01 - Appendix D. Restructuring the Meaning of Earl

Appendix D. Restructuring the Meaning of Early Memories through Experiential Techniques

I have put techniques to restructure the meaning of early experience in an appendix because they are more advanced and may not apply to many of your clients. These Gestalt-­type techniques have been adapted to the cognitive model, specifically to change dysfunctional beliefs, and are more often used with clients with personality disorders than with clients who have acute disorders, though not exclusively so. You use these techniques toward the middle or end of treatment, when clients have already begun to modify their dysfunctional beliefs. Note that it may be important for some clients to focus more heavily on recalling positive memories and deriving positive meanings to fortify their adaptive beliefs about themselves, their worlds, and/or other people. I present two ways to restructure the meaning of memories below. Technique 1: Restructuring the Meaning of Early Experience through Reenactment and Therapist–­Client Role Play. Below, I first ask Abe about a distressing situation, suggesting he focus on the somatic sensations attached to his negative emotion to activate his core beliefs and distress more intensely. I do this so he can gain greater access to an earlier memory with the same theme. Judith: Abe, you look pretty down today. Abe: Yeah. My ex-wife called. I was supposed to babysit for my grandchildren this morning, but I had to cancel at the last minute because I had forgotten I had a doctor’s appointment. Judith: What did she say to you? Abe: That I’m a terrible grandfather. Judith: What went through your mind when she said that? Abe: She’s right. I am a terrible grandfather. Judith: And how are you feeling? APPENDIX D Restructuring the Meaning of Early Memories through Experiential Techniques

Abe: [expressing her emotion] Sad. Real sad. [expressing his core belief] I’m such a failure. Judith: Just as a grandfather or overall? Abe: It feels like overall. Judith: [heightening his affect to facilitate memory retrieval] Do you feel this sadness and failure somewhere in your body? Abe: (Points to chest.) Here, in my chest. There’s this heaviness. Next, we collaboratively decide not to focus on this current situation at the moment. Instead, I take advantage of Abe’s negative mood state to identify an important early experience, in which the same core belief had been activated. I ask him to imagine the scene. Then we discuss the memory on the intellectual level, and I help Abe see an alternative explanation for his mother’s outburst in which she blamed and criticized him. Judith: When is the first time you remember feeling this way, as a kid? Abe: (pause) Probably when I was about 11 or 12. I remember my mother coming home really late from work because she had missed her bus. She got really upset with me because my brothers were playing with colored clay in the kitchen and it was all over the table and on the floor. Judith: Can you picture the scene in your mind? Were you and your brothers and mom in the kitchen? Abe: Yes. Judith: What did her face look like? What did she say? Abe: Well, she looked pretty mad. She really yelled. She said something like “Abe, what am I going to do with you? Just look at this place!” Judith: What did you say? Abe: I don’t think I said anything. My mom kept yelling at me. She said something like “Don’t you know how hard I work? I don’t ask you to do much. But why did you let your brothers get clay all over the place. You should have been watching them. Is that really so hard to do?” Judith: [empathizing] You must have felt pretty bad. Abe: I did. Judith: Do you think this was a reasonable way for her to act? Abe: (Thinks.) I don’t know . . . She was pretty tired and stressed out. Judith: Is this something you found yourself saying a lot to your own kids? Abe: No. I never said anything like that. I didn’t expect them to look after each other. Judith: Can you remember when your son was 11 years old—and your daughter was, what, 8? Abe: Yes. Judith: If you had come home one day after work, you were really late and really tired and stressed out, and the table and floor were covered with clay, what would you have said to them? Appendix D

Abe: Umm . . . I guess I’d have said something like—“Uh-oh. Okay, there’s clay all over the table and on the floor. Stop what you’re doing and clean it up. And next time, don’t let it get so messy.” Judith: That’s really good. Do you have any idea why your mother didn’t just ask you to clean up the clay? Abe: I’m not sure. Judith: I wonder, from what you’ve told me before, if it could be because she was overwhelmed with being a single parent. I wonder whether seeing the kitchen messy made her feel out of control. Abe: That’s probably right. It was hard for her. Next, I change the focus so Abe can engage in experiential learning through role play. Initially he plays his mother; then we switch roles and he plays himself. Judith: Okay, how about if we do a role play? I’ll play you at age 11; you play your mom. Try to see things from her point of view as much as you can. You start. You’ve just come home from work, you see clay all over the table and the floor, and you say . . . Abe: [as Mom] Abe, look at this mess. You should have stopped your brothers. Judith: [as Abe] Mom, I’m sorry. It is a mess. I’ll start cleaning it up. Abe: Don’t you know how hard I work? Is it really too much to expect you to watch your brothers? Judith: I was watching them, and I did tell them to clean up, but they wouldn’t listen to me. Abe: You have to make them. Judith: I don’t know how to do that. I’m only 11. You’re expecting too much from me. I’ll clean it up now. I don’t know why you’re making such a big deal out of this. You’re making me feel like such a failure. Is that what you think I am? Abe: No, I don’t want you to think that. It’s not true. I just want you to do better. Next, I help Abe draw a different conclusion about the experience: Judith: Okay, out of role. What do you think? Abe: I wasn’t really a failure. I did most things okay. Mom was probably just really stressed. Judith: How much do you believe that? Abe: I think I do believe it. Judith: How about if we do the role-play again, but this time we’ll switch parts. You be your 11-year-old self, and let’s see how well you can talk back to your mom.

Restructuring the Meaning of Early Memories

Following this second role play, I ask Abe to summarize what he learned. Then we discuss how his conclusions apply to the current situation in which his ex-wife called him a failure. Technique 2: Restructuring the Meaning of Early Experience through Reenactment and Older Client–­Younger Client Role Play. This technique starts out in the same way. Here are the steps: 1.  Identify a specific situation that is currently quite distressing to a client and is associated with an important dysfunctional belief. Heighten the clients’ affect by focusing on her automatic thoughts, emotions, and somatic sensations. 2.  Help the client identify a relevant early experience by asking, “When do you remember feeling like this when you were growing up?” or “When is the earliest time you remember believing this about yourself? [or ‘When did your belief get much stronger?’]” Elicit a description of a specific situation and the meaning the client put to it. Use Socratic questioning to help her reframe the dysfunctional belief that had been activated. 3.  Ask the client to reexperience the situation as if she is the child (the “younger self”) and as if it is happening to her right then. Until you’re finished with the technique, speak to the younger self using vocabulary and concepts appropriate for her developmental level. As she tells you about the experience, elicit automatic thoughts, emotions, and beliefs of the younger self. Ask her to rate how much she believes her beliefs. (You often need to give the younger self a multiple choice: “Do you believe it a little? A medium amount? A lot?” If you ask the younger self for a percentage, she will mentally shift to her older [current] self.) Ask the client to continue to imagine the scene, always speaking as the younger self, using the present tense, until the trauma is over and she’s in a safer place. 4.  Ask the younger self if she wants to have her older self come into the scene (the safer place) and help her understand what happened. Facilitate a dialogue between the younger self (the emotional mind) and the older self (the intellectual mind) to reframe the dysfunctional belief. If the younger self is confused or doesn’t believe her older self, make suggestions to the older self about what she can say (using developmentally appropriate language and concepts). 5.  Ask the younger self to re-rate how much she now believes the dysfunctional belief. If her degree of belief has reduced, ask the younger self if she has anything else she wants to ask or say to her older self; then facilitate their saying good-bye. 6.  Ask the client, “What do you conclude from what we’ve just done?” A typical conclusion is that the dysfunctional belief was not true, or certainly, not completely true, and that the younger self was vulnerable and deserved protection and good treatment. The client may also agree to begin talking to herself in a more compassionate manner (in the way her older self talked to her younger self) as part of her Action Plan. Appendix D