I’m going on holiday and I won’t be able to see you that week:
Abandonment and the therapeutic relationship
My therapist went to a conference this weekend. I felt like she had abandoned me and was running away from me. My session was a day late and it felt like I hadn’t seen her for years. We were in constant contact but it felt like she was avoiding me.
These are difficult feelings to manage, particularly when my safety relies on the consistency and stability of the therapeutic relationship. These feelings are even harder to tolerate when I feel like I’m being unreasonable and irrational. This article will look at why I feel like this, in the hope that it will apply to you too, and it will suggest ways to manage and reduce these feelings of abandonment.
Why do I feel abandoned?
There are a number of reasons that I have found for why I react in an extreme way to any disruption to therapy.
Firstly, it takes huge trust to go to therapy at all. I have been tricked and betrayed many times, and this and my abusive experiences in general make it very difficult to trust anyone, let alone to trust them with my secrets. It can often feel that I am putting myself in life-threatening danger to go to therapy and sometimes I feel very suspicious of my therapist. It requires a lot of faith in my therapist to feel confident enough to begin to tell my story and to feel that my therapist can be trusted with what I am telling her.
If I feel that therapy has been disrupted in even the slightest way, this feels like a threat to the safety and stability of the therapeutic relationship, and therefore a threat to my trust. If my therapist has gone away for a few days, I feel very suspicious that this is the point at which everything is going to go wrong, everyone will find out my secrets, and I will be in trouble. I then often go further than that and feel that she definitely has abandoned me, which feels like a horrendous betrayal of my trust and is very destabilising.
Secondly, therapy requires me to be open about my needs – and I really need my therapist. Gradually I am more honest with my therapist about what I need from her and how important she is, so if she goes away, I feel like I have been humiliated as well as abandoned. There is a big risk in being open and the vulnerability of it makes me feel exposed, so I need things to stay very stable and consistent to help me to feel that the risk hasn’t gone wrong.
Thirdly, I think in an all or nothing way. My therapist is either here and committed to me, or she has gone and I will never see her again. It is very difficult and requires disciplined thinking to even consider the thought that maybe it is somewhere in between and she has gone but is still committed to me – let alone to believe that thought. I find it uncomfortable to consider grey areas and it is much easier to think in black and white, even though the black thinking is very distressing and not very helpful.
Fourthly, I have Dissociative Identity Disorder, and there are parts of me who are children. These parts think in childlike ways, which are also very all or nothing, and their world view is based on traumatic experiences. These children believe that my therapist is there when she is there, but when something changes it is difficult for them to have a bigger picture or understand the concept of a long term and committed therapeutic relationship. These children just feel abandoned and sad. This doesn’t only apply to people with Dissociative Identity Disorder, because I believe that everyone has elements of themselves which are more childlike.
Fifthly, I don’t cope with change well. I like it when things stay exactly the same and I find this very reassuring. When things change, I feel frightened and threatened. The concept of a world which is dynamic feels alien and threatening to me and I resist every change as strongly as I can. This is particularly important in the therapeutic relationship, which should be as stable and safe as possible. So when circumstances change, even if only temporarily, I feel very unsettled and anxious.
There are more reasons why I can feel abandoned by my therapist, but the simplest way to explain it is this: what I have been through has given me a lot of issues with attachment and trust, and I need my therapist to stay as safe and stable as possible so that healing through the therapeutic relationship is possible. If I feel that there is any disruption or unsettlement in the therapeutic relationship, I try to protect myself by making predictions about what will happen, and I act and react to that. However, these predictions are based on a world which is different to the one I live in now, so what should protect me ends up hurting me.
Why shouldn’t I feel ashamed of feeling like this?
These strong feelings of abandonment, distrust, and fear are completely normal. I don’t think I’m the only one who feels like this!
Feeling abandoned because of even the slightest change is a logical response to bad experiences. Further than that, the experience of therapy requires me to make myself vulnerable, in a safe and supportive place. It is important to become vulnerable and open in this way because it is only by doing this that I can be honest about what I need and move towards having those needs met. This vulnerability can at times be excruciating and can make me feel abandoned, but it is an essential part of the healing process through therapy.
If I turn the situation around to look for positives, I can see that these feelings of abandonment can actually be a sign that things are going well in therapy. For me to feel abandoned, I have to feel that the relationship is important. So if I am feeling abandoned, it means that therapy has reached the point of becoming important and valuable to me, and that I am becoming attached to my therapist. This might feel scary but it is actually a very positive thing that shows progress.
Also, it is important for me not to forget that my therapist is a professional. The majority of us who have therapy go through a phase (mine has been a very long phase!) of feeling so vulnerable that we feel abandoned after the slightest disruption. This is part of therapy, because it is an aspect of relearning attachment. So this is a part of my therapist’s job, and she has seen this many times before.
What can I do to make the feelings more tolerable?
Here are some suggestions which have helped me to cope with feelings of abandonment:
It is quite common for feelings of vulnerability and abandonment to turn into anger. This is a defensive mechanism to try and protect you from being hurt if you are feeling vulnerable. However, it is not helpful to keep it inside or to make decisions based on it.
I have found that it is a good idea to talk to my therapist about what is going on. It is important to acknowledge my feelings and it is helpful for her to know how I am feeling and that they have had an impact on me. She might be able to tell me her side of the story and explain anything that I feel hurt by. It can be very helpful to be able to tell my therapist that I feel angry with her and to talk about it, and it can feel very healing to be met with a listening and accepting response, and even to get an apology.
I try to be aware of the reasons for why I feel angry. It helps me to remember that it is a defensive response to feeling vulnerable, and not necessarily a response to my therapist doing anything wrong (unless she has also done something wrong). This is important to remember because it would not be sensible to take action like quitting therapy based on these feelings. It is always more helpful and effective when I deal with the root cause of a feeling, and in this case the root cause is how the openness and vulnerability of the therapeutic relationship makes me feel and why.
It helps me when I find ways to express how I am feeling. Anger is a difficult emotion to cope with. I try to be creative: I draw, paint, write about, sing about, and generally try to be creative in expressing how I feel. Sometimes I try doing something physical like going for a run. Occasionally I allow myself to express it by having a little shout or a cry. It is crucial that I express how I am feeling in some way, and before it turns in on myself and becomes destructive and harmful.
Sometimes a disruption to therapy can have a negative impact on therapy, and it is important to try and deal with this as soon as possible. When my therapist is back, it is very important to address the issues and talk about them. Every rupture which is addressed and dealt with is a big achievement and will strengthen trust – but it is essential that it really is addressed and dealt with. It is also important for me to try and hold onto hope that things will get back to normal. I read through old emails to remind myself that my therapist is worthy of my trust, and try to get through the period of rebuilding that trust.
How can I prevent this from happening again?
Unfortunately, I can’t, or at least not for the time being. These feelings are part of the therapeutic journey, as I become open and fully engaged with my therapist, and as I start to heal. I have found that the foundations of the therapeutic relationship have got much stronger over time, which helps me to stay rooted. However, there are things I can do right now to make it more manageable, which might help you too: forewarned is forearmed.
Physical vs. Psychosomatic: What’s the Difference?
I am in constant pain. I don’t mean emotional pain – dear me, please! I don’t feel emotional pain! – I mean physical pain. Aches and pains and creaking and groaning. Often I can identify a link between my inner pain and my physical pain. Sometimes I wonder what the difference is between physical and emotional pain. In this article I will discuss some of what I have learnt through experience and describe what helps me in the hope that it will help you too.
What is somatisation?
As I understand it, somatisation is the process where emotional pain, or unprocessed trauma, is transformed into physical pain. I see similarities between this and other things like conversion disorder, psychosomatic pain, and body memories. For me, it essentially boils down to: my heart can’t hurt any more, so my body has to take some of the hurt. Or: my heart refuses to hurt, so my body has to instead.
What causes it?
In my experience, the reasons behind somatisation are complex and the term somatisation seems to include many different types of pain. Dissociative disorders form when we are subjected to horrors which are too great to endure, and so we escape by escaping in our minds. We can’t cope with the memories or the knowledge, so we just don’t remember or know about it. The out-of-body experience of dissociation makes it seem as though we never felt anything. But unfortunately, I have found that my body does remember, and my mind does hold the knowledge and memories somewhere, even if I can’t or won’t access them.
What types of somatic pain are there?
For me, there are distinct types of somatic pain. These vary from person to person, and it can be difficult to distinguish one from another. This is my interpretation, each illustrated with the example of a sore neck.
I have a checklist for myself which is based on what has worked for me in the past. This checklist may differ from person to person, and it is not a substitute for medical advice.
The following are some suggestions based on what has helped me. It isn’t a comprehensive list and some aspects of it may not be relevant to you, but I hope that it can help you or at least be a launchpad for your own ideas.
Firstly, and unfortunately, the best way I have found to fix psychosomatic pain is to deal with the root cause. I say unfortunately because of course none of us want to face up to the horrendous things that have happened to us. It is also unfortunate because it is not a quick fix. For me, this means years of therapy and constant outside-of-therapy therapeutic work. But we should actually look at this as fortunate, because it really is possible for us to fix our agonising pain and to come to terms with our experiences. It certainly isn’t easy, but it certainly is possible.
Secondly, it is important to ask why. I find it very empowering if I can work out the reason why I am in pain. I heard recently of a three step approach: 1. Notice it (in this case, notice the reason behind the pain). 2. Acknowledge it. 3. Let it go. Easier said than done! The point is that it is helpful to work out the root cause for the pain and to take control of the pain by knowing why, but it isn’t helpful to be a detective and dig too deep. The reason why you are feeling the pain physically is because it is too much to manage emotionally, so it’s not going to help the situation to investigate too thoroughly.
Thirdly, acknowledge it for what it is. It is all too easy to use physical pain to distract from the cause. I much prefer to feel sorry myself for my aching back than to open the can of worms that is the cause of the pain. But, as above, it is a much more effective pain relief to acknowledge that the can of worms is there.
Fourthly, look after yourself. Do whatever you do when you are triggered: deep breathing exercises, relaxation music or guided meditation, pilates or yoga, painting, running, having a scream, having a cry, writing, listening to your favourite music, put on some children’s cartoons, be around someone safe, talk to your therapist, post on a safe forum, distract yourself, watch a safe film… Do whatever you can to make yourself feel safe and soothed.
Fifthly, listen to what your body is telling you. Your pain might be showing you that you need to start acknowledging something, or that you need to talk about something in therapy, or that you’re taking on too much and you’re overwhelmed, or that you’re in a triggering situation. Value your body as another voice which deserves to be equally heard (another easier said than done!).
Sixthly, don’t blame yourself. Sometimes it can be hard not to feel guilty for being in pain. But it isn’t your fault that you’re hurting, and it’s good to notice it and take action by looking after your body and you.
Finally, have hope. It isn’t always going to be like this. It might be a while before it gets better, and it might fluctuate in strength and frequency, but it isn’t going to be like this for the rest of your life. I can’t promise that you will be pain-free, but I can say that it won’t always be at this intensity. This is just another part of reeling from horrific things and gradually picking yourselves up from it and moving forward. It isn’t always going to be like this: there is hope.
I often say that I am dissociated, but this is actually an umbrella term that covers a wide range of experiences and sensations. According to the DSM-IV, there are six main types of dissociative experiences and/ or disorders. In the following article I will explain some of these terms by describing how I personally experience them.
The first is amnesia, which is basically forgetfulness. This means that I very frequently have absolutely no idea of pretty important things like where I am, who I am, what year it is, how old I am, and what I’m supposed to be doing. This can be really alarming and frightening, and can put me in danger. It can also be really alarming for other people.
The second is depersonalisation. If you have ever had a sudden trauma like being in a car accident, you may have experienced this. It is an out of body sensation, feeling disconnected from your physical self and your whole sense of self. I experience this in many different ways. I may be floating, sometimes inside my body, sometimes outside of it. I may be observing myself from afar. I may not recognise my face and be puzzled when I look down and see my body. I may not be able to feel my body (which is dangerous, eg when cooking). I may not be able to move very well, seeing as it’s not my body. I may just simply feel on another planet.
The third is derealisation. This and depersonalisation get a bit blurred for me. Derealisation means that the outside world goes weird. Again this can happen in many ways. One way to describe it is the Alice in Wonderland effect. I feel tiny and the world is huge and intimidating. The walls are closing in on me. The floor is rippling and moving. The floor is slanting upwards or moving around. If I look at people who I am close to, I might be able to recognise who they are but they seem somehow unfamiliar and very far away and I stare at their faces wondering who they actually are. Noises might be distorted or muffled, sensations numbed, and speaking is a strange experience, trying to project into such a bizarre and distant world.
The fourth is fugue. This is essentially one of the consequences of other types of dissociation and lost time. Imagine that you are sitting comfortably in your house. The next second you find yourself curled up in a wooded area by the verge of a busy main road in the middle of the night. This is fugue. There is a big gap between now and the last thing you remember, you’ve found yourself somewhere and have no idea how you got there, and you also have amnesia so you don’t know who you are or where you are. This experience, until you work out what’s going on and sort things out, can be very short, or it can last months or years. It goes without saying that this can be extremely frightening and dangerous.
The fifth is Dissociative Disorder Not Otherwise Specified, or DDNOS, which is diagnosed in 40% of dissociative cases (O’Neil et al (2008)). This diagnosis is another umbrella term. The most common presentation of DDNOS involves either people where there are not two or more distinct personality states evident, or where the person does not have amnesia for important personal information (Spring, R., Multiple Parts (2013)). For example, the person experiences themselves as lots of different “me’s” and watches their other selves from afar. DDNOS is a controversial diagnosis because the line between it and DID is not clear and there are many issues with the process of diagnosis. It is a difficult diagnosis to have because it does not have the recognition that DID has and can leave the person feeling even more confused and isolated.
The sixth, and the furthest along the dissociative spectrum, is Dissociative Identity Disorder, or DID. Here, all of the dissociative symptoms above are present, and the dissociation has occurred to the extent that the person’s personality has actually fractured. According to the DSM-IV, having DID means that you have two or more personality states and have amnesia between them. Sometimes the term polyfragmented is used, which I understand to mean 100+ parts, or multiple systems (separate groups of parts). Life with DID is extremely confusing and fragmented. Non-DID life is linear, which means that you can remember your day from the moment you got up until now in a straight line with no gaps. My experience of life is completely different. My life is shared between hundreds of people, and that means my time too. I cannot remember a whole day without lots of gaps, and my experience of time is here there and everywhere, like a jigsaw taken apart or an exploded party popper. My experience of living is also very different. There are few moments in my life where I am not experiencing some kind of dissociation. That means that there are few moments when I am fully connected and in step with the outside world.
Finally, there are other aspects of dissociative experiences which are not given a label. Some of these can be explained by the intensity of my inside world which is often much more real than the outside world, for example, voices and chatter, screaming, sensations from inside my brain, and so on. Some can be explained by body memories, flashbacks, and hallucinations, such as crawling skin, seeing things on the outside, and feeling things on my body. This, and multiple parts, can also explain things like feeling much shorter or taller, older or younger, weaker or stronger, in agonising pain or unable to feel pain, and more or less well. Dissociation has lots of day to day effects, like clumsiness, loss of balance, and poor short term memory. There are lots of other dissociative experiences but I can’t think of them right now – I’m too dissociated!