mechanism, or pathway of internal experiences that led my colleague to this place. Perhaps it was an emotional bond with this person. This patient cared enough about the psychologist that the dynamic experience between the two was internalized (a newer object relationship), and caring developed. Caring for the therapist resulted in a moral standard against hurting the therapist or anyone the therapist cares for; and maybe my colleague felt this change. But this would be a clinical explanation after the fact, derived mostly from object relations and psychodynamic theories. My colleague had already acted and invited this patient home from a residential treatment facility. I knew this was well outside of my comfort zone. And years later this patient has thrived from this real-life trusting relationship with the psychologist and en vivo experience with boundaries and rules.

Accuracy and efficacy of intuition—does it work? A word that often precedes intuition is trust: “trust your intuition.” But assessing the accuracy of, or usefulness of your intuitive gifts can be difficult. As psychologists we know that like the people we treat, we are susceptible to our own self-serving biases and the use of defenses. For example, if a patient decompensated following the use of intuition, would it be noted? Would the patient be held responsible for simply defending against the truth. Said differently, the intervention was accurate and useful but it was the patient’s resistance that thwarted the intuitive wisdom—remember it is a patient’s job to use defenses against things that are painful. Maybe operating intuitively was off the mark. Another question that surfaces is, would the misaligned intuitive intervention even be noticed by the clinician? Social psychology tells us that Biased Scanning is used to confirm our biases. Consequently we only notice, acknowledge, and count/log those events that are consistent with what we believe to be true. The evidence that suggests that we might be wrong is never even noticed.

I have found that one of the best ways to keep myself accurate and honest is through the use of supervision, especially peers that will offer honest observations rather than personal judgments. It is the group that will come to see your patterns, strengths and weaknesses even when you don’t. Peers also pose the recurrent question either directly or indirectly, “why do you think this was, or would be helpful for this patient?” This challenge can reorganize the scientist in all of us, allowing for critical reason-based thinking as well as the integration of what I believe is one of our greatest gifts, sensitivity. To correspond regarding this or other articles, please contact me, Dr. Jason Camu via email at: dr.camu@fuelforemotionalhealth.com.

(Download this article as a PDF)

[/twocol_one_last]

[twocol_one]

By Dr. Jason N. Camu

licensed clinical psychologist

dr.camu@fuelforemotionalhealth.com

Ironically it seems obvious that our chosen profession is perhaps the greatest metaphor for the implementation of unconscious psychological defense. Over the years I am in the least let down, and at the most genuinely surprised, when a colleague says: “I really just wanted to help people and that’s why I became a psychologist.” We are indeed just as vulnerable to our own blind spots as are our patients.

The motivation to help others is as much a part of our own personal upbringing and biology as are the presenting problems and symptoms of our patients. Said differently, the choice to become a psychologist will include our own unresolved emotional issues and conflicts—this is certainly not a novel proposition. But the subsequent step of personal and professional introspection includes very difficult questions for the psychologist.

Why do we choose such an obviously masochistic profession? We listen to people’s problems for hours on end. We often complain about being overworked and underpaid. If one pays attention to our conversations amongst ourselves, we are also an exceedingly critical group. The role of psychologist could be viewed as not about working through our own personal issues, but about using the career and doctor position to deny, sublimate, and avoid issues while simultaneously acting out to gain pleasure.

Close examination yields more precisely these insecurities and vulnerabilities. Perhaps not surprisingly, one of our most troubled patient groups can provide a mirror reflection of our own painful inadequacies — the narcissistic patient. Our obvious identification with this patient, as evidenced by career choice, is the guarded secret. The result is a career choice that is the psychological defense. Of course we want to feel valued, loved, special, and powerful.

The helping professions provide a wonderful vehicle to solidify denial and avoidance while also providing a near perfect sublimation. Much like the attorney who is rewarded for reducing his adversary to spittle with guile, aggression and force, we too are rewarded. We help those in need, we are special in our suffering whilst also embodying the most revered qualities of human beings — we have compassion and empathy and put the needs of others before our own. At least it would seem so.

Speaking so highly of ourselves is a delicate exercise, because we must be careful to deny our pride as well. To be too impressed with one’s self is selfish, egocentric, and narcissistic. To indulge oneself in the hour of treatment is to take the attention from the patient to utilize the interaction for ourselves. Consequently we defend our modesty as indeed unrivaled. Perhaps.

Narcissism. The word is provocative and has multiple meanings for the clinical psychologist. Whatever the case, the narcissistic patient is often loathed by many in the helping professions. Why must we hate pride and selfishness so much? Because “we” are bigger than, of course. We mock the unsophisticated and transparent narcissistic defenses. We are so much smarter than the narcissist who must demean and diminish others to feel powerful. He or she makes others feel uncomfortable and small in the unconscious goal of feeling powerful. The insecurity is projected onto the object and often identified with when the receiver feels threatened or intimidated. When the treating clinician experiences the projection in a form of broadly defined

[/twocol_one] [twocol_one_last]

countertransference, he or she is enraged. Ironically, the aforementioned summary should sound familiar — we too are perpetrators.

How dare that patient make us feel so insecure, even intimidated. After all we are the doctors. Intellectually we can strike back. How ridiculous they look with their overstated presence; the cars, couture, carats and glitter, all to feel whole, special, and safe. As we work so hard to separate ourselves from this type of patient, that very same hard work can serve a synonymous function.

Similarly, the genesis of motivation for some who enter the field of psychology is based in narcissistic injury. Said succinctly, the psychologist’s own insecurities, needs for power, control, gratification and subsequent sadism may be primary motivators to become a helper.

Helpers would appear to be those without the intention of personal gain. Yet the field of clinical psychology is replete with opportunity for covert abuses. Foremost we are often experienced by others as “mind readers.” “Are you analyzing me right now,” is not unusual to hear at a party. Or, “those tests don’t really tell you anything.” We are feared and while many cannot acknowledge a fear of us openly, a psychologist has the power to intimidate. We are in a position of authority and inequity. Even if you are treating a peer, you are the voyeur with the privilege of intrusive questions, personal probing, and the one charged with holding secrets. If not for fear of our intelligence and fantasized mind reading abilities, we are at least scary because we are the keepers of what could be the ultimate weapon. In short, our role makes us feel powerful.

We are able to withhold, disclose, rescue, direct, and even taunt. What of the ill-timed interpretation for a bright patient; are you certain that the exploration of affect on that day was not designed to diminish him or her to reassert a personal emotional need for the self. How curious is supervision when we patronize, dramatize, and sexualize all to keep our selves feeling healthy, stimulated, and most importantly distinct from the patient.

My intention in writing on this subject matter is again to promote wonder about who we are, and why we treat. Consequently we may develop a greater understanding of what is really helpful to our patients. My general experience is that anger, aggression, selfishness, desires for power and control, and even sadistic hurtful wishes are commonly denied amongst helping professionals. Rather, some embrace the antithetical — peace, calm and serenity — the makings of reaction formation.

It seems almost sad that healthy narcissism must be so vehemently denied and concealed within a profession. Understanding our ugliness if it must be judged, can include a functional compromise formation resulting in greater acceptance of ourselves. Such acceptance and compassion for our own intense needs and forceful drives can also include greater compassion for the weaknesses of others, including our least favorite patients.

It is not unusual for my voice to be considered self-absorbed or even “cocky;” I have been criticized for both. If the reader is looking to find fault in this author for his rather presumptuous posit, I have successfully engendered the merging of the content and process. To correspond regarding this or other articles, please contact me, Dr. Jason Camu via email at: dr.camu@fuelforemotionalhealth.com.

(Download this article as a PDF)

[/twocol_one_last]

[twocol_one]

By Dr. Jason N. Camu

licensed clinical psychologist

dr.camu@fuelforemotionalhealth.com

(Download this article as a PDF)

“Oh, he makes a big deal about boundaries, he’s so serious he won’t even hug her, she’s an old woman for God’s sakes.” The snickers suggest that my reticence about hugging a patient on the unit is based in my own character deficits, namely that I’m mean or overly rigid.

My reasons for refraining from indulging that patient in a hug were based in a comprehensive diagnostic impression of that patient. I posited that hugging her actually interfered with her treatment, and I could describe why. This syrupy sweet and caring old woman used hugs to deny her own hostility and project responsibility and rage onto the recipient of the unwanted hug; the patient was malodorous, disheveled, and had head-lice, yet was exceedingly bright with a high functioning history. Rather than admit to repulsion and rage, clinicians colluded with the patient in a myriad of unspoken issues of anger, dependency, and helplessness.

Knowing what you are doing and why you believe treatment to be effective differentiates you the psychologist from any layperson offering emotional support.

Not all treatment is the same. Selecting which treatment is appropriate is based in diagnosis.

The borderline diagnosis is rich with a peculiar excitement for clinicians. It arouses what seems to be a pathologizing tendency that allows us to feel separate from and consequently healthy unlike our troubled patients, while simultaneously reveling in our own masochism as we suffer to help a noble savage. The DSM classification while useful in some ways, is a simple grouping of symptoms/behaviors etc. that are often confounded in a co-morbid mess with multiple other character and mood disorders, and does little to inform treatment.

For some treating professionals, grounding in theory provides a sound base for determining treatment modality—and perhaps even more importantly identifying the psychologist’s limitations in treatment.

For those who rely upon psychoanalytic or structural theory, the difference between borderline and neurotic is essential in shaping treatment. It is unfortunate that this basically simple theoretical approach has become synonymous with sex and cigar myths, not only in the lay community but now commonly infiltrating our field.

The distinction between borderline and neurotic sets the groundwork for selecting a treatment modality. Often attacked as effusive and narcissistic, analytic theory (structural theory) is very concrete in this regard and can organize a clinician’s approach to treatment. Said succinctly, differentiating patient pathology is what drives treatment and modality. An illustrative example is the fledgling therapist with the best of intentions who walks blindly into an exploration of trauma and affect with the borderline patient. The ensuing fallout can include a destructive deluge of rage, suicidality, or if lucky the calm before the storm with the exalted idealization.

[/twocol_one] [twocol_one_last]

The reason one might not use insight-oriented therapy is because the borderline patient lacks key Ego functions, namely he or she is incapable of self-reflection and has a profound difficulty managing affect. In my own work I have come to see this lack of self-reflection as a limitation in biology or genetics, not parental influence or environment. Consequently, I am unable to create or develop a self-reflective skill through treatment for the borderline patient. Similarly, a patient with developmental disability will reach an IQ ceiling defined by genetics even with extensive intervention.

Those patients demonstrating a reflective capacity, even if it is poorly developed, may be candidates for dynamic or insight oriented psychotherapy including the slow work of new compromises between drives for pleasure, and one’s conscious and unconscious prohibitions against those drives, e.g., telling a lie for personal gain and feeling guilty. Conflict resolution (a new compromise) might involve more comfort telling lies (challenging Superego and encouraging Id), or tighter control on the impulse to lie (strengthening the superego). Intelligence, attention span, affect tolerance, affect modulation and regulation, as well as other conceptual distinguishing features like a “sense of self,” are all key data that inform how or whether I will provide treatment.

In addition to a psychoanalytic practice, much of my work at present involves assessment for the international consulting and matchmaking organization Valenti International. As with all of my work, theory drives the diagnostic impression which then shapes evaluation. The written evaluation is read by the client. Thus, the very same diagnostic concepts must be considered. Only those who are self-reflective (can empathize via internalized object representations) can become clients. I must then consider how defended or protected this client is, so I may determine what is digestible for that client who will read his or her evaluation. The answers or hypotheses define what a client will be able to tolerate and hopefully use to develop, grow, and improve, making that person more prepared for a meaningful relationship.

It seems that a contemporary attitude about treatment is increasingly a blanket approach aimed at simply supporting a patient. Arguably empathy and caring are essential in treatment, but knowing how they facilitate cure or improvement should be readily explainable.

For example, mirroring a patient with a cohesive and articulated sense of self is patronizing and he or she will tell you so if you unnecessarily provide support (words) when something else was needed. Softening a Superego, supercharging Id, or supporting Ego functioning, or however one thinks about the mechanism of cure should not be mysterious at the time of intervention.

This commentary was provided as a sample of one clinician’s curiosity about treatment and how and why interventions are selected for each patient or client who has contact with a psychologist. Defining what we do can present a confusing picture of psychotherapy to most patients, it should not be so confusing to ourselves. To correspond regarding this or other articles, please contact me, Dr. Jason Camu via email at: dr.camu@fuelforemotionalhealth.com.

(Download this article as a PDF)

[/twocol_one_last]

[twocol_one]

By Dr. Jason N. Camu

licensed clinical psychologist

dr.camu@fuelforemotionalhealth.com

(Download this article as a PDF)

The term conjures a variety of different images of self-centered and troubled characters. Curiously, these may also be the patients we love to make important in our minds and in time with colleagues, reliving the therapeutic hour in a verbose parallel process.

Yet a closer examination of the term reveals widespread variation in what the term actually means to clinicians. I have found that for some, especially those that unknowingly identify with the projected feelings and inadequacy of the narcissistic patient (expanded upon later in the prose), the word is an opportunity to disparage the individual, differentiating oneself from this malignant form of self love.

It seems most often, that “narcissistic” unless explained in greater detail by the treating professional, is ambiguous and less than useful. And in fact the term appears to be a simple metaphor for a particular form of counter transference. The reaction I refer to is distaste for this patient’s unregulated self-aggrandizing braggadocio, and egocentric self-centered view of him or herself and the world. Even half a step back with an objective lens reveals this struggling person’s pathetic need for attention, acceptance and approval. Yet when you are the target of projected insignificance and used as a defensive object with whom to see unwanted parts of the self, finding compassion for this patient is more difficult. Complicating matters, the lay-public uses the terms “narcissist” or “narcissistic” to mean a multiplicity of other ambiguous characters, including sociopaths. As I have mentioned in other articles, our responsibility to our patients is to understand more than the layman.

It is the narcissistically damaged patients’ use of defenses that makes them so difficult (perhaps even feared), especially when they are highly intelligent and at times, smarter than the doctor, a fact that may be difficult to accept. Because of their keen awareness of threat, need to sustain their precious image, and sometimes finely tuned interpersonal skills, these patients may be affluent, attractive, articulate, and present other confounding variables to the therapist. These factors are also infuriatingly juxtaposed to the helping professional’s selfless image and prized modesty and humility.

Juvenile-like needs to engage the psychologist in competitions are just the first of so many challenges. Belittling, challenges to competence, aggressive highly personal observations and comments, and a persistent general picking at the therapist may make this fractured person difficult work, i.e., “I [patient] notice you [psychologist] always wear a suit and tie, I remember when I used to have to wear a monkey-suit.”

Narcissistic defenses are generally unattractive with a primitive sometimes almost assaultive quality. Thus,commonly when the narcissistic patient is being described or the term is being used it is the defenses that are being described not the state of the person For example, take the remarkably self-centered individual that demeans. As a very smart, preened, and mega-wealthy patient once said to me, “So you’re a psychologist, I have a number of those on my team, they are like whores to the court, they [psychologists] work great for us [lawyers].” While your reaction can reveal a lot about yourself, this “narcissist” is communicating in the only way he knows how. He must make himself feel bigger and better in a desperate attempt to feel adequate. He must make me as small as possible. Yet in doing so he will succeed in again avoiding his issues with his arsenal of defenses. Only competence will help this patient feel comfortable, safe, and able to use insight to face his greatest weaknesses. With multiple failed relationships he continues to hurt those he loves with immature acting out and cruel and insensitive insults. However, he does love and care for other people. This capacity to take another’s perspective is a fundamental differentiation diagnostic feature that is so important in his treatment. He uses people as objects to inflate the self, but with overwhelming hunger he also craves the very same objects’ respect, love and approval.

Yet like the ill-equipped adolescent, he will not let his image slip in favor of vulnerability. The narcissist acts compulsively and almost instinctively to hurt others. While most of us

[/twocol_one] [twocol_one_last]

may understand why to some degree—he feels small himself—it is the origins of his smallness, and the nature of his strengths that require key diagnostic attention.

I find the narcissistic diagnosis to be remarkably helpful in the broadest sense; it speaks to a category of painful injuries that have damaged this person’s internal self-image. The term in my work refers to an individual with a variety of strengths and abilities but with dire, deeply painful injuries to the self. Said simply, as this patient was in the process of forming his identity he received remarkably damaging and piercing injuries to his self under construction. The developmental process of creating a sense of oneself, that is the biological organism’s interaction with his or her early world and the feedback received, marks the origins of either a healthy internal representation of the self, or a pathological narcissistic formation. Succinctly put, did this person receive adequate praise and recognition along with criticism to create a functional and sufficiently content sense of self? If the biological organism with his or her own unique strengths and weaknesses was met with a poor match in primary caregivers, we may see the genesis of a damaged/inadequate sense of self. I find this concept particularly useful in that it also traverses theoretical orientations while maintaining an essential theme. For example, whether you think in terms of internal representations, schemas, or simply self-image, you can see that the mental image held in memory is fractured, frail and in constant danger of demolition. These deeply stored memories contain interactions with other objects (people), the affect/charge that binds the interaction, and are the basis for identity, but also the seedlings of morality, a conscience, and operation of oneself as an adult.

When the feedback or mirroring from primary caregivers serves to severely damage the blossoming enthusiastic narcissism of the developing child, narcissistic issues may be formed. It is this realization that will ultimately aid the psychologist in finding the elusive compassion for this type of person. With patience, the treating professional will ultimately wade through—perhaps battered and beaten—the onslaught of the patient’s attacks to find the real story, a story rich with deeply hurtful experiences for the patient. Often, although not exclusively the experiences will be easily identified in the form of criticisms and acrid, caustic insults from key developmental figures. As one patient recalled from when he was just a young boy: “I picked a flower, probably just like a weed or something for a neighbor girl. My father said, ‘What are you hiding behind your back there, you little queer?’ He smashed the flower on the ground with his shoe [like a cigarette] and boy did I get a beating.”

Most important are the distinguishing diagnostic characteristics of the narcissistic character. It is here that I find psychoanalytic concepts so helpful. Extending well beyond the limitations of the DSM groupings of symptoms, an excellent diagnostic impression (commonly called ego-assessment) can shape treatment. Unlike the borderline patient who can also attack and criticize, the narcissistic patient has the ability for self-reflection. Under the proper conditions, the narcissistically damaged character can and will look at his or her contribution to life. The borderline patient cannot use introspection, pushing the patient to do so will typically result in disorganization and/or a defensive split, making the therapist the hated agent rather than the bringer of wisdom. It is this distinguishing quality (self-reflection) that makes these patients treatable with insight oriented approaches, not just supportive techniques.

Key assessment considerations include intelligence, strength and forcefulness of drives, focus and attention, affect management and tolerance abilities and skills, ability to articulate feelings, quality of sense of self, and most importantly the ability for introspection. Many patients with insight capabilities may first require tools for affect regulation and management. But he or she may ultimately benefit from more insight oriented forms of treatment because they can acknowledge weaknesses through self-reflection—a process that is based in innate abilities as well as the early internalization of key primary objects that form a conscience and lead to empathy. Carefully using diagnostic labels and terms for oneself, and fully understanding what we mean (for ourselves) by those terms will only strengthen how we implement treatment and help our patients improve. To correspond regarding this or other articles, please contact me, Dr. Jason Camu via email at: dr.camu@fuelforemotionalhealth.com.

(Download this article as a PDF)

[/twocol_one_last]