Psychological Correlates to Stages in Therapy

When I was finishing my master's program in counseling psychology, I was shocked at how few therapists felt solid with their ability to address traumatization. The state and nonprofit agencies that hire counseling and social work masters tend to focus on addictions and family treatments. These lend themselves to operational systematization to some extent. But even though we were encouraged to choose--drugs or families--it seemed to me that traumatization was fundamental to both types of problems as well as depression and anxiety (the most common complaints seen at outpatient clinics). While interning at the local Veteran's Administration hospital, I asked my supervisor what percentage of therapists he'd guess were capable of addressing trauma. He estimated 1:7.

Wow. An entire field devoted to the study of human psychology yet avoidant (the other 6:7) of the most basic problem in human psychology. What's more, as inexperienced interns, most of us were thrown into crisis situations we were not prepared for--situations that were difficult enough that our elders in the field generally avoided whenever they could. They didn't teach much crisis management in our program because that was just case management--social work--not insight therapy per se. Clients in crisis were deemed not appropriate for insight therapy (because they were struggling with intense day-to-days). What's more, many clients were deemed "resistant" to conversation about feelings when they tried to insist on addressing more external issues like paying the rent and coming up with enough gas money to get their kids to school. Inappropriate and resistant because of crisis.

Anyway, it seems helpful to me to see a few different stages in therapy and recognize psychological responses that seem appropriate to the varying situations. The stage that is often most intense and potentially harmful is crisis management. This occurs when people are concerned about making it through the night, through the weekend, through the next encounter with their spouse. When I'm in crisis mode, it's back-to-the-wall time. You're basically in a fragile situation where desperate times may call for desperate measures. Desperate thinking in these situations may not be most helpful, but it is certainly normal. Crises can make people feel crazy or fragmented even though they aren't necessarily crazy. Crisis management was most lacking in my education and traumatization during crises often results when they are not handled well. (Our field has struggled to come up with an agreed-upon definition of "resilience" partially due to not differentiating some of these stages and psychological responses clearly.) If you survive crisis, that is all that can really be expected. Insight therapy is generally inappropriate to crises.

At the next stage, we are dealing with case management--making sure that the physical needs can be met on a regular basis. So in crisis management, you may be trying to find some place to sleep tonight. With case management, you are looking for finding a place to sleep on a consistent basis. Desperation is not called for at this point (but can result from unrealistic expectations or prior traumatization). This is part of where Americans are generally spoiled rather than tough. We think of these situations as crises when they are not. Durability is called for, mental toughness, grit, persistence, whatever you want to call it. This grit is the same thing that many therapists consider to be resistance in insight therapy. Low income-clients (myself included in this economic class) are often deemed inappropriate or resistant because they tend to be insistent that what they need more than a focus on their emotional state is a consistent job, place to live, source of income and therefore food, etc. Farmers and blue-collar workers need to make grit part of their personalities, something they bring to work every day, and it is inappropriate to consider that grit to be inappropriately resistant or antisocial. At this stage, we are not even dealing with emotional resilience yet. We are hammering in mental toughness, tempering one's will and character for difficulty.

Between these two stages, we begin to differentiate between definitions of resilience. One common definition focuses on the ability to handle adversity without being traumatized. Another common definition focuses on the ability to handle adversity and come out stronger, better, healthy, whole, etc. Because this differentiation already exists, I'll call the first durability and the second resilience. By this definition of resilience, there is a certain "spring" to one's emotional response, a healthy tension and room for healthy shifts in emotions as one's situation changes. This is different from--but may coincide with--a consistent toughness that may have little "spring" to it. Some people are tough but not optimistic, and I'll call them durable; they may or may not be "resilient" as it is often meant in psychology circles. We can see where an attitude of opportunism may look like resilience from one angle and it may look like idealism from a more "realistic" angle, depending on circumstances. Looking for opportunity often goes with a positive affective tone, so opportunism may be mistaken for resilience, and a lack of opportunism may be mistaken for "resistance" or lack of resilience. Generally, then, opportunism and apparent resilience will correlate, but caution should not be mistaken for a lack of resilience.

Beyond case management, once clients are in a stable economic and relatively stable emotional setting, we can start talking about therapy with a focus on insight. There is a shift away from survival and continuity towards optimization of experience. Many therapists would like to ignore the first two stages, and while it is fine for many to focus on insight therapy, it would be helpful to interns and clients in case management or crisis management situation for those in the field to learn the whole continuum. With insight therapy, we're mostly focused on sensitization of emotional awareness, reducing reactivity, improving communications and connection, and enriching experience. Mindfulness will be helpful for achieving some of these goals, but most clients do not take up consistent meditation at this point.

When we speak of optimization of psychological experience, regardless of whether one is more internally or externally focused, we are talking about moving from competence to expertise in being able to structure one's life and psyche so as to achieve consistent flow. Affluence and professional expertise help set the context for optimization, but adversity will also bring out the best in some individuals. This is another class that helps define another unique definition of resilience. There are a rare number of individuals who are something like "adversity superstars". These folks need more pressure than most to perform at their peak. We recognize them when they grow up in, or find for themselves, situations that are demanding enough to draw out their best. They are analogous to athletes who perform best in the big games in that they may do very well under great duress; they may also be under-stimulated and perform poorly without it.

But other than the adversity superstars, most of us will look our best (feel it too) within a supportive context. We will want enough challenge but not too much. And besides challenge, we will mostly look for physical, emotional, and social comfort. The right physical and social situations will support that pursuit of optimization or flow. (And flow is the general point of most of the rest of this blog.)

So rather than having some definition of resilience that lacks contextualization, we can say that there are different types of contexts that make wildly varying psychological responses "reasonable". At worst, it is a do-whatever-it-takes mentality during crises; this can look crazy to outsiders. Up one step, durability can look like stubborness, cynicism, antisocial behavior, and an avoidance of emotionality. It is--evolutionarily--a luxury to get to the point of economic and emotional stability and resilience. And beyond that, optimization of experience takes a different type of expertise than simple emotional awareness and normal communicational effectiveness. Trying to introduce emotional resilience in a crisis may not be effective, just as trying to introduce optimization to a couple that just wants to be able to communicate with one another may not take hold.