Integrating the Somatic, Intrapsychic, Social, Contextual, and Meaning-Making Dimensions: The Case of Heidi
Brown and Bryan (2007) describe how feminist analysis informed psychotherapy with one woman living with complex trauma who used SIV. Because SIV is a resistance strategy that is very likely to pull for authoritarian or coercive behaviors on the part of a therapist, it provides a useful example of how a feminist strategy of empowerment would lead to a therapist behaving in certain ways working with someone practicing SIV. The following is adapted from their discussion of Heidi’s psychotherapy with the first author.
Heidi was a 32-year-old, Euro American woman born and raised in a small town. She lived below or close to the poverty line growing up. Her earliest memories are of her mother trying to smother her with a pillow. She was custodially kidnapped by her father shortly after her third birthday; he began to sexually abuse her the first night she stayed with him. She can recall digital penetration and forced fellatio occurring regularly during the next 3 years. From about age 6 until about age 9 she was forced by her father into sexual activities with other children and adults for the purposes of producing pornography; these included sadistic and humiliating treatment. Heidi recalls beginning to dissociate around this time.
Heidi thinks that it was around the time she was 9 years old that her father and stepmother were arrested for their crimes. Her memories of that abuse are compromised by the effects of trauma as well as by the sedative hypnotic drugs she was given during that time to facilitate her compliance as she grew older and more resistant. She was placed in foster care where she lived until age 15. She described this foster home as not abusive, but as cold and formal.
Heidi began to practice SIV not long after she moved into the foster home. She noted that she never felt especially bothered or worried about what she did to herself because it always paled by contrast with what her biological parents and stepmother had done. By mid-adolescence Heidi was regularly piercing her skin with needles, cutting herself on her upper thighs and stomach (where the cuts were invisible to others), and punching herself on the head repeatedly until she became dizzy. She reported realizing in retrospect that her SIV methods depended in part on whether she was alone or in company, as she did not want anyone to notice her actions: “By then I knew this was weird.” She was also able to discuss that SIV varied depending on what she was attempting to accomplish. “Cutting is really good for calming myself down. I cut, I see the blood, and I feel like I can breathe again, like I can stay alive a little longer. I hit myself when I’m mad at myself, but cutting is sort of a nice thing I do for myself when I’m feeling numb or freaked out or want to die.”
At age 15 Heidi ran away from the foster home and hitchhiked to a major city where she lived on the streets. She made money as a prostitute, but also enrolled in community college, lying about her age to get her GED. After completing her GED, she enrolled in an allied health care program, graduating with honors at age 19. While she continued to occasionally practice SIV when upset or frightened, she reported that her need to utilize it decreased during her early and mid-20s as she stabilized and improved her quality of life.
Five years before she started individual psychotherapy, Heidi became a target of sexual harassment in the workplace by a powerful supervisor. Heidi dates the onset of the harassment around the time that she had lost considerable weight. “I had started doing rock-climbing, so I was going to the gym and working out to get my upper body stronger. I think the sick S.O.B. hadn’t noticed me until then ‘cause I was a kind of dumpy little thing.” The supervisor began by making suggestive remarks, then began to trap her in storerooms and press himself against her. This sexual assault triggered Heidi’s dormant posttraumatic symptoms and responses: She reported that the day after the first assault, she went home and cut herself again for the first time in several years.
The sexual harassment continued for 3 years, during which time Heidi became extremely symptomatic. She dissociated during the sexual assaults, increased her SIV, withdrew from her circle of friends, and lost appetite and sleep. When her work suffered, her supervisor fired her for poor performance, telling her that she was no longer fun to have sex with anymore either. The firing and his comment sparked rage; Heidi decompensated and trashed the equipment room, which led to her arrest. Her defense attorney, sensing that something was amiss, sent her to a psychologist for an evaluation, in turn uncovering the story of sexual harassment, although not Heidi’s full history. After finding corroboration, the attorney went to the hospital administration, which then dropped the charges, fired the supervisor, and made an out-of-court settlement with Heidi, who the evaluating psychologist referred to therapy.
Heidi entered the office as if she were not in her body; her face was almost devoid of expression, her voice low, and her eyes averted. She radiated shame and inertia. The therapy office dog laid his head on her knee; his presence facilitated the first 2 years of therapy, as she would frequently address to him topics that she felt ashamed or fearful of bringing up more directly to the therapist.
Heidi found it difficult to accept the invitation to set the agendas for therapy. Her fear of authority had been aggravated by her most recent experiences, and both her biological mother and her stepmother had been involved in abuses against her, making women as frightening to her as men. However, simply because it was difficult for Heidi to articulate her own therapy goals did not mean that the therapist set goals for her. Instead, the therapist asked permission to ask her some questions about her life experience, telling Heidi that she was free to not answer and would not have to explain or justify her decision to withhold information, as it was her private life and the therapist was a stranger.
The no-coercion rule thus applies from the start of feminist therapy. Although it is valuable to gather a complete personal history from clients, a first step to empower happens by acknowledging the essential absurdity of the request that personal information be shared with a complete stranger on demand simply because that stranger is a therapist. The client-as-expert rule also applies immediately; if a person is yet unable to know what her goals are, the job of the feminist therapist is to create conditions under which that client can come to know those goals, rather than imposing the therapist’s own goals in order to fill the vacuum.
Heidi had had prior experience of therapy while in foster care and was suspicious of this stance, expecting to be terminated for noncooperation. The therapist persisted in offering her the option of deciding what to share and what not, and validated that it might feel risky to her to say “no” since she had just had a terrible experience at work. She later shared that the therapist’s insistence on her right to refuse without penalty was, “besides the dog,” the only reason she returned for a second session. She was in treatment for 10 years.
It took the better part of 3 months of meeting weekly before Heidi decided to tell some details about her childhood and the abuse to which she had been subjected. During that time, Heidi chose to focus on coping with daily life, which had become unmanageable for her in the wake of what initially looked like severe depression. Heidi began her reports of childhood abuse with the least unusual details (“I was sexually abused as a kid”), and as time went on and the therapist neither flinched nor patronized her, she revealed more and more. The entire story of her abuse history unfolded over the course of the first 2 years in therapy, and even during the last 2 years of that decade, details emerged that amplified and clarified some aspects of what she had already disclosed. Many of her revelations were followed by an increase in emotional distress, and thus the process of slowly learning her life narrative was interspersed with the client and therapist beginning to collaborate on ways to reduce distress and improve Heidi’s quality of life.
The therapist at this point offered to Heidi an empowerment strategy developed with feedback from other people working on memories (Gold & Brown, 1997). The therapist told Heidi that (a) they knew that when she told about something terrible, she usually had a very difficult time for a few days, and (b) this would often lead to an increase in suicidality (and as she shared shortly thereafter, SIV). The therapist offered to her the notion that before she shared new trauma history, they would work on strengthening her abilities to feel as safe as possible and have a protocol for what to do afterward. She would wrap herself tightly in a throw that was on the couch, take out a crystal that she had found on a walk, and then focus on it while telling her story. The dog was usually recruited after she shared information to assist her in being in the present by offering a tangible, safe, alive hugging object. They agreed that the therapist would call her early in the evening after such a session to check in and that she would go home and swaddle herself there until the call came.
They also developed a plan for what she would eat, as she noticed that she often dissociated from her body and thus her nutritional needs after such an episode. This was major movement for Heidi in empowerment on the somatic/biological axis, as it was an indication of awareness of bodily need. All of these collaborative strategies for increasing self-care laid the groundwork both for her revelation of SIV and for how the two women proceeded in response to that revelation.
Around month 5, as Heidi’s life as someone living with the consequences of complex trauma that predated the recent sexual assaults at her work became more apparent, the therapist decided to bring up the topic of SIV to her. By then both women knew that she was often dissociative, both when she was recounting abuse experiences in therapy sessions and at times in the rest of her life where she would describe her experiences of detachment and depersonalization. The therapist framed this as a “normal in context” phenomenon, commenting, “I’ve known a lot of people, clients and some friends, who’ve had lives as lousy as yours was growing up. Probably about 90% of them did stuff to themselves to help themselves cope, and 100% of those 90% felt totally ashamed to tell anyone. A lot of folks who go out of their bodies the way we know you do especially find this something they deal with. So in case there’s something you might want to tell the dog about, well, it won’t be the first time we’ve heard about it. Or the last, either, I think.”
Inviting clients to share this sort of private, shameful information in this manner often normalizes the coping strategy. By using descriptive, nonjudging language, it offers a less shaming way to communicate about it. Sometimes the dog is involved in therapy; sometimes people will bring art, or photos, or a poem. As a shame-reducing strategy, which creates empowerment on the psychological/intrapersonal axis of empowerment, a feminist therapist can offer information to clients about the common experiences of others.
Heidi then had several sessions in which she hinted that she might have something to tell about SIV, and in which the therapist reminded her that she would do so if and only if it made sense to her. At one point the therapist apologized for possibly creating pressure for her to tell something, after which Heidi became exasperated, saying, “It’s okay to be a little more pushy sometimes, you know. You’re not trying to strangle me, so what’s the big deal?” The therapist, meeting Heidi in tone, joked back that strangling was so far below practice standards that she hated to think that anyone who didn’t strangle her could do what they wanted. Although both laughed, Heidi later told the therapist that this was another important point in the work. “You actually thought I deserved to be treated with care. That I had boundaries to be respected. It was so shocking. I couldn’t tell if you were naive or just a pushover. But whatever, it was kind of nice to see that you wouldn’t let me talk you into treating me badly. That was kind of cool in a weird way.”
At the next meeting Heidi came in with a sheaf of paper that she thrust into the therapist’s hands, stating, “Read this first.” She then curled up on the couch hugging the dog, her face buried in his fur. On the papers were descriptions of her SIV practices and how she used each one of them. The writings ended with, “Now I know you’ll get rid of me, because I can’t stop this.”
It feels hard to convey the magnitude of gratitude and respect the therapist felt for Heidi at that moment. Feminist therapists are aware that giving trust, particularly informed trust, is an act of power, even though it feels terribly vulnerable. The therapist told Heidi how large a gift of trust she had given the therapist by sharing this information and praised her for finding a way to do so that would allow her to feel somewhat protected by the dog while the therapist was reading. The therapist then shared her belief that people practice SIV for good reasons and that she had respect for those reasons because all of them were about finding ways to stay alive.
The therapist then shared her philosophy of working with SIV. “If you don’t want to stop, you don’t have to stop. It can become a problem for some people to continue because they accidentally hurt themselves enough to require medical treatment and then the system starts to try to interfere with their lives and control their bodies. Some people miscalculate and can end up dead, which from what I’m reading here, I don’t think you want. Everyone I know who has ever done this has told me that the alternatives I can offer don’t work as well as SIV does at first, and sometimes don’t ever really work as well. If you want alternatives, or want to experiment with doing this less, we can do that, like we’ve come up with some ways to help you with dissociation. If you want to talk about it, you can do that. It’s your body, Heidi.”
So began a 6-year period in which SIV was on the table in therapy. It was not foreground most of the time, but it was always discussed. Heidi would tell of using SIV. The therapist would ask her, in the service of becoming more powerful on the psychological/intrapersonal and somatic axes, to become more aware of her feelings, thoughts, and situations before using SIV, as well as her responses to applying the solution to those difficulties. By inviting Heidi to become mindful in her use of SIV, she was in a position of greater choice. It was via this method that Heidi became able to understand the specifics of her SIV practice even better and to appreciate how completely lifesaving it had been for her. “If I hadn’t started to cut myself again when that shithead [her supervisor] was raping me, I probably would have killed myself.”
Greater mindfulness also led to the possibilities of change. “You’re spoiling it for me,” she sputtered one day after the therapist once again inquired into antecedents and results. “Spoiling?” the therapist queried back. “Yeah, as in, if I actually stop to pay attention and think about what I’m doing, I gross myself out. What am I thinking?” she exclaimed dramatically.
The therapist then commented that it was her experience, and probably Heidi’s as well, that kids who do SIV come upon it by accident and find out that it works before they have a chance to reflect on what they’re up to. She offered Heidi some writing about the concept of symptom-as-resistance-strategy, commenting that some people had found it useful. In feminist therapy, making information available to clients is common.
The therapist also asked her at that point if she had any interest in any of the alternatives to SIV, noting that Heidi’s comment about it being no longer as effective might be an invitation for the therapist to open that topic. “How about free-climbing?” Heidi joked, referring to a risky rock-climbing practice that eschews the use of ropes and carries high risk for injuries or death. “How about mindfulness meditation?” the therapist responded. “How about we compromise, like, I could take kung fu. There’s a school in town that offers classes to women only. I think I like the idea of moving around… I’d probably punch someone if I had to sit still and meditate.”
Kung fu turned out to be the alternative to SIV that eventually worked for Heidi. Her school, owned and operated by a woman who was herself a survivor of interpersonal violence, had many students with scars like Heidi’s, which they referred to, in a term invented by feminist author Alice Walker, as “warrior marks.” As Heidi commented around the point when her SIV was no longer a preferred coping strategy, “One of the things I realized, between you and kung fu, is that I was in combat all of my childhood, in terrible combat zones where I was wounded. Cutting myself and hitting myself were some of those wounds, but they weren’t stupid and they weren’t wrong. They were what I knew how to do at the time to survive the battle. And now I’m a veteran—but with no benefits,” the last said jokingly. At her kung fu school she learned to be more disclosing of her history of SIV, which made major inroads into her shame, and she became less isolated and found ways to be in her body. While this often frightened her, Heidi was able to bring that fear into therapy and move forward rather than continue in posttraumatic avoidance.
This reframe of her experiences of abuse was only one component of what made the martial arts a good SIV alternative and an example of a feminist intervention of somatic empowerment. Feminist therapists do not prescribe a martial art, or any other particular strategy, but will offer possibilities, based on what is known from research on effective strategies for people who have wished to stop using SIV, such as mindfulness meditation, self-soothing practices, and the movement and body therapies, as well as what they have learned from people who practice SIV.
Heidi’s process of changing her relationship to her body, which included continued practice and increasing mastery of her martial art, led her to develop and bring into her therapy more self-generated strategies for helping herself other than SIV, although she continued to practice it intermittently for most of her first 6 years of therapy. At one point, she became invested in making herself stop, which first led to an increase in frequency, and then to her own awareness that just as being forced by someone else to do something against her will was traumatizing to her, so, too, was self-imposed coercion or disrespect. Therapist and client noted together that she was incorporating the values of feminist therapy into her relationship with herself; empowerment begins to move out of the office and into the larger realm of life.
At one point during her kung fu training, Heidi struggled through a period of injuries and needed to sit out classes for several months. Both parties in the therapy noticed how unusual it was for her to notice pain and injury in her body and to respect her body’s message to her requesting a rest; this was another important turning point in her process of moving out of SIV. She commented during this time that since she was trying to avoid using SIV, the enforced rest from kung fu pushed her into finding other ways to do self-care. “So guess what, I’m going to get a dog,” she announced, beaming. “A rescue dog, you know, someone with complex trauma like me, because I think I know how to care for someone like that.”
During this time later in treatment, the therapist invited Heidi to consider a prior period of low levels of SIV in her life, which happened during her initial years in the workforce before the sexual harassment and assaults. This was empowerment on the axis of being able to think about and analyze one’s own behaviors—in this case, for Heidi to gain a cognitive grasp of how she had previously developed alternatives to SIV. It is important, in feminist therapy, for clients to see themselves as the agents of their own change. Reminding Heidi that she had done this work on her own before was a way of making her change less about the therapist and more about Heidi.
CHALLENGES IN THE APPLICATION OF FEMINIST THERAPY
Feminist therapy in general has been a successful approach to working with a multitude of clients from many types of backgrounds and with different presenting problems, based upon the feedback that feminist therapists receive from the most authoritative source, those who have been its clients. For this reason, its use in practice has increased in psychology and counseling, as has its influence on other fields. However, the integrity of feminist therapy is threatened today in some manners that are unique to its political roots. In this section, I will discuss these threats and their implications.
Three types of threats to the integrity of feminist practice emerge. The first two lie outside of feminist practice. The first challenge arises from within what I (Brown, 1997) called the “medical-industrial complex” of managed mental health care, in which cutbacks of funding for psychotherapy, intrusions by number-crunching case managers, and absence of parity for psychological interventions abound. Ballou and Hill (2008) discuss the impact of corporate and governmental “ownership of therapy” (p. 3) on the work of feminist therapists, especially the many practitioners whose ability to earn a living is dependent in some manner on maintaining good relationships, not with clients, but with the third parties paying the bill. It can be extremely difficult for a therapist to hold fast to an ethic of client empowerment and the creation of feminist consciousness when sitting in the room with her or him and the client is the managed care staff person who is counting symptoms and symptom reduction, not empowerment.
This problem is not unique to feminist therapy. McWilliams (2005), speaking from a psychoanalytic perspective, referred to the same dilemma present for today’s psychodynamic practitioners, who face threats to their sense of humanity and their capacities to engage in the long-term relational work of that theoretical model coming from the same corporatized system for the delivery of what is reductionistically referred to as “behavioral health.” Note the absence of emotional, psychosocial, spiritual, or political variables in this term.
A different threat to the integrity of feminist therapy has emerged from one arm of the movement toward more evidence-based practice. Although within the field of psychology there is not consensus on what constitutes good evidence for a practice (Norcross, Beutler, & Levant, 2005), some psychologists aver that only treatments supported by randomized controlled trials or replicated single-participant designs can be considered supported by evidence (Kihlstrom, 2005). Such treatments are designed as interventions for specific DSM diagnoses and are often manualized and performed in the same way with each client. Even though this stance is not universally accepted and is under fire from psychologists, feminist and otherwise, with interests in human diversity (Brown, 2005; Levant & Silverstein, 2005; Olkin & Taliaferro, 2005; Sue & Zane, 2005), it has been framed in the discourse on evidence in psychotherapy as representing the most rigorous—that is, scientific—form of evidence, with some funding sources only reimbursing for treatments that are on lists of such empirically supported treatments.
Feminist therapists consequently need to be aware of what evidence basis does support their practice. As will be discussed in chapter 5, feminist therapy situates its evidentiary basis within the research on empirically supported therapy relationships, on psychotherapy process, and in research on psychotherapist characteristics. Feminist therapists, particularly those in training in the early 21st century, frequently encounter colleagues who are dismissive of this model due in part to its political roots, but also due to the alleged lack of evidence for the theory, leading some feminist therapists to question the value of what they offer. The integrity of the practice is strengthened by knowledge of the extensive evidence supporting the model of an egalitarian, empowering therapy that attends to gender and social location rather than only to specific patterns of symptoms and distress.
The final challenge to the integrity of feminist therapy comes from within feminist therapists themselves. Raised in patriarchal cultures like all human beings, imbued with aversive biases of sexism, racism, heterosexism, classism, ableism, and ageism, like all human beings, and trained in models of psychotherapy that do not support egalitarian relationships with clients, feminist therapists must be continuously alert to the ways in which they are pulled out of a stance of client empowerment. As noted by Maracek and Kravetz (1998) in their survey of 25 self-identified practicing feminist psychotherapists, it is easy to slip out of a feminist political consciousness in one’s work and into an essentialist “women’s therapy with women” model that emphasizes the nurturing quality of therapy delivered by a woman and underplays the importance of social context and power.
Hart (2008) discusses the manner in which a psychotherapist’s context for practice can make it difficult to be consistent in the application of feminist theory that is at the core of a feminist psychotherapy. She notes that limits on sessions, rules of agencies, and the reality of clients’ capacities to afford therapy can each create a situation in which a feminist therapist feels impelled to abandon her theory and simply get symptoms reduced by the most effective method, ignoring questions of therapist power or client identity in the process. However, she also notes that it is possible to persist in feminist practice in almost any setting, with “a constant awareness of the implications of behavior and decisions, a great deal of creativity and flexibility, and often courage” (p. 9).
Indeed, creativity and thoughtful analysis of how empowerment and attention to gender might be enacted in a manner attentive to gender, power, and social location that enables the creation of feminist consciousness are the hallmark of the work of feminist therapists who have practiced in settings and with people who would not immediately spring to mind as appropriate for feminist therapy. Such work requires thinking of power not as an either/or phenomenon, but rather on a continuum, of the presence of constraints as boundaries to therapist choice as experiences for the privileged therapist that can increase empathy for clients’ experiences of disempowerment rather than function as cues to abandon one’s model. Feminist therapists who are self-employed must search for strategies that create access to services for clients while supporting their own economic well-being and consider the effects of consumer culture on that assessment. Those employed in agency settings need to analyze how the goals of feminist practice and those of the employer can be made mutual, rather than positioned as in conflict. All of these require a feminist therapist to be internally grounded in the application of a feminist frame and analysis; each of these is a challenge already addressed and surmounted by other feminist therapists. Isolation is thus not an option for feminist therapy practice. A therapist’s feminist consciousness can be challenged by such isolation, leaving her or him to believe that difficulties in negotiating patriarchal systems, be they managed care, agency directives, or the norms of colleagues, are due to the failings of her or his model rather than to the oppressive nature of larger systems that exemplify cultural norms of disempowerment. For feminist therapy to occur, the therapist must be grounded in the social realities of feminist political awareness and have support, both personal and professional, for being consistent in the application of a feminist analysis to her or his work. It was not for nothing that the first authors of the Feminist Therapy Institute Code of Ethics included a section about the importance of psychotherapist self-care. Aside from the common ways in which this construct is parsed, self-care for a feminist therapist means regular access, via reading, the Internet, consultation, or attendance at workshops and meetings, to feminist thought and to emerging developments in feminist therapy theory and practice.
Evaluation
THE EVIDENCE BASE OF FEMINIST PRACTICE
Because of its use of technical integration, isolating components of feminist therapy to study them in a controlled, experimental design strategy can be quite difficult. How does one operationalize empowerment or egalitarian practice when so much of those processes occur in the moment? Additionally, because of the unfortunate reality that very few practitioners of feminist therapy have been in the position to conduct outcome research, there is currently a paucity of empirical material demonstrating feminist therapy’s effectiveness or efficacy.
Judith Worell and her colleagues have contributed several studies demonstrating the internal consistency of feminist therapy as a specific intervention, as well as some information about its effectiveness. For approximately a decade, this group conducted studies attempting to empirically demonstrate that feminist therapy was both effective and distinctive from either nonsexist or nongender informed psychotherapies.
FEMINIST THERAPY AS A DISTINCTIVE PRACTICE
Robinson (1994), using the Therapy with Women Scale (TWS; Robinson & Worell, 1991) found two factors, empowerment of the client and advocacy for feminist goals, that distinguished between self-identified feminist therapists and therapists who did not so identify. Using a client response version of this scale, the Client TWS (Worell, Chandler, & Robinson, 1996), this research team queried therapy clients and found that they reported their therapists using the feminist methodologies claimed by those therapists (Worell, Chandler, Robinson, & Cobelius, 1996).
Niva Piran (1999) developed the Feminist Frame Scale (FFS). In a study of 112 psychotherapy clients in Toronto, she found that clients in feminist therapy reported therapist behaviors that organized on three factors: respectful validation, empowerment, and unsilencing trauma. Piran compared responses to the FFS for clients from feminist, person-centered, and medical-model psychotherapists and found that clients described feminist therapists behaving in ways consistent with the feminist model. Piran is currently conducting a longer-term study of feminist therapy’s effectiveness with a large group of women clients (personal communication, September 19, 2005).
Rader & Gilbert (2005) studied 42 female therapists who were asked whether they self-identified as feminist therapists. Their participants completed measures assessing their use of feminist therapy behaviors (Feminist Therapy Behavior Checklist) and power-sharing behaviors (TWS). One of each therapist’s current female clients completed measures assessing her perceptions of both treatment collaboration (Working Alliance Inventory) and power-sharing behaviors (Client TWS). These researchers found that participants who identified as feminist therapists were more likely to report engaging in power-sharing behaviors when compared to participating therapists who did not. Furthermore, as hypothesized, clients of feminist therapists were more likely to report that their therapists engaged in power-sharing behaviors. This study again identified empowerment as the crucial variable distinguishing feminist from other therapies, irrespective of sex of therapist or client.